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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4800
} | Medical Text: Admission Date: [**2141-3-8**] Discharge Date: [**2141-3-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Weakness, chest pressure
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
This is a [**Age over 90 **]-year-old female with a history of hyperlipidemia
and hypertension that lives alone in [**Hospital3 4634**] and is said
to be awake, alert and oriented. She was ambulating to the
bathroom this am when she felt acutely dizzy. She collapsed to
the ground where she was unsure if she lost consciousness. She
dragged herself to the bathroom but noted onset of sub-sternal
chest pressure, nausea, shortness of breath, and bilateral arm
numbness. She called help using the pull cords and 911 was
called. She was brought to the ED and was found to be very cold.
An EKG revealed the patient to have ST elevations in the
inferolateral leads. She also dropped her heart rate to the
30's and is said to be in complete heart block. She is
currently being 100% paced with external pacer pads to a HR of
60. Her blood pressure dropped to the 40's systolic. She was
given a total of 2 doses of atropine and a 300 cc saline bolus
as well and with the pacer pads is now in the low 80's systolic.
She is on a 100% non-rebreather but sats can't be obtained due
to cold temperatue. Her rectal temp was 97. She was given ASA
81 mg x 4, Plavix 600 mg, Liptor 80 mg and Morphine 2 mg for
chest pain after the pacer pads were placed. She will be
accompanied by her daughter-in-law.
.
In OSH ED, hypotensive in 3rd degree AV block, SBPs to 60s. EKG
showed ST elevations in inferior leads with reciprocal changes
in V2, aVL, early repolarization in lateral leads. External
pacers placed and pt. transferred here for cath.
.
In cath lab, LAD mid 60% stenosis, L circ 70% at origin, mid RCA
99%, RCA stented with BMS. Currently denies discomfort but
notes mild shortness of breath.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
hyperlipidemia
hypertension
GERD
Pneumonia in the past
COPD
hypothyroidism
h/o rheumatic fever
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 98.2, BP 95/53, HR 75 , RR 14, O2 99% on 4L
Gen: Elderly female in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2141-3-9**] 03:09AM BLOOD WBC-8.5 RBC-3.29* Hgb-9.9* Hct-29.1*
MCV-88 MCH-30.0 MCHC-34.0 RDW-13.5 Plt Ct-239
[**2141-3-8**] 08:07PM BLOOD Neuts-93.0* Bands-0 Lymphs-4.6* Monos-2.0
Eos-0.2 Baso-0.2
[**2141-3-11**] 08:40AM BLOOD Plt Ct-214
[**2141-3-11**] 08:40AM BLOOD Glucose-114* UreaN-30* Creat-1.3* Na-141
K-3.9 Cl-107 HCO3-26 AnGap-12
[**2141-3-8**] 08:07PM BLOOD Glucose-135* UreaN-36* Creat-1.7* Na-139
K-4.7 Cl-108 HCO3-25 AnGap-11
[**2141-3-8**] 08:07PM BLOOD CK(CPK)-331*
[**2141-3-9**] 03:09AM BLOOD ALT-117* AST-163* LD(LDH)-314*
CK(CPK)-1087* AlkPhos-51 Amylase-72 TotBili-0.3
[**2141-3-9**] 04:21PM BLOOD CK(CPK)-1354*
[**2141-3-10**] 07:30AM BLOOD CK(CPK)-806*
[**2141-3-8**] 08:07PM BLOOD CK-MB-40* MB Indx-12.1*
[**2141-3-9**] 03:09AM BLOOD CK-MB-144* MB Indx-13.2* cTropnT-3.15*
[**2141-3-9**] 04:21PM BLOOD CK-MB-118* MB Indx-8.7*
[**2141-3-10**] 07:30AM BLOOD CK-MB-47* MB Indx-5.8 cTropnT-3.05*
[**2141-3-11**] 08:40AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.2
[**2141-3-9**] 03:09AM BLOOD calTIBC-221* VitB12-1027* Folate-GREATER
TH Ferritn-273* TRF-170*
[**2141-3-9**] 03:09AM BLOOD %HbA1c-5.4
[**2141-3-9**] 03:09AM BLOOD Triglyc-112 HDL-44 CHOL/HD-4.1
LDLcalc-116 LDLmeas-121
CXR:
The cardiomediastinal silhouette is within normal limits. The
aortic knob is calcified. Mild increase in interstitial markings
indicate mild interstitial fluid overload. There is no focal
consolidation or pneumothorax.
IMPRESSION: Mild interstitial fluid overload.
Cardiac Cath:
1. Selective coronary angiography of this right dominant system
revealed three vessel coronary artery disease. The LMCA had no
angiographically apparent flow-limiting stenoses. The LAD was
diffusely
diseased with a mid vessel 60% lesion. The LCX had a 70% origin
stenosis. The RCA had a mid vessel 99% lesion.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 18 mm Hg and PCWP mean of 17 mm Hg.
There was
mild pulmonary arterial hypertension of 32/19 mm Hg. There was
systemic
arterial hypotension at 98/44 mm Hg. The cardiac index was
preserved at
3.5 l/min/m2.
3. Left ventriculography was deferred.
4. Successful stenting of the mid RCa with a 2.5 X 12 mm Vision
bare
metal stent with no residual stenosis (see PTCA comments for
detail).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right and left sided filling pressures.
3. Successful stenting of the mid RCA with a bare metal stent.
4. Successful treatment of STE IMI with primary PTCA.
TTE:
The right atrial pressure is indeterminate. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with basal to mid
inferior hypokinesis/akinesis. The remaining segments contract
normally (LVEF = 50 %). The estimated cardiac index is
borderline low (2.0-2.5L/min/m2). Right ventricular chamber size
is normal. with focal basal free wall hypokinesis. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is an anterior space which most likely represents
a fat pad.
IMPRESSION: Inferior wall hypokinesis/akinesis consistent with
myocardial infarction.
Brief Hospital Course:
CAD/Ischemia: The patient suffered an inferior STEMI with
culprit lesion found in the RCA s/p bare metal stent. Her
initial course was complicated by hypotension and bradycardia
requiring dopamine and external pacing. However, both of these
resolved quickly after stenting and resolution of coronary flow.
She was begun on metoprolol, lisinopril, ASA, Plavix, and
atorvastatin. Her lipid panel did show both an elevated total
cholesterol and an elevated LDL. Her HbA1c was normal at 5.4%.
She will follow up with Dr. [**Last Name (STitle) **] as her new cardiologist.
Pump: Initially the patient showed signs of volume overload with
pulmonary edema. She initially recieved IV lasix for diuresis
and was maintained on a stable regimen of 20mg PO lasix. An
echocardiogram showed an EF of 50% with inferior hypokinesis and
1+MR/AI. She was begun on metoprolol and lisinopril with good
effect.
Rhythm: The patient was initially bradycardiac with a high
degree of AV block. However, this resolved after coronary
intervention. She remained in normal sinus rhythm for the rest
of her hospitalization. She was begun on a low dose of
metoprolol with good effect.
Anemia: The patient exhibited a normocytic anemia on
presentation. She was guaiac negative. Iron studies, B12 and
Folate were normal. The patient received 2 units of PRBCs with
expected rise in her hematocrit. Her hematocrit remained stable
for the duration of her hospitalization.
ARF: The patient presented with a creatine of 1.7, up from a
baseline of 1.3. This was likely due to her hypotension and poor
forward flow. It continued to improve after blood transfusion
and returned to baseline at the time of discharge.
Hypothyroid: Continued on synthroid
FEN: low salt HH diet
Prophylaxis: hep SC, no PPI indicated, bowel regimen,
Code: FULL CODE
Communication: with daughter-in-law [**Name (NI) 714**] [**Name (NI) 9969**] [**Telephone/Fax (1) 77241**]
Medications on Admission:
- diovan/hctz (80mg/12.5mg)
- actonel
- synthroid
- xalatan eye drops
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 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*
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Inferior ST elevation myocardial infarction s/p baremetal stent
to right coronary artery
Hypertension
Hyperlipidemia
Hypothyroidism
Discharge Condition:
All vital signs stable, chest pain free, ambulatory
Discharge Instructions:
You were admitted with a heart attack. This was caused by a
blockage in one of the vessells that supplies blood to your
heart. This was opened up with a stent. We have altered your
medications to better protect your heart. It is very important
that you take your aspirin and Plavix every day to prevent a
clot from forming int that stent.
Please take all your medications as prescribed and attend all of
your follow up appointments.
Please call your doctor or return to the emergency room if you
experience chest pain, shortness of breath, fevers, chills, or
any other symptoms that concern you.
Followup Instructions:
Please call Dr.[**Name (NI) 77242**] office at [**Telephone/Fax (1) 4475**] to schedule a
follow up appointment in the next 2-4 weeks.
Please call Dr.[**Name (NI) 5907**] office (new cardiologist) at ([**Telephone/Fax (1) 12384**] to schedule a follow up appointment in the next [**12-21**]
weeks.
ICD9 Codes: 5849, 4019, 2720, 496, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4801
} | Medical Text: Admission Date: [**2185-2-20**] Discharge Date: [**2185-3-1**]
Date of Birth: [**2118-1-11**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: This is a 67-year-old Korean
gentleman with a history of hepatitis B and hepatoma status
post chemoembolization x 3 who has been on the transplant
list for several months. He has a history of grade I varices
and portal gastropathy. He has ascites which is relatively
controlled with diuretics. His preoperative work-up revealed
no evidence of metastasis from his hepatoma. He presents to
[**Hospital1 69**] now that a liver has
become available for transplantation.
PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2.
Hypertension. 3. Hepatitis B cirrhosis. 4. Hepatoma as
described [**Known lastname **] the history of present illness.
PAST SURGICAL HISTORY: 1. Status post cholecystectomy [**Known lastname **]
[**2166**]. 2. Status post inguinal hernia repair [**Known lastname **] [**2180**], [**2183**].
MEDICATIONS ON ADMISSION: 1. NPH Insulin 30 units q.a.m. 2.
Lamivudine 100 mg p.o. q.d. 3. Vitamin B and folate. 4.
Zantac 150 mg p.o. b.i.d. 5. Aldactone 25 mg p.o. t.i.d.
SOCIAL HISTORY: Positive for tobacco abuse, one pack per day
for 20 years, quit 20 years ago. He admits to occasional
alcohol.
PHYSICAL EXAMINATION: Mr. [**Known lastname **] is a well-appearing gentleman
with mild jaundice. He is consistent with his stated age of
67 years old. HEENT: Pupils were equal, round, and reactive
to light; extraocular movements intact; mucous membranes
moist and without oropharyngeal lesions. Neck: No cervical
lymphadenopathy and his neck was supple. Lungs: Clear to
auscultation bilaterally. Heart: Regular rate and rhythm
without evidence of murmurs, gallops, or rubs. Abdomen:
Soft, nontender with mild ascites and normal active bowel
sounds.
LABORATORY DATA: Pertinent laboratory studies on admission
revealed a complete blood count with white count of 6.9,
hematocrit 27.8, platelet count 52. PT 14.5, PTT 33.0, INR
1.4, fibrinogen 17.3. Potassium 4.2, BUN 30, creatinine 1.3,
ALT 30, AST 111, alkaline phosphatase 70, total bilirubin
1.6, albumin 2.7. AFP 30.0, CEA 4.1, CA [**00**]-9 51.
Serologies: HIV negative, HCV negative, CMV negative, HSV-I
and II positive, HBeAb positive, HBeAg negative.
HOSPITAL COURSE: On the day of admission Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a
piggyback liver transplantation. The procedure was performed
by Dr. [**Last Name (STitle) **] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The liver was
prepared on the back table for transplantation. After Mr.
[**Known lastname **] hepatectomy the liver was transplanted. He had a portal
vein to portal vein anastomosis and a CBD to CBD anastomosis.
Please see the previously dictated operative note for more
details. The procedure was performed with an accompanying
2,500 cc blood loss. Mr. [**Known lastname **] [**Last Name (Titles) 8337**] the procedure well and
was transferred to the surgical intensive care unit intubated
[**Known lastname **] stable condition.
Mr. [**Known lastname **] was extubated on postoperative day number one and
never required pressors to maintain his hemodynamic status.
On postoperative day number three it was noted that his total
bilirubin had bumped from 3.9 to 5.6. This prompted an
ultrasound of his liver which failed to reveal consistent
pulsatile flow through the hepatic artery. A follow-up
angiogram revealed that [**Known lastname **] fact there was good flow through
the hepatic artery. Mr. [**Known lastname **] returned to the surgical
intensive care unit and was continued to be followed
carefully.
During Mr. [**Known lastname **] postoperative course it was noted that his
platelets had been low and he required several platelet
transfusions beginning on postoperative day zero. Hematology
was consulted. Despite an extensive hematology work-up no
definitive cause was found for his thrombocytopenia. His
hydralazine was discontinued and his platelet count was
stable at the time of discharge.
By postoperative day number seven Mr. [**Known lastname **] had both of his
[**Location (un) 1661**]-[**Location (un) 1662**] drains removed and was tolerating a regular
diet. He was able to ambulate. He was stable on his
medication regimens.
Mr. [**Known lastname **] immunosuppression included CellCept starting at the
time of the operation and FK-506. At the time of discharge
he was on CellCept 1,000 mg p.o. b.i.d., prednisone 15 mg
p.o. q.d., and cyclosporine 275 mg p.o. b.i.d. His
cyclosporine level at the time of discharge was stable at
314.
Examination on discharge showed that the patient looked well
and was [**Known lastname **] no distress. He was afebrile with a temperature
of 98.9. His pulse was 58, blood pressure 160/88. He was
breathing comfortably on room air. His lungs were clear to
auscultation bilaterally. His heart was regular. His belly
was soft, nontender and nondistended. His incision was
healing well with no drainage. There was a dressing over a
freshly removed [**Location (un) 1661**]-[**Location (un) 1662**] drain site. He had no
extremity edema.
Laboratory studies on the day of discharge showed a complete
blood count with a white count of 6.0, hematocrit 33.1,
platelet count 110. Coagulation studies showed a PT of 12.4,
PTT 26.3, INR 1.0. Chemistries showed a sodium of 134,
potassium 4.1, chloride 103, bicarbonate 25, BUN 27,
creatinine 1.2, glucose 97, ALT 74, AST 18, alkaline
phosphatase 98, and total bilirubin 1.7.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Bactrim 1 tablet p.o. q.d.
2. Valciclovir 450 mg p.o. q.d.
3. Lamivudine 100 mg p.o. q.d.
4. CellCept 1,000 mg p.o. b.i.d.
5. Prednisone 15 mg p.o. q.d.
6. Cyclosporine (Neoral) 275 mg p.o. b.i.d.
7. Clonidine 0.1 mg p.o. t.i.d.
8. Lopressor 150 mg p.o. b.i.d.
9. Protonix 40 mg p.o. q. day.
10. Lasix 20 mg p.o. q.d.
11. Oxycodone p.r.n.
12. He will receive an additional dose of hepatitis B
immunoglobulin. This dose will be given on his [**Hospital 702**]
clinic appointment on Monday, [**3-7**]. His last dose
received [**Known lastname **] the hospital was given on [**2-28**].
FOLLOW UP: The patient will follow up with the transplant
surgery clinic and has been given instructions to call for a
follow-up appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2185-3-1**] 10:50
T: [**2185-3-1**] 11:14
JOB#: [**Job Number 93522**]
ICD9 Codes: 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4802
} | Medical Text: Admission Date: [**2168-6-21**] Discharge Date: [**2168-7-1**]
Date of Birth: [**2109-8-21**] Sex: F
Service: SURGERY
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Ureteral stricture
Major Surgical or Invasive Procedure:
[**2168-6-22**] Exploratory laparotomy with lysis of adhesions,
extensive ureteral mobilization of right ureter with
ureteropyelostomy to transplanted kidney.
[**2168-6-22**] 1. Cystoscopy with bilateral stent placement.
2. Open ureterotomy with stent placement.
3. Ureteral pyelostomy
History of Present Illness:
58 y.o. F with h/o hypercoagulable disorder (elevated
factor VIII). She developed ESRD [**3-16**] strep glomerulonephritis,
s/p LRRT [**2164**] with subsequent nephrectomy for acute thrombus,
re-transplanted [**8-/2167**] c/b hematoma requiring
evacuation/washout.
Post transplant course further complicated by multiple
UTIs (VRE,MDR E.coli), ureteral stricture, hydronephrosis and
renal insufficiency. On [**2168-3-2**], she underwent aborted
uretero-ureterostomy secondary to excessive bleeding with
retention of nephrostomy tube. Now presents for re-attempt at
revision of transplant ureter tomorrow. Last UTI (E.coli) [**2168-4-17**]
treated with Imipenem until [**5-12**].
Nephrostomy tube study scheduled for today in IR and OR
scheduled
tomorrow for uretero-ureterostomy. Last dose of coumadin was Sat
[**6-18**]. However, has been taking aspirin daily.
ROS: Has been feeling well. Appetite good. Sleeping well, but
does have trouble falling asleep (takes a couple hours to fall
asleep). Denies fever, chills, nausea, vomiting, sob, cp,
indigestion, diarrhea, constipation, dysuria. Did have scant
amout of blood in urine when she voided yesterday. Voids small
amount once daily. No futher bleeding. No longer menstrates.
Nephrostomy tube output has been great without hematuria or
cloudy urine. Insertion site without s/o infection
Past Medical History:
ESRD secondary to possible streptococcal glomerulonephritis
([**2153**]) on hemodialysis since [**1-/2165**], then underwent
living-related renal transplant from her daughter in [**9-/2165**] (at
[**Hospital3 2358**]) but kidney thrombosed and was removed within 24
hours. S/p 2nd renal transplant on [**2167-8-18**], post op course
complicated by retroperitoneal bleeding with washout x2,
pulmonary edema requiring intubation and CVVH, many blood
transfusions, UTI/pan-resistant E.coli, removal of ureteral
stent was removed, vaginal bleeding likely secondary to
peritoneal hematoma.
[**2168-6-22**] Exploratory laparotomy with lysis of adhesions,
extensive ureteral mobilization of right ureter with
ureteropyelostomy to transplanted kidney.
5/11/11Cystoscopy with bilateral stent placement. Open
ureterotomy with stent placement. Ureteral pyelostomy
Elevated factor VIII levels/high fibrinogen levels: on coumadin
Hypertension - well controlled on metoprolol
Gout - on allopurinol
DM - on glipizide
Social History:
Lives in [**Location **] with her husband, no smoking, drinking or drug use,
currently unemployed but worked as a nurse.
Family History:
-mother alive at age 82 with HTN and DM2
-father alive at age [**Age over 90 **] with TBI and vision loss
-four siblings, all healthy
-children all healthy
Physical Exam:
VS:96.8 HR 72 106/63 RR 14 97% RA wt 84kg, height 5'5 [**2-14**] inc
Gen: A&O, NAD, appears well. Husband present
CVS: RRR, sys murmur
Pulm: clear bilat
Abd: non-distended, non-tender, soft, +bowel sounds, well healed
incisions, LLQ nephrostomy tube site without redness/drainage,
clear yellow urine in NT bag
ext: no edema
Labs: Creatinine 2.0. INR 2.0
Pertinent Results:
[**2168-6-21**] 03:10PM BLOOD WBC-6.3 RBC-4.05* Hgb-12.1 Hct-35.5*
MCV-88 MCH-29.9 MCHC-34.1 RDW-15.8* Plt Ct-221
[**2168-6-28**] 02:30AM BLOOD Hct-24.2*
[**2168-7-1**] 06:00AM BLOOD PT-16.7* PTT-25.5 INR(PT)-1.5*
[**2168-6-21**] 03:10PM BLOOD Glucose-79 UreaN-45* Creat-2.0* Na-139
K-4.7 Cl-105 HCO3-25 AnGap-14
[**2168-7-1**] 06:00AM BLOOD Glucose-128* UreaN-38* Creat-2.2* Na-135
K-4.1 Cl-100 HCO3-27 AnGap-12
Brief Hospital Course:
She was admitted the day prior to surgery for a nephrostomy tube
study that demonstrated moderated hydronephrosis with complete
obstruction of ureter as previously noted.
On [**2168-6-22**], she underwent exploratory laparotomy with lysis of
adhesions,extensive ureteral mobilization of right ureter with
ureteropyelostomy to transplanted kidney. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 816**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] performed cystoscopy with bilateral
stent placement, open ureterotomy with stent placement and
ureteral pyelostomy. Please refer to operative notes for further
details.
Postop, she experienced hyperkalemia for which she required
dialysis. She was transferred to the SICU for management. She
did well. Vital signs remained stable with good urine output via
the nephrostomy tube. Creatinine decreased to 1.6 likely
secondary to the dialysis. She was extubated on [**6-23**] without
incident with stable vital signs. She was transferred out of the
SICU on [**6-23**].
Temporary dialysis line was removed as potassium remained in the
normal range. Creatinine ranged between 1.6-2.2. Urine output
was primarily draining via the nephrostomy tube. Minimal urine
was draining via the foley. Foley output was bloody. The JP
output was sanguinous and minimal (~10-0cc)
Heparin drip was started given h/o elevated factor V and
fibrinogen levels. HCT dropped on [**6-28**] to 24 from 29. Heparin
was stopped and she was given 2 units of PRBC without incident.
Post transfusion remained stable. Coumadin 3mg was initiated on
[**6-28**] and continued until discharge to home. INR was 1.5 on [**7-1**].
Diet was advanced slowly due to nausea related to ileus that
resolved. She was finally able to tolerated regular food and was
passing BMs at time of discharge to home.
Physical therapy declared her safe for home. She was independent
in drain/foley care and felt that she did not require VNA
services. She will have PT/INR and chem 7/trough prograf level
on [**7-4**].
Follow up with Dr. [**Last Name (STitle) 3748**] will be determined at time of follow
up with Dr. [**Last Name (STitle) 816**] on [**7-7**]. Of note, she does have ureteral stent.
Medications on Admission:
allopurinol 100mg qd, lasix 20mg qd, gabapentin 300mg tid,
glipizide 5mg qd, metoprolol succinate 100mg qd, myfortic 180mg
[**Hospital1 **], omeprazole 40mg qd, pravastatin 10mg qd, bactrim ss 1 qd,
prograf 1.5mg [**Hospital1 **], coumadin 1mg [**Last Name (LF) **], [**First Name3 (LF) **] 81mg qd, mvi qd, senna 1
[**Hospital1 **]
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
2. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
12. Outpatient [**Hospital1 **] Work
[**Hospital1 766**] [**7-4**]: stat PT/INR
13. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
14. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
15. Outpatient [**Month/Year (2) **] Work
[**Month/Year (2) 766**] [**7-4**]:
chem 7 and trough prograf level
fax to [**Telephone/Fax (1) 697**] attention [**Name6 (MD) 5036**] [**Name8 (MD) 5039**] RN
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
17. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Ureteral stricture
Ureteral necrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience
the following:
fever, chills, nausea, vomiting, increased abdominal
distension/pain, decreased urine output from nephrostomy tube,
incision redness/bleeding/drainage
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-7-7**]
10:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2168-8-2**] 10:20
Completed by:[**2168-7-1**]
ICD9 Codes: 4019, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4803
} | Medical Text: Admission Date: [**2108-2-3**] Discharge Date: [**2108-2-13**]
Date of Birth: [**2053-12-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 54-year-old male with
history of diabetes, hypertension, hypercholesterolemia, with
positive family history for myocardial infarction who now
comes in with NSTE myocardial infarction. Patient denies
prior cardiac history, however, exercise treadmill test done
on [**2105-8-22**] for screening purposes showed 2 to 2.[**Street Address(2) 18425**] depression in V4 to V6 after 10 minute standard [**Doctor First Name **]
protocol.
Patient was last well three days prior to admission when he
was on the stairmaster for five minutes when he developed
substernal pressure, nonradiating, not associated with
nausea, diaphoresis or shortness of breath. Pain resolved
with rest. This occurred on the stairmaster one day prior to
admission. The night prior to admission, the patient awoke
at 2:30 a.m. feeling well, then at 3 a.m. developed severe
substernal chest pain again without associated symptoms.
Symptoms relieved in the Emergency Department with aspirin
and nitroglycerin times two. An electrocardiogram showed ST
elevation 2 mm in V2 to V3 and T wave inversion in III and
aVF. The patient was started on heparin, Integrilin, and
Plavix, as well as nitroglycerin drip. Currently patient is
pain free and patient is free of electrocardiogram changes.
ALLERGIES: Hypercholesterolemia, gout, elevated serum
protein, diabetes (diet controlled), status post knee
surgery, status post ankle surgery, osteoarthritis, benign
prostatic hypertrophy.
MEDICATIONS:
1. Hydrochlorothiazide 12.5.
2. Allopurinol.
3. Flomax 0.4 q.d.
4. Pravachol 40.
5. Atenolol 50.
SOCIAL HISTORY: No tobacco, rare ethanol, works as an
accountant, lives with wife.
FAMILY HISTORY: Uncle who died at age 50s with heart
disease. Mother is alive with history of heart disease and
father died at age 76 with heart disease.
PHYSICAL EXAMINATION: Temperature 98 degrees. Blood
pressure 119/70. Heart rate 52. Respiratory rate 17,
saturating 96% on two liters. Generally, patient is
pleasant, comfortable without any apparent distress.
Examination of the head, eyes, ears, nose and throat revealed
extraocular movements intact. Pupils equal, round and
reactive to light, anicteric. Mucous membranes were moist.
Exam showed neck revealed no jugular venous distention, no
bruits. Neck was supple. No lymphadenopathy was noted and
normal carotid pulse. Examination of the heart revealed
bradycardia, was regular without any murmurs, rubs or
gallops. Lungs revealed clear to auscultation bilaterally.
Examination of the abdomen revealed soft, nontender,
nondistended abdomen. Examination of the extremities
revealed no edema with 2+ dorsalis pedis and posterior tibial
pulses.
LABORATORIES ON ADMISSION: White blood cell count 11.7,
hematocrit 47.4, platelet count 254,000. Sodium 137,
potassium 3.7, chloride 98, bicarbonate 28, BUN 20,
creatinine 1.0, glucose 164, magnesium 1.8, INR 1.2, MB was
117, troponin 0.63.
Chest x-ray showed no congestive heart failure, no effusions,
no consolidations.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Medicine Service. Patient was continued on aspirin,
beta-blocker, nitroglycerin, Plavix and statin and heparin
drip. On hospital day number two, patient had no complaints
of chest pain or shortness of breath and patient underwent
cardiac catheterization.
The cardiac catheterization showed left main coronary artery
had one vessel coronary artery disease and mildly depressed
ventricular function. The left main coronary artery had 70%
distal lesion at the bifurcation, left anterior descending
with small vessel that did not reach the apex, had mild
diffuse disease. The left circumflex accessories, serial 70%
lesions in the mid and distal AVG. The lateral
>.........<hazy and with appearance of acute lesions. The
right coronary artery was large vessel with mild diffuse
disease that wrapped around this and supplied the apex.
On hospital day number three, patient continued to deny chest
pain, shortness of breath. Symptoms were markedly improved.
He remained afebrile with stable vital signs. Patient was
continued on a heparin drip.
On hospital day number five, patient was taken to the
Operating Room for coronary artery bypass graft times four.
Patient had left internal mammary artery that went to left
anterior descending, saphenous vein graft to OM1 and OM2 and
saphenous vein graft to posterior descending artery. Patient
had a mean arterial pressure of 91, central venous pressure
of 14, PAD of 16, and >.......< of 21 with 84 normal sinus
rhythm. Patient was on a nitro drip 0.5 when the patient was
transferred to the Cardiac Surgery Recovery Unit.
Patient,in the Cardiac Surgery Recovery Unit, initially
received nitro drip to titrate to maintain the >.....<of less
than 90, central venous pressure initially 78, however, the
patient progressively set increase up to maximum of 20. At
the same time, PA pressure started to increase 30 to
40s/15-20s. The blood pressure started to decrease and nitro
drip was stopped. Patient received fluid bolus of 500
>.....<with a good result for maintaining the blood pressure.
Patient was extubated on postoperative day number one.
Patient remained afebrile with stable vital signs in normal
sinus rhythm. Patient was started on Lasix, chest tubes were
removed and was transferred to the floor. On postoperative
day number two, patient remained afebrile with stable vital
signs, taking good po and making good urine. The final chest
tubes were removed. JP was removed and the Foley was removed
and wires were removed. The patient had good laboratories
that were within normal limits. His hematocrit, however, was
25, which was continued to be monitored.
On hospital day number two, patient seemed to do well,
remained afebrile with stable vital signs. He continued to
have a low hematocrit, which was continued to be monitored.
On postoperative day number four, the patient continued to do
well, was afebrile with normal vital signs, taking in good po
and making good urine. Patient complained of not being able
to have a bowel movement and patient was put on magnesium
citrate which helped in having a bowel movement. Patient was
continued on physical therapy and started on iron.
On postoperative day number five, the patient remained
afebrile with stable vital signs, taking good po, and making
good urine. Patient worked with physical therapist who felt
that the patient was ready to be discharged in terms of
physical therapies standpoint of view. Patient was
discharged in good condition.
CONDITION OF DISCHARGE: Good.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft times four.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po b.i.d. times one week.
2. Potassium chloride 20 mEq b.i.d. times one week.
3. Colace 100 mg po b.i.d.
4. Aspirin 325 mg po q.d.
5. Percocet #5 1-2 tablets q. 4-6 hours prn pain.
6. >.......<0.4 mg slow release, 1 capsule q.d.
7. Pravastatin 40 mg po q.d.
8. Allopurinol 300 mg po q.d.
9. Iron 325 mg po q.d.
10. Lopressor 25 mg po b.i.d.
FO[**Last Name (STitle) **]P PLAN: Please follow-up with Dr. [**Last Name (STitle) 97590**] in one to
two weeks. Please follow-up with Dr. [**Last Name (Prefixes) **] in four
weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 26192**]
MEDQUIST36
D: [**2108-2-13**] 01:10
T: [**2108-2-13**] 14:02
JOB#: [**Job Number 99144**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4804
} | Medical Text: Admission Date: [**2192-3-17**] Discharge Date: [**2192-5-28**]
Date of Birth: [**2127-11-3**] Sex: F
Service: MEDICINE
Allergies:
penicillin G
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2192-3-18**] Open reduction and intramedullary nail fixation
right femur fracture
[**2192-3-26**] Cyberknife
[**2192-3-28**] Cyberknife
[**2192-3-29**] Cyberknife
[**2192-4-8**] IR-guided therapeutic paracentesis
[**2192-4-17**] IR-guided therapeutic paracentesis
[**2192-4-18**] Cyberknife
[**2192-4-19**] Cyberknife
[**2192-4-20**] Cyberknife
[**2192-4-23**] IR-guided therapeutic paracentesis
[**2192-5-5**] Therapeutic paracentesis
History of Present Illness:
64yo woman, Hindi/Urdu-speaking only, with h/o Hepatitis C
cirrhosis (in past, has been decompensated with ascites,
encephalopathy; has known varices), probable HCC w/ plans for
Cyberknife, DMII, recently discovered L2-4 lumbar fx (just
discharged yesterday for this) who presents with L hip fracture.
She was discharged yesterday from [**Hospital1 18**] after being admitted
from [**3-13**]->[**3-16**] - was admitted for back pain and found to have
L2-L4 compression fractures on MRI. She was doing well at home,
her appetite was returning and her back pain was better
controlled overnight. This morning ~ 9 AM she got up to get out
of bed and reached for her walker, but tripped and fell and
landed on her R hip. Her son was in the next room and heard her
cry out - she did not lose consciousness, did not hit her head,
was not confused. She complained of pain - EMS was called and
she was taken to [**Hospital3 **]. There, Xray showed 'left
intertrochanteric and subtrochanteric proximal left femur
fracture with mild varus angulation. femoral shaft is displaced
1cm med, 1cm anterior, no dislocation.' She was given 4 mg IV
morphine x 4, zofran, and 1L NS and transferred to [**Hospital1 18**] at the
request of her family since here care is here.
.
In the ED, initial VS 98.0 98 118/68 18 97% on RA. She was in
extreme pain w/ L hip flexed and externally rotated. Labs were
mostly at baseline though K was 5.6. CXR showed no acute
process. Ortho was consulted and recommended admission to
medicine for optimization prior to surgery. They plan to take
her to the OR either tmrw PM or on Monday.
.
Currently, the patient is in pain. Her R leg is flexed up and
her L leg is flexed and externally rotated. She intermittently
moans in pain. Her son helps to translate. Other than the back
pain, she has not otherwise been recently ill. She ambulates
with a walker at home and has been doing well with this. She is
oriented x 3 and has no complaints other than L hip pain. The
morphine helped a little with the pain at OSH. Oxycodone makes
her very nauseated.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Complications of her hepatitis C: ascites, esophageal varices,
has
had banding performed on three occasions in [**Country 9819**], the most
recent of which was 1.5 years ago. She is known to have
esophageal varices documented by an endoscopy in [**Hospital **] Hospital
and is currently on nadolol. She has had four to five
paracenteses, the last of which was performed in [**Month (only) **] and is
maintained now on diuretics without any recurrence of ascites.
-She has had intermittent periods of confusion and difficulty
sleeping and is maintained on lactulose for treatment of hepatic
encephalopathy.
-Diabetes for 30 years.
-She has been tested negative for TB
-thyroid surgery performed in the past, but again there
was no evidence of any cancer.
- L2,3,4 compression fractures from [**2-/2109**] MRI; there is some
question of pathologic fractures
-Appendiceal mucocele diagnosed on abdominal CT [**2-16**]
- Sub-5-mm cystic lesions noted within the inferior aspect of
the head of the pancreas which may represent either side branch
IPMN vs. other cystic lesions of the pancreas from [**11-25**] CT w/
elevated CA [**99**]-9 to 238
- Right adrenal lesion with MR [**First Name (Titles) **] [**Last Name (Titles) **]
concerning for
phaeochromocytoma; catecholamines normal
Social History:
SOCIAL HISTORY: She recently moved from [**Country 9819**] to the United
States one year ago. She has two sisters and two brothers who
live nearby and have been helping her with care. She is married
and she lives with her son and daughter-in-law. She is a former
teacher who retired 15 years ago in [**Country 9819**]. She speaks Urdu
and Hindi. She does not drink any alcohol and she smokes one
cigarette per day for the last two years.She has received two
blood
transfusions, one about one and a half years ago and the second
one about 30 years ago. She has no history of intravenous drug
use or tattoos.
Family History:
FAMILY HISTORY: Her mother also was diagnosed with cirrhosis.
She reports that one of her brothers had lung nodules but this
disappeared without any treatment. She otherwise denies any
history of cancer in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 96 106/58 18 97% on RA
GENERAL: Looks uncomfortable, intermittently moans in pain,
wearing back brace
HEENT: Sclera icteric. MMM
CARDIAC: RRR with no excess sounds appreciated
LUNGS: As she is wearing back brace only eval'd anterior lung
fields - clear
ABDOMEN: soft, ND, NT
EXTREMITIES: no edema, WWP; R leg is flexed up, L leg is flexed
and externally rotated; 2+ dp pulses bilaterally, sensation in L
leg intact
Neuro: A&Ox3, EOMI, full strenth in bil UE, wiggles toes in bil.
LE
.
DISCHARGE PHYSICAL EXAM:
Physical Exam:
Vitals: 97.9 123/55 99 20 100%RA
General- alert, diffusely jaundice
HEENT- Sclera icteric
Lungs- coarse breath sounds throughout
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- non-tender, soft, mildly distended, bowel sounds
present, no rebound tenderness or guarding
Ext- warm, well perfused, 2+ edema to the knees, pneumoboots in
place
Neuro- A&O x3
Pertinent Results:
[**2192-3-16**] 05:05AM BLOOD WBC-3.2* RBC-3.80* Hgb-9.1* Hct-29.8*
MCV-78* MCH-24.0* MCHC-30.6* RDW-17.9* Plt Ct-48*
[**2192-3-17**] 07:40PM BLOOD WBC-6.4# RBC-4.04* Hgb-9.8* Hct-30.3*
MCV-75* MCH-24.4* MCHC-32.5 RDW-18.0* Plt Ct-71*
[**2192-3-18**] 07:05AM BLOOD WBC-5.7 RBC-3.54* Hgb-8.8* Hct-26.6*
MCV-75* MCH-25.0* MCHC-33.2 RDW-18.2* Plt Ct-63*
[**2192-3-18**] 10:57AM BLOOD WBC-8.5 RBC-3.77* Hgb-9.7* Hct-29.0*
MCV-77* MCH-25.8* MCHC-33.6 RDW-17.8* Plt Ct-118*#
[**2192-3-19**] 06:25AM BLOOD WBC-7.6 RBC-2.99* Hgb-7.6* Hct-23.4*
MCV-78* MCH-25.4* MCHC-32.6 RDW-17.9* Plt Ct-91*
[**2192-3-19**] 05:00PM BLOOD WBC-7.9 RBC-3.65* Hgb-10.1*# Hct-28.4*
MCV-78* MCH-27.8 MCHC-35.7* RDW-17.3* Plt Ct-70*
[**2192-3-20**] 06:20AM BLOOD WBC-7.6 RBC-3.72* Hgb-10.1* Hct-29.5*
MCV-79* MCH-27.2 MCHC-34.3 RDW-17.8* Plt Ct-62*
[**2192-3-21**] 05:15AM BLOOD WBC-6.3 RBC-3.44* Hgb-9.4* Hct-28.2*
MCV-82 MCH-27.4 MCHC-33.4 RDW-18.2* Plt Ct-70*
[**2192-3-22**] 06:35AM BLOOD WBC-5.5 RBC-3.53* Hgb-9.8* Hct-28.9*
MCV-82 MCH-27.7 MCHC-33.8 RDW-18.5* Plt Ct-80*
[**2192-3-23**] 06:30AM BLOOD WBC-4.5 RBC-3.22* Hgb-9.0* Hct-26.9*
MCV-83 MCH-27.9 MCHC-33.5 RDW-19.3* Plt Ct-55*
[**2192-3-24**] 06:50AM BLOOD WBC-5.3 RBC-3.18* Hgb-9.0* Hct-26.3*
MCV-83 MCH-28.3 MCHC-34.3 RDW-19.7* Plt Ct-70*
[**2192-3-25**] 06:40AM BLOOD WBC-5.9 RBC-2.98* Hgb-8.4* Hct-25.1*
MCV-84 MCH-28.2 MCHC-33.4 RDW-20.7* Plt Ct-53*
[**2192-3-26**] 06:30AM BLOOD WBC-5.0 RBC-2.85* Hgb-8.1* Hct-24.6*
MCV-86 MCH-28.4 MCHC-32.9 RDW-22.0* Plt Ct-60*
[**2192-3-27**] 06:50AM BLOOD WBC-4.3 RBC-2.77* Hgb-8.1* Hct-23.8*
MCV-86 MCH-29.1 MCHC-33.9 RDW-22.2* Plt Ct-83*
[**2192-3-28**] 06:05AM BLOOD WBC-5.5 RBC-2.78* Hgb-8.3* Hct-24.8*
MCV-89 MCH-29.8 MCHC-33.4 RDW-23.2* Plt Ct-103*
[**2192-3-29**] 06:00AM BLOOD WBC-6.5 RBC-2.89* Hgb-8.5* Hct-26.5*
MCV-92 MCH-29.3 MCHC-32.1 RDW-23.7* Plt Ct-127*
[**2192-3-30**] 05:58AM BLOOD WBC-6.1 RBC-2.64* Hgb-7.8* Hct-24.5*
MCV-93 MCH-29.5 MCHC-31.7 RDW-24.5* Plt Ct-126*
[**2192-3-31**] 06:00AM BLOOD WBC-5.9 RBC-2.68* Hgb-8.0* Hct-26.3*
MCV-98 MCH-29.6 MCHC-30.3* RDW-24.7* Plt Ct-128*
[**2192-4-1**] 05:15AM BLOOD WBC-6.3 RBC-2.80* Hgb-8.5* Hct-27.8*
MCV-99* MCH-30.4 MCHC-30.6* RDW-24.8* Plt Ct-118*
[**2192-4-2**] 05:35AM BLOOD WBC-6.5 RBC-2.81* Hgb-8.3* Hct-27.7*
MCV-99* MCH-29.6 MCHC-30.0* RDW-24.8* Plt Ct-106*
[**2192-4-3**] 05:30AM BLOOD WBC-4.2 RBC-2.71* Hgb-8.2* Hct-27.1*
MCV-100* MCH-30.2 MCHC-30.3* RDW-24.5* Plt Ct-91*
[**2192-4-4**] 05:20AM BLOOD WBC-3.8* RBC-2.71* Hgb-8.2* Hct-26.8*
MCV-99* MCH-30.1 MCHC-30.4* RDW-24.3* Plt Ct-81*
[**2192-4-27**] 05:15AM BLOOD WBC-5.4 RBC-2.66* Hgb-8.4* Hct-27.4*
MCV-103* MCH-31.6 MCHC-30.7* RDW-20.4* Plt Ct-80*
[**2192-4-28**] 06:27AM BLOOD WBC-4.8 RBC-2.51* Hgb-8.1* Hct-26.6*
MCV-106* MCH-32.2* MCHC-30.4* RDW-20.2* Plt Ct-62*
[**2192-5-3**] 06:30AM BLOOD WBC-6.0 RBC-2.12* Hgb-6.6* Hct-21.6*
MCV-102* MCH-30.9 MCHC-30.3* RDW-19.8* Plt Ct-63*
[**2192-5-4**] 04:49PM BLOOD WBC-6.1 RBC-2.50* Hgb-8.1* Hct-25.4*
MCV-101* MCH-32.2* MCHC-31.8 RDW-21.1* Plt Ct-63*
[**2192-5-7**] 05:55AM BLOOD WBC-5.0 RBC-1.97* Hgb-6.3* Hct-20.0*
MCV-102* MCH-32.0 MCHC-31.5 RDW-20.8* Plt Ct-49*
[**2192-5-8**] 02:59AM BLOOD WBC-5.1 RBC-2.77* Hgb-8.8* Hct-28.0*
MCV-101* MCH-31.8 MCHC-31.4# RDW-21.0* Plt Ct-44*
[**2192-5-13**] 06:00AM BLOOD WBC-7.3 RBC-2.78* Hgb-9.0* Hct-28.1*
MCV-101* MCH-32.4* MCHC-32.0 RDW-21.0* Plt Ct-27*
[**2192-5-16**] 05:20AM BLOOD WBC-3.9* RBC-2.32* Hgb-7.6* Hct-23.6*
MCV-102* MCH-32.8* MCHC-32.3 RDW-21.5* Plt Ct-33*
[**2192-5-20**] 06:00AM BLOOD WBC-4.7 Hct-25.5* Plt Ct-39*
[**2192-5-21**] 05:09AM BLOOD WBC-4.5 RBC-2.48* Hgb-8.4* Hct-26.2*
MCV-106* MCH-33.8* MCHC-32.1 RDW-22.3* Plt Ct-36*
[**2192-5-22**] 05:25AM BLOOD WBC-4.2 RBC-2.31* Hgb-7.9* Hct-23.9*
MCV-103* MCH-34.0* MCHC-32.9 RDW-22.2* Plt Ct-36*
[**2192-5-24**] 05:21AM BLOOD WBC-3.8* RBC-2.28* Hgb-7.9* Hct-23.7*
MCV-104* MCH-34.6* MCHC-33.3 RDW-22.6* Plt Ct-37*
[**2192-5-25**] 04:38AM BLOOD WBC-4.6 RBC-2.33* Hgb-7.7* Hct-24.4*
MCV-105* MCH-33.0* MCHC-31.7 RDW-22.5* Plt Ct-38*
[**2192-5-26**] 06:33AM BLOOD WBC-4.4 RBC-2.28* Hgb-8.0* Hct-23.7*
MCV-104* MCH-35.0* MCHC-33.7 RDW-22.5* Plt Ct-40*
[**2192-5-27**] 05:09AM BLOOD WBC-3.5* RBC-2.23* Hgb-7.7* Hct-23.5*
MCV-106* MCH-34.6* MCHC-32.7 RDW-22.4* Plt Ct-44*
[**2192-5-28**] 06:49AM BLOOD WBC-2.8* RBC-2.21* Hgb-7.8* Hct-23.0*
MCV-104* MCH-35.3* MCHC-33.9 RDW-22.6* Plt Ct-45*
[**2192-3-16**] 05:05AM BLOOD PT-14.6* PTT-32.4 INR(PT)-1.4*
[**2192-3-17**] 07:40PM BLOOD PT-14.3* PTT-34.2 INR(PT)-1.3*
[**2192-3-20**] 06:20AM BLOOD PT-16.6* PTT-36.2 INR(PT)-1.6*
[**2192-3-29**] 06:00AM BLOOD PT-17.4* PTT-41.8* INR(PT)-1.6*
[**2192-3-30**] 05:58AM BLOOD PT-20.7* PTT-43.8* INR(PT)-2.0*
[**2192-4-1**] 05:15AM BLOOD PT-23.4* PTT-66.6* INR(PT)-2.2*
[**2192-4-6**] 05:30AM BLOOD PT-21.2* PTT-45.4* INR(PT)-2.0*
[**2192-4-8**] 05:40AM BLOOD PT-19.7* PTT-44.2* INR(PT)-1.9*
[**2192-4-20**] 05:40AM BLOOD PT-18.8* PTT-36.5 INR(PT)-1.8*
[**2192-4-22**] 05:50AM BLOOD PT-17.9* PTT-34.1 INR(PT)-1.7*
[**2192-4-30**] 05:45AM BLOOD PT-22.1* PTT-51.4* INR(PT)-2.1*
[**2192-5-3**] 06:30AM BLOOD PT-25.9* PTT-45.0* INR(PT)-2.5*
[**2192-5-4**] 06:21AM BLOOD PT-27.3* PTT-53.5* INR(PT)-2.6*
[**2192-5-8**] 02:59AM BLOOD PT-31.8* INR(PT)-3.1*
[**2192-5-9**] 02:25PM BLOOD PT-35.5* PTT-59.9* INR(PT)-3.5*
[**2192-5-9**] 05:44PM BLOOD PT-36.6* PTT-59.9* INR(PT)-3.6*
[**2192-5-10**] 03:57AM BLOOD PT-35.2* PTT-54.6* INR(PT)-3.4*
[**2192-5-21**] 05:09AM BLOOD Plt Ct-36*
[**2192-5-22**] 05:25AM BLOOD PT-28.8* PTT-51.8* INR(PT)-2.8*
[**2192-5-25**] 04:38AM BLOOD PT-27.1* PTT-45.2* INR(PT)-2.6*
[**2192-5-27**] 05:09AM BLOOD PT-26.0* PTT-45.0* INR(PT)-2.5*
[**2192-5-28**] 06:49AM BLOOD PT-25.4* PTT-44.7* INR(PT)-2.4*
[**2192-3-16**] 05:05AM BLOOD Glucose-135* UreaN-19 Creat-1.1 Na-132*
K-4.6 Cl-99 HCO3-27 AnGap-11
[**2192-3-17**] 07:40PM BLOOD Glucose-100 UreaN-21* Creat-1.1 Na-128*
K-5.6* Cl-95* HCO3-24 AnGap-15
[**2192-3-18**] 07:05AM BLOOD Glucose-78 UreaN-24* Creat-1.2* Na-131*
K-5.1 Cl-98 HCO3-24 AnGap-14
[**2192-3-18**] 10:57AM BLOOD Glucose-87 UreaN-22* Creat-1.2* Na-135
K-5.2* Cl-100 HCO3-26 AnGap-14
[**2192-3-19**] 06:25AM BLOOD Glucose-269* UreaN-22* Creat-1.1 Na-131*
K-4.7 Cl-102 HCO3-19* AnGap-15
[**2192-3-19**] 05:00PM BLOOD Glucose-247* UreaN-20 Creat-1.0 Na-134
K-3.9 Cl-105 HCO3-20* AnGap-13
[**2192-3-20**] 06:20AM BLOOD Glucose-158* UreaN-20 Creat-0.9 Na-135
K-3.5 Cl-102 HCO3-26 AnGap-11
[**2192-3-21**] 05:15AM BLOOD Glucose-179* UreaN-20 Creat-0.8 Na-134
K-3.9 Cl-103 HCO3-24 AnGap-11
[**2192-3-24**] 06:50AM BLOOD Glucose-162* UreaN-19 Creat-0.6 Na-129*
K-4.4 Cl-100 HCO3-25 AnGap-8
[**2192-3-26**] 06:30AM BLOOD Glucose-156* UreaN-16 Creat-0.8 Na-131*
K-4.9 Cl-99 HCO3-26 AnGap-11
[**2192-3-28**] 06:05AM BLOOD Glucose-245* UreaN-25* Creat-1.5* Na-130*
K-5.2* Cl-98 HCO3-24 AnGap-13
[**2192-3-29**] 06:00AM BLOOD Glucose-176* UreaN-29* Creat-1.8* Na-130*
K-5.4* Cl-96 HCO3-27 AnGap-12
[**2192-3-29**] 03:30PM BLOOD UreaN-29* Creat-1.9* Na-133 K-5.4* Cl-99
HCO3-26 AnGap-13
[**2192-4-4**] 05:20AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-131*
K-4.1 Cl-101 HCO3-24 AnGap-10
[**2192-4-6**] 05:30AM BLOOD Glucose-133* UreaN-12 Creat-0.7 Na-131*
K-4.4 Cl-100 HCO3-25 AnGap-10
[**2192-4-9**] 05:40AM BLOOD Glucose-67* UreaN-12 Creat-0.8 Na-132*
K-4.2 Cl-99 HCO3-26 AnGap-11
[**2192-4-10**] 05:45AM BLOOD Glucose-240* UreaN-10 Creat-0.7 Na-127*
K-4.9 Cl-96 HCO3-26 AnGap-10
[**2192-4-13**] 05:40AM BLOOD Glucose-234* UreaN-14 Creat-0.7 Na-127*
K-5.3* Cl-95* HCO3-25 AnGap-12
[**2192-4-14**] 05:45AM BLOOD Glucose-218* UreaN-16 Creat-0.8 Na-127*
K-5.3* Cl-95* HCO3-26 AnGap-11
[**2192-4-27**] 05:15AM BLOOD Glucose-274* UreaN-39* Creat-0.9 Na-129*
K-4.2 Cl-93* HCO3-30 AnGap-10
[**2192-4-28**] 06:27AM BLOOD Glucose-181* UreaN-40* Creat-0.8 Na-130*
K-4.3 Cl-94* HCO3-30 AnGap-10
[**2192-4-30**] 05:45AM BLOOD Glucose-152* UreaN-47* Creat-1.0 Na-127*
K-5.3* Cl-93* HCO3-28 AnGap-11
[**2192-5-3**] 06:30AM BLOOD Glucose-217* UreaN-70* Creat-1.5* Na-125*
K-5.1 Cl-88* HCO3-27 AnGap-15
[**2192-5-5**] 05:15AM BLOOD Glucose-164* UreaN-90* Creat-1.9* Na-126*
K-4.6 Cl-88* HCO3-28 AnGap-15
[**2192-5-5**] 05:15PM BLOOD Glucose-98 UreaN-95* Creat-2.0* Na-128*
K-4.6 Cl-88* HCO3-25 AnGap-20
[**2192-5-6**] 04:55AM BLOOD Glucose-209* UreaN-100* Creat-2.1*
Na-123* K-5.3* Cl-86* HCO3-23 AnGap-19
[**2192-5-7**] 05:55AM BLOOD Glucose-193* UreaN-113* Creat-2.5*
Na-123* K-5.7* Cl-84* HCO3-20* AnGap-25*
[**2192-5-7**] 05:48PM BLOOD Glucose-669* UreaN-102* Creat-2.4*
Na-110* K-4.1 Cl-73* HCO3-17* AnGap-24*
[**2192-5-7**] 07:15PM BLOOD Glucose-171* UreaN-117* Creat-2.5*
Na-127* K-4.8 Cl-86* HCO3-19* AnGap-27*
[**2192-5-8**] 02:59AM BLOOD Glucose-150* UreaN-118* Creat-2.7*
Na-125* K-5.2* Cl-87* HCO3-18* AnGap-25*
[**2192-5-8**] 04:01PM BLOOD Glucose-125* UreaN-117* Creat-2.6*
Na-124* K-5.9* Cl-89* HCO3-22 AnGap-19
[**2192-5-9**] 02:07AM BLOOD Glucose-90 UreaN-117* Creat-2.4* Na-128*
K-5.5* Cl-89* HCO3-21* AnGap-24*
[**2192-5-9**] 02:25PM BLOOD Glucose-147* UreaN-110* Creat-2.0*
Na-130* K-5.2* Cl-90* HCO3-22 AnGap-23*
[**2192-5-9**] 05:44PM BLOOD Glucose-170* UreaN-109* Creat-1.8*
Na-131* K-5.3* Cl-90* HCO3-23 AnGap-23*
[**2192-5-10**] 03:57AM BLOOD Glucose-228* UreaN-103* Creat-1.4* Na-137
K-4.4 Cl-96 HCO3-25 AnGap-20
[**2192-5-10**] 02:04PM BLOOD Glucose-214* UreaN-77* Creat-0.8 Na-138
K-3.3 Cl-101 HCO3-23 AnGap-17
[**2192-5-21**] 05:09AM BLOOD Glucose-88 UreaN-42* Creat-0.3* Na-133
K-5.5* Cl-96 HCO3-29 AnGap-14
[**2192-5-21**] 02:15PM BLOOD Glucose-79 UreaN-41* Creat-0.4 Na-133
K-5.0 Cl-95* HCO3-29 AnGap-14
[**2192-5-25**] 04:38AM BLOOD Glucose-114* UreaN-37* Creat-0.7 Na-129*
K-5.1 Cl-91* HCO3-26 AnGap-17
[**2192-5-26**] 06:33AM BLOOD Glucose-92 UreaN-38* Creat-0.7 Na-126*
K-5.0 Cl-90* HCO3-25 AnGap-16
[**2192-5-27**] 05:09AM BLOOD Glucose-117* UreaN-40* Creat-0.9 Na-129*
K-5.1 Cl-92* HCO3-25 AnGap-17
[**2192-5-28**] 06:49AM BLOOD Glucose-84 UreaN-40* Creat-0.8 Na-125*
K-5.0 Cl-89* HCO3-27 AnGap-14
[**2192-3-16**] 05:05AM BLOOD ALT-34 AST-69* LD(LDH)-141 AlkPhos-168*
TotBili-1.6*
[**2192-3-17**] 07:40PM BLOOD ALT-40 AST-97* CK(CPK)-31 AlkPhos-191*
TotBili-2.1*
[**2192-3-18**] 07:05AM BLOOD ALT-40 AST-88* AlkPhos-180* TotBili-2.1*
[**2192-3-19**] 06:25AM BLOOD ALT-26 AST-63* LD(LDH)-210 AlkPhos-139*
TotBili-2.3*
[**2192-3-20**] 06:20AM BLOOD ALT-18 AST-39 LD(LDH)-165 AlkPhos-115*
TotBili-5.8*
[**2192-3-21**] 05:15AM BLOOD ALT-20 AST-41* LD(LDH)-153 AlkPhos-117*
TotBili-2.9*
[**2192-3-22**] 06:35AM BLOOD ALT-17 AST-38 LD(LDH)-144 AlkPhos-135*
TotBili-2.8*
[**2192-3-23**] 06:30AM BLOOD ALT-15 AST-31 LD(LDH)-129 AlkPhos-114*
TotBili-5.0*
[**2192-3-24**] 06:50AM BLOOD ALT-16 AST-38 LD(LDH)-139 AlkPhos-131*
TotBili-4.9*
[**2192-3-25**] 06:40AM BLOOD ALT-14 AST-34 LD(LDH)-143 AlkPhos-109*
TotBili-6.2* DirBili-2.5* IndBili-3.7
[**2192-3-26**] 06:30AM BLOOD ALT-13 AST-34 LD(LDH)-125 AlkPhos-110*
TotBili-6.6*
[**2192-3-27**] 06:50AM BLOOD ALT-11 AST-32 LD(LDH)-142 AlkPhos-110*
TotBili-7.3*
[**2192-3-28**] 06:05AM BLOOD ALT-14 AST-36 LD(LDH)-178 AlkPhos-129*
TotBili-7.2*
[**2192-3-30**] 05:58AM BLOOD ALT-9 AST-34 LD(LDH)-174 AlkPhos-90
TotBili-8.6*
[**2192-3-31**] 06:00AM BLOOD ALT-15 AST-55* LD(LDH)-221 AlkPhos-108*
TotBili-8.9*
[**2192-4-1**] 05:15AM BLOOD ALT-17 AST-66* AlkPhos-111* TotBili-9.1*
[**2192-4-2**] 05:35AM BLOOD ALT-16 AST-54* LD(LDH)-187 AlkPhos-115*
TotBili-8.2*
[**2192-4-3**] 05:30AM BLOOD ALT-15 AST-48* LD(LDH)-199 AlkPhos-118*
TotBili-7.5*
[**2192-4-4**] 05:20AM BLOOD ALT-13 AST-44* LD(LDH)-201 AlkPhos-129*
TotBili-7.0*
[**2192-4-5**] 05:15AM BLOOD ALT-15 AST-44* LD(LDH)-217 AlkPhos-143*
TotBili-6.5*
[**2192-4-6**] 05:30AM BLOOD ALT-15 AST-41* LD(LDH)-210 AlkPhos-141*
TotBili-5.8*
[**2192-4-7**] 06:13AM BLOOD ALT-12 AST-45* LD(LDH)-202 AlkPhos-156*
TotBili-5.7*
[**2192-4-8**] 05:40AM BLOOD ALT-17 AST-44* AlkPhos-162* TotBili-5.4*
[**2192-4-9**] 05:40AM BLOOD ALT-15 AST-38 LD(LDH)-214 AlkPhos-162*
TotBili-4.7*
[**2192-4-10**] 05:45AM BLOOD ALT-15 AST-39 LD(LDH)-242 AlkPhos-193*
TotBili-4.7*
[**2192-4-11**] 05:33AM BLOOD ALT-15 AST-41* LD(LDH)-204 AlkPhos-168*
TotBili-4.7*
[**2192-4-15**] 04:45AM BLOOD ALT-18 AST-48* AlkPhos-195* TotBili-4.4*
[**2192-4-17**] 05:48AM BLOOD ALT-22 AST-58* AlkPhos-198* TotBili-4.5*
[**2192-4-18**] 05:44AM BLOOD ALT-21 AST-66* AlkPhos-179* TotBili-4.4*
[**2192-4-19**] 06:06AM BLOOD ALT-23 AST-81* AlkPhos-212* TotBili-4.1*
[**2192-4-20**] 05:40AM BLOOD ALT-21 AST-70* AlkPhos-209* TotBili-3.8*
[**2192-4-21**] 05:50AM BLOOD ALT-26 AST-79* AlkPhos-247* TotBili-4.1*
[**2192-4-30**] 05:45AM BLOOD ALT-44* AST-134* AlkPhos-247*
TotBili-3.8*
[**2192-5-3**] 06:30AM BLOOD ALT-83* AST-235* AlkPhos-198*
TotBili-4.7*
[**2192-5-9**] 02:07AM BLOOD ALT-34 AST-101* AlkPhos-100 TotBili-14.0*
[**2192-5-9**] 02:25PM BLOOD ALT-30 AST-96* LD(LDH)-281* AlkPhos-88
TotBili-13.4*
[**2192-5-9**] 05:44PM BLOOD ALT-32 AST-100* LD(LDH)-298* AlkPhos-90
TotBili-13.8*
[**2192-5-10**] 03:57AM BLOOD ALT-32 AST-99* AlkPhos-99 TotBili-15.4*
[**2192-5-11**] 02:22AM BLOOD ALT-28 AST-85* AlkPhos-86 TotBili-15.6*
[**2192-5-12**] 05:00AM BLOOD ALT-27 AST-76* LD(LDH)-186 AlkPhos-90
TotBili-16.8*
[**2192-5-13**] 06:00AM BLOOD ALT-32 AST-86* LD(LDH)-264* AlkPhos-102
TotBili-23.7*
[**2192-5-14**] 03:40AM BLOOD ALT-34 AST-102* LD(LDH)-232 CK(CPK)-22*
AlkPhos-106* TotBili-25.9* DirBili-15.8* IndBili-10.1
[**2192-5-15**] 04:08AM BLOOD ALT-35 AST-116* LD(LDH)-264* AlkPhos-97
TotBili-27.0*
[**2192-5-16**] 05:20AM BLOOD ALT-28 AST-89* AlkPhos-78 TotBili-26.2*
[**2192-5-17**] 06:00AM BLOOD ALT-25 AST-79* AlkPhos-103 TotBili-25.4*
[**2192-5-18**] 05:19AM BLOOD ALT-27 AST-82* AlkPhos-111* TotBili-27.6*
[**2192-5-19**] 05:00AM BLOOD ALT-28 AST-89* LD(LDH)-250 AlkPhos-117*
TotBili-27.7*
[**2192-5-20**] 06:00AM BLOOD ALT-30 AST-100* AlkPhos-131*
TotBili-29.7*
[**2192-5-21**] 05:09AM BLOOD ALT-33 AST-118* AlkPhos-137*
TotBili-30.4*
[**2192-5-22**] 05:25AM BLOOD ALT-27 AST-92* LD(LDH)-251* AlkPhos-121*
TotBili-28.5*
[**2192-5-23**] 05:11AM BLOOD ALT-28 AST-97* AlkPhos-140* TotBili-29.6*
[**2192-5-24**] 05:21AM BLOOD ALT-33 AST-102* AlkPhos-156*
TotBili-31.3*
[**2192-5-25**] 04:38AM BLOOD ALT-35 AST-107* LD(LDH)-276* AlkPhos-168*
TotBili-33.4*
[**2192-5-26**] 06:33AM BLOOD ALT-40 AST-107* AlkPhos-191*
TotBili-33.8*
[**2192-5-27**] 05:09AM BLOOD ALT-37 AST-106* AlkPhos-184*
TotBili-36.3*
[**2192-5-28**] 06:49AM BLOOD ALT-40 AST-102* AlkPhos-194*
TotBili-34.2*
[**2192-5-9**] 02:20PM BLOOD calTIBC-113* Ferritn-244* TRF-87*
[**2192-3-25**] 06:40AM BLOOD Hapto-33
[**2192-5-9**] 02:20PM BLOOD Triglyc-53 HDL-4 CHOL/HD-6.8 LDLcalc-12
LDLmeas-<50
[**2192-5-9**] 02:20PM BLOOD 25VitD-11*
[**2192-3-29**] 06:00AM BLOOD Cortsol-8.9
[**2192-5-9**] 02:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2192-5-9**] 02:20PM BLOOD AMA-NEGATIVE
[**2192-5-9**] 02:20PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2192-5-9**] 02:20PM BLOOD CEA-5.6* AFP-3.2
[**2192-5-9**] 02:20PM BLOOD IgG-1443 IgA-368
[**2192-4-1**] 03:20PM BLOOD C3-51* C4-12
[**2192-5-18**] 05:19AM BLOOD Vanco-22.6*
[**2192-5-11**] 08:50AM BLOOD Vanco-12.2
[**2192-3-20**] 06:20AM BLOOD Phenyto-<0.6*
[**2192-5-9**] 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-5-9**] 02:20PM BLOOD HCV Ab-POSITIVE*
[**2192-3-30**] 12:42AM BLOOD Lactate-2.7* Na-131* K-4.8 Cl-97
[**2192-3-31**] 07:04AM BLOOD Lactate-2.9*
[**2192-5-7**] 10:04AM BLOOD Lactate-4.6* Na-121* K-4.8
[**2192-5-8**] 04:49PM BLOOD Lactate-2.1*
[**2192-5-15**] 01:30PM BLOOD Lactate-1.8
[**2192-5-9**] 02:20PM BLOOD CA [**99**]-9 -Test
[**2192-5-9**] 02:20PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2192-5-9**] 02:20PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test
Microbiology:
[**2192-3-18**] 10:58 am URINE Source: Catheter.
**FINAL REPORT [**2192-3-20**]**
URINE CULTURE (Final [**2192-3-20**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2192-3-24**] 12:50 pm URINE Source: Catheter.
**FINAL REPORT [**2192-3-26**]**
URINE CULTURE (Final [**2192-3-26**]):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 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-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2192-5-9**] 2:26 pm URINE Source: Catheter.
**FINAL REPORT [**2192-5-13**]**
URINE CULTURE (Final [**2192-5-13**]):
[**Female First Name (un) **] (TORULOPSIS) GLABRATA. 10,000-100,000
ORGANISMS/ML..
SPECIATION REQUESTED BY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 91204**].
CT Abd [**4-8**]
IMPRESSION:
1. Rapidly enlarging abdominal ascites accounts for abdominal
distention. No bowel obstruction.
2. Cirrhosis with two known lesions in the dome and segment
III, both status post CyberKnife treatment. No definite new
lesion on this single phase study but assessment is limited.
3. Cirrhosis, splenomegaly, and large effusion with likely
varices,
consistent with portal hypertension.
4. Splenic cyst and bilateral renal cysts.
5. Known pancreatic cystic lesions seen on prior MR [**First Name (Titles) **] [**Last Name (Titles) 91205**]
on current exam.
6. Enhancing right renal nodule, characterized on prior MR as
concerning for pheochromocytoma.resolution to exclude neoplasm.
7. Tree-in-[**Male First Name (un) 239**] appearing nodular opacity in the right lung
base, suggestive of infection or inflammation but should be
followed to 8. Multilevel thoracolumbar wedge compression
fractures involving T12-4, new lesions at T12, L1, and L3. Wedge
compressions in L2 and 4 are stable as compared to [**Month (only) 956**]
[**2192**]. 4 mm retropulsion at T12.
TTE [**2192-5-12**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The estimated cardiac index is normal (>=2.5L/min/m2).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular cavity is
mildly dilated with normal free wall contractility. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation.] The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are structurally normal.
Mild (1+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is borderline 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 no pericardial
effusion.
IMPRESSION: Right ventricular cavity dilation with preserved
systolic function. Normal left ventricular cavity size with
preserved global systolic function. Moderate to severe tricuspid
regurgitation. At least borderline pulmonary artery systolic
hypertension.
Abdominal U/S [**5-14**]
IMPRESSION:
1. Very slow flow in the portal veins without definite evidence
of thrombus. If clinical concern for thrombus persists, a
multiphase CT may be performed.
2. Sludge-filled gallbladder.
MRI Abd [**2192-5-15**]
IMPRESSION:
1. Cirrhosis with large volume intra-abdominal ascites, and
splenomegaly. The portal vein is patent.
2. Previously described lesions consistent with HCC which have
undergone
previous CyberKnife are not delineated on this examination due
to
non-breathhold technique and sub-optimal contrast bolus. If
these need to be further evaluated immediately then a
multiphasic CT of the liver should be performed.
Brief Hospital Course:
Primary Reason for Hospitalization:
64yo lady, Hindi/Urdu-speaking only, with h/o Hep C cirrhosis
c/b ascites, encephalopathy, varices, HCC undergoing Cyberknife,
recently hospitalized for L2-L4 vertebral fractures readmitted
for L hip fracture
Active Issues:
# L hip fracture: Pt underwent open reduction and intramedullary
nail fixation
for her left femur fracture on [**2192-3-18**]. She tolerated the
procedure well, although pain control was a significant issue
post-operatively. Initially pain was controlled with PO
oxycodone, however she had nausea/vomiting and AMS. Also
developed poor GI motility (see below). Narcotics were
discontinued and her pain was managed with tylenol and tramadol.
She was started on calcium and vitamin D, and calcitonin.
There was some concern whether her recent fractures (vertebral
body fractures and now femur fracture) could be pathologic
fractures [**2-16**] progression of her HCC, however she had a bone
scan which showed no uptake at areas other than her fractures so
this was felt unlikely. She received daily physical therapy and
her mobility improved, especially with a rolling walker. She
should f/u with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] four weeks after discharge.
# N/V, Abdominal Distension: Patient had intermittent
nausea/vomiting and abdominal distension during her
hospitalization. She continued to have regular BMs on lactulose
so ileus and SBO were felt unlikely. Thought most likely due to
a combination of ascites and slow GI motility [**2-16**] narcotic pain
medications. Narcotic pain medications were discontinued, and
an NG tube was placed to suction to decompress the stomach. She
had a CT scan of her abdomen which showed large volume ascites.
She had IR-guided therapeutic paracenteses on [**4-8**] and and [**4-17**]
and her abdominal distension improved. Diuretics were uptitrated
on [**5-18**] which produced adequate diuresis to prevent frequent
[**Doctor First Name 4397**]. She also had bedside paracentesis on [**5-22**] with 6L tap with
improvement in distention and pain. She had a dobhoff tube
placed and remained on tube feeds for the majority of her
hospitalization, removed upon discharge due to her ability to
tolerate a normal diet without abdominal discomfort or
nausea/vomiting.
# HCC: Pt had two focal HCC lesions. Not a good candidate for
RFA or TACE given her impaired liver function, had been
evaluated by rad/onc prior to admission for CyberKnife therapy.
Given her frequent hospitalizations, it was decided to proceed
with CyberKnife in the inpatient setting. She completed 6
treatments.
# ARF with oliguria: Early in hospital course, creatinine
increased from 0.6 to 1.9 while urine output decreased to
10-15cc/hr. Thought most likely due to poor renal perfusion [**2-16**]
cirrhosis and hypervolemia. She was fluid repleted with IV 5%
albumin and her renal failure resolved. However, at HD44,
creatinine began to rise again. There was concern for HRS, and
patient was treated with albumin for intravascular repletion.
Renal ultrasound was unmarkable. She developed increasing
somnolence, hypotension and anuria requiring transfer to ICU for
monitoring. The cause of her [**Last Name (un) **] during this ICU stay was
thought to be pre-renal and from her sepsis physiology. She
improved with IV fluids and her creatine returned to baseline.
She was transferred back to the floor and her creatinine
remained stable. HRS was not thought to be the cause of her
elevated creatinine as she improved rapidly with IV fluids and
albumin.
#Altered mental status: On [**5-7**], she was found to be obtunded
and minimally responsive on the floor. She was transferred to
the ICU where she was started on broad spectrum antibiotics and
given aggressive doses of lactulose. Her MS subsequently
improved. She was continued on fluconazole/vanc/meropenem for a
7 day course, the source of her presumed infection was not
clearly identified. After her antibitoics were discontinued,
her MS again slowly deteriorated and she was again transferred
to the ICU on [**5-14**] when she was found to be obtunded and there
was concern that she would be unable to protect her airway. On
[**5-16**] she returned to the floor and remained there in stable
condition with standing lactulose/rifaximin.
# UTIS: Developed Klebsiella UTI during hospitalization, treated
as complicated UTI due to indwelling foley catheter and treated
with 10 day course of ciprofloxacin. Later in hospital course
urine cultures grew E coli, and she was treated with 10 day
course of levofloxacin (levofloxacin used to cover for
concurrent pneumonia). This was followed by urine culture
positive for yeast, which was treated with fluconazole for 14
days. She then developed a UTI with presumed streptococcus,
which was treated with 7 days of levofloxacin.
# Vertebral compression fractures: Pt had L2-L4 lumbar fractures
(seen on imaging during previous hospitalization). Initially
concerning for pathologic fractures given known HCC, however
bone scan showed uptake at areas of fractures but no other areas
of uptake, which lowered suspicion for metastatic disease. She
continued to wear TLSO brace when OOB, and was continued on
calcium/Vitamin D and calcitonin. Pain was managed with
tylenol, lidoderm patch, and tramadol. Upon discharge, she was
ambulatory with assist and walker, working with PT daily.
# Orthostatic hypotension: Pt had significant orthostatic
hypotension post-operatively, also endorsed postural dizziness.
Felt most likely [**2-16**] hypovolemia given poor PO intake and
concurrent renal failure and decreased UO. She was fluid
repleted with IV 5% albumin. Her nadolol was discontinued and
she was started on midodrine, and her orthostasis improved.
# Liver Cirrhosis: Pt has cirrhosis due to h/o chronic HCV
genotype C, c/b ascites, encephalopathy and varices. Her
bilirubin continued to rise and upon discharge was ~30. Her MELD
scores were consistently near 30. Not eligible for transplant
(see below). Continued on lactulose/rifaximin upon discharge, as
well as lasix 40 [**Hospital1 **] and aldactone 100 [**Hospital1 **].
# Social: Since she is in this country illegally she is only
eligible for limited insurance, which would not provide for a
liver transplant. Family was looking into attempts to return the
patient to [**Country 9819**]/[**Country 11150**] for possible transplant evaluation
there. Social work and case management worked closely with the
family of the patient, particularly her son, who upon discharge
was her primary caretaker as she is not elligible for rehab/[**Hospital1 **]
placement due to her insurance/immigration status. She
unfortunately is also not eligible for services at home. Her
family ensured the staff that they would pay out of pocket for
24/7 home services, however as her son has vacation for 3 weeks
after discharge, he was not willing to initiate services until
he needs to return to work.
#DM: Blood sugars were often labile during hospitalization,
possibly [**2-16**] enteral feeding. [**Last Name (un) **] consult provided assistance
with adjustment of standing glargine and sliding scale. At the
time of discharge, FSBS were stable.
Medications on Admission:
Calcium + D qday
Vitamin D [**Numeric Identifier 1871**] 1/week x 8 weeks
Lasix 60 mg qday
Lantus 50U at bedtime
HISS
Lactulose 30 ml TID; titrate to [**3-18**] bm per day
Spironolactone 50 mg qday
Levothyroxine 125 mcg qday
Nadolol 40 mg qday
Omeprazole 20 mg qday
Rifaximin 550 mg [**Hospital1 **]
Tylenol prn
Clobetasol cream [**Hospital1 **]
Lidocaine patch 12 hrs on/12 hrs off
Calcitonin - 200U qday
Ultram 50 mg q4h prn pain
Discharge Medications:
1. equipment
One Ortho Nova Rolling "Rollator" Walker.
Disp #1
No refills.
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
6. spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. insulin glargine 100 unit/mL Solution Sig: 34 AM, 36 PM units
Subcutaneous twice a day: 34units qAM
36units qPM.
Disp:*2100 units* Refills:*2*
9. insulin regular human 100 unit/mL Solution Sig: see attached
sliding scale units Injection see attached sliding scale.
Disp:*1000 units* Refills:*2*
Discharge Disposition:
Home
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
End stage liver cirrhosis
Left hip fracture s/p ORIF on [**2192-3-18**]
Hepatocellular carcinoma status post cyberknife treatment
Acute renal failure
Toxic Metabolic encephalopathy
Hepatic encephalopathy
Sepsis from undetermined source
Urinary tract infection
Vertebral compression fractures
Chronic:
Diabetes Mellitus
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a left hip fracture and then suffered from
a prolonged hospital course of over 70 days due to many
complications from advanced end-stage liver disease. You
unfortunately are not a transplant candidate due to
insurance/citizenship reasons.
You are being discharged home in the care of your family.
Because you are are not elligble for full insurance due to your
immigration status, you are not eligible for free services at
this time.
You should have your family call your liver doctor with any
concerning signs or symptoms prior to initiating a transfer back
to the hospital. You are quite sick and we would like to
maximize the amount of time that you have at home with your
family.
You have been in the hospital for quite some time. We will
discharge you with prescriptions for all of your medications.
The prescriptions you leave with are your new medications from
this point forward; stop taking all old medications that you
have at home.
Followup Instructions:
Department: LIVER CENTER
When: FRIDAY [**2192-6-1**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2192-6-7**] at 2:10 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16163**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389, 5849, 2761, 5990, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4805
} | Medical Text: Admission Date: [**2110-7-31**] Discharge Date: [**2110-8-4**]
Date of Birth: [**2110-7-31**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is 4095 gram
former 38 week gestation female infant [**Known lastname **] to a 33 year-old
G3 P2 now 3 mother with prenatal screens unremarkable except
for GBS positive. No antepartum antibiotics. Mother's
pregnancy is notable for IDDM. The baby was [**Name2 (NI) **] by repeat C
section. Apgars were 7 and 8. She initially went to the
Newborn Nursery and was noted to have a low blood sugar of 28
at one to two hours of age with poor feeding. She was then
admitted to the Neonatal Intensive Care Unit for further
evaluation and management of hypoglycemia.
PHYSICAL EXAMINATION: Baby girl [**Known lastname **] is a nondysmorphic
infant with macrosomia. She was well saturated and perfused
in room air. No skin lesions. HEENT within normal limits.
Cardiovascular normal S1 and S2 with a 1 out of 6 systolic
ejection murmur at mid left sternal border. Lungs were
clear. Abdomen was benign. Normal female genitalia. Hips
were normal. Spine intact. Neurological examination was
nonfocal and age appropriate.
ASSESSMENT: Baby girl [**Known lastname **] is a term infant with
hypoglycemia and mild respiratory distress probably related
to maternal diabetes.
HOSPITAL COURSE: 1. Respiratory: [**Female First Name (un) **] initially had mild
respiratory distress with grunting, flaring and retraction,
which quickly resolved within two to three hours of arrival
in the Neonatal Intensive Care Unit. She remains on room air
throughout her Neonatal Intensive Care Unit stay, however,
she did have profound desaturations down to the 30s to 40s on
day of life one associated with apnea. The last episode was
on [**8-1**] in the evening and has not had any since then.
She has been maintaining this saturation on room air.
2. Cardiovascular: [**Female First Name (un) **] has been stable hemodynamically
throughout her Neonatal Intensive Care Unit course. Her
initial murmur has now resolved.
3. FEN: [**Female First Name (un) 51156**] initial blood glucose in the Neonatal
Intensive Care Unit was in the 40s to 60s. She was started
on D10W intravenous fluids at 60 cc per kilo per day, which
was quickly weaned given stable blood glucose. She has been
tolerating Enfamil 20 and breast milk 20 po ad lib at 80 cc
per kilogram per day minimum without any difficulties. Her
weight on admission was 4095 grams. Her weight on discharge
was 3970 grams.
4. Infectious disease: [**Female First Name (un) 51156**] initial CBC revealed a white
count of 10.6000 with 35 polys and 11 bands. Blood culture
was sent off and antibiotics were started given the left
shift. The antibiotics were discontinued at 48 hours when
blood cultures remained negative. Given the profound
desaturation at approximately 24 hours of life. An LP was
performed to rule out meningitis, which was negative.
5. Neurological: A neurological workup was pursued given
[**Female First Name (un) 51156**] profound desaturation at approximately 24 hours of
life. A head CT had revealed no bleeds and neurological
consult had recommended no electroencephalogram at this time.
6. Hematology: [**Female First Name (un) 51156**] initial hematocrit was 41.8 and
prior to discharge hematocrit remained stable at 40.8. Her
blood type is O negative, Coombs negative.
7. Audiology: Hearing screen was performed automated
auditory brain stem responses and [**Female First Name (un) **] passed both ears.
CONDITION ON DISCHARGE: [**Female First Name (un) **] has been stable on room air.
No desaturation for greater then 48 hours prior to discharge
tolerating po feeds well.
DISCHARGE DISPOSITION: [**Female First Name (un) **] is to be discharged to home
with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43579**], phone number
[**Telephone/Fax (1) 1142**].
CARE AND RECOMMENDATIONS: Feeds at discharge Enfamil 20 and
breast milk po ad lib. Medications, none. Car seat position
screening passed. State newborn screen sent. Immunizations
received hepatitis B on [**8-4**]. Follow up appointment
scheduled with Dr. [**Last Name (STitle) 43579**] on [**8-6**].
DISCHARGE DIAGNOSES:
1. Infant with diabetic mother.
2. Hypoglycemia.
3. Respiratory distress with apnea and desaturations.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Dictator Info 51157**]
MEDQUIST36
D: [**2110-8-4**] 12:01
T: [**2110-8-4**] 12:16
JOB#: [**Job Number 51158**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4806
} | Medical Text: Admission Date: [**2134-6-3**] Discharge Date: [**2134-6-8**]
Date of Birth: [**2052-1-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin / Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Subdural Hematoma found on OSH head CT
Major Surgical or Invasive Procedure:
Left Burr hole evacuation Subdural Hematoma
History of Present Illness:
82 year old male h/o HTN s/p fall 2.5 months ago with
dizziness and slight gait difficulties intermittently. He had a
head CT today and went to an OSH ER after it showed a large SDH.
Then the patient was transferred to [**Hospital1 18**]. He had a repeat head
CT here that was stable and was loaded with dilantin. He
currently has no dizziness, headache, numbness, or tingling. The
patient reports having some difficulty walking. He has no SOB or
chest pain. The patient is allergic to aspirin and does not take
any anticoagulation. Of note, he did have a GI bleed 3 years
ago.
Past Medical History:
Hypertension
Chronic Obstructive Pulmonary Disease
Bilateral lower extremity neuropathy
Upper GI bleed 3 years ago
lung CA s/p R lung lobectomy
Social History:
lives at home with his wife
has 90 pack year history of smoking but quit in [**2118**]
Drinks one shot of EtOH per day
No drug use
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM:
T:97.8 BP:128/59 HR:70 RR:17 O2Sats:95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 1+ edema bilaterally
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light. Visual fields
are
full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-10**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
[**2134-6-3**] 05:15PM GLUCOSE-95 UREA N-15 CREAT-0.8 SODIUM-143
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-28 ANION GAP-13
[**2134-6-3**] 05:15PM estGFR-Using this
[**2134-6-3**] 05:15PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.2
[**2134-6-3**] 04:24PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2134-6-3**] 04:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2134-6-3**] 04:10PM cTropnT-<0.01
[**2134-6-3**] 04:10PM WBC-8.0 RBC-4.97 HGB-14.8 HCT-44.4 MCV-89
MCH-29.8 MCHC-33.4 RDW-13.9
[**2134-6-3**] 04:10PM NEUTS-72* BANDS-2 LYMPHS-16* MONOS-8 EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2134-6-3**] 04:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2134-6-3**] 04:10PM PLT COUNT-239
[**2134-6-3**] 04:10PM PT-11.8 PTT-28.6 INR(PT)-1.0
[**2134-6-3**] EKG:Sinus rhythm with ventricular premature beats. Left
anterior fascicular block.
Low QRS voltage in the precordial leads. No previous tracing
available for
comparison.
Radiology
[**2134-6-3**] Noncontrast Head CT:There is a large extra-axial
collection overlying the left cerebral convexity. The collection
crosses the left frontoparietal suture line, measures 2.5 cm in
greatest axial dimension, and demonstrates low attenuation
consistent most consistent with a subacute- to- chronic subdural
hematoma. Note is made of increased attenuation of the
compressed adjacent dura. There is associated 9- mm right
midline shift as well as mass effect on the anterior [**Doctor Last Name 534**] of the
left lateral ventricle. There is no evidence of acute
hemorrhage. The ventricles and sulci are otherwise normal in
size and configuration. The visualized paranasal sinuses are
clear. No fracture is identified.
IMPRESSION: Large left frontoparietal subdural hematoma of
subacute-to-
chronic time course with associated right lateral shift and mass
effect on the left lateral ventricle.
[**2134-6-4**] Noncontrast Head CT:The patient is status post
evacuation of a large frontoparietal fluid collection, with a
transfrontal catheter ending in the cavity. Small amount of
fluid remains present, layering in the dependent portion of the
cavity. Associated 9 mm right midline shift remains present.
There is no evidence of acute hemorrhage. The ventricles and
sulci are otherwise normal in size and configuration. Moderatel
left maxillary mucosal thickening.
IMPRESSION:
1. Status post evacuation of subacute to chronic subdural
collection, with no evidence of new intracranial hemorrhage.
2. Persistent right lateral midline shift.
[**2134-6-5**] Noncontrast Head CT:Decreased size of post-evacuation
cavity over the left convexity; given attenuation differences in
the fluid over the convexity raises the possibility of a new
slow bleeding with layering - recommend follow up CT to assess.
[**2134-6-7**] Noncontrast Head CT: tatus post interval removal of the
left subdural drainage catheter. No gross interval change in
size of the left convexity subdural hematoma with associated
mass effect detailed above.
Brief Hospital Course:
Hospital Course
[**2134-6-3**]
large left Subdural Hematoma
- Admit for q 4 hour neuro checks
-Dilantin 1g loading dose,then 100mg TID
- SBP < 140
- Pre-op for burr holes
-Serial NC head CAT Scans
-Physical Therapy Consult
[**2134-6-4**]
To Operating Room for Left frontal and parietal burr holes for
evacuation of subdural hematoma.
[**2134-6-5**]
-Subdural drain for 48 hours
-IV Ancef
-advance diet as tolerated
[**2134-6-6**]
-Physical/Occupational Therapy Consult
[**2134-6-7**]
-D/C subdural drain today
-D/C foley catheter today
[**2134-6-8**]
-Discharged home with Services for Home Physical Therapy)
Medications on Admission:
Lasix
Lisinopril
Lumigan
Alphagan
Klor-con
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day) for 30 days.
Disp:*120 Capsule(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*0*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours:
PLEASE DO NOT DRIVE WHILE ON THIS MEDICATION.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after staples have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
1. Call Dr. [**Last Name (STitle) **] office to set up a time to have your sutures
removed in 1 week [**Telephone/Fax (1) **]
2.You will need to be seen in our office in 2 weeks with a CT
scan of the brain [**Telephone/Fax (1) **] with Dr [**First Name (STitle) **], please call for
appt.
3.Follow-up with your Primary Care Physician [**Last Name (NamePattern4) **] 1 week / your
PCP will follow your dilantin levels. You will only need to be
on this medication for seizure prevention for 30 days from a
neurosurgical standpoint.
Completed by:[**2134-6-25**]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4807
} | Medical Text: Admission Date: [**2152-12-10**] Discharge Date: [**2152-12-22**]
Date of Birth: [**2120-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 32 year-old man with a PMH of MR, CP and
seizures who presented with from his group home after a
seizures. This history is obtained from his parents and the
group
home as he has not been treated here before.
Per the group home, Mr. [**Known lastname **] has been in his USOH today, when he
was found unresponsive in the bathroom with his eyes closed. He
then had a couple of minutes of UE shaking and was given ativan
2
mg, after which his symptoms resolved. He was then transferred
here and had UE rhythmic shaking, for which he was given 2mg of
ativan. These movements resolved however he continued to have
intermittent jerking of either arm or leg lasting < 1 min and
was
given another 2 mg of ativan. He has since then had not had any
further jerking movements. I witnessed these movements prior to
the last dose of ativan and they resembled clonus. His group
home
attendant however stated that these movements were not the same
as what he had done at home. His father states that the
movements
resembled both his seizures and his clonus.
His parents tell me that Mr. [**Known lastname **] has had intermittent seizures
over the years starting at age 18. These are always GTC and are
often status. They are typically associated with a low Depakote
level and or infection. His last seizure was last year and he
has
them every 8-12 months. His mother is very concerned that he is
very sensitive to medications and is very easily overly sedated.
She tells me that he has been over medicated with ativan and
dilantin often with these presentations and during his last
admission was in the ICU unresponsive for 9 days after
aggressive
medication management.
I attempted to reach his OP Neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 81507**], to obtain more information and to inquire what
Depakote level is usually therapeutic for him. I was told that
the covering physician was Dr. [**Last Name (STitle) 81508**] [**Telephone/Fax (1) 81509**], however
per
his answering service, he is not covering. The answering service
paged another physician twice but this person never called back.
I am therefore unable to confirm his prior levels of Depakote of
further history.
Past Medical History:
- meconium aspiration at birth, with complicated delivery and
resuscitation
- hx of hydrocephalus, no shunt
- MR [**First Name (Titles) **] [**Last Name (Titles) **], baseline wheel chair bound but able to feed himself
and responds to verbal stimuli, but is non-verbal. requires
supervision at all times
- blind secondary to retinal artery detachments
- multiple surgeries for contracture
- Seizures, GTC with hx of status as described above
- Pica, has had hx of eating very toxic objects in the past
- strep meningitis 7-8 years ago
- eczema and allergic rhinitis
Social History:
-no etoh, tobacco or drugs
-lives in a group home, ([**Telephone/Fax (1) 81510**]) and the program
director's
number is [**Telephone/Fax (1) 81511**]
-parents are legal guardians: father [**Name (NI) 449**] [**Name (NI) **] [**Telephone/Fax (1) 81512**] and
mother [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 81513**]
Family History:
Non contributory
Physical Exam:
Vitals: T: 96.8 BP: 157/93 R: 16 -28 BP: 130-90's SaO2: 98% on
non-rebreather
General: unresponsive to verbal or tactile stimuli
HEENT: NC/AT
Neck: slightly restricted ROM in neck, no carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: unresponsive to verbal or tactile stimuli
CN
I: not tested
II,III: as bellow
III,IV,V: atrophied eyes w/ corneal opacification, no pupil
visualized
V: no nasal tickle or corneals
VII: face grossly symmetric
VIII: UA
IX,X: weak gag
[**Doctor First Name 81**]: UA
XII: UA
Motor: no movement to nox stim in any extremities, contracture
of
all limbs with wrists flexed and increased tone throughout, per
father this is his baseline appearance and tone
Reflex: sustained clonus bilaterally in LE
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 0 mute
R 2 2 2 2 0 mute
-Sensory: no withdrawal to nox stim in all extremities
-Coordination: na
-Gait: na
Pertinent Results:
EEG [**12-10**]
This is a relatively featureless EEG without evidence of
ongoing seizures. It is not clear whether the lack of voltage
gradient
represents a normal finding for this individual, or represents a
sign of
extensive brain dysfunction such that the cortical/subcortical
generators of background rhythm have been affected. Clinical
correlation is recommended.
CThead/CTA [**12-10**]
1. Normal appearance of the intracranial vessels.
2. [**Doctor Last Name **]/white matter differentiation is better seen than on the
[**2152-12-9**] non- contrast head CT. Small size of the sulci may
represent the patient's
baseline.
3. Findings suggestive of a Dandy-Walker variant. Enlargement of
the lateral and third ventricles.
CXR [**12-12**]
Unchanged bilateral pleural effusions and left lower lobe
atelectasis versus consolidation compared to examination of two
days prior. Findings compatible with aspiration.
Brief Hospital Course:
This is a 32M with cerebral palsy & mental retardation, seizure
disorder, unresponsive after apparent seizure event, also with
massive aspiration pneumonia, low urine output, hematuria,
anemia, relative thrombocytopenia, and intermittent bradycardia
with 4 second pauses, whose family is declining invasive
diagnostic or therapeutic measures. Pt is now awake and
responsive at his baseline, according to family and caretakers.
Mr [**Known lastname **] had a brief admission to the ICU unit for seizures. His
Depakote levels were optimized. Seizures were not captured on
his EEG. His hypoxia and pauses in his telemetry raised concern
for his ongoing issues with regards to sepsis, and his care was
kindly taken over by the medicine team. His parents were
informed on a daily basis.
HOSPITAL COURSE BY PROBLEMS:
.
# Hypoxia: Given the rapid time course of the development of
infiltrates and hypoxia, this is most likely secondary to
massive aspiration, though there may be a component of [**Known lastname **]. Pt
had been on Ceftriaxone and Vancomycin initially for empiric
treatment, and was switched to Levo/Flagyl given high likelihood
of aspiration pna. Pt had been largely afebrile throughout
admission. CHF is less likely, given minimal findings on CXR,
and limited response in hypoxia to trial of Lasix. Pt triggered
on night of [**12-13**], with desat to 89% on 50% face mask, improving
to upper 90s on 100% NRB. VBG on tranfer did not show severe
metabolic abnormality. Pt triggered on [**12-15**] for hypoxia to 87%
on 2L. O2 increased to 100% NRB after minimal response to
increasing O2 on NC, then 50% FM. Pt was asymptomatic throughout
this time. Pt initially failed several attempts to wean from
NRB, and was continued on this on the floor. As BIPAP is not
clinically indicated for [**Last Name (LF) **], [**First Name3 (LF) **], or aspiration PNA, pt would
likely not have progressed to BIPAP or MICU transfer if hypoxia
had worsens. Toward end of stay, pt weaned from
NRB->51%FM->31%FM->3L-> RA over days. Pt completed a 10-day+
total IV antibiotic course. PICC was removed prior to discharge.
.
# Sinus bradycardia: Pt had been having [**4-9**] second sinus pauses,
but was hemodynamically stable. Pt has no prior history of ACS,
and EKG on admission did not show any signs of ischemia. Pt has
not had any associated apneic episodes or correlation of
episodes with vagal stimuli. An unclear toxic/metabolic cause is
most likely. Pt's family did not want any further invasive
measures, e.g. pacer. VBG on transfer was wnl (family would
prefer that pt not have ABG performed.) HR remained largely
stable in 60-80s. Electrolytes were repleted as needed. Pt
continued to be hemodynamically stable on day of discharge.
.
# Altered mental status: Per familiy, pt is non-verbal at
baseline, though does respond to auditory stimuli. Pt has had a
long hx of blindness, CP, and MR, lives in a group home, and has
a low functional status per family. Bleed was ruled out by a
negative Head CT, and non-convulsive status was ruled out by
negative EEG. Pt was initially on the Neuro service for
management of the AMS. He was continued on Depakote (dose was
increased) and Keppra. Eventually, on day discharge, pt had
become more vocal and responsive, with frequent smiling and
eyelids staying open when spoken to. Per father, pt is back at
his baseline.
.
# Anemia: On admission, crit was 35. Pt's baseline crit is
unclear (no history in [**Name (NI) **].) Crit had been trending downwards
since admission. DDx for etiologies included dilution from
continuous IVF, hemolysis, DIC, bleed. So far, there have been
no signs of bleed. Pt has continued to be hemodynamically
stable. LDH is normal and smear shows absence of schistocytes.
Crits have been stable (24.4 on [**12-19**]), and guiaic negative x 1.
.
# Thrombocytopenia on admission: Etiology is unclear, as well as
baseline. Plt count improved now to upper 200s. Heparin sc was
requested to be d/c'ed per family to minimize sticks.
.
# Transaminitis: LFTs were mildly elevated on admission.
Etiology is unclear. LFTs at baseline are unknown. Tox screen
was negative. LFTS have now been trending down. Abdominal exam
has been benign, including no HSM.
.
# Elevated TSH: Pt had an elevated TSH on admission, but FT4 was
wnl. Levothyroxine started in ICU was subsequently discontinued.
Pt should f/u TSH as outpt.
.
# UTI: Pt has had several u/a's that show signs of infection but
urine cultures have shown NGTD. Urine is slightly bloody in
foley, but this was likely secondary to foley trauma (pt has
pica, and family requested that Mitts be applied to prevent
pulling, e.g. at lines.) Family is ok with foley removal
([**2155-12-10**]). Condom cath was placed per family request and was
discontinued before discharge.
.
# FEN: Purees thin liquids were recommended by initial speech
and swallow eval. Per Nutrition, intake has been fair/good.
Family plan to feed pt regular diet, and refused additional
speech/swallow eval prior to discharge.
.
# PPX: Heparin SC d/c'ed per family to minimize sticks,
Famotidine
.
# ACCESS: PICC placed inadvertantly prior to consent. After
discussion family, was ok with PICC. This was dicontinued on
[**12-21**].
.
# CONTACT: father [**Name (NI) 449**] [**Name (NI) **] [**Telephone/Fax (1) 81512**] and mother [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 81513**]
.
# CODE/Goals of Care: DNR/DNI, confirmed on multiple occasions
with family. Family has clearly stated their desire to avoid
aggressive interventions (including intubation, resuscitation,
pacemaker). Otherwise, they understand the severity of pt's
present pneumonia, and are hopeful that he will "pull through,"
but understand the risk that pt could expire from his current
illness. If so, they are interested in organ donation. Thus,
invasive procedures were avoided(e.g. ABGs, addl lines), but
continue with antibiotics and other medications.
.
# DISPO: Home today, as hypoxia has resolved and mental status
is back at baseline per father.
Medications on Admission:
- multivitamins PO QD
- valproic acid 750mg PO QAM and 500 mg PO QHS
- keppra 1250mg Qam and 1250mg PO QHS
- tylenol 325mg PRN
- erythromycing oint
- zyprexa 5 mg PO QHS
- alavert 10mg PO QD
- prilosec OTC 20mg PO QD
- docusate 100mg
- senna 8.6mg
- Benadryl 25mg PRN
- Nasonex [**Hospital1 **]
- milk of mg PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Fifteen
(15) ml PO Q12H (every 12 hours).
Disp:*900 ml* Refills:*2*
3. Levetiracetam 100 mg/mL Solution Sig: 12.5 ml PO Q 12H (Every
12 Hours).
Disp:*qs ml* Refills:*2*
4. Radiology
Please perform AP chest xray. Dx Aspiration Pneumonia. Please
fax results to Dr. [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) **] at fax #[**Telephone/Fax (1) 81514**]
Please call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 8454**] with any questions
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Alavert 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Docusate Sodium 100 mg Capsule Sig: [**1-5**] Capsules PO once a
day as needed for constipation.
9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
10. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal twice a day.
11. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) dose PO
once a day as needed for heartburn.
12. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration Pneumonia
Acute Lung Injury
Seizure
Secondary:
Mental Retardation
Cerebral Palsy
Discharge Condition:
Hemodynamically stable, with oxygen saturations of 95-100% on
room air. Bed bound, wheelchair dependent. Non-verbal, vocalizes
frequently.
Discharge Instructions:
You were admitted for after having a seizure in your group home.
.
If you experience any recurrence in seizures, fever, chills,
return to the ED.
Followup Instructions:
Please have a repeat chest xray in 6 weeks to evaluate your
lungs after the pneumonia has improved. This result will be
faxed to your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) **] (Fax: #[**Telephone/Fax (1) 81514**])
Completed by:[**2153-1-5**]
ICD9 Codes: 5070, 5990, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4808
} | Medical Text: Admission Date: [**2128-5-7**] Discharge Date: [**2128-5-10**]
Date of Birth: [**2044-9-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Chief Complaint: Respiratory Distress
Reason for MICU transfer: BIPAP
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 83 year old gentleman with a history of recent
shoulder fracture, afib (not on coumadin), HTN, esophageal
stricture, prostate cancer who is admitted from his rehab with
respiratory distress.
In brief, Mr. [**Known lastname 87081**] has experienced significant cognitive and
functional decline over the past 2 years after sustaining a
cervical fracture. Most recently he was admitted to an OSH in
[**Month (only) 116**] with a R. humerus fx. Admission was complicated by mental
status changes, pneumonia and a left sided pleural effusion. He
was treated with a 7 day course of ctx/azithromycin with good
clinical improvement. He was seen by s+s and was cleared for a
regular diet. An MRI head was unremarkable. He was followed by
ortho-hand and discharged in late [**Month (only) 116**] to [**Hospital3 2558**] rehab
where he had done well with clinical improvement alhtough his
mental status has waxed and waned.
Yesterday, the patient was noted to have a runny nose, loss of
appetite and he complained of abdominal pain. This morning the
patient was found slumped and tachypneic. EMS was called and
found the patient hypoxic on room air to the 60s. Vitals were
100/60 115 15 97.7 74% on 15L o2. CPAP was started en route w/
improvement in his saturations. At Coolige House, his last labs
on [**5-4**] were significant for WBC 5.2, hct 34.4 (diff N 58.6 L
23.6 M 12.9 E 4.0 B 1.2)
In the ED, pressures 110/60 from 85/67, 98/37 and the patient
was afebrile. he was initially unreponsive to sternal rub. Exam
was significant for rhoncherous bilateral breath sounds. Labs
demonstrated wbc 20.6, hct 43.4, plts 351, Cr 1.5 and trop
<0.01. A lactate was 6.9. A UA was positive for ketones and
few bacteria. He was started on bipap 100/60 with improvement
in his o2 to 100%. A CXR revealed a RLL opacity concerning for
pna. The patient was given 1g Vancomycin and cefepime was
ordered but not yet given. An albuterol neb was given w/ no
improvement. The wife and primary care were contact[**Name (NI) **] and
confirmed the patient has baseline severe dementia and unable to
make understandable speech and further both confirmed the
patient is DNR/I. A bedside ultrasound revealed no GB and
dilated loops of bowel and murphys sign was negative. After 1L
of NS the patient's blood pressure improved to the 110s/80s and
his mentation improved. Vitals on transfer were: 120 26 100% on
bipap 100/60 and rectal temp 98.8.
On arrival to the MICU, initial vitals were: 98.1 125 147/82
98% on BiPAP and RR 24. He appeared uncomfortable on the
non-invasive and was weaned to a non-rebreather. He was alert
and smiling and denied pain. He had course rhoncherous breath
sounds and bed-side suctioning reveaed dark brown secretions. An
NG tube was placed and 700cc of coffee ground fluid was
aspirated. The patients wife and a family member accompanied
the patient and indicated the patient was DNR/I and would not
like invasive or heroic measures including no blood
transfusions.
Review of systems: Unable to Obtain
Past Medical History:
PAST MEDICAL HISTORY:
?????? Hip fracture, intertrochanteric
?????? Atrial fibrillation
?????? Hypertension
?????? Vitamin D deficiency
?????? Hyperlipidemia LDL goal < 100
?????? Anemia
?????? Prostate cancer: '[**15**] psa>9 had bx (neg), and in '[**19**] again
climbing and urol was considering another bx late '[**19**] but then
psa declined again; regular f/u urol [**2121-10-8**]; 3rd bx had 1 of
5 cores CA - not felt needs 'ectomy nor bracytx - referred for
xrt at [**Last Name (un) 1724**] by urol; it is felt that this will remain
encapsulated and so unlikely to bring probs lifetime
?????? Esophageal stricture: Ring with recurent dilatations by egd,
last seen [**10-26**] and was advised prilosec 20 and call GI if gerd
sx/dysphagia but o/w just cont ppi [**2121-10-8**]; taking ppi, no sx
[**2122-10-13**] ;[**2123-12-27**]- egd with ring dilated , 5 cm hh and gastric
erosions on qd ppi-
?????? Actinic keratosis
?????? Cervical vertebral fracture: s/p hospitalization for fractures
C5,6,7 and right rib fractures d/t fall down stairs on
[**2126-6-8**]. He underwent decompression laminectomy with posterior
instrumentation to C4-T1 at the [**Hospital1 18**].
?????? Rib fracture
?????? Sciatica: MRI [**2-/2126**]: multilevel degenerative disk disease
with mild impingement of the nerve roots. No mets.
Past Surgical History:
1. Posterior laminotomy bilaterally at C3. [**2125**]
2. Cervical posterior laminectomy at C4, C5, C6, C7. [**2125**]
3. Hip Fracture
4. Shoulder Fracture [**3-/2128**] [**Hospital6 **]
Social History:
Lives with his wife of 15 years. Baseline dementia. Recognizes
only his wife. Extremely hard of hearing. Former painter. No
tobacco, etoh or illicits. No children.
Family History:
Did not obtain.
Physical Exam:
PHYSICAL EXAM ON ADMISSION TO MICU:
Vitals: 98.1 125 147/82 98% on BiPAP and RR 24
General: Somnolent, a+o x 0
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregular rate and rhythm, normal S1 + S2
Lungs: Rhoncherous transmitted BS, decreased BS on left lung
base w/ course BS, no wheeze
Abdomen: abdmonen distended and mildly tender to diffuse
palpation
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema no cyanosis
Neuro: CNII-XII grossly, unable to cooperate w/ exam
.
Pertinent Results:
ADMISSION LABS:
[**2128-5-7**] 09:54AM BLOOD WBC-20.6* RBC-4.62 Hgb-13.2* Hct-43.4
MCV-94 MCH-28.5 MCHC-30.4* RDW-14.3 Plt Ct-351
[**2128-5-7**] 09:54AM BLOOD Neuts-79* Bands-4 Lymphs-15* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2128-5-7**] 09:54AM BLOOD PT-10.7 PTT-24.9* INR(PT)-1.0
[**2128-5-7**] 09:54AM BLOOD Glucose-192* UreaN-35* Creat-1.5* Na-135
K-4.3 Cl-93* HCO3-24 AnGap-22*
[**2128-5-7**] 09:54AM BLOOD Lipase-72*
[**2128-5-7**] 09:54AM BLOOD cTropnT-<0.01
[**2128-5-7**] 09:54AM BLOOD Calcium-10.1 Phos-6.8* Mg-2.3
[**2128-5-7**] 09:54AM BLOOD Lactate-6.9*
CHEST X-RAY ([**2128-5-7**]): Multifocal infiltrates in the right lung
with possible left retrocardiac opacity as well suspicious for
pneumonia in the proper clinical setting. Recommend repeat after
treatment to document resolution.
KUB ([**2128-5-7**], 1:53 PM): Dilated small bowel loops concerning for
obstruction.
KUB ([**2128-5-7**], 3:35 PM): Single left lateral decub radiograph was
provided. There is no evidence of free air. Again seen are
multiple stacked loops of dilated bowel concerning for
obstruction. NG tube is incompletely visualized.
Brief Hospital Course:
This is an 87 year old gentleman with severe dementia who
presented from a nursing facility with hypoxic respiratory
distress in the setting of pneumonia.
# Goals of Care: Patient continues to have significant
respiratory secretions and high o2 requirment. He is likely
chronically aspirating in setting of severe dementia. His wife
[**Name (NI) **] reported she did not want him to suffer, stated death would
be preferred over prolonged suffering. Given his profound
hypoxia and respiratory distress a family meeting was held to
discuss goals of care in which it was decided to focus his care
around comfort. All medications including antibiotics were
discontinued except for morphine, ativan and scopolamine.
Patient ultimately died on [**2128-5-10**] at 1714. Family was at
bedside and declined autopsy.
Medications on Admission:
1. Celebrex 200mg daily
2. MVT one tablet daily
3. Vantin? 200mg daily
4. Tylenol 650mg q6hrs pain
5. Omeprazole 20mg daily
6. Calcium + vit D 600-400mg daily
7. Aspirin 81 mg daily
8. Metoprolol XR 50mg daily
9. Amlodipine 2.5mg daily
10. Namenda 5mg daily
11. Levothyroxine 25 mcg daily
12. Lidocaine topically on l shoulder daily 5%
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2128-5-11**]
ICD9 Codes: 5070, 5849, 2851, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4809
} | Medical Text: Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-26**]
Date of Birth: [**2089-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Critical aortic stenosis with a bicuspid valve
Major Surgical or Invasive Procedure:
[**2141-12-21**]:
1. Aortic valve replacement with a size 23 St. [**Male First Name (un) 923**] Regent
mechanical valve.
2. Ascending aortic aneurysm resection and replacement with
ascending aortic tube graft, size 24 Gelweave
History of Present Illness:
52 y/o female with known heart murmur presented to [**Hospital 1474**]
Hospital after she had an episode of syncope. She walked up two
flights of stairs and felt dizziness and had a loss of
consciousness for approximately five minutes.
Family member (nursing student) performed CPR. Patient
recovered
from her syncoipe and absolutely refused to go to hospital at
that time. She went to see the Rocketters in [**Location (un) 86**] and then
went home. Family members then convinced her to go to ER for
evaluation. MI was ruled out. ECHO EF of 55-60%. [**Location (un) 109**] 0.6 cm2.
Cardiac cath at [**Hospital1 1474**] showed normal coronary arteries.
Patient is referred for AVR.
Cardiac Catheterization: Date: [**12-15**] - normal coronaries
Place: [**Hospital 1474**] Hospital
Past Medical History:
Heart Murmur
Social History:
Married lives with family. Denies Tobacco and ETOH
Family History:
non-contributory
Physical Exam:
Admission:
Pulse:80 (SR) Resp:16 O2 sat: 98% RA
B/P Right: Left:
Height: Weight:
General:NAD, alert, cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] II/VI SEM across precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []+2 edema bilaterally with varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: murmur radiates to both
carotids
Pertinent Results:
Echo [**2141-12-21**]:
PRE-CPB:
The aortic valve is bicuspid with apparent fusion of the left
and non-coronary cusps. . The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis. Mild
(1+) aortic regurgitation is seen.
The ascending aorta is mildly dilated.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
POST-CPB:
A mechanical aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally. The peak
gradient across the aortic valve is 18mmHg, the mean gradient is
8mmHg. There is no apparent paravalvular leak.
A graft is seen in the ascending aorta. In the posterior aspect
of the graft-to-root anastamosis, there appears to be a small
area of turbulent flow which can be seen in multiple views.
There is no obvious flow across the suture line, and there is no
evidence of fluid collection outside of the aortic root. No
thoracic aortic dissection is seen.
Chest CT
[**2141-12-19**]:
1. Ascending thoracic aorta aneurysm, measuring up to 4.7cm in
diameter at
the mid ascending aorta.
2. Aneurysmal outpouching of the inferior wall of the aorta at
the level of
the distal arch. The aorta measures 3 cm in diameter at this
level.
3. 6 mm right middle lobe pulmonary nodule. Chest CT in 12
months is
recommended for further evaluation, provided the patient has no
risk factors
for malignancy (e.g. nonsmoker, no history of malignancy).
4. Extensive calcifications of the aortic valve.
Carotid Dopper
[**2141-12-19**]: On the right side, peak systolic velocities are 53
cm/sec, 66 cm/sec and 74 cm/sec in the internal, common and
external carotid arteries respectively. The right ICA to CCA
ratio is 0.8.
On the left side, peak systolic velocities are 81 cm/sec, 96
cm/sec and 82
cm/sec in the internal, common and external carotid arteries
respectively. The left ICA to CCA ratio is 0.84.
Both vertebral arteries presented antegrade flow.
IMPRESSION: There is no evidence of significant stenosis within
the internal carotid arteries bilaterally.
Brief Hospital Course:
On [**2141-12-21**] she was brought to the operating room and underwent
Aortic valve replacement with a [**Street Address(2) 11688**]. [**Male First Name (un) 923**] Regent mechanical
valve; Ascending aortic aneurysm resection and replacement with
ascending aortic tube graft, size 24 Gelweave (see operative
report for further details). In the first twenty four hours she
was weaned from sedation, awoke neurologically intact, and was
extubated without complications. She continued to progress on
post operative day one and was started on diuretics and beta
blockers. She was transferred to the floor and was started on
Coumadin that evening for her [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical valve.
Respiratory: aggressive pulmonary toilet, nebs, and incentive
spirometer she titrated off oxygen.
Chest tubes: mediastinal and pericardial chest tubes were
removed on POD2.
Cardiac: She remained hemodynamically stable in sinus rhythm on
low dose beta-blockers and aspirin were started. Pacing wires
were removed [**2141-12-24**]
GI: H2 Blockers and bowel regime
Nutrition: cardiac healthy diet
Renal: she was gentley diuresed, renal function normal with good
urine output.
Heme: Coumadin 5 mg was started [**2141-12-23**] [**Male First Name (un) 923**] Mechanical
Valve. INR Goal 2.0-3.0. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17887**] will manage her
Coumadin as an outpatient.
ID: Amoxicillin was continued for her in-complete root canal.
Pain: Well controlled with narcotics.
Disposition: she was seen by physical therapy who deemed her
safe for home. She was discharged on [**2141-12-26**] and will
follow-up with Dr. [**Last Name (STitle) **], her cardiologist and PCP as an
outpatient.
Medications on Admission:
Amoxicillin
Discharge Medications:
1. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2.0-3.0
Coumadin dose to be determined by Dr. [**Last Name (STitle) 17887**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Critical Aortic Stenosis with a bicuspid valve
Syncope
s/p AVR (#23 regent mech AVR), ascending aortic aneurysm repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
-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
-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
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**
Your Coumadin will be followed by Dr. [**Last Name (STitle) 17887**] [**Telephone/Fax (1) 6699**]
Goal INR 2.0-3.0 for mech aortic valve
Your first INR will be drawn on [**2141-12-27**] and the results called
to Dr. [**Last Name (STitle) 17887**] at [**Telephone/Fax (1) 6699**] for coumadin dosing.
You will need a follow up chest CT scan in 6 -12 months for a
right middle lobe nodule.
You will need to stay on amoxicillin until you have your root
canal.
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Doctor Last Name **] [**Telephone/Fax (1) 170**] on [**2142-1-17**] at 1pm
Cardiologist: to be determined by PCP
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 17887**] [**Telephone/Fax (1) 6699**] next week for Coumadin
management
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] Mechanical
Aortic Valve
Goal INR 2.0-3.0
First draw [**2141-12-27**]
Results to Phone: [**Telephone/Fax (1) 6699**]
Fax: [**Telephone/Fax (1) 69014**]
You will need a follow up chest CT scan in 6 -12 months for a
right middle lobe nodule.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-1-3**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4810
} | Medical Text: Admission Date: [**2120-7-8**] Discharge Date: [**2120-7-12**]
Date of Birth: [**2060-8-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo F with widely metastatic breast cancer including likely
leptomeningeal spread on cycle 2 of taxol and avastan admitted
with subacute, progressive unresponsiveness and a hypotensive
episode.
.
The patient has reportedly had 2 weeks of confusion and
lethargy. She was admitted to [**Hospital3 **] for altered mental
status and increasing unresponsiveness within the past week. At
that time she was found to be hypokalemic to K of 2.6 and
dehydrated. After IV fluid rescucitation and potassium repletion
she was discharged home.
.
On the day of admission, she came to clinic for a scheduled XRT
treatment. She was found to be hypokalemic with severely
depressed mental status. At that visit she opened her eyes to
her name but was not speaking or following commands. She did
respond to painful stimulus. On arrival to the oncology floor,
the patient had vitals of 96.0 92 108/64 22 97% RA. She was
noted to be minimally responsive. Out of concern for mass effect
and/or seizure activity, the patient received 10mg dexamethasone
and 1mg IV ativan. Subsequently her blood pressure declined to
sbp 80 and then 60. She received a 1L NS bolus with return of
sbp to 107. The patient also became bradypneic with this
episode. She was transferred to the ICU for further care.
.
After transfer, the patient's primary oncologist had a
discussion with the patient and her family. The decision was
made for no further invasive tests or imaging studies. The
patient will receive IV fluids, antibiotics and other IV
medications as well as have lab draws.
.
ROS: Unable to obtain.
Past Medical History:
- Metastatic breast cancer. Initially presented in [**2119-11-14**]
with a lytic lesion in the left leg and a breast mass. Biopsy
revealed infiltrating carcinoma. HER-2/neu negative, ER
positive. S/p cyberknife radiation therapy to an 8mm left
cerebellar lesion. Known bony mets. Likely leptomeningeal spread
on MR brain [**2120-4-30**]. Received palliative XRT to the thoracic
spine. She is on cycle 2 of Taxol and Avastin.
- Multiple episodes of severe malignancy associated
hypercalcemia and altered mental status.
- S/p surgical repair of left tibia on [**2120-1-2**]
- Prior hysterectomy and bilateral salpngo-oophorectomy in [**2115**]
for benign causes.
- Surgery for ectopic pregnancy in [**2090**].
Social History:
Married. Previous associate principal in a middle school. 2
daughters in their 40's. Lifetime nonsmoker with rare alcohol
use.
Family History:
Half-sister with breast CA at age 63. No other known cancers in
the family.
Physical Exam:
PE 79 102/38 6 99% RA
Gen: Unresponsive. Moans once. Not following any commands. Not
responding to painful stimulus.
HEENT: PERRL. Eyes pointing upwards.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally.
Abd: Soft, nontender. No distention or organomegaly.
Ext: Trace left lower extremity edema. No right lower extremity
edema.
Neuro: Unresponsive to commands or painful stimulus. PERRL.
Flexed right upper extremity slowly improved with movement.
Unable to ilicit reflexes at the patella. Upgoing toes
bilaterally.
.
Pertinent Results:
Labs: Na 143, K 2.9, Cl 110, Bicarb 22, BUN/Cr 5/0.5, Ca 9.0, Mg
1.7, Phos 2.1, WBC 4.3 (76% N, 14% L), Hct 32.0, platelets 259.
.
ALT 14, AST 43, AP 339, LDH 539, T Bili 0.6, Alb 3.1.
.
CEA 97, CA 27.29 pending.
.
EKG: None available.
.
Micro:
Blood culture
([**2120-6-24**]): No growth.
([**2120-7-8**]): Pending.
Urine culture
([**2120-6-24**]): No growth.
.
Imaging:
MR brain with and without contrast ([**2120-4-30**]): 1. New metastatic
involvement of the leptomeninges, most notable of the posterior
fossa. 2. Stable minimal residual enhancement at the site of
treatment of the left cerebellar metastasis. No new brain
parenchymal lesions. 3. Interval slight worsening in calvarial
metastases including infiltration of the skull base and upper
cervical vertebra.
Brief Hospital Course:
Mr [**Known lastname 77692**] is a 59 yo woman with history of metastatic breast
cancer presenting with two weeks duration of confusion and
icreasing lethargy.
Ms. [**Known lastname 77692**] was admitted to the [**Hospital Unit Name 153**] for subacute, progressive
unresponsiveness and a hypotensive episode likely due to volume
depletion. Her unresponsiveness was likely secondary to
progression of her widely metastatic breast cancer, including
possible leptomeningeael spread. Also, considered was seizure
activity with post-ictal state and toxic-metabolic mediated
altered status in the setting of hypercalcemia and hypocalemia.
On admission to the [**Hospital Unit Name 153**], initially, the goals of care were
discussed, and it was decided not to pursue further chest
x-rays, MRI brain, EEG or lumbar puncture. She was volume
resuscitated, and her electrolytes were repleted. The next
morning, [**2120-7-9**], both palliative care and social work met with
the family to continue to discuss goals of care, which included
being able to take her home with comfort (but not CMO). Per her
neuro-oncologist, however, CT head and MRI of head and neck as
well as EEG were ordered with agreement from family. She was
given a Keppra load and will start on maintenance doses on the
oncology floor. She was deemed stable for transfer to the
oncology floor on [**2120-7-9**].
On the floor the patient remained stable hemodynamically and
neurolgically. The patient received phenytoin and was continued
on levitiracetam on Neuro/onc recomendation. The MRI showed no
evidence of leptomeningeal disase with stable CNS disease.
Continous EEG was obtained which showed evidence of
encephalopathy.
The patient was noted electrolyte abnomalities suggestive of non
anion gap metabolic acidosis which improved on IVF.
The patient's discomfort was managed with IV morhine which was
transitioned to concerntrated elixir at discharge. After a
discusion with the family regarding the goals of care a decision
was made to transition care at home with comfort care.
Palliative care was involved in the management of this patient
and family discussions.
Medications on Admission:
Meds, Inpatient:
- Heparin 5000U subq
- Pantoprazole 40mg Daily
.
Meds, Outpatient:
- Oxycodone prn
- Compazine
- Zofran
- Oxycontin
- Colace prn
- Prilosec prn
- Ativan prn
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1hrs
as needed for pain, discomfort, agitation, shortness of breath.
Disp:*30 ccs* Refills:*0*
2. Ativan 1 mg Tablet Sig: 1-2 Tablets PO q2-4hrs as needed for
agitation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary: encephalopathy
Discharge Condition:
Comfortable
Discharge Instructions:
You were admitted because of altered mental status. This is
probably from progression of your cancer.
Unfortunately, this was not from a reversible process.
Followup Instructions:
None
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
Completed by:[**2120-7-17**]
ICD9 Codes: 2768, 4589, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4811
} | Medical Text: Admission Date: [**2168-2-26**] Discharge Date: [**2168-3-19**]
Date of Birth: [**2083-12-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Transfer from [**Hospital **] Hospital for further management of Acute
coronary Syndrome, NSTEMI, evaluation for AVR
Major Surgical or Invasive Procedure:
[**2168-2-26**] Cardiac catheterization
[**2168-3-4**] Extraction of tooth #18
[**2168-3-9**] Aortic Valve Replacement (25 mm CE Magna Ease
pericardial)/ Coronary artery bypass graft x4 with left internal
mammary artery to left anterior descending coronary artery;
reverse saphenous vein single graft from aorta to distal right
coronary artery; reverse saphenous vein single graft from aorta
to first diagonal coronary artery; reverse saphenous vein single
graft to the ramus intermedius coronary artery/Replacement of
ascending aorta (26mm Gelweave sidearm graft)/Aortic
endarterectomy
[**2168-3-10**] Mediastinal exploration and closure of sternum
History of Present Illness:
84 year-old male with CAD (70-80% stenosis prox LAD, 90%
stenosis mid diagonal branch, LCX 60-70%, 80% proximal RCA
stenosis), aortic stenosis (valve area 0.6cm2)admitted [**2168-2-25**]
to [**Hospital **] Hospital with chest and back pain and shortness of
breath, found to have NSTEMI and decompensated heart failure. He
reported chest pain with climbing stairs or walking, but not
present at rest. He also reported a cough, with blood tinged
sputum for the past few days. He also reported back pain on and
off regardless of activity. At the OSH, his oxygen saturation
78% room air, mid-90s on 6L nasal canula. Troponin 0.27, proBNP
[**Numeric Identifier 890**]. EKG with new ST depressions inferolaterally (V4-V6, II,
aVF), and chest radiograph with increased hilar markings. He was
given Lasix 20mg IV with good diuresis. Heparin gtt was
initiated. Norvasc, atenolol were held; ASA 81mg continued;
Lopressor 25mg po q6hrs was started, and Lipitor dose was
increased to 80mg daily. Given cough/malaise, leukocytosis, and
?RLL infiltrate on chest radiograph, ceftriaxone (? of allergy
to PCN with leg edema, but suspicion low) and azithromycin
started. He was transferred to [**Hospital1 18**] for further management of
NSTEMI, diuresis, and evaluation of aortic stenosis.
Past Medical History:
Dyslipidemia
Hypertension
Coronary artery disease
Aortic stenosis
Paroxysmal atrial fibrillation
Resected squamous cell carcinoma, s/p Moh's surgery scalp
Prostate cancer s/p radiation therapy ([**2164**])
Bilateral knee ostearthritis
Radiation proctitis
Lower GIB [**2164**]
Diverticulosis [**2164**]
s/p Tonsillectomy
Social History:
The patient is married and lives with his wife. The patient is
retired, retired since [**2140**]. He walks on his own without a
walker or a cane, and lives in a flat level home without stairs.
He takes care of his wife. Denies tobacco use. Quit smoking in
[**2107**]. Used to drink 1 scotch per day, now drinks 1 beer with
lunch.
Family History:
There is a family history of hypertension, diabetes, and heart
disease. There was no history of strokes. His mother died at
age 86 of old age. His father died at 75 years of an MI(?).
Physical Exam:
Pulse: 87 Resp: 24 O2 sat: 92% on 6l
B/P Right: 119/67 Left:
Height: Weight:
General:
Skin: Dry [x] intact [xx]
HEENT: PERRLA ]x EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x], slightly tachypneic
Heart: RRR [x] Irregular [] Murmur III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 0
Varicosities: +1
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right/Left: transmitted murmur
Pertinent Results:
[**2168-2-26**] 03:57PM BLOOD Glucose-152* UreaN-47* Creat-1.2 Na-138
K-3.8 Cl-101 HCO3-26 AnGap-15
[**2168-3-5**] 08:45AM BLOOD Glucose-178* UreaN-66* Creat-1.7* Na-143
K-4.5 Cl-103 HCO3-29 AnGap-16
[**2168-3-6**] 06:35AM BLOOD Glucose-150* UreaN-69* Creat-1.9* Na-141
K-3.6 Cl-102 HCO3-26 AnGap-17
[**2168-3-8**] 04:45AM BLOOD Glucose-131* UreaN-67* Creat-1.6* Na-143
K-4.3 Cl-105 HCO3-26 AnGap-16
[**2168-3-11**] 02:00AM BLOOD Glucose-86 UreaN-52* Creat-2.1* Na-144
K-5.0 Cl-112* HCO3-25 AnGap-12
[**2168-3-12**] 01:29AM BLOOD Glucose-88 UreaN-58* Creat-1.9* Na-139
K-4.1 Cl-106 HCO3-24 AnGap-13
[**2168-3-13**] 03:07AM BLOOD Glucose-105* UreaN-60* Creat-1.6* Na-143
K-4.2 Cl-109* HCO3-26 AnGap-12
[**2168-3-14**] 02:36AM BLOOD Glucose-87 UreaN-56* Creat-1.5* Na-147*
K-3.4 Cl-111* HCO3-30 AnGap-9
[**2168-3-15**] 04:44AM BLOOD Glucose-93 UreaN-54* Creat-1.3* Na-151*
K-4.0 Cl-114* HCO3-29 AnGap-12
[**2168-3-15**] 05:23PM BLOOD Glucose-107* UreaN-46* Creat-1.2 Na-154*
K-4.1 Cl-113* HCO3-32 AnGap-13
[**2168-3-16**] 09:24AM BLOOD Glucose-178* UreaN-41* Creat-1.3* Na-150*
K-3.9 Cl-112* HCO3-31 AnGap-11
[**2168-3-17**] 05:09AM BLOOD Glucose-146* UreaN-33* Creat-1.1 Na-142
K-4.0 Cl-106 HCO3-28 AnGap-12
[**2168-3-19**] 03:57AM BLOOD WBC-7.9 RBC-3.47* Hgb-10.6* Hct-30.6*
MCV-88 MCH-30.6 MCHC-34.6 RDW-14.4 Plt Ct-240
[**2168-3-18**] 05:39AM BLOOD WBC-7.7 RBC-3.49* Hgb-10.4* Hct-31.0*
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.2 Plt Ct-189
[**2168-3-14**] 02:36AM BLOOD PT-15.7* PTT-24.8 INR(PT)-1.4*
[**2168-3-15**] 04:44AM BLOOD PT-71.1* INR(PT)-8.3*
[**2168-3-15**] 06:17AM BLOOD PT-76.8* PTT-28.6 INR(PT)-9.1*
[**2168-3-15**] 04:33PM BLOOD PT-27.3* PTT-29.1 INR(PT)-2.7*
[**2168-3-16**] 09:24AM BLOOD PT-50.5* INR(PT)-5.5*
[**2168-3-16**] 08:16PM BLOOD PT-38.4* INR(PT)-4.0*
[**2168-3-17**] 05:09AM BLOOD PT-21.5* INR(PT)-2.0*
[**2168-3-17**] 10:16AM BLOOD Plt Ct-181
[**2168-3-18**] 05:39AM BLOOD PT-23.7* INR(PT)-2.3*
[**2168-3-19**] 03:57AM BLOOD PT-22.0* INR(PT)-2.1*
[**2168-3-18**] 05:39AM BLOOD Glucose-88 UreaN-34* Creat-1.0 Na-144
K-3.9 Cl-108 HCO3-28 AnGap-12
[**2168-3-19**] 03:57AM BLOOD Glucose-100 UreaN-35* Creat-1.1 Na-141
K-4.0 Cl-106 HCO3-27 AnGap-12
[**2168-3-10**] 01:03AM BLOOD ALT-192* AST-305* LD(LDH)-784* AlkPhos-42
Amylase-68 TotBili-2.3*
[**2168-3-16**] 09:24AM BLOOD ALT-44* AST-55* LD(LDH)-451* AlkPhos-167*
Amylase-198* TotBili-1.0
[**2168-3-18**] 05:39AM BLOOD ALT-48* AST-55* AlkPhos-140* Amylase-186*
TotBili-1.2
[**2168-3-17**] 05:09AM BLOOD Calcium-7.4* Mg-2.1
[**2168-2-29**] Carotid U/S: Right ICA stenosis 40-59% (low end). Left
ICA stenosis <40%.
[**2168-3-1**] CTA TORSO: 1. Extensive noncircumferential calcified
atherosclerosis of the ascending aorta, aortic arch and
descending aorta. No evidence of porcelain aorta, aneurysm or
dissection. 2. Severe aortic valve calcification and markedly
decrease aortic valve excursion with an orifice area of 68.3mm2
at systole. Pre-operative transcatheter aortic valve replacement
measurements are described in this report. 2. Moderate bilateral
pleural effusion and interstitial as well as alveolar pulmonary
edema and cardiomegaly consistent with CHF. Pulmonary arterial
enlargement may be a secondary phenomenon. 3. Subcentimeter
hypodense lesion in the liver is too small to characterize but
likely consistent with a cyst.
[**2168-3-9**] Echo: PRE-CPB: The left atrium is markedly dilated. No
thrombus is seen in the left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal while the left ventricular cavity is
severely dilated. Overall left ventricular systolic function is
severely depressed, estimated EF is 20%. The right ventricular
cavity is mildly dilated with normal free wall contractility.
There are complex (mobile) atheroma in the ascending aorta. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. No thoracic aortic
dissection is seen. There are three aortic valve leaflets. The
aortic valve leaflets are severely thickened/deformed. Only the
non-coronary cusp appears to be mobile. There is severe aortic
stenosis. Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is decreased length
of coaptation zone. Mild to moderate ([**2-14**]+) central mitral
regurgitation is seen. This most likely represents functional MR
due to dilated LV. Pulmonary vein flow Doppler shows systolic
blunting, consistent with elevated [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1934**]. There is a very
small pericardial effusion. There is a moderate left pleural
effusion. POST-CPB: A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis is well seated and the
leaflets appear to move normally. There is a small intravalvular
leak seen in the area of the anatomic right coronary cusp. This
jet is centrally directed and is no longer seen on
re-examination fifteen minutes later by a second examiner. The
peak gradient across the aortic valve prosthesisis 34mmHg and
the mean gradient is 16mmHg with a CO of 6. A tube graft is seen
in the ascending aorta. With a smaller LV chamber size, the
walls appear mild-to-moderately hypertrophied. The LV systolic
function continues to be severely depressed, now with regional
hypokinesis more notable in the inferior wall. The estimated EF
is 25%. The MR has improved to mild. The TR is also now mild.
There is no evidence of aortic dissection. Dr.[**Last Name (STitle) 914**] was
notified in person of the results at the time of study.
[**2168-3-10**] Head CT: There is no evidence of acute intracranial
hemorrhage, mass effect, or large territorial infarction. Dense
vascular atherosclerotic calcifications. Bilateral mucosal
thickening at the maxillary sinuses and pool of secretions is
noted at the nasopharynx, the patient is intubated.
[**2168-3-18**] CXR: CHEST (PA & LAT) 1. Stable right pleural effusion
and improvement in left pleural fluid collection, now containing
several lucencies likely representing locules of air.
2. Interval improved aeration within the left lung with residual
patchy
opacifications in the left upper lobe and right lung.
[**2168-3-19**] Echo: read pend
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Name14 (STitle) 85253**] is an 84 year-old male with
Coronary artery disease and aortic stenosis who was admitted
[**2168-2-25**] to [**Hospital **] Hospital with chest and back pain, shortness of
breath, and concern for NSTEMI and decompensated heart failure.
EKG showed ST depression in V3-V6, II-aVF, and troponin
elevation; had subsequent pulmonary edema and diuresed at OSH.
Patient has known three vessel coronary disease and had cath
[**2-26**], without intervention, which showed LAD 70% proximal
stenosis, major diag with severe irregular 90% proximal
stenosis, 60-80% stenosis of Ramus, LCx with 100% proximal
occlusion, and RCA with 95% hazy proximal stenosis followed by
60-80% disease in proximal-mid segment. He was transferred to
[**Hospital1 18**] for surgical intervention. Upon admission he was medically
managed and underwent extensive pre-operative work-up. This
included echo, carotid U/S, CTA of Torso and dental clearance.
Pre-op he required significant diuresis for pulmonary edema and
acute on chronic systolic heart failure. He initially
symptomatically improved; however, he became difficult to
diurese given acute renal insufficiency. As above, repeat echo
showed worsened EF of 30%, dilated and hypertrophied left
ventricle with moderate to severe global systolic dysfunction;
moderate functional mitral and tricuspid regurgitation, and
moderate to severe pulmonary hypertension. He was placed on a
Lasix gtt, but his creatinine bumped. On evening of [**3-4**], he had
flash pulmonary edema with desats to 80s on 6L. He was given
Lasix boluses, and his O2 sats improved. He continued to be
fluid overloaded and was placed on gentle Lasix gtt. On the
evening of [**2168-2-29**] he had large bloody bowel movement. GI was
consulted and thought it was most likely secondary to
hemorrhoids. He was treated with hydrocortisone suppositories
for 1 week. He had no more episodes of bleeding with several
guaiac negative stools. On [**2168-3-9**] he was brought to the
operating room where he underwent coronary artery bypass x 4,
aortic valve replacement and replacement of his ascending aorta.
Please see operative report for surgical details. He was
transferred to the CVICU in fair condition with an open, packed
chest due to significant bleeding intraoperatively, and on
titrated epinephrine, milrinone, Levophed, vasopressin, and
propofol drips. The following morning he returned to the
operating room for chest closure. Inotropic and pressor support
was weaned slowly over the next few days. On [**3-10**] he was noted
to have possible seizures and neurology was consulted. He
underwent head CT, which was negative, although neurology felt
he sustained some sort of embolic infarct. He remained stable
over next several days with no further episodes and was weaned
from sedation on post-op day three, awoke neurologically intact
and extubated. Also on this day chest tubes were removed with
subsequent chest x-ray's revealing bilateral pneumothoraces.
During the remainder of his hospital course these pneumothoraces
significantly decreased in size. Amiodarone was resumed and was
eventually placed on Heparin with transition to Coumadin for
atrial fibrillation. Beta blockers and diuretics were initiated
and he was gently diuresed towards his pre-op weight. Epicardial
pacing wires were removed per protocol. On post-op day five he
was transferred to the telemetry floor for further care. On this
day his INR was found to be 8.3, with repeat INR of 9.1. He
received FFP and Vitamin K. Initially INR trended down following
treatment with FFP and Vitamin K to 2.7 but the following day
was found to have an INR of 5.5. Vitamin K was given once and
INR came down to 2.0 the following day. Coumadin was restarted
at 0.5mg on [**3-17**]. INR was 2.3 on [**3-18**] and 2.1 on [**3-19**], the day of
discharge. He should receive 1mg of Coumadin on [**3-19**] and receive
close monitoring of INR daily. Echo performed on day of
discharge to evaluate EF, results pending. The patient was
evaluated by the physical therapy service during this admission
for assistance with strength and mobility. By the time of
discharge on POD 10 the patient needed assistance with
ambulating, the wound was healing and pain was controlled
without need for oral analgesics. The patient was discharged in
good condition with appropriate follow up instructions.
Medications on Admission:
MEDICATIONS AT HOME:
ASA 81mg PO daily
Norvasc 5mg PO daily
Lipitor 40mg PO daily
Atenolol 25mg PO daily
Fosinopril 20mg daily
.
MEDICATIONS ON TRANSFER:
Lopressor 25mgpo q6hrs
Lipitor 80mg qday
SLNTG 0.4mg q5 mins prn
Morphine 1-2mg IV q1-2hrs prn
Lasix 20mg IV q24hrs
Rocephin 1g IV q24hrs
Zithromax 500mg IV q24hrs
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*15 Tablet(s)* Refills:*0*
5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. 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*
7. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
8. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for temperature >38.0.
10. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. potassium chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day).
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: until
lower extremity edema and at baseline weight of 71 kg.
13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg daily for 7 days then decrease to 200mg ongoing.
14. warfarin 1 mg Tablet Sig: as directed for afib Tablet PO
DAILY (Daily): dose based on INR goal 2.0-2.5
***very sensitive to coumadin****.
15. Outpatient Lab Work
daily INR until stable for afib
Goal INR 2.0-2.5
Discharge Disposition:
Extended Care
Facility:
Clipper [**Hospital1 **]
Discharge Diagnosis:
Coronary artery disease, Aortic Stenosis and Calcified Aorta s/p
Coronary artery bypass graft x 4, Aortic valve replacement,
Replacement of ascending aorta and aortic endarterectomy
NSTEMI
Acute on chronic systolic heart failure
Past medical history:
GI bleed
Paroxysmal atrial fibrillation
Mitral regurgitation
Acute on chronic systolic heart failure
Community acquired pneumonia
Hypertension
Hypercholesterolemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema .2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2168-4-12**] at 1pm
[**Hospital Unit Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 60004**] [**2168-4-18**] 9:00am in [**Doctor Last Name 3012**] office
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 60843**] in [**5-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation
Goal INR 2-2.5
Please arrange for Coumadin followup/dosing with PCP or
cardiologist on discharge from rehab
Completed by:[**2168-3-19**]
ICD9 Codes: 4241, 486, 5185, 2851, 5849, 4280, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4812
} | Medical Text: Admission Date: [**2133-8-30**] Discharge Date: [**2133-9-8**]
Service: [**Month/Day/Year 662**]
Allergies:
E-Mycin / Levofloxacin / Aspirin / Metronidazole /
Nitrofurantoin / Tetracycline
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Name13 (STitle) 4027**] is a [**Age over 90 **] year old woman with atrial fibrillation on
warfarin admitted for multifactorial hypoxia secondary to
pneumonia, pulmonary edema, and question of COPD exacerbation,
transfered to ICU in setting of acute intracranial bleed s/p
fall. She was started initially on vancomycin and zosyn for
pneumonia, transitioned to community acquired coverage with
cefpodoxime and azithromycin. She was also given lasix for
pulmonary edema which improved her respiratory symptoms. There
was also some concern initially for a potentialy COPD
exacerbation, so she was given a dose of methylprednisolone
125mg then switched to prednisone. She received one dose of
prednisone, and it was discontinued.
Patient fell out of chair around 3:30am morning of MICU
admission. Head CT showed small right subdural bleed, and
mental status was alert and oriented x3. In late morning,
patient complained of headache and had new word finding
difficulties. Neurosurgery was consulted and suggested repeat
Head CT 12 hours after previous one and reversal of INR. She
was given 1 unit of FFP and 10mg IV vitamin K along with an
extra dose of 40mg IV lasix in the late morning. Because she
sounded fluid overloaded on morning rounds, she had received an
extra dose of 40mg IV lasix in addition to home dose 2mg bumex
as well. After FFP, patient developed respiratory distress,
presumed to be secondary to flash pulmonary edema. She was
triggered on the floor for tachypnea. She received an extra
dose of 40mg IV lasix in early afternoon, and a foley was
placed. Nitro paste was also placed. CXR showed pleural
effusions, right greater than left, and pulmonary edema. MICU
consult was initiated, at which time, patient was verbally
responsive to her name but not oriented and not able to hold
conversation. She was weaned from face mask to 2L nasal canula,
on which she was satting 93%. She underwent stat head CT which
showed significantly expanded subdural hematoma bilaterally,
left worse than right. She had an episode of nausea with
dry-heaving on return to the floor. No mass effect was seen on
CT. Neurosurgery evaluated patient at bedside, had coversation
with family that patient may recover if INR is reversed quickly.
Patient was given another unit of FFP and transfered to the
MICU for further management in setting of mental status and
concern for potential respiratory instability.
Of note, patient was also noted to be having loose stools on the
floor. Stool sample was sent for c diff prior to MICU transfer.
On arrival to the MICU, patient was somnolent and tachypneic,
unable to converse
Past Medical History:
1. Hypertension.
2. Hypothyroidism.
3. Polymyalgia rheumatica off prednisone for >2yrs
4. History of upper extremity peripheral neuropathy.
5. Peptic ulcer disease with history of GI bleed secondary
to aspirin 7 years ago.
6. Status post cholecystectomy.
7. Diverticulitis
8. Complete heart block s/p DDD pacer in 5/00
9. COPD
10. CVA in past with no residual deficit on plavix qod for GIB
11. insulin resistance-with prednisone use in past
12. A fib - on coumadin since [**2128-10-25**]
13. ? Polio when she was a child whicmh may have lead to her
neuropathy?
Social History:
She lives in [**Location (un) 538**] in senior housing independent living.
She gets dinner and she makes her other meals. Her daughters buy
her food. She is independent of ADLS and independent of
accounting and meal preparation for breakfast and lunch. She
does her own medications. Her husband passed away 10 years ago.
She uses a rolling walker to ambulate. She has 6 children - 4
sons and 2 daughter who are involved in her care.
She does not smoke or drink alcohol but smoked 1ppd for approx
20 years up to age 62 (20 pack-years). No IVDU.
Her HCP: [**Name (NI) **] [**Last Name (NamePattern1) 21598**] [**Telephone/Fax (1) 21599**]- she lives in [**Hospital1 789**]
RI
Retired billing supervisor at the [**Hospital1 882**]
Family History:
Father: died of MI at 75
Mother: died at 84 of heart attack
brother: died of MI
No other hx of COPD, CA, DMII or CVA.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.5 BP: 146/46 P: 75 R: 36 O2: 96% on 2L NC
General: sleepy appearing, not oriented, responding to name
HEENT: Sclera anicteric, pupils 2mm bilaterally and responsive
to light
Neck: supple, JVP elevated
Lungs: harsh bibasilar crackles and bilateral expiratory wheeze
CV: Regular rhythm, normal rate
Abdomen: soft, non-tender, non-distended
GU: foley draining very light yellow urine
Ext: warm, palpable DP pulses, no peripheral edema
Neuro: pupils symmetric and reactive, cannot cooperate with full
neuro exam but moving all extremities on her own
Discharge Physical Exam:
Vitals: T: 97.8 HR 75 RR 15 BP 145/53 O2% 94% 2LNC
General: Lethargic but arousable. Waxing and [**Doctor Last Name 688**] levels of
conciousness. She squeezes fingers and wiggles toes with
request. Looks at you after hearing her name but appears aphasic
and doesnt respond verbally. She appears in pain but is in NAD
HEENT: Sclera anicteric, pupils 2mm bilaterally and responsive
to light
Neck: supple, JVP not elevated
Lungs: patient not able to follow commands to breath deeply but
sounds clear to auscultation
CV: Regular rhythm, normal rate, 2-3/6 systolic mumur heard
throughout the precordium
Abdomen: soft, non-tender, non-distended, good bowel sounds.
Tenderness over iliac crest and patient points to iliac crest
when in pain
GU: foley draining yellow urine
Ext: Cool but palpable DP pulses, no peripheral edema
Neuro: pupils symmetric and reactive, cannot cooperate with full
neuro exam but moving all extremities on her own. Arousable to
name and squeezes hands and moves toes on request
Pertinent Results:
Admission Labs:
[**2133-8-30**] 07:10AM BLOOD WBC-20.6* RBC-3.93* Hgb-12.4 Hct-35.3*
MCV-90 MCH-31.6 MCHC-35.2* RDW-14.2 Plt Ct-314
[**2133-8-30**] 07:10AM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2133-8-30**] 07:10AM BLOOD PT-26.9* PTT-35.7* INR(PT)-2.6*
[**2133-8-30**] 07:10AM BLOOD Glucose-143* UreaN-30* Creat-1.1 Na-135
K-5.6* Cl-99 HCO3-24 AnGap-18
[**2133-8-30**] 04:19PM BLOOD Type-ART pO2-65* pCO2-36 pH-7.44
calTCO2-25 Base XS-0
Discharge Labs:
[**2133-9-7**] 04:25AM BLOOD WBC-17.2* RBC-3.74* Hgb-11.3* Hct-33.3*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.1 Plt Ct-243
[**2133-9-7**] 04:25AM BLOOD PT-12.9 INR(PT)-1.1
[**2133-9-7**] 04:25AM BLOOD Glucose-168* UreaN-29* Creat-1.0 Na-145
K-4.0 Cl-108 HCO3-29 AnGap-12
[**2133-9-7**] 04:25AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.3
INR: Supratherapuetic 4.9 on floor before transfer to ICU.
In ICU: After Vitamin K and 2 units FFP
[**2133-9-2**] 03:50PM BLOOD PT-18.4* PTT-27.9 INR(PT)-1.7*
[**2133-9-3**] 12:52AM BLOOD PT-13.7* PTT-25.1 INR(PT)-1.2*
[**2133-9-3**] 04:51AM BLOOD PT-13.2 PTT-24.8 INR(PT)-1.1
[**2133-9-3**] 07:03PM BLOOD PT-13.0 INR(PT)-1.1
[**2133-9-7**] 04:25AM BLOOD PT-12.9 INR(PT)-1.1
Imaging:
CT Head [**9-2**]
New extra-axial collection measuring up to 6 mm in greatest
thickness, ithout significant mass effect. No fracture
Serial CT Heads
CT Head [**9-2**]
1. Dramatic short-interval increase in the left subdural
collection, as well as new right-sided subdural collection, with
foci of hypodensity in both representing hyperacute bleeding.
Increased associated mass effect with effacement of the
ventricles and sulci as well as stable 6-mm rightward shift of
the normally-midline structures.
2. Trace amount of new subarachnoid hemorrhage inover the left
parietal lobe
Serial CT Heads without interval change x 4 (most recent
[**2133-9-5**])
Hip X-Ray [**9-4**]:
AP view of pelvis, two views left hip done with portable
technique. There is large amount of bowel gas obscuring
visualization of the pelvis. Severe degenerative changes in the
lumbar spine and sacroiliac joints. No discrete fracture of the
proximal femur identified, but if this is clinically suspected,
then CT or MRI would be more sensitive for detection of subtle
fractures radiographically occult. There is mild degenerative
change of the femoro-acetabular joints.
Wrist X-Ray [**9-3**]: No Fracture
Elbow X-Ray [**9-3**]: No Fracture
Shoulder X-Ray [**9-3**]: No Fracture
Brief Hospital Course:
[**Age over 90 **]yo F PMHx Afib on coumadin, diastolic heart failure, who
initially presented to [**Hospital1 18**] w hypoxia and shortness of breath,
found to have a pneumonia and acute on chronic heart failure,
course complicated by fall and bilateral subdural hematomas, now
w improved respiratory status, residual stable confusion being
discharged to rehab
.
ACTIVE
# Pneumonia and Acute Diastolic CHF: Pt w O2 requirement,
leukocytosis, initially treated for healthcare-associated
pneumonia and heart failure exacerbation. Pt was given
vancomycin, pipercillin/tazobactam, and azithromycin. In
setting of fall (see below) she was switched to vancomycin and
cefepime [**3-4**] concern that azithromycin could increase her INR.
Patient was diuresed w prn lasix with improvement in respiratory
function. Patient completed a full course of abx prior to
discharge.
.
# Subdural hematoma: Course was complicated by unwitnessed fall
[**2133-9-2**]. STAT NCHCT demonstrated subdural hematoma. F9
Complex, FFP, and vitamin K were given for anticoagulation
reversal. Patient was initally AOx3 and attentive, but
subsequently she developed HA and dysarthria. Patient
subsequently had rapid deterioration of mental status, but she
remained without focal neurologic signs. Repeat NCHCT
demonstrated increased Lsided subdural collection and new Rsided
subdural collection, small L parietal subarachnoid hemorrhage
and mass effect. She was transferred to the ICU. Neurosurgery
did not feel surgery was indicated [**3-4**] her comborbidities. Per
neurosurgery recommendations, serial CT imaging was performed,
without significant worsening. Patient remained w waxing and
waining mental status, and she developed worsening dysarthric,
eventually demonstrating both expressive and receptive aphasia.
Per Neurosurgery, this course is expected and she will likely
have waxing and wainig mental status for some time before she
returns back to baseline.
.
# Altered Mental Status: As above, pt w waxing and waining
mental status in setting of fall and subdural. Pain was also
felt to likely be contributing as well and was treated w
tylenol, morphine and lidoderm patch.
.
# Leukocytosis: Patient w chronic leukocytosis, without
significant findings on culture data or physical exam during
this hospital stay.
.
# Atrial fibrillation - Patient on chronic coumadin, found to
have a supratherapeutic INR of 4.9. In setting of fall,
coumadin was held and INR was reversed. At time of discharge
INR was 1. Per neurosurgery consult, anticoagulation should
continue to be held for one month after fall. Would recommend
conversation with family regarding risk/benefits of restarting
anticoagulation vs future falls.
.
# Hyperglycemia - Patient was found to have elevated blood
sugars during this admission, in the setting of several doses of
steroids; she was placed on an insulin sliding scale. Her
sugars will need to be followed, with plan for eventual
evaluation for diabetes
.
INACTIVE
# Hypothyroidism - Continued home levothyroxine dose.
.
# Hyperlipidemia - Continued home statin therapy.
.
Transitional Issues:
1. Code status - Patient DNR/DNI
2. Pending - at time of discharge Blood Cultures from [**9-3**], [**9-5**]
remained pending and will need to be followed up by rehab
facility
3. Transition of Care:
- [**Hospital1 18**] Neurosurgery Follow up in 4 weeks ([**2133-10-14**] at 10:30
for CT imaging, office appointment 11:15am)
- Blood pressure goal is SBP<160
- Hold anticoagulation for one month after fall, can resume
[**2133-10-3**] once discussion with family re: risks/benefits has been
conducted
Medications on Admission:
Home Medications:
1. Maalox as needed.
2. Simvastatin 20 mg q.p.m.
3. Simethicone 80 mg p.o. before meals.
4. Lisinopril 5 mg daily (started at the [**Hospital1 18**] in [**Location (un) 86**] during
her recent hospitalization).
5. Amlodipine 10 mg daily.
6. Bumex 2mg daily.
7. Levothyroxine 75 mcg daily.
8. Spiriva 18 mcg daily.
9. Vitamin D3 1000 units daily.
10. Oxazepam 30 mg at bedtime p.r.n. insomnia.
11. Tylenol p.r.n.
12. Coumadin as directed.
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as
needed for SOB.
7. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q8H (every 8 hours) as needed for pain/fevers.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for body pain.
11. Saline Flush 0.9 % Syringe Sig: One (1) 3ml Injection twice
a day: Please Flush PICC line with Saline only. Please do not
flush line with Heparin.
12. morphine 2 mg/mL Syringe Sig: 0.5 ml Injection Q4H (every 4
hours) as needed for Pain Refractory to Tylenol.
13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
14. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*3*
15. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for
nausea/vomiting.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
18. insulin lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous ASDIR (AS DIRECTED): Per printed sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia
Acute on chronic heart failure
Bilateral subdural hematomas
?COPD
?Diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Awake, but periods of rousable lethargy.
Activity Status: Out of bed with assist. Fall precautions.
Discharge Instructions:
Dear Ms. [**Name13 (STitle) 4027**],
It was a pleasure treating you during your hospitalization. You
were initially admitted to the hospital for pneumonia and acute
worsening of your heart failure. You were treated with IV
Vancomycin and Cefpodoxime/Cefepime antibiotics for your
pneumonia and you improved. Your heart failure was treated with
oxygen and taking your extra fluid off.
During your hospitalization, you experienced a fall while in
your room. As a result of the fall you developed subdural
hematomas (bleeding in the brain) both on the left and right
side of your head. Because you were on Coumadin, your blood was
thin and made you more prone to bleeding into your brain injury;
this was fixed by giving you Factor 9 Complex, Vitamin K and
Fresh Frozen Plasma. Your initial Head CT showed subdural
hematomas but serial CT scans after correcting your
anticoagulation did not show changes in the hematomas (they were
stable). You were occasionally confused and sleepy, which were
felt due to the bleeding in your brain. According to
Neurosurgery, this is the normal course for subdural hematoma
and you were discharged in stable condition to Rehab for
monitoring mental status, physical therapy and improvement in
subdural hematomas.
The following changes to your medications were made:
- Please do not take your home Coumadin
- Please do not take any medications that can cause blood
thinning including Aspirin, Plavix or ibuprofen, naproxen or any
other non-steroidal anti-inflammatories.
- Please Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Specialty: INTERNAL [**First Name3 (LF) 662**]
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**]-[**Location (un) **]/WESTW
Address: [**Street Address(2) 21600**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 17753**]
Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.
.
Department: RADIOLOGY
When: WEDNESDAY [**2133-10-14**] at 10:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: NEUROSURGERY
When: WEDNESDAY [**2133-10-14**] at 11:15 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 486, 5990, 2760, 4280, 2449, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4813
} | Medical Text: Admission Date: [**2163-3-23**] Discharge Date: [**2163-3-26**]
Date of Birth: [**2088-9-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male who
was originally admitted to care for hypoxia, hypertension,
and mental status changes. Reportedly, the patient had
abrupt onset of dyspnea and was found to be hypoxic. At
outside hospital, the gas on 100% FIO2 of 85, pCO2 30, pH
7.47 with a systolic blood pressure of 70. He denies other
symptoms at that time. Chest x-ray revealed extensive
bilateral pulmonary disease consistent with lymphangitic
carcinomatosis and perhaps pulmonary edema.
Electrocardiogram demonstrated inferior ST elevation and ST
depression in V2 and Q waves in the inferior leads. He did
have a history of an old inferior myocardial infarction.
Troponin-I peak at 1.92, peak CK at 210. CT scan of the
chest was negative for pulmonary embolus. Echocardiogram
demonstrated ejection fraction of 50% with posterior wide
hypokinesis, mild MR and mild TR. He was then transferred to
the [**Hospital6 **], where he underwent catheterization
revealing 90% lesion in the mid right coronary artery with
thrombus. He was referred to [**Hospital1 188**] for PCI of the right coronary artery lesion.
Catheterization here revealed 60-70% lesion in the mid circ
and distal circ in addition to the right coronary artery
lesion. The right coronary artery lesion was stented in two
places with much difficulty.
In the holding area, he was noted to have decreased mental
status and increased confusion. O2 sat was found to be 70%.
He was given Lasix, intravenous nitroglycerin, and placed on
100% nonrebreather at which time his oxygen saturation
improved to 90-100%. He was then transferred to the CCU for
further evaluation.
PHYSICAL EXAMINATION: Vitals at that time included a heart
rate of 58, blood pressure 132/61, respirations 19, and he
was 96% on nonrebreather. He is a pleasant man in no acute
distress. Pupils are small but reactive. Heart: He had a
regular, rate, and rhythm with a II/VI crescendo systolic
murmur. His lungs have bibasilar dry, rhonchorous, coarse
throughout especially in the lower lobe. Abdomen was soft,
nontender, nondistended with positive bowel sounds with no
hepatosplenomegaly. He had no clubbing, cyanosis, or edema.
PAST MEDICAL HISTORY:
1. Metastatic prostate cancer with bone metastases to the
right humeral.
2. Coronary artery disease status post myocardial infarction
six years ago treated with medical therapy. A recent ETT
showed inferior fixed defects, ejection fraction of 50%.
3. Hypertension.
4. Zoster.
5. High cholesterol.
6. Status post appendectomy.
HOME MEDICATIONS:
1. Atenolol 50.
2. Zocor.
3. Neurontin.
4. Vicodin.
5. Levaquin.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He lives with his daughter. [**Name (NI) **] positive
alcohol 1-2 drinks. He quit smoking tobacco 50 years ago.
HOSPITAL COURSE: Hospital course is relatively
uncomplicated. He was admitted to CCU. He was gently
diuresed with Lasix and intravenous nitroglycerin. He was
gradually weaned. His oxygen was gradually weaned down to 2
liters nasal cannula, however, there was not much improvement
following this intervention. It was thought that his O2
requirement could possible be due to a primary pulmonary
process that could have been lymphangitic carcinomatosis or
fibrosis, perhaps from her Taxotere therapy.
Patient was transfused 1 unit of packed red blood cells to
maintain his hematocrit above 30 with a recent coronary
event. His laboratories on admission were 17.7, 32.4
hematocrit, platelets 189. Sodium 144, potassium 3.8,
chloride 110, bicarb 21, BUN 42, creatinine 0.8, glucose 157,
calcium 8.7, magnesium 2.0, phosphorus 3.9.
Cardiovascular: He had two stents placed to his RCA. He was
continued on Plavix, aspirin, beta blockers, and ACE
inhibitor. He was kept on Integrilin for 18 hours.
Reportedly at the outside hospital, the patient was found to
have an atypical pneumonia. He was continued on Levaquin.
His QTC was monitored because of the prepencity of Levaquin
to lengthen QTC.
Patient was seen by Physical Therapy who said that he was
safe to be discharged home and recommended PT visit to
maximize rehabilitation.
He was discharged home in good condition after speaking with
the patient's oncologist with close followup to further
workup the primary lung process causing him to have a new
oxygen requirement. The patient was discharged home with
home O2.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg po q day x4 days.
2. Simvastatin 2 mg po q day.
3. Gabapentin 400 mg po bid.
4. Protonix 40 mg po q day.
5. Lasix 40 mg po q day.
6. Atenolol 50 mg q am, 25 mg q pm.
7. Aspirin 325 mg po q day.
8. Home O2 by 2 liters nasal cannula continuous.
9. Plavix 75 mg po q day.
FOLLOW-UP INSTRUCTIONS: The patient was to followup with Dr.
[**Last Name (STitle) 2912**] in two weeks. In addition, he has an appointment
with his oncologist the following week.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D.
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2163-3-27**] 15:33
T: [**2163-3-29**] 08:00
JOB#: [**Job Number 45323**]
ICD9 Codes: 486, 4280, 412, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4814
} | Medical Text: Admission Date: [**2194-10-22**] Discharge Date: [**2194-10-29**]
Date of Birth: [**2123-6-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Exploratory laparotomy, gastrotomy, extraction of approximately
1 liter of clot from gastric remnant and oversewing marginal
ulcer
History of Present Illness:
Mr. [**Known lastname 84279**] is a 71 year-old Russian with a history of
coronary artery disease s/p CABG and PCI [**7-/2194**] with DES, as
well as a remote history of gastric ulcers s/p resection of [**1-8**]
of his stomach, who was discharged earlier today after admission
for weakness, chest pain, and bright red blood per rectum. He
represents to the ED with an upper GI bleed.
.
The pt was discharged from [**Hospital1 **] earlier today with a HCT of 33.5.
At home he had emesis of bright red blood and EMS was called.
The volume of bright red blood he had while EMS was there is
unknown and his blood pressure was noted to be in the 70s by
EMS.
.
On arrival to the ICU vitals were 105 79/50 22 98%. He vomited
blood in the ED and passed bloody stool on arrival to the ED.
Over the first hour in the ED he put out 1500cc of bloody
emesis. His OG tube put out 100cc of bright red blood. His BPs
in the Ed were initially in the 70s yo 90s. HCT was 25.3 down
from 33.5 this AM. A cordis and 2 20 gauge IVs were placed. The
patient received 3L of fluid and 4 units of packed RBCs. His BP
after the packed RBCs was 140s. His WBC was 16.2. He was
discharged on both ASA and plavix as received doses of both
medications this Am. He required intubation with etomidate and
succ given repeated episode of bloody emesis. He was placed on
fentanyl and versed. In the ED he was grabbing his chest. His
EKG was notable for depressions in the lateral leads. He was
seen by GI who planned to scope him on arrival to the ICU and
surgery was also consulted.
.
On previous admission he required 12 units of packed red blood
cells and 2 EGDs. His stomach showed gastritis and his duodenum
was notable for an ulcer just distal to the gastroduodenal
anastomosis. He received electrocaudery during the first scope
and at the second scope a gold probe was applied for hemostasis.
.
On arrival to the ICU vitals were 98.7 141/87 88 19 100%. An a
line was placed and he was given 2 units of FFP and 1 bag of
platelets. HCT on arrival to the floor was 30.7. The patient
then received 2 units of blood and HCT was 33.9. An EGD was
performed and showed an ulcer at the site of anastamosis but no
evidence of active bleed. There was a large clot adherant to the
ulcer. It was injected with epinephrine.
.
Past Medical History:
-hx Bilroth I for ulcer many years ago
-hypertension
-dyslipidemia
-CABG: 3 vessels in [**Country 532**]; [**2186**] per patient
-PCI [**11/2193**] with diffuse native disease and grafts open. PTCA
and stenting of proximal LCx with BMS. [**7-/2194**] stenting of Lcx
with DES.
-appendectomy
Social History:
He previously smoked 1 PPD but quit in 12/[**2192**]. He has recently
decreased his alcohol intake from TID vodka but now drinks very
seldom. He lives with his wife.
Family History:
Noncontributory
Physical Exam:
VS: 98.7 141/87 88 19 100%
GENERAL: intubated and sedated
HEENT: bloody oropharynx, pupils constricted and reactive
CARDIAC: regular, no murmur appreciated
LUNGS: vented breath
ABDOMEN: Soft, NTND, +BS. No HSM or tenderness.
EXTREMITIES: Peripheral pulses not palpable but dopplerable.
Evidence of multiple vein graft harvesting sites
Pertinent Results:
Admission labs:
[**2194-10-21**] 11:35PM WBC-16.2*# RBC-2.89* HGB-8.5* HCT-25.3*
MCV-88 MCH-29.5 MCHC-33.7 RDW-15.9*
[**2194-10-21**] 11:35PM NEUTS-83.3* LYMPHS-13.4* MONOS-2.7 EOS-0.4
BASOS-0.3
[**2194-10-21**] 11:35PM PT-15.3* PTT-23.6 INR(PT)-1.3*
[**2194-10-21**] 11:35PM ALT(SGPT)-18 AST(SGOT)-14 LD(LDH)-128 ALK
PHOS-46 TOT BILI-0.6
[**2194-10-21**] 11:35PM GLUCOSE-231* UREA N-27* CREAT-1.0 SODIUM-142
POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-24 ANION GAP-13
[**2194-10-22**] 01:58AM WBC-13.0* RBC-3.65*# HGB-10.8*# HCT-30.7*
MCV-84 MCH-29.6 MCHC-35.1* RDW-15.9*
[**2194-10-22**] EGD :
Extensive solid clot extending from the stomach into the
duodenum.
Clot appeared to be coming from and adherent to the previously
seen ulcer at the anastamotic site.
The ulcer appeared to be at least 2 cm but possibly bigger as at
least half was obscured by clot. There was no evidence of active
bleeding.
Epinephrine injection was performed to attempt to prevent
rebleeding.
The remainder of the stomach and duoCOMPLETE BLOOD COUNT WBC RBC
Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2194-10-28**] 09:35 34.3*
Source: Line-picc
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2194-10-21**] 23:35 83.3* 13.4* 2.7 0.4 0.3
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2194-10-27**] 05:58 204
Source: Line-picc
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2194-10-22**] 10:47 287
Source: Line-art
[**2194-10-22**] 03:04 262
Source: Line-arterial
LAB USE ONLY
[**2194-10-27**] 05:58
Source: Line-picc
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2194-10-28**] 06:40 160*1 9 0.5 143 4.0 109* 25 13
Brief Hospital Course:
Mr. [**Known lastname 84279**] is a 71 year-old man with a history of CAD s/p
recent DES on ASA and Plavix presents with recurrent upper GI
bleed with known ulcer at the site of his anastomosis. He was
admitted to the Medical service for management and then was
intubated for airway protection.
In the MICU he was resuscitated with 11 units of pRBC in the
first 12 hours of his hospitalization t maintain a HCT in the
low 30's. A Protonix drip was started, ASA and Plavix were
held. EGD demonstrated ulcer at the site of anastomosis but no
evidence of active bleed. Pt with large adherent clot.
Epinephrine was injected. However, he continued to lose blood.
He was taken to the Operating Room urgently for an exploratory
laparotomy.
He tolerated the procedure well and returned to the ICU in
stable condition maintaining a stable hematocrit and blood
pressure. He was gradually weaned and extubated from the
respirator the next day and subsequently developed some throat
discomfort and occasional wheezes. He improved with humidified
air and nebulizer treatments. ENT was consulted and a bedside
laryngoscopy was done which was normal with no edema or
obstruction.
From a cardiac standpoint given his history he underwent R/O Mi
protocol at the time of his admission and post operatively. He
had a mild Troponin bump to 0.08 along with lateral ST
depression on his EKG which was attributed to demand ischemia in
the setting of a GI bleed. He had no chest pain post
operatively.
Following transfer to the Surgical floor he continued to make
good progress. Due to his poor nutritional status prior to
surgery he began hyperalimentation but was soon able to tolerate
a regular diet and gradually increased his calories. He was
having normal bowel movements and his abdominal wound was
healing well.with minor redness at the staple sites.
He was evaluated by the Physical Therapy service due to his
recent multiple admissions and deconditioning and he worked with
them daily to improve his endurance.
Afre an uncomplicated reovery he was discharged to home on
[**2194-10-29**] and will return for staple removal next week.
Medications on Admission:
pantoprazole 40 mg po q12
-clopidogrel 75 mg po daily
-senna 8.6 mg PO BID
-aspirin 81 mg po daily
-atorvastatin 20 mg po daily
-docusate sodium 100 mg po BID
-isosorbide mononitrate 60 mg po daily
-cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection DAILY (Daily) for 2 days.
-amlodipine 5 mg (2) Tablet PO DAILY
-metoprolol tartrate 25 mg PO BID
-enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/HA.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Enteric coated.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding marginal ulcer
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-14**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment [**2194-11-4**]. your staples will be removed at that time.
Completed by:[**2194-10-29**]
ICD9 Codes: 2851, 4019, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4815
} | Medical Text: Admission Date: [**2110-8-5**] Discharge Date: [**2110-8-23**]
Date of Birth: [**2055-6-23**] Sex: M
Service: SURGERY
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
colonoscopy
colostomy and mucous fistula
History of Present Illness:
55 year old man with a history of rectal cancer s/p resection
([**7-13**]) and ileostomy takedown [**1-14**], as well as cirrhosis [**2-5**]
hepC + EtOH abx, who was recently admitted with SBO ([**5-14**], to
surgery/[**Doctor Last Name 1120**]) now presents with abdominal discomfort x 1day
with nausea and fever at home to 100.0. He denies emesis,
reports flatus, with recent BM last PM, no brbpr or melena. He
typically moves his bowels 5-6 times per day - had normal BM's
yesterday (non bloody, brown), none today- but states he has not
eaten today due to pain. Pain is located around his scar from
prior ileostomy.
States that he has been feeling better since arriving at the ED,
and currently is hungry and pain free.
No chest pain, dyspnea or palpatations. ROS otherwise negative
in full.
In the ED: 98.2 70 131/77 18 98% RA; repeat temp at 2110 was
101.9. Exam notable for soft abd with mild tenderness @ RLQ, no
rebound or guarding; prior ostomy site clean and intact w/o
erythema or induration. A CT abdomen with contrast demonstrated
no signs of obstruction. A chest CXR did not demonstrate focal
consolidation. Though his pain had improved, he was admitted
for fever workup.
Past Medical History:
Hep C/EtOH Cirrhosis, T2N0 Rectosigmoid CA sp LAR w/ diverting
loop ileostomy ([**7-13**]) and Ileostomy takedown ([**1-14**]), HTN, Aortic
Stenosis, GERD, EtOH abuse
Past Surgical History:
Open LAR w/ diverting loop ileostomy c/b ureteral injury s/p
reimplantation, anastomotic stricture s/p balloon dilitations &
stent placement, Ileostomoy takedown [**1-24**] c/b wound infection.
Social History:
He lives alone. He smokes 1.5 ppd since age 15. He has largely
quit EtOH for the last 3 yrs but reports drinking occasionally.
He used to drink 0.5l hard alcohol. He uses marijuana but denies
IVDU. He is currently unemployed.
Family History:
No history of liver disease or malignancies
Physical Exam:
Obese man, NAD
VS: T 100, 124/69, 71, 18, 97% RA
HEENT: MMM
PULM: lungs are clear in all fields
CV: RRR no MRG
ABD: obese, many healed surgical scars, mildly tender over site
of prior ileostomy, no rebound or guarding, hypoactive bowel
sounds
ext: no c/c/e
neuro: fluent speech, moves all 4
psych: appropriate affect
Pertinent Results:
[**2110-8-5**] 12:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
[**2110-8-5**] 12:26PM URINE RBC-<1 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2110-8-5**] 12:26PM PLT COUNT-106*#
[**2110-8-5**] 12:26PM NEUTS-85.5* LYMPHS-9.6* MONOS-3.6 EOS-1.1
BASOS-0.2
[**2110-8-5**] 12:26PM WBC-5.0# RBC-3.61* HGB-12.0* HCT-34.3* MCV-95
MCH-33.2* MCHC-35.0 RDW-15.0
[**2110-8-5**] 12:26PM ALBUMIN-4.0
[**2110-8-5**] 12:26PM LIPASE-27
[**2110-8-5**] 12:26PM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-70 TOT
BILI-0.8
[**2110-8-5**] 12:26PM GLUCOSE-164* UREA N-15 CREAT-1.0 SODIUM-135
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13
[**2110-8-5**] 09:58PM LACTATE-1.0
.
CXR: prelim negative
CT ABD: prelim: Relative transition with dilated fecal loaded
sigmoid colon proximal to the point of the sigmoid-rectal
reanastomosis most compatible with a component of anastomatic
narrowing. No evidence of small bowel obstruction though the
ileoileo reanastomosis has a tethered appearance to the anterior
abdominal wall. No evidence of abcess. Cirrhosis. Sequelae of
portal hypertension.
[**8-8**] TTE: Conclusions
The left atrium is dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 65%). Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.8 cm2). The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
No definite vegetations seen
Compared with the findings of the prior study (images reviewed)
of [**2107-9-28**], the findings are similar.
If clinically indicated, a transesophageal echocardiographic
examination is recommended.
IMPRESSION: no definite vegetations seen but best excluded by
transesophageal echocardiography
[**8-14**] KUB:
FINDINGS: There is no evidence of free air. The previously seen
dilated
loops of bowel are much less prominent on today's study. There
is a
[**Last Name (un) **]-rectal stent seen within the pelvis. The visualized osseous
structures are unremarkable.
[**2110-8-16**] Doppler Liver
IMPRESSION:
1. Echogenic cirrhotic liver without discrete lesions.
2. Doppler assessment of the hepatic vasculature including the
portal and
superior mesenteric veins and main hepatic artery are widely
patent with
appropriate waveforms.
3. Splenomegaly.
4. Cholelithiasis.
Brief Hospital Course:
- Abdominal Pain: Mr. [**Known lastname 32126**] was initially admitted to the
medical service for work-up of abdominal pain and fevers. He had
an admission CT that revealed fecal loading with an associated
dilated proximal colon. There was no evidence of obstruction,
ascites, or colitis per report. He was placed on an aggressive
bowel regimen and had 2 BMs within 24 hours of admission. U/A
and CXR were negative. His diet was slowly advanced, which he
tolerated well. He was started on Oxycodone, which was titrated
up to 10mg Q4H PR. Pt underwent colonoscopy with dilation of
anastamotic stricture on [**2110-8-11**] which he tolerated well,
however, afterwards became apneic requiring transfer to ICU. A
metal stent was placed on [**8-13**] which he tolerated and f/u KUB
showed decreased bowel distension. On [**8-14**], his stent was
dislodged and the following day it was removed and he was
transferred to the transplant service for evaluation. He had an
abdominal [**Month/Year (2) 950**] performed to assess his liver vasculature,
which showed patent vessels. He went to the OR on [**8-19**] for end
colostomy and mucous fistula. He returned to the floor in stable
condition and on POD 1 his diet was advanced to clears and he
was restarted on his pre-operation medications. He ambulated to
chair and his pain was controlled on oral pain medication. On
POD 2 he was advanced to a regular diet and his foley was
discontinued. He complained of abdominal pain around his ostomy
site but that was controlled on narcotics and he ambulated
within his room. He was evaluated by physical therapy on [**2110-8-22**]
and was cleared to go home. He was in stable condition and ready
for discharge to home with visiting nurse services on [**2110-8-23**].
- GPC bacteremia: Admission blood cultures grew GPC in pairs and
chains. He was started empirically on Vancomycin and Cefazolin,
which was narrowed to Vancomycin monotherapy. He continued to
have daily evening fevers. Speciation revealed Strep viridans so
abx coverage was narrowed to ceftriaxone. Flagyl was also on
for GI coverage. TTE was neg for vegetations and f/u cultures
were neg. Because of the concern for over sedation, it was
decided to treat the patient empirically for endocarditis with 4
weeks of ceftriaxone. A PICC line was placed and the patient
was sent home with IV ceftriaxone and flagyl until [**9-5**]. He is
to follow up with ID on [**9-4**].
- Apnea: After the colonoscopy with dilation of anastatamotic
stricture, pt became apneic on the floor and a code was called.
Pt required high doses of sedatives/narcotics to be comfortable.
He received Fentanyl 300mg IV and Versed 8mg IV during the
procedure. Given high doses of fentanyl/versed in the setting
of liver disease, patient was monitored after the procedure for
an hour. During this time, he was awake and well. When he was
brought up to the medicine floor he became unresponsive and
apneic. His O2 saturation was 100% at this time, and he was
hemodynamically stable with BP ~140/80 and HR 71. After
receving narcan, patient became responsive and respiratory rate
normalized. He was transfered to [**Hospital Unit Name 153**] for observation.
Overnight, pt remained alert and comfortable. Pt was breathing
well on room air. Sedating meds were slowly reintroduced.
- Pancytopenia: Patient had a pancytopenia on admission, which
is his baseline. There were no signs of overt GI bleeding and no
hemodynamic instability that would suggest a hematologic
catastrophe. He was given neupogen, to which he responded with
an increase in his WBC. Most likely, pancytopenia is secondary
to history of chronic alcohol abuse.
- Hypertension: BP was stable on his home meds.
- Cirrhosis: There was no evidence of an acute decompensation,
although varices and splenomegaly were noted on CT abdomen. He
should follow w/ Dr. [**Last Name (STitle) 497**] as outpt per routine.
- Insomnia: His home Seroquel, Neurontin, Ambien were continued
initially however held in ICU given apnea [**2-5**] oversedation. He
was restarted on these medications while on the transplant
service.
Medications on Admission:
1. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
2. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. nadalol Sig: Twenty (20) mg qAM, 60 mg qPM
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Wellbutrin 100 mg Tablet Sig: Two (2) Tablet PO once a day.
8. Neurontin 1500 mg HS
Discharge Medications:
1. nadolol 20 mg Tablet Sig: Three (3) Tablet PO QPM (once a day
(in the evening)).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO QAM (once a day (in the morning)).
4. nadolol 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
5. spironolactone 100 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for pain.
8. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
9. gabapentin 300 mg Capsule Sig: Five (5) Capsule PO HS (at
bedtime).
10. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
13. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for pain.
14. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours).
15. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours).
16. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
strep viridans bactremia
Colonic stricture
Colon cancer s/p resection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted initially to the medicine service with several
days of fever and abdominal pain and found to have bacteria in
your blood. You underwent a colonoscopy which showed a stricture
at the anastomosis. Please call Dr.[**Name (NI) 1369**] office at
[**Telephone/Fax (1) 673**] if you experience any fevers, chills, high output
blood in your ostomy bag, difficulty tolerating solids or
liquids, increasing pain, or redness around the wound site.
Do not do any heavy lifting >10 lbs for six weeks. Do not drive
while taking narcotic medications. Please resume a regular diet
and your home medications as well those prescribed from the
hospital. You can shower but do not take baths or showers for at
least a week after surgery or until follow-up in clinic. You
were started on antibiotics for the bacteria in your blood,
which will continue until [**9-5**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2110-8-27**] 10:40
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 32437**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2110-9-4**]
9:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2110-9-4**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]., MD [**2110-9-30**] 10:15a at [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) **]. Colon/Rectal CC3 (NHB)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2110-8-23**]
ICD9 Codes: 5715, 7907, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4816
} | Medical Text: Admission Date: [**2151-9-29**] Discharge Date: [**2151-10-12**]
Service: NMED
Allergies:
Codeine / Ether / Fish Product Derivatives
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Change in mental status, Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 84 year old female with past medical history
of hypertension, abdominal aortic aneurysm who presented on
[**2151-9-28**] as a transfer from [**Hospital **] hospital for evaluation of
right cerebellar hemorrhage.
Patient lives at an [**Hospital3 **] facilty. When she failed to
show up at scheduled breakfasst meal on day of admission, aides
went to check on her in her room. Found lying on bed in room.
They noted her to be difficult to arouse. EMS was called at
12:27
and she was transferred to [**Hospital **] hospital.
On arrival there, initial BP 191/133. Heart rate into 150s. Exam
there notes her to be arousable to voice and pupil asymmetry
with
L>R. Noncontrast head CT showed right cerebellar hemorrhage. She
was started on a nipride drip for blood pressure control.
Cardizem given for rapid heart rate. Transferred here.
On arrival here, initial temp 98.3, HR 120s atrial fibrillation,
BP 122/95. In ED, given dose of Bactrim DS for possible urinary
tract infection.
On review of systems, she denies headaches, visual changes, word
finding difficulties, focal weakness, paresthesias, chest pain,
shortness of breath, palpitations. She has had intermittent
nausea and emesis. She reports feeling generally weak.
Past Medical History:
1. Hypertension
2. Diverticulitis
3. Abdominal aortic aneurysm
4. Glaucoma
5. Osteoarthritis
Social History:
Widowed. She has 8 children. Lives in an [**Hospital3 **]
facility. Denies tobacco, drug or alcohol use. Her daughter
[**Name (NI) 5321**] [**Last Name (NamePattern1) 7518**] is her HCP [**0-0-**].
Family History:
No history of stroke or seizure.
Physical Exam:
Tc: 98.3 BP:137/77 (116-143/44-91) HR: 92 (87-150)
RR: 20 O2Sat.: 98-100%/RA
Gen: WD/WN, comfortable appearing female, lying on left side in
gurney , NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, "[**Hospital1 **], the [**Hospital **] hospital", and
"Wednesday, [**9-11**]-00-2". Able to recite [**Doctor Last Name 1841**] forwards and
backwards. Speech fluent with good comprehension and repetition.
Naming intact. Moderate dysarthria. No paraphasic errors. No
apraxia, no neglect.
Cranial Nerves:
I: Not tested
II: Pupils asymmetric L>R, react briskly. Visual fields are full
to confrontation.
III, IV, VI: Extraocular movements intact bilaterally with right
beating nystagmus, worse on right lateral gaze. Saccadic
pursuits.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-14**] throughout. No pronator drift.
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right 2 2 2 1 1
Left 1 1 1 1 1
Grasp reflex absent. Toes downgoing bilaterally.
Coordination: Dysmetria and ataxia on finger-nose-finger and
heel-to-shin right>left.
Pertinent Results:
[**2151-10-5**] 05:40AM BLOOD WBC-9.3 RBC-3.91* Hgb-10.1* Hct-31.6*
MCV-81* MCH-25.9* MCHC-32.1 RDW-16.3* Plt Ct-193
[**2151-9-29**] 09:41PM BLOOD Neuts-77.1* Lymphs-16.0* Monos-6.5
Eos-0.3 Baso-0.1
[**2151-10-5**] 05:40AM BLOOD Plt Ct-193
[**2151-10-4**] 04:55AM BLOOD PT-13.5 PTT-34.3 INR(PT)-1.2
[**2151-10-5**] 05:40AM BLOOD Glucose-111* UreaN-18 Creat-1.0 Na-138
K-3.9 Cl-105 HCO3-25 AnGap-12
[**2151-9-30**] 03:32AM BLOOD Fibrino-203
[**2151-10-5**] 05:40AM BLOOD ALT-10 AST-7 AlkPhos-58 TotBili-0.9
[**2151-9-28**] 07:25PM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2151-9-29**] 02:00AM BLOOD cTropnT-0.07*
[**2151-9-29**] 06:42AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2151-10-1**] 03:45AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2151-10-5**] 05:40AM BLOOD Albumin-3.4 Calcium-9.1 Phos-3.1 Mg-1.8
[**2151-10-1**] 03:45AM BLOOD %HbA1c-6.2*
[**2151-10-1**] 03:45AM BLOOD Triglyc-135 HDL-48 CHOL/HD-4.2
LDLcalc-128
[**2151-10-1**] 03:45AM BLOOD TSH-2.1
[**2151-10-1**] 03:45AM BLOOD Free T4-1.0
Brief Hospital Course:
She was found to have a right cerebellar hemorrhage on CT Scan.
She was also found to be in atrial fibrillation (new onset).
She was initially admitted to the Neuro-ICU for further
management. On [**9-30**] she was transferred to the Neurology
floor.
1. Neuro:
The patient was admitted to the neuro-ICU. Neurosurgery was
also consulted and followed the patient during her
hospitalization-they felt that surgical management was not
indicated. The most likely etiology of her hemorrhage is HTN.
She was started on mannitol 25g IV q6hours which was tapered,
then d/c'd on [**10-1**]. To keep her SBP<140, she was started on
labetolol drip. She was switched to metoprolol and her blood
pressure remained controlled. All anti-platelet agents were
held initially-she will re-start ASA 81mg on [**10-13**] (2
weeks post hemorrhage). She will need to start Coumadin in the
future for stroke prevention (since she has Afib). Coumadin
should be started in one month. Please discontinue aspirin once
Coumadin is initiated. Her neurologic exam has remained stable,
although her ataxia has improved to some degree. She will need
follow up imaging (MRI/MRA) in one month to evaluate parenchyma
and intracranial circulation. She should also follow up in
stroke clinic with Dr. [**Last Name (STitle) **] after the MRI is done.
2. CV:
She was found to be in rapid Afib (new onset). She was started
on a labetalol drip and converted to metoprolol with adequate
rate control. Anti-coagulation was contra-indicated in the acute
setting of ICH and Coumadin was therefore not started (this
should be started in one month as noted above). She had mild
troponinin elevation 0.11 which trended down over her course.
Echo showed moderately dilated left and right atria, mild
symmetric left ventricular hypertrophy, moderate global left
ventricular hypokinesis with preservation of basal wall motion.
Overall left ventricular systolic function is moderately
depressed (EF 30-39%), Moderate AS, Mild to moderate ([**12-11**]+)
mitral regurgitation. She was started on ACEI. Cardiology was
consulted and recommended increasing metoprolol as tolerated to
reach goal HR of 60bpm, starting amiodarone 400mg tid for 2
weeks, then decreasing dose to 400mg daily for two weeks, then
decreasing the dose again to 200mg daily. Because the patient
was intermittently in NSR, we did not pursue TEE and
cardioversion. Cardiology also recommended outpatient stress
test to evaluate for CAD.
She should have her TFTs and LFTs checked as an outpatient since
she will be on Amio.
4. Endo:
Free T4 and TSH were normal. Her HbA1C was mildly elevated.
She should follow a diabetic diet and have her fingersticks
monitored daily while in rehab. Please re-check her HbA1C as an
outpatient.
7. ID:
She was found to have and elevated WBC and left shift. Urine
culture grew pan sensitive E.coli. She is s/p 7 day course of
Levofloxacin.
8. Ophthal:
Glaucoma meds were continued.
9. Rehab:
Pt was followed by PT and will require continued physical
therapy.
Medications on Admission:
1. Zestril 40 mg po qd
2. Norvasc 5 mg po qd
3. Celebredx 200 mg po bid
4. ECASA 325 mg po qd
5. Xalatan eye drops OU qHS
6. Alphagan eye drops OU [**Hospital1 **]
7. Trusopt eye drops OU [**Hospital1 **]
8. Paxil 12.5 mg po qd
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*1 * Refills:*2*
2. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
3. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*1 * Refills:*2*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO QD ().
Disp:*15 Tablet(s)* Refills:*2*
5. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
Disp:*1 * Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. 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*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
10. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
().
Disp:*30 Tablet(s)* Refills:*2*
11. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO three
times a day for 13 days.
Disp:*39 Tablet(s)* Refills:*0*
12. Amiodarone HCl 400 mg Tablet Sig: One (1) Tablet PO once a
day for 14 days: Start Monday, [**10-18**].
Disp:*14 Tablet(s)* Refills:*0*
13. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: Start [**2151-11-1**].
Disp:*30 Tablet(s)* Refills:*2*
14. To start [**10-13**]: ASA 81mg po qd
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Right Cerebellar Hemorrhage
Discharge Condition:
Improved: Exam sig for mild dysarthria, nystagmus on right
lateral gaze, ataxia on finger to nose and heel to shin
bilaterally (right>>left)at time of discharge
Discharge Instructions:
You will be discharged to rehabilitation hospital for continued
physical therapy. Please continue to take your medications as
directed. In one month, you need to have an MRI/MRA of the
brain performed at [**Hospital3 **]. Please call radiology
[**Telephone/Fax (1) 57465**] to schedule the MRI. In one month, you should
start taking Coumadin for stroke prevention. This medication is
a blood thinner and requires frequent monitoring by your primary
care physician. [**Name10 (NameIs) 357**] return to the emergency room for
evaluation if you experience change in your mental status such
as excessive lethargy or confusion, dizziness, weakness,
numbness, or difficulty speaking.
Followup Instructions:
1. Please call [**Telephone/Fax (1) 57465**] to schedule an appointment for MRI
and MRA in one month.
2. Please call Dr.[**Name (NI) 34043**] office [**Telephone/Fax (1) 657**] to make an
appointment after discharge from rehab hospital. (You should
have the MRI prior to your appointment with Dr. [**Last Name (STitle) **]
3. Please schedule an appointment with your primary care doctor
after discharge from Rehab. Your doctor will need to start you
on Coumadin and monitor your INR. You should also have your
thyroid funcion tests and liver function tests re-checked in 2
weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 4019, 5990, 486, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4817
} | Medical Text: Admission Date: [**2120-11-25**] Discharge Date: [**2120-12-6**]
Date of Birth: [**2067-2-8**] Sex: M
Service: CARDIOTHORACIC SURGERY
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: This is a 53-year-old man with a
severe three-vessel coronary artery disease based on a
[**11-19**] catheterization, hypertension, diabetes mellitus,
status post kidney-pancreas transplant in [**2107**] with a recent
admission for cholangeitis, who reported mild exertional
angina which was relieved by Nitroglycerin.
He also reported left foot pain which was decreased with
Oxycodone. He denied any shortness of breath or abdominal
pain.
His blood sugars remained stable since [**2107**].
PAST MEDICAL HISTORY: Diabetes mellitus. Status post
pancreas transplant in [**2107**]. Cadaveric renal transplant
times two in [**2107**] and [**2114**]. Left foot Charcot deformity.
Polycythemia. Status post appendectomy. Status post
cholecystectomy. Status post parathyroidectomy. Status post
multiple AV grafts. Status post right retinal detachment and
right eye blindness.
SOCIAL HISTORY: He has a 20 pack-year smoking history. He
currently smokes one pack per week. He no alcohol use. No
illicit drugs. He is married. He lives in [**Location 686**] with
his daughter in an apartment.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Lopressor 50 twice a day, Aspirin
325 mg once a day, Prednisone 5 mg once a day, CellCept [**Pager number **]
mg twice a day, Prograf 5 mg twice a day, TUMS, Colace,
Oxycodone p.r.n., Nitroglycerin p.r.n.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile, pulse 55, oxygen saturation 100% on room air.
General: Oriented times three. The patient was in no
apparent distress. Head and neck: Right eye blindness.
Moist mucous membranes. He had an old parathyroidectomy
wound. No carotid bruit. Cardiovascular: Regular, rate and
rhythm. There was a 2 out of 6 systolic ejection murmur.
Lungs: Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended with multiple well-healed surgical
scars. Extremities: There were multiple upper extremity
grafts and fistula scars. His left antecubital scar has a
fistula underlying it with a palpable thrill. His left side
has gauze where his Charcot foot deformity is.
LABORATORY DATA: [**11-19**] catheterization showed
two-vessel disease status post systolic and diastolic
dysfunction, ejection fraction of 50%, apical and
hypokinesis. His LVEDP is 18.
All of his preoperative labs were within normal limits and
notable for a hematocrit of 50.1 and creatinine of 1.1.
HOSPITAL COURSE: Once the patient was consented, the patient
was taken to the Operating Room for a coronary artery bypass
grafting procedure. Please refer to the operative note
dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] detailing the specifics of this
surgery. The patient tolerated the procedure well and was
transferred to the CSRU in good condition on Neo-Synephrine
and Propofol drips.
Both of these drips were discontinued on the night of
surgery. The patient was extubated soon after.
On postoperative day #2, the patient was transferred to the
floor where he stayed until his discharge on [**2120-12-6**], when he was discharged home with VNA care.
Neurological: The patient presented with a blind right eye
and continued throughout the hospital course with a blind
right eye.
The patient's pain was controlled well with Oxycodone;
however, the patient did begin complaining of some
hallucinations on postoperative day #8, which seemed to
improve once the patient was taken off Oxycodone and other
opiates.
From the point the opiates were discontinued until his
discharge, the patient did not really complain of any pain
and seemed to be stable with just taking Tylenol.
A psychiatric consult was obtained, and they diagnosed the
patient with improving postoperative delirium, as well as
schizo-type/paranoid personality disorder; however, no
pharmacologic interventions were recommended.
Cardiovascular: The patient presented with coronary artery
disease, and he underwent a coronary artery bypass grafting
procedure. The surgery went well, and he did very well
postoperatively.
Postoperatively the patient did have some atrial fibrillation
which was converted with Amiodarone. The patient continued
on Amiodarone and should continue this as an outpatient.
The patient's chest and mediastinal tubes were pulled on
postoperative day #5. Of note, the patient was orthostatic
and somewhat dehydrated and had some orthostatics and also
had a bump in his creatinine. The patient was given boluses
to resuscitate him which allowed his renal numbers to
improve.
Pulmonary: The patient was intubated postoperatively until
postoperative day #1. He had no further pulmonary
complaints.
Gastrointestinal: The patient tolerated a regular diet soon
after his surgery.
Heme: There were no heme issues.
Endocrine: The patient did have an increased Insulin
requirement after surgery and actually required baseline
Insulin dosing prior to discharge, which was recommended to
be continued after surgery. His glycated hemoglobin level
however was normal, indicating that the patient did not have
high sugars prior to surgery.
In addition, the patient was noted to have increased TSH and
normal free T4 levels, possibly indicating a subclinical
hypothyroidism. The patient was started on Synthroid and
will be followed as an outpatient.
GU: The patient was diagnosed with a urinary tract infection
on postoperative day #2. His Foley catheter was
discontinued, and he was started on Levaquin which was
continued through the rest of his admission for a total of 14
days.
In addition, the patient did have some signs of acute renal
failure with an increasing creatinine which reached its peak
of 1.7 on postoperative day #8 and dropped back down to 1.3
which was very close to his baseline of 1.1 by the time of
discharge.
Transplant: Due to the dose of the Amiodarone and
Levofloxacin, the patient's Prograf requirement decreased,
and his outgoing dose of Prograf was 4 mg twice a day rather
than the 5 mg twice a day on admission.
In addition with respect to his pancreas, he did an
increasing Insulin requirement. With his kidney, he did have
a slight peak in his creatinine level which resolved itself
with hydration. Moreover, the renal transplant ultrasound on
[**12-4**] did not show any abnormalities.
On [**12-6**], the patient was discharged home with VNA care
to assist with ADLs, medication administration, evaluation
for home health aide, assist with blood glucose monitoring
and wound care and inspection.
DISCHARGE DIAGNOSIS:
1. Pancreatic transplant.
2. Diabetes, type 1.
3. Diabetic retinopathy.
4. Diabetic nephropathy.
5. Status post left upper extremity AV fistula, now with
pseudoaneurysm.
6. Status post cadaveric renal transplant times two in [**2107**]
and [**2114**].
7. Venous stasis.
8. Charcot foot.
9. Hypertension.
10. Angina pectoris.
11. Polycythemia.
12. Coronary artery disease status post coronary cardiac
catheterization.
13. Status post coronary artery bypass grafting.
14. Urinary tract infection.
15. Atrial fibrillation.
16. Hypothyroidism.
17. ................ hypertension.
18. Postoperative delirium.
19. Schizo-type personality.
20. Hypocalcemia.
FOLLOW-UP: He is recommended to have follow-up appointments
with Dr. ............, his primary care physician, [**Last Name (NamePattern4) **] [**12-28**]
weeks to discuss his blood sugars, as well as his thyroid
function. He is also recommended to have follow-up with Dr.
................... in [**1-29**] weeks and with Dr. [**Last Name (STitle) 1537**] in one
month. He also has follow-up appointments with Dr. [**Last Name (STitle) 16991**] of
Hematology and with Dr. [**Last Name (STitle) 15473**] of Transplant Surgery.
DISCHARGE MEDICATIONS: CellCept [**Pager number **] mg twice a day,
Prednisone 5 mg once a day, Prograf 4 mg twice a day,
Amiodarone 200 mg twice a day for 10 days, then 200 mg p.o.
once a day, Metoprolol 12.5 mg twice a day, Aspirin 325 once
a day, Levofloxacin 500 mg once a day for 5 days, Plavix 75
mg p.o. q.d., TUMS 5000 mg p.o. b.i.d., Colace 100 mg p.o.
b.i.d., hold for loose stools, Zoloft 25 mg p.o. once a day,
Synthroid 15 mcg p.o. q.d., Insulin sliding scale during
which she gets 12 U q.a.m. and 5 U q.p.m., and then a regular
Insulin sliding scale.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2120-12-16**] 14:41
T: [**2120-12-16**] 15:22
JOB#: [**Job Number 39740**]
ICD9 Codes: 4111, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4818
} | Medical Text: Admission Date: [**2126-8-26**] Discharge Date: [**2126-8-31**]
Service: Medicine
IDENTIFICATION/CHIEF COMPLAINT: The patient is an 80 year
old female who was admitted for a lower gastrointestinal
bleed from [**Hospital1 5042**].
PAST MEDICAL HISTORY: 1. Coronary artery disease; patient
has had coronary artery bypass grafting times two with
saphenous vein grafts to the posterior descending artery and
left anterior descending artery as well as aortic valve
replacement for critical aortic stenosis and tricuspid valve
repair in [**2126-5-14**] at [**Hospital6 1129**];
postoperative course complicated by a stroke, renal failure,
tracheotomy, percutaneous endoscopic gastrostomy tube
insertion and tracheal stenosis. 2. Hypertension. 3.
Chronic renal failure. 4. Chronic obstructive pulmonary
disease. 5. Hyperthyroidism. 6. Clostridium difficile.
7. Methicillin resistant Staphylococcus aureus/Klebsiella
pneumoniae. 8. Tracheal stenosis.
ALLERGIES: Codeine.
MEDICATIONS ON ADMISSION: Atenolol, Epogen, Flagyl, Pepcid,
albuterol, Combivent, l-thyroxin, metoclopramide, NPH
insulin, sliding scale insulin, vitamin C, Nepro, Flovent,
trazodone, iron sulfate, renal multivitamins, heparin
subcutaneously.
HISTORY OF PRESENT ILLNESS: The patient was transferred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for lower
gastrointestinal bleeding at [**Hospital1 5042**]. The patient was noted
to pass large blood clots from her rectum and was
subsequently hypotensive at [**Hospital1 5042**]. The patient was
transferred here for stabilization. She underwent a
colonoscopy which demonstrated a proctosigmoiditis. The
patient was treated with Rowasa and hydrocortisone enemas as
recommended by the gastroenterology service. During her
stay, the patient also was followed by the nephrology service
for dialysis treatments. The patient was maintained on her
medications as she had been on at [**Hospital1 5042**].
PHYSICAL EXAMINATION: The patient, when transferred out of
the Intensive Care Unit to the medical service, was in no
acute distress. She had stable vital signs and she was
afebrile. On neurological examination, the patient was
responsive to voice and seemed to communicate with facial
expressions. She obeyed commands in all of her extremity
except for her right arm, which was related to her previous
stroke. On cardiovascular examination, the patient had
normal heart sounds and no murmurs appreciated. The
respiratory examination demonstrated coarse breath sounds
bilaterally. On abdominal examination, the patient had a
percutaneous endoscopic gastrostomy tube and a slightly
distended abdomen, bowel sounds were present, she was soft
and nontender. On musculoskeletal examination, the patient
did not have any edema.
HOSPITAL COURSE: The [**Hospital 228**] hospital course proceeded as
stated in the history of present illness. She also underwent
a procedure on [**2126-8-30**] in the Operating Room for a
T-tube change and rigid bronchoscopy. She was transferred to
the Post Anesthesia Care Unit and subsequently to the floor
in stable condition. In initial attempt at capping the
T-tube was made and the patient was not able to tolerate it
immediately postoperatively.
The gastroenterology division recommended that the patient
was likely to have some ongoing bleeding from her
proctosigmoiditis and, thus, will need continued monitoring
of her hematocrit. She was also recommended to continue with
both her Rowasa and hydrocortisone enemas. The
hydrocortisone enemas were to be discontinued on [**2126-9-5**]. Her Rowasa enemas were to continue once a day for a
month and then change to an as needed basis. It was also
recommended that the patient should follow up with an
affiliated gastroenterology with [**Hospital1 5042**].
DISPOSITION: The patient was discharged to [**Hospital1 5042**] in
satisfactory condition on [**2126-8-31**].
DISCHARGE MEDICATIONS:
Protonix 40 mg per PEG-tube q.d.
Flagyl 250 mg per PEG-tube t.i.d.
Levofloxacin 250 mg per PEG-tube q.o.d.
Rowasa enema p.r.q.p.m. times one month then p.r.n.
Hydrocortisone enema p.r.q.a.m. until [**2126-9-5**].
Metoclopramide 5 mg per PEG-tube q.6h.
L-thyroxine 0.15 mg per PEG-tube q.d.
Ritalin 5 mg per PEG-tube b.i.d.
Nepro tube feeds 10 cc/hour per PEG-tube, advance q.4h. until
goal is reached and held for residuals greater than 150 cc.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 26201**]
MEDQUIST36
D: [**2126-8-30**] 17:56
T: [**2126-8-30**] 19:35
JOB#: [**Job Number 35391**]
ICD9 Codes: 5789, 4275, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4819
} | Medical Text: Admission Date: [**2194-1-2**] Discharge Date: [**2194-1-7**]
Date of Birth: [**2165-8-10**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Hydroxyzine / Chlorpromazine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
RUQ/epigastric pain c/w prior episodes of pancreatitis -
admitted to MICU with persistent tachycardia likely due to EtOH
withdrawal
Major Surgical or Invasive Procedure:
Midline placement
History of Present Illness:
Patient is a 28 yo male with pmhx depression, etoh
abuse/withdrawl, alcoholic pancreatitis who presents with 10/10
epigastric/RUQ pain radiating to his back. Patient reports the
pain feels like severe muscle cramping/stabbing c/w prior
episodes of pancreatitis after heavy drinking. The patient
reports that he is currently having problems with his fiance and
decided to drink [**12-4**] gallon of vodka last night. Last drink was
either last night or this am, pt cannot remember. Patient also
reports severe nausea and approx "30" episodes of vomiting
coffee ground material over the last 6 hours (gastro-occult
positive) but not frankly bloody. Patient also feels sweaty and
c/o chest pain associated with retching. Denies dizziness,
headache, vision changes, sob, melena, hematochezia, dysuria. Pt
has not been able to void since coming to the ED. Patient has
not eaten today, but reports feeling hungry.
.
Recent admission [**Date range (1) 31643**]/08 for abdominal pain, found to have
pancreatitis secondary to ETOH; this was his 10th admission (and
12th ED visit) in 1 year for abdominal pain or alcohol related .
He was treated for ETOH withdrawal though he did not have any
signs/symptoms.
.
Initial vs in ED were T 98.6, P 128, BP 149/86, R 20, O2 sat 99%
on RA, [**9-12**] pain. In the ED, patient received 8 mg dilaudid
over 5 hours, 2 mg IV ativan, 5 mg IV diazepam, 5 mg po
diazepam, bananna bag, zofran 4 mg x1, phenergan 25 mg x 1, 1
liter of NS with 2 grams of Magnesium. Social work and case
management were contact[**Name (NI) **] and patient was put in for section 35
as he was thought to be a danger to himself given multiple
alcohol-related ED visits.
Past Medical History:
1) Alcohol Abuse - multiple ED visits with intoxication
2) Abdominal Pain with self-reported history of recurrent
pancreatitis - though no objective evidence for such.
3) Depression and Anxiety--> reported history of prior suicide
attempts
4) Anemia
5) Esophagitis - EGD [**January 2193**]
6) Drug-seeking behavior
7) possible mesenteric adenitis by CT scan
Social History:
Owns tile company. History of alcohol abuse. Denies history of
seizure, DT. Denies tobacco and illicit drug use. Denies IVDA.
Semi-professional boxer.
Family History:
Positive for depression and anxiety. Grandfather with lung
cancer
Physical Exam:
VS: Temp: 99.6 BP: 145/76 HR: 140 RR: 27 O2sat 95% on RA
GEN: diaphoretic, writhing in pain, uncomfortable
HEENT: NCAT, PERRL, EOMI, anicteric, MM dry, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, tacchy, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, tender in epigastrium and RUQ, no guarding,
+ rebound, negative murphy'ssign, no masses or
hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: guaic positive in ED
Emesis: guaic positive and black
Pertinent Results:
ADMISSION LABS
[**1-2**]: Na 140, K 3.9, Cl 94, HCO3 22, BUN 14, Cr 0.8, Gluc 90; AG
= 28
[**1-2**]: WBC 9.4, HCT 47.9, Plt 457
[**1-2**]: ALT 54, AST 53, AlkP91, TotBili 0.5
[**1-2**]: ETOH 234
[**1-2**]: osm 353
[**2194-1-2**] 09:42PM TSH-4.4*
.
EKG: rate 120, rhythm sinus, axis nl, nl intervals, j point
elevation in v2, v3, TWI III, AVF
.
IMAGING:
CXR: no cardiopulmonary process
.
CT abdomen [**2194-1-3**]
1. No CT evidence of pancreatitis or complications related to
pancreatitis.
2. Fatty liver.
3. Small hiatal hernia.
Brief Hospital Course:
Mr. [**Known lastname 1001**] is a 28 yo old man with extensive history of ETOH use
and pancreatitis who presents with epigastric pain c/w with
previous episodes of pancreatitis, admitted to ICU for
tachycardia and hypertension thought likely associated with ETOH
withdrawal.
.
# Abdominal pain - His pain was mid abdominal, sharp, crampy and
radiated to his back, consistent with the descriptions of
previous episodes. It was felt to be likely pancreatitis as
lipase elevated to 111 and c/w prior episodes. Could also be
esophagitis, gastritis, PUD, GERD as patient is having guaic
positive emesis. Biliary disease unlikely given nl tbili and alk
phos; RUQ U/S on [**10-14**] with same presentation was negative. This
could also be alcoholic hepatitis although transaminitis is
mild. Patient was kept NPO, received fluid resusciitation with
NS x 4L, and then kept on maintenance fluids. For pain control
he received Dilaudid 1-2 mg Q1h and sedation was closely
monitored (he remained alert). Nausea control was achieved with
zofran and phenergan. His last ABD CT in [**December 2193**] non-conclusive
[**1-4**] motion artifact, [**10-10**] showed no appendicitis or acute
pancreatitis - and was repeated as his pain was very strong,
with negative results.
He also developed hiccups and was given thorazine which resulted
in confusion that resolved. For the rest of his hospitalization
in the MICU he had pain out of proportion to exam. He continued
to require high doses of narcotic medications for continued
reports of cramping abdominal pain with a benign exam. A pain
service consult was obtained, and the patient was started on a
PCA of IV dilaudid and neurontin with some improvements in his
symptoms. Upon arrival to the floor, he continued to complain
of extreme pain, despite having a normal abdominal exam, with no
tenderness to palpation when the patient was distracted, and a
normal appetite. Upon weaning him off of the dilaudid, the
patient was found to have several dilaudid pills in his bedside
table. Security was called to do a room and patient search
which was unremarkable. Social work was consulted to attempt to
set up a sober holding program for the patient until inpatient
alcohol rehab became available to avoid a section 35 started in
the ED. THe patient left AMA within 24hours of arrival to the
floor.
.
# Guaic positive emesis-He had a few episodes of emesis that was
dark and guiaic positive. He was given Promethazine 12.5mg IV
Q6 and Ondansetron 8mg IV Q8 and Pantoprazole 40mg IV Q12. He
had a midline placed for access as peripherals consistently
failed due to patient movement. He was monitored on tele and
had an active type and screen. His hematocrit remained stable
and he ceased having dark emesis by HD#2.
.
# ETOH withdrawal - Patient's Ciwa score on admission was 5 and
peak was 17; points for sweatiness, anxiety, n/v. He received
bananna bag in ED as well as 2 mg IV ativan, 5 mg IV diazepam, 5
mg po diazepam in the ED. While he was in the MICU he was on a
CIWA scale as well as 10mg valium q 6 hours standing. He
recieved a large amount of valium during his first two HDs, but
then was weaned. His standing q6h valium was ceased, and his
CIWA scale was decreased, requiring less PRN diazepam.
In addition he was on MVI, Thiamine 100mg IV, Folic Acid 1mg
.
# Tachycardia - He had sinus tachycardia while in the hospital,
initially going up to 150. EKG was normal and this was felt to
be likely secondary to fluid losses [**1-4**] to repeated vomiting and
withdrawal. Other contributors are probably pain, alcohol
withdrawl. Resolved with fluid rescusitation, pain management
and valium. Cocaine negative.
Plan was for continued maintenance fluids and occasional
boluses, pain control with dilaudid, Ciwa scale with diazepam,
and a TSH check (which was normal). By HD#3 his tachycardia was
largely resolved, most often ranging in the 80s in NSR.
.
# Anion Gap acidosis: Anion gap was 28 on labs from ED; Osm gap
was 12 taking into account his etoh level. Urine ketones 15,
also possible pt has starvation or alcohol ketosis. Acetone
negative, lactate 1.6, ASA negative. No evidence of DKA, uremia,
not taking INH, methanol. Resolved with fluids within the first
12hr of hospitalization.
.
# Depression: Patiently currently denies desire/plans to harm
himself.
Continued Zoloft 50mg QD and Seroquel 800 QHS.
SW consult (seen on multiple visits by SW/Psych).
F/U on Section 35: cannot be initiated on weekend; if moving
forward with it then must contact [**Name (NI) **] [**Name (NI) **] of legal dept
(7-1888) Sunday night to let her know plans to move forward with
Section 35 in the morning. Will need to send 1) affidavit
2)updated medical course from overnight and 3) written
description of pt to [**Doctor First Name **] by 9am so that lawyer can go to court
to request section 35.
# Pruritis: Bilirubin is normal, unlikely to be cause for
pruritis. Patient's skin appears dry. Recent shaving of torso
hair may also contribute to pruritis.
- Benadryl 25mg IV, Sarna cream given with good results.
Medications on Admission:
zoloft 200mg QD and seroquel 800 mg qhs.
Discharge Medications:
Not yet determined
Discharge Disposition:
Home
Discharge Diagnosis:
Patient left AMA
Discharge Condition:
Patient left AMA
Discharge Instructions:
Patient left AMA
Followup Instructions:
Patient left AMA
ICD9 Codes: 2762, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4820
} | Medical Text: Admission Date: [**2173-12-20**] Discharge Date: [**2173-12-21**]
Date of Birth: [**2115-2-13**] Sex: M
Service:
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old
morbidly obese man with diabetes type 2, CAD status post
multiple MIs, stents, prior V-fib arrest x2 resident at
[**Hospital3 **] Hospital Rehab had hemodialysis as usual
on [**2173-12-18**].
Date prior to admission, complained of GI distress treated
with Reglan. Day of admission was found with malaise,
shaking chills, hypotensive with temperature of 99.1, blood
pressure 60/palp, heart rate in the 120s, O2 saturation 97%,
and he denied chest pain. Transferred to [**Hospital1 18**] for workup
for hypotension.
On admission, he denied chest pain, shortness of breath,
nausea, vomiting, abdominal pain, malaise, and fatigue.
Past hospitalizations: [**2173-8-12**] to [**2173-9-20**] V-fib arrest,
Clostridium difficile colitis, MRSA, VRE bacteremia,
aspiration pneumonia. On [**2173-9-23**] acute pulmonary edema. He
has also had a history of mid LAD instent thrombosis status
post re-stented, intubation complicated by failure to wean
requiring tracheostomy, Citrobacter, and VRE bacteremia,
Pseudomonas, and Citrobacter, ventilator-associated
pneumonia, meropenem desensitization, ATN leading to renal
failure, sepsis from Pseudomonas, VRE, and Citrobacter. VRE
bacteremia, Pseudomonas infection of bladder, bacteremia,
tracheitis. Urticaria from an allergic reaction to Zosyn.
Pseudomonas found later to be associated with pneumonia and
Zosyn desensitization, meropenem desensitization.
PAST MEDICAL HISTORY:
1. CAD status post MI in '[**60**], '[**67**], '[**68**], [**2171**], and [**2172**].
Multiple stents.
2. V-fib arrest x2, the last in [**8-5**] status post pacemaker
placement, no AICD.
3. Diabetes type 2, insulin dependent.
4. GERD.
5. Obstructive-sleep apnea; unable to tolerate BiPAP or CPAP,
currently with trache.
6. Hypercholesterolemia.
7. Morbid obesity weighing over 400 pounds on initial
admission, currently at 300 pounds.
8. CHF due to systolic dysfunction.
9. Clostridium difficile colitis.
10. MRSA bacteremia.
11. Sacral decubitus ulcers Stage IV.
12. End-stage renal failure on dialysis from diabetes and
ATN.
13. Anxiety.
ALLERGIES: Cephalosporins and Zosyn.
FAMILY HISTORY: Father died of MI.
SOCIAL HISTORY: Sixty pack year tobacco history, D/C'd in
'[**60**]. Used to work in the trucking industry.
EXAM ON ADMISSION: Temperature 97.2, blood pressure 108/56,
pulse of 95, respirations 16, and 98% on trache collar.
General: Obese man in no acute distress. PERRLA. EOMI. OP
dry. No JVD. Trache collar. Distant breath sounds.
Distant regular heart rate. Chest: Right PICC and dialysis
catheter without erythema or discharge. Abdomen is soft,
obese, and nontender, positive bowel sounds, incontinent of
stool. Trace edema on extremities. Neurologic: Awake with
occasional slurring, lethargic, conversant with 1-2 words at
a time, moves all four extremities to command.
EKG paced at 94, unchanged since [**2173-11-4**].
Chest x-ray: No infiltrate, no failure, right PICC up
towards right IJ, right dialysis catheter in place, trache,
pacer wires from the left.
LABORATORIES: White count 23, hematocrit 33, platelets 223.
Creatinine 4.6. Troponin 0.21, INR of 1.3. Lactate of 7.
HOSPITAL COURSE BY ISSUE:
1. ID: Sepsis. Patient had multiple possible sources for
sepsis, most likely is Stage IV sacral decubitus ulcer
approximately 30 x 30 x 20 cm in dimension draining liquid
stool. Question of rectal fistula as possible etiology or
osteo.
Patient also had possibly UTI. Other etiologies include
lines and catheters, pneumonia which although not appreciated
radiographically still in the differential as well as
Clostridium difficile colitis currently on Vancomycin with
watery stools. He was continued on meropenem, linezolid, and
p.o. Vancomycin for empiric coverage for Pseudomonas, VRE,
MRSA, and Clostridium difficile. He received one dose of
gentamicin. Cultures were obtained. He was continued on the
antibiotics.
2. Cardiac: Patient was hypotensive. History of ischemic
cardiomyopathy. He was enrolled in the ........ protocol.
He received 6 liters of fluid. Initially, the patient was
anuric. His blood pressure continued to drop over the course
of his hospitalization. His CVP had remained between 10 and
15. He was started on pressors. He was started first on
Neo-Synephrine then Levophed, and vasopressin, and dobutamine
with little response. His mixed venous O2 was 71%. His
troponins trended down from 0.21 to 0.19, and patient's
lactate continued to rise to a high of 14.4 over the course
of his hospitalization.
3. CAD: He was continued on aspirin, Plavix, and Lipitor.
His beta blocker and ACE inhibitor were held. For V-fib, he
was continued on his amiodarone.
4. Pulmonary: His ventilatory status was stable on
admission. He was placed on CPAP and pressure supports 10
and 5. The patient over his hospitalization, he had acute
respiratory distress likely flash pulmonary edema, was
changed to assist control with improvement of his ventilation
and respiratory status. He did, however, continue to become
progressively acidotic with severe lactic acidosis.
5. Renal: He was hydrated. No hemodialysis due to his
hypotension. He had an anion gap acidosis secondary to
hyperperfusion and lactic acidosis.
6. Code: Patient was initially admitted as full code.
Daughter, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who is the healthcare proxy after
multiple discussions with the daughter over the course of his
hospitalization, given his status as well as his poor
prognosis, patient was made CMO on [**2173-12-21**] at 9 a.m.
Patient was pronounced on [**2173-12-21**] at 10:20 a.m. No autopsy
was to be done per the daughter.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 757**]
MEDQUIST36
D: [**2173-12-21**] 11:03
T: [**2173-12-22**] 07:57
JOB#: [**Job Number 44905**]
ICD9 Codes: 0389, 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4821
} | Medical Text: Admission Date: [**2103-8-7**] Discharge Date: [**2103-9-23**]
Date of Birth: [**2056-3-4**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Hypercalcemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 4003**] is a 47 year old woman who carries a diagnosis of
HTLV-associated adult T-Cell leukemia/lymphoma who presents from
routine clinic appointment with hypercalcemia, with a corrected
calcium of 15.5. She received a liter of normal saline, but no
bisphosphonate, and was subsequently admitted to the floor.
.
She was recently hospitalized from [**2103-7-11**] through [**2103-8-4**], also
for hypercalcemia with acute mental status changes, which was
attributed to progression of her hematologic malignancy.
Following IV hydration and zometa, her calcium normalized, and
she underwent treatment with [**Hospital1 **] cycle 1. Her post-chemo
course was unfortunately complicated by DIC requiring multiple
cryoprecipitate, C. dif colitis, CMV viremia, and a severe
abdominal pain requiring bowel rest with TPN. She developed a
LLL pnuemonia towards the end of her hospitalization and was
discharged on a 10 day course of levaquin in addition to home
TPN.
.
Since her discharge, Ms. [**Known lastname 4003**] has been slowly regaining her
strength, noting persistent fatigue which has acutely worsened
today. She denies acute confusion or mental status changes which
accompanied her previous hypercalcemic episode. She notes no
pain or paresthesias or tetany. Her last hospitalization was
complicated by severe abdominal pain requiring bowel rest- she
remains on home TPN and has been tolerating light meals due to a
sense of fullness. She also had CXR evidence of LLL pneumonia
and had been discharged on levaquin, which she has taken. She
had also developed C.dif, and CMV viremia, which had been
maintained on PO flagyl x 14d and valganciclovir in the
outpatient setting.
.
On review of systems, the patient denies fevers, chills, nausea,
vomiting, diarrhea, malaise, rigors, abdominal pain, blood in
the stools, shortness of breath, cough, dysuria, hematuria,
paresthesias, weakness.
Past Medical History:
Stage [**Doctor First Name **] mycosis fungoides (Cutaneous T-cell lymphoma, stage IV
1A) with transformation to CD-30 positive large cell lymphoma
and development of HTLV-1 Adult T-cell Leukemia Lymphoma
.
- [**10-29**]: The patient developed a pruritic, papular rash. She
was seen in the internal medicine and dermatology clinics on
several occasions and was treated with antibiotics,
triamcinolone, clobetasol, and IV triamcinolone w/ no
improvement.
- [**2100-3-12**]: Skin Bx 1: LLE: Superficial and deep perivascular
lymphohistiocytic infiltrate with perivascular and interstitial
eosinophils consistent with a hypersensitivity rxn. Scabies neg.
- [**2100-7-13**]: Skin Bx 2: Atypical superficial and deep dermal
lymphoid infiltrate containing CD30-positive cells and showing
epidermotropism. PCR analysis for the T-cell receptor gamma gene
showed two sharp bands with a migration pattern suggestive of a
clonal rearrangement.
- [**2100-8-24**]: [**Hospital **] clinic: WBC 10.6 with 57% Lymphocytes S??????zary
cells.
Immunophenotypic analysis -> expanded T-cell population with
increased CD4:CD8 ratio (15) and loss of CD7. Due to her high
count of circulating S??????zary cells, she was felt to have Stage
[**Doctor First Name 690**] mycosis fungoides.
- [**2100-9-8**] CT scan: Infiltrating, hypo-enhancing lesion in the
R. kidney (?infiltrating neoplasm vs pyelonephritis) compatible
w/ lymphomatous involvement of the kidney but was not present on
a follow-up scan on [**2101-1-21**].
- [**9-30**]: Photopheresis therapy through an indwelling central
venous catheter, placed due to poor venous access.
- [**2101-1-5**]: Skin Bx 3: CTCL with large-cell transformation.
- [**2101-1-10**]: Interferon alpha at 3M units 3x/wk given w/ with
photopheresis every other week and PUVA.
- [**2101-1-26**]: Interferon alpha increased to 6Munits 3x/wk; PUVA was
d/ced [**12-26**] side effects.
- [**2101-2-23**]: Interferon alpha decreased to 4.5Munits 3x/wk on
[**2101-2-23**] b/c fatigued. Photopheresis was d/ced when catheter
removed due to a line infection (last treatment [**2101-3-10**]).
- [**2101-8-4**]: The patient presented for a follow-up evaluation with
clear evidence of disease progression. Interferon alpha was
increased to 6M units three times weekly and bexarotene was
started at 150mg daily, decreased to 75mg daily due to poor
tolerability.
- [**2101-8-25**]: Mtx added to interferon alpha and bexarotene and the
dose was up-titrated to 45mg weekly.
- [**2101-10-18**]: Hospital admission for severe lower extremity pain
at the site of new, large, papular skin lesions. Biopsy showed
cutaneous T-cell lymphoma with large cell transformation,
involving the panniculus with an unusual angiocentric pattern.
The patient was prescribed vorinostat 400mg daily (started
[**2101-10-27**]) with continuation of interferon alpha 6M units TIW. Due
to thrombocytopenia, interferon alpha was decreased to 3M units
3x/wk.
- [**2101-12-22**]: Cycle 1 Day 1 liposomal doxorubicin plus gemcitabine.
Vorinostat and interferon alpha were d/ced. Side Effect: severe
palmar-plantar erythrodysesthesia [**12-26**] to liposomal doxorubicin.
- [**2102-1-17**]: Cycle 1 Day 1 bortezomib plus gemcitabine,
dose-reduced during Cycle 2 due to neutropenia.
- [**2102-2-9**] 3M units TIW Interferon alpha restarted
- [**2102-3-9**]: Due to the observation that peripheral T-cells
contained floret-like nuclei, immunophenotypic analysis was
performed on peripheral blood, revealing findings consistent
with involvement by patient's known T cell lymphoproliferative
disorder as well as CD25 co-expression in a significant
population of the neoplastic CD3+ lymphocytes, suggesting a
diagnosis of HTLV-1 associated lymphoma. PCR for HTLV-1 DNA was
positive.
- [**2102-5-26**]: Following a treatment break, the patient was started
on pentostatin 4mg/m2 weekly x4 doses with reinitiation of
interferon alpha at 3Munits 3x/wkly , increased to 3M
units 5x/wkly. She d/ced therapy after 2 cycles in [**7-2**] in favor
of a Chinese herbal preparation she received in [**Location (un) 4708**].
- [**2102-8-18**]: Evaluation in the [**Hospital 18**] [**Hospital 3242**] clinic: good candidate
for allo SCT.
- [**2102-9-26**]: CT scan: s/p 3 mo off therapy: stable to improved
disease: lymph nodes in the chest, abdomen, and pelvis, are
stable to decreased in size since [**2102-7-28**], with no new pathologic
LAD identified. Decreased size of the previously enlarged
spleen, now within normal limits in size.
- [**2102-12-25**] Initiation of ONTAK therapy Cycle 1 [**2102-12-25**], Cycle 2
[**2103-1-15**], Cycle 3 [**2103-2-5**], Cycle 4 [**2103-2-26**], Cycle 5
[**2103-6-4**], Cycle 6 [**2103-7-2**]
- [**2103-4-26**]: 2 weeks of total skin electron beam therapy at the
[**Hospital3 2358**] under the care of Dr. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **]. Therapy was held
[**2103-5-18**] through [**2103-5-24**] [**12-26**] fatigue. She received a single dose
on Friday [**2103-5-25**].
- [**2103-5-29**]: Hypercalcemia: IVF and Zometa.
- [**2103-5-29**]: Treatment Discussion: Re: Total Skin Electron Beam
Therapy: Progressive Disease and Difficulty tolerating therapy.
Decision to resume ONTAK therapy with intention of initiating
auto-transplant as she demonstrates response.
-[**2103-7-11**]: admitted for AMS in the setting of hypercalcemia,
which was thought to be due to progression of ATLL. Started
[**Hospital1 **] [**7-11**], complicated by c dif, CMV viremia, DIC.
Social History:
The patient is from [**Location (un) 4708**]. She moved to the U.S. 11 years
ago. She is married and has two children. She denies past or
current tobacco, etoh or illicit drug use.
Family History:
Mother had an MI. Her father with CAD.
Physical Exam:
VS: T98.9 BP128/86 P109 RR18 Sa02100RA
GENERAL: Fatigued appearing female in no acute distress
HEENT: EOMI, PERRLA, white plaques along lateral left border of
tongue, pharyngeal wall nonerythematous without exudates
PULMONARY: Minimal bibasilar crackles, otherwise clear to
auscultation
CARDS: RRR, normal S1, S2, 3/6 systolic ejection murmur. no rubs
or gallops.
ABDOMEN: soft, nondistended, positive bowel sounds, mild
tenderness to palpation of the RUQ which is chronic, no rebound
tenderness or guarding.
EXTREMITIES: nonedematous, 2+ PT, DP pulses bilaterally
NEUROLOGIC: CN II-XII intact bilaterally. Strength 5/5
throughout though deconditioned. Sensation to soft touch intact
throughout. DTRs depressed.
SKIN: no rashes or lesions appreciated.
Pertinent Results:
ADMISSION LABS:
.
[**2103-8-7**] 11:30AM PT-15.1* PTT-35.9* INR(PT)-1.3*
[**2103-8-7**] 11:30AM PLT COUNT-129*#
[**2103-8-7**] 11:30AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2103-8-7**] 11:30AM NEUTS-38* BANDS-3 LYMPHS-45* MONOS-6 EOS-0
BASOS-0 ATYPS-8* METAS-0 MYELOS-0
[**2103-8-7**] 11:30AM WBC-16.9* RBC-2.57* HGB-8.5* HCT-25.5*
MCV-99* MCH-32.9* MCHC-33.2 RDW-17.9*
[**2103-8-7**] 11:30AM ALBUMIN-2.9* CALCIUM-14.6* PHOSPHATE-7.2*#
MAGNESIUM-2.2
[**2103-8-7**] 11:30AM ALT(SGPT)-14 AST(SGOT)-26 ALK PHOS-209* TOT
BILI-0.4
[**2103-8-7**] 11:30AM GLUCOSE-103* UREA N-34* CREAT-1.1 SODIUM-145
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-31 ANION GAP-13
[**2103-8-7**] 06:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2103-8-7**] 06:57PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2103-8-7**] 09:48PM CALCIUM-14.1*
.
IMAGING:
CXR [**2103-8-12**]: Cardiac size is normal. ET tube tip is in a
standard position 3.8 cm above the carina. Right PICC tip is in
the mid SVC. Left subclavian catheter tip is in the proximal
SVC. There is no pneumothorax. New bibasilar opacities, left
greater than right, are a combination of pleural effusions and
atelectasis. Superimposed infection on the left cannot be
totally excluded. NG tube tip is in the stomach.
.
HEAD MRI [**2103-8-12**]:
FINDINGS: There is mild prominence of sulci and ventricles
inappropriate for patient's age. There is no midline shift or
mass effect. There is no hydrocephalus. There is no acute
infarct seen on diffusion images. Following gadolinium, there is
no abnormal parenchymal, vascular or meningeal enhancement
identified. In particular, there is no leptomeningeal
enhancement seen.
Soft tissue changes are visualized in the paranasal sinuses due
to mucosal thickening. Diffuse low signal is identified within
the bony structures,
which could be secondary to marrow hyperplasia. It should be
noted that on
FLAIR images, increased signal identified at the sulci at the
convexity is
secondary to these images were obtained following gadolinium.
IMPRESSION: No acute infarcts or enhancing brain lesions are
identified. No mass effect or hydrocephalus. Other findings as
described above.
.
PORTABLE ABDOMEN [**2103-8-12**]:
NG tube tip is in the stomach. There is no evidence of bowel
obstruction.
Nondistended air-filled large bowel loops are seen. There are no
pathologic intraabdominal calcifications.
.
CT Torso: [**2103-8-27**]
1. No evidence of pulmonary embolus or acute aortic syndrome.
2. Interval development of right middle upper lobe airspace
consolidation
most consistent with pneumonia, with additional focus of opacity
in the left perihilar region, possibly representing additional
focus of infection,
although enlargement of left hilar lymph nodes is difficult to
exclude.
Followup imaging following treatment to ensure resolution is
recommended.
3. Splenomegaly.
4. Retroperitoneal adenopathy, grossly stable from [**2103-6-24**].
5. No intra-abdominal explanation for fever. Colon is diffusely
fluid-filled but thin-walled and without associated inflammatory
change. There is no loculated fluid collection or abscess
identified.
6. Diffuse soft tissue anasarca.
.
Bronchial Embolization: [**2103-9-4**].
IMPRESSION: Uncomplicated embolization of the right bronchial
artery with
300-500 micron Embospheres until stasis was achieved.
.
CT Head [**2103-9-17**].
No acute hemorrhagic mass seen, nor large area of edema or mass
effect on non-contrast head CT. However, for evaluation of
subtle process,
MRI before and after IV gadolinium would be recommended for more
sensitive
evaluation.
.
Peripheral Blood Analysis:
Flow Analysis:
INTERPRETATION
More than 99% of the peripheral blood lymphocytes are
CD4-positive subset with co-expression of CD3, CD2, CD5. They
have loss of expression of CD7. About half of these T-cells
also express CD25. These immunophenotypic findings and the
presence of "floret-like cells" in peripheral blood smear are
consistent with involvement by patient's known "Adult T cell
leukemia/lymphoma".
.
Microbiology:
Major Studies/Findings listed here:
[**2103-9-4**] 4:49 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2103-9-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2103-9-6**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2103-9-11**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2103-9-4**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2103-9-5**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2103-9-17**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2103-9-5**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2103-10-3**]):
No Cytomegalovirus (CMV) isolated.
[**2103-8-28**] 1:43 pm BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE, RIGHT MIDDLE LOBE.
GRAM STAIN (Final [**2103-8-28**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2103-8-30**]): NO GROWTH, <1000
CFU/ml.
POTASSIUM HYDROXIDE PREPARATION (Final [**2103-8-29**]):
NO FUNGAL ELEMENTS SEEN.
This is a low yield procedure based on our in-house
studies.
TEST REQUESTED BY PULMONARY FELLOW [**Numeric Identifier 28457**] [**2103-8-29**].
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2103-8-29**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2103-9-14**]):
YEAST.
NOCARDIA CULTURE (Final [**2103-9-17**]): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2103-8-29**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
[**2103-8-28**] 11:31 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2103-9-14**]**
GRAM STAIN (Final [**2103-8-28**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2103-8-30**]):
RARE GROWTH Commensal Respiratory Flora.
YEAST. RARE GROWTH.
FUNGAL CULTURE (Final [**2103-9-14**]):
YEAST.
.
[**2103-8-12**] 11:24 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2103-8-14**]**
GRAM STAIN (Final [**2103-8-12**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2103-8-14**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
.
[**2103-8-21**] 9:31 pm URINE Source: CVS.
**FINAL REPORT [**2103-8-23**]**
URINE CULTURE (Final [**2103-8-23**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 6.5 H <0.5
.
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
358 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
Brief Hospital Course:
In brief, Ms. [**Known lastname 4003**] was a 47 year old lady with a diagnosis of
HTLV-1 associated Adult T cell leukemia/lymphoma who initially
presented with hyerpcalcemia. Her hospital course was
complicated by Mental Status changes which after ICE therapy
necessitating an admission to the ICU without any acute evidence
of an intracranial process. Her hospital course at this time was
also complicated by persistent ATLL, hypercalcemia, renal
tubular acidosis, acute renal failure, C. Diff colitis, and CMV
viremia. Subsequently she developed hypoxic respiratory failure
secondary to invasive aspergillosis with pulmonary hemorrhage.
She underwent a pulmonary embolization procedure and a second
intubation and ICU stay. Upon returning to the floor, no
additional therapeutic intervention was started for her ATLL.
Her mental status continued to deteroirate, and she stopped
taking PO. Due to disease progression in addition to a
persistent fungal infection and concern for aspiration goals of
care were discussed with her family. Due to her poor prognosis,
she was made DNR/DNI, and subsequently CMO. She passed
peacefully on [**2103-9-23**].
Medications on Admission:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day). Disp:*60 Tablet(s)* Refills:*2*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours). Disp:*28 Tablet(s)* Refills:*0*
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea, anxiety.
6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
7. Doxepin 25 mg Capsule Sig: [**11-25**] Capsules PO once a day.
8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO twice a
day.
9. Pyridoxine 100 mg Tablet Sig: Four (4) Tablet PO once a day.
10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
12. Benadryl Oral
13. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
9 days. Disp:*9 Tablet(s)* Refills:*0*
14. Line flush order Sodium chloride 5-10ml pre- and post
infusion Heparin 10units/ml [**12-29**] ml infused as a final flush
15. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for nausea.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
None
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2103-10-17**]
ICD9 Codes: 486, 5849, 2762, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4822
} | Medical Text: Admission Date: [**2176-9-14**] Discharge Date: [**2176-9-16**]
Date of Birth: [**2176-9-14**] Sex: M
Service: NB
DIAGNOSES: Premature male infant at 34 and 5/7 weeks
gestation.
Status post immature feeding.
Status post brief transient tachypnea of newborn.
HISTORY OF PRESENT ILLNESS: [**Doctor Last Name **] is a former 2.815 kg male
infant born at 34 and 5/7 weeks gestation admitted to the
Neonatal Intensive Care Unit at [**Hospital6 2018**] for management of prematurity.
The infant was born to a 28-year-old A-negative, prima
gravida whose prenatal screens revealed she was group B strep
unknown but remaining screens were noncontributory. The
pregnancy was complicated by pregnancy-induced hypertension
since [**Month (only) 216**] for which the mother was placed on labetalol.
She was also betamethasone complete.
The mother was induced due to worsening blood pressures, no
maternal fever, no prolonged rupture of membranes, clear
amniotic fluid, mother delivered by cesarean section with
Apgars of eight and eight.
HOSPITAL COURSE: On admission, the baby weighted 2.815 kg,
length 48 cm, head circumference 35 cm; all appropriate for
gestational age.
On admission, the baby was breathing comfortably with
occasional grunting, no retractions. Lungs were clear. This
was thought to be mild transient tachypnea of the newborn.
Cardiac: There were no cardiac issues. No murmur was
appreciated.
Feeding and nutrition: The infant initially required some
gavage feedings but at the time of transfer to the newborn
nursery weighed 2.740 kg and was feeding ad lib demand with
occasional breastfeeding.
Infectious Disease: There were no Infectious Disease issues.
The infant was delivered for worsening maternal pregnancy-
induced hypertension.
Hematologic: Mother was [**Name (NI) 57108**], baby AB positive, [**Name (NI) 36243**]
negative. The infant did not appear to be jaundiced to any
significant degree prior to transfer.
The infant was transferred to the newborn nursery on the
morning of [**2176-9-16**]. I discussed the transfer and the
baby's status with the mother. The patient will be followed
up at [**Hospital1 **] [**Location (un) 1468**] by Dr. [**Last Name (STitle) **] who will also
follow the baby on the newborn nursery until he is ready to
be discharged home.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2176-9-16**] 10:19:12
T: [**2176-9-16**] 10:36:31
Job#: [**Job Number 57109**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4823
} | Medical Text: Admission Date: [**2181-12-4**] Discharge Date: [**2181-12-24**]
Date of Birth: [**2118-10-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
left arm weakness
Major Surgical or Invasive Procedure:
Microsurgical stereotactic volumetric tumor resection of right
precentral metastatic tumor
She underwent a T6 vertebrectomy, Anterior arthrodesis T5-T6 &
T6-T7 and posterior fusion of T2-T10
History of Present Illness:
Ms. [**Known lastname **] is a 63 year old woman with renal cell carcinoma, who
presented to clinic on [**2181-12-3**] for follow up, at which time she
complained of progressive left arm weakness and sensation of
coldness in her left hand for the last two weeks. She reports
subjective leg weakness (although no problems with ambulation),
imbalance (with one fall). She was empirically started on
dexamethasone 4mg [**Hospital1 **] and had a stat MRI last evening which
demonstrated a 14mm mass in the right frontal lobe with
extensive edema and midline shift, along with a 4mm mass in the
left occipital lobe and a 2mm mass in the superior right frontal
lobe. Decadron was increased to 6mg TID, with the plan to follow
up on Monday with neuro-oncology. However, given multiple
questions from family members and no dramatic improvement, the
decision was made today for direct admission.
Past Medical History:
ONCOLOGIC HISTORY:
Her oncologic history began in [**2179-1-27**] when a right kidney
mass was suspected on angiography (status post superficial
femoral angioplasty and stenting). In [**2179-6-29**], she underwent
abdominal/pelvic CT which revealed a right kidney mass. Chest CT
in [**2179-7-30**] revealed 2 small pulmonary nodules
suspicious for metastatic disease. She underwent left lower lobe
wedge resection in [**2179-8-29**] with pathology revealing
renal cell carcinoma of clear cell type. She underwent
laparoscopic right radical nephrectomy on [**2179-10-4**] with
pathology revealing renal cell carcinoma, clear cell type,
[**Last Name (un) 9951**] grade [**1-2**] with extension into the renal vein. She was
followed on observation with stable pulmonary nodules until
[**2181-2-27**] when progression was noted. She was planned for
high-dose IL-2 therapy with stress echo showing anterior
ischemia. She underwent cardiac catheterization with a 90-95%
stenosis of the proximal LAD noted. She had a balloon
angioplasty and stenting of the LAD. She recovered well without
cardiac issues and passed follow-
up stress test to meet eligibility for the high-dose IL-2 select
trial. She is status post one cycle of high-dose IL-2. She had a
CT scan done of the torso on [**2181-8-27**] and this showed interval
slight increase in the size of her multiple pulmonary nodules.
There also was slight interval increase in the size of the left
hilar node. The decision was made to stop IL-2 at that point.
PAST MEDICAL HISTORY:
- Diabetes
- Hyperlipidemia
- Hypertension
- Peripheral vascular disease, s/p R superficial femoral artery
stenting x 2
- CAD, cardiac catheterization revealing a 95-99% proximal
stenosis of the LAD; s/p PCI stenting in [**2181-3-29**]
Social History:
She continues to live in [**Hospital1 392**] and will occasionally help out
at her relatives' Chinese restaurant answering phones.
Family History:
non-contributory
Physical Exam:
VITALS: T 97.9F, HR 80, BP 140/80, RR 16, Sat 97%RA, finger
stick 209, wt 134lbs
GENERAL: Well-appearing, no acute distress
HEENT: OP clear, anicteric, EOMI, PERRL
NECK: No JVD appreciated
CARD: RRR, no m/r/g
RESP: CTA bilaterally; mildly tender to palpation along anterior
right costal margin
ABD: Soft, non-tender
BACK: Two demarcated areas of hyperpigmentation, mildly pruritic
EXT: Warm, well-perfused. mild ankle edema. Rash along medial
aspect of right ankle, mildly pruritic
NEURO: 5/5 strength in both upper and lower extremity on right
and in left lower extremity; [**1-31**] in left upper extremity, more
marked in distal muscle groups (e.g. flexion/extension at
wrist). CN II-XII intact, with ? decreased sensation over right
face. Normal finger-to-nose. Negative Romberg. Gait not tested
secondary to patient feeling "unsteady".
Pertinent Results:
LABS:
[**2181-12-4**] 11:55PM BLOOD WBC-10.2# RBC-4.13* Hgb-9.7* Hct-29.7*
MCV-72* MCH-23.6* MCHC-32.8 RDW-14.9 Plt Ct-271
[**2181-12-10**] 05:37AM BLOOD WBC-12.2* RBC-4.39 Hgb-10.4* Hct-31.7*
MCV-72* MCH-23.6* MCHC-32.7 RDW-14.8 Plt Ct-242
[**2181-12-4**] 11:55PM BLOOD PT-11.7 PTT-24.5 INR(PT)-1.0
[**2181-12-3**] 05:00PM BLOOD Glucose-193* Creat-1.2*
[**2181-12-10**] 05:37AM BLOOD Glucose-85 UreaN-30* Creat-1.0 Na-140
K-4.7 Cl-104 HCO3-23 AnGap-18
[**2181-12-4**] 11:55PM BLOOD Calcium-9.5 Phos-2.9 Mg-2.3
[**2181-12-10**] 05:37AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
IMAGING:
MR [**Name13 (STitle) 430**] ([**12-3**]): IMPRESSION:
14 mm enhancing lesion in the right frontal lobe with extensive
surrounding edema and mild shift of midline structures.
4-mm left occipital lobe enhancing lesion with surrounding
edema, 2 mm right superior frontal lobe enhancing lesion.
Overall, findings consistent with metastatic renal cell
carcinoma.
CXR ([**12-5**]): IMPRESSION: No evidence of osseous metastasis.
Multiple similar size pulmonary nodules consistent with
metastatic disease.
MR [**Name13 (STitle) 430**] ([**12-7**]): IMPRESSION: Limited pre-op WAND study, for
resection, demonstrating the dominant 15-mm right frontovertex
enhancing lesion with large zone of associated vasogenic edema,
additional punctiform enhancing lesion in the right frontal
corona radiata, at the dorsal margin of the edematous zone, and
5.5-mm enhancing lesion with adjacent vasogenic edema in the
left occipital pole.
CT Head ([**12-8**]): IMPRESSION: Expected postsurgical changes status
post right frontal craniotomy and lesion resection. No large
intracranial hemorrhage.
MR [**Name13 (STitle) 430**] ([**12-9**]): Pending
Brief Hospital Course:
The patient is a 63year old woman with a history of renal cell
carcinoma with known metastasis to the occipital lobe/T6
vertebrae and lungs, CAD s/p DES to proximal LAD on [**4-5**], DM,
hypertension, and hyperlipidemia who presented with left arm
pain and outpatient MRI head on [**12-3**] showing a 14 mm enhancing
lesion in the right frontal lobe with extensive surrounding
edema and mild shift of midline structures, 4-mm left occipital
lobe enhancing lesion with surrounding edema, and 2 mm right
superior frontal lobe enhancing lesion. Her Dexamethasone had
been increased at home from 4 mg [**Hospital1 **] to 6 mg tid. Neuro-oncology
was consulted who recommended resection of the dominant right
frontal lesion. Her Aspirin and Plavix were discontinued. Pre-op
MRI WAND study was limited, but showed the dominant 15-mm right
frontovertex enhancing lesion with large zone of associated
vasogenic edema, additional punctiform enhancing lesion in the
right frontal corona radiata, at the dorsal margin of the
edematous zone, and 5.5-mm enhancing lesion with adjacent
vasogenic edema in the left occipital pole.
She underwent a MRI and CT scan demonstrated a T6 metastasis
with involvement of the [**5-5**] foramen. She was determined to be
symptomatic and at risk for instability. She underwent a T6
vertebrectomy, Anterior arthrodesis T5-T6 & T6-T7 and posterior
fusion of T2-T10. Post operatively she was full strength, her
incision was clean and dry she tolerated a regular diet and was
voiding without difficulty. She was noted to have a bump in
creatinine and renal was consulted she was treated with fluid
and her diovan and bactrim were dc'd. Her creatinine on dc was
0.7, she was treated with Levaquin for a UTI. She was allowed to
go home with PT.
She is scheduled as an outpatient for CyberKnife on [**12-28**], she
should also follow up with Dr [**Last Name (STitle) 4253**] in one month.
Medications on Admission:
- Dexamethasone 6mg TID
- Plavix 75mg daily
- Glipizide 10mg [**Hospital1 **]
- Pioglitazone 30mg daily
- Simvastatin 80mg daily
- ASA 81mg daily
- Calcium 500 + 400U Vitamin D
- Multivitamins daily
- Omega-3 fatty acids
- Telmisartan 20mg daily
Discharge Medications:
1. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Oxycodone 5 mg Capsule Sig: [**11-30**] Capsules PO every six (6)
hours as needed for pain.
Disp:*30 Capsule(s)* Refills:*0*
4. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Calcium 500 + D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Omega-3 Fatty Acids Oral
9. Telmisartan 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. Outpatient Physical Therapy
Outpatient physical therapy for renal cell carcinoma with brain
metastases.
14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
16. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 4 doses.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*40 Capsule(s)* Refills:*0*
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
19. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): start on [**12-26**].
Disp:*40 Tablet(s)* Refills:*2*
20. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
21. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) for 2 days: Stop on [**12-26**] and change to new dose see other
RX.
Disp:*2 Tablet(s)* Refills:*0*
22. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
23. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
25. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
PRIMARY:
Renal Cell Carcinoma with Brain Metastases (14 mm right frontal,
4 mm left occipital, 2 mm right superior frontal) and left
pedicle and left transverse process of T6
SECONDARY:
Hypertension
Hyperlipidemia
Diabetes
PVD
UTI
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
You have an radiosurgery appointment on Friday [**12-28**] @ 3pm. If
you have any questions please call Dr.[**Name (NI) **] at
[**Telephone/Fax (1) 9710**] and a nurse will call from his office. ***You
need to increase your Decadron on [**12-26**] for that appointment see
prescription****
You have a follow up appointment with Dr. [**Last Name (STitle) **] in
Hematology/Oncology ([**Telephone/Fax (1) 22**]) on [**2181-12-31**] at 2:30 pm in the
[**Hospital Ward Name 23**] Center, [**Location (un) 24**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
You will need to see Dr [**Last Name (STitle) 548**] in 6 weeks scan call [**Telephone/Fax (1) 2992**]
for an appointment
PLEASE RETURN TO THE OFFICE IN 7 days for REMOVAL OF YOUR
STAPLES call [**Doctor Last Name **] for an appointment [**Telephone/Fax (1) 1669**] for an
appointment
Make an appointment with Dr [**Last Name (STitle) 4253**] (Neuro Onc) in 1 month
call [**Telephone/Fax (1) 1844**] for an appointment
Completed by:[**2181-12-24**]
ICD9 Codes: 5849, 2724, 4019, 4439, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4824
} | Medical Text: Admission Date: [**2156-5-24**] Discharge Date: [**2156-5-30**]
Date of Birth: [**2098-4-2**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
known coronary artery disease, status post multiple PCIs in
the past, had a recent positive stress echocardiogram and was
referred for a cardiac catheterization. This revealed severe
3-vessel disease with 70% proximal LAD lesion, 90%
circumflex, 80% mid RCA, and an EF of 58%. He was then
referred for coronary artery bypass graft surgery.
PAST MEDICAL HISTORY: Status post multiple PCIs,
hypercholesterolemia, nephrolithiasis, status post
appendectomy, status post cholecystectomy, type 2 diabetes.
The patient also has Parkinson disease.
MEDICATIONS AT HOME: Aspirin 81 mg daily, Lopressor 50 mg
b.i.d., Glucotrol XL 5 mg daily, Glucophage 500 mg a.m. and
100 mg p.m., Zestril 2.5 mg daily, Zocor 20 mg daily,
Sinemet, Lodosyn 25 mg q.i.d.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He works as a mechanic. He never smoked. He
does not drink. He has no history of recreational drug use.
PREOPERATIVE LABORATORY DATA: White blood count of 5.6,
hematocrit of 35.1, platelets of 114. INR of 1.1, PTT of
28.9. Sodium of 135, potassium of 4.7, chloride of 103,
bicarbonate of 29, BUN of 29, creatinine of 1.2, glucose of
221. His LFTs were normal. His UA was negative.
RADIOLOGIC STUDIES: His preoperative chest x-ray showed no
evidence of acute cardiopulmonary process.
Cardiac catheterization results were mentioned in the HPI.
PHYSICAL EXAMINATION ON ADMISSION: He was a well-appearing
58-year-old male in no acute distress. Neurologically, he was
grossly intact. A tremor was noted of the left hand. No
carotid bruits. His heart rate was regular in rate and
rhythm. Positive S1 and S2. No clicks, rubs, murmurs, or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was soft, nontender, and nondistended. Positive
bowel sounds. The extremities revealed the groin saphenous
vein site was clean and dry without hematoma. His legs were
warm without edema or varicosities. He had positive DP and PT
pulses bilaterally.
HOSPITAL COURSE: After discussion with the patient he was
consented for bypass surgery the following day. On [**2156-5-25**] he was brought to the operating room and underwent
coronary artery bypass graft x 4 with a LIMA to the LAD,
saphenous vein graft to diagonal, saphenous vein graft to
ramus and OM sequence. Please refer to the OP note for full
surgical details. The patient tolerated the procedure well.
Cardiopulmonary bypass time was 75 minutes. Cross-clamp time
was 49 minutes.
Following the procedure the patient was transferred to the
CSICU with a CVP of 11, heart rate of 80, A paced. He was
being titrated on Neo-Synephrine currently at 0.8 mcg/kg/min,
propofol, and insulin. Later that day propofol was weaned.
The patient became less sedated, and he was awake, alert, and
followed commands. He was extubated. The extubation went
well. He was neurologically intact, and there were no
deficits, and he was responding to all commands.
On postoperative day #1, beta blockade and diuresis were
started per protocol. His chest tubes were removed. He was
hemodynamically stable. Later that day he was transferred to
the telemetry floor on [**Hospital Ward Name 121**] Two. On postoperative day #2, he
appeared to be doing well. He was continuing to get out bed
and ambulate good. His Foley was removed. On postoperative
day #3, his epicardial pacing wires were removed. He appeared
to be doing well in his postoperative course, getting out of
bed. His physical exam was unremarkable. His labs were
stable. On postoperative day #4, once again the patient
appeared to be well. He was complaining of shoulder and back
pain which were resolved with typical pain medication. His
physical exam was unremarkable, and he was still getting out
of bed well and continued using inspiratory spirometer. On
postoperative day #5, once again the patient had a pretty
unremarkable postoperative course. He was at level 5. His
labs were stable. His physical exam was unremarkable. His
lungs were clear. His heart was regular in rate and rhythm.
His sternum was stable. The incision was clean, dry, and
intact. His blood glucose did remain to be high; and
therefore [**Last Name (un) **] was consulted before the patient's
discharge, and he will follow up in the [**Hospital **] Clinic for
diabetic management as an outpatient.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: He was discharged to home with VNA
services.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft x 4 on [**2156-5-25**].
2. Hypercholesterolemia.
3. Nephrolithiasis.
4. Diabetes.
5. Parkinson disease.
6. Status post multiple percutaneous coronary interventions.
7. Status post appendectomy.
8. Status post cholecystectomy.
DISCHARGE FOLLOWUP: He was recommended to follow up with Dr.
[**Last Name (STitle) 70**] in 6 weeks, follow with the cardiologist in 2
weeks, and with PCP [**Last Name (NamePattern4) **] 1 week.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg p.o. daily.
2. Ranitidine 150 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Carbidopa/levodopa 50/200 mg 1 daily.
5. Lodosyn 25 mg take 2 p.o. q.i.d.
6. Carbidopa/levodopa 25/250 mg p.o. q.i.d.
7. Glipizide 5 mg p.o. daily.
8. FeSO4 300 mg p.o. daily.
9. Vitamin C 500 mg p.o. b.i.d.
10. Multivitamin p.o. daily.
11. Dilaudid 2 mg 1 to 2 tablets p.o. q.4h. p.r.n. (for
pain).
12. Metformin 500 mg p.o. daily.
13.
Metformin 500 mg 2 tablets p.o. daily.
14. Lopressor 50 mg 1-1/2 tablets p.o. b.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 11830**]
MEDQUIST36
D: [**2156-6-23**] 14:27:07
T: [**2156-6-24**] 18:16:10
Job#: [**Job Number 23067**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4825
} | Medical Text: Unit No: [**Numeric Identifier 74113**]
Admission Date: [**2120-5-26**]
Discharge Date: [**2120-6-9**]
Date of Birth: [**2120-5-26**]
Sex: M
Service: NB
IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname **] is a 2-week-old former 34 and
[**3-9**] week gestation premature infant who is being transferred
from the [**Hospital1 69**] Neonatal
Intensive Care Unit to [**State 20192**] Center
Neonatal Intensive Care Unit.
HISTORY: Baby [**Name (NI) **] [**Known lastname **] was born on [**2120-5-26**] as the 2450
gm product of a 34 and [**3-9**] gestation pregnancy to a 30-year-
old gravida 1, para 0, now 1, mother with prenatal laboratory
studies including blood type A+, antibody negative, RPR
nonreactive, hepatitis B surface antigen negative, rubella-
immune and group B strep negative. Estimated date of delivery
was [**2120-7-3**]. Pregnancy was complicated by maternal
admission for premature contractions at approximately 31-
weeks gestation, at which time she was given a course of
betamethasone. Mother presented on the day of delivery with
preterm rupture of membranes followed by preterm labor. She
was subsequently allowed to progress to vaginal delivery.
Rupture of membranes occurred 10 hours prior to delivery,
there was no maternal fever noted and mother received
antibiotics beginning approximately 7 hours prior to
delivery. At delivery the infant was vigorous with Apgar
scores of 9 and 9. Infant was admitted to the NICU due to
prematurity.
GROWTH PARAMETERS ON ADMISSION: Weight 2450 gm, head
circumference 31.5 cm, length 46 cm.
HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant has
remained stable on room air throughout hospitalization
without significant work of breathing. Occasional spells have
been noted initially associated with apnea and more recently
associated with feeding discoordination. Last spell was noted
on [**2120-6-6**] and this was with a feeding.
Cardiovascular: The infant has removed hemodynamically stable
throughout admission. Intermittent soft murmur has
occasionally been heard.
FEN: Infant was initially maintained on IV fluids with
introduction of enteral feeds on day of life 3 followed by
gradual advancements to full volume enteral feeds without
difficulty. Dstiks remained normal throughout and electrolytes at
24 hours of life were within normal limits. Urine and stool
output remained normal as well. At the time of transfer the
infant is receiving 150 cc per kg per day of breast milk
supplemented to 24 calories per ounce with human milk
fortifier. The infant is being fed p.o. and p.g. with gradually
improving oral intake.
GI: The infant did exhibit moderate hyperbilirubinemia with a
max bilirubin level of 13.9/0.3 on day of life 3, and received
3 days of phototherapy with improvement. The last bilirubin
level was measured on [**2120-6-9**], day of transfer, and this
was reassuring at 6.3/04.
Heme/ID: CBC and blood culture were sent on admission. CBC
was reassuring and blood culture was negative. The infant did
not receive antibiotics. Initially hematocrit was 44.8 and
infant was subsequently begun on iron supplementation at 2 mg
per kg per day.
Neurologic: The infant has maintained a normal neurologic
exam throughout admission. Hearing screen has not yet been
performed, but is recommended prior to discharge. Eye exam is
not indicated.
CONDITION ON DISCHARGE: At the time of transfer the infant
is stable on room air with resolving spells. Infant is
receiving full volume enteral feeds, both p.o. and p.g. The
infant's temperature is stable in an open crib.
DISCHARGE DISPOSITION: The infant is being transferred to
[**State 20192**] Center Neonatal Intensive Care
Unit. Infant's care was discussed with Dr. [**Last Name (STitle) 74114**] [**Name (STitle) **] who
accepts the transfer.
NAME OF PRIMARY PEDIATRICIAN: Primary pediatrician is Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] in [**Location (un) 8117**], [**Location (un) 3844**].
CARE AND RECOMMENDATIONS:
1. Feedings. Breast milk 24 calories per ounce supplemented
with human milk fortifier at 150 cc per kg per day.
2. Medications. Fer-In-[**Male First Name (un) **] 0.2 mL or 5 mg by mouth daily.
3. Car seat position screening has not yet been performed.
4. State newborn screens were sent on [**5-29**] and [**6-8**]
with no abnormal results reported to date.
5. Immunizations: The infant received hepatitis B vaccine on
[**2120-6-2**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 4/7 weeks.
2. Apnea of prematurity.
3. Feeding immaturity.
4. Hyperbilirubinemia.
5. Sepsis evaluation.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2120-6-9**] 15:45:56
T: [**2120-6-9**] 17:23:17
Job#: [**Job Number 74115**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4826
} | Medical Text: Admission Date: [**2148-8-4**] Discharge Date: [**2148-8-5**]
Date of Birth: [**2091-9-13**] Sex: F
Service: MEDICINE
Allergies:
Darvon / Codeine / Valium / Percocet / Demerol (PF) / Darvocet-N
100 / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Lithium Toxicity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Known firstname 553**] [**Known lastname 1806**] is a 56 year-old woman with a history of bipolar
disorder, hypothyroidism, psoriatic arthitis, and diabetes
mellitus who presents with mental status changes since [**8-2**].
According to her family she was in her usual state of health
until about a week ago when she started having difficulty with
word finding, short term memory, using household items, and was
walking slowly. They also state that she seemed slightly
unsteady while walking but has had no other abnormal movements.
Of note, she was prescribed TMP/SMX on [**7-30**] for nasal cellulitis.
Her son, a nurse, suspected lithium toxicity and called her PCP
who referred them to the ED.
In the ED, her initial vitals were T 98.8, HR 63, BP 144/64, RR
20, 100% RA. She was found to have a Cr of 1.3 from a baseline
of 0.7 and a lithium level of 2.0. Glucose was 215 (she has had
episodes of hyperosmolar hyperglycemic episodes in the past).
Toxicology was consulted, recommending dialysis due to her
symptoms. Nephrology recommended aggressive hydration first,
and regardless, the patient refused to have dialysis or Foley
catheters placed. She received 3 L NS in the ED with marked
improvements in her symptoms, although she did not return to
baseline. She was admitted to the MICU for monitoring and
aggressive diuresis.
Upon arrival, her vitals were T 36.4, HR 66, BP 154/69, RR 19,
Sat 99% RA. She was comfortable and in NAD.
ROS: Positive for loose stools for several months, and
increased urinary frequency for one day. She had no fevers,
chills, chest pain, dyspnea, nausea, vomiting, dysuria, urinary
frequency, or extremity pain.
Past Medical History:
Diabetes type II on insulin
Psoriatic Arthritis
Thyroid cancer s/p resection and radioactive iodine
Hypothyroidism
Bipolar disorder
Anxiety disorder
Asthma
Social History:
SH: She used tobacco in her early 20s, no alcohol, no other
drugs. Lives at home with husband.
Family History:
Strokes in mother and father. Renal disease and MI in brother.
Physical Exam:
Admission Exam:
Vitals: T 36.4, HR 66, BP 154/69, RR 19, Sat 99% RA
General: obese woman, comfortable, NAD
CV: RRR, systolic murmur
Pulm: CTAB
Abd: Soft, nontender, nondistended, positive bowel sounds
Extr: cool, well-perfused, 1+ pulses, no edema
Neuro:
Mental status: A&Ox3, no dysarthria or aphasia, generally
appropriate responses but seems somewhat confused, impaired
concentration on WORLD and serial 7s
CN II-XII intact
Strength 5/5 throughout and symmetric
Sensation intact to light touch throughout
Discharge Exam:
Vitals: Afebrile, HR 59 RR 18 BP 122/52 92% 2L NC
General: Obese woman, comfortable, NAD, alert and interactive
CV: RRR, systolic murmur heard throughout precordium
Pulm: Mild crackles at RLL but otherwise CTAB
Abd: Soft, nontender, nondistended, good bowel sounds
Extr: cool, well-perfused, 1+ pulses, no edema
Neuro:
Mental status: A&Ox3, no dysarthria or aphasia, generally
appropriate responses but seems somewhat confused, impaired
concentration on WORLD and serial 7s
CN II-XII intact
Strength 5/5 throughout and symmetric
Sensation intact to light touch throughout
Pertinent Results:
Admission Labs:
[**2148-8-4**] 05:40PM BLOOD WBC-6.2 RBC-3.83* Hgb-12.0 Hct-33.0*
MCV-86 MCH-31.5 MCHC-36.5* RDW-13.7 Plt Ct-166
[**2148-8-4**] 05:40PM BLOOD Neuts-56.0 Lymphs-34.6 Monos-2.8 Eos-5.2*
Baso-1.4
[**2148-8-4**] 05:40PM BLOOD PT-13.1 PTT-26.5 INR(PT)-1.1
[**2148-8-4**] 05:40PM BLOOD Glucose-215* UreaN-28* Creat-1.3* Na-135
K-4.1 Cl-107 HCO3-22 AnGap-10
[**2148-8-4**] 05:40PM BLOOD ALT-34 AST-37 LD(LDH)-226 CK(CPK)-49
AlkPhos-81 TotBili-1.5
[**2148-8-4**] 05:40PM BLOOD CK-MB-4
[**2148-8-4**] 05:40PM BLOOD cTropnT-<0.01
[**2148-8-4**] 05:40PM BLOOD Albumin-3.7
[**2148-8-4**] 10:06PM BLOOD Calcium-8.4 Phos-2.7 Mg-1.6
[**2148-8-4**] 05:40PM BLOOD Osmolal-295
[**2148-8-4**] 05:40PM BLOOD TSH-1.3
[**2148-8-4**] 06:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-8-4**] 06:11PM BLOOD Lactate-1.8
Lithium Trend:
[**2148-8-4**] 05:40PM BLOOD Lithium-2.0*
[**2148-8-4**] 10:06PM BLOOD Lithium-1.6*
[**2148-8-5**] 02:58AM BLOOD Lithium-1.2
[**2148-8-5**] 11:37AM BLOOD Lithium-1.1
Discharge Labs:
[**2148-8-5**] 02:58AM BLOOD WBC-5.9 RBC-3.54* Hgb-11.1* Hct-31.3*
MCV-88 MCH-31.4 MCHC-35.6* RDW-13.8 Plt Ct-128*
[**2148-8-5**] 11:37AM BLOOD Glucose-222* UreaN-17 Creat-0.8 Na-137
K-4.4 Cl-114* HCO3-19* AnGap-8
[**2148-8-5**] 11:37AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.8
Brief Hospital Course:
[**Known firstname 553**] [**Known lastname 1806**] is a 56 year-old woman with a history of
insulin-dependent DMII, bipolar disorder, and psoriatic
arthritis who presents with altered mental status, acute kidney
injury, and elevated lithium levels.
# Altered mental status: Altered mental status most likely cause
by lithium toxicity in the setting of acute kidney injury. No
evidence of infection on UA, no fever or leukocytosis. She has a
history of AMS with hyperosmolar hyperglycemic states, but her
hyperglycemia was relatively mild and her serum osmolarity was
normal. Toxicology initially recommended dialysis, but
nephrology recommended trying aggressive diuresis before
dialyzing the patient, who said that she would refuse a dialysis
catheter. Lithium was held, [**Known lastname **] was held and she was
hydrated agressively with LR, since patient has received 6 L NS
and developed a hyperchloremic acidosis. Lithium levels were
checked Q6hours and she was discharged when Lithium levels
returned to [**Location 213**]
# Acute kidney injury: Her creatinine was elevated to 1.3 from a
baseline of 0.7 on admission. This was thought to be most
likely intrinsic from TMP/SMX usage, but there she may have had
prerenal physiology as well due to decreased PO intake. There
was no evidence of obstruction or infection. [**Location **] and
[**Location **] were held, she was hydrated and electrolytes were
followed.
# Diabetes mellitus: Chronic issue which was stable during
admission. She was kept on her sliding scale insulin, metformin
was held. She refused to take her long acting insulin
# Psoriatic arthritis: Symptoms were stable. She can continue
taking her Methotrexate and Enbrel as an outpatient
# Hypothyroidism: Chronic, stable. Continued home levothyroxine.
# Bipolar and anxiety disorders: Chronic, stable. She has no
mood symptoms and her altered mental status is not at all
consistent with mania or depression. We continued her home
benzodiazepines and held lithium in the setting of acute
toxicity.
# Anemia: Initial hematocrit was normal, but that may be in the
setting of hemoconcentration. No evidence of acute bleeding.
Stool Guiac was negative and serial crits were stable.
Transitional Issues:
- She was told to hold her [**Location **]. Restarting should be
decided by outpatient physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] may have increased her Lithium level in setting of
[**Last Name (un) **]. [**Last Name (un) **] should not be used for her in the future. Again,
she was instructed to follow up with her outpatient PCP
regarding [**Last Name (un) **] use.
- She needs to be encouraged to keep her outpatient
appointments.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs(s) by mouth every four (4) to six (6) hours as needed for
cough/wheezing
CLONAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day
DERMATOLOGIC APPLICATIONS - (Prescribed by Other Provider) -
-
ETANERCEPT [ENBREL] - 25 mg Kit - inject twice a week
FLUOCINONIDE - 0.05 % Cream - apply to affected area twice daily
INSULIN ASPART [NOVOLOG FLEXPEN] - 100 unit/mL Insulin Pen - 4
units or as directed subcutaneously Before meals As directed on
your sliding scale
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 20 units subcutaneously At bedtime Increase as directed by
your physician
[**Name Initial (PRE) 103820**] [LEVOXYL] - 75 mcg Tablet - 1 Tablet(s) by mouth
daily and extra [**12-24**] tab on Sundays Take fasting with water only
-
No Substitution
[**Month/Day (2) **] - 10 mg Tablet - 1 Tablet(s) by mouth once a day
LITHIUM CARBONATE - (Prescribed by Other Provider) - 300 mg
Tablet - 3 Tablet(s) by mouth at bedtime as needed for total of
900 mg daily
LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth at bedtime as needed for sleep
METFORMIN - 500 mg Tablet Extended Release 24 hr - 2 Tablet(s)
by
mouth every evening
METHOTREXATE SODIUM - 25 mg/mL Solution - 20 mg once per week
taken on Wednesday
SYRINGE (DISPOSABLE) - Syringe - 30g, [**12-24**]"-1" needle, use with
methotrexate weekly
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): With an extra half a tablet on Sundays. Take fasting
with water only .
4. lithium carbonate 300 mg Tablet Sig: Three (3) Tablet PO at
bedtime: Take 3 tablets at bedtime for total of 900mg Daily.
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
6. methotrexate sodium 25 mg/mL Solution Sig: Twenty (20) mg
Injection once a week: taken on Wednesdays.
7. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO once a day.
8. insulin aspart 100 unit/mL Insulin Pen Sig: As directed units
Subcutaneous before meals: As directed by your sliding scale.
9. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
(20) units Subcutaneous at bedtime.
10. Enbrel 25 mg Kit Sig: One (1) Subcutaneous twice per week.
Discharge Disposition:
Home
Discharge Diagnosis:
Lithium toxicity
Acute Kidney Injury
Insulin Dependent Diabetes Mellitus
Psoriatic Arthritis
Thyroid Cancer s/p resection and radioactive iodine
Hypothyroidism
Bipolar Disorder
Anxiety Disorder
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 1806**],
It was a pleasure treating you during your hospitalization. You
were admitted to [**Hospital1 18**] with Lithium toxicity and Acute Kidney
Injury. It is believed that because of your nasal cellulitis you
became dehydrated which affected your kidneys ability to clear
Lithium. The [**Hospital1 **] antibiotic you took for cellulitis may have
also caused some kidney injury which may have increased your
Lithium level as well. Dehydration, kidney injury and increasing
Lithium levels in your blood caused your altered mental status,
difficulty finding words and unsteady walking. You were treated
with aggressive hydration and stopping Lithium. You were
observed and as your Lithium levels fell to normal range you
became more alert and mentally clear. You are being discharged
in stable condition with a normal Lithium level.
The following changes to your medications were made:
- You can begin taking your Lithium again tomorrow [**8-6**] at your
regular home dose
- You should avoid taking [**Month/Year (2) **] again in the future because it
may have increased Lithium levels on your body
- Please do not take your [**Month/Year (2) 21177**] until you see your
outpatient physician. [**Name10 (NameIs) **] can elevate Lithium levels.
- No other changes to your medications were made, please
continue taking your home medications as prescribed
- It is very important that you see your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **]e. You have been scheduled appointments with Dr.
[**Last Name (STitle) 14973**] and Dr. [**Last Name (STitle) 67006**].
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: THURSDAY [**2148-8-8**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 103821**], MD [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
** This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care physician after this
visit.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Address: 57 [**Location (un) **] TERRACE, [**Location (un) **],[**Numeric Identifier 103822**]
Phone: [**Telephone/Fax (1) 103823**]
Appointment: Thursday [**2148-8-15**] 12:00pm
Department: [**Hospital **] MEDICAL GROUP
When: TUESDAY [**2148-9-3**] at 10:45 AM
With: [**First Name11 (Name Pattern1) 132**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: RADIOLOGY
When: TUESDAY [**2148-9-17**] at 9:30 AM [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 5849, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4827
} | Medical Text: Admission Date: [**2107-4-30**] Discharge Date: [**2107-5-2**]
Service: MICU/[**Location (un) **]
CHIEF COMPLAINT: Postictal state versus cerebrovascular
accident.
HISTORY OF THE PRESENT ILLNESS: The patient is an
86-year-old female nursing home resident with dementia who on
[**2107-4-30**] reportedly was found unresponsive with left arm
jerking motion and eye deviation to the left. This episode
lasted approximately ten minutes and then she was noted to be
weak on the left side with gradual improvement in her
strength. The nursing home report was not entirely clear.
There was also a statement that the patient was found
unconscious in a room with one pupil dilated and a weak left
side. At baseline, the patient is alert and "complains a
lot". She walks independently with a limp and she is able to
feed herself and remembers to take baths and eat meals.
On presentation to the hospital, the patient was found to
have elevated cardiac enzymes and in fact ruled in for a
myocardial infarction. The EKG showed an inferior MI.
Cardiology was involved, but after assessment deemed that it
was too late for intervention for the patient. The patient's
family also opted for medical treatment versus
catheterization or surgical care. The patient was initially
admitted to the floor in the hospital; however, a code was
called when she became bradycardiac and hypotensive. This
hypotension responded to Atropine and the patient was found
to be in atrial fibrillation rhythm and was transferred to
the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Hypothyroidism.
4. Dementia.
5. Diabetes mellitus.
6. Osteoarthritis.
ALLERGIES: Vioxx.
ADMISSION MEDICATIONS:
1. Coumadin 2 mg q.d.
2. Seroquel 25 mg q.d.
3. Atenolol 25 mg q.d.
4. Motrin 400 mg three times a day.
5. Synthroid 100 micrograms q.d.
6. Aricept 10 mg q.d.
7. Daily aspirin.
SOCIAL HISTORY: As stated, the patient is a nursing home
resident and her family is involved in her care.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96, blood pressure 112/80, heart rate 87, respiratory rate
17, pulse ox 93% on 2 liters nasal cannula. General: She
was in no apparent distress when she was left alone.
However, she would become somewhat restless when examined.
HEENT: The pupils were not entirely reactive. The right
pupil was slightly more sluggish than the left; however, this
was reported to be an old finding. Her oropharynx was quite
dry. No noted JVD. Chest: The patient had reasonable air
flow bilaterally with some basilar crackles but would not
make an inspiratory effort for the examination. Cardiac:
Irregularly/irregular rhythm, S1, S2, with no murmur.
Abdomen: Positive bowel sounds, soft. Diffuse moans to
palpation. Extremities: No edema, 2+ femoral pulses
bilaterally and nonpalpable dorsalis pedis pulses
bilaterally. The patient was moving all extremities.
Neurologic: The patient only moaned. There was some
question as to whether she would follow some simple commands
such as opening her eyes; however, this was not reliable and
she seemed to be hypersensitive to palpation. She did make
meaningful movements to pull the sheets over her body.
LABORATORY/RADIOLOGIC DATA: Chemistries: Sodium 137,
potassium 4.6, chloride 105, bicarbonate 22, BUN 22,
creatinine 1, glucose 252, anion gap 15. White count 7.8,
hematocrit 34.7, platelet count 300,000. Her CK was
initially 516 and repeat was 914. Her troponin was 23.5.
Her INR was 1.5.
EKG showed a rate of about 90, irregularly/irregular with
left axis deviation, slight ST depression in V2, ST elevation
in III, aVF, and V3 as well as Qs in II and aVF.
Head CT showed no hemorrhage or mass lesion.
Chest x-ray showed some atelectasis versus consolidation at
the left base.
ABGs were 7.4/36/293 on a nonrebreather.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for supportive care. She gradually improved
slightly and her mental status would become more arousable
and speak several words.
On [**2107-5-1**], her first day in the ICU, the patient had an
episode of apnea and bradycardia and became hypotensive. At
arrival to the bedside, her heart rate was found to be
in the 60s. She was given 1 mg of Atropine with
no response to her hypotension. A repeat mg of Atropine
caused her blood pressure to increase to greater than 100
systolic and a heart rate to increase to over 100 systolic,
becoming tachycardiac. She was given a small dose of
Lopressor which brought her heart rate under good control.
She was also given fluids to increase her blood pressure.
The case was discussed with the family and they wished for no
invasive methods to be used to monitor her blood pressure or
resuscitate her. Neurology continued to follow the patient.
They recommended an EEG to determine whether she was having
any seizure activity given her initial presentation. In the
meantime, she was loaded with phosphenytoin.
On [**2107-5-2**], the patient had a second bradycardiac
episode. At this point, she was given 0.5 mg of Atropine and
observed as her heart rate and blood pressure gradually
returned to a normal range for her.
On the evening of [**2107-5-2**], the patient had several
additional episodes of bradycardia, hypotension. On the
fourth episode, she was unresponsive to Atropine and her
blood pressure and responsiveness decreased. She became
increasinly unresponsive and passed away. She was pronounced
dead at 10:55 p.m. The patient's family, including her sister and
daughter, were [**Name (NI) 653**]. The patient's attending was made aware
of the event.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.12.948
Dictated By:[**Last Name (NamePattern1) 107548**]
MEDQUIST36
D: [**2107-6-8**] 03:31
T: [**2107-6-12**] 08:26
JOB#: [**Job Number 107549**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4828
} | Medical Text: Admission Date: [**2194-8-24**] Discharge Date: [**2194-8-28**]
Date of Birth: [**2112-2-19**] Sex: F
Service: MEDICINE
Allergies:
Belladonna Alkaloids
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
AMS, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 108328**] is an 82 year old female with MDS, Crohn's disease,
CAD s/p NSTEMI, CRI, h/o DVT with saddle embolus on weekly
lovenox due to h/o GIBs, h/o breast cancer, on home O2 who
presents with dyspnea, AMS. Of note, patient was discharged 6
days ago with left upper extremity DVT from PICC and subsequent
port placement.
.
In ED, patient presented solmnolent with marked tachypnea from
ambulance. ABG 7.21/80/76 given baseline pCO2 60 patient was
started on BiPAP. CXR with effusions, but unclear if any
consolidation. Mildly positive UA, minimal urine output. Patient
was started on Vanc/Zosyn and given methylpred 125mg
empirically. Patient with troponin at baseline. K noted to be
7.0: 60 gm kayexelate enema (with no significant bowel
movement), amp D50, 10 unit insulin iv, albuterol/ipratropium
nebs, and 1 gm calcium gluconate. EKG no peaked Ts, QRS 130
which is baseline and no other concerning ST/T changes. Patient
repeat K pending. Renal aware of K+ but given EKG felt no need
for urgent HD. Given recent left upper extremity DVT, patient
got 60 mg lovenox in ED as has not gotten today. Unable to get
PE CTA given renal failure. Minimal improvement on BiPAP in
terms of mental status. Current vitals: temp afebrile by rectal,
BP 140/40s, HR 50s, O2sat 97% on bipap 8/5, 2LNC.
.
Event prior to transfer: SBP 70s suddenly, and SBP improved 100s
off BiPAP, still sinus brady. Patient slightly more awake now
off BiPAP, getting 500 ml bolus. ABG just prior 7.27/68/74.
.
Upon arrival to MICU, patient somnulent off BiPAP. Patient
placed back on BiPAP and want unable to answer questions.
Daughter provided the following history. Daughter reports since
discharge from hospital patient has been weak, not interested in
eating, and intermittently very somnulent. Daughter reports her
mother is [**Name2 (NI) 18248**] and then not confused. [**Name2 (NI) 108329**] describes 2
episodes of confusion this week in the setting of document
hypoxia to 70s, that resolved upon increasing oxygen. Daughter
reports mother [**Name (NI) **] hot w/o fever by thermometer, and w/o chills.
Over the week the daughter has noted she issues with oxygenation
and has changed her O2 between 1.5 to 3LNC. Usually her mother
is only on O2 at night, but has been on it continuously since
just prior to last hospitalization. Daughter has been giving her
Bactrim and vitamins to help. She also gave her mother [**Doctor Last Name **]
yesterday, because she wanted her to retain water and was
concerned she was becoming dehydrated. Daughter reports
increased UOP earlier in the week followed by minimal urine
output today. Early on day of admission patient called out to
daughter and reports not seeing well and wanting to get out of
bed. Per daughter, these are symptoms of hypercarbia in her
mother. Daughter also report mother has had non-productive
cough, but without coughing after eating. Per daughter [**Name (NI) **] [**Name2 (NI) **]
check was K =5.3 from VNA labs.
.
Review of systems: (+) Per HPI. Daughter reports ongoing groin
rash.
Past Medical History:
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**]
-CRI w baseline Cr 1.5-1.8
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, now off Lovenox as well for GIB
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
-?Arrhythmia unspecified which daughter says is tx with
metoprolol
-dHF with EF 60-70%
-s/p CY 10 yrs ago
-s/p Lumpectomy 13 yrs ago
Social History:
[**Year (4 digits) 595**] speaking only. Married; lives with her daughter [**Name (NI) 108329**],
[**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. [**Name (NI) 108329**] is the caretaker
for both of her parents. Has daily visiting nurse at home.
Family History:
Non-contributory
Physical Exam:
Initial MICU exam:
General Appearance: Thin
Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Conjunctiva
pale, conjugate gaze
Head, Ears, Nose, Throat: Normocephalic, on BiPAP
Lymphatic: No(t) Cervical WNL
Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: No(t)
Systolic)
Peripheral [**Name (NI) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : ), anterior, lateral
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right: 1+ edema, Left: 1+ edema, legs wrapped in
ACE bandages
Skin: Warm, Rash: in groin erythematous.
Initial floor exam:
Vitals: 99.2 72 140/58 22 93% 0.5LNC
Gen: pleasant elderly woman lying in bed, in NAD
[**Name (NI) 4459**]: NC/AT, EOMI, MMM, supple neck
CV: RRR, normal S1S2, no m/r/g
Lungs: CTA b/l, decreased breath sounds, no rales/wheezing
appreciated
Abd: soft, nt, nd, +bs, no masses
Ext: 2+ edema in all extremities, +distal pulses
Pertinent Results:
Labs on Admission: [**2194-8-24**]
WBC-5.9 RBC-2.41* Hgb-8.5* Hct-27.3* MCV-114* RDW-23.9* Plt
Ct-244
Neuts-51.8 Lymphs-36.6 Monos-8.3 Eos-2.6 Baso-0.8
PT-10.5 PTT-22.3 INR(PT)-0.9
Glucose-115* UreaN-31* Creat-1.9* Na-140 K-7.0* Cl-105 HCO3-34*
AnGap-8
Calcium-8.7 Phos-4.1 Mg-2.7*
ALT-7 AST-11 CK(CPK)-16* AlkPhos-103 TotBili-0.3
Lipase-61*
proBNP-4081*
.
.
Micro:
[**2194-8-24**] Blood cultures: pending
[**2194-8-24**] Urine culture: URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
.
Other Studies:
[**2194-8-24**] EKG: Possible wandering atrial pacemaker or irregular
sinus bradycardia with premature atrial contractions and first
degree A-V block. Right bundle-branch block. Non-specific ST-T
wave changes. Compared to tracing #1 no significant change.
[**2194-8-24**] CXR: 1. Moderate left and small right pleural effusions.
2. Left retrocardiac opacity, atelectasis and/or consolidation.
[**2194-8-24**] CT Head w/o: No acute intracranial pathology. Stable
encephalomalacic changes as described. However, MRI would be
more sensitive for [**Month/Day/Year 2742**] of acute infarct if clinical
concern warrants.
[**2194-8-25**] Echo: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild pulmonary artery systolic
hypertension. Mild mitral regurgitation. Compared with the prior
study (images reviewed) of [**2194-4-8**], the estimated pulmonary
artery systolic pressure is now lower. The right ventricular
cavity is also smaller/now normal.
[**2194-8-25**] Left arm U/S: 1. Deep vein thrombosis is identified in
one of the two brachial veins. Flow within the axillary vein
appears to be normal on today's exam. 2. Stable appearing
hematoma in the left upper arm.
[**2194-8-26**] CXR: The Port-A-Cath catheter tip is in superior SVC.
The left retrocardiac consolidation which is most likely a
combination of atelectasis and pleural effusion is unchanged.
Infectious superimposed process cannot be excluded. There is
interval worsening of [**Month/Day/Year 1106**] engorgement with currently
[**Month/Day/Year 1106**] engorgement seen in the perihilar areas bilateral.
There is no pneumothorax. The patient is after cholecystectomy
Brief Hospital Course:
This is an 82 year old female with MDS, Crohn's with multiple GI
bleeds, CAD s/p NSTEMI, CKD, h/o DVT/saddle embolus on daily
Lovenox, breast ca, on home O2 only at night secondary to
non-compliance with bipap, admitted for altered mental status
and dyspnea.
.
#. AMS. The patient was admitted to the MICU with lethargy and
confusion which the daughter felt was due to hypercarbia. Upon
arrival to MICU, the patient was somnolent off BiPAP and
improved after being placed back on BiPAP. Ever since her last
admission, the daughter reports that the patient has been weak,
not interested in eating, and intermittently very somnolent. She
was found to have a questionable retrocardiac pneumonia on CXR
and a UTI. Her AMS resolved after antibiotic coverage and her
ABG returned to her baseline on nasal cannula prior to leaving
the ICU. She was treated empirically for HAP and UTI with
vanco, cefepime, and ciprofloxacin starting on [**8-24**] in the MICU.
Her antibiotics were modified to cefepime only for a total of a
10 day course to be completed at home. Blood cultures were
negative on discharge and urine culture was positive for
enterobacter sensitive to cefepime.
.
#. Dyspnea. She is slightly dyspneic at baseline, but was
satting well on room air prior to discharge. Her current chest
imaging does not have a clear infiltrate and just shows interval
worsening of [**Month/Year (2) 1106**] engorgement in bilateral perihilar areas
which may be secondary to fluid overload. Cefepime alone would
also provide good lung coverage in case the patient has a
non-focal pneumonia. She does have a history of PE, but no RV
strain was seen on ECHO on admission. She will most likely need
some gentle diuresis with her home dose of Lasix 10mg. She will
continue on her stress dose steroid [**Month/Year (2) 15123**] that was started in
MICU, and per the daughter's request will be tapered back slowly
by 5mg every 2 days down to her 20mg chronic dose after
discharge.
.
#. Hyperkalemia. This seems to be a chronic issue. Her Bactrim
was switched to atovaquone as Bactrim can sometimes contribute
to hyperkalemia. Her potassium had remained stable without
intervention over the two days prior to discharge.
.
#. Anemia. She was transfused 2 units [**8-26**] which appropriately
increased her hematocrit from 23.5 to 31.3. Her hematocrit
remained stable thereafter. Her stools were guaiac negative.
Her monthly B12 shot was administered [**2194-8-25**] and she was
continued on daily folic acid.
.
#. LUE DVT. Last ultrasound was done on [**2194-8-25**] which revealed
a stable hematoma and upper extremity DVT. She continued daily
Lovenox 60mg and her hematocrit was followed closely.
.
#. MDS. She has transfusion dependent disease and she was
transfused to keep her hematocrit greater than 23. Her PCP
prophylaxis was switched from Bactrim to Atovaquone.
.
#. Crohn's disease. Her home mesalamine was continued and her
steroids were stress dosed. She will be tapered back to her
20mg home dose slowly.
.
#. CAD s/p NSTEMI. She is not on ASA secondary to her history
of multiple GI bleeds. She was continued on her beta blocker.
.
#. Chronic b/l LE edema/venous stasis. Her home trimacinolone
cream was continued PRN as well as intermittent Lasix 10mg PRN.
.
#. GERD. She was maintained on daily pantoprazole 40mg during
the admission.
.
#. CKD - Her baseline creatinine is around 2 and was 1.9 on the
day of discharge. She will be continued on weekly Epogen 40,000
units as an outpatient, but was given 10,000 units on a
Monday/Wednesday/Friday schedule as an inpatient.
.
#. Fungal groin rash. Miconazole QID was given during admission.
Medications on Admission:
Folic Acid 1 mg daily
Mesalamine 1200 mg TID
Bone Reenforcement (MVI/Ca/D/Mg/vitC)
Trimethoprim-Sulfamethoxazole 80-400 mg every other day -- took
daily for 10 days for UTI prior to last hospital presentation
and has been taking almost daily since discharge from last
hospitalization for subj fevers.
Ciprofloxacin 250 mg [**Hospital1 **], taken PRN for diarrhea, last taken [**3-4**]
wks ago
Epoetin Alfa 40,000 unit/mL weekly
Miconazole Nitrate 2 % Powder TID:PRN rash
Omeprazole EC 20 mg daily
Lasix 10mg daily:PRN leg swelling - got tues or wed this past wk
Cyanocobalamin 1,000 mcg/mL INJ monthly - due this week
Triamcinolone Acetonide 0.025 % Cream to affected area [**Hospital1 **]
Prednisone 20 mg daily
Lovenox 60 mg INJ daily - got Wed-Fri, missed Mon/Tues due to no
supply, missed Sat/Sun as not feeling well and daughter worried
about giving
Metoprolol Tartrate 12.5 mg prn SBP >130 (daughter checks at
home) last given saturday.
Discharge Medications:
1. Cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q24H
(every 24 hours) for 6 doses.
Disp:*6 grams* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 ML(s)* Refills:*0*
3. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five
(5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Disp:*30 ML(s)* Refills:*0*
4. Sodium Chloride 0.9 % 0.9 % Solution Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
Disp:*60 ML(s)* Refills:*0*
5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q24H (every 24 hours).
6. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily) as needed for to lower extremities.
7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin.
9. Epoetin Alfa 10,000 unit/mL Solution Sig: 40,000 units
Injection once a week.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day as
needed.
12. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Portacath care
Portacath supplies
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
18. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) MLs PO DAILY
(Daily).
Disp:*300 MLs* Refills:*2*
19. Prednisone 10 mg Tablet Sig: Take 55mg for 2 days, 50mg for
2 days, 45mg for 2 days, 40mg for 2 days, 35mg for 2 days, 30mg
for 2 days, 25mg for 2 days, then continue with 20mg daily
Tablet PO once a day.
Disp:*QS Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Pneumonia
urinary tract infection
altered mental status
Secondary diagnoses:
-h/o hyperkalemia
-PICC associated left upper extremity DVT and hematoma [**5-8**]
-BL DVTs and saddle embolus in [**2190**] and [**2193**], previously on
warfarin, on weekly lovenox due to prior UGIB, recently [**8-18**]
increased to daily lovenox for upper extremity DVT.
-Multifactorial anemia ([**3-3**] CRI, chronic disease, MDS)
-MDS dx 3 yrs ago
-Crohn's disease
-CAD s/p NSTEMI '[**89**] AND chronic diastolic congestive heart
failure: EF 60-70%
-CRI w baseline Cr 1.4-1.7
-Chronic BL LE edema
-Breast cancer s/p lumpectomy & XRT
-GERD
-Intracranial bleed and fx after pedestrian vs car 20 yrs ago
-Cataracts
-Venous stasis dermatitis
-Tinea pedis
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
[**Hospital1 2742**] of altered mental status. You were found to have a
pneumonia, urinary tract infection and a high potassium level.
Your potassium levels were treated and have remained stable. At
first you were extremely somnolent and were cared for in the
intensive care unit where you were treated with broad spectrum
antibiotics to cover a pneumonia as well as a urinary tract
infection. Your mental status improved with oxygen and
antibiotics. For your congestive heart failure, please weigh
yourself every morning, call your primary care doctor if your
weight > 3 lbs. You should continue to dose Lasix as needed to
take off any extra fluid. Please adhere to a 2 gm sodium and
low potassium diet.
The following changes have been made to your medication regimen:
-You will take 6 more doses of Cefepime 1 gram IV daily
-You will [**Hospital1 15123**] your prednisone dose as directed by 5mg every 2
days back down to 20mg daily
-You will take atovaquone 1500mg daily
-You will stop taking Bactrim
Please keep all of your follow-up outpatient medical
appointments.
Please seek medical care for any concerning symptoms such as
confusion, fevers, chills, vomiting, increased shortness of
breath, chest pain, or bloos in your stool.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 486, 5990, 5119, 5180, 2767, 412, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4829
} | Medical Text: Admission Date: [**2184-10-10**] Discharge Date: [**2184-10-12**]
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
gentleman admitted on [**2184-10-10**] with the complaint of a bruise
to his right eye. He presented stating that three days
previous he had bumped his head on a microwave and awoke on
[**2184-10-10**] feeling more tired than usual and "not quite
alright." His symptoms were accompanied by right periorbital
bruise and a left tongue contusion. There was no associated
headache, focal numbness, or weakness.
PHYSICAL EXAMINATION: The patient's vitals were stable. He
was alert and oriented x3, in no acute distress with normal
affect. Pupils are 3 mm, reactive with ecchymosis of the
left eye. Cranial nerves II through XII were intact.
Strength was equal bilaterally, upper and lower extremities.
Sensory was intact throughout. Cardiac showed S1 and S2,
regular rate and rhythm. Lungs were clear to auscultation
bilaterally. Abdomen was soft, nontender, and nondistended.
Extremities: No clubbing or edema.
DIAGNOSTIC STUDIES: CAT scan here showed fracture along the
left side of the orbit, contusion in the left
frontotemporal lobe, and traumatic subarachnoid hemorrhage.
HOSPITAL COURSE: The patient was admitted for observation
and treatment and has had an unremarkable stay with no
complications. He has been evaluated by physical therapy and
will be evaluated for home safety on discharge.
DISCHARGE DISPOSITION: The patient will be discharged to
home in stable condition with home safety evaluation.
DISCHARGE MEDICATIONS:
1. Lisinopril 10 mg.
2. Multivitamins.
3. Dilantin 100 mg.
4. Protonix 40 mg.
5. Atenolol 25 mg.
DISCHARGE INSTRUCTIONS: The patient is to call Dr.[**Name (NI) 1334**]
office if he develops worsening symptoms, worsening
headaches, any changes in mental status, vision changes,
vomiting, or fever. The patient is to follow up with Dr.
[**Last Name (STitle) 1132**] in one month and obtain a CAT scan of the head before
his appointment. The patient will be discharged to home
again in stable condition with home safety evaluation.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 30499**]
MEDQUIST36
D: [**2184-10-12**] 11:43:29
T: [**2184-10-12**] 15:52:52
Job#: [**Job Number 30500**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4830
} | Medical Text: Admission Date: [**2158-5-26**] Discharge Date: [**2158-6-12**]
Date of Birth: [**2121-2-5**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 37 year old
gentleman with a history of end stage AIDS complicated by
multiple opportunistic infections and long history of
cardiomyopathy of unclear etiology who had been managed for
several weeks as an outpatient with increasing episodes of
diarrhea and a weight loss of approximately ten pounds.
Approximately ten days prior to admission, he had also begun
to develop some shortness of breath associated with some
chest tightness and coughing. He had been seen in the
Emergency Department where a CT angiogram of his chest had
been performed and revealed a pneumonia and he was treated
over the next week with Augmentin for this. However, he
continued to have pleuritic chest pain, shortness of breath
and temperature of 102.
On follow-up office visit to his primary care physician, [**Name10 (NameIs) **]
was found to have collapse of the right middle lobe on chest
x-ray. Given his ongoing pulmonary complaints as well as
diarrhea and poor nutritional status, he was admitted to the
hospital for further workup.
PAST MEDICAL HISTORY:
1. HIV complicated by end stage AIDS first diagnosed [**2142**],
presumably secondary to heterosexual sex with wife
complicated by multiple opportunistic infections including
PCP times five, MAC and HSV, also with [**Doctor First Name **] brain abscess
leading to seizure disorder complicated by DDI induced
pancreatitis and complicated by peripheral neuropathy.
2. Questionable history of hypercoagulability, status post
axillary vein thrombosis associated with PICC line in [**2154**],
and status post deep vein thrombosis in [**2157-12-29**].
3. History of cardiomyopathy of unclear etiology, status
post echocardiogram [**2-/2157**], showing ejection fraction of 25%
with focal wall motion abnormalities.
4. Hypertension.
MEDICATIONS ON ADMISSION:
1. Acyclovir 400 mg p.o. b.i.d.
2. Atenolol 50 mg p.o. q.d.
3. Augmentin one tablet p.o. b.i.d.
4. Azithromycin 250 mg p.o. b.i.d.
5. Ciprofloxacin 500 mg p.o. b.i.d.
6. Claritin 10 mg p.o. q.d.
7. Dilaudid 2 mg p.o. q3hours p.r.n.
8. Erythropoietin 20,000 units subcutaneous q.week.
9. Ethambutol 400 mg p.o. t.i.d.
10. Flonase two sprays to each nostril b.i.d.
11. Glimepiride 150 mg p.o. b.i.d.
12. Lomotil p.r.n.
13. Mepron 250 mg p.o. q.d.
14. M.S. Contin 30 mg p.o. t.i.d. p.r.n.
15. Mycelex 10 t.i.d. used p.r.n. for thrush.
16. Neupogen 300 mcg subcutaneous biweekly.
17. Neurontin 800 mg p.o. t.i.d.
18. Tincture of Opium 10% strength 1 cc p.o. q.i.d. p.r.n.
19. Paxil 20 mg p.o. q.d.
20. Aerosolized Pentamidine 300 units q.month.
21. Keletra three capsules p.o. b.i.d.
22. Sporanox 200 mg p.o. q.d.
23. Stavudine 400 mg p.o. b.i.d.
24. Ultrase two capsules t.i.d. with meals.
25. Warfarin 5 mg p.o. q.d.
ALLERGIES: Bactrim which leads to an aseptic meningitis.
SOCIAL HISTORY: The patient lives in an apartment with his
girlfriend and has visiting nurses once a week. He is a
current smoker of one pack per week, occasional alcohol and
denies any intravenous drug use.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAMINATION: On admission, temperature was 98.1,
pulse 70, blood pressure 118/80, respiratory rate 18, oxygen
saturation 97% in room air. Weight is 64.7 kilograms. On
examination, he was awake, alert and oriented, thin and
comfortable in no acute distress. On head, eyes, ears, nose
and throat examination, the pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
are intact. Moist mucous membranes. He had thrush in his
oropharynx. The neck was supple with lymphadenopathy and no
masses. His lung examination revealed decreased breath
sounds at the right base with a few scattered crackles and
otherwise clear. His cardiovascular examination revealed a
regular rate and rhythm, normal S1 and S2 with no murmurs,
rubs or gallops appreciated. The abdomen was soft,
nontender, nondistended with positive bowel sounds. Spleen
tip was palpable. Extremity examination revealed a palpable
cord over the left medial thigh which was nontender. He had
no edema and had 2+ pulses.
LABORATORY DATA: Sodium 142, potassium 4.1, chloride 102,
bicarbonate 23, blood urea nitrogen 25, creatinine 1.1,
glucose 97. Calcium 9.2, magnesium 1.9, phosphorus 3.4.
White count 4.2, hematocrit 49.9, platelets 206,000. INR
2.6. Partial thromboplastin time 33.7.
HOSPITAL COURSE: The patient was admitted to the Medical
Service for workup of pneumonia and diarrhea and was treated
for a number of complications throughout his hospitalization.
1. Pulmonary - The patient had been treated as an outpatient
for approximately ten days with Augmentin for presumed right
middle lobe pneumonia which had not been improving. His
medical regimen at the time of admission included Augmentin,
Ciprofloxacin and Azithromycin. During his stay, however, he
was found to have bilateral deep vein thrombosis and upon
reread of his CT concern was raised for potential pulmonary
embolism.
For this reason, he underwent a CT angiogram on [**2158-6-6**],
which revealed a large left pulmonary artery embolism as well
as possible right sided pulmonary emboli. Given his likely
hypercoagulable state and evidence of thrombus despite
presumably therapeutic INR levels, both the pulmonary and
hematology teams were consulted to help guide his therapy.
Placement of an inferior vena caval filter was entertained
given his tenuous respiratory status, known bilateral deep
vein thrombosis and concern that subsequent deep vein
thrombosis could be fatal. The issues were discussed with
the patient as well as among his attendings and it was felt
that a filter would likely present a nidus for infection as
well as further clot and was generally not worth the risks of
the procedure.
Instead, the patient was placed on Lovenox therapy given
presumed failure to Coumadin therapy although it was noted
that he may have required higher doses of Coumadin, i.e.,
levels greater than 3.5 in order to truly be anticoagulated
with Coumadin. He will, however, be discharged on Lovenox
therapy.
The hematology and pulmonary teams were also concerned about
the use of Epogen and whether a hematocrit of greater than
50.0 may be associated with high risk of thrombosis. It was
decided to continue Epogen therapy with goal hematocrit to be
maintained less than 40.0.
Throughout his hospital stay, the patient continued to
require intermittent oxygen with saturation documented well
below 88. For this reason, arrangements were made for him to
continue to receive oxygen therapy at home upon his
discharge. He was also treated for presumed pneumonia with
Azithromycin and Ciprofloxacin to finish out fourteen day
courses.
2. Cardiovascular = During his hospital stay, the patient
experienced acute episode of shortness of breath associated
with left sided chest pain. Electrocardiogram was obtained
which showed significant ST elevations in the inferior leads,
and the patient was transported urgently to the
catheterization laboratory for presumed acute myocardial
infarction. At catheterization, the patient was found to
have an occluded right coronary artery and received 99
millimeters of stents with good final result.
He subsequently underwent an echocardiogram which showed a
preserved ejection fraction of 50% although he continued to
have right ventricular hypertrophy, right ventricular
dilatation and severe global right ventricular hypokinesis as
a result of his inferior myocardial infarction. He was also
noted to have a small atrial septal defect of unclear
significance.
He was placed on Aspirin and Plavix and slowly introduced to
an ace inhibitor as his blood pressure tolerated.
3. Infectious disease - The patient has a long history of
HIV, now end stage AIDS and CD4 count of 2. His course has
been complicated by multiple opportunistic infections as
detailed above. During his course, he was treated for
presumed pneumonia which is felt to complicate his pulmonary
emboli. He was otherwise continued on his extensive
outpatient antiretroviral regimen given his highly resistant
viral strain. He was also continued on Azithromycin, Mepron
and Ciprofloxacin for prophylaxis.
During his hospital stay, he was noted to have question of a
line infection in the CCU and was treated with a fourteen day
course of intravenous Vancomycin to cover for any true
infection, although his blood cultures remained negative.
4. Gastrointestinal - On admission, the patient had been
complaining of several week history of persistent diarrhea
complicated by a ten pound weight loss. He had undergone an
extensive outpatient workup for infections which had been
negative and this was again repeated during his
hospitalization. He also underwent a colonoscopy with
biopsies which was unremarkable. The biopsies were all
negative. He continued to have episodes of diarrhea and was
ultimately placed on Kaopectate for symptomatic relief given
no infectious source. His etiology is presumably related to
medications which cannot be altered at this time.
5. Hematology - The patient has a history of clots in the
past although a partial hypercoagulability workup had been
unrevealing. During his hospital stay, he was also found to
have bilateral lower extremity deep vein thrombosis as well
as a left jugular vein deep vein thrombosis associated with a
line. Hematology consultation was ordered as above and a
hypercoagulability workup was sent off. Given presumed
failure to Coumadin although his doses had been only dosed in
the 2.5 to 3.5 range, the patient was switched to Lovenox
therapy which he will continue as an outpatient.
CODE STATUS: The patient had previously indicated his wishes
not to undergo emergency treatment should he decompensate
acutely, however, in the setting of his chest pain and
presumed myocardial infarction, the patient had decided to
pursue aggressive measures and so his Code Status was
reversed to full code for his hospitalization. This can be
readdressed as an outpatient.
DISCHARGE STATUS: At the time of this dictation, it is
presumed that the patient will be discharged with extensive
VNA help and on oxygen.
Medications will be delineated in a further dictation to
follow on the day of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. [**MD Number(1) 9562**]
Dictated By:[**Name8 (MD) 15231**]
MEDQUIST36
D: [**2158-6-10**] 12:27
T: [**2158-6-10**] 14:10
JOB#: [**Job Number 15232**]
ICD9 Codes: 4254, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4831
} | Medical Text: Admission Date: [**2189-3-23**] Discharge Date: [**2189-3-28**]
Date of Birth: [**2117-6-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Atrial flutter ablation on [**2189-3-24**]
s/p cardiac catheterization on [**2189-3-26**]
History of Present Illness:
71 year old male with no known cardiac history and likely [**Hospital 2182**]
transferred from OSH with afib with RVR (vs aflutter), EKG
suggestive of past MI and 9 beat run of VTach. Patient
travelled to South America 3 weeks prior to admission where he
developed shortness of breath, cough. Patient denies any fever,
although this was documented in OSH records. He was on an 11
day trip to [**Location (un) 72427**] and Patagonia with his fiancee. He
noted dyspnea on exertion when he was carrying luggage on a 95
degree day. He states his symptoms seemed to be intermittent,
although he admits that they probably never completely resolved
and have persisted since. Symptom onset was approximately 3
weeks ago. He returned home around [**2189-3-9**] and thought his
symptoms were getting better. However, noted non-productive
cough, dyspnea on exertion and orthopnea which seemed to be
worsening and his fiancee convinced him to go to the [**Location (un) 59322**] ED. He did not c/o chest pain, fever or palpitations,
although he was found to be in AFib with RVR. His EKG was
notable for poor r wave progression, nonspecific T wave changes
suggestive of possible old anterior MI. His troponin was
negative. His CXR and Chest CT showed mild interstitial edema
and hyperinflated lungs (possible COPD, mild CHF). Echo done
showed EF 30%. He was started on Cardizem gtt and continued at
8mg/hr although HR remains 100-120's in AFib. He was also
started on heparin and coumadin, but the coumadin was stopped on
[**3-21**] when INR 3.1 given possible transfer to [**Hospital1 18**] for cardiac
cath. On [**3-20**], he had a 9 beat run of VTach.
Past Medical History:
(has not seen a doctor [**First Name (Titles) **] [**Last Name (Titles) **] 50 yrs)
s/p tonsillectomy
likely COPD
former tobacco
Social History:
Former 50 pack-year tobacco, quit [**2187**]. Rare EtOH (1
drink/month). No other drug use. Engaged. 4 grown children.
Family History:
No sudden cardiac death
Physical Exam:
VS - 96.0F HR 147 BP 114/69 RR 24 100%RA
Gen: WDWN elderly male with red face, otherwise, NAD. Speaking
in full sentences. Oriented x3. Mood, affect appropriate.
Seemed to have dyspnea with moving around in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Regular, tachycardic, normal S1, S2.
Chest: No chest wall deformities, scoliosis or kyphosis. Limited
air movement bilaterally. No wheezes, rales, rhonchi
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: warm, well-perfused, no edema
Skin: No stasis dermatitis, ulcers
Pertinent Results:
[**2189-3-23**] WBC-7.3 RBC-5.88 Hgb-16.8 Hct-48.8 MCV-83 MCH-28.6
MCHC-34.4 RDW-15.0 Plt Ct-231 Neuts-76.3* Lymphs-17.2* Monos-5.7
Eos-0.6 Baso-0.2
[**2189-3-24**] WBC-6.9 RBC-5.63 Hgb-16.2 Hct-47.0 MCV-84 MCH-28.8
MCHC-34.5 RDW-15.2 Plt Ct-223
[**2189-3-24**] WBC-6.5 RBC-5.65 Hgb-16.2 Hct-47.5 MCV-84 MCH-28.7
MCHC-34.1 RDW-15.1 Plt Ct-222
[**2189-3-25**] WBC-7.1 RBC-5.70 Hgb-16.2 Hct-47.7 MCV-84 MCH-28.4
MCHC-33.9 RDW-15.1 Plt Ct-187
[**2189-3-26**] WBC-6.0 RBC-5.78 Hgb-16.1 Hct-48.6 MCV-84 MCH-28.0
MCHC-33.2 RDW-15.3 Plt Ct-222
[**2189-3-28**] WBC-6.7 RBC-5.26 Hgb-15.2 Hct-44.9 MCV-85 MCH-28.8
MCHC-33.8 RDW-15.4 Plt Ct-225
.
[**2189-3-23**] PT-20.5* PTT-36.7* INR(PT)-2.0*
[**2189-3-24**] PT-19.6* PTT-91.3* INR(PT)-1.9*
[**2189-3-25**] PT-18.8* PTT-58.2* INR(PT)-1.8*
[**2189-3-26**] PT-16.4* PTT-65.5* INR(PT)-1.5
[**2189-3-28**] 07:10AM BLOOD PT-17.9* PTT-150* INR(PT)-1.7
.
[**2189-3-23**] Glucose-111* UreaN-19 Creat-1.0 Na-136 K-4.5 Cl-98
HCO3-27 Calcium-9.4 Phos-3.5 Mg-2.0
[**2189-3-24**] Glucose-117* UreaN-16 Creat-1.0 Na-136 K-4.4 Cl-101
HCO3-26 Calcium-9.1 Phos-3.6 Mg-2.1 Cholest-142
[**2189-3-25**] Glucose-97 UreaN-18 Creat-0.9 Na-135 K-4.7 Cl-99
HCO3-26 Calcium-8.6 Phos-3.1 Mg-2.1
[**2189-3-26**] Glucose-128* UreaN-17 Creat-0.9 Na-134 K-4.3 Cl-100
HCO3-22
[**2189-3-28**] Glucose-124* UreaN-18 Creat-1.2 Na-135 K-4.4 Cl-99
HCO3-26 Calcium-9.1 Phos-3.9 Mg-2.2
.
[**2189-3-26**] 09:00AM CK(CPK)-41 CK-MB-NotDone cTropnT-0.10*
[**2189-3-26**] 07:42PM CK(CPK)-31* CK-MB-2 cTropnT-0.06*
[**2189-3-27**] 06:03AM BLOOD CK(CPK)-26* CK-MB-NotDone
*
[**2189-3-26**] 07:42PM BLOOD ALT-28 AST-24 CK(CPK)-31* AlkPhos-73
TotBili-1.9*
.
[**2189-3-24**] 08:05AM BLOOD Triglyc-95 HDL-37 CHOL/HD-3.8 LDLcalc-86
[**2189-3-26**] 07:42PM BLOOD TSH-2.0
.
[**3-27**] CXR: [**Month (only) 116**] be minimal edema in the lower lungs. Upper lungs
clear. Heart size is normal. There is no pleural effusion.
.
[**3-26**] Cardiac Catheterization:
report not finalized
Brief Hospital Course:
71 year old male with HTN, hyperlipidemia, possible CAD (EKG
with poor R wave progression, EF 30%) transferred from OSH with
Atrial flutter/atrial fibrillation.
.
#. CAD - no known CAD although patient with risk factors: former
tobacco, EKG with poor R wave progression, EF 30%. Continued
aspirin and statin dose increased from 10 to 40mg qday. Holding
on ACE Inhibitor during hospitalization. He underwent cardiac
catheterization on [**3-26**] with stents placed to LAD and left
circumflex coronary arteries.
.
#. Pump - Echo at OSH with EF 30%. Held ACE Inhibitor in
setting of cardiac catheterization. Mild volume overload on
admission resolved with lasix. Patient should likely have
repeat ECHO as outpatient.
.
#. Rhythm - In Atrial flutter on admission that was very
difficult to rate/rhythm control despite diltiazem drip and
beta-blockers. He underwent atrial flutter ablation on [**3-24**].
He converted to sinus rhythm, but then [**Doctor First Name **] into atrial
fibrillation with rapid ventricular response. He under went
cardiac catheterization as above (once INR < 1.5) and load on
amiodarone in the CCU post-cath. On [**3-27**], he converted to sinus
rhythm on amiodarone and beta-blockers. He was monitored on
telemetry throughout hospitalization. Coumadin was held prior
to cathaterization and he was bridged with heparin drip during
this time. Coumadin was started post-cath. His INR on
discharge was 1.8. He is to bridge with lovenox at home and
have outpatient primary care physician follow INR as outpatient
and adjust coumadin, stop lovenox once INR therapeutic. He is to
continue amiodarone taper as outpatient.
.
# COPD - started on advair and combivent inhalers at OSH. Also
underwent pulmonary function tests at OSH.
.
#. PPx: anticoagulated on heparin gtt/coumadin, PPI
.
#. FULL CODE
.
#. Dispo: patient was discharged to home with primary care and
cardiology follow-up. He was instructed to have INR blood
levels drawn every 3 days as an outpatient until INR
therapeutic. He will bridge with lovenox until INR therapeutic
and received lovenox teaching. He is to continue amiodarone
taper as outpatient.
Medications on Admission:
Medications on transfer:
cardizem gtt 8mg/hr
coumadin (on hold since [**3-21**])
heparin gtt
combivent 2 puffs inh qdaily
advair 250/50 inh [**Hospital1 **]
lasix 20mg po qdaily
lisinopril 2.5mg po qdaily
lopressor 50mg po qdaily
KCl 10mEq qdaily
ASA 81 qdaily
xanax prn
protonix 40mg po qdaily
.
home medications:
ASA 81mg qdaily
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:*6*
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-6**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
Disp:*qs 1 month * Refills:*3*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg (2 tablets) twice daily for 5 days,
then take 400mg once daily for 7 days, then take 200mg daily
indefinitely thereafter.
Disp:*120 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime: You
must have your blood INR level checked frequently while taking
this medication.
Disp:*60 Tablet(s)* Refills:*2*
8. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice
a day for 5 days: Have your INR checked while taking this
medication and stop using the medication when INR is greater
than 2.
Disp:*10 * Refills:*1*
9. Outpatient Lab Work
You must follow up on Monday [**2189-3-27**] at an outpatient lab to
have your blood INR level checked. You should continue to have
this level checked 3 times per week. Please send these results
to Dr. [**Last Name (STitle) **] (phone [**Telephone/Fax (1) 5003**]; fax [**Telephone/Fax (1) 9672**]) and Dr.
[**Last Name (STitle) 11250**] (phone [**Telephone/Fax (1) 11254**]). They will give you
instructions regarding adjusting your coumadin dose and when to
stop taking Lovenox.
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
coronary artery disease
atrial flutter
atrial fibrillation
congestive heart failure EF 30%
COPD
Discharge Condition:
stable, ambulating, breathing comfortably on room air
Discharge Instructions:
Please call your primary care physician or call 911 if you
experience chest pain, shortness of breath, palpitations, leg
swelling, bleeding, or other concerning symptoms.
.
You have been started on new medications. It is very important
to continue to take your plavix every day to keep your stent
open. Amiodarone was started to help control your heart
rate/rhythm. This will be decreased over the next couple of
weeks (please follow the prescribed instructions).
.
A medication called coumadin has also been started. This is a
blood thinner. You must follow up on Monday [**2189-3-27**] at an
outpatient lab to have your blood INR level checked. You should
continue to have this level checked 3 times per week. Please
send these results to Dr. [**Last Name (STitle) **] (phone [**Telephone/Fax (1) 5003**]; fax
[**Telephone/Fax (1) 9672**]) and Dr. [**Last Name (STitle) 11250**] (phone [**Telephone/Fax (1) 11254**]).
.
You will also take Lovenox until your blood INR level is found
to be greater than 2 on coumadin. Please discuss with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 11250**] to determine when the Lovenox can be
discontinued.
Followup Instructions:
Please schedule a follow-up with a primary care physician. [**Name10 (NameIs) **]
you need a primary care physician you can be seen at the [**Hospital1 **] and can schedule an outpatient appointment at
[**Telephone/Fax (1) 250**].
.
We have started a medication called coumadin. It is important
that you get your blood drawn to check your coumadin level in 3
days after discharge from the hospital. Please go to the
nearest blood draw center and have these results sent to your
primary care physician.
.
Please schedule a follow-up appointment with Electrophysiology.
Completed by:[**2189-3-29**]
ICD9 Codes: 4280, 496, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4832
} | Medical Text: Admission Date: [**2115-12-4**] Discharge Date: [**2115-12-7**]
Date of Birth: [**2067-6-14**] Sex: M
Service: CCU
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with
a history of hypertension who presented to an outside
hospital Emergency Department with complaints of chest pain.
The patient reports that he was well until the morning of
admission when he awoke with chest pain that radiated to the
left arm. He noted shortness of breath and diaphoresis but
denied any lightheadedness or nausea. He attempted to go to
work that a.m. but drove himself to the outside hospital
Emergency Department when his symptoms persisted.
Electrocardiogram at the outside hospital showed evidence of
anterior myocardial infarction and he was started on aspirin,
intravenous nitroglycerin, Aggrastat and transferred to the
[**Hospital1 69**] Emergency Department for
cardiac catheterization.
In the catheterization laboratory the patient was found to
have two lesions which were both stented. A proximal left
anterior descending artery lesion which was 50% to 60%
occluded and stented, and an 80% mid left anterior descending
artery lesion which was also stented successfully. The
patient was admitted into the cool myocardial infarction
study and he was made hypothermic to 33.6 degrees and then
transferred to the Coronary Care Unit for post
catheterization care.
At the time of admission to the Coronary Care Unit he denied
any chest pain, shortness of breath, lightheadedness,
palpitations, diaphoresis, nausea, vomiting, fever, or
chills.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is a one pack per day smoker with
significant alcohol abuse history. The patient denies, but
wife supports active crack cocaine use. No intravenous drug
abuse. The patient is a carpenter and is presently
undergoing divorce proceedings.
FAMILY HISTORY: Family history negative for coronary artery
disease.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were heart
rate of 67, respiratory rate 17, blood pressure 123/73, and
satting 98% on room air. In general, a 48-year-old male
looking older than stated age, in no acute distress. Head,
ears, nose, eyes and throat was normocephalic and atraumatic.
Pupils were equal, round, and reactive to light. Neck was
supple. No lymphadenopathy. No jugular venous distention.
Chest was clear to auscultation bilaterally. Cardiovascular
had a regular rate and rhythm, normal first heart sound and
second heart sound. Distant heart sounds but no murmurs,
rubs or gallops appreciated. The abdomen was soft and
nontender, positive bowel sounds, nondistended. Extremities
had no clubbing, cyanosis or edema. Groin sheath both
arterial and venous on the right, and venous on the left were
negative for hematoma or bruit. Dorsalis pedis and posterior
tibialis pulses were 2+ bilaterally. Neurologically,
nonfocal, alert and oriented times three.
LABORATORY DATA ON PRESENTATION: White blood cell count 9.4,
hematocrit 39.1, platelets 426. Sodium 140, potassium 4.7,
chloride 106, bicarbonate 27, blood urea nitrogen 15,
creatinine 0.9, and glucose of 152. Calcium 9,
phosphate 3.5, magnesium 2.3. PT 12.7, PTT 48.2, INR 1.1.
Creatine kinase of 276, MB 26, index 9.4, and troponin I of
less than 50. Arterial blood gas was 7.4/44/158.
RADIOLOGY/IMAGING: Electrocardiogram prior to myocardial
infarction showed ST elevations in V2 to V3, peak T waves in
V2 to V5, and reciprocal ST depressions in II, III, and aVF.
Subsequent electrocardiogram half an hour later showed
changes resolving.
Catheterization report revealed proximal left anterior
descending artery with 50% to 60% lesion, mid left anterior
descending artery with 80%, ejection fraction of 40%, and
anterolateral/apical hypokinesis with a pulmonary capillary
wedge pressure of 25.
HOSPITAL COURSE: CARDIOVASCULAR: The patient with
significant anterior myocardial infarction and two distinct
lesions in the left anterior descending artery, but
angiography showed good flow throughout the coronaries.
Therefore, there was question of whether a thrombus had been
dislodged since prior to catheterization versus vasospasm
secondary to recent cocaine use. Urine and serum toxicology
both returned negative, and the patient denied any recent
use. Beta blockade was avoided secondary to concern about
unopposed angioneuralgic stimulation. A dose of labetalol
was attempted, and the patient developed orthostatic
hypotension. Therefore, the labetalol was discontinued. The
patient was started on aspirin and Plavix and received an
18-hour course of Aggrastat. His lipids were checked post
myocardial infarction and were satisfactory. Therefore, the
patient was not sent home on Lipitor. His creatine kinases
peaked at a total of 378 and subsequently trended down.
The patient remained symptom free for the remainder of his
hospitalization denying any chest pain, shortness of breath,
nausea, vomiting, diaphoresis, but he did become hypotensive
as stated earlier when started on labetalol. After labetalol
was discontinued a trial of ACE inhibitor was attempted
secondary to the patient's recent anterior myocardial
infarction. He remained asymptomatic but did have one
episode of systolic blood pressure in the 70s upon standing.
He denied any associated lightheadedness or dizziness and was
able to walk throughout the halls with Physical Therapy at
that time without any stigmata of hypotension. It was
possible that this subsequent hypotension on ACE inhibitor
was secondary to the fact that the patient was started on
lisinopril at 4:30 p.m. the previous afternoon and then
received his morning dose the subsequent day at 8 a.m.
Therefore, having an excessive load of ACE inhibitor at the
time of standing with Physical Therapy.
Prior to discharge the patient's blood pressure was rechecked
and was satisfactory with a systolic blood pressure of
greater than 100 and remained asymptomatic.
DISCHARGE STATUS: The patient was discharged home on
[**12-7**].
DISCHARGE FOLLOWUP: Plans to follow up with his primary care
physician in two weeks. The patient preferred care in close
proximity to his home. Therefore, he was planning on
choosing a primary care physician in [**Name9 (PRE) **] and will plan
follow up at the scheduled time. The patient was also to
follow up with Dr. [**Last Name (STitle) **] who is a cardiologist in [**Hospital1 **].
The patient may consider rehabilitation in the next four to
six weeks, and also his lipids should be rechecked as an
outpatient in the future. The patient was also advised to
follow up for his substance abuse history and was repeatedly
reminded that cocaine and alcohol abuse could be
significantly detrimental to his cardiac and overall health.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 10 mg p.o. q.d. (the patient was advised to
discontinue this medication and call his primary care
physician if he becomes lightheaded and/or dizzy).
2. Enteric-coated aspirin 325 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d. times 27 days.
4. Sublingual nitroglycerin p.r.n.
CONDITION AT DISCHARGE: Condition on discharge was stable.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 15885**]
MEDQUIST36
D: [**2115-12-7**] 13:32
T: [**2115-12-13**] 09:28
JOB#: [**Job Number 36847**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4833
} | Medical Text: Admission Date: [**2164-1-13**] Discharge Date: [**2164-1-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
84yo M w/ h/o TBI s/p [**2164**]0 yrs ago, presented to OSH after
developing respiratory distress at home. Has no diagnosis of
CHF, but had developed inc DOE and LE edema over last several
days. Per wife's report, went to lie down after dinner and when
he awoke, complained of feeling SOB and unwell. Taken to [**Location (un) 620**]
ER where a nasal intubation was performed. An OG tube was also
placed. An EKG was taken, as was a CXR (pulm edema), but the EKG
was concerning for possible STEMI (with EKG changes that showed
ST elevations in III, [**Location (un) **], VI, as well as ST depressions in I,
II, V2-V6). He was started on a heparin gtt and sent to [**Hospital1 18**].
In the [**Hospital1 18**] ER, he was felt to be agitated and was given 2mg
versed and 50mcg of fentanyl.
.
Of note, approx one month ago, pt was at a respite for a week
and was diagnosed w/ CHF. Wife is unclear what happened to cause
this, but stated that pt was not discharged on a diuretic.
.
ROS: Unobtainable as pt is sedated and intubated and wife is not
present.
Past Medical History:
1. TBI following a fall in [**2143**]
- intracranial hemorrhage -> 6 weeks of vegetative state
- s/p VP shunt placement
- garbled speech/dysarthria at baseline
- baseline = wheelchair/walker
2. Hypothyroidism
3. Glaucoma
4. COPD - no PFTs available
5. h/o UTI w/ MRSA in [**10-12**]
6. ? left DVT - date unknown, but on coumadin for this
7. Anemia - both iron and B12 deficient in the past
8. BPH s/p TURP on [**2162-1-4**] (underwent general anesthesia)
Social History:
Per CareWeb, the patient is wheelchair-bound, lives with wife,
who continues to work part-time as a chemistry teacher, quit
smoking 30 years ago. The patient is a retired airline pilot and
teacher. No children.
Family History:
NC
Physical Exam:
VS - Afebrile, BP 100/67, HR 52, 95% on vent
Vent - CMV, FiO2 100%, PEEP 8, Vt 486-520, RR 14
Gen: Sedated, intubated
HEENT: Pupils pinpoint bilaterally. Sclera anicteric. Nasal
intubation, NG tube in place, draining bilious material.
Neck: No JVP appreciated.
CV: III/VI late systolic murmur best heard over RUSB, radiating
to carotids. Normal S1, S2 is somewhat obscured by murmur.
Lungs: Coarse, vented BS anteriorly.
Abd: Soft, NTND. + BS. Several old, healed surgical scars are
across his abdomen and torso.
Ext: 2+ pitting edema up to his knees bilaterally. + nonpitting
edema of his hands bilaterally. Ext cool, dry.
Skin: No rashes
Neuro: Not withdrawing to painful stimuli in any of his 4
extremities. Pupils pinpoint, round, but nonreactive.
Pertinent Results:
Labs on admission:
WBC 12.4, Hgb 13.0, Hct 38.0, MCV 88, Plt 234
(DIFF: Neuts-85.1* Bands-0 Lymphs-9.4* Monos-3.9 Eos-1.4
Baso-0.2)
PT 47.6*, PTT 150*, INR(PT) 5.6*
ALT 16, AST 68*, AlkPh 63, TBili 0.3
Ca 8.8, Phos 3.2, Mg 1.7
TSH 3.0
ABG: pH 7.32, pO2 419*, pCO2 57*
proBNP 2856*
.
Cardiac enzymes:
[**2164-1-13**] 12:55AM BLOOD CK(CPK)-254* CK-MB-27* MB Indx-10.6*
cTropnT-0.30*
[**2164-1-13**] 04:16AM BLOOD CK(CPK)-484* CK-MB-57* MB Indx-11.8*
cTropnT-1.28*
[**2164-1-13**] 02:22PM BLOOD CK(CPK)-425* CK-MB-46* MB Indx-10.8*
cTropnT-5.99*
[**2164-1-13**] 05:58PM BLOOD CK(CPK)-328* CK-MB-33* MB Indx-10.1*
cTropnT-5.01*
[**2164-1-13**] 10:32PM BLOOD CK(CPK)-246* CK-MB-21* MB Indx-8.5*
cTropnT-3.89*
[**2164-1-14**] 05:15AM BLOOD CK(CPK)-178* CK-MB-12* MB Indx-6.7*
cTropnT-2.97*
.
Labs on discharge:
WBC 9.2, Hgb 13.0*, Hct 36.8*, MCV 87, Plt 248
PT 27.2*, PTT 33.9, INR(PT) 2.8*
Na 137, K 4.2, Cl 97, HCO3 31, BUN 36, Cr 1.6, Glu 95, Mg 2.0
.
Imaging:
CXR [**2164-1-14**]: Portable erect AP radiograph of the chest is
reviewed, and compared with previous study dated yesterday. The
tip of the endotracheal tube is identified slightly above the
thoracic inlet. A nasogastric tube courses towards the stomach.
Minimal patchy
atelectasis is seen at the lung bases. The lungs are clear
otherwise without evidence of pulmonary edema. The heart is top
normal in size. There is continued mild tortuosity of the
thoracic aorta. The previously identified right upper lobe
opacity has been improving. No pneumothorax is identified.
.
CXR [**2164-1-13**]: 1. Unchanged appearance of right upper lobe opacity.
2. Improved pulmonary edema.
.
CXR [**2164-1-13**]: Mild pulmonary edema. Right upper lobe opacity,
which could be secondary to summation of structures; however
dedicated PA and lateral views are recommended prior to
discharge to exclude a pulmonary nodule.
Brief Hospital Course:
84yo M w/ presumed hypoxic respiratory failure from worsening
CHF. Etiology of his CHF exacerbation is unclear, but likely
contributors include worsening AS and demand ischemia.
.
# PUMP: On admission, we had no information on Mr. [**Known lastname 21617**] EF
but he had an obvious late peaking systolic murmur best heard at
LUSB and radiating to his carotids bilaterally, as well as gross
peripheral edema. BNP on admission was >2800. He was placed on a
lasix gtt and aggressively diuresed. His BP remained stable,
even slightly hypertensive, so an ACE inhibitor was added for
afterload reduction. An ECHO was performed after the patient was
extubated and showed an EF of >55%, but worsening AS, so he
likely has diastolic failure exacerbated by worsened severe AS.
He is not a surgical candidate for [**Last Name (LF) 1291**], [**First Name3 (LF) **] it was decided to
medically manage his AS and CHF. His weight was monitored daily
and strict I/Os were kept. By discharge, he was switched over to
once daily ACE-inhibitor and lasix.
.
# ISCHEMIA: His EKG on admission was concerning for diffuse ST
and T wave changes, likely demand-related in setting of his
worsened heart failure. His cardiac enzymes were cycled and
peaked at a max CK of 484, CK MB of 57, and trop of 5.99 on
[**2164-1-13**]. He was admitted on a heparin gtt, but that was stopped
once his labs came back w/ PTT >150 and INR of 5.6. After it was
decided that his enzyme leak was most consistent with demand
ischemia, his aspirin was also discontinued as it was felt that
he was a bleeding risk.
.
# RHYTHM: He was monitored on telemetry while his cardiac
enzymes were cycled. He remained mostly in NSR with occasional
runs of AIVR/NSVT, which was felt to likely be a reperfusion
rhythm. By discharge, his telemetry was normal, with no further
arrhythmias.
.
# COPD/ASTHMA: He had no evidence of a COPD or asthma
exacerbation (no wheezing, no hyperinflation on CXR, no
difficulty w/ ventilation or oxygenation). Mr. [**Known lastname 21617**]
respiratory symptoms appeared to be mostly due to volume
overload from heart failure. After approximately 2-3L had been
removed, he was able to be extubated without any complications.
He was diuresed first with a lasix gtt, then switched to IV,
with a total of >6L removed. He was switched to PO lasix prior
to discharge, with the goal of keeping his I/O even.
.
# DVT: He has a h/o of a DVT in the past, which his wife says is
the reason that he is on coumadin. His INR on admission was
elevated at 5.6 so his coumadin was held. He was given one dose
of PO vitamin K and his INR trended down. He had been on a
heparin gtt on admission for ? NSTEMI, but once in the CCU, it
was felt that his enzyme leak was more likely from demand
ischemia so his anticoagulation was held due to his
supratherapeutic INR. The goal was to hold off on restarting
coumadin until his INR <2.
.
# HYPOTHYROIDISM: Mr. [**Known lastname 21615**] is hypothyroid and is treated with
levothyroxine. His TSH was 3.0 on [**2164-1-13**]. He was continued on
his outpatient dose of levothyroxine.
.
# ANEMIA: Mr. [**Known lastname 21615**] has a history of chronic anemia, but he
has been only mildly anemic here, with a stable Hct in the range
of ~36-38. His anemia is normocytic, with no evidence of Fe
deficiency or B12 deficiency as he has had in past. His Hct was
checked daily to insure that it remained stable. He had one
guaiac positive and his stools were guaiac negative.
.
# ACCESS: Peripheral IV x2
.
# FEN: Mr. [**Known lastname 21615**] was not able to cooperate for a full speech
and swallow evaluation, but tolerated a regular, soft dyphagia
diet w/ nectar prethickened liquids. He was not given any IVF as
our goal was to diurese him and his electrolytes, during
diuresis, were checked [**Hospital1 **] to insure that his electrolytes
remained within normal.
.
# PPX: Mr. [**Known lastname 21617**] INR was supratherapeutic on admission so
anticoagulation and DVT ppx were held. He was given a PPI and
bowel regimen.
.
# CODE: Full, confirmed with wife on [**2164-1-13**].
.
# DISPO: To rehab.
Medications on Admission:
Meds (at home):
Coumadin 2.5mg PO QHS
Levothyroxine 0.125mg PO QD
Betimol 0.5% eye drops
Sonata 5mg [**Name2 (NI) **] QD
.
Meds (on transfer):
Heparin gtt
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please restart once patient's INR is less than 2. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary diagnosis:
CHF
Demand ischemia
Severe aortic stenosis
.
Secondary diagnosis:
Asthma
TBI
Hypothyroidism
Glaucoma
h/o UTI w/ MRSA
h/o DVT
Discharge Condition:
Good.
Discharge Instructions:
1. Please call your PCP or go to the ER if you develop any of
the following symptoms: chest pain, chest pressure, shortness of
breath, increased leg swelling, nausea, vomiting, fevers,
chills, or any other worrisome symptoms.
2. Please take all your medications as prescribed.
3. Please follow-up with your PCP as scheduled.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on Friday, [**1-27**] at 11:15am. His number is 1-[**Telephone/Fax (1) 6163**]. Please call his
office if you have any questions or concerns.
ICD9 Codes: 4280, 4241, 4271, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4834
} | Medical Text: Admission Date: [**2116-3-20**] Discharge Date: [**2116-3-24**]
Date of Birth: [**2065-10-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath and Fatigue
Major Surgical or Invasive Procedure:
1. Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary
artery; reverse saphenous vein single graft from the
aorta to the first obtuse marginal coronary; reverse
saphenous vein single graft from the aorta to the
posterior left ventricular coronary artery.
2. Endoscopic right greater saphenous vein harvesting.
History of Present Illness:
History of Present Illness:88 year old male who initially
presented on [**2116-3-7**] to [**Hospital3 417**] Hospital via EMS with
2-3 days of nausea, vomiting, diarrhea, and diaphoresis. During
the days up to admission, he also developed dyspnea on exertion
and had progressively more difficulty climbing stairs, requiring
rest, which was a change in baseline. In hindsight, he actually
reports progressive dyspnea while walking for the past several
months (4-6 months). Functionally, he feels he can no longer
walk
1 block or do 1 flight of stairs due to his breathing. He also
reported weakness and fatigue. He was admitted to [**Hospital3 417**]
and an echocardiogram was done and found to have aortic stenosis
with valve area 0.4cm2, he was then transferred to [**Hospital1 18**] for
further evaluation and a cardiac surgery evaluation for an
aortic
valve replacement.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia
2. CARDIAC HISTORY:
- Acute inferior ST-elevation MI treated with PCI to RCA in [**2106**]
- NSTEMI [**2110**]: Coronary catheterization with balloon angioplasty
to the posterior descending artery and placement of drug eluting
stent
to the posterolateral artery off PDA
.
-PERCUTANEOUS CORONARY INTERVENTIONS:
.
[**7-17**]:
1) 90% PLB lesion, 80% PDA lesion
2) Successful PCI of PLB with 2.5x28mm Cypher stent
3) Successful PTCA of PDA with 2.0x0mm balloon
4) Selective coronary angiography revealed the above findings.
In
addition, 60% D1 lesion and 40% distal LAD lesion beyond the D1
take-off
was noted. Both of the above were unchanged since the last
cardiac
catherization in noted to be occluded at the ostium. This is a
new
finding since 8/[**2106**]. OM2 and OM3 were found to have diffuse,
mild
disease.
5) Left ventriculography revealed mild inferior and
anterolateral
hypokinesis with mildly reduced ejection fraction of 42%.
6) Normal LV filling pressure (LVEDP 13).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful placement of drug eluting stent in the RPL branch
and PTCA to R-PDA.
.
[**8-13**]:
1. Resting hemodynamics post-intervention demonstrated slightly
elevated biventricular filling pressures. The mean PCWP was 15
mmHg; prominent V waves were noted. The Fick cardiac index was
normal.
2. Selective coronary angiography of this right dominant system
demonstrated two vessel and branch coronary artery disease. The
left
main was normal. The mid-LAD had a tubular 50% stenosis. The
D1 was
60% stenosed proximally. The left circumflex was normal. The
small OM1 was 90% stenosed proximally. The larger OM2 and OM3
branches were normal. The dominant RCA had an ulcerated 80%
proximal stenosis. The distal RCA was 70% stenosed, and a large
posterolateral branch was thrombotically occluded. The R-PDA
was normal.
3. Successful PTCA and stenting of the RPL were performed with a
2.5 x 23 mm Bx Velocity Hepacoat stent. The proximal RCA was
successfully direct stented with a 3.5 x 33 mm Bx Velocity
Hepacoat stent. Final angiography revealed normal flow, no
dissection and 0% residual stenosis.
FINAL DIAGNOSIS:
1. Two vessel and branch coronary artery disease.
2. Acute inferoposterolateral myocardial infarction, managed by
PTCA and stenting of the RPL and RCA.
3. Mildly elevated biventricular filling pressures.
.
3. OTHER PAST MEDICAL HISTORY:
- Hiatal Hernia repair
Social History:
-Tobacco history: [**1-13**] ppd x 30 years
-ETOH: 3 beers every night
-Illicit drugs: None
- Construction worker
Family History:
Father: Died 76 from MI
Physical Exam:
Physical Exam
Pulse:92 Resp:18 O2 sat:96/2L
B/P Right:112/74 Left:111/76
Height:5'[**15**].5" Weight:87.7 kgs
General: No acute distress, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [x] Murmur [x] systolic grade III/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] mild bilat
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: dop Left: dop
PT [**Name (NI) 167**]: dop Left: dop
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2116-3-24**] 08:52AM BLOOD WBC-7.3 RBC-3.35* Hgb-10.4* Hct-29.2*
MCV-87 MCH-31.2 MCHC-35.8* RDW-12.8 Plt Ct-188#
[**2116-3-24**] 08:52AM BLOOD Plt Ct-188#
[**2116-3-24**] 08:52AM BLOOD UreaN-13 Creat-0.8 Na-137 K-4.2 Cl-100
[**2116-3-24**] 08:52AM BLOOD Mg-2.1
PA&Lat [**3-23**]:
FINDINGS: Frontal and lateral radiographs of the chest show no
pneumothorax.
Inspiratory lung volumes are persistently low with bibasilar
atelectasis
greater on the left than the right. Background increased
interstitial lung
markings are unchanged. No large pleural effusion or focal
consolidation is
present. The pulmonary vasculature is not engorged. Patient is
status post
median sternotomy and CABG with wires intact.
IMPRESSION:
1. No pneumothorax.
2. Stable postoperative appearance.
Brief Hospital Course:
The patient was admitted to the hospital for cath
pre-operatively and found to have significant CAD and brought to
the operating room on [**2116-3-20**] where the patient underwent CABGx3
(LIMA-LAD, v-om,c-Pl). Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. He
required low dose vasopressin and phenylephrine. POD #1 pressors
were weaned off. He extubated soon after the OR and remained
alert and oriented and breathing comfortably. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery On POD #1. Chest tubes and
pacing wires were discontinued without complication. While on
the floor he continued to progress well. His betablocker was
increased due to tachycardia. On POD#3 he spiked temp to 101,
work-up was negative. He was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD #4 the patient was ambulating freely and
deemed safe for discharge to home with VNA services. His wounds
were healing well and his pain was controlled with oral
analgesics. The patient was discharged in good condition with
appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN 80 mg Tablet daily
LISINOPRIL 5 mg Tablet daily
METOPROLOL SUCCINATE 50 mg Tablet Extended Release daily
ASPIRIN 325 mg 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. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 5 days.
Disp:*5 Tablet, ER Particles/Crystals(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p multiple leg surgeries
right rotator cuff surgery
hernia repair inguinal and umbilical
stomach surgery r/t trauma from car accident
Plan for left shoulder surgery for tendon tear
Past Cardiac Procedures:
PCI's: 2.5 x 23mm RPL, 3.5 x33mm to RCA; hepacoat stents [**8-/2106**]
2.5 x 28mm PLB cypher stent [**7-/2110**], PTCA to PDA; PROMUS 3.0 DES
to RCA [**9-/2114**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**4-2**] @
10am
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2116-4-23**]
1:15
Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 4475**] on [**2116-4-14**] 10AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2116-6-18**] 3:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2116-6-18**] 1:45
Completed by:[**2116-3-24**]
ICD9 Codes: 412, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4835
} | Medical Text: Admission Date: [**2139-3-8**] Discharge Date: [**2139-3-20**]
Date of Birth: [**2056-10-31**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Penicillins / Sulfa (Sulfonamide
Antibiotics) / Shellfish / adhesive tape
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Inferior epigastric artery embolization
Drug eluting stent placement
History of Present Illness:
Ms. [**Known lastname **] is an 82 year-old female with HTN, DM, CAD s/p VF
arrest with anterior STEMI and LAD stenting in [**4-5**], pacemaker
placement, h/o TIA, who presents from [**Hospital3 **] for
presumed NSTEMI. She has been having intermittent heavy left
sided chest pain radiating to arm, neck and back for a couple
days. She additionally c/o diarrhea for 1 week prior to
presentation in addition to nausea. No fevers or chills. She
notes stopping clopidigrel a week ago. At [**Hospital1 **], she was found
to have a trop of 1.15. EKG was ventricularly paced without new
signs of ischemia. Patient was given ASA 325 mg and stared on
heparin and nitroprusside gtts with improvement in pain from
[**9-9**] to [**3-12**]. She also received zofran 4mg for nausea. She was
subsequently transferred to [**Hospital1 18**].
.
In the ED, initial vitals were: T 97.6, P 81, BP 186/113, RR 18,
O2sat 99% on 3L O2. Patient is stable with no further complaints
of chest pain. JVD elevated but lungs clear without complaints
of dyspnea on 3L O2. She did complain of nausea and stomach
upset at times. Exam notable for red, hot, and mildly edematous
(nonpitting) RLE without pain; nontender. RLE U/S negative for
DVT. EKG was ventricularly paced with ?LBBB but no ST changes.
Trop here 0.57, CK not sent; Cr 1.2. Anion gap 17. The patient
was continued on Heparin gtt and nitro gtt (titrated down in ED)
and started metoprolol 25 mg po bid. Patient also given zofran
8mg IV. On transfer to floor, vitals were: T 97.8, P 65, BP
140/88, RR 22, O2sat 99% on 3L.
.
On arrival to the floor her initial VS were: , patient currently
feels well, denies any CP, SOB, nausea, vomiting or diarrhea.
Her back pain has improved since getting off the stretcher in
the ER.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
Hypertension
CAD s/p MI and s/p LAD stenting
CHF EF (last know EF 25 % [**2134**])
Mitral regurgitation
Tricuspid regurgition
VF arrest s/p pacemaker placement
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: S/p ppm
3. OTHER PAST MEDICAL HISTORY:
DM
TIA
Breast cancer s/p R mastectomy
DVTs with a questionable hypercoagulable state in the past (pt
report of occurrence with pregnancy and s/p hysterectomy)
Chronic low back pain s/p epidural injections in past
Osteoarthritis
H/o pneumonia
Depression
LE neuropathy
B/l knee surgery
Social History:
lives at home alone. Used to work as a waitress. Daughter lives
locally.
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Brother with CAD. Father with CVA in 40s. Mother with CVA.
Physical Exam:
On admission:
VS: T=98.3 BP=119/83 HR=78 RR=20 O2 sat=98% on RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple with JVP about 3cm above the clavicle
CARDIAC: RR, normal S1, S2 II/VI systolic murmur at RUSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. mildly TTP in LLQ, no rebound or guarding
EXTREMITIES:1+ bilateral LE edema, chronic venous stasis changes
SKIN: No ulcers, scars
NEURO: AOx3, CNII-XII intact, non-focal motor and sensory exam
(has symmetrically decreased strength in distal lower ext;
decreased proprioception b/l, report pain in both lower ext to
touch [**3-4**] neuropathy)
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
.
On discharge:
VS: Tm 98.3, 136/64, 66, 16, 95-9% RA; FS 190
GENERAL: awake, alert, AOx2, dysarthria
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple with elevated JVP, no LAD
CARDIAC: RR, normal S1, S2; [**3-8**] holosystolic murmur at apex
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Poor inspiratory effort
with decreased breath sounds at bases
ABDOMEN: Soft, mildly tender in RLQ and LLQ, no suprapubic
tenderness. No rebound or guarding
EXTREMITIES: no pedal edema, faint distal pulses
SKIN: No ulcers, scars; chronic venous stasis changes of LE b/l
NEURO: CNII-XII intact, L ankle dorsiflexion spasticity with
withdrawal, downgoing toes on R side, 4/5 strength hip flexors
bilaterally, [**4-4**] plantarflexion L ankle, [**6-4**] R ankle; [**6-4**] in all
UE motor groups; no focal sensory deficits
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
Admission [**Month/Day (1) **]:
---------------
[**2139-3-8**] 05:40PM BLOOD WBC-6.3 RBC-3.80* Hgb-12.1 Hct-35.6*
MCV-94 MCH-31.9 MCHC-34.1 RDW-14.6 Plt Ct-206
[**2139-3-8**] 05:40PM BLOOD Neuts-59.9 Lymphs-32.0 Monos-5.3 Eos-2.0
Baso-0.8
[**2139-3-8**] 05:40PM BLOOD PT-17.6* PTT-57.1* INR(PT)-1.6*
[**2139-3-8**] 05:40PM BLOOD Glucose-158* UreaN-25* Creat-1.2* Na-141
K-3.9 Cl-108 HCO3-16* AnGap-21*
[**2139-3-8**] 05:40PM BLOOD CK-MB-15* MB Indx-7.6* cTropnT-0.57*
[**2139-3-9**] 02:00AM BLOOD CK-MB-24* MB Indx-8.5* cTropnT-0.94*
[**2139-3-9**] 09:30AM BLOOD CK-MB-18* MB Indx-8.3* cTropnT-0.94*
[**2139-3-10**] 06:40AM BLOOD CK-MB-8 cTropnT-0.57*
[**2139-3-14**] 03:06AM BLOOD CK-MB-3 cTropnT-1.09*
[**2139-3-8**] 05:40PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2
[**2139-3-16**] 07:25AM BLOOD VitB12-686 Folate-9.1
[**2139-3-9**] 06:10PM BLOOD %HbA1c-5.9 eAG-123
[**2139-3-9**] 09:30AM BLOOD Triglyc-92 HDL-34 CHOL/HD-3.4 LDLcalc-64
LDLmeas-73
Discharge [**Year/Month/Day **]:
---------------
[**2139-3-19**] 07:45AM BLOOD WBC-8.0 RBC-3.25* Hgb-10.4* Hct-30.4*
MCV-93 MCH-32.0 MCHC-34.2 RDW-14.3 Plt Ct-282
[**2139-3-16**] 07:25AM BLOOD Neuts-75.2* Lymphs-16.5* Monos-6.1
Eos-1.7 Baso-0.6
[**2139-3-19**] 07:45AM BLOOD Glucose-159* UreaN-43* Creat-1.1 Na-146*
K-3.4 Cl-110* HCO3-25 AnGap-14
[**2139-3-15**] 06:55AM BLOOD ALT-24 AST-24 AlkPhos-45 TotBili-0.8
Imaging / Procedures:
Cardiac cath: [**2139-3-9**]
1. Selective coronary angiography of this right dominant system
demonstrated 3-vessel coronary artery disease. The LMCA was free
of angiographically significant disease. There was in stent
restenosis of the proximal LAD to 70%. The remainder of the LAD
was free of angiographically significant disease. A ramus
demonstrated serial 90% stenoses. The Lcx gave rise to a small
OM that was totally occluded and filled late via left to left
collaterals. There was a mid vessel 60% stenosis. There was a
thrombotic occlusion of the distal RCA which was an ectatic
vessel throughout. Left to right collaterals supplied the distal
RCA.
2. Resting hemodynamics revealed significantly elevated right
and left heart filling pressures (RA mean 17mmHg, PCW mean
19mmHg). There was severe pulmonay artery hypertension
(PASP=80mmHg PADP=33mmHg PA mean=48mmHg). The cardiac output and
index were low at 3.8L/min and 1.98L/min/m2. The SVR was
elevated at 2147 dynes/sec/cm-5 and PVR severely elevatd at 611
dynes/sec/cm-5.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with culprit vessel for
NSETMI likely RCA thrombosis. Lesion not well suited for PCI so
surgical evaluation recommended.
2. Elevated left and right heart filling pressures consistent
with LV diastolic and systolic dysfunction given low cardiac
output.
3. Severe pulmonary artery hypertension with increased pulmonary
vascular resistence.
.
TTE [**2139-3-10**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is severe regional left ventricular
systolic dysfunction with mid- and distal septal, anterior, and
basal inferior akinesis. There is moderate hypokinesis of the
remaining segments, most c/w multivessel CAD (LVEF = 25%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
estimated cardiac index is depressed (<2.0L/min/m2). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severe regional and global left ventricular systolic
dysfunction, c/w multivessel CAD. Mild right ventricular
systolic dysfunction. Moderate to severe mitral and tricuspid
regurgitation. Severe pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2134-6-10**], LV
systolic function has substantially deteriorated, primarily due
to inferior wall akinesis. Mitral and tricuspid regurgitation
have increased in severity and pulmonary pressures are higher.
.
Carotid U/S:
Findings are consistent with less than 40% stenosis bilaterally.
Somewhat reduced velocities were seen in the vertebral arteries
bilaterally.
.
FDG Cardiac viability study:
1. Viable myocardium in the anterolateral wall and anterior
portion of the apex with left ventricular dilation.
2. Mildly decreased FDG avidity in the remainder of the
myocardium. This could represent non viable myocardium due to an
interval infarct. A more recent perfusion study may be helpful
to evaluate global myocardial perfusion.
3. LUL 15 mm nodule, could represent focal atelectasis.
Recommend short interval dedicated chest CT for follow-up.
.
Cardiac cath [**3-13**]:
1. Three vessel coronary artery disease.
2. Successful PCI of distal RCA and proximal LAD.
3. PCI of Ramus could be done if necessary but would be very
long small stent
4. Stenting of distal RCA could be done if recurrent ischemia
5. Medical management of LM lesion.
.
Cardiac cath [**3-13**]:
1. Retroperitoneal bleeding from a small [**Last Name (un) **] of inferior
epigastric artery.
2. Successful coil embolization of the inferior epigastric
artery to control the course of retroperitoneal bleeding.
.
CT abd [**3-13**]:
1. Large right retroperitoneal hematoma from right groin,
extending to right rectus muscle into the right retroperitoneum,
up to the tip of the liver. Small amount of hemorrhage seen in
the cul-de-sac. Expansion of the right pelvic retroperitoneal
space with displacement of the urinary bladder. No hematoma
below the inguinal ligament.
2. Bilateral small pleural effusions and bibasilar atelectasis.
3. Innumerous renal hypodensities and small cysts.
.
CXR [**3-14**]:
This is a slightly rotated film. Given technique, there is no
significant interval change compared to prior. There is a
pacemaker with two leads projecting over the heart in expected
locations. There is moderate cardiomegaly. There is increased
retrocardiac opacity that could be due to volume
loss/infiltrate/effusion. The right lung is clear.
.
CT head [**3-15**]:
No acute intracranial pathologic process. Specifically no
evidence of hemorrhage or recent infarction.
.
CXR [**3-16**]: Improved aeration of the left lung.
.
CXR [**3-18**]: In comparison with the study of [**3-16**], there has been
placement of a Dobhoff tube that curls within the upper stomach.
Little change in the appearance of the heart and lungs and the
pacemaker device.
.
Brief Hospital Course:
82-year-old female with HTN, DM, CAD s/p VF arrest with anterior
STEMI and LAD stenting in [**4-5**], pacemaker placement, h/o TIA,
who presents from [**Hospital3 **] with NSTEMI, now s/p PCI with
2 DES to prox LAD ISR, and POBA/export thrombectomy of RCA,
procedure complicated by retroperitoneal bleed s/p coiling of
inferior epigastric artery, and delirium.
===========================================================
ACTIVE ISSUES:
--------------
.
# NSTEMI with stenting, complicated by retroperitoneal bleed: pt
presented with typical chest pain, cardiac enzymes peaked (trop
0.94). She was started on heparin drip, full dose ASA. She
underwent cardiac cath which showed 3-vessel disease. After a
long discussion between CT surgery, patient, and her family they
decided not to pursue CABG given high risk of procedure and pt's
wishes. She underwent a FDG PET cardiac viability study which
showed viable myocardium in the anterolateral wall and anterior
portion of the apex, and decreased FDG activity in the rest of
the myocardium. Pt underwent repeat catheterization with PCI of
distal RCA and proximal LAD, and POBA/export thrombectomy of
RCA. Post-cath course was complicated by RP bleed which was seen
on CT, pt was taken back to cath lab and had successful coil
embolization of the inferior epigastric artery to
control the course of retroperitoneal bleeding. She was
transferred to the CCU for overnight observation.
.
Brief CCU course:
Patient underwent a planned cardiac catheterization on [**2139-3-13**]
in which two drug-eluting stents were placed to her proximal LAD
in-stent stenosis. An export thrombectomy was performed on her
RCA. After the procedure the patient complained of back pain,
was found to have a 5 point hematocrit drop and evidence of a
large right-sided retroperitoneal bleed on CT. She was
immediately taken back to the cath lab, and the bleeding artery
(right inferior epigastric) was succesfully embolized with
coils. The patient was transferred to the CCU for monitoring.
Her post-cath check was normal. Serial hematocrits were
monitored and remained stable. She did not require any blood
products. Her vital signs remained stable and within normal
limits. She was transferred back to her primary team for further
management.
.
After return to the floor, pt did not have any chest, back, or
abdominal pain. She did not have shortness of breath or any
events on telemetry. We continued her ASA 325mg daily, plavix
75mg daily, toprol XL 25mg daily. Her amlodipine 5mg was changed
to lisinopril 5mg for myocardial protection. She will follow up
with Dr. [**Last Name (STitle) **] after discharge from rehab.
.
# Delirium: pt developed altered mental status and hypoactivity
after transfer from CCU. Though delirium was likely related to
ICU stay and hospitlization in a patient with some underlying
dementia, we pursued work-up of other etiologies. Infectious
work-up was unrevealing with negative urine and blood cultures,
and CXR without pneumonia. Her Foley was pulled out to minimize
delirium. CT head was negative. Pt underwent speech/swallow
evaluation which found dysphagia (likely due to inattention
rather than mechanical causes). She was made NPO and meds
crushed in apple sauce. Pt slowly improved daily with increased
alertness and orientation, though continued to be below baseline
per family. Neurology was consulted and believes that
encephalopathy is likely hospital-related delirium vs post-cath
microemboli vs medication-related (oxycodone and gabapentin were
held after pt developed altered mental status). They proposed
that deficits will likely improve with time. An NG tube was
placed and tube feeds were initiated, pt should have repeat
swallow evaluation at rehab and NG tube can be taken out once
she does not show aspiration. On discharge, pt's speech was
clearer, she was AOx2-3 (knew month and year, not day of week).
She was slightly lethargic but easily arousable and interactive.
.
# Chronic systolic heart failure (last EF 25 % in [**2134**], now LV
systolic function has substantially deteriorated, primarily due
to inferior wall akinesis. Mitral and tricuspid regurgitation
have increased in severity and pulmonary pressures are higher).
Pt was initially diuresed with IV lasix and after cath/PCI, she
remained overall euvolemic on exam. Her renal function was 1.1
at time of discharge. We continued metoprolol and started an
ACE-i on discharge. She should continue lasix 20mg PO daily
after discharge to maintain her volume status.
.
INACTIVE ISSUES:
----------------
# Hypertension - BP elevated to 180s/80s on admission, she was
started on nitro gtt with improvement to SBP 130s/80s. She was
quickly weaned off the nitro drip and had well controlled BP's
on toprol XL 25mg daily and amlodipine 5mg daily. Prior to
discharge, amlodipine was changed to ACI-i as above.
.
# Diabetes: per patient, she is diet controlled at home. We
placed her on diabetic diet and insulin sliding scale during
hospitalization with control of blood sugars.
.
# Spinal Stenosis: pt has chronic pain from spinal stenosis, she
was recently started on Ultram for pain at home which caused her
GI upset. We initially gave her oxycodone with good control of
pain, but discontinued this after she developed delirium, as
above. She can continue on low dose oxycodone when her mental
status improves.
.
TRANSITION OF CARE:
-------------------
# Pulmonary nodule - PDG viability study showed LUL 15 mm
nodule, which could represent focal atelectasis. Recommend short
interval dedicated chest CT for follow-up. A copy of this
discharge summary will be faxed to pt's PCP and cardiologist,
Dr. [**Last Name (STitle) 10543**], who can scheduled a follow-up for this.
.
# NG tube - pt was discharged with NG tube and tube feeds due to
dysphagia in setting of delirium. She should have a repeat
swallow evaluation in [**3-5**] days and once aspiration is not noted,
NG tube can be removed.
.
# [**Name (NI) **] - pt should have Chem 7 checked in [**3-5**] days at rehab to
trend Cr, Na since she was recently started on tube feeds and is
restarting gentle diuresis with PO lasix, as above.
.
# Pain control - as above, has spinal stenosis pain. Took Ultram
prior to admission with GI upset. Had good pain control
initially with oxycodone, which was held after altered mental
status developed. Gabapentin also held due to AMS. Discharged
with Lidocaine patch on back and tylenol prn. Can restart
oxycodone and gabapentin when mental status improves.
Medications on Admission:
Aspirin 325mg daily
Gabapentin 600mg daily
Metoprolol XL ?50mg daily
Tramadol 50mg [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
Please have your Chemistry 7 panel checked within 1-2 days of
discharge. [**Name8 (MD) 6**] MD at your rehab facility can follow up on the
results.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale.
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please
place on back for spinal stenosis pain.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, headache.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
13. heparin Sig: 5000 (5000) units Subcutaneous three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary:
NSTEMI
Retroperitoneal bleed
Delirium
Congestive heart failure
Secondary:
Hypertension
Diabetes type 2
Spinal stenosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] with chest pain and we found that you
had a heart attack. We started you on medications for your heart
attack and did a cardiac catheterization, which showed 3-vessel
disease of your coronary arteries (the vessels feeding your
heart). The surgeons discussed possibility of bypass surgery
with you, but given the high risk of the procedure, you and your
family decided not to pursue surgical treatment. We did an MRI
of your heart and decided to put stents into some of your
vessels to help the blood flow to your heart. You had successful
stenting of your coronary arteries, but developed a small bleed
in your abdomen which we repaired. You were observed overnight
in the cardiac care unit and transferred to the floor the next
day. After the procedure, you developed some confusion and
disorientation which is likely caused by delirium from being in
the hospital. Our neurology team evaluated you and believes that
you will regain much of your function with time. You were having
difficulty swallowing and an evaluation of your swallowing
showed that you were aspirating food and drink into your lungs.
We placed a nasogastric tube for feeding, which can be removed
once another swallow evaluation at your rehab facility shows
that you can swallow well.
You will be going to a rehab facility to regain your strength
and should follow up with Dr. [**Last Name (STitle) 10543**] after your discharge (see
below).
We have made the following changes to your medications:
- START aspirin 325mg daily
- START plavix 75mg daily (it is very important to take this
medication daily without missing any doses, it helps keep your
stents open)
- START atorvastatin 80mg daily
- START lisinopril 10mg daily and toprol XL 50mg daily for blood
pressure and heart failure
- TAKE lasix 20mg daily for your heart failure
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.--Cardiologist
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt: We are working on a follow up appt for you. The office
will call you at home with an appt. If you dont hear from them
by tomorrow, please call them directly to book follow up for
your cardiology needs.
Completed by:[**2139-3-20**]
ICD9 Codes: 5849, 2762, 2930, 4168, 4280, 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4836
} | Medical Text: Admission Date: [**2139-1-10**] Discharge Date: [**2139-1-11**]
Date of Birth: [**2113-10-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
ethanol withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 83745**] is a 25 year-old man with no significant PMH who
presented with left shoulder pain in the setting of intoxication
and is admitted to MICU for concern for alcohol withdrawal.
He presented to the ED last night after falling and sustaining a
forehead lac, and he had an alcohol level of 391 with an
otherwise negative tox screen. He was complaining of left
shoulder but plain films were negative. Per report, he received
haldol during this ED admission and was later discharged home
with ibuprofen. His parents picked him up but brought him back
this morning because of worsening left shoulder pain. Initial VS
were: 98 144/26 24 99%ra. He had repeat plain films this morning
that were again thought to be negative for fracture or
dislocation. He became agitated while in the ED and was thought
to have alcohol withdrawal, with increasing agitation and a
repeat ethanol level of 17. He received diazepam 10 mg iv x 3
and was admitted for further monitoring.
On arrival, he is somnolent but arousable and appropriate. Last
drink was last night.
REVIEW OF SYSTEMS:
No fevers, chills, weight loss, diaphoresis, headache, visual
changes, sore throat, chest pain, shortness of breath, nausea,
vomiting, abdominal pain, constipation, diarrhea, melena,
pruritis, easy bruising, dysuria, skin changes, pruritis.
Past Medical History:
None
Social History:
Works as a research associated for [**Company 61992**]. Drinks >5
beers/night on weekends only. No past history of drug abuse per
him and his family. No other drug use
Family History:
non contributory
Physical Exam:
VS: 98 149/85 103 18 100%ra
GEN:The patient is in no distress and appears comfortable
SKIN:No rashes or skin changes noted
HEENT:No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES:no peripheral edema, warm without cyanosis. full ROM
in left shoulder, TTP along anterior deltoid
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-13**], and BLE [**5-13**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
Pertinent Results:
[**2139-1-10**] 06:09PM BLOOD WBC-9.6 RBC-4.26* Hgb-13.6* Hct-39.3*
MCV-92 MCH-32.1* MCHC-34.7 RDW-13.7 Plt Ct-222
[**2139-1-10**] 06:09PM BLOOD Neuts-76.6* Lymphs-14.3* Monos-8.6
Eos-0.3 Baso-0.3
[**2139-1-10**] 06:09PM BLOOD PT-13.0 PTT-27.6 INR(PT)-1.1
[**2139-1-10**] 06:09PM BLOOD Glucose-99 UreaN-8 Creat-0.7 Na-140 K-4.2
Cl-107 HCO3-26 AnGap-11
[**2139-1-9**] 09:05PM BLOOD Glucose-121* UreaN-7 Creat-0.8 Na-144
K-4.0 Cl-102 HCO3-30 AnGap-16
[**2139-1-10**] 01:15PM BLOOD ASA-NEG Ethanol-17* Acetmnp-10.6
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2139-1-9**] 09:05PM BLOOD ASA-NEG Ethanol-391* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2139-1-10**] 06:49PM BLOOD Lactate-1.6
MRSA SCREEN (Final [**2139-1-13**]): No MRSA isolated.
[**2139-1-9**] CT C-SPINE:
IMPRESSION: No acute fracture or malalignment.
[**2139-1-9**] CT HEAD:
IMPRESSION:
1. No acute intracranial abnormality.
2. Left frontal subgaleal hematoma without underlying fracture.
3. Mild sinus disease.
[**2139-1-10**] SHOULDER XRAY:
IMPRESSION: No fracture or dislocation of the shoulder.
Brief Hospital Course:
ASSESSMENT & PLAN:
Mr. [**Known lastname 83745**] is a 25 year-old man with no significant PMH who
presented with left shoulder pain in the setting of intoxication
and is admitted to MICU for concern for alcohol withdrawal.
# Alcohol abuse/withdrawal: He was initially quite agitated in
ED and required diazepam 10 mg iv x 3. He had no prior history
of withdrawal or seizures per patient and discussion with
family. His tox screen was negative for other substances. He was
admitted to the MICU for close monitoring and concern for
further withdrawals requiring significant doses of diazepam. He
only received 1 further dose of diazepam while in the MICU. He
was discharged the following day once stable and not requiring
any further doses of benzodiazepines. He was discharged home
with thiamine and folate. He was advised to refrain from
consuming alcohol. He was seen by social work here and given
information for rehab programs and AA.
# Shoulder pain: the patient complained of left shoulder pain.
He had an XRAY which did not show any shoulder disclocation. He
was given a prescription for ibuprofen PRN pain.
# Forehead laceration: patient had a forehead laceration which
was repaired with sutures. He will need to see his PCP at the
end of the week for suture removal. His CT spine was negative
for any fracture. CT head was negative for intracranial
pathology.
Medications on Admission:
none
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for shoulder pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Alcohol Withdrawal
Alcohol Intoxication
Discharge Condition:
stable, normal mental status, ambulatory
Discharge Instructions:
You were admitted to [**Hospital1 18**] for alcohol intoxication and
withdrawal. You were treated in the ED, then in the ICU with a
medication called diazepam. You recovered from these withdrawal
symptoms, and you did not have any seizures. You also had
shoulder pain, which was likely a sprain from trauma. You did
not have any evidence of dislocation on the xray of your
shoulder. You had sutures placed on your forehead, and you
should follow up with your PCP at the end of this week to have
these removed.
We recommend that you avoid drinking alcohol, as this was likely
the cause of your fall, and then you developed these withdrawal
symptoms.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20784**] [**Telephone/Fax (1) 81883**] to make an appt
Thursday or Friday ([**1-15**] or [**1-16**]) for follow up and to remove the
sutures
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4837
} | Medical Text: Admission Date: [**2104-6-3**] Discharge Date: [**2104-6-9**]
Date of Birth: [**2047-6-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Fever, rash
Major Surgical or Invasive Procedure:
Skin biopsy
History of Present Illness:
Ms. [**Known lastname 28412**] is a 56 year old woman with history of diabetes,
hypothyroidism, and remote history of Hodgkin's disease who
presented for the evaluation of fever and rash. Last Wednesday
(six days prior to admission, she noticed a rash on her face.
She went with her husband to his doctor's appointment, and he
took a urine sample and diagnosed her with the flu. The rash
started on her face and then spread over her entire body,
including extremities, although she denies involvement of the
hands and soles. It is not painful and not itchy. She then
developed chills and fevers to 101F, along with "excruciating"
intermittent headaches, located over her right eye, for which
she was prescribed Vicodin with good effect on both her
headaches and ability to sleep. She also reports muscle and
joint aches, as well as diffuse body weakness. She was not
improving, and the day prior to admission, her daughter took her
to an OSH (but she vomited in the car on the way to the hospital
and traveled the rest of the way via ambulance), where she had
an elevated white count, was diagnosed with a UTI, given IVF,
ciprofloxacin and compazine, and sent home. She denies sick
contacts, genital ulcers or lesions, travel outside of the
country, prolonged exposure in the [**Doctor Last Name 6641**] (although she does have
to walk in high grass to and from the mailbox), tick or mosquito
bites, pets, unusual foods, and raw seafood. She denies new
medications preceding the rash, and she denies use of new
deodorants or lotions. Per her family (daughter), she seemed to
have trouble concentrating, but was not particularly altered in
cognition. Mental status worsened with fevers/rigors but
improved after Tylenol. She reports being up to date on all her
vaccines. Of note, her husband recently had quadruple bypass
surgery two weeks ago at [**Hospital1 18**] and is currently recovering; she
reports increased stress and minimal sleep since the operation.
.
In the ED, her vitals were T99.6F, HR 109, BP 148/81, RR 24, Sat
100%2LNC. She was given IVF, diphenhydramine without improvement
in the rash. She was transferred to the floor.
Past Medical History:
1)Type 2 Diabetes
2)Hypercholesterolemia
3)s/p Hodgkin's lymphoma, rx splenectomy/radiation 20 years ago
4)Hypothyroidism
Social History:
Lives in [**Location 51056**] with husband. Denies tobacco, alcohol,
and drugs. Has not been sexually active with husband in several
weeks, but denies sexual activity outside of marriage.
Family History:
Significant for diabetes and coronary artery disease.
Physical Exam:
VS: T:102.1F, BP:148/76, HR:117, RR:22, O2:96%RA
GEN: Uncomfortable appearing
HEENT: EOMI, PERRL, dry mucus membranes
NECK: Supple, no cervical lymphadenopathy, no meningismus
CHEST: Bibasilar dry crackles at bases, no wheezes or rhonchi
CV: Tachycardic, no m/r/g
ABD: Soft, voluntary guarding, decreased (but present) bowel
sounds, mild tenderness to palpation in RUQ
EXT: No clubbing, cyanosis, edema
NEURO: A&O x3, but easily distractable; speaking coherently in
full sentences
SKIN: Diffuse macular blanchable rash on trunk, extremities,
back, and with partial involvement of palms and soles
Pertinent Results:
U/A: Tr prot, 150 ket, otherwise unremarkable
.
Lactate 1.8
.
Na 135 K 4.9 Cl 99 HCO3 20 BUN 17 Creat 1.0 Gluc 74
.
WBC 12.9
N:83 Band:0 L:11 M:2 E:0 Bas:0 Atyps: 4
Hgb 11.5
Hct 34.0
Plt 545
MCV 85
.
ALT: 69 AST: 48 AP: 191 Tbili: 0.4 LDH: 323
.
Blood Cx x 2: Pending
Urine Cx: Pending
Lyme serologies: Pending
RPR: Pending
Monospot: Pending
.
ECG: None performed
.
CXR: Mild edema with small bilateral pleural effusions. There is
presumed partially calcified mass lesion likely within the
anterior
mediastinum of indeterminate etiology. Diagnostic considerations
include prior granulomatous disease or possibly treated
lymphoma. A calcified mass possibly from thyroid origin is also
in the differential diagnosis. This lesion does not likely
represent an acute finding. If indicated, consider non-urgent
outpatient chest CT for further characterization.
Brief Hospital Course:
A/P: Ms. [**Known lastname 28412**] is a 56 year old woman with remote history of
Hodgkin's disease, and history of diabetes, presenting with
fever, intermittent headache, malaise, fatigue,
arthralgias/myalgias, mild transaminitis, and diffuse macular
blanching rash.
.
#. Fever and rash. Dermatology and ID were consulted.
Doxycycline initially added to cover rickettsial/atypical
infections, then stopped. Initially there was concern for
Sweet's; however, pathology from skin biopsy was not consistent
with this. Pathology prelim with edema and perivascular
neutrophilic infiltrate (similar to urticaria, but not
consistent with clinical picture). No evidence of leukemic
infiltrate. Rheumatology was consulted following biopsy results
(as could be consistent with Still's); felt to be non-rheum in
nature. Differential included post viral hypersensitivity
reaction, drug reaction, less likely viral exanthem. The
following serologies and additional studies were obtained during
her admission: Parvovirus IgG/IgM negative, Mycoplasma IgG
pos/IgM neg, RPR neg, Lyme neg, monospot neg, resp viral antigen
neg, Rubella and Rubeola IgG pos, ESR 115, RF 20, [**Doctor First Name **] neg.
Blood and urine cultures negative.
Her rash improved significantly (in intensity and distribution)
over the course of her admission without any intervention. At
discharge she had also been afebrile x >48hours.
.
# Atrial fibrillation with rapid ventricular response. On [**6-5**]
was noted to be tachycardic to 160s+ on routine vitals, ECG with
?MAT. Back into sinus with IV lopressor and fever control. On
[**6-6**] again persistently tachycardic to 140s with rhythm more
consistent with atrial fibrillation, very difficult to rate
control. Briefly transferred to MICU where received diltiazem
gtt. Normotensive during episodes but did drop briefly into
upper 80s with receiving dilt. Eventually titrated up to
diltiazem 360 daily plus metoprolol 150 daily; with this regimen
she has been in and out of Afib with rates generally in 90s,
very briefly increasing into 120's. Heparin gtt as bridge to
coumadin started. Cardiology was consulted and she will have
followup with them as an outpaient. INRs will be checked by her
PCP. [**Name10 (NameIs) **] control can further be adjusted by her PCP. [**Name10 (NameIs) **]
reason for Afib was unclear. She had repeat echo without
significant change (normal LV function, no evidence of RV
strain, normal atrial size). No underlying pulmonary disease,
though did have new pulmonary edema on CXR (despite normal LV
function on echo) which may have triggered the arrhythmia. TSH
normal.
.
#. Hypoxia/pulmonary edema. Pulmonary edema and effusions on
chest xray (?cardiogenic vs. noncardiogenic/inflammatory
source). This initially worsened during admission with new O2
requirement; with diuresis this improved and she was not
requiring O2 at discharge. Unclear why she developed pulmonary
edema as above. BNP was elevated at 3855.
.
#. Transaminitis. Likely related to above viral/hypersensitivity
process. Transaminases peaked at admission and subsequently
declined. However, alk phos continued to rise through her
discharge (353 at discharge) with elevated GGT as well. RUQ
ultrasound without significant gallbladder/liver findings. LFTs
will be followed by her PCP following discharge.
.
# Anemia. Hct slowly trended down since admission. Fe studies
c/w inflammation. No evidence of active bleeding. She should
have repeat CBC as an outpatient.
.
# Thrombocytosis. Most likely is reactive given significant
inflammtion/acute illness. ASA was continued.
.
# Leukocytosis. Unclear as to etiology. Stable in 13-15K range.
Neutrophilia without bandemia.
.
#. Diabetes. Held PO meds and administered sliding scale
insulin.
.
#. Hypothyroidism. Continued levothyroxine. TSH normal.
Medications on Admission:
Ciprofloxacin 500mg [**Hospital1 **]
Vicodin 1 tab Q6H
Compazine (but not taking)
Aspirin 325mg daily
Metformin 500mg [**Hospital1 **]
Glyburide 1.25mg [**Hospital1 **]
Sertraline 100mg daily
Synthroid 125mcg daily
Pravastatin 40mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Diltiazem HCl 360 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:*1*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
Disp:*90 Tablet(s)* Refills:*1*
9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Rash, NOS
Atrial fibrillation with rapid ventricular response
.
Pulmonary edema
Diabetes type II
Hypothyroidism
Leukocytosis
Anemia
Thrombocytosis
Transaminitis
Discharge Condition:
Stable, afebrile, with intermittent rate controlled Afib
Discharge Instructions:
You were admitted with fever and rash. You were seen by
multiple specialists regarding your illness. Although the exact
cause is still unknown, you have improved significantly. You
will continue to follow with your doctors closely over the next
few weeks.
.
Please return to the hospital or call your doctor immediately if
you again develop fever, shortness of breath, chest pain,
palpitations, lightheadedness or fainting, bleeding, or any new
symptoms that you are concerned about.
.
Since you were admitted, we have made the following changes to
your medications:
- You have started a blood thinning medication, COUMADIN.
- You have started 2 new medications for fast heart rate,
DILTIAZEM and METOPROLOL.
Followup Instructions:
You have the following followup appointments:
- Dr. [**Last Name (STitle) **]: you need to see him in the office this week. We
were unable to schedule an appointment for you prior to
discharge. We will call his office in the morning and then call
you with an appointment time.
- Dermatology with Dr. [**First Name (STitle) **]. [**7-24**] at 9:15 am. [**Telephone/Fax (1) 1971**].
- Cardiology with Dr. [**Last Name (STitle) **]. [**7-9**] at 3pm. Located on
[**Location (un) 436**] of [**Hospital Ward Name 23**]. [**Telephone/Fax (1) 285**]
.
You will need to have the following labwork done this week: INR
(because of coumadin), CBC, LFTs. Dr. [**Last Name (STitle) **] can order these
labs for you at your appointment this week.
ICD9 Codes: 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4838
} | Medical Text: Admission Date: [**2165-12-19**] Discharge Date: [**2165-12-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Repeated small bowel obstructions
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Small bowel resection.
4. Extended regional mesenteric lymphadenectomy.
5. Wedge biopsy of lesion in left lateral segment of the liver.
History of Present Illness:
81-year-old lady with a history of hypertension, anemia,
gastroesophageal reflux disease, and a possible right renal cell
carcinoma, who has been admitted on three separate occasions to
[**Hospital3 36606**] Hospital in [**Hospital1 189**] over the last several months
for repeated small bowel obstructions. Each time her hospital
stays ranged from 3-5 days and resolved with conservative
management. On one occasion, she required nasogastric tube
decompression. She states that prior to presentation to this
hospital, she had significant complaints of crampy abdominal
pain with excessive nausea and vomiting. She was told that these
repeated bowel obstructions were secondary to adhesions related
to her prior abdominal operations. She saw Dr. [**Last Name (STitle) 1940**] for a
second opinion concerning her management. An upper GI series
with small bowel follow-through was obtained on [**2165-12-6**], and this showed evidence of a 5-cm stricture at the
jejunoileal transition, suggestive of an inflammatory process
but also
consistent with infection, ischemia, or tumor. Pt was referred
to Dr. [**Last Name (STitle) 1924**] for a consideration of resection of this
strictured segment of bowel.
Past Medical History:
hypertension, anemia, gastroesophageal reflux disease, and a
possible right renal cell carcinoma
Social History:
The patient is married and is accompanied to
this visit today by her husband as well as by one of her three
children ([**Female First Name (un) 24743**]). She lives in [**Location 15005**] and remains quite active
around the house. She has a distant trivial smoking history,
having quit more than 30 years ago. She does not consume
alcohol.
Family History:
There is no family history of malignancies or inflammatory bowel
disease.
Physical Exam:
On examination, blood pressure is 138/70, and pulse is 98. In
general, she appears younger than her stated age and quite
readily hops on to the examination table. Sclerae are anicteric.
Neck is supple without lymphadenopathy. There are no carotid
bruits. Lungs are clear to auscultation bilaterally. Heart is
regular rate and rhythm without murmur. Abdomen reveals a right
paramedian as well as a lower midline incision. There is no
evidence of hernia. Her abdomen is soft and nontender without
palpable mass. Rectal examination is heme negative without
palpable mass. Extremities show no edema.
Pertinent Results:
[**2165-12-22**] 04:50AM BLOOD Hct-30.2*
[**2165-12-21**] 10:20AM BLOOD Hct-31.5*
[**2165-12-20**] 05:50AM BLOOD WBC-7.6 RBC-3.81* Hgb-10.7* Hct-31.6*
MCV-83 MCH-28.1 MCHC-34.0 RDW-14.9 Plt Ct-179
[**2165-12-20**] 05:50AM BLOOD Plt Ct-179
[**2165-12-23**] 06:05AM BLOOD Glucose-98 UreaN-10 Creat-0.7 Na-144
K-3.3 Cl-106 HCO3-28 AnGap-13
[**2165-12-22**] 09:30PM BLOOD Glucose-130* UreaN-9 Creat-0.7 Na-142
K-3.4 Cl-106 HCO3-25 AnGap-14
[**2165-12-22**] 06:11AM BLOOD Glucose-136* UreaN-10 Creat-0.8 Na-142
K-4.1 Cl-106 HCO3-25 AnGap-15
[**2165-12-20**] 05:50AM BLOOD Glucose-102 UreaN-15 Creat-1.0 Na-146*
K-4.3 Cl-113* HCO3-25 AnGap-12
[**2165-12-23**] 06:05AM BLOOD Phos-2.2* Mg-1.8
[**2165-12-22**] 09:30PM BLOOD Phos-1.8* Mg-2.0
[**2165-12-22**] 06:11AM BLOOD Calcium-9.1 Phos-2.2* Mg-1.6
[**2165-12-21**] 10:20AM BLOOD Mg-1.9
[**2165-12-20**] 05:50AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.4*
[**2165-12-23**] 09:40AM BLOOD TSH-<0.02*
[**2165-12-18**] CT
1. Circumferential soft tissue mass/wall thickening of the
jejunum, with adjacent lymphadenopathy. This lesion could be
amenable to percutaneous biopsy.
2. Right renal mass, for which the differential includes
oncocytoma or renal cell carcinoma.
3. Complex left renal cyst.
4. Mesenteric and retroperitoneal lymphadenopathy, including a
calcified mesenteric nodal mass.
5. Thyroid goiter.
6. Findings consistent with pulmonary hypertension.
7. No pulmonary masses to correspond to recent chest x-ray.
[**2165-12-23**] ECHO The left atrium is mildly dilated. The left
ventricular cavity size is normal with normal/hyperdynamic
systolic function. There is a mild resting left ventricular
outflow tract obstruction (may be due to hyperdynamic state).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic gradient is
likely related to high cardiac output. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension.
Brief Hospital Course:
Patient was admitted on [**12-19**] following small bowel resection
for stricture causing obstruction. Patient tolerated the
procedure well, and following stabilization overnight in the
PACU was transferred to a surgical care floor for post-operative
care. Patient was maintained NPO with IVF, IV pain medications,
and antibiotics. Postoperatively the patient remained AF with
VSS, the only complication being low urine output for which the
patient responded well to fluid boluses. On POD3, patient was
noted to have episode of Afib. EKG was obtained which was
consistent for afib, and Hct were sent which was WNL. Patient
was asymptomatic with episode, and responded to 10mg IV
lopressor. Patient monitored on telemetry, placed on lopressor
for beta-blockade, and cardiology consulted. Cardiology
advocated continuance of lopressor, d/c of norvasc, and TTE, but
no need for anticoagulation. Cardiology also felt that the
patient's two episodes of syncope in the past were the result of
autonomic dysfunction, advocating slow elevation from the
bedside or from a sitting position to avoid further episodes.
ECHO on patient was as listed above, and following physical
therapy clearance, patient was discharged to home with good PO
intake, appropriate ambulation, and good pain control on [**12-24**].
Medications on Admission:
lisinopril 30 mg p.o. daily, Norvasc 10 mg
p.o. daily, Protonix 40 mg p.o. daily, and hydrochlorothiazide
25
mg p.o. daily.
Discharge Medications:
1. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel stricture, question malignant etiology.
Discharge Condition:
Stable
Discharge Instructions:
You may restart your home medications. Please call a physician
or go to the emergency room if you experience fever >101.4F,
pain unrelieved by medication, intractable nausea or vomiting,
or foul-smelling drainage coming from your incision.
Followup Instructions:
Call Dr.[**Name (NI) 12822**] clinic at ([**Telephone/Fax (1) 55864**] to schedule a
follow-up appointment in [**2-10**] weeks.
Provider: [**Name10 (NameIs) 7548**] WEST SEDATION RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2166-1-3**] 2:00
Please follow up with your cardiologist within 4 weeks to update
him on your atrial fibrillation episode in the hospital
Completed by:[**2165-12-24**]
ICD9 Codes: 4240, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4839
} | Medical Text: Admission Date: [**2149-5-30**] Discharge Date: [**2149-6-6**]
Date of Birth: [**2068-4-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 81 yo gentleman with PMH significan for CHF, MI s/p
CABG and valve replacement who on Friday [**5-29**] was going to his
cardiologist's office by means of ambulance from a rehab
facility. On arrival the ambulance personel found him to be
hypotensive with SBP's in the 70s. He was taken to [**Hospital3 12748**] where he was give a 1L bolus of IVF and his SBP
pressures rose to the 90s. On admission his hematocrit was found
to be 28 and it was uncertain as to why at that time. He was
then transferred to [**Hospital1 18**] and admitted to the medical ICU. Mr.
[**Known lastname 68713**] does occasionally have bouts of hypotension as he describes
occuring about twice a week. They are associated with some light
headedness but denies chest pain, shortness of breath, arm/jaw
pain, changes in vision or increased perspirations with any of
these events. He did mention one prior episode of syncope
occuring 3-4 months prior assoicated with only light headedness
and no other symptoms. He woke up according to him seconds after
the event occurred. He also mentioned a decrease in his
nutritional intake for approximately two weeks since his last
admission to this hospital. He has not been eating or drinking
as much as he usually does. He denies missing doses of
antibiotics. He does endorse anorexia and poor PO intake but
says these have both been present for a while.
.
While in the medical ICU his initial SBP's were in the low 100s
and had a few bouts of light-headedness but unclear if these
were at the times of hypotension. Patient received volume
repletion of 3L in the ED, no additional volume in the MICU. His
ACEi, BB, Spironolactone and Torsemide were held. His pressures
increased somewhat overnight without further volume
adminisitration. His antibiotics were continued.
.
At the time of transfer he said he was feeling well back to his
normal baseline functioning. He did report a continuing cough
that began approximately 2 weeks ago and is productive of white
sputum. It has not been getting better or worse and denies any
recent history of a URI.
Past Medical History:
History of erosive gastritis
Diverticulosis/itis (13y ago)
Chronic Systolic Congestive Heart Failure (EF 15-20%)
Coronary Artery Disease
CABG complicated by Mitral Valve endocarditis(Eneterococcus)
Bioprosthetic MVR [**2148-2-7**]
Tricuspid annuloplasty
BiV pacemaker
Hypertension
Hyperlipidemia
Type II Diabetes Mellitus (diet-controlled)
Obstructive Sleep Apnea (patient denies having this dx)
Cataracts
Glaucoma bilaterally
Pulmonary nodule left lower lobe
Diverticulitis
Ventral hernia
Social History:
He lives with his wife and sister in law usually but has been in
rehab since his last discharge.
Occupation: retired electrical engineer; designed the radio
transmitter that was responsible for communication between the
NASA lunar module and orbiting capsule during the space race of
the [**2097**]
Tobacco: quit 25 years ago; 40-60 PYHx
ETOH: rare occ.
Recreational Drugs: denies use
Family History:
Son with MI requiring CABG at age 50. Brother had an MI at age
63. Mother died 65 believed to have lung dz otherwise
unspecified
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.3 HR 82 BP 92/51 (ranging high 80s to 110s) RR 16 94%
RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: rhonchorous breath sounds B/L, symm CW expansion, white
sputum observed after coughing
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: left melanocytic [**Last Name (un) **] on nipple
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
Lymph:no cervical or inguinal lymphadenopathy present
DISCHARGE PHYSICAL EXAM:
Cards: RRR S1/2 no Murmurs, rubs, gallops
Pulm: CTABL, symm chest wall expansion,
Ext: LE 2+ pitting edema to mid calf, 2+ pedal pulses
Rest of exam unchanged from admission
Pertinent Results:
Admission Labs:
[**2149-5-30**] 08:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2149-5-30**] 08:20PM GLUCOSE-87 UREA N-29* CREAT-1.3* SODIUM-139
POTASSIUM-5.7* CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
[**2149-5-30**] 07:55PM WBC-10.5 RBC-3.38* HGB-8.3* HCT-27.5* MCV-81*
MCH-24.4* MCHC-30.0* RDW-19.9*
[**2149-5-30**] 07:55PM NEUTS-82* BANDS-0 LYMPHS-9* MONOS-7 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2149-5-30**] 07:55PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2149-5-30**] 07:55PM PT-13.3 PTT-22.1 INR(PT)-1.1
[**2149-6-1**] 07:40AM BLOOD WBC-9.1 RBC-3.39* Hgb-8.1* Hct-27.5*
MCV-81* MCH-23.9* MCHC-29.5* RDW-19.7* Plt Ct-371
[**2149-6-1**] 07:40AM BLOOD Glucose-102* UreaN-23* Creat-1.2 Na-141
K-3.7 Cl-105 HCO3-27 AnGap-13
Cardiac Enzymes
[**2149-5-30**] 08:20PM cTropnT-0.02*
[**2149-5-31**] 04:46AM BLOOD CK-MB-9 cTropnT-0.03*
[**2149-5-30**] 08:20PM BLOOD cTropnT-0.02*
[**2149-5-31**] 04:44PM BLOOD CK(CPK)-121
[**2149-5-31**] 04:46AM BLOOD CK(CPK)-115
[**2149-6-1**] 07:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8
Discharge Labs:
[**2149-6-6**] 05:45AM BLOOD WBC-8.1 RBC-3.29* Hgb-8.5* Hct-27.0*
MCV-82 MCH-26.0* MCHC-31.6 RDW-19.2* Plt Ct-336
[**2149-6-6**] 05:45AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-142
K-4.3 Cl-107 HCO3-28 AnGap-11
[**2149-6-6**] 05:45AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0
URINE CULTURE (Final [**2149-5-31**]): NO GROWTH
Blood Cx no growth to date
CHEST XRAY [**2149-5-30**]:
1. Mild pulmonary edema.
2. Bilateral stable small-to-moderate pleural effusion.
3. Bibasilar opacities at the lung bases could be atelectasis,
cannot exclude superinfection in appropriate clinical setting.
Brief Hospital Course:
This is an 81 year old man with a past medical history of severe
CHF, CAD, and s/p MVR presenting after recent hospitalization
for GI bleed and endovascular infection with hypotension.
1) Hypotension: Differential is, of course, concerning including
sepsis vs cardiogenic shock. That being said pt had no fevers,
is on broad spectrum antibiotics, and does not suggest any signs
or have ECG suggestive of myocardial ischemia. He also was
minimally symptomatic and improved dramatically with fluid
boluses suggesting perhaps simply dehydration. His blood
pressures have remained mostly stable with systolic blood
pressures ranging between 90s-110s following the 1L NS given at
[**Hospital3 **] and another 3L NS given in ED at [**Hospital1 18**]. On the
hospital floor we have slowly started him back on his home
cardiac meds: metoprolol 12.5mg [**Hospital1 **] instead of 25mg [**Hospital1 **] which is
his home regimin and lisinopril 2.5mg QHS and his blood
pressures have remained stable. We have decided to stop
torsemide and spironolactone. During this admission. We tried to
begin torsemide during this admission but Mr. [**Known lastname 68713**] experienced
an episode of hypotension. We then reduced his home torsemide to
half what he was taking as an out patient and he had another
episode of hypotension. It seems as though Mr. [**Known lastname 68713**] might be
having difficulty keeping his daily oral intake up with his
current diuretic doses. He might need to have his cardiac
medication doses adjusted to this lower level of fluid intake.
We are holding his diuretics at the time of discharge and we
would like him to follow up with his cardiologist for further
changes to his cardiac meds.
2)Hx of GI Bleed/ UE DVT: Pt developed DVT in left arm around
his PICC line. We the pulled the PICC line and started him on a
Heparin Drip. Later on that evening he had a bloody bowel
movement and his hematocrit dropped to 23. We then transfused
two units of red blood cells and discontinued his heparin and
aspririn. His Hct has been stable since this episode and with ID
approval we switched him over to oral antibiotics for his
endocarditis. He currently does not have a PICC line in place
and was placed on Heparin 5000U SQ for prophylaxis. He also has
a questionable diagnosis of lymphoma that is being followed by
Heme/onc. Mr. [**Known lastname 68713**] at this time does not want to work up this
any further. We informed him that this may be the cause of his
hypercoagulable state but he is not willing at this time to
investigate this further.
3) Acute Kidney Injury on CKD: Likely due to dehydration from
poor PO, which is also contributing to hypotension. His Cr has
been trending down since admission after institution of fluid
boluses. His renal function has returned to his baseline.
4) CAD: No signs of acute ischemia at this time and low index of
suspicion for acute CV event causing shock. Troponins were 0.02,
0.03., 0.02 on this admission.
5)Cough: Persistent since last hospitalization without change.
Sounds like viral cough. Benzonatate was given for cough
suppression and his symptoms have improved since admission.
6)Anemia: Iron supplementation continued in the hospital. His
hemoglobin returned back to his baseline levels.
7)Left nipple Melanocytic nevi- This lesion was found on
admission physicial exam. We feel this finding warrants out
patient evaluation.
8)Transional: Has follow up appointments scheduled including
ultrasound of upper extremeties. He also has follow up apt with
his cardiology to discuss cardiac meds.
Would consider restarting Torsemide if pt gains three pounds.
He will also have weekly labs drawn at rehab to monitor for side
effects of linezolid. In addition they will be checking your
blood counts at rehab to make sure you are not continuing to
bleed.
Medications on Admission:
torsemide 10 mg PO once a day.
spironolactone 25 mg PO DAILY
metoprolol succinate 25 mg PO twice a day.
aspirin 81 mg PO once a day.
lisinopril 2.5 mg PO at bedtime.
simvastatin 40 mg PO DAILY
pantoprazole 40 mg PO once a day.
Metamucil Oral
ascorbic acid 250 mg PO twice a day.
ferrous gluconate 325 mg PO twice a day
Benzonatate 100 mg PO TID
docusate sodium 100 mg PO BID
ciprofloxacin 500 mg PO Q12H (intended through [**5-30**])
metronidazole 500 mg PO Q8H (intended through [**5-30**])
daptomycin 500 mg Q24H (intended through [**2149-6-23**])
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for until [**2149-6-23**] weeks.
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
11. ascorbic acid 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
12. linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Primary Diagnosis- CHF
Secondary Diagnosis-
Endocarditis
Chronic cough
Anemia
CAD
Acute Kidney Injury
Left nipple melanocytic [**Last Name (un) **]
Primary Diagnosis-
CHF
DVT
Secondary Diagnosis-
Endocarditis
Chronic cough
Anemia
CAD
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 68713**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital because of a
bout of low blood pressure. Your blood pressure rose in response
to IV fluids suggesting that you were dehydrated on admission.
Please make sure to eat and drink regularly. Also please weigh
lbs. We have also changed your antibiotics to Linezolid and have
revomed you IV line. Also due to the recent blood clots found in
both of your arms we have placed you on Heparin injections twice
a day.
We would like you to follow up with your Cardiologist regarding
the current state of your heart failure and for any medication
modifications they would like to make to your current regimin.
Changes in Medications:
STOPPED Daptomycin, Torsemide, Aspirin, and spironolactone
STARTED Linezolid 600mg every 12hrs
CHANGED Metoprolol to 12.5mg twice a day
You will also have weekly labs drawn at rehab to monitor for
side effects of linezolid. In addition they will be checking
your blood counts at rehab to make sure you are not continuing
to bleed.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2149-6-11**] at 1:45 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2149-6-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: MONDAY [**2149-6-23**] at 9:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4589, 5849, 5789, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4840
} | Medical Text: Admission Date: [**2182-9-26**] Discharge Date: [**2182-10-6**]
Date of Birth: [**2128-7-4**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 54 year old white male has
no history of coronary artery disease and reported some chest
discomfort radiating to the arms and jaw occurring over the
previous weekend. He reports that the sensation subsided and
he was fine for three days and awoke on the a.m. of
[**2182-9-25**], with the same feeling lasting for two hours and
then resolving. He was seen in his primary care physician's
office with minor nonspecific ST-T changes on his
electrocardiogram and was admitted to outside hospital for
evaluation and stress test. He ruled in for a non ST
elevation myocardial infarction and was transferred to [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY: History of anxiety.
Hyperlipidemia.
Gastroesophageal reflux disease.
Hypertension.
Question of sleep apnea.
Status post left colectomy for recurrent diverticular bleed.
Status post appendectomy.
Status post tonsillectomy and adenoidectomy.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Zinecard 20 mg p.o. daily.
2. Aspirin 162 mg p.o. daily.
3. Lipitor 10 mg p.o. daily.
4. Prevacid 15 mg p.o. p.r.n.
5. [**Doctor First Name **] 180 mg p.o. p.r.n.
6. Meter dose inhalers for asthma.
SOCIAL HISTORY: He is married and works full time. He does
not smoke cigarettes. Drinks four to five drinks per week.
FAMILY HISTORY: Significant for coronary artery disease.
REVIEW OF SYMPTOMS: Significant for asthma, headache.
PHYSICAL EXAMINATION: On physical examination, he is a well-
developed, well-nourished white male in no apparent distress.
Vital signs stable, afebrile. Head, eyes, ears, nose and
throat examination is normocephalic and atraumatic.
Extraocular movements intact. The oropharynx is benign.
Neck was supple with full range of motion. No
lymphadenopathy or thyromegaly. Carotids two plus and equal
bilaterally without bruits. The lungs are clear to
auscultation and percussion. Cardiovascular examination
revealed regular rate and rhythm, normal S1 and S2, with no
murmurs, rubs or gallops. The abdomen was obese, soft,
nontender, with positive bowel sounds, no masses or
hepatosplenomegaly. Extremities were without cyanosis,
clubbing or edema. Pulses were two plus and equal
bilaterally throughout. Neurologic examination was nonfocal.
HOSPITAL COURSE: He was admitted and underwent cardiac
catheterization which revealed a 70 percent mid left anterior
descending coronary artery lesion and 90 percent circumflex
lesion and 90 percent obtuse marginal lesion, 80 percent
distal right coronary artery lesion with an ejection fraction
of 72 percent. Dr. [**Last Name (STitle) 70**] was consulted and on
[**2182-9-30**], the patient underwent a coronary artery bypass
graft times four with left internal mammary artery to the
left anterior descending coronary artery, reversed saphenous
vein graft to diagonal, obtuse marginal and right
posterolateral. Cross clamp time was 50 minutes, total
bypass time was 90 minutes. He was transferred to the CSRU
in stable condition on Nitroglycerin, Neo-Synephrine and
Propofol. He was extubated on his postoperative night. He
was transferred to the floor on postoperative day number one
in stable condition. He had his chest tubes discontinued.
On postoperative day number two, he had his epicardial pacing
wires discontinued and progressed well in his postoperative
course. On postoperative day number five, he was discharged
to home in stable condition.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day for seven days.
2. Potassium 20 meq p.o. twice a day for seven days.
3. Colace 100 mg p.o. twice a day.
4. Aspirin 325 mg p.o. daily.
5. Prevacid 30 mg p.o. daily.
6. Lipitor 10 mg p.o. daily.
7. Ibuprofen 600 mg p.o. q6hours p.r.n. pain.
8. Plavix 75 mg p.o. daily.
9. Dilaudid 2 mg p.o. q4-6hours p.r.n. pain.
10. Lopressor 75 mg p.o. twice a day.
11. Vitamin C 500 mg p.o. twice a day.
12. Ferrous Gluconate 325 mg p.o. daily.
13. Multivitamin one p.o. daily.
His laboratories on discharge were white blood cell count
9.8, hematocrit 27.9, platelet count 615,000. Sodium 138,
potassium 4.4, chloride 101, CO2 25, blood urea nitrogen 16,
creatinine 0.8, blood sugar 107.
DISCHARGE DIAGNOSES: Coronary artery disease
Hypertension.
Hypercholesterolemia.
Anxiety.
FOLLOW UP: He will follow-up with Dr. [**Last Name (STitle) 6700**] in one to
two weeks, Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] two to three weeks and Dr. [**Last Name (STitle) 70**] in
six weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2182-10-5**] 14:30:22
T: [**2182-10-5**] 15:13:20
Job#: [**Job Number 57174**]
ICD9 Codes: 4271, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4841
} | Medical Text: Admission Date: [**2189-12-6**] Discharge Date: [**2189-12-31**]
Date of Birth: [**2128-3-31**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids / Lisinopril / Celebrex / Rofecoxib / Tegaderm
/ Ciprofloxacin / Allopurinol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Pre-TACE hydration
Reason for Transfer to [**Hospital Unit Name 153**]: Hypoxemia
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
Left radial arterial line
History of Present Illness:
61F with pancreatic neuroendocrine CA metastatic to the liver
s/p CBD stent and chronic diastolic CHF admitted to OMED [**12-6**]
for hydration prior to TACE on [**12-7**]. Started on zosyn [**12-6**],
followed by vanc/cefepime/flagyl on [**12-9**] for possible
aspiration pneumonia. Notably, CT chest [**12-11**] showed ethiodol
uptake in the lung, concerning for a portosystemic shunt.
Azithromycin was added [**12-15**], and cefepime was stopped in favor
of levo/[**Last Name (un) 2830**] on [**12-15**]. She has also been treated with bolus
diuresis for acute diastolic CHF. She states that she felt as if
she was improving on treatment as of yesterday but then became
more short of breath with minimal exertion, with a cough
productive of yellow-light green sputum. She endorses orthopnea
but denies PND. No fever, chills, sweats, chest pain,
palpitations, nausea, vomiting, diarrhea, or calf pain.
On routine vitals found to have O2sat 88%5L (had been on 5L NC
since [**12-14**]) - improved to 92-94%8L FM. Given lasix 20 mg IV
with 300 UOP. ABG on NRB 7.45/47/72/34. CXR showed extensive
right-sided airspace disease. Vital signs prior to transfer 97.3
102/59 95 22 98%NRB.
Past Medical History:
Oncologic History (from Dr.[**Name (NI) 52983**] [**9-16**] note)
[**1-6**]: Had UGI bleeding, EGD revealed gastric ulcer (official
report unavailable)
[**2-7**]: Developed chronic fatigue and anorexia soon after
returning home from let hip and knee surgery.
[**3-10**]: Presented to PCP with [**Name9 (PRE) 5283**] pain and worsening jaundice for
2 weeks. RUQ US demonstrated pancreatic head mass and multiple
liver nodules suspicious for metastasis. Admitted to [**Hospital **]
hospital, where CT scan confirmed US findings. ERCP at [**Hospital1 18**]
demonstrated duodenal invasion (with stigmata of recent
bleeding,) and extrinsic compression of CBD, which was stented.
Duodenal biopsy returned poorly differentiated neuroendocrine
carcinoma. MRCP demonstrated numerous hepatic metastases.
US-guided biopsy of one hepatic lesion revealed same findings as
duodenal biopsy. The picture was consistent was metastatic,
poorly differentiated neuroendocrine carcinoma.
.
Other PMH:
1. Chronic anemia, underwent EGD and diagnosed with bleeding
ulcer in [**11/2186**] and 12/[**2187**].
2. Colonoscopy [**12-6**] --> polyp, repeat from [**1-6**] --> normal
3. Arthritis
-Hip replacement [**2183**] and revision in [**2184**].
-Hip debridement in [**2-7**]
-Left knee torn cartilage repair in [**2-7**].
4. Hysterectomy for fibroids
5. Mitral valve prolapse
6. Obstructive sleep apnea
7. Asthma
8. Coronary artery "spasms" based on cath in [**2162**] and [**2179**]
9. Diabetes mellitus, type II
10. Hypertension
11. Hyperlipidemia
12. Obesity
13. Chronic diastolic CHF
14. Depression
Social History:
Widow, husband murdered in [**2162**]. Lives with daughter and her
family in [**Name (NI) **], MA. Has two healthy children and 3 healthy
grandchildren. Previously worked as lab technician in hospital.
Tob: smoked for six months in [**2149**]; none current
EtOH: none
Family History:
Half sister died from uterine cancer in her 40s
Paternal half sister - uterine cancer
Paternal brother -- esophageal cancer in 50s
Maternal cousin died of renal cancer at 46
Maternal cousin died of lung cancer at 46.
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: T 97.6 HR 93 BP 100/48 RR 20 O2sat 93%NRB
GEN: Cachectic, appears comfortable, resp nonlabored
HEENT: pale OP clear dry MM
NECK: JVP 10 cm H20
CV: reg rate nl S1S2 no m/r/g
PULM: coarse rales [**3-4**] right lung field and at left base no
wheeze
ABD: soft NTND
EXT: warm, dry +PP tr pedal edema no calf tenderness
NEURO: awake, alert, conversing appropriately
Pertinent Results:
[**2189-12-6**] 01:26AM BLOOD WBC-3.9* RBC-3.24* Hgb-10.2* Hct-32.6*
MCV-100* MCH-31.6 MCHC-31.5 RDW-15.4 Plt Ct-128*
[**2189-12-6**] 01:26AM BLOOD Neuts-67.4 Lymphs-22.6 Monos-6.6 Eos-2.7
Baso-0.7
[**2189-12-6**] 01:26AM BLOOD PT-17.8* PTT-33.3 INR(PT)-1.6*
[**2189-12-6**] 01:26AM BLOOD Glucose-118* UreaN-5* Creat-0.7 Na-141
K-3.9 Cl-106 HCO3-29 AnGap-10
[**2189-12-6**] 01:26AM BLOOD ALT-34 AST-54* LD(LDH)-143 AlkPhos-191*
TotBili-0.5
[**2189-12-6**] 01:26AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
[**2189-12-8**] 08:50PM BLOOD ALT-236* AST-562* LD(LDH)-722*
AlkPhos-269* TotBili-1.2
[**2189-12-8**] 06:45AM BLOOD Lipase-7
[**2189-12-9**] 06:40AM BLOOD proBNP-1324*
[**2189-12-7**] 07:05AM BLOOD CEA-7.2* AFP-2.1
[**2189-12-16**] 06:04AM BLOOD Digoxin-<0.2*
[**2189-12-16**] 06:34AM BLOOD Type-ART pO2-72* pCO2-47* pH-7.45
calTCO2-34* Base XS-7
[**2189-12-16**] 03:39PM BLOOD Lactate-1.4
[**2189-12-16**] 03:08PM BLOOD B-GLUCAN- < 31 pg/mL negative
[**2189-12-16**] 03:08PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1,
negative
[**2189-12-18**] 08:03AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2189-12-18**] 08:03AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2189-12-18**] 08:03AM URINE RBC-9* WBC-0 Bacteri-MOD Yeast-NONE Epi-0
[**2189-12-18**] 08:03AM URINE AmorphX-MANY
[**2189-12-18**] 08:03AM URINE Eos-NEGATIVE
[**2189-12-18**] 08:03AM URINE Hours-RANDOM UreaN-533 Creat-142 Na-<10
K-45 Cl-<10
[**2189-12-18**] 08:03AM URINE Osmolal-363
===================
MICROBIOLOGY
===================
[**2189-12-15**]
- urine legionella antigen- negative
[**2189-12-16**]
- MRSA screen- negative
- BAL: No polys seen. No microbes seen. Respiratory cultures
negative. Legionella culture negative. Negative PCP. [**Name10 (NameIs) **]
fungal (prelim). AFB negative. AFB culture negative (prelim).
Viral culture negative (prelim)
- Urine cx- negative
- Blood cx- negative
[**2189-12-17**]
- Blood cx- negative
[**2189-12-18**]
- Blood cx [**3-3**]- pending
- Rapid respiratory viral screen & culture: negative
- sputum: moderate growth of yeast
- Urine cx- negative
[**2189-12-19**]
- Blood cx- pending
- Urine cx- negative
[**2189-12-20**]
- Blood cx- pending
- C. diff toxin- negative
===============
INTERNVETION
===============
[**2189-12-7**]
- Common hepatic artery and left hepatic artery arteriogram.
- Transarterial chemoembolization of the left lobe of liver.
- Angio-Seal closure device deployment to the right common
femoral artery
access site.
FINDINGS:
1. There is conventional celiac axis anatomy as demonstrated on
previous
arteriograms.
2. Common hepatic artery arteriogram demonstrates multiple
arterially
enhancing masses throughout both lobes of liver.
3. The left hepatic artery arteriogram confirmed large enhancing
masses in the left lobe of liver, which was successfully
targeted with the
chemotherapeutic [**Doctor Last Name 360**], with 60 mg of doxorubicin, 20 mL of
lipoidol, and 20 mL of intra-arterial lidocaine, and one and a
half vials of 100-300 micron Embospheres administered.
IMPRESSION: Satisfactory left hepatic artery chemoembolization
======================
IMAGING
======================
[**2189-12-8**]
- CT Abdomen/Pelvis: There is dependent atelectasis at the
bilateral lung bases without effusion or focal consolidation to
suggest pneumonia. Some hyperdensity is newly seen at the lung
bases, which most likely reflects systemic ethiodol distribution
secondary to small intrahepatic portosystemic shunt. Coronary
calcifications are noted. Hyperdense material within multiple
right lobe liver lesions is stable from [**2189-11-13**],
compatible with sequelae of prior chemoembolization.
Additionally, there is newly noted extensive hyperdense material
within the left lobe of the liver and caudate lobe, most
concentrated at the sites of previously noted
arterially-enhancing lesions, compatible with recent left
hepatic artery chemoembolization. Other than the aforementioned
hyperdensity at the lung bases, there is no definite evidence of
extrahepatic Ethiodol uptake. Hyperdense material dependently
within stomach appears intraluminal, most likely reflecting
ingested medication. The spleen, adrenal glands, and kidneys
remain unremarkable. Contrast in the collecting system reflects
recent angiography. There are no contour-altering renal mass
lesions. The pancreatic tail is again noted to be atrophic. The
known pancreatic head mass is not well appreciated without
intravenous contrast. Stranding inferior to the pancreatic head
is noted, possibly reflecting the sequelae of prior
pancreatitis. There is a metallic common bile duct stent in
standard position, with left lobe pneumobilia compatible with
stent patency. The stomach, duodenum, and intra-abdominal loops
of small and large bowel are
normal in caliber and configuration. There is no bowel
distention or bowel wall thickening. There is no free fluid or
free air identified.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions
identified.
IMPRESSION:
1. Extensive Ethiodol uptake within the left lobe of the liver,
most
concentrated at the site of previously noted
arterially-enhancing lesions seen on [**2189-11-13**].
2. Hyperdensity at the lung bases is most compatible with
Ethiodol, likely secondary to a small intrahepatic
porto-systemic shunt. There is no further evidence of
extrahepatic Ethiodol uptake.
3. Common bile duct stent in standard position. Left lobe
pneumobilia is
compatible with stent patency. Known pancreatic head mass is not
well
appreciated given lack of intravenous contrast.
[**2189-12-11**]
- Echo: The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and low normal global left ventricular systolic
function.
[**2189-12-14**]
- The heart is normal in size. Mitral annular calcifications are
noted.
Atherosclerotic calcifications of the aortic arch are present.
Low attenuation of the intracardiac blood pool suggests
underlying anemia. There is a right central venous catheter,
with tip terminating within the SVC. A right paratracheal lymph
node is mildly enlarged measuring 15 mm, which is larger from
prior study, and is likely reactive. The airways are patent to
the subsegmental level. There is interval development of diffuse
ground-glass airspace opacities, most severely involving the
upper lobes. These findings are new compared to a CT Torso from
[**2189-9-30**]. The previously seen hyperdense foci within the lower
lobes suggestive of extra-hepatic Ethiodol are less apparent on
this study. The previously seen dense consolidation of the lower
lobes are also improved. There is no pleural or pericardial
effusion. This examination is not tailored for subdiaphragmatic
evaluation. Extensive Ethiodol uptake within the left lobe of
the liver is again noted. Osseous structures reveal no
suspicious lesion.
IMPRESSION:
1. Interval development of diffuse ground-glass opacities
throughout the lungs, most severe within the upper lobes
bilaterally. The differential diagnosis includes infection
(including atypical infections from PCP or fungal if the patient
is immunocompromised), pulmonary edema, and pulmonary
hemorrhage.
2. Previously seen hyperdense foci in the lung bases felt to
represent extra-hepatic Ethiodol are less apparent on this
study.
3. Extensive Ethiodol uptake within the left lobe of the liver.
[**2189-12-16**]
- LENIS: The deep veins of bilateral lower extremity, namely the
common femoral vein, the superficial femoral vein, the popliteal
vein, the peroneal and the posterior tibial veins proximally in
the calf region are patent, show normal caliber,
compressibility, and phasicity. On spectral wave Doppler, good
augmentation and phasicity waves are noted. There is no evidence
of acute or chronic thrombus at this time .
IMPRESSION: No evidence of deep venous thrombosis in the
bilateral lower
extremity deep veins on the available images at the time of the
study.
[**2189-12-19**]
- CXR: Pulmonary consolidation has been severe in the right lung
since [**12-13**]. Today, it has progressed dramatically in the
left upper lobe. Whether this is pneumonia or pulmonary
hemorrhage is radiographically indeterminate. Sparing of left
lower lobe suggests that it is not edema. Severe cardiomegaly
persists along with mediastinal and hilar vascular engorgement.
Tip of the endotracheal tube is above the upper margin of the
clavicles, no less than 3 cm from the carina. No pneumothorax.
[**2189-12-21**]
- Echo: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is high
(>4.0L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. No 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 no pericardial effusion.
Compared with the prior study (images reviewed) of [**2189-12-11**],
left ventricular systolic function is more dynamic and the heart
rate is higher. The estimated pulmonary artery systolic pressure
is now higher.
[**2189-12-23**]
- CT Chest
Brief Hospital Course:
61 y/o with metastatic neuroendocrine CA admitted for hydration
prior to TACE on [**12-7**], presented to the ICU with hypoxemic
respiratory failure due to what was thought to be
hospital-acquired pneumonia vs acute on chronic diastolic CHF vs
pneumonitis secondary to a portosystemic shunt communicating
from her TACE procedure. Ms. [**Name14 (STitle) 52984**] had a prolonged course in
the ICU, requiring ventilatory assitance
# Hypoxemic respiratory failure/Lung infiltrates. Patient was
transferred from oncology service after her TACE for increased
respiratory distress with a subacute decompensation, which was
initially thought to be from acute on chronic diastolic heart
failure, pneumonia, aspiration, hemorrhage or VTE with a small
component of portosystemic shunt. She was intubated for
increased work of breathing on [**2189-12-16**]. However, subsequent
bronchoscopy did not suggest an infectious or hemorrhagic
etiology as BAL was negative and bronchoscopy showed mostly
clear aspirate. She was continued on vancomycin which was
started prior to her transfer to ICU, and she was started also
on meropenem so that both would cover for HAP as well as
levofloxacin to cover atypical pneumonia. She completed a 5 day
course of levofloxain and 12 day course of vancomycin.
Meropenem was kept for pseudomonal coverage for a planned course
of 14 days. Methylprednisolone was initiated at 20 mg q8h for
possible pneumonitis as patient's hypoxic respiratory failure
persists despite antibiotics treatments. Her respiratory status
continued to be without progress on the steroid, requiring FiO2
of 50-60%. Thoracic surgery was consulted for possible VATS
biopsy to obtain a more definitive diagnosis to patient's
parenchy infiltrates seen on CXR and CT. However, no VATS is
possible given her clinical status, and the risk outweighs the
benefit for patient to undergo open thoracotomy for tissue
biopsy. As her sepsis improved, she was able to tolerate
intermittent dose of lasix to diurese the presumed pulmonary
edema as her total length of state fluid balance was positive.
Family meeting was held to discuss her respiratory status, and
patient was made CMO. Patient was extubated on the night of
[**12-30**] and she passed away shortly therafter.
# Shock, liekly [**3-3**] distributive/sepsis with SvO2 78% and
initial SVV [**5-17**]. Patient initially required Levophed support
as well as fluid boluses to maintain her MAP and urine output.
The likely source for the sepsis is pulmonary
infection/inflammation based on radiographical evidence as her
other culture data have been negative. No evidence of adrenal
insufficiency, thyroid toxicosis, PE. She was able to be weaned
off pressors.
# Acute Renal insufficiency, likely from pre-renal azotemia
secondary to sepsis. This was noted as her Crt trended up to 1.5
from baseline 0.6-0.8. FeUrea was found to be < 35% and FENa <
1%. She initially required pressors and IVF boluses for the low
urine output. Her SVO2 and SVV were monitored closely to help
guide therapy. She gradually improved and was able to be weaned
off of pressors and tolerate diuresis with improved and stable
Crt.
# Hypernatremia. Free water deficit initially about 3.8L. She
was treated with D5W fluid bolus then maintenance with the
likely goal of starting free water flushes into her tube feed.
# Acute on Chronic Diastolic CHF, likely with some component of
pulmonary edema which contributes some to the respiratory
function. Initial echocardiogram showed LVEF of 50-55%. Diovan
and diltiazem were soon held after her arrival to the [**Hospital Unit Name 153**]
secondary to hypotension and requirement of pressor, Levophed.
Her repeat echocardiogram showed hyperdynamic ventricular
function, correlating to her distributive shock picture. As she
was weaned off pressor on [**2189-12-21**]. She was able to tolerate
intermittent low dose of furosemide for diuresis given that
patient's length of stay fluid balance was positive.
#Pancytopenia, likely [**3-3**] recent chemotherapy. Her CBC was
monitored on a daily basis. Her white count, anemia, and
thrombocytopenia were stably low. She did not have episodes of
acute bleeding. Active type and screen were maintained.
# Neuroendocrine cancer. Patient was admitted to the hospital
for TACE. Her LFT was elevated after TACE, but gradually
trended downward during her stay in the ICU.
# Diabetes Mellitus. Patient was placed on an insulin sliding
scale with 70/30 and regular finger stick blood sugar
monitoring.
# Goals of Care. Full code, confirmed on [**2189-12-16**]. However,
prior to intubation, patient voiced that she would not want to
be on the ventilator for a prolonged period of time, and she
would give herself 4-6 weeks on the ventilator only if she was
unable to be successfully extubated. She stated that she would
not want to have a trach or a PEG prior to [**2189-12-16**]. Her
health care proxy is her daughter, [**Name (NI) **] [**Name (NI) 16745**] [**Telephone/Fax (1) 52985**].
A fmily meeting was held on [**2189-12-30**]. At that point Ms. [**Known lastname 52986**]
family decided that in light of her continued deterioration and
in respect for her clear wish not to have prolonged life
supporting care if her lung function was not improving to make
comfort the sole goal and will discontinue any therapy not
directed at comfort. She passed away that evening.
Medications on Admission:
Deceased.
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2190-1-1**]
ICD9 Codes: 0389, 486, 5849, 2760, 5789, 4280, 4240, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4842
} | Medical Text: Admission Date: [**2120-4-16**] Discharge Date: [**2120-4-19**]
Date of Birth: [**2053-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypoxia, increased secretions
Major Surgical or Invasive Procedure:
J-tube reinsertion
central venous catheter insertion
History of Present Illness:
67 YO M w complicated surgical history after a distant
esophageal resection for esophageal Ca c/b TEF and recurrent
PNAs requiring chronic trach/intermittent vent and j-tube who
presented with increased secretions and hypoxia. The patient is
not able to provide history so information was obtained from his
daughter and medical records. The patient was in his usual state
of health, living in a chronic vent facility, on [**4-14**]. On the
evening of [**4-15**], while off the vent, he was noted to have
shortness of breath with a large amount of secretions. He was
hypoxic and was placed back on the vent. On the morning of [**4-16**],
he was noted to be restless with SBPs in the 70s-80s with
minimal response to IVF boluses. He was therefore given cefepime
and vanc and sent to the ED.
.
Upon arrival to the ED, VS were: 98, 83/64, 22, 97% on AC with
FiO2 60%, VT 500, RR 12, peep 5. He was noted to be comfortable.
RT suctioned thick yellow secretions. Labs were notable for
bandemia 7% and hct 22. CXR was c/f multifocal pneumonia. He was
started on levophed.
.
Upon arrival to the ICU, he is unable to provide any further
history. He denies pain or shortness of breath.
Past Medical History:
-Hypertension
-Hypothyroidism
-Prostate cancer s/p XRT
-h/o esophageal CA s/p XRT with 3-hole esohagectomy in [**2104**] at
[**Hospital1 112**]. Recently hospitalized at [**Hospital1 18**] for PNA and found to have
stricture near cricopharyngeus, with evidence of TEF. EGD showed
no cancer recurrence. J-tube placed [**4-/2119**]
-Small bowel obstruction
-Cognitive deficit NOS vs limited safety awareness
-Orthostatic hypotension - hospitalization [**1-/2119**] after fall
-DVT of the L subclavian and L axillary vein
-R hip fracture s/p ORIF by Dr. [**Last Name (STitle) **] @ [**Hospital1 112**]
-R septic hip [**2114**]
-RLL PNA [**1-10**], treated with levofloxacin
-multiple stab wounds to the abdomen in the [**2079**]
-right sided PTX after bronchoscopy s/p CT placement
-Tonsillectomy and adenoidectomy
-R wrist and hand surgery
-large bowel obstruction in [**2119**] s/p exploratory laparotomy with
reduction of a paraesophageal hernia and was left with an open
abdomen due to edema and bowel distention s/p closure on [**2119-10-17**]
Social History:
Originally from [**State 9512**]. He has three daughters. One daughter
lives in [**State 4260**], another is in [**Name (NI) 86**], [**First Name3 (LF) 2184**] who is very involved.
Reports he recently stopped smoking. Although he has a history
of binge drinking, he reports he hasn't drank since [**Month (only) 1096**] of
[**2118**]. Retired construction worker and plumber.
Family History:
Mother died of a blood clot. Doesn't know what his father died
of. Sister died of obesity and "fat around her heart"
Physical Exam:
ADMISSION EXAM:
Vitals: 98.5, 95/53, 77, 21
General: Alert, oriented to person only, no acute distress,
cachectic
HEENT: Sclera anicteric, MM dry
Neck: Supple, JVP not elevated
Lungs: Clear to auscultation anteriorly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended; + BS; J-tube
dislodged/entire tube taped to his abdominal wall; midline scar
with eschar and surrounding granulation tissue
GU: Condom cath; left femoral CVL
Ext: Profoundly wasted extremities; 2+ dps bilaterally
.
DISCHARGE EXAM:
Vitals: 98.2, 76, 134/72, 20, 98% on vent (FiO2 50%)
General: Alert, oriented to person only, no acute distress,
cachectic
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP not elevated, Right IJ central line in place
Lungs: Coarse breath sounds throughout, crackles at bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended; + BS; J-tube in place,
midline scar with eschar and surrounding granulation tissue
Ext: Profoundly wasted extremities; 2+ dps bilaterally
Pertinent Results:
ADMISSION LABS:
[**2120-4-16**] 07:25PM BLOOD WBC-13.2*# RBC-2.47* Hgb-7.2* Hct-22.4*
MCV-91 MCH-29.2 MCHC-32.2 RDW-16.0* Plt Ct-279
[**2120-4-16**] 07:25PM BLOOD Neuts-83* Bands-7* Lymphs-7* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2120-4-16**] 07:25PM BLOOD PT-13.9* PTT-31.8 INR(PT)-1.2*
[**2120-4-16**] 07:25PM BLOOD calTIBC-204* VitB12-517 Folate-GREATER TH
Ferritn-1083* TRF-157*
[**2120-4-16**] 07:25PM BLOOD TSH-20*
[**2120-4-17**] 06:21AM BLOOD T4-3.4*
[**2120-4-17**] 06:21AM BLOOD ALT-19 AST-21 LD(LDH)-142 CK(CPK)-72
AlkPhos-143* TotBili-0.3
.
PERTINENT LABS:
[**2120-4-17**] 06:21AM BLOOD ALT-19 AST-21 LD(LDH)-142 CK(CPK)-72
AlkPhos-143* TotBili-0.3
[**2120-4-16**] 07:25PM BLOOD calTIBC-204* VitB12-517 Folate-GREATER TH
Ferritn-1083* TRF-157*
[**2120-4-17**] 06:21AM BLOOD Hapto-365*
[**2120-4-16**] 07:25PM BLOOD Ret Aut-1.1*
[**2120-4-16**] 07:25PM BLOOD TSH-20*
[**2120-4-17**] 06:21AM BLOOD T4-3.4*
.
DISCHARGE LABS:
[**2120-4-19**] 04:03AM BLOOD WBC-8.2 RBC-2.73* Hgb-8.1* Hct-24.5*
MCV-90 MCH-29.8 MCHC-33.1 RDW-16.2* Plt Ct-284
[**2120-4-19**] 04:03AM BLOOD Glucose-79 UreaN-30* Creat-0.7 Na-149*
K-3.6 Cl-115* HCO3-27 AnGap-11
[**2120-4-19**] 04:03AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1
.
MICROBIOLOGY:
[**2120-4-16**] Blood Cx: No growth to date
[**2120-4-16**] Catheter Tip Cx: Corynebacterium >15 colonies
[**2120-4-16**] Sputum Cx:
GRAM STAIN (Final [**2120-4-16**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2120-4-18**]):
Unable to definitively determine the presence or absence of
commensal respiratory flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
BETA STREPTOCOCCI, NOT GROUP A. MODERATE GROWTH.
.
IMAGING:
[**2120-4-16**] CXR: Tracheostomy tube remains in unchanged position.
Surgical clips are noted projecting over the left mediastinum as
well as left upper quadrant of the abdomen. There are
ill-defined opacities within both lung bases, predominantly
involving the right upper lobe as well as the left upper lobe
concerning for multifocal pneumonia, which appear progressed
when compared to the prior study. There is likely an element of
mild pulmonary edema as the pulmonary vasculature is somewhat
indistinct and there is mild perihilar haziness. Small bilateral
pleural effusions are likely present, but not completely imaged
on this exam. Old left-sided rib fractures are noted.
[**2120-4-19**] CXR: No appreciable change is demonstrated as compared
to the prior study in the location of the tracheostomy, right
internal jugular line as well as the mediastinal contours and
widespread parenchymal consolidations, pleural effusions, and
lungs hyperexpansion. No interval development of pneumothorax
has been noted.
.
[**2120-4-19**] Abdominal XR with gastrograffin: J-tube in place; no
leakage.
Brief Hospital Course:
67 year old man with a distant esophageal resection for
esophageal Ca c/b TE fistula and recurrent pneumonias requiring
chronic trach/intermittent vent and j-tube who presented with
increased secretions and hypoxia.
.
# Increased secretions, hypoxia, bandemia, hypotension
suggestive of SIRS [**3-6**] pneumonia. He was initially started on
levophed for hypotension. He was weaned off of this almost
immediately with the aid of fluid boluses. He was started on
vancomycin and cefepime for hospital acquired pneumonia. Sputum
cultures grew gram negative rods. Blood culture grew
corynebacterium in one bottle, which was thought to be a
contaminant. Urine culture was negative. He has been afebrile
and his leukocytosis is resolving. He will be treated with a
10-day course of the vanc/cefepime for healthcare associated
pneumonia, to be completed on [**2120-4-25**].
.
# Anemia: Iron studies were consistent with anemia of chronic
disease. Stool was guiac negative and there was no gross
bleeding noted. A colonoscopy in [**2115**] revealed friability
consistent with prior radiation therapy. He received 1 unit of
packed red blood cells and his hematocrit was stable in the
mid-20s.
.
# J-tube dislodged: This was replaced by interventional
radiology and placement was confirmed by abdominal x-ray. He was
maintained on the same tube feeding regimen.
.
# Hypothyroidism: IV levoxyl was continued. His TSH was slightly
elevated, however it is decreased from a prior level drawn
during his prior admissions. Difficult to interpret in the
setting of active infection. Recommend repeating thyroid studies
after pneumonia resolves.
.
# DNR/DNI: Confirmed with patient and similar to previous
hospitalizations.
Medications on Admission:
1. transderm-sc 1.5mg q3d (unknown medication)
2. vitamin D 1000units daily
3. combivent 2puffs q6h prn
4. levoxyl 150mcg daily
5. tylenol 650mg q4h prn
6. heparin 5000u TID
7. omeprazole 40mg daily
8. celexa 20mg daily
9. cefepime 2g q12h
10. vancomycin 1g q24h
11. sodium chloride flushes
Discharge Medications:
1. Vitamin D 1,000 unit Tablet [**Year (4 digits) **]: One (1) Tablet PO once a
day.
2. Combivent 18-103 mcg/Actuation Aerosol [**Year (4 digits) **]: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
3. Levoxyl 150 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
4. Tylenol 325 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO every four (4)
hours as needed for pain: not to exceed 2g daily.
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Celexa 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
7. vancomycin 1,000 mg Recon Soln [**Year (4 digits) **]: 1000 (1000) mg
Intravenous every twelve (12) hours: To be taken through
[**2120-4-25**].
Disp:*13 doses* Refills:*0*
8. cefepime 2 gram Recon Soln [**Month/Day/Year **]: Two (2) gram Injection Q12H
(every 12 hours): To be taken through [**2120-4-25**].
Disp:*13 doses* Refills:*0*
9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Primary:
Ventilator Associated Pneumonia (Gram Negative Rods, not yet
speciated)
.
Secondary:
Chronic respiratory failure with tracheostomy
Hypertension
Tracheo-esophageal fistula
Esophagectomy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for shortness of breath, low
blood pressures and increased oxygen requirements. You were
found to have a pneumonia causing your shortness of breath and
increased oxygen requirements. You were treated with IV
antibiotics and increased vent support and frequent suctioning
which you should continue with as outlined elsewhere in your
discharge paperwork.
.
You likely became dehydrated in the setting of having an
infection leading to your low blood pressures. You were given IV
fluids with improvement in your blood pressure.
.
In addition, your J-tube fell out and was replaced in
interventional radiology.
.
We made the following changes to your medications:
- Heparin subcutaneous injections were held due to low body mass
- Vancomycin was changed from 1000mg daily to 1000mg q12h
Followup Instructions:
Please follow up with your regular physicians at Radius. You
should also be seen by a wound care nurse.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2120-4-19**]
ICD9 Codes: 0389, 486, 2859, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4843
} | Medical Text: Admission Date: [**2104-4-20**] Discharge Date: [**2104-5-1**]
Date of Birth: [**2029-8-6**] Sex: F
Service: Medical Intensive Care Unit
CHIEF COMPLAINT: Hypercarbic respiratory failure and
hypotension requiring pressors.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female with a past medical history significant for coronary
artery disease status post CABG x2, aortic stenosis, status
post aortic valve replacement on Coumadin with recent
prosthetic valve thrombosis, status post TPA thrombolysis,
congestive heart failure with an ejection fraction of less
than 20% with 2+ mitral regurgitation, and 2+ tricuspid
regurgitation, and history of ventricular fibrillation arrest
requiring pacemaker and ICD placement, now presents from
rehabilitation with acute renal failure and hypertension
requiring pressors.
The patient is status post a prolonged hospital course from
[**Month (only) 404**] to [**2104-3-15**] for non-ST elevation myocardial
infarction requiring a redo CABG. The patient's
postoperative course was complicated by renal failure
requiring CVVH, worsening heart failure requiring
intra-aortic balloon pump complicated by rectus sheath
hematoma, failure to wean from the ventilator requiring
tracheostomy placement, atrial fibrillation requiring
amiodarone, ventricular fibrillation arrest, requiring ICD
placement, and prosthetic aortic valve thrombus requiring TPA
thrombolysis complicated by ICD pocket hematoma.
The patient was discharged to rehabilitation early [**Month (only) 958**],
however, returned to the hospital from [**Date range (1) 31609**] for ICD
pocket infection with methicillin-sensitive Staphylococcus
aureus. The patient underwent removal of the ICD and was
started on oxacillin for treatment of MSSA cellulitis. The
[**Hospital 228**] hospital course was complicated by congestive heart
failure and the patient was discharged to rehabilitation on
[**4-15**] on diuretics including Zaroxolyn, Lasix, and
aldactone, as well as oxacillin to complete a three week
course.
The patient was doing well initially at rehabilitation,
however, several days postdischarge, was noted to have
progressively increasing BUN and creatinine (creatinine 3.4,
BUN 106), and hyponatremia with confusion. The patient's
diuretics were initially reduced, however, the patient's
renal failure was thought to be secondary to worsened
congestive heart failure with a total body volume overload
and ineffective renal perfusion. More aggressive diuresis
was attempted, however, with minimal effect. The patient
subsequently became hypotensive and was brought to an outside
hospital Emergency Department, where she received normal
saline boluses, and was started on dopamine secondary to
systolic blood pressures in the 60s. The patient was
subsequently transferred to the [**Hospital1 188**] Emergency Department, where a chest x-ray revealed
diffuse bilateral infiltrates consistent with worsened heart
failure. The patient was transferred to the Medical
Intensive Care Unit with hemodynamic instability.
PAST MEDICAL HISTORY:
1. Coronary artery bypass graft in [**2092**] with redo CABG in
[**2104-1-16**]. The patient underwent repeat cardiac
catheterization on [**2104-2-9**] for acute graft closure
with PTCA and stenting of the LIMA to the left anterior
descending artery and saphenous vein graft to the diag.
2. Congestive heart failure with biventricular failure,
ejection fraction less than 20% with severe global right
ventricular free wall hypokinesis, 2+ mitral regurgitation,
2+ tricuspid regurgitation.
3. Atrial fibrillation with rapid ventricular response.
4. Ventricular fibrillation arrest [**2104-2-16**] status
post ICD placement with dual pacer.
5. Bilateral carotid endarterectomy.
6. Hypertension.
7. Diabetes mellitus.
8. Peripheral vascular disease.
9. Status post rectus sheath hematoma.
10. ICD pocket infection status post ICD and pacer removal.
11. Failure to wean from ventilator status post tracheostomy
and PEG tube placement in [**2104-2-16**].
12. Depression.
13. Hypothyroidism secondary to amiodarone.
14. Aortic stenosis status post bileaflet aortic valve (St.
[**Male First Name (un) 1525**] replacement) complicated by valve thrombosis requiring
TPA thrombolysis.
MEDICATIONS ON ADMISSION:
1. Amiodarone 400 mg po q day.
2. Synthroid 25 mg po q day.
3. Coumadin 5 mg po q hs.
4. Reglan 10 mg po tid.
5. Lansoprazole 30 mg po q day.
6. Aspirin 81 mg po q day.
7. Enalapril 2.5 mg po bid.
8. Lipitor 10 mg po q day.
9. Lasix 100 mg IV bid.
10. Aldactone 25 mg po q day.
11. Zaroxolyn 5 mg po bid.
12. Vitamin C.
13. Multivitamin.
14. Zinc 270 mg po q day.
15. Sliding scale insulin qid.
16. Glipizide 10 mg po q day.
17. Albuterol MDI q4h prn.
18. Colace 100 mg po bid.
19. Dulcolax 10 mg po prn.
20. Oxacillin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a widow with a 15 pack year
tobacco history (quit 15 years ago), and no history of
alcohol use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.5, heart
rate 80, respiratory rate 26, oxygen saturation is 89-94%,
FIO2 of 40%. In general, the patient is an obtunded,
chronically debilitated woman. HEENT exam: Normocephalic,
atraumatic. Anicteric sclerae. Pupils are equal, round, and
reactive to light and accommodation. Moist mucous membranes,
clear oropharynx. Neck examination supple with no jugular
venous distention or lymphadenopathy. Cardiac examination:
3/6 systolic ejection murmur at the left upper sternal border
radiating to the neck, otherwise normal S1, S2. Pulmonary
examination: Coarse breath sounds throughout anteriorly. No
wheezes or rales appreciated. Abdominal examination is
distended with normoactive bowel sounds, soft, no rebound or
guarding. PEG tube in place with guaiac positive rectal
examination. Extremities: Cool with no edema appreciated.
Skin examination: ICD pocket dressing in place, clean, dry,
and intact with left thigh dressing in place secondary to a
saphenous vein graft harvest site infection with failure to
heal. Minimal serous drainage and pressure ulcers on
bilateral heels.
LABORATORIES AND STUDIES ON ADMISSION: Complete blood count
with a white blood cell count of 22.8, hematocrit 31.6, 24 on
repeat, and platelets of 203. White blood cell differential
with 93% polys, 3.3% lymphocytes, 3.2% monocytes, and no
eosinophils. Chem-7 with a sodium of 127, potassium 4.6,
chloride 87, bicarb 23, BUN 115, and creatinine of 3.0 with a
glucose of 180. Coags with a PT of 17.4, INR 2.0, and PTT of
28.2. LFTs with a total bilirubin of 1.3, ALT 140, AST 70,
alkaline phosphatase 857, amylase 103, calcium 9.3, phosphate
6.3, and magnesium 2.7. In addition, urinalysis with large
blood, trace leukocyte esterase, greater than 50 red blood
cells, 21-50 white cells, many bacteria, no yeast, and [**3-19**]
squamous cells (chronic Foley).
Chest x-ray with diffuse patchy infiltrates, no pneumothorax
and right IJ and PICC line in place. Portable abdominal
x-ray with no dilated loops of bowel.
Arterial blood gas on assist control tidal volume 500, PEEP
of 5, respiratory rate 18, FIO2 of 100% with a pH of 7.28,
pCO2 62, and pO2 of 52.
HOSPITAL COURSE: The patient underwent a very complicated
hospital course. Was complicated by hypoxic and hypercarbic
respiratory failure secondary to congestive heart failure and
concomitant pneumonia requiring continuous ventilatory
support, sepsis requiring pressors, and acute persistent
renal failure. A Swan-Ganz catheter was placed on [**4-21**]
for hemodynamic monitoring with evidence of increased
pulmonary capillary wedge pressure, decreased vascular
resistance and decreased cardiac output consistent with
concomitant sepsis and heart failure.
The patient was continued on oxacillin for
methicillin-sensitive Staphylococcus aureus cellulitis, and
placed on empiric broad-spectrum antibiotics for sepsis of
unknown etiology. Multiple blood cultures, urine cultures,
and sputum cultures were obtained without growth throughout
the hospitalization.
On presentation, patient was noted to have a lower
gastrointestinal bleed thought secondary to mesenteric
ischemia in the setting of hypotension. The patient's
hematocrit dropped as low as 24 requiring multiple blood
transfusions, however, the patient was felt too unstable to
undergo colonoscopy. The patient's gastrointestinal bleed
stabilized.
On [**4-23**], the patient developed atrial fibrillation with
a rapid ventricular rate and hemodynamic compromise. After
multiple unsuccessful attempts at DC cardioversion, the
patient was started on digoxin with adequate heart rate
control. Secondary to excessive intravenous fluid boluses in
the setting of sepsis, the patient became totally body volume
overload with increasing oxygen requirement. Aggressive
diuresis with intravenous Lasix and Zaroxolyn was attempted
without effect. The Electrophysiology, Heart Failure, as
well as Infectious Disease Services were consulted for
further input.
On [**4-29**], the patient complained of abdominal pain with
increasing abdominal distention and decreased bowel sounds.
An abdominal and pelvic CT scan was obtained with evidence of
new large rectus sheath hematoma with bladder compression.
The patient's Heparin was held, however, the patient's
hematocrit continued to decrease requiring continuous blood
transfusion. General Surgery was consulted without surgical
options and the patient's hematoma continued to grow.
On [**5-1**], the patient developed ventricular fibrillation
arrest at a rate of 200 with no detectable blood pressure. A
code was called, CPR performed with multiple rounds of
shocks, Epinephrine, atropine, as well as amiodarone loading.
After approximately 45 minutes of ACLS, the patient developed
sinus rhythm with a systolic blood pressure in the 150s on
dopamine, amiodarone, as well as Morphine. The patient
remained unresponsive, the family was [**Name (NI) 653**], and made
aware of the situation and continued to express wishes for
continued full support.
After 20 minutes, however, the patient again developed
ventricular fibrillation. CPR was again performed with
multiple shocks, Epinephrine, and atropine. The code was
called by Dr. [**Last Name (STitle) 2146**] secondary to refractory ventricular
fibrillation. At 10:05 am, on [**5-1**], the patient ceased
spontaneous breathing and expired.
DISCHARGE/EXPIRATION DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft surgery.
2. Systolic congestive heart failure.
3. Atrial fibrillation with rapid ventricular rate.
4. Aortic stenosis status post aortic valve replacement.
5. Aortic valve thrombosis status post TPA thrombolysis.
6. Ventricular fibrillation arrest.
7. Status post ICD placement and removal.
8. Hypertension.
9. Methicillin-sensitive Staphylococcus aureus cellulitis.
10. Acute renal failure secondary to acute tubular necrosis.
11. Hypoxic and hypercarbic respiratory failure.
12. Rectus sheath hematoma.
13. Peripheral vascular disease.
14. Diabetes mellitus.
15. Hypothyroidism.
16. Sepsis with hypotension requiring pressors.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2104-5-11**] 15:05
T: [**2104-5-15**] 12:45
JOB#: [**Job Number 31610**]
ICD9 Codes: 0389, 4280, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4844
} | Medical Text: Service: GENERAL Date: [**2125-5-22**]
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], M.D. [**MD Number(1) 16133**]
DATE OF DISCHARGE: To be determined.
HISTORY OF THE PRESENT ILLNESS: This is a 77-year-old man
with history of cerebral palsy, mild mental retardation,
coronary artery disease, seizure disorder, and small-bowel
obstruction, who presented from [**Hospital3 **] Center
with diffuse lower abdominal pain with radiation to the back,
fever, nausea, and vomiting for two days. The patient first
noted this pain when his wheelchair struck another one, five
days prior to admission. He was also complaining of a
productive cough of yellow-to-brown sputum. Vital signs in
the emergency room revealed temperature 100.3, pulse 118,
blood pressure 91/54, respiratory rate 20, oxygen saturation
95% on 1.5 liters. The patient was given IV Ampicillin,
Gentamicin, and Flagyl in the emergency room and he was
admitted to the Surgery Service initially. Of note,
Levofloxacin 500 mg p.o.q.d. had been started at the [**Hospital3 1761**] on [**5-7**]. Per report, he has a baseline
congested cough.
LABORATORY DATA: Admission labs are significant for an
increased white blood cell count 34.1, ALT 242, AST 122,
alkaline phosphatase 166, amylase [**2049**], lipase 750, total
bilirubin 1.2. CT of the abdomen was consistent with
pancreatitis with question of organizing collection inferior
to the head of the pancreas, mild left intrahepatic duct
dilation. MRCP was done consistent with acute pancreatitis,
no filling defects in biliary tree and free fluid in abdomen
and pelvis. He was treated with IV fluids, pain medications
sternotomy and bowel rest. He was started on IV antibiotics.
In addition, PICC line was placed. The patient continued to
be febrile the first few days of hospitalization. TPN was
started as he was NPO and on [**5-2**] because the LFTs,
amylase, and lipase were all back to normal and the patient's
test was resolving, he was transferred to the Medicine
Service. Because his MRCP was inconclusive, ERCP was done on
[**5-11**] with the finding of stone and sludge at the
biliary tree. The stone was removed and sphincterotomy was
done. Common bile duct was dilated to 12-mm.
PAST MEDICAL HISTORY:
1. Cerebral palsy.
2. Mild mental retardation.
3. Coronary artery disease status post myocardial
infarction, EF 35%.
4. Seizure disorder.
5. Asthma.
6. [**Doctor Last Name 15532**] esophagus with stricture.
7. Status post ileocecetomy in [**2122**].
8. Status post Total hip replacement, right side.
9. Status post open reduction and internal fixation.
10. Small-bowel obstruction status post LOA [**2123-5-24**].
11. History of cholecystectomy, open.
MEDICATIONS ON ADMISSION:
1. Enteric coated aspirin 325 mg p.o.q.d.
2. Digoxin 0.25 mg p.o.q.d.
3. Diltiazem 30 mg p.o.q.i.d.
4. Lasix 20 mg p.o.q.d.
5. Neurontin 600 mg p.o.t.i.d.
6. Prevacid 30 mg p.o.q.d.
7. Cozaar 25 mg p.o.q.d.
8. Multivitamin, one tablet p.o.q.d.
9. Percocet t.i.d.
10. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o.q.d.
11. Primidone 250 mg p.o.q.h.s.; 125 mg p.o. q.a.m.
12. Ambien 5 mg p.o.q.h.s.
13. Combivent MDI.
14. Vanceril MDI.
MEDICATIONS ON TRANSFER TO THE MEDICINE SERVICE:
1. IV fluids.
2. Protonix IV q.d.
3. TPN.
4. Flagyl 500 mg IV t.i.d.
5. Levofloxacin 500 mg IV q.d.
6. Lopressor 25 mg per NG tube t.i.d.
7. Hydromorphone 0.5 mg to 1 mg q.3h. to 4h.p.r.n.
8. Digoxin.
9. Diltiazem.
10. Gabapentin.
11. Losartan.
12. Ambien.
13. Albuterol nebulizers.
14. Beclovent MDI q.i.d.
15. Combivent MDI q.i.d.
16. Pneumoboots.
17. Droperidol 0.625 mg IV p.r.n.
18. Primidone
ALLERGIES: The patient is allergic to DILANTIN, CAPOTEN, AND
SHELLFISH.
SOCIAL HISTORY: The patient lives at [**Hospital3 **]
Center. He has a niece in [**Location (un) 8985**] [**State 3914**]. He transfers
with assistance and self-propels himself in a wheelchair. He
is independent with medications and needs assistance with
toiletting.
FAMILY HISTORY: Noncontributory.
CODE STATUS: Full.
PHYSICAL EXAMINATION: Examination revealed the following:
On [**5-8**], vital signs revealed the following:
Temperature 100.3, pulse 118, blood pressure 91/54,
respiratory rate 20, oxygen saturation 91% on two liters.
GENERAL: The patient was in no acute distress, conversant,
poor historian, alert, and oriented times three. HEENT:
Anicteric, pale skin. PULMONARY: Coarse breath sounds,
crackles at the bilateral bases. CARDIAC: Regular rate and
rhythm. ABDOMEN: Soft, diffusely tender, especially in the
right upper quadrant greater than right lower quadrant;
positive [**Doctor Last Name **] sign, positive voluntary guarding and
rebound; negative tap shake; 3 x 2 incisional hernia; no
incarcerated bowel; easily reducible contents,
guaiac-negative; normal tone; decreased stool in vault.
EXTREMITIES: Warm, spastic left upper extremity and
bilateral lower extremities.
LABORATORY DATA: Laboratory data revealed the following:
WBC 34.1, hematocrit 41.1, MCV 98, differential 88%
neutrophils, 3 bands, 3 lymphocytes, 6 monocytes, platelet
count 153,000. Urinalysis: Yellow, clear, specific gravity
1.001, large blood, negative nitrite, negative protein,
negative glucose, negative ketones, small bilirubin, 0.2
urobilirubin, 5.5 pH, trace leukocyte esterase, greater than
50 red blood cells, 5 white blood cells, few bacteria, no
yeast. Sodium 144, potassium 4.4, chloride 105, bicarbonate
25, BUN 26, creatinine 1.3, glucose 103, anion gap 18, ALT
242, AST 122, alkaline phosphatase 166, amylase [**2049**], total
bilirubin 1.2, lipase 750. C. difficile negative. Blood
cultures revealed no growth. Urine culture revealed no
growth.
Portable AP chest x-ray revealed no evidence of pneumonia.
Portable abdomen: Marked limited abdominal examination, no
clear obstructive pattern identified.
Abdominal ultrasound: The patient is status post
cholecystectomy, common bile duct appears unremarkable,
limited evaluation of the rest of the abdomen due to
overlying gas.
CT of the abdomen with contrast as well as pelvis:
Pancreatitis with a probable organizing collection inferior
to the head of the pancrease; mild left intrahepatic ductal
dilatation.
MR of the abdomen, [**5-10**], [**2125**]: No MR evidence of
filling defects in the biliary tree and limited study;
changes consistent with acute pancreatitis; prominent head of
the pancreas; free fluid in the abdomen and pelvis.
Chest AP, [**5-10**]: Successful placement of PICC, the tip
of which is in the SVC ready for use.
[**5-12**], [**2125**], portable abdominal film, dilated small
bowel loops and earlier partial small-bowel obstruction
suspected.
[**5-12**], portal AP: Slight elevation of the left
hemidiaphragm with subsegmental atelectasis at the left base,
otherwise, no interval change.
[**5-13**]: Portal AP: Worsened fluid status versus prior
increased bibasilar atelectasis.
[**5-13**]: Portal AP: Intraperitoneal free air on the
upright projection.
[**5-14**]: Portal AP: No evidence of pneumonia or CHF,
atelectasis left base unchanged.
[**5-14**]: CT with reconstruction of the abdomen and
pelvis; interval progressive of peripancreatic inflammatory
changes less than 30% of the pancreatic parenchyma
demonstrating a lack of contrast enhancement; interval
increase in size or probable organizing phlegmon in the
region of the inferior pancreatic head; no drainable fluid
collection; free air within the biliary tree presumably
secondary to the recent ERCP; inadequate assessment of
previously-described thickened loops of jejunum secondary to
lack of distention with oral contrast; paraumbilical and
right inguinal hernias; small bilateral pleural effusions.
[**5-16**]: Portal AP: Film is rotated to the left. NG
tube extends below diaphragm. Heart size is borderline, but
difficult to assess. No definite CHF, pulmonary edema, or
pulmonary consolidation, no pneumothorax.
AP chest: [**5-17**]: NG tube in distal stomach with distal
end not included on the film, heart size normal, low lung
volume with bibasilar atelectasis, no pneumothorax, no
evidence for CHF.
Chest AP [**5-18**]: Status post right brachial vein, PICC
line placement, line is ready for immediate use with tip in
the distal SVC. HIT Antibody negative.
EKG: [**5-8**], sinus tachycardia with ventricular ectopy,
PR interval 0.2, leftward axis, rate of 140, grouping ST
segments in leads 1, AVL and V5 through V6.
IMPRESSION: This is a 77-year-old gentleman with history of
gallstones who was admitted with gallstones pancreatitis, now
status post ERCP with sphincterotomy.
#1. GASTROINTESTINAL: The patient has gallstone
pancreatitis, status post ERCP with sphincterotomy and stone
removal. Initially, after the ERCP the patient did well and
started to tolerate sips of fluid. The patient was afebrile
on [**5-11**]. He was still on Levofloxacin and Flagyl at
that time for possible fluid collection in the head of the
pancreas. On the evening of [**5-11**], the patient's urine
output began to decline, despite continuing IV fluid and the
patient complained of increasing abdominal pain and was noted
to have increasing abdominal distention. His pain was
controlled with Dilaudid. He was given antiemetics p.r.n.
The following morning on [**5-12**], these were more
exaggerated and NG tube was placed with the return of large
amounts of bilious fluid. The patient's abdomen decreased in
size with this, however, because of his clinical status, he
was transferred to the Intensive Care Unit for further
management. In the Intensive Care Unit, the patient's
antibiotic spectrum was widened. He was found to be
hypotensive, probably secondary to third spacing his amylase,
lipase, and LFTs all within normal limits at that time. He
was not thought to be having post ERCP pancreatitis. The
patient did continue to spike in the ICU. Antibiotics were
widened to Ampicillin, Levofloxacin, and Flagyl. The
patient's hypertension resolved with aggressive IV hydration.
Repeat CT was done, which showed continuing fluid collection
in the head of the pancreas, however, it was decided to
discontinue antibiotics on [**5-15**] and watch him and his
fever curve off antibiotics. The patient was though to be
stable enough to transfer back to the floor on [**5-16**].
He was continued off antibiotics. He was NPO for two days,
without nausea or vomiting. The patient was continued on TPN
at that point with pain control and IV fluids.
On [**5-18**], the patient removed his NG tube and it was
kept out as he was having no nausea or vomiting. He began to
pass gas and to have bowel movements, which became diarrhea.
Stool cultures were sent for C difficile stool cultures and
stool leukocytes, which are still pending to date. General
Surgery, Gastrointestinal, and ERCP Team continued to follow
the patient. His diet was slowly advanced to the point of a
regular diet on [**5-22**] without decompensation. However,
TPN was continued even when he began taking p.o. given his
poor caloric intake. The patient should followup with
Dr. [**Last Name (STitle) **], his surgeon, one month after discharge and he
should have a repeat CT of the abdomen to evaluate the fluid
collection the head of the pancreas six weeks after
discharge. NG lavage was positive for coffee-ground and the
patient was started on Protonix IV then p.o. b.i.d.
#2. FLUIDS, ELECTROLYTES, AND NUTRITION: Upon transfer to
the Medicine Team on [**5-11**], the patient was
hypernatremic at 153. This may have contributed to his
decompensation the following day with hypotension. The
patient was placed on half normal saline. However, when his
urine output dropped, he was bolused with normal saline.
Urine output improved with IV hydration. Electrolytes were
repleted, both in his IV fluid and through his TPN. He was
able to advance his diet to regular on [**5-22**]. However,
he was continued on TPN.
#3. CARDIOVASCULAR: The patient had a history of
cardiovascular disease with CHF. While the patient was in
the Intensive Care Unit between [**5-12**] and [**5-16**], he
was noted to have a troponin leak with no active chest pain
or EKG changes. He was started on IV Lopressor because he
was tachycardiac and this controlled the tachycardia well.
Aspirin was held off given his occult blood in his NG lavage
fluid. The patient continued to complain of intermittent
chest pain each time without EKG changes he was ruled out two
to three times during this admission for myocardial
infarction. Tachycardia was also thought perhaps to be due
to his pain.
#4. PULMONARY: The patient has history of asthma, chronic
obstructive pulmonary disease. The patient was continued on
his MDIs and nebulizers while in house with good relief.
Occasionally, he was felt to be fluid overloaded and
responded well to Lasix.
#5. HEMATOLOGY: The patient had a decrease in his
hematocrit when he went to the unit and transfused two units
of packed red blood cells. The hematocrit then stabilized.
The patient also was noted to have a decrease in his platelet
count to 100. HIT antibody was checked and found to be
negative. Only for the first day three days of
hospitalization was the patient receiving Heparin
subcutaneously. This was then switched to pneumoboots for
DVT prophylaxis. Platelets improved to normal.
#6. NEUROLOGICAL: The patient has a history of seizure
disorder and he is on Neurontin and Primidone at home. These
were taken off when the patient was NPO and on the evening of
[**5-19**], the patient reported to the nurse that he had had
a brief seizure, which was normal for him. He was restarted.
He did not have a postictal state. He was restarted on
Neurontin and Primidone at that point. The following day all
of his medications were switched to PO and he restarted on
his old cardiac medications such as Digoxin and Cozaar.
#7. PROPHYLAXIS: Protonix b.i.d. and Pneumoboots. Physical
therapy was asked to see the patient prior to discharge as
well. The Department of Nutrition followed the patient for
his nutritional recommendations.
This is a summary of the hospital course to [**2125-5-22**].
The rest of the [**Hospital 228**] hospital course will be dictated by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He will do an addendum to this summary and
add a condition of discharge, discharge status, discharge
medications, and discharge diagnoses.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 177**] 12-972
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2125-5-22**] 14:46
T: [**2125-5-22**] 15:00
JOB#: [**Job Number 99116**]
ICD9 Codes: 4280, 2765, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4845
} | Medical Text: Admission Date: [**2197-3-5**] Discharge Date: [**2197-3-16**]
Date of Birth: [**2124-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increasing fatigue and SOB
Major Surgical or Invasive Procedure:
AVR(23 StJude tissue)MVR(33 StJude tissue)CABGx4
LIMA-LAD,SVG-Ramus-OM,SVG-PDA)[**3-7**]
History of Present Illness:
72 yo M with SOB and increasing fatigue since last [**Month (only) 547**].
Hospitalized in [**12-1**] with volume overload and diuresed 40
pounds and had cardiac cath which showed severe CAD. Echo showed
PFO/AI/MR, referred for surgery.
Past Medical History:
PMH: HTN, ^chol, PVD, OA B/L shoulder, Bursitis L shoulder, CHF,
Afib
PSH: s/p R THR, Renal lithotripsy, tonsillectomy
Social History:
retired
no tobacco
rare social etoh
Family History:
Father with MI at 66
son with pacemaker
Physical Exam:
Admission
HR 76 RR 14 BP 128/56
NAD
Lungs CTAB
Heart irreg rate 2/6 SEM
Abdomen soft, NT,ND
Extrem warm, no edema, bilateral dependent rubor
Discharge
VS T 97.1 HR 76 BP 124/54 RR 20 o2sat 996% RA
Gen NAD
Neuro A&Ox3 nonfocal exam
Pulm diminished bases, otherwise clear
CV irreg irreg, no murmur. Sternum stable, incision CDI.
Abdm soft, NT/ND/+BS. Chole tube draining bileous material, site
CDI
Ext warm well perfused. Rt arm with 3-5 inch phlebitis, no cord
Pertinent Results:
[**2197-3-5**] 08:09PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2197-3-5**] 01:10PM GLUCOSE-173* UREA N-31* CREAT-1.1 SODIUM-138
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
[**2197-3-5**] 01:10PM ALT(SGPT)-34 AST(SGOT)-30 LD(LDH)-180 ALK
PHOS-165* TOT BILI-0.7
[**2197-3-5**] 01:10PM ALBUMIN-4.1
[**2197-3-5**] 01:10PM %HbA1c-7.1*
[**2197-3-5**] 01:10PM WBC-8.1 RBC-4.39* HGB-13.7* HCT-37.3* MCV-85
MCH-31.3 MCHC-36.8* RDW-14.0
[**2197-3-5**] 01:10PM PLT COUNT-189
[**2197-3-5**] 01:10PM PT-14.3* PTT-27.9 INR(PT)-1.2*
[**2197-3-16**] 06:18AM BLOOD WBC-11.0 RBC-2.96* Hgb-9.1* Hct-26.6*
MCV-90 MCH-30.8 MCHC-34.3 RDW-14.9 Plt Ct-111*
[**2197-3-16**] 06:18AM BLOOD Plt Ct-111*
[**2197-3-16**] 06:18AM BLOOD PT-18.2* PTT-39.8* INR(PT)-1.7*
[**2197-3-16**] 06:18AM BLOOD Glucose-107* UreaN-18 Creat-0.9 Na-136
K-3.9 Cl-106 HCO3-22 AnGap-12
[**2197-3-14**] 02:13AM BLOOD ALT-25 AST-43* AlkPhos-292* Amylase-70
TotBili-1.2
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2197-3-16**] 7:45 AM
CHEST (PORTABLE AP)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
72 year old man s/p AVR/MVR, CABGx4
REASON FOR THIS EXAMINATION:
eval for pleural effusions
INDICATION: Followup.
COMPARISON: [**2197-3-14**].
FINDINGS: In the interval, the PICC line has obviously been
retrieved by several centimeters. Unchanged cardiomegaly with
retrocardiac atelectasis. Unchanged right-sided pleural
effusion. No newly appeared parenchymal opacity.
IMPRESSION: Retrieval of the PICC line. Otherwise, no relevant
radiographic changes.
RADIOLOGY Final Report
GB DRAINAGE,INTRO PERC TRANHEP BIL US [**2197-3-12**] 8:08 PM
GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL DRAINA
Reason: POSETIVE HIDA SCAN
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY
INDICATION: Cholecystitis. Positive HIDA scan.
OPERATORS
Dr. [**Last Name (STitle) 10269**] and Dr. [**Last Name (STitle) 1968**] who was present and available
throughout the procedure.
TECHNIQUE
Written informed consent was obtained prior to commencing the
procedure. A pre-procedure timeout was performed confirming
patient identity and procedure to be performed.
The skin was prepped with Betadine. 1% lidocaine was used to
anesthetize the skin and subcutaneous tissue. Via a right
anterior subcostal approach, an 8.5- French pigtail drainage
catheter was inserted into the gallbladder through a segment of
liver. This was performed with ultrasound guidance. There was
immediate return of bile from the tube. The pigtail was formed
within the lumen of the bladder. Approximately 100 cc of bile
was aspirated from the catheter. Fluid was sent for microbiology
for analysis. The catheter was secured to the skin.
The procedure was well tolerated. There were no immediate
complications. Post-procedure orders were entered on the POE
system.
IMPRESSION: Percutaneous cholecystostomy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78153**]Portable TTE
(Complete) Done [**2197-3-11**] at 2:00:59 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2124-6-12**]
Age (years): 72 M Hgt (in): 65
BP (mm Hg): 160/90 Wgt (lb): 136
HR (bpm): 76 BSA (m2): 1.68 m2
Indication: Post op AVR/MV repair. Hypotensive. Left ventricular
function.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2197-3-11**] at 14:00 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W002-0:41 Machine: Vivid [**7-31**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Mitral Valve - Peak Velocity: 2.1 m/sec
Mitral Valve - Mean Gradient: 6 mm Hg
Mitral Valve - Pressure Half Time: 80 ms
TR Gradient (+ RA = PASP): *29 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
descending aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). No
AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated, with normal leaflet/disc motion and transvalvular
gradients. No MR. [Due to acoustic shadowing, the severity of MR
may be significantly UNDERestimated.]
TRICUSPID VALVE: Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - ventilator. The rhythm appears to be
atrial fibrillation. Right pleural effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with severe hypokinesis of the
basal inferior and inferolateral walls, post-op septal motion,
and mild hypokinesis of the remaining segments (LVEF = 35 %).
Right ventricular chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated. A bioprosthetic
aortic valve prosthesis is present. It appears well seated with
good leaflet mobility. A gradient could not be assessed. No
aortic regurgitation is identified. A bioprosthetic mitral valve
prosthesis is present. The mitral prosthesis appears well
seated, with normal leaflet motion and transvalvular gradients.
No mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Well seated aortic and mitral bioprostheses with
normal transmitral gradien and aortic leaflet excursion.
Regional left ventricular systolic dysfunction c/w CAD. Mild
pulmonary artery systolic hypertension.
CLINICAL IMPLICATIONS:
Based on [**2196**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2197-3-11**] 14:21
Brief Hospital Course:
He was admitted preoperatively for IV heparin as his coumadin.
Carotid duplex showed right 60-69% stenosis, and occluded right
veterbral, left less than 40% stenosis and distal left veterbral
occlusion. On [**3-7**] he underwent an AVR/MVR and CABG x 4. He was
transferred to the ICU in critical but stable condition on
milrinone, levophed, propofol and insulin. He was given 48 hours
of vanocmycin as he was in the hospital preoperatively. He was
extubated on POD #1. His vasoactive drips were weaned to off on
POD #2. He had RUQ tenderness and was found Cholelithiasis
without acute cholecystitis on ultrasound. He was transferred to
the floor. He was found unresponsive and hypotensive in the
chair, but awoke with fluid resuscitation. He was transferred
back to the ICU. His abdominal pain worsened and gall bladder
scan showed acute cholecystitis. He was seen by general
surgery. He received a percutaneous cholecystostomy tube on [**3-12**]
with improvement of symtoms. He was placed on sipro and flagyl.
He was started on heparin gtt for rate controlled atrial
fibrillation. He was transferred back to the floor on POD7. He
developed and IV infiltrate/ phlebitis of his right forearm
which was treated w/Vancomycin and heat packs with improvement
the following day.
On POD 9 it was decided he was stable and ready for discharge to
rehabilitation at West View Health Care Center in [**Location (un) 50909**], RI.
Medications on Admission:
Lasix 40', Aspirin EC 81', Atorvastatin 10', Captopril 25'''
Carvedilol 40', Digoxin 0.125', Spironolactone 25'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. 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:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) bag of 500 mg/100ml Intravenous Q8H (every 8 hours):
until [**2197-3-26**].
Disp:*90 bag of 500 mg/100ml* Refills:*0*
7. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) 400 mg/40 ml
bag Intravenous Q12H (every 12 hours): until [**2197-3-26**].
Disp:*60 400 mg/40 ml bag* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
10. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
target inr 2-2.5.
11. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once for 1 days:
[**3-16**] dose.
12. Neomycin-BacitracnZn-Polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical QID (4 times a day).
13. Urea 20 % Cream Sig: One (1) Topical [**Hospital1 **] (2 times a day).
14. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1 gm
Intravenous Q 12H (Every 12 Hours) for 4 doses.
18. heparin Sig: 5000 (5000) units Subcutaneous three times a
day.
Discharge Disposition:
Extended Care
Facility:
west view care center
Discharge Diagnosis:
s/p AVR/MVR/CABG post-op acute cholecystitis s/p percutaneous
cholecystostomy tube
PMH: AS, MR, CAD, HTN, ^chol, PVD, OA B/L shoulder, Bursitis L
shoulder, CHF, Afib
PSH: s/p R THR, Renal lithotripsy, tonsillectomy
Discharge Condition:
Stable
Discharge Instructions:
Calll with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 4541**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks-please call for appt([**Telephone/Fax (1) 1504**])
Dr. [**First Name (STitle) **] 2 weeks please call for appt
Dr. [**Last Name (STitle) 816**]([**Telephone/Fax (1) 673**]) in 2 weeks
Completed by:[**2197-3-16**]
ICD9 Codes: 2875, 2859, 4019, 2720, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4846
} | Medical Text: Admission Date: [**2124-10-8**] Discharge Date: [**2124-10-30**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right frontal hemorrhage
Major Surgical or Invasive Procedure:
G T placement
History of Present Illness:
HPI: 82 year old RHM with past history of hypertension and R
frontal ischaemic CVA in [**Month (only) 205**] of this year associated with
seizure. Today presented to OSH with confusion. History from
patient limited. Notes indicate was found on the street trying
to
get into a car and appeared confused. Mr [**Known lastname 68933**] says he fell
but could not give any other details regarding the events of the
day. At [**Hospital3 4107**] sugar was alert and oreinted x1. Blood
pressure was 137/64 and sugar 159. NCHCT showed R frontal
hemorrhage. Patient was loaded with fos-phenytoin (1500mg) and
transferred to [**Hospital1 18**].
Presented in [**Month (only) 205**] of this year to [**Hospital1 **] with speech
difficulties
and GTC seizure in the ED. CT initially negative. MRI showed R
frontal ischaemic CVA. He had apparently been on aspirin 81mg
daily at that time. According to discharge summary, other
investigations at that time included carotid ultrasound negative
for significant carotid stenosis, TEE showing atrial septal
aneurysm without clot and negative bubble study. Lipids showed
Chol 170 Triglyc 70, HDL 34 LDL 122 and he was commenced on a
statin. He was then commenced also on aggrenox. EEg in [**Month (only) 205**]
showed R hemispoheric slowing and R sided sharp activity.
Dr [**First Name (STitle) 2808**] spoke with patient's brother who knew little of
medical
details but was unaware of any further seizures.
Past Medical History:
HTN
Sinus Bradycardia (50s [**2124-6-17**])
CVA presenting with seizure in [**2124-6-17**]
Social History:
Discharged home in [**Month (only) 205**] to previous accomodation. Wife
deceased. Lives alone. Limited contact with brother. [**Name (NI) **] with
congenital MR lives in supported facility in [**Location (un) 38**]. Has
supportive friends. Retired mail carrier. Apparently returned
to pre stroke function driving independently and working
voluntarily in rehab centre and grocer located in his building.
Non smoker. Unsure of EtOH/drug history.
Family History:
Unknown
Physical Exam:
T-97.8 BP-133/55 HR-54 RR-16 O2Sat97% RA
Gen: Lying in bed, eyes closed
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: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: GCS 13 eyes closed, open to voice, confused,
cooperative with exam intermittently. Irritable and
occassionally
making derogatory remarks to examiner. Inappropriate laughter
at
times and would say "you are aggravated" following failure to
cooperate with aspects of exam. Oriented to person, place, not
time. Refusing tests of attention. Speech is fluent
repetition
and naming intact. No dysarthria. No right left confusion
indicating body parts L/R (was confused for ED attending).
Requesting I call friend [**Name (NI) 2127**]. [**Name2 (NI) **] number correctly. Also
phoned another friend with success who reported he was clarly
confused.
Cranial Nerves:
Pupils equally round and reactive to light, 2 to 1.5 mm
bilaterally. Extraocular movements intact bilaterally, no
nystagmus. Fundi and fields difficult. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid normal bilaterally.
Tongue midline, movements intact.
Motor:
Normal bulk bilaterally. Tone mildly increased x4 limbs. L>R
large amplitude resting tremor.
No pronator drift
Antigravity movements x4 limbs with some resistance
throughout.
Symmetric power.
Sensation: Withdraws to noxious stimuli x4 limbs.
Reflexes:
+2 UE T/B/Br; 1+ K bilat, ankles 0 bilat.
Toes downgoing R up L
Coordination: reaching to my finger grossly normal bilat
Gait: Not tested
Romberg: Not tested
Pertinent Results:
WC 6.3 Hg 13.8 Plt 145. PT 13.5 PTT 31.6 INR 1.2
Na 138 K 4.0 CL 105 CO2 25 BUN 20 Cr 1.0 Gluc 99
CK 152 CKMB and Trop negative
[**2124-10-10**] 07:20AM BLOOD TSH-5.0*
[**2124-10-10**] 07:20AM BLOOD VitB12-908*
[**2124-10-10**] 07:20AM BLOOD ALT-20 AST-28 AlkPhos-87 Amylase-87
TotBili-0.9
[**2124-10-8**] 03:40PM BLOOD CK(CPK)-152
[**2124-10-10**] 07:20AM BLOOD Lipase-28
Imaging
CT from OSH shows R frontal hemorrhage extending from white
matter into [**Doctor Last Name 352**] matter measuring 3.6 x 2.7 cm and approximate
40cc volume.
CT at [**Hospital1 18**] on [**10-8**] confirmed these findings, and a CT Scan on
[**10-12**] showed no progression of bleed
EEG - suggests cortical and subcortical dysfunction of the
right frontal region, with a corresponding cortical
irritability. Shows bilateral frontal slowing and a slow
(8Hz)and disorganized background suggests an encephalopathy.
CT torso with IV contrast - 1.5 cm mass in the right kidney
which contains an enchancing soft tissue component and dense
focal calicification, which was reported to be unlikey to be a
primary malignancy for a metastatic brain lesion, it could also
not be ruled out.
Abdomen and Pelvic MRI: 1. The non-enhancing right renal mass
likely represents a cyst, an area of old scarring or infarct. 2.
No enhancement, on early phases, is evident. However,
definitive characterization of this tiny left renal lesion
cannot be made on this
examination, as the later phases were motion corrupted. The
small size is
quite unlikely to be the source of metastatic disease.
Brief Hospital Course:
Patient was intially admitted to the ICU for close monitoring
because of actue intracerebral hemorrhage right frontal lobe,
demonstrated by CT. ASA and aggrenox were held and pt was loaded
on dilantin. After patient was stablized he was transferred to
the floor. Initially,he was intermittnetly confused and
irritable, but did cooperate was alert to person and place.
Physical Exam demonstrated mild left sided weakness, bilteral
resting tremor, increased tone in upper extremities and
cogwheeling.
1) Neuro:
Patient continued to be disoriented while on the floor, his
level of conciousness would wax and wane througout the day, he
was found attempting to get out of bed, and at times became
aggressive twords the nurses, appearing paraniod ("you're trying
to trick me") and required physical restraints for safety. A
delerium workup was conducted was negative (no infection source,
lytes, LFTS, ammonium normal with Vit B12 and TSH mildly outside
of normal range, CXR normal). And EEG was done, which
demonstrated multiple abnormalities, as well as generally slow
and disorganized background consistant of encephalopathy. A
concern was that patients agitation may be secondary to an
underlining depression and Celexa 10 mg was started on [**2124-10-12**]
and increased to 20 mg Over time, he because more interactive
and verbal. There were concerns that there may be some
vasogenic edema associated with the bleed; therefore, Decadron
was started with further improvment in mental status. Started
weaning decadron on [**2124-10-25**]. Eventually the dex should be
weaned to OFF.
Dilantin was loaded for seizure prophylaxis. There were no
clinical seizures during this admission; therefore, Dilantin
wean has been initiated.
A CT of torso was obtained to look for metastatic cancer as a
possible etiology for her hemorrhage. A 1.5 center mass in
kidney was found which contained enchanced tissue and
calcifications, and while was unlikley to represent a primary CA
site, they could also not rule that out. A MRI of the torso was
done, which was not concerning for any metastatic cancer.
HOWEVER, and PRIMARY cerebral tumor has not yet been ruled out
given blood obscures the area we are interested on MRI. Thus he
has been set up to get an MRI of the brain in 6 weeks ([**2124-11-17**])
to establish the presence or absence of an underlying mass.
The patient had Parkinsonian symptoms on admission with resting
tremor and rigidity. Sinemet has been started with titration of
the dose based on improved of the rigidity. He has improved
since admission. He remains on 25/250mg tabs, 4 tabs a day.
2) CV: Patient had episode of atrial flutter on [**2124-10-11**], which
resolved on its own. He had another episode on [**10-24**] with
nonsustained vtach. Cardiology was consulted and felt that the
rhythm was NOT aflutter but rather artifact due to his tremor.
They felt that no intervention was necessary for the vtach but
did recommend an echo for his heart murmur. An echo was done on
[**2124-10-24**] which showed Overall normal EF with mild AR and
physiologic mitral regurgitation.
3) GI: He has been evaluatd by speech who felt that with his
confusion and somnolence, he was at risk for an aspiration
event. A NG tube was initially placed for nutritional support.
On [**2124-10-26**], a G tube was placed for permanent feeding tube
access.
3) Psychosocial: Paperwork was filled out for brother-in-law to
be his guardian. His brother-in-law, [**Name (NI) 1399**] [**Name (NI) 68934**], became his
temporary guardian. Paperwork has been attached.
Medications on Admission:
Aspirin 81mg po qd
Aggrenox 1 tab po bid
Atenolol 25 mg po qd
Lovastatin 40mg po qd
Valsartan (diovan) 160mg po qd
Hydrochlorothiazide 12.5mg po qd
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: One (1)
Injection TID (3 times a day).
2. Therapeutic Multivitamin Liquid [**Name (NI) **]: One (1) Cap PO DAILY
(Daily): via GJ tube.
3. Folic Acid 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily):
via GJ tube.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] daily ().
5. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day) as needed: via GJ tube.
6. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY
(Daily): via GJ tube.
7. Valsartan 160 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily):
via GJ tube.
8. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): via GJ tube.
9. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: [**12-20**] PO Q4-6H (every
4 to 6 hours) as needed: via GJ tube, max 4 grams per day.
10. Citalopram 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily): via GJ tube.
11. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily): via GJ tube.
12. Carbidopa-Levodopa 25-250 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO
QID (4 times a day): via GJ tube.
13. Atenolol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily):
via GJ tube.
14. Dilantin taper
Current dose: Phenytoin 100mg/100mg/200mg.
Taper as follows: 100mg TID x 3 days, 100mg [**Hospital1 **] x 3 days, 100mg
daily x 3 days, then off.
15. Dexamethasone taper
6 mg PO QD x 2 days, then 5mg PO QD x 2 days, then 4 mg PO QD x
2 days, then 3mg PO QD x 2 days, then 2mg PO QD x 2 days, then
1mg PO QD x 2 days, then discontinue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right frontal lobe hemorrhage - unclear etiology, mass has not
yet been ruled out completely
Hypertension
history of prior ischemic stroke in right frontal lobe.
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications and follup with your
physicians.
Please remove T fasteners (near the GJ tube) on [**11-3**].
Followup Instructions:
Follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP, [**Telephone/Fax (1) 7164**]) after discharge from
the hospital. [**11-27**] at 3pm. [**Street Address(2) **], [**Hospital1 392**], MA.
Fax: [**Telephone/Fax (1) 63453**].
Follow up with Stroke, [**Name6 (MD) **] [**Name8 (MD) **], M.D., on [**2123-12-27**] on
3:30pm. The clinic's phone number is [**Telephone/Fax (1) **]. It is
located in the [**Hospital Ward Name 23**] Building on the [**Location (un) **].
You need to follow up with a Head MRI/A, scheduled for Tuesday,
[**2124-12-12**] at 5:45pm [**Telephone/Fax (1) 327**]. THIS MRI IS TO
RULE OUT TUMOR, PLEASE ATTEND THIS EXAM AND FOLLOWUP WITH DR.
[**Last Name (STitle) **].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 2761, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4847
} | Medical Text: Admission Date: [**2137-2-26**] Discharge Date: [**2137-3-9**]
Date of Birth: [**2101-5-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
relatively asymptomatic
Major Surgical or Invasive Procedure:
[**2137-2-26**] Bentall Procedure utilizing [**Street Address(2) 64443**]. [**Male First Name (un) 923**]
mechanical aortic valve and 34 millimeter Ascending Aortic Tube
Graft.
History of Present Illness:
35 yo male with connective tissue disorder, most likely Marfan
syndrome. Found to have bicuspid AV and dilated aorta. Referred
for aortic root replacement by Dr. [**Last Name (STitle) 1290**].
Past Medical History:
MVP
myopia
scoliosis
incomplete RBBB
s/p appy [**2111**]
Social History:
lives with wife and 2 year old daughter
patent attorney
never used tobacco
social ETOH
Family History:
positive for sudden cardiac death of great uncle (30's) and
cousin ( 40's)
Physical Exam:
6'4" 170 #
HR 60 RR 18 right 111/70 left 107/59
tall, thin in NAD
skin,HEENt unremarkable
neck supple with full ROM, no bruits
CTAB
RRR with holosystolic murmur at left sternal border
extrems warm and well-perfused, no edema or varicosities
neurop grossly intct
2+ bil. fem, 1+ bil. DP/PT pulses
Pertinent Results:
[**2137-3-9**] 04:50AM BLOOD PT-20.9* INR(PT)-2.0*
[**2137-3-9**] 04:50AM BLOOD Plt Ct-535*
[**2137-3-7**] 05:40AM BLOOD Glucose-97 UreaN-14 Creat-0.9 Na-134
K-5.2* Cl-99 HCO3-25 AnGap-15
[**2137-3-9**] 04:50AM BLOOD UreaN-13 Creat-1.0 K-4.5
Brief Hospital Course:
Admitted on [**2-26**] and underwent Bentall procedure with Dr.
[**Last Name (STitle) 1290**] ( St. [**Male First Name (un) 923**] 31mm mech. valve/ graft composite
34mm).Transferred to the CSRU in stable condition on amicar and
propofol drips. Vent wean on POD #1 on insulin, nitroglycerin
and propofol drips. Swan removed on POD #2 and lasix /lopressor
started. Transferred to the floor on POD #3. Chest tubes
removed.Had an episode of hypoxia the next night with confusion.
Neuro exam nonfocal. This cleared and he began to work on
increasing his activity level. Pacing wires removed without
incident. Heparin drip continued until INR therapeutic.
Lopressor changed to his home dose of betaxolol, and this was
titrated up. He experienced some confusion periodically at night
, but was able to reorient himself. When INR was 2.0 on POD #9,
heparin was stopped. Thoracentesis performed for left pleural
effusion on POD #10 and repeat CXR cleared him for discharge to
home on POD #11.
Medications on Admission:
betaxolol 20 mg daily ( pt. unsure of dose)
occuvite daily
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Check INR [**3-11**] with results called to Dr. [**Last Name (STitle) **]. Goal INR
2.0-3.0
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Betaxolol 10 mg Tablet Sig: Three (3) Tablet PO QD ().
Disp:*90 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Connective Tissue Disorder - most likely Marfan Syndrome,
Biscuspid aortic valve and ascending aortic aneurysm - s/p
Bentall procedure, Postop Pleural Effusion - s/p thoracentesis,
mitral valve prolapse, myopia, scoliosis, incomplete RBBB, s/p
appendectomy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**4-10**] weeks, please call office for appt.
Dr. [**Location (un) 57220**] on [**2137-3-11**] @ 10 AM for followup appt and
PT/INR check.
Dr. [**First Name (STitle) **] in [**2-8**] weeks, please call office for appt
Completed by:[**2137-3-29**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4848
} | Medical Text: Admission Date: [**2201-3-19**] Discharge Date: [**2201-3-24**]
Date of Birth: [**2121-8-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
fever and blood from rectum
Major Surgical or Invasive Procedure:
None
See discharge summary from [**3-17**] for previous admission
procedures.
History of Present Illness:
79M with a complicated 6 week course involving ischemic colitis
following AAA repair. Procedures from previous admission were
the following: open pararenal AAA, takeback for retroperitoneal
bleeding, L colectomy for ischemia, extended L colectomy, end
transverse colostomy, s/p attempted abd closure, fascial
closure, and bedside perc trach.
He was discharged on [**3-17**] to vent rehab to complete another 10
day course of Zosyn for MSSA & Klebsiella PNA.
He was transferred back to the [**Hospital1 18**] ED from rehab on [**3-19**] for
BRBPR and fever
to 101.4.
Past Medical History:
1. CAD s/p MI (EF 40%), CABG [**4-/2184**], multiple PCI's/stent to
circ/RCA
2. Hyperlipidemia
3. HTN
4. Cervical myelopathy
5. s/p cervical fusion
6. GERD
7. Schatzki's ring
8. Mohs surgery
9. s/p open pararenal AAA [**2201-2-2**] ([**Doctor Last Name **])
10. s/p takeback for retroperitoneal bleeding [**2201-2-2**] ([**Doctor Last Name **])
11. s/p L colectomy [**2201-2-3**] ([**Doctor Last Name **])
12. s/p completion sigmoid colectomy, proctectomy, transverse
colectomy [**2201-2-4**] ([**Doctor Last Name **])
13. s/p end transverse colostomy [**2201-2-6**] ([**Doctor Last Name **])
14. s/p fascial closure [**2201-2-10**] ([**Doctor Last Name **])
15. s/p bedside perc trach [**2201-2-17**] ([**Doctor Last Name **])
Social History:
Married with three children and worked as a lawyer, rare alcohol
Family History:
NC
Physical Exam:
Admission PE
VS - T103.0 88 98/47 16 100%VM
NAD, lying on stretcher. pt interactive.
No jaundice or icterus
ronchi bilaterally right > left
RRR
Abd soft, NT, ND. abdominal wound dressing intact, not removed.
ostomy pink and healthy. bag with air and liquid green stool.
Rectal: small amount of bloody mucous
No LE edema.
R AC PICC line in place
pulses fem [**Doctor Last Name **] AT pt
r 2+ 2+ d 2+
l 2+ 2+ d 2+
Pertinent Results:
On arrival to ED he was also noted to have a respiratory
acidosis
(pH 7.23 pCO2 58) and placed back on the ventilator.
[**2201-3-19**] WBC-14.4 Hct-23.2*
[**2201-3-20**] WBC-10.7 Hct-30.1*
[**2201-3-21**] WBC-9.2 Hct-31.4*
[**2201-3-22**] WBC-10.1 Hct-29.8*
[**2201-3-23**] WBC-9.4 Hct-28.5*
[**2201-3-24**] WBC-8.9 Hct-27.6*
[**2201-3-19**] UreaN-53* Creat-2.9* Na-148* K-4.5 Cl-116* HCO3-22
AnGap-15
[**2201-3-20**] UreaN-50* Creat-2.5* Na-146* K-4.7 Cl-117* HCO3-21*
AnGap-13
[**2201-3-23**] UreaN-43* Creat-2.3* Na-147* K-5.5* Cl-116* HCO3-22
AnGap-15
[**2201-3-24**] UreaN-45* Creat-2.2* Na-146* K-5.2* Cl-115* HCO3-21*
AnGap-15
[**2201-3-19**] 10:49AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2201-3-19**] 10:49AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2201-3-18**] 9:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
[**Female First Name (un) **] PARAPSILOSIS.
[**2201-3-19**] 10:49 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2201-3-19**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2201-3-21**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Brief Hospital Course:
The blood from rectum was most likely retained blood from his
Hartmann's Pouch. No scope was performed and the bleeding did
not recur.
In the ER, he was febrile to 103 and requiring
ventilation. He was hypotensive to the high 80s but did not
require pressors. He was transfused two PRBC for a hct of 23.
He was treated in the ER with vancomycin, levofloxacin and
flagyl, but was started on empiric therapy with
vancomycin and Zosyn in the SICU. His fever was initially
thought to be due to
partial lobar collapse discovered on a [**3-20**] CT torso. There was
no evidence of abscess in the abdomen or pelvis. Postoperative
changes from AAA repair were seen.
However a blood culture from [**3-18**] grew yeast. Following his
fevers in the ER he became hypothermic consistent with a
fungemia. An ID consult was obtained. He was started on
mycofungin and the vanco/zosyn was stopped. He became
normothermic and his white count decreased from 14 to 9. An
echo on [**3-23**] showed no vegetations and an EF of 40-45%.
Opthalmology was consulted to rule out fungal endophthalmitis.
They recommended tobramycin for 5 days.
His mental status was alert, oriented, and cooperative with
occasional episodes of confusion. He would become more
lethargic in the evenings. He was rested on the ventilator
overnight and placed to trach collar during the day. He had a
tracheostomy change on the 14th and passy muir valve was
employed successfully.
His foley catheter was removed [**3-20**]. He pulled out his picc
line on [**3-21**] which was to be removed anyway because of infection
risk.
He was advanced to a regular diet, eating full meals and taking
in over a liter of fluid and supplements by HD 3. He became
hypernatremic to 150, but this resolved with IV free water.
His abdominal wound was intially treated with wet to dry
dressings and then with a vac. His sacral pressure ulcer was
treated by the wound nurse and frequent positioning changes.
He was seen by PT and he was able to get OOB to a chair.
Prior to discharge his fungal coverage was changed from
mycofungin to fluconazole. A picc line was placed by IR for
access.
Medications on Admission:
[**Last Name (un) 1724**]:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]
2. Albuterol Sulfate 90 mcg 4 Puff Inhalation Q4H prn
3. Heparin 5,000 unit/mL TID
4. Ursodiol 300 mg PO BID
5. Hydromorphone 2-4 mg PO Q4H prn
6. Camphor-Menthol 0.5-0.5 % Lotion QID prn
7. Bisacodyl 10 mg Rectal HS prn.
8. Aspirin 81 mg DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Acetaminophen 325 mg PO Q6H prn
11. Pantoprazole 40 mg PO Q24H
12. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment
13. Erythromycin 5 mg/g QHS
14. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25g
Recon Solns Intravenous Q6H (every 6 hours) for 10 days.
15. Heparin as needed for line flush.
16. Metoclopramide 5 mg/mL Q6H prn.
Discharge Medications:
Fluconazole 200 mg IV Q24H to finish [**4-2**]
Tobramycin 0.3% Ophth Soln 1 DROP LEFT EYE TID to finish [**3-26**]
Insulin SC Sliding Scale 03/14 @ 0936 View
Acetaminophen 325-650 mg PO Q6H:PRN [**3-21**] @ 0929 View
Metoclopramide 5 mg PO QIDACHS [**3-19**] @ 0045 View
Pantoprazole 40 mg PO Q24H [**3-19**] @ 0045 View
Metoprolol Tartrate 12.5 mg PO BID [**3-19**] @ 0045 View
Aspirin 81 mg PO DAILY [**3-19**] @ 0045 View
Ursodiol 300 mg PO BID [**3-19**] @ 0045 View
Heparin 5000 UNIT SC TID [**3-19**] @ 0045 View
Albuterol Inhaler 4 PUFF IH Q4H:PRN [**3-19**] @ 0045 View
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab
Discharge Diagnosis:
Fungemia
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
Draw creatinine, LFTs in one week to assess for elevation from
Fluconazole.
It is normal to feel weak and tired, this will last for [**6-15**]
weeks
Increase activities as pt can tolerate- do not do too much right
away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-10**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks.
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Keep ostomy bag on. Change as needed. Monitor ostomy output.
If ostomy output decreases significantly or pt is unable to
tolerate po intake then call office.
Followup Instructions:
Please call Dr.[**Name (NI) 1720**] Office for follow up appt. at ([**Telephone/Fax (1) 19173**].
Call Dr.[**Name (NI) 1482**] Office for follow up appt at ([**Telephone/Fax (1) 8818**].
Completed by:[**2201-3-24**]
ICD9 Codes: 2762, 2760, 5849, 5789, 412, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4849
} | Medical Text: Admission Date: [**2128-2-17**] Discharge Date: [**2128-3-2**]
Date of Birth: [**2046-3-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
[**2128-2-19**] cardiac catheterization
[**2128-2-23**] Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna
Ease aortic valve bioprosthesis, serial number [**Serial Number 31772**], model
number 3300TFX. Coronary bypass grafting times 1 with a reverse
saphenous vein graft from aorta to the distal right coronary
artery.
History of Present Illness:
81 year old female who was recently admitted [**Date range (2) 31773**]
after she presented with chest pain and developed new onset
atrial fibrillation. She was started on amiodarone but declined
cardioversion, and spontaneously converted back into sinus
rhythm prior to discharge. TEE that admission showed severe
aortic stenosis, with valve area 0.8-1cm. On [**2128-2-9**], her son
called the cardiology office to report that his mother had an
episode of atrial fibrillation with rates up to 110-120. She had
taken atenololas directed and converted back to sinus later
that day. She presented to the ED [**2128-2-13**] with epistaxsis; her
INR was 6.7 and she was disharged home with coumadin on hold and
returned for cardiac catherization for preoperative evaluation.
Past Medical History:
Aortic Stenosis
Atrial fibrillation
Rheumatoid arthritis
Hypertension
Hypercholesterolemia
PMR
History of DVT
COPD
Hyperthyroidism
Osteopenia
Large ventral hernia
Hearing loss
C-Section x 3
Ventral hernia repair x 2
Social History:
Lives with: Husband
Occupation: Retired
Tobacco:+Tobacco abuse - 1 pack per day since [**2062**]
ETOH: no history of drug or alcohol abuse
Family History:
Mother died of a ruptured AAA at age 70. Father died of
leukemia. No family history of premature coronary artery
disease, unexplained heart failure, or sudden death.
Physical Exam:
Pulse: AF 98 Resp: 20 O2 sat: 96%
B/P Right: 122/72 Left: 141/71
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]. +Large ventral hernia, non-reducible hernia, non-tender.
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
B/L
LE varicosities. None []
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: soft bruit Left: soft bruit
Pertinent Results:
[**2128-3-2**] 04:36AM BLOOD WBC-10.2 RBC-3.29* Hgb-9.9* Hct-30.1*
MCV-92 MCH-30.2 MCHC-33.0 RDW-16.0* Plt Ct-215
[**2128-2-17**] 09:19PM BLOOD WBC-14.5* RBC-3.59* Hgb-10.8* Hct-31.6*
MCV-88 MCH-30.0 MCHC-34.1 RDW-12.8 Plt Ct-564*
[**2128-2-17**] 09:19PM BLOOD Neuts-78.4* Lymphs-13.7* Monos-7.1
Eos-0.5 Baso-0.4
[**2128-3-2**] 04:36AM BLOOD Plt Ct-215
[**2128-3-2**] 04:36AM BLOOD PT-20.0* PTT-29.7 INR(PT)-1.8*
[**2128-2-17**] 09:19PM BLOOD PT-20.2* PTT-39.3* INR(PT)-1.9*
[**2128-2-16**] 09:50AM BLOOD PT-27.3* INR(PT)-2.7*
[**2128-2-23**] 04:52PM BLOOD Fibrino-215
[**2128-3-2**] 04:36AM BLOOD Glucose-114* UreaN-35* Creat-1.3* Na-138
K-3.5 Cl-96 HCO3-37* AnGap-9
[**2128-3-1**] 06:13AM BLOOD Glucose-91 UreaN-38* Creat-1.4* Na-139
K-3.5 Cl-95* HCO3-36* AnGap-12
[**2128-2-27**] 02:02AM BLOOD Glucose-78 UreaN-31* Creat-1.9* Na-136
K-3.5 Cl-96 HCO3-28 AnGap-16
[**2128-2-16**] 09:50AM BLOOD UreaN-25* Creat-1.3* Na-135 K-4.8 Cl-97
HCO3-25 AnGap-18
[**2128-3-1**] 06:13AM BLOOD ALT-10 AST-31 LD(LDH)-316* AlkPhos-69
Amylase-33 TotBili-1.1
[**2128-2-19**] 07:35AM BLOOD ALT-32 AST-25 LD(LDH)-264* AlkPhos-93
Amylase-31 TotBili-0.6
[**2128-2-28**] 06:00AM BLOOD ALT-13 AST-40 AlkPhos-87 Amylase-33
TotBili-1.7*
[**2128-3-2**] 04:36AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8
[**2128-2-17**] 09:19PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.0
ABDOMINAL ULTRASOUND:
Liver parenchyma is homogeneous with no focal hepatic lesions.
Portal vein is
patent with normal hepatopetal flow. There is no biliary ductal
dilatation
with the common duct measuring 3 mm. Multiple echogenic
gallstones are again
noted within the gallbladder lumen, which does not display any
significant
distension. In addition, there is moderate amount of layering
echogenic
sludge. Mild persistent wall thickening in the region of the
fundus measuring
slightly greater than 4 mm is little changed from [**2124**] exam and
may represent
underlying adenomyomatosis. No significant edema or
pericholecystic fluid is
noted on today's exam. Trace amount of ascites as well as small
right pleural
effusion noted. Left kidney measures 10.2 cm and right kidney
measures 10.8
cm with no hydronephrosis or stones noted. The echogenic focus
noted in the
right kidney on the prior ultrasound is not appreciated on
today's
examination; the kidneys appear mildly echogenic which could
partly be related
to technique. Moderate amount of atherosclerotic disease is
again noted
within the aorta, which remains non-aneurysmal.
IMPRESSION:
1. Persistent cholelithiasis with moderate amount of biliary
sludge. Mild
wall thickening within the fundus persists which likely reflects
fundal
adenomyomatosis. No secondary findings of acute cholecystitis on
today's
examination or biliary ductal dilatation.
2. Aortic atherosclerotic disease.
HISTORY: 81-year-old female status post CABG and aortic valve
replacement,
postop day number 7. Patient status post chest tube removal.
COMPARISON: Portable chest radiograph from [**2128-2-27**].
PA AND LATERAL CHEST RADIOGRAPHS: A right central venous
catheter tip
projects over the expected location of the upper SVC. The right
and left
pigtail pleural drains have been removed. There is no
pneumothorax. The
pulmonary edema has significantly decreased compared to prior
with minimal
vascular engorgement and small residual pleural effusions, right
greater than
left. The cardiomediastinal contours are enlarged but unchanged.
Median
sternotomy wires are intact.
IMPRESSION:
1. Interval removal of the bilateral chest tubes. No
pneumothorax.
2. Right central venous catheter, tip at upper SVC.
3. Decreased pulmonary edema now minimal.
4. Small residual pleural effusions, right greater than left.
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *72 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 40 mm Hg
Aortic Valve - LVOT VTI: 18
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Simple atheroma in descending aorta. No
thoracic aortic dissection.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Bioprosthetic aortic
valve prosthesis (AVR). AVR leaflets move normally. Critical AS
(area <0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. TVP. Moderate
[2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial flutter. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-CPB:
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.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. Critical aortic stenosis is
seen, estimated [**Location (un) 109**]=0.5cm2. Moderate (2+) aortic regurgitation
is seen.
The mitral valve leaflets are mildly thickened. There is
systolic doming of the anterior mitral leaflet. Mild (1+) mitral
regurgitation is seen.
The tricuspid valve leaflets appear slightly redundant. There is
prolapse of the tricuspid valve. The annulus is mildly dilated.
Moderate tricuspid regurgitation is seen.
POST-CPB:
There is a bioprosthetic valve in the aortic position. The valve
is well-seated, the leaflets are normally mobile. The peak
gradient across the aortic valve is 30mmHg, the mean gradient is
11mmHg with CO of 3.5. A small paravalvular leak in the area
adjacent to the interatrial septum was initially seen but this
is no longer observed after completion of protamine. There is no
aortic insufficiency.
The LV systolic function remains normal; the chamber size is
small, consistent with relative hypovolemia. The RV systolic
function appears normal.
The TR remains moderate.
There is no evidence of aortic dissection.
Brief Hospital Course:
Presented with chest pain, and underwent evaluation which
including ruling out for myocardial infarction. After INR
decreased, she underwent cardiac catheterization, see report for
further details. She completed preoperatve workup and underwent
aortic valve replacement and coronary artery bypass graft
surgery on [**2128-2-23**]. See operative report for further details.
Post operatively she was transferred to the intensive care unit
for post operative management on milirone for heart failure but
was weaned off in 48 hours. Within the first twenty four hours
she was weaned from sedation, awoke neurologically intact, and
extubated without complications. However she developed
respiratory distress not responsive to bipap and was reintubated
on [**2-25**]. Additionally she had episodes of rapid atrial
fibrillation treated with betablockers and amiodarone. She also
had bilateral chest tubes placed on [**2-25**] due to respiratory
distress and bilateral effusions. She was improving however and
was extubated [**2-26**], but creatinine increased to 1.9 peak [**2-27**] -
acute kidney injury, and has trended down with creatinine 1.3 on
discharge, which ace inhibitor was not initiated and should be
considered as an outpatient. Physical therapy worked with her
on strength and mobility. She continued to make progress
however had nausea with vomiting, and not tolerating oral
intake. Surgery was consulted for evaluation due to known hernia
and there was no acute processes and lever functions were
normal. She was resumed on liquid diet and advanced to regular
diet with medications time spread out without any further nausea
or vomiting. She was ready for discharge to rehab on
postoperative day eight with coumadin for atrial fibrillation.
Discharged to [**Hospital 19771**] nursing and rehab.
Medications on Admission:
AMIODARONE - 200 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily)
BUPROPION HCL [BUDEPRION SR] - 150 mg Tablet Extended Release -
1
Tablet(s) by mouth once a day for 3 days and then twice a day
there after
HYDROXYCHLOROQUINE [PLAQUENIL] - 200 mg Tablet - 1 (One)
Tablet(s) by mouth twice a day
PRAVASTATIN [PRAVACHOL] - 20 mg Tablet - 1 Tablet(s) by mouth
once a day
WARFARIN - 2.5 mg Tablet - 1 Tablet(s) by mouth Once Daily at 4
PM
ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth
once a day
CALCARB 600 - 600 mg (1,500 mg) Tablet - 1 (One) Tablet(s) by
mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 1,000 unit Tablet - 1
Tablet(s) by mouth daily
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet
- 1 (One) Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS [FISH OIL] - (OTC) - 1,000 mg Capsule -
once a day
Discharge Medications:
1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO twice
a day.
5. Outpatient Lab Work
Labs: PT/INR
Coumadin for Atrial Fibrillation
Goal INR 2.0-2.5
First draw [**3-3**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease to twice a week if on stable dosing
Rehab physician to monitor and dose coumadin while at rehab -
please arrange coumadin follow up with PCP prior to discharge
from rehab
6. warfarin 1 mg Tablet Sig: goal INR 2-2.5 Tablets PO once a
day: to be dosed by rehab physician based on INR results -
received 1mg on [**3-31**], [**3-1**], [**3-2**] - INR [**3-2**] 1.8.
7. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever, pain.
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours) as needed for constipatioon.
12. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
QID (4 times a day) as needed for dry nares .
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
15. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
18. ace inhibitor
Unable to start while in hospital due to creatinine increase -
please consider resuming as outpatient
Discharge Disposition:
Extended Care
Facility:
Hellenic - [**Location (un) 2624**]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Coronary artery disease s/p CABG
Acute on chronic diastolic heart failure
Acute kidney injury (peak cr 1.9)
Atrial fibrillation
Rheumatoid arthritis
Hypertension
Hypercholesterolemia
Chronic obstructive pulmonary disease
Hyperthyroidism
Osteopenia
Large ventral hernia
Hearing loss
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with tylenol
Sternal Incision - healing well, no erythema or drainage
Right leg - EVH and thigh incision with steri strips ecchymosis
no drainage no erythema
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**2128-3-19**] 1:15
Cardiologist Dr.[**Name (NI) 3733**] [**Telephone/Fax (1) 62**] [**2128-4-9**] 10:40
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 713**] in [**3-9**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for Atrial Fibrillation
Goal INR 2.0-2.5
First draw [**3-3**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease to twice a week if on stable dosing
Rehab physician to monitor and dose coumadin while at rehab -
please arrange coumadin follow up with PCP prior to discharge
from rehab
Completed by:[**2128-3-2**]
ICD9 Codes: 4241, 5185, 5849, 4280, 4019, 496, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4850
} | Medical Text: Admission Date: [**2174-1-13**] Discharge Date: [**2174-1-28**]
Date of Birth: [**2093-5-21**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Amoxicillin / Penicillins
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
aphasia and right sided weakness
Major Surgical or Invasive Procedure:
IVtPA at OSH, IAtPA, MERCI and PENUMBRA device applications at
[**Hospital1 18**].
History of Present Illness:
per admitting resident:
The patient is an 80 year old woman with a history of atrial
fibrillation s/p PPM not on Coumadin due to fall risk,
hypertension, and perforated diverticulitis s/p ex lap and
sigmoidectomy [**2173-9-6**] who was last seen normal at 12:00 pm who
presented to an OSH with stuttering symptoms of aphasia and
right
sided weakness who received IV tPA at 2:13 pm and was
transferred
to [**Hospital1 18**] for possible further intervention, called as a CODE
STROKE. She is accompanied by her daughter and son.
Per the patient's daughter, the patient was last seen normal at
12:00 pm when she left the house to walk to the post-office to
drop off her [**Holiday **] cards. Apparently, a woman had found her
mother down and called EMS. Approximately 30 minutes later, EMS
knocked on the daughter's door (as the patient was able to say
her address at that time). After that, the patient had decreased
conversation, and was awake but "like a drunk." En route to
hospital had an episode of right sided flaccidity that lasted
1-2
minutes. At [**Hospital3 **], her daughter says that she became more
aware, and was talking for an approximately 3 minute period
(asking for her coat) before receiving tPA, but then became
aphasic again.
She was initially taken to [**Hospital3 **]. On initial arrival to ED
at 1:17 am she was talking, answering questions, and had an
intact neuro exam. Within about 5 minutes her clinical status
deteriorated and she developed aphasia, dysarthria, right facial
droop, and right sided weakness UE>LE. On exam, she had left
gaze
preference, right facial droop, right sided neglect, aphasia,
dysarthria, unable to hold RUE against gravity, RLE [**5-9**]. NIHSS
16. Labs showed INR 1.0, WBC 8.1, Hct 37.6, plt 277, Na 138, K
3.9, Cl 100, glucose 133, BUN 21, Cr 1.0, Ca 9.6, Mg 1.4, Phos
3.8, alk phos 310, ALT 39, AST 32, CK 47, CKMB 1.8. Neurology
was
consulted, and head CT/CTA showed prelim no acute bleed,
proximal
left ICA occlusion with slow flow to M1 and M2 branches, likely
occlusion of left MCA. tPA was bolused at 2:13 pm, with no
significant improvement in her symptoms after tPA bolus. She was
transferred to [**Hospital1 18**] for possible IA tPA or embolectomy.
A CODE STROKE was called at 16:36 pm, and Neurology was
immediately at the bedside. Per the ED, the EKG also showed some
T-wave inversions.
NIHSS Score:
1a. LOC: 0
1b. LOC Questions: 2
1c. Commands: 1 (squeezes left hand, but does not close eyes)
2. Best Gaze: 0
3. Visual Fields: 2 (does not blink to threat on the right)
4. Facial Palsy: 2 (right)
5. Motor Arm: 3 (right)
6. Motor Leg: 2 (right)
7. Limb Ataxia: X
8. Sensory: X
9. Best Language: 2 (almost completely globally aphasic, but
does
try to make a few vocal utterances: no, I don't know)
10. Dysarthria: 2
11. Extinction/Neglect: X
NIHSS Score Total: 16
Past Medical History:
Hypertension
Atrial fibrillation s/p PPM not on Coumadin due to fall risk
RA
Sigmoid diverticulitis and perforated diverticulitis s/p ex lap
and sigmoidectomy [**2173-9-6**] c/b peritonitis
h/o PNA
Syncope s/p right arm and wrist fracture 5 years ago
Osteoporosis
Anxiety
Kidney disease
Pulmonary nodules
Social History:
She lives at home with her daughter, and does not
use a cane or walker at baseline. She is a former seamstress,
but
had to stop working after her right arm/wrist fracture 5 years
ago. She works part-time as a lunch monitor at an elementary
school. She does not use cigarettes, EtOH, or illicit drugs.
Family History:
There is no family history of strokes.
Physical Exam:
Physical Examination:
VS: temp 97.4, bp 138/85, HR 67, RR 22, SaO2 94% on RA
Genl: Awake, alert
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Irregularly irregular rate, Nl S1, S2, no murmurs, rubs, or
gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen, surgical scar on abdomen
Neurologic examination:
Mental status: Awake and alert, occasionally follows commands
(squeezes hand on the left and breathes in and out for chest
auscultation, however she will not protrude her tongue or close
her eyes). Unable to name. Unable to read (but does say "I don't
know"). Intermittently says "no" and makes rare other vocal
utterances. Unable to say her age or the month. No dysarthria
when she does speak.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. Blinks to threat on the left but not the
right.
Extraocular movements intact bilaterally with limited upgaze.
Flat right NLF. Will not phonate to elevate palate. Will not
follow command to protrude tongue.
Motor: Normal tone bilaterally in UE and LE. No observed
myoclonus, asterixis, or tremor. She is able to keep her left
arm
against gravity for 10 seconds and her left leg against gravity
for 5 seconds (at least). Upon initialy exam, she has minimal
movement of her right arm when asked to lift it above gravity,
but does not sustain against gravity. Of note, when this
examiner
lifts her right arm against gravity she actively tries to push
it
down. However, 15 minutes later on repeat exam she is able to
briefly keep her right arm extended against gravity. However, 1+
hour after that she is again unable to lift her right arm
against
gravity and is more sleepy. She lifts her right leg against
gravity, but it drifts back to the bed in <5 seconds.
Sensation: She cannot cooperate with pinprick testing.
Reflexes: 3+ in right biceps/brachioradialis, 2+ on the left. 3+
and symmetirc in triceps and knees. Toes upgoing bilaterally
(but
more so on the right then left).
Gait: Deferred
Exam at time of discharge:
Pertinent Results:
Labs on admission:
[**2174-1-13**] 04:50PM BLOOD WBC-11.2* RBC-3.87* Hgb-11.4* Hct-34.4*
MCV-89 MCH-29.4 MCHC-33.1 RDW-13.9 Plt Ct-283
[**2174-1-16**] 01:27AM BLOOD WBC-13.5* RBC-3.56* Hgb-10.7* Hct-30.7*
MCV-86 MCH-30.0 MCHC-34.8 RDW-13.5 Plt Ct-245
[**2174-1-13**] 04:50PM BLOOD Neuts-87.3* Lymphs-10.3* Monos-1.8*
Eos-0.4 Baso-0.2
[**2174-1-13**] 04:50PM BLOOD PT-12.9 PTT-26.4 INR(PT)-1.1
[**2174-1-13**] 04:50PM BLOOD Glucose-114* UreaN-20 Creat-1.0 Na-138
K-4.2 Cl-102 HCO3-27 AnGap-13
[**2174-1-16**] 01:27AM BLOOD Glucose-105 UreaN-19 Creat-0.9 Na-138
K-3.8 Cl-102 HCO3-26 AnGap-14
[**2174-1-13**] 04:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-14**] 02:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-13**] 04:50PM BLOOD CK(CPK)-48
[**2174-1-14**] 02:50AM BLOOD CK(CPK)-34
[**2174-1-13**] 04:50PM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0
[**2174-1-14**] 02:50AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.7 Cholest-147
[**2174-1-14**] 02:50AM BLOOD Triglyc-254* HDL-30 CHOL/HD-4.9
LDLcalc-66
[**2174-1-14**] 02:50AM BLOOD %HbA1c-5.7
[**2174-1-14**] 09:30PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
labs during course of hospital stay
[**2174-1-15**] 02:12AM BLOOD WBC-10.4 RBC-3.51* Hgb-10.5* Hct-31.2*
MCV-89 MCH-29.9 MCHC-33.6 RDW-14.1 Plt Ct-219
[**2174-1-18**] 05:10AM BLOOD WBC-9.5 RBC-3.60* Hgb-10.6* Hct-31.9*
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.0 Plt Ct-265
[**2174-1-21**] 05:30PM BLOOD WBC-12.1* RBC-3.99* Hgb-11.5* Hct-34.8*
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.2 Plt Ct-377
[**2174-1-25**] 04:15AM BLOOD WBC-13.0* RBC-4.10* Hgb-11.8* Hct-35.6*
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.4 Plt Ct-444*
[**2174-1-27**] 04:20AM BLOOD WBC-11.6* RBC-3.84* Hgb-11.2* Hct-34.5*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.9 Plt Ct-516*
[**2174-1-21**] 03:45PM BLOOD Plt Ct-354
[**2174-1-24**] 05:35AM BLOOD PT-13.0 PTT-26.2 INR(PT)-1.1
[**2174-1-26**] 05:19AM BLOOD PT-12.6 PTT-28.2 INR(PT)-1.1
[**2174-1-17**] 02:42AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
[**2174-1-19**] 05:05AM BLOOD Glucose-119* UreaN-27* Creat-0.7 Na-140
K-3.4 Cl-102 HCO3-27 AnGap-14
[**2174-1-21**] 05:30PM BLOOD Glucose-120* UreaN-31* Creat-0.7 Na-138
K-3.9 Cl-101 HCO3-27 AnGap-14
[**2174-1-23**] 06:45AM BLOOD Glucose-109* UreaN-32* Creat-0.7 Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
[**2174-1-24**] 05:35AM BLOOD Glucose-109* UreaN-34* Creat-0.7 Na-142
K-4.3 Cl-105 HCO3-26 AnGap-15
[**2174-1-25**] 04:15AM BLOOD Glucose-99 UreaN-31* Creat-0.8 Na-141
K-4.5 Cl-102 HCO3-31 AnGap-13
[**2174-1-27**] 04:20AM BLOOD Glucose-94 UreaN-28* Creat-0.8 Na-142
K-4.6 Cl-105 HCO3-25 AnGap-17
[**2174-1-13**] 04:50PM BLOOD CK(CPK)-48
[**2174-1-14**] 02:50AM BLOOD CK(CPK)-34
[**2174-1-13**] 04:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-14**] 02:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2174-1-15**] 03:23PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.5
[**2174-1-17**] 02:42AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1
[**2174-1-19**] 05:05AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1
[**2174-1-21**] 05:30PM BLOOD Calcium-9.3 Phos-4.0 Mg-2.1
[**2174-1-24**] 05:35AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.2
[**2174-1-26**] 05:19AM BLOOD Calcium-9.9 Phos-4.4 Mg-2.4
[**2174-1-14**] 02:50AM BLOOD %HbA1c-5.7
[**2174-1-14**] 02:50AM BLOOD Triglyc-254* HDL-30 CHOL/HD-4.9
LDLcalc-66
[**2174-1-14**] 02:50AM BLOOD Digoxin-0.2*
Microbiolgy
urine culture [**1-14**]- negative
Blod culture [**1-15**]- negative
sputum culture [**1-16**]- normal flora
Urine studies
[**1-14**], [**1-26**], [**1-27**]- negative for infection
Imaging
CTP/CT head [**1-13**]:
IMPRESSION:
1. Decreased perfusion in the left MCA distribution concerning
for a large
acute infarct, with possible mismatch between the cerebral blood
volume and
cerebral blood flow.
2. Hypodensity of the left basal ganglia on CT likely reflects
an area of
acute infarct.
3. White matter hypodensities are a nonspecific finding, but
likely
represents the sequela of chronic microangiopathy given the
patient's age
ECHO [**1-14**]
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
aortic regurgitation. Mild mitral regurgitation. Moderate
tricuspid regurgitation. Moderate pulmonary hypertension.
[**1-13**] CXR - no acute process
CT head [**1-14**]:
IMPRESSION:
1. Evolving left MCA territory infarct with mild local mass
effect and shift of midline structures to the right. No
intracranial hemorrhage identified. A wet read was provided by
Dr. [**Last Name (STitle) **].
CXR [**1-15**]:
IMPRESSION: No evidence of pneumonia
CXR [**1-19**]
FINDINGS: As compared to the previous examination, the
nasogastric tube and
the left-sided pacemaker are in unchanged position. The
pre-existing
retrocardiac opacity has completely resolved. There is no
evidence of focal
parenchymal opacity, notably no evidence of pneumonia. Unchanged
moderate
cardiomegaly without signs of overhydration or pulmonary edema.
No pleural
effusions. No hilar or mediastinal adenopathies.
CXR [**1-25**]
IMPRESSION:
Stable chest findings with cardiac enlargement including left
atrial contour
prominence. No evidence of new infiltrates.
Video swallow test [**1-20**]
IMPRESSION: Profound delay in transporting bolus through the
oral phase of
swallow. Penetration with thin and nectar barium. Small residue
in the
pyriform sinuses.
Duplex Doppler Kidneys [**1-24**]
IMPRESSION:
1. Decreased left main renal artery peak systolic flow with
absent diastolic
flow within the interpolar arteries. These findings suggest
stenosis on the
left side, however, not matched by the size discrepancy between
the right and
left kidneys. Therefore, at this time, an MRA of the kidneys may
be warranted
for further evaluation
USG kidneys [**1-24**]
The right kidney measures 8 cm in size. The main renal vein is
patent. The
main renal artery demonstrates brisk upstroke with a peak
systolic velocity of
81 cm/sec. The interpolar arteries are patent without evidence
of parvus
tardus. There is mild decreased diastolic flow.
The left kidney measures 9.2 cm in size. The main renal vein is
patent. The
main renal artery is patent without evidence of parvus tardus
and a peak
systolic velocity of approximately 38 cm/sec. The interpolar
arteries on the
left side do not demonstrate parvus tardus, however, demonstrate
absent
diastolic flow. The constellation of these findings suggests
left renal
artery stenosis.
Brief Hospital Course:
80 year old woman with atrial fibrillation s/p PPM not on
Coumadin due to
prior fall and HX of syncope, HTN who presented to an OSH with
stuttering symptoms of aphasia and right sided weakness,
received IV tPA and was transferred to [**Hospital1 18**] for possible
further intervention. On arrival her NIH SS was still 16, while
her exam briefly improved in the ED (able to lift her right arm
off the bed) she then again deteriorated.
CTA head from the OSH showed a T Left ICA occlusion and a CT at
[**Hospital1 **] showed loss of the left insular ribbon with initial read of
CTP showing increased MTT in left MCA territory, CBV is
generally preserved indicating penumbra to be saved.
Patient was treated with IA tPA, PENUMBRA and MERCI clot
retrieval by IR and was admitted to NEURO ICU for further
monitoring and treatment.
NEURO. On admission to ICU, patient was intubated, had global
aphasia, withdrew flexor to noxious on left and no movement on
the right. BP was allowed to auto regulate with a goal of
140-160 maintained as best as possible (BP range of 100 - 180).
Normoglycemia and normothermia were maintained. Repeat CT head
showed
increased hypo density and size of the left middle cerebral
artery territory infarction and a 4-mm shift of midline
structures to the RIGHT. Etiology of stroke was felt to be of
embolic origin in pt. w/ fib off anticoagulation.
Patient was extubated on HD#1. Her exam at that time was notable
for arousal to voice, open eyes with left [**Hospital1 **] deviation,
inability to follow commands, motor and comprehension aphasia
and AG strength on L with extensor withdrawal to noxious on the
right.
She was transferred to floor for further care. she was
evaluated by PT/OT who recommended that she would require long
term support and acute rehab level of care on discharge. She was
seen and evaluated by speech and swallow therapy team . She was
on tube feeds during her hospital stay and attempts were made to
try PO feeds as tolerated but it was felt that she would require
[**Hospital1 282**] tube for long term feeding measures which was discussed with
her daughter who is also her health care proxy and [**Name2 (NI) 282**] tube was
placed on [**1-27**].
CV. Atrial fibrillation. She was continued on digoxin, Isordil
and Toprol XL was changed to an equivalent 1/2 dose of
metoprolol. ROMI was completed, EKG showed no evidence of
ischemia. TTE showed mild symmetric left ventricular
hypertrophy with nl EF, mild AR/MR, moderate TR and PAH. She
was noted to have worsening hypoxemia on HD#2 and evidence of
pulmonary congestion on CXR. Her Lasix was increased to daily
dosing. After transfer to floor she was continued on Lasix PO,
however she was noted to be dehydrated and her BUN /CR ratio was
high hence Lasix was stopped. Other outpatient meds including
digoxin were continued. Her Blood pressure was on the higher
side and her renal USG showed renal art stenosis for which she
was seen by renal who did not recommend stenting. MRI was not
possible owing to pacer. For blood pressure , hydralazine was
increased with moderate response and calcium channel blocker
amlodipine was added. she was stared on Coumadin after [**Month/Year (2) 282**] tube
and ASA as well as SC heparin ( for DVT Prophy) should be
stopped after her INR becomes therapeutic.
PU LM. Extubated on HD#1. Hypoxemia and volume overload were
treated with increasing PO Lasix to 40 mg daily. she was
transferred to floor and was maintaining good saturations on
room air. she underwent repeat chest xray which did not show any
new infiltrates.
PPX. Heparin SC was started on HD#2, maintained on Protonix.
ID- she underwent work up for excluding infections such as UA,
chest xray on periodic basis which were negative.
The goals of care were discussed with her daughter ,[**Name (NI) 2270**] who is
also her HCP and prognosis was explained from time to time.
Her neuro exam at the time of discharge was notable for - she
spontaneously opens her eyes, no verbalization, has hemi neglect
towards right side but does track slightly past midline, facial
droop on right side, R sided hemiplegia with upgoing toe, left
side is normal strength.
Suggested plan of care at DC
1. Frequent checks on her neuro status. aggressive physical
therapy and occupational therapy to prevent contracture and to
possible gain some function. Evaluation by speech and swallow
therapist for language function and swallow tests.
2. continuation of tube feed now with adequate calorie intake.
3. Adjustments of blood pressure meds for goal of 120-140
systolic. use of prn IV hydralazine for SBP more than 180. we
have held her Lasix as she was dehydrated with high BUN/Cr
ratio. if clinically indicated, she can be started again on
Lasix
4. prevention of bedsores, and stomach ulcers and treatment of
fungal rash over buttocks
5. watch over closely for any clinical signs of infection such
as development of UTI or pneumonia
6. Continue aspirin till she becomes therapeutic on Coumadin
with frequent INR checks. Aspirin should be stopped once her INR
becomes [**3-9**]. ( For A fib, to prevent further strokes. She is on
heparin SC for DVT prophylaxis which should be stopped once her
INR is therapeutic. we avoided heparin bridge given large stroke
and possible hemorrhagic conversion.
7. Medical management as felt appropriate by the team for blood
sugars, pain control, Electrolyte balance and other medical
issues.
Medications on Admission:
ASA 325 mg daily
Omeprazole 20mg daily
Digoxin 125mcg every other day
Toprol XL 100mg [**Hospital1 **]
Ambien 5mg QHS prn
Hydralazine 10mg [**Hospital1 **]
Isordil 5mg [**Hospital1 **]
Hydroxychloroquine 200mg every other day
Lasix 20mg every other day
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
3. Isosorbide Dinitrate 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for thick secretions.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing, shortness of breath.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
13. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO
EVERY OTHER DAY (Every Other Day).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H
(every 6 hours) as needed for bp control: FOR SBP MORE THAN 160.
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please Stop the aspirin when the INR is therapeutic (between
[**3-9**]).
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
Left MCA infarct
s/p t PA and MERCI, PENUMBRA
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound
Discharge Instructions:
You were admitted for evaluation of stroke. You were found to
have left MCA stroke and underwent thromolytic and endovascular
therapy for the stroke.
Please take your medicines as prescribed, please call 911 or
your doctor if you develop any concerning symptoms.
Followup Instructions:
Please follow up in neurology clinic -
Scheduled Appointments :
Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2174-3-4**]
10:30
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 486, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4851
} | Medical Text: Admission Date: [**2165-5-5**] Discharge Date: [**2165-5-8**]
Date of Birth: [**2096-5-3**] Sex: F
Service: NEUROSURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
s/p fall - wrist fracture, visual deficit
Major Surgical or Invasive Procedure:
[**5-6**] angio with coiling PCOMM / amgioseal
History of Present Illness:
This is a 69 year old female on 81 mg Aspirin daily with
known right PCOM aneurysm 7 mm as seen on MRI in [**Month (only) 956**] of
this
year was transferred from [**Hospital6 **] following a 5
minute episode of "triple vision" , blurred vision. She
describes this as when she looked at the receptionist at [**Hospital6 **] she saw three heads stacked upon each other
instead of one. The patient was about to be discharge from [**Last Name (un) 1724**]
with a left sprain wrist. After she experienced the triple
vision a head ct was performed which was found to be negative.
Given the patient's known right PCOM aneurysm , she was
transferred here for further evaluation and treatment by this
Neurosurgery service.
The patient originally had the MRI in [**Month (only) 956**] due to an episode
of slurred, non sensical speech. She states that she was at an
appointment and her words became garbled. She notified her PCP
who ordered an MRI. The patient was to see Neurology to discuss
the MRI findings later this week on Tuesday.
Currently, the patient has no neurological complaints. She
denies diplopia, speech difficulty, weakness other than at the
location of her sprained left wrist. The patient denies
weakness, numbness, tingling sensation. She denies bowel or
bladder dysfunction or hearing deficit.
Past Medical History:
Right lens implant, asthma, HTN, hypothyroidism, hyperactive
bladder, renal CA with partial nephrectomy 5 years ago- treated.
Social History:
NC
Family History:
NC
Physical Exam:
O: T:98.4 BP: 109/96 HR: 90 R: 16 O2Sats:98% RA
Gen: comfortable, NAD.
HEENT: Pupils: Pupils are bilaterally reactive . right eye is
irregular surgical pupil 5mm and left pupil is 5-4mm EOMs:
intact
Neck: Supple.
Extrem: left wrist sprain
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils are bilaterally reactive . right eye is irregular
surgical pupil 5mm and left pupil is 5-4mm.Visual fields are
full
to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-15**] throughout EXCEPT left wrist
was
not challenged due to sprain.. No pronator drift
Sensation: Intact to light touch, proprioception bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Upon Discharge:
Alert, oriented x3, R pupil surgical, L pupil reactive, MAE full
motor
Pertinent Results:
[**2165-5-5**] NCHCT at [**Hospital6 **]
Impression:
1. No evidence of acute large vessel territorial infarct or
intracranial hemorrhage.
2. Nonspecific periventricular and subcortical white matter
hypoattenuation, likely the sequelae of microangiopathic
disease.
MRI Brain [**2165-3-25**]:Impression:
1. Right posterior communicating artery aneurysm measuring
7 mm,directed posteriorly and slightly laterally.2. Fetal
origin
of the right posterior communicating artery withnonvisualization
of the right P1 segment.3. Stenosis of the proximal right
internal carotid artery of approximately 55%.4. Mild
nonspecific
periventricular and subcortical white matter disease, likely the
sequela of small vessel ischemic change in a patient this age.
Brief Hospital Course:
Patient was admitted to Neurosurgery on [**2165-5-5**] to the
Neurosurgery Service - ICU. On [**5-6**], she underwent the above
stated procedure. Please review dictated operative report for
details. She was transferred back to ICU in stable condition.
She did well overnight and was transferred to the SDU on [**5-7**].
On [**5-8**], she remained nonfocal, afebrile, tolerating a regular
diet and ambulating without difficulty.
Medications on Admission:
synthroid, amlodipine, vesicare, lisinopril, singulair, MVI,
calcium+D, ASA 81, benefiber
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: began [**5-6**].
Disp:*5 Tablet(s)* Refills:*0*
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen Extra Strength 500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for pain.
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Vesicare 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: Begin
5 days prior to your angiogram.
Disp:*35 Tablet(s)* Refills:*0*
13. prednisone 20 mg Tablet Sig: Two (2) Tablet PO 16 hrs, 8
hrs, & 2 hrs prior to your angiogram for 3 doses.
Disp:*6 Tablet(s)* Refills:*0*
14. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day for
3 doses: Begin with steroids.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Posterior communicating artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily starting 5 days
prior to your scheduled angiogram in one month. We will provide
you with a Rx for 35 tablets as you will continue Plavix one
month post-coiling.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate. You may return to work when you feel
ready as long as you are able to maintain the above restrictions
for 7 days.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
****** Pre-op Meds for angio in one month ******
Plavix 75 mg daily - begin 5 days prior to your angio
Prednisone 20 mg tablets (for dye allergy)
Take 2 tablets (40 mg) by mouth 16 hours prior to the
procedure or test, 8 hours prior, and 2 hours prior.
Zantac (Ranitidine) 150 mg tablets
Take 1 tablet by mouth twice daily along with the
Prednisone.
Please be sure to take 1 dose one hour prior to your
procedure or testing. (Will be given in the hospital)
Benadryl 25 mg capsules
Take 2 capsules (50 mg) by mouth one hour prior to your
procedure or testing.
Followup Instructions:
Please call [**Telephone/Fax (1) 4296**] to schedule a Cerebral Angiogram with
completion of coil with stent assist in one month. You will need
to take steroids prior for your allergy to dye. Also take Plavix
75mg for 5 days prior.
Completed by:[**2165-5-8**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4852
} | Medical Text: Admission Date: [**2142-3-20**] Discharge Date: [**2142-3-26**]
Date of Birth: [**2067-5-5**] Sex: M
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy, lysis of adhesions.
2. Refashioning of distal small bowel ostomy
History of Present Illness:
74yo w/ hx of ileostomy secondary to bowel ischemia from
volvulus in [**2139**] c/b prolapse in [**2141**]. Transferred from [**Hospital 18**]
[**Hospital **] Campus after developing abdominal pain with concern for
small bowel obstruction.
Past Medical History:
PMH: Parkinson's, urosepsis, very debilitated, sigmoid and cecal
volvulus
PSH: total colectomy, small bowel resection, and end ileostomy
Social History:
no tobacco, no EtOH
Family History:
NC
Physical Exam:
VS- 98.1, 86, 121/62, 16, 99% RA
Gen- NAD, AxOx3, cooperative
HEENT- anicteric, oral mucosa dry
Lungs: CTA b/l
Heart: RRR, S1S2
Abd: flat, boggy, tender to palpation b/l LQ, no rebound, ostomy
intact and working, high pitched BS, midline incision intact, no
masses or hernias
Pertinent Results:
[**2142-3-20**] 12:17AM BLOOD WBC-17.8* RBC-3.72* Hgb-11.8* Hct-36.2*
MCV-97 MCH-31.7 MCHC-32.6 RDW-15.2 Plt Ct-427
[**2142-3-23**] 06:20AM BLOOD WBC-8.0 RBC-3.04* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.2 MCHC-33.5 RDW-16.8* Plt Ct-286
[**2142-3-20**] 12:17AM BLOOD Glucose-173* UreaN-48* Creat-1.7* Na-137
K-4.4 Cl-102 HCO3-22 AnGap-17
[**2142-3-23**] 06:20AM BLOOD Glucose-135* UreaN-31* Creat-1.2 Na-142
K-3.4 Cl-108 HCO3-26 AnGap-11
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] (transferred from an OSH) on
[**2142-3-20**] with a high grade partial small bowel obstruction. At
CT scan showed dilated loops of small bowel with an apparent
stenosis just prior to the right lower quadrant stoma, no free
intraperitoneal air. He was immediately started on an NG tube
for decompression and it put out 2 liters rather quickly. His
WBC count was 17 and he was afebrile. His NG tube output was
feculent. He was taken to the OR later that day for an
exploratory laparotomy, lysis of adhesions, and refashioning of
distal small bowel ostomy, right lower quadrant. Please see
operative note for details. The operation went well with no
complications. He was admitted directly to the ICU. He was
extubated on POD 0. On POD 1 he was re-started on his
Parkinsonian medications. He was started on Lopressor for BP
control. His oxygen was weaned. He was kept NPO on TPN with an
NG tube. He was started on Levaquin and Flagyl for penumonia (7
day course). He also had [**11-29**] bottle of a blood culture grew
back Streptococcus. He recieved 2 untis of packed red blood
cells for post operative blood loss anemia and his hematocrit
responded appropriatly. On POD 2, his HG tube was discontinued.
He was started on sips of clears and he has hep-locked. He was
trransferred to the floor. On POD 3 his deit was advanced to
regular. A repeat chest X-ray showed improving pneumonia. On
POD 5 he was discharged to rehab in good condition.
Medications on Admission:
sinemet, requip, tasmar, amantadine, MVI, vit C, simethicone,
prilosec
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
3. Amantadine 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
11XDAILY ().
5. Methenamine Mandelate 1 g Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Tolcapone 100 mg Tablet Sig: One (1) Tablet PO three times
daily ().
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 days. Tablet(s)
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
13. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO 8X DAILY ().
14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
15. 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
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
complete small bowel obstruction caused by an adhesion
Discharge Condition:
good
Discharge Instructions:
Please call or come to the ED with any fevers > 101, nausea,
vomiting, diarrhea, constipation,
redness/warmth/tenderness/drainage from your surgical incisions,
or any other worrisome issues [**Last Name (un) 9888**] may arise. Diet and
avctivity as normal. You may shower but do not soak incisions
in water for 2 weeks.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up in
[**9-8**] days at ([**Telephone/Fax (1) 33502**].
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2142-3-26**]
ICD9 Codes: 7907, 486, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4853
} | Medical Text: Admission Date: [**2151-3-5**] Discharge Date: [**2151-3-11**]
Date of Birth: [**2082-8-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2151-3-5**] Three Vessel CABG utilizing left internal mammary to
left anterior descending and vein grafts to diagonal and obtuse
marginal
History of Present Illness:
Mr. [**Known lastname 63812**] is a 68 year old male with history of CAD. He is
status post anterior MI and Cypher stent placement to LAD in
[**2150-6-26**]. For the last several months, he has complained of
exertional chest discomfort. Cardiac catheterization on [**2-24**] demonstrated a 50% distal left main lesion; an ostial 40%
circumflex stenosis; and an ostial 70% LAD lesion with a 50% mid
vessel lesion. The RCA was small, and nondominant. Subsequent
echocardiogram showed an LVEF of 40-45%. There was only trivial
MR. Based on the above results, he was referred for cardiac
surgical intervention. He underwent routine preoperative and
was electively admitted for surgical revascularization.
Past Medical History:
Coronary artery disease
Hypertension
Diabetes Mellitus
Hypercholesterolemia
Asthma
Asbestosis
Carotid Disease
Social History:
Patient had prior tob use, quit in [**2130**], social drinker (not
daily), currently works as Longshoreman, lives alone in [**12-28**] of a
two family home while daughter lives in other half.
Family History:
Patient states mother and 2 brothers with "heart problems" but
unable to elaborate.
Physical Exam:
Vitals: BP126/50 , HR 69, RR 17, SAT 100% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign, EOMI, PERRL
Neck: supple, no JVD, no carotid bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 1+ distally
Neuro: nonfocal
Pertinent Results:
Echo [**3-5**]:Pre-CPB: There are simple atheroma in the descending
thoracic aorta. 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. Post CPB: Preserved
biventricular systolic function. EF 50 - 55%. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **].
Aorta intact. Other parameters as pre-CPB.
CXR [**3-11**]: Increased left pleural effusion and probable left
basilar atelectasis. Infectious consolidation cannot be
excluded.
[**2151-3-5**] 11:30AM BLOOD WBC-14.1*# RBC-2.98* Hgb-7.4* Hct-23.1*
MCV-77* MCH-24.8* MCHC-32.1 RDW-16.9* Plt Ct-181
[**2151-3-9**] 05:30AM BLOOD WBC-13.0* RBC-3.55* Hgb-9.2* Hct-27.9*
MCV-79* MCH-25.8* MCHC-32.9 RDW-16.9* Plt Ct-266
[**2151-3-5**] 12:29PM BLOOD PT-14.5* PTT-29.3 INR(PT)-1.3*
[**2151-3-7**] 05:00AM BLOOD PT-15.3* PTT-26.2 INR(PT)-1.4*
[**2151-3-5**] 12:29PM BLOOD UreaN-17 Creat-0.9 Cl-110* HCO3-22
[**2151-3-9**] 05:30AM BLOOD Glucose-108* UreaN-21* Creat-0.9 Na-134
K-3.8 Cl-97 HCO3-26 AnGap-15
[**2151-3-11**] 05:15AM BLOOD Mg-2.1
[**2151-3-6**] 05:36AM BLOOD freeCa-1.15
Brief Hospital Course:
Mr. [**Known lastname 63812**] was admitted and taken directly to the operating
room where Dr. [**Last Name (STitle) 914**] performed three vessel coronary artery
bypass grafting. The operation was uneventful and he was brought
to the CSRU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated. He was weaned from
inotropic support without difficulty. Amiodarone was started for
intermittent episodes of atrial fibrillation. PRBCs were
intermittently transfused to maintain hematocrit near 30%. He
otherwise maintained stable hemodynamics and was transferred to
the SDU on postoperative day three. He remained mostly in a
normal sinus rhythm. Amiodarone was continued and beta blockade
was advanced as tolerated. K and Mg levels were monitored
closely and repleted per protocol. Over several days, medical
therapy was optimized and he continued to make clinical
improvements with diuresis. Physical therapy worked with patient
throughout post-op course for strength and mobility. No further
atrial fibrillation was noted and he was cleared for discharge
to home with VNA services on postoperative day six.
Medications on Admission:
Aspirin 325 qd, Plavix 75 qd, Lisinopril 10 qd, Toprol XL 100
qd, Singulair 10 qd, Pravocol 20 qd, Advair [**Hospital1 **],
Glyburide/Metformin 2.5/500 [**Hospital1 **]
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO BID (2 times a day).
Disp:*180 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
10. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: then drop to 200 mg (one tablet) once daily.
Disp:*60 Tablet(s)* Refills:*1*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
1 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Home care
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
Postop Atrial Fibrillation
Hypertension
Diabetes Mellitus
Hypercholesterolemia
Asthma
Asbestosis
Carotid Disease
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac [**Last Name (LF) 5059**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in [**3-31**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12922**] in [**1-29**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**1-29**] weeks.
Completed by:[**2151-3-26**]
ICD9 Codes: 4111, 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4854
} | Medical Text: Admission Date: [**2143-2-15**] Discharge Date: [**2143-2-18**]
Service:
PRINCIPLE DIAGNOSIS AT DISCHARGE:
Right caudate thalamic hemorrhage secondary to hypertension.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 46608**] is a 60-year-old man
with past medical history of hypertension and coronary artery
disease. Has been having fevers over the last three days.
On the night prior to admission he began to complain that
"something is happening to me." According to his wife at
baseline he ambulates with a walker because of "back
problems." [**Name2 (NI) **] has had a fever since [**2143-2-12**] with a dry cough
but no other localizing symptoms and he was being empirically
treated with antibiotics by his primary care physician. [**Name10 (NameIs) **]
night prior to admission he got up to urinate and was unable
to take off his pants or later to put them back on. He also
developed a left sided throbbing headache at that time.
However, he went back to sleep in the morning. He had the
sense that something was wrong and his wife brought him to
[**Name (NI) 16843**] Hospital where a Head CT was obtained that showed
a right caudate hemorrhage without extension into the
ventricles. He was then transferred to [**Hospital1 190**] for further evaluation and treatment.
REVIEW OF SYSTEMS: He has had fevers without change in
urination. He has had decreased hearing and he wears a
hearing aid in the right ear. he complains of chronic left
hip pain and back pain. The patient denied any problems with
sore throat, nausea, vomiting, visual changes, difficulty
swallowing, chest pain, palpitations, short of breath,
abdominal pain or change in bowel and bladder habits.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Left hip replacement [**2141**].
3. Coronary artery disease. Status post three vessel
Coronary artery bypass graft in [**2130**]. Angioplasty in
[**2131**].
4. Hypercholesterolemia.
5. Gout.
6. Prostate cancer [**2128**].
7. Colon surgery for gastrointestinal bleed/diverticulosis
in [**2138**].
8. Cholecystectomy in [**2138**].
9. Bladder sphincter surgery in [**2135**].
10. Ear surgery times three.
11. Hernia repair times three.
12. Bilateral cataract surgery.
ALLERGIES: Sulfa gives him a rash. Penicillin gives a rash.
Demerol and Ambien with unknown reaction.
MEDICATIONS:
1. Aspirin 325 mg p.o. q day.
2. KCL 10 mg p.o. twice a day.
3. Hydralazine 15 mg p.o. three times a day.
4. Flomax 64 mg p.o. q day.
5. Aciphex 20 mg p.o. q day.
6. Zocor 40 mg p.o. q day.
7. Allopurinol 100 mg p.o. q day.
8. Norvasc 5 mg q day.
9. Lasix 20 mg p.o. q day.
10. Iron 325 mg p.o. q day.
11. Hydrocodone twice a day p.r.n.
SOCIAL HISTORY: Originally from [**State 9512**], worked as an Air
Force plane mechanic. Married with children. Positive
smoking history
PHYSICAL EXAMINATION: At presentation his temperature was
97.1, blood pressure is 177/76, heart rate was 87.
Respiratory rate was 24. He was sating 100% on two liters.
In general the patient appeared his stated age lying in bed
in no acute distress. His head was normocephalic and
atraumatic. Eyes: Nonicteric. Oropharynx was clear without
lesions. Mucous membranes were moist. Neck was supple with
no jugular venous distention or bruits. Lungs were clear to
auscultation bilaterally. Cardiac exam revealed a normal S1
and S2. 2/6 systolic ejection murmur heard best at the upper
sternal border. Abdomen was soft, nontender, nondistended
with normal bowel sounds. Extremities were warm with no
clubbing or cyanosis. He had mild pitting edema at the
ankles. Neurologic: He was awake, alert, cooperative,
appeared grossly oriented. He was able to provide some
detail of recent and remote events. Serial 3's were intact.
His object naming was intact. Registration intact with four
attempts. Recall [**3-5**] items in three minutes. He followed
simple commands. Speech: Normal voice quality and
articulation. Comprehension is coherent. He was fluent
without paresthesias. He was able to say no if's, and's and
but's intact.
Cranial nerve exam: The patient with left lower facial droop
without trismus. His extraocular movements intact without
nystagmus. His visual fields intact with confrontation. His
funduscopic exam revealed normal vasculature with sharp optic
discs. Pupils were reactive to light directly and
consensually, 3 mm to 2 mm, palate was symmetric and tongue
was midline. Hearing was decreased to finger rub
bilaterally. His neck and shoulder shrug however, were
normal. On motor examination his legs were adducted at rest
with increased tone. There is no upper extremity cogwheeling
rigidity. There is no pronator drift. His interphalangeal
testing was limited by pain. Strength exam was symmetric
with 5- strength in the deltoids, 5 in the biceps, 5 in the
wrist flexors and extensors, 5 in the finger flexors, 5- in
the finger extensors. 4 on the hip flexors, 5 in the knee
flexors, 4+ in the knee extensors, 5- in the ankle flexors,
4+ in the ankle extensors, 5 in the toe reflexes, 4+ in the
toe extensors. Reflexes were 2+ and symmetric in the biceps,
triceps and brachioradialis. Lower extremity they were 4+ in
the patella on the left and 3+ on the right. Achilles jerks
were absent and toes were upgoing bilaterally. There is no
ankle clonus. Sensory: Pinprick is decreased on the left
face, arm and leg. Vibration is decreased in the toes.
Proprioception intact in the fingers. Coordination
finger-to-nose intact with mild action tremor. Heel-to-shin
was intact. Rapid alternating movements intact. Toe tap was
intact. Gait was very unsteady with retropulsion, normal
base but short step and stride.
HOSPITAL COURSE: Mr. [**Known lastname 46608**] was admitted to the
neurological Intensive Care Unit for further evaluation and
treatment of his right caudate hemorrhage. An magnetic
resonance scan of his head was done with Gadalidium to look
for additional reasons for sensory changes such as an
ischemic stroke and none were found. There was no evidence
of enhancement underneath the hemorrhage to suggest a lesion
which later bled. Systolic blood pressure was maintained
between 120 to 140 and his aspirin was held and will continue
to be so for the next 10 days. The following day Mr.
[**Known lastname 46608**] was transferred to the floor. However, on the 16th
he was found to be much less responsive and to have fevers
and the source of his fevers were eventually found however,
over the next day Mr. [**Known lastname 46608**] was no longer febrile and was
back to his baseline.
On the 17th Mr. [**Known lastname 46608**] was observed to ambulate well with
his walker avoiding obstacles and was able to transfer in and
out of his bed with minimal assistance.
DISCHARGE INSTRUCTIONS: Mr. [**Known lastname 46608**] was discharged to home
on [**2143-2-18**].
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q day.
2. Amlodipine 5 mg p.o. q day.
3. Allopurinol 100 mg p.o. q day.
4. Zocor 40 mg p.o. q day.
5. Hydralazine 50 mg p.o. three times a day.
6. KCL 10 mEq p.o. twice a day.
7. Slow-Mag 64 mg p.o. q day.
8. Aciphex 20 mg p.o. q day.
9. Iron 325 mg p.o. q day.
10. Hydrocodone one tab twice a day p.r.n.
He is to hold his aspirin for one further week and then may
resume all pre-admission medications.
DIET: Low sodium, low cholesterol.
He has been asked to return for follow-up with Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) **] on [**2143-3-12**], [**Telephone/Fax (1) 46609**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**MD Number(1) 2107**]
Dictated By:[**Last Name (NamePattern1) 660**]
MEDQUIST36
D: [**2143-2-18**] 20:29
T: [**2143-2-18**] 20:09
JOB#: [**Job Number **]
ICD9 Codes: 431, 2720, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4855
} | Medical Text: Admission Date: [**2185-5-25**] Discharge Date: [**2185-5-30**]
Date of Birth: [**2140-3-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ketorolac
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
[**5-25**] bilateral mini-MAZE and left atrial appendage ligation
History of Present Illness:
44-year-old woman with a longstanding history of paroxysmal
atrial fibrillation. She presented for surgical evaluation.
Past Medical History:
atrial fibrillation
chronic systolic heart failure,
osteomyelitis
median nerve injury secondary to carpal tunnel surgery,
bilateral carpal tunnel repair
cholecystectomy
right knee operation
cesarean
nerve transplantation.
Social History:
Lives with spouse
Disabled
ETOH rare
Tobacco denies
Family History:
Father with myocardial infarction at 28 and died at age 54.
Physical Exam:
Pulse: 42 SB O2 sat: 98%
B/P Right: 122/78
Height: 69" Weight: 190
General: WDWN female in NAD
Skin: Warm, dry, No C/C. Trace LE edema
HEENT: PERRLA [X] EOMI [X], NCAT Nonhyperemic oral/pharygeal
mucusa
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: SB Nl S1-S2, No M/R/G appreciated
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: None appreciated (B)
Pertinent Results:
[**2185-5-30**] 09:05AM BLOOD WBC-4.9# RBC-3.39* Hgb-10.3* Hct-31.2*
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.7 Plt Ct-257
[**2185-5-25**] 05:32PM BLOOD WBC-10.6# RBC-3.59* Hgb-11.1* Hct-32.4*
MCV-90 MCH-30.9 MCHC-34.3 RDW-13.4 Plt Ct-242
[**2185-5-30**] 09:05AM BLOOD Plt Ct-257
[**2185-5-30**] 09:05AM BLOOD PT-11.7 INR(PT)-1.0
[**2185-5-25**] 08:15AM BLOOD PT-14.8* PTT-29.0 INR(PT)-1.3*
[**2185-5-30**] 09:05AM BLOOD Glucose-97 UreaN-20 Creat-0.8 Na-141
K-4.5 Cl-104 HCO3-30 AnGap-12
[**2185-5-25**] 05:32PM BLOOD UreaN-13 Creat-0.7 Cl-106 HCO3-26
[**2185-5-30**] 09:05AM BLOOD Mg-1.8
[**2185-5-26**] 02:08AM BLOOD Calcium-8.0* Mg-2.1
[**2185-5-29**] 04:45AM BLOOD TSH-4.2
[**2185-5-29**] 04:45AM BLOOD T4-7.4 T3-71*
Brief Hospital Course:
Admitted same day surgery and underwent bilateral mini
thoracotomy, MAZE and left atrial appendage ligation. Please see
the operative note for details, of note she was extubated in the
operating room. She received Cefazolin for perioperative
antibiotics. She did well post operative except for pain and
medications were adjusted, acute pain services placed bilateral
paravertebral catheters on post-operative day one. Physical
therapy worked with her on strength and mobility. Her
medications were adjusted for her rhythm and she was noted to
have episodes of junctional rhythm and atrial
fibrillation/flutter post operatively. She is currently on
amiodarone and coreg of which she will continue at discharge
with [**Doctor Last Name **] of hearts monitor at discharge. Her coumadin was
resumed for atrial fibrillation.
Of note she had an allergic reaction to toradol with facial
swelling and rash. Rash resolving and edema completely
resolved, plan to use benadryl for itching as needed.
Pain medications adjusted and resumed morphine sulfate immediate
release for breakthrough pain. Discharged home with services on
post operative day five.
Medications on Admission:
AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth twice a day
CARVEDILOL - (Prescribed by Other Provider) - 6.25 mg Tablet -
1
Tablet(s) by mouth daily
FENTANYL - (Prescribed by Other Provider) - 100 mcg/hour Patch
72 hr - 1 patch q72 hours
FENTANYL - (Prescribed by Other Provider) - 75 mcg/hour Patch
72
hr - 1 patch q72 hours Total 175mcg q72hours
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
MORPHINE - (Prescribed by Other Provider) - 30 mg Tablet - 1
Tablet(s) by mouth as needed
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
POTASSIUM CHLORIDE [KLOR-CON] - (Prescribed by Other Provider)
-
Dosage uncertain
WARFARIN - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth daily
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. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
3. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 1 months.
Disp:*90 Capsule(s)* Refills:*0*
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing for atrial fibrillation - goal INR
2.0-2.5 with results to Dr [**Last Name (STitle) 41297**] coumadin clinic
[**Telephone/Fax (1) 19666**] - first draw [**6-1**]
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: please have INR checked [**6-1**] for further dosing by Dr
[**Last Name (STitle) 41297**] .
Disp:*30 Tablet(s)* Refills:*0*
10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours: total dose 175 mcg patch -
prescription from Dr [**Last Name (STitle) 1884**] .
15. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours: total dose 175 mcg patch -
prescription from Dr [**Last Name (STitle) 1884**] .
16. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Paroxysmal atrial fibrillation
chronic systolic heart failure
osteomyelitis
median nerve injury
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
No heat or cold directly to incisions
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
PT/INR for coumadin dosing for atrial fibrillation - goal INR
2.0-2.5 with results to Dr [**Last Name (STitle) 41297**] coumadin clinic
[**Telephone/Fax (1) 19666**] - first draw [**6-1**]
[**Doctor Last Name **] of hearts monitor to be followed by Dr [**Last Name (STitle) 73**]
Please seek medical attention if facial swelling returns,
continue with benadryl as needed for itch
Followup Instructions:
please call for the following appointments:
Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] (PCP) in 1 week ([**Telephone/Fax (1) 56653**])
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 41297**] (cardiologist) in [**1-4**] weeks.
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2185-6-7**] 1:00
Dr [**Last Name (STitle) 1884**] [**Name (STitle) 766**] [**6-13**] at 1230 pm (pain management)
PT/INR for coumadin dosing for atrial fibrillation - goal INR
2.0-2.5 with results to Dr [**Last Name (STitle) 41297**] coumadin clinic
[**Telephone/Fax (1) 19666**] - first draw [**6-1**]
Completed by:[**2185-5-30**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4856
} | Medical Text: Admission Date: [**2194-2-22**] Discharge Date: [**2194-3-7**]
Date of Birth: [**2114-7-25**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Opioids: Morphine & Related
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
SOB CP
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
This is a 79 yof with hx of HTN, Hyperlipidemia, Hypothyroidism,
who presented to [**Hospital 8641**] Hosp with SOB and chest pressure.
According to the Caridiology note from [**Location (un) 8641**], the patient was
feeling more SOB recently and was having "panic attacks", where
she felt more SOB. On the evening of her admission, she
developed severe SOB and EMS was called. Initial EKGs were
concerning for VT, so she was given Lidocaine 50mg followed by
Amiodarone 150mg and her tachycardia broke into a LBBB. On
arrival to the ED she was tachypneic, cyanotic and diaphoretic
and was intubated. CXR showed pulmonary edema. Presumptive
diagnosis was Acute MI given her acute SOB as well as ?chest
pressure along with Vtach and LBBB not known to be old. She was
given ASA, plavix, bival and taken to Cath lab. LCA was widely
patent with minor plaquing, RCA was widely patent with minor
plaquing. LV was noted to be enlarged with dyssynchronous
contraction, diffuse hypokinesis, EF of 30%. Impression by the
cardiology team was that she had Acute Pulm Edema [**12-23**] acute
systolic CHF, CHF due to chronic non-ischemic cariomyopathy,
?COPD. Of note, patient was also hyperglycemic and given insulin
during her c.cath. The day following her admission [**2-21**], she was
noted to have Left facial and neck swelling, which was
concerning for subcutaneous emphysema. She became febrile
overnight on [**2194-2-21**], she was also noted to have purulent
secretions so she was started on Vancomycin and Zosyn. CT neck
was done on [**2-22**] which showed significant air between her trachea
and esophagus. Bronchoscopy was done which showed a tracheal
tear with oozing. Depth could not be characterized [**12-23**]
bleeding. She was transferred to [**Hospital1 18**] for furhter management
out of concern for mediastinitis and ?need for tracheal surgery.
Of note, per c.cath note from OSH, LBBB was later found to be
old since [**2181**]. Patient also diuresed 3.5 liters between
[**Date range (1) 82735**]
.
Patient was transferred to the [**Hospital1 18**] SICU. she was extubated
successfully 2 hours after transfer. Bronchoscopy was performed
on [**2194-2-23**] showed no evidence of tear. She has been treated with
Vancomycin, CTX and fluconazole for mediastinitis. Vanco then
discontinued per ID recommendation. Today, the patient
developed wide complex tachycardia to 150s. Med
consult/cardiology was called, ECG reviewed and seems to be afib
with RVR with aberrancy. She was given Metoprolol 5mg IV x 2
with no effect. She was then given Dilt 20mg IV loading dose
and started on Dilt 5mg/hr gtt. Oxygen saturation dropped to
89% and increased with nebs. She was given Lasix 20mg IV x 1
and CXR ordered. She remained normotensive and was transferred
to the CCU for further care.
.
On arrival the patienet denies Chest pain, SOB, N/V,
palpitations or radiating pain. She does report +chills and
subjective fevers over the past few days along with diarrhea x 2
days. She denies abdominal pain. No other complaints.
Past Medical History:
Hypertension
Hypothyroidism
Hyperlipidemia
Anxiety and Depression followed at Seeacoast Mental Health
Social History:
Denies tobacco, EtOH or illicit drug use
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: Somnolent, speaking softly with eyes closed. Oriented
x2 to self and date, when asked for place she said "[**State **]"
HEENT: NCAT, EOMI, MMM, +pursed lip breathing
NECK: Edematous, with +subcutaneous emphysemia, JVP
unappreciable [**12-23**] edema
CARDIAC: Irregularly irregular +S1/S2, no M/R/G
LUNGS: Decreased Breath sounds at bilateral bases with mild
crackles, +expiratory ronchi, no wheezes
ABDOMEN: Soft, NTND, normal BS
EXTREMITIES: No c/c/e
SKIN: No rashes
PULSES: +2 radial and pedal
Pertinent Results:
[**2194-2-22**] 07:54PM BLOOD WBC-21.0* RBC-3.60* Hgb-11.8* Hct-34.4*
MCV-96 MCH-32.8* MCHC-34.3 RDW-14.3 Plt Ct-289
[**2194-2-23**] 03:15AM BLOOD WBC-23.4* RBC-3.88* Hgb-12.5 Hct-36.9
MCV-95 MCH-32.3* MCHC-33.9 RDW-14.3 Plt Ct-297
[**2194-2-24**] 02:11AM BLOOD WBC-20.0* RBC-3.70* Hgb-11.4* Hct-34.7*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.4 Plt Ct-317
[**2194-2-25**] 05:00AM BLOOD WBC-18.0* RBC-3.76* Hgb-11.6* Hct-35.1*
MCV-93 MCH-30.8 MCHC-33.0 RDW-14.5 Plt Ct-351
[**2194-2-22**] 07:54PM BLOOD Neuts-94.4* Lymphs-3.2* Monos-2.1 Eos-0.1
Baso-0.1
[**2194-2-22**] 07:54PM BLOOD Glucose-112* UreaN-33* Creat-0.8 Na-140
K-4.0 Cl-110* HCO3-22 AnGap-12
[**2194-2-23**] 03:15AM BLOOD Glucose-117* UreaN-34* Creat-0.8 Na-141
K-3.9 Cl-110* HCO3-22 AnGap-13
[**2194-2-23**] 05:19PM BLOOD Glucose-113* UreaN-33* Creat-0.7 Na-143
K-3.6 Cl-111* HCO3-24 AnGap-12
[**2194-2-24**] 02:11AM BLOOD Glucose-109* UreaN-31* Creat-0.7 Na-145
K-3.8 Cl-113* HCO3-23 AnGap-13
[**2194-2-24**] 05:26PM BLOOD UreaN-34* Creat-0.8 Na-148* K-4.6 Cl-114*
HCO3-22 AnGap-17
[**2194-2-25**] 05:00AM BLOOD Glucose-121* UreaN-32* Creat-0.8 Na-149*
K-4.2 Cl-114* HCO3-24 AnGap-15
[**2194-2-24**] 02:11AM BLOOD ALT-18 AST-15 AlkPhos-74 TotBili-1.0
[**2194-2-23**] 07:17AM BLOOD CK-MB-5 cTropnT-0.03*
[**2194-2-23**] 12:33PM BLOOD CK-MB-4 cTropnT-0.03*
[**2194-2-23**] 05:19PM BLOOD CK-MB-4 cTropnT-0.03*
[**2194-2-24**] 02:11AM BLOOD TSH-3.3
[**2194-2-24**] 02:11AM BLOOD Free T4-0.78*
[**2194-2-22**] 08:28PM BLOOD Type-ART Temp-37.3 pO2-101 pCO2-43
pH-7.38 calTCO2-26 Base XS-0
[**2194-2-23**] 01:00AM BLOOD Type-ART Temp-36.5 pO2-80* pCO2-45
pH-7.34* calTCO2-25 Base XS--1
[**2194-2-23**] 05:38PM BLOOD Type-ART pO2-82* pCO2-37 pH-7.41
calTCO2-24 Base XS-0
CXR
[**2-24**]
The cardiomediastinal silhouette is unchanged and
enlarged. There are increased perihilar and interstitial
markings consistent
with increasing mild volume overload. Small bilateral pleural
effusions
have also increased. A left retrocardiac opacity is persistent.
Extensive
subcutaneous edema predominantly within the left chest wall has
mildly
decreased in extent.
[**2-23**]
Slightly worse fluid status and increased retrocardiac density
with left effusion. Pneumonia cannot be excluded.
[**2-21**]
Tip of the ETT is 2.9 cm above the carina. NGT extends below the
diaphragm
with the side port near the level of the EG junction. There is a
retrocardiac
opacity, likely atelectasis and possibly an effusion. The right
lung shows no
discrete consolidation. Incidental note is made of some
subcutaneous
emphysema in the neck and left chest soft tissues.
No pneumomediastinum.
[**2194-2-25**] TTE:
The left atrium is elongated. The estimated right atrial
pressure is 10-15mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is severe global left ventricular hypokinesis (LVEF =
20%), with apical segments thickening better than basal
segments. This suggests a non-coronary etiology of LV
dysfunction (tachycardia-mediated, toxic, metabolic, etc). The
estimated cardiac index is depressed (<2.0L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) 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. Moderate to severe (3+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Dilated and hypertrophied left ventricle with severe
global systolic dysfunction and low forward stroke volume.
Moderate to severe mitral regurgitation. At least mild pulmonary
hypertension.
CT NECK
[**2-26**]
. Multiloculated collections in the lower neck ending into the
mediastinum
containing air and oral contrast from the recent video swallow
examination
and suggestive of abscesses with evolving mediastinitis. As seen
on the same
day neck CT this is likely secondary to esophageal perforation.
No definite
tracheo- esophageal fistulous connection is identified but this
should be
correlated with bronchoscopy.
2. Mild hydrostatic edema and superimposed aspiration/infection
in the upper
lobes.
3. Geographic hypoattenuation in the liver, likely representing
a focal fatty
sparing infiltration. Small nodule in the left adrenal gland
likely
representing an adenoma. If clinically indicated, these findings
could be
further characterized by MRI when the patient's symptoms
subside.
[**3-4**]
1. Significant interval improvement in the upper left neck
collection with no
evidence of abscess on the prior study as well as no evidence of
extravasation
of the contrast from the esophagus. Blunting of the left
piriform sinus with
thickening of the soft tissues at the area is still present, but
no obvious
evidence of abscess or mediastinitis is currently seen.
2. Patchy ground-glass opacities unchanged since [**2194-2-26**],
consistent
with areas of infection [**Last Name (un) **] than aspiration given it's
persistence.
Brief Hospital Course:
79 yof with hx of HTN, Hyperlipidemia, Hypothyroidism, who
presented to [**Hospital 8641**] Hosp with SOB and chest pressure, found to
be in acute CHF, transferred here s/p traumatic intubation c/b
tracheal tear and subcutaneous emphysema. Now transferred to
CCU for management of afib with RVR.
# Wide Complex Tachycardia: ECG consistent with afib with RVR in
setting of known LBBB. Afib likely exacerbated by
CHF/mediastinitis. Rate and rythm control with Amiodarone. He
was started on Heparin for anticoagulation with plan to
transition to warfarin. Please check INR and dose warfarin
accordingly. Goal INr [**12-24**].
# CHF: Patient with EF of 30% on LV at OSH. Patient
desaturated likely secondary to mild flash pulm edema in setting
of afib. Oxygenation improved with atrovent and Lasix 20mg IV x
2. TTE showed severe systolic dysfunction and mod-severe MR. She
was diuresed with IV lasix until euvolemic. She remained
euvolemic for several days before discharge.
# Subcutaneous Emyphysema/Oropharyngeal Perforation: Patient
was transferred to [**Hospital1 18**] initially for management of this
complication. Bronch done here showed no tear. Tear likely
healed and subQ emphysema now resolved. She was started on CTX
and Fluc for treatment of possible mediastinitis as she was
febrile at OSH and cont with WBC of 20. Thoracic surgery was
consulted and did not feel any further intervention was
warrented. However, patient spiked fever 2 days later and a CT
showed esophageal perf - likely from traumatic intubation in
field and peri-esophageal abscess. She was taken to the OR and
the abscess was drained. Antibiotics were broadened to include
Vanc, fluc, Zosyn, and cipro. Her blood cx were negative. Swab
cx were positive for GNR ([**11-22**]). Her antibiotics were tailored to
Fluconazole, Zosyn, and Ciprofloxacin (all started on [**2194-2-26**] to
be continued until f/u in thoracic clinic on [**2194-3-14**]).
Antibiotics, stitches, and single remaining penrose with be
d/c'd in thoracic clinic on [**2194-3-14**].
# FEN: Patient had PEG placed during I&D as would not be able to
eat for at least 1 week after abscess drainage given esophageal
rupture. On discharge she had a video study to evaluate her
ability to tolerate oral intake and she exhibited concern for
aspiration. She will require another swallow study within the
next week to evaluate if can transition to oral intake. She did
not have any obvious evidence of a leak, but did aspirate all
liquid consistencies given today [**12-23**] significant
posterior pharyngeal wall swelling. Pt will likely be able to
resume a full PO diet once pharyngeal swelling subsides. Until
then patient will remain NPO with ice chips only.
# HTN: on enalapril at home, continued Enalipril IV while NPO
and then transitioned to PO regimen.
# Anxiety/Depression: held Zoloft and Mirtazapine while NPO.
Held Lorazepam IV given somnolence. Restarted prior to
discharge.
# Hyperlipidemia: held statin while NPO
# Hyperthyroidism: restarted Levothyroxine
Medications on Admission:
MEDICATIONS (at home):
Fosamax 70mg once weekly
ASA 81mg daily
levothyroxine 75mcg daily
Enalapril 20mg daily
mirtazapine 15mg daily
zoloft 50mg daily
Lipitor 10mg daily
ativan 2mg prn
MVI
MEDICATIONS (on transfer):
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
CeftriaXONE 1 g IV Q24H
Lorazepam 0.5-2 mg PO/IV Q4-6H:PRN
Diltiazem 5 mg/hr IV DRIP INFUSION
Enalaprilat 1.25 mg IV Q6H
Famotidine 20 mg IV Q12H
Fluconazole 400 mg IV Q24H
Heparin 5000 UNIT SC TID
Vancomycin 1000 mg IV Q 24H
Metoprolol Tartrate 7.5 mg IV Q6H
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. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed.
3. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous Q6H (every 6 hours) as needed for sticky
secretions.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: Hold for sedation.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tablet PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
16. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) bag Intravenous Q8H (every 8 hours) for 7 days.
17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 1 days.
18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**2194-3-9**] and d/c 400 mg [**Hospital1 **].
19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
20. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 2 days.
23. Outpatient Lab Work
Please check Chem-7, INR on sunday [**3-9**] and call results
to provider and Dr.[**Name (NI) **] office at [**Telephone/Fax (1) 4741**]
goal INR= 2.0-3.0.
24. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
25. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Peri-esophageal abscess
Esophageal perforation
Tracheal tear
Atrial Fibrillation
Discharge Condition:
Patient was afebrile, hemodynamically stable prior to discharge
Discharge Instructions:
You were admitted to the hospital with a rapid heart rate. You
were treated with medications for this.
Medication changes include:
START: Coreg
START: Spironolactone
START: Cipro last day [**2194-3-14**]
Please remember to follow up with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] surgeon,
on [**2194-1-14**]. You will continue antibiotics until that
appointment. At that time the surgeon may elect to remove the
remaining penrose drain as well as the stitches.
Please come back to the hospital or call your primary care
physician if you have fevers, fainting or near-fainting,
shortness of breath, chest pain, palpitations, abdominal pain,
nausea, vomiting, blood in your stools or black tarry stools,
leg swelling or any other concerning symptoms.
Followup Instructions:
Surgery:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4741**] [**2196-3-13**]:00am in the
[**Hospital Ward Name 121**] Building Chest Disease Center [**Hospital1 **] I.
Cardiology:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time:
Monday [**3-24**] at 4:00pm. You will have another echocardiogram
before this appt at 2:00pm. This will be on the [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 436**]. [**Hospital Ward Name 516**] of [**Hospital1 18**].
Primary Care:
Please see Dr. [**Last Name (STitle) 80251**] 1-2 weeks after you have been discharged
from NE [**Hospital1 **]
Completed by:[**2194-3-7**]
ICD9 Codes: 4254, 2760, 5180, 4019, 2449, 496, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4857
} | Medical Text: Admission Date: [**2139-6-18**] Discharge Date: [**2139-6-26**]
Date of Birth: [**2080-11-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Gram Negative rods in CSF.
Major Surgical or Invasive Procedure:
Omaya reseveroir was removed and an external ventricular drain
was placed and subsequently removed.
History of Present Illness:
Mrs. [**Known lastname 1007**] is a 58 yo woman with metastatic breast Ca and
newly dx'd leptomeningeal disease involving brain and spinal
cord. She has had various chemotherapeutic regimens as listed
below, but most recently has been receiving Temodar po and
DepoCyte by Omaya Shunt. On [**2139-6-13**], she was admitted for
nausea and vomitting and was found to have a UTI. After 48
hours, she was discharged home with levaquin. Her husband
reports that she had an outpatient lumbar puncture as well as a
tap of her Omaya shunt earlier today based on some findings from
her MRI on saturday the 23rd. He was told that During there was
a lesion suspicious for puss vs. tumor vs. blood. Today's tap
per pathology, showed three tubes from the LP that were clean,
and one tube from the Omaya shunt that had 3+ Gram Negative
Rods.
The patient was called at home and told that she would be
admitted based on these findings.
Past Medical History:
Metastatic Breast CA with leptomeningeal disease
Hypothyroidism
Social History:
She has a bachelor's degree. She is retired.
She used to work as an insurance [**Doctor Last Name 360**]. She is married. She
lives with her spouse. She does not smoke. She does not drink.
She denies any recreational drug abuse.
Family History:
Mother died at 77 of bowel obstruction. She had
a difficult surgery, and bowel obstruction was secondary to
prior
surgeries for colon cancer. Her father died at 77 with coronary
problems. [**Name (NI) **] sister is alive at 47 in good health. She has one
brother who died at 27 in a fire, and she has three other
brothers, 59, 57, 15, in good health. She has two daughters, 30
and 26, in good health and a son, 32, in good health.
Physical Exam:
VITALS: Tc=98.0, P: 116, 110/64, 20
GEN: Appears slightly dry. Thin. Tired. Older than her stated
age. Alert, attentive with exam
CHEST: CTA bilaterally
Back: Sacral ulcer without dressing. No puss or erythema.
CV: regular rate and rhythm No MG/R
ABD: soft, nontender, nondistended, +BS
EXTREM: warm. Well perfused. 2+ DP Bilaterally.
NEURO:
Mental status:
Patient is A+O times 3. She's tired but attentive, flat affect,
speech fluent. Per husbands report, she is at her baseline with
no changes in personality or level of alertness.
Quiet, but speaks spontaneously. Memory intact. Attention good.
Names low frequency objects and follows commands.
HEENT: Head - left frontal region has Omaya reservoir below
sub-cutaneously. No erythema, no edema, no fluctuance. No other
signs of infxn at site.
Eyes - Pupils reactive bilaterally 5 to 4 L and [**2-23**] Right. EOMI.
VFF. No nystagmus. Mouth - Tongue midline, palate elevated
symmetrically. No thrush
Neck - soft, supple
Cranial Nerves: II-VII, IX-XII intact. Intact hearing
bilaterally
Motor - good effort on exam, 4+5 in bilateral UEs
LEs: I/P Legflex LegExt DF PF
R [**2-25**] 4-/5 [**2-25**] 4- 4
L [**2-25**] [**2-25**] 4+/5 4+ 4+
Sensory: intact in all four extremities to LT, PP, cold.
Reflexes:
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 1 1 1 0 0 mute
LEFT: 1 1 1 0 0 mute
Cereberllar: Normal FNF. Gait small steps, requires assist of 1
person. At baseline per husband.
Pertinent Results:
[**2139-6-18**] 01:06PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-12*
POLYS-32 LYMPHS-5 MONOS-0 ATYPS-1 MACROPHAG-62
[**2139-6-18**] 01:06PM CEREBROSPINAL FLUID (CSF) PROTEIN-1080*
GLUCOSE-197 LD(LDH)-144 MISC-CEA=26
[**2139-6-18**] 02:40PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-130*
POLYS-3 LYMPHS-39 MONOS-58
[**2139-6-18**] 02:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-101*
GLUCOSE-134 LD(LDH)-27
Brief Hospital Course:
The patient is a 58-year-old female who is well known to the
neuro-oncology/neurosurgery service at the [**Hospital **] [**Hospital **] Medical
Center. She is known to have metastatic breast carcinoma. The
patient suffers from meningeal carcinomatosis. She had recently
had a CSF reservoir/access device placed by Dr. [**Last Name (STitle) 739**].
The patient now returns several weeks later with a
ventriculitis. The patient is
neurologically in good condition. The Gram stain of the recent
CSF specimen revealed 3+ gram negative rods. The patient is in
need of removal of the previous CSF access
device and placement of a new intraventricular EVD for
infiltration of intrathecal antibiotics which were never given.
She was admitted to the ICU for close neuro observation and
care.She was followed by ID and treated initially with Vanco and
Ceftazdime. Her EVD was kept in until [**6-22**]. She was
transferred to the floor on [**6-23**].
LM disease - pt received IT depocyte and 6/7 days of TMZ. -
MRI of L spine shows stable disease
2) ID - pt now in step down unit. ID wants a full 14days of
Vanc/Ceftaz (ceft started [**6-20**], Vanc started [**6-22**]), all of her
CSF cultures have been negative (1st set done before Abxs). On
Discharge ID recommened 14 days of Levaquin
3) Myopathy - in proximal thighs, probably from steroids, pt was
on decadron taper before, will have husband cont it once d/c'd
from hospital
4) thrush - None today, but would cont nystatin s&s as pt on
decadron
5) GI - spoke to [**MD Number(3) 101312**] service and nurse who will see if pt
is accurate in her statment of no BM for one week.
7) Cerebral edema - husband should cont decadron taper as brain
MRI stable. He has taper schedule given to him.
8) Nausea - cont zydis 10 mg qD, pt not had any nausea since
being put on zydis.
Her exam on discharge was:
Patient is tired but attentive, flat affect, fluent, presodic
speech. A&Ox3. Registration intact. ABle to count 20-->1 without
diff, serial 3's got to 21 and then stopped. Intact
repetition/naming/[**12-26**]-step command. No R/L disorientation. No
ideomotor apraxia. Recall: 0/3 spont, [**11-25**] with lists
HEENT: Head - NC/AT, alopecic from radiation
Eyes - PERRL. EOMI. VFF. No nystagmus.
Mouth - Tongue midline, palate elevated symmetrically. No thrush
Neck - soft, supple
Cranial Nerves: II-VII, IX-XII intact. Intact hearing
bilaterally
Motor - good effort on exam, [**3-27**] in bilateral UEs
LEs: I/P Legflex LegExt DF PF
R [**2-25**] 5/5 [**3-27**] 5 5
L [**2-25**] 5/5 [**3-27**] 5 5
Sensory: Pt stated intact LT even over groin area,
Cereberllar: Normal appendicular coordination. Didn't test gait
Medications on Admission:
Decadron 2 mg Q8H PO
Dolasetron Mesylate 12.5 mg Q8H:PRN IV [**2139-6-13**] @ 1900
Insulin - Sliding Scale Sliding Scale 0 UNIT ASDIR SC [**2139-6-13**]
Pantoprazole 40 mg Q24H PO [**2139-6-13**] @ 1900
Prochlorperazine 10 mg Q6H:PRN IV [**2139-6-13**] @ 1900
Prochlorperazine Maleate 10 mg Q6H:PRN PO [**2139-6-13**] @ 1900
Senna 1 TAB [**Hospital1 **]:PRN PO [**2139-6-13**] @ 1900
Docusate Sodium 100 mg [**Hospital1 **] PO [**2139-6-13**] @ [**2132**]
Clotrimazole 1 TROC QID PO [**2139-6-13**] @ 2200
Olanzapine (Disintegrating Tablet) 5 mg QHS PO [**2139-6-13**] @ 2200
Levothyroxine Sodium 44 mcg QSUN ([**Doctor First Name **]) PO [**2139-6-14**] @ 1300
Pregabalin 50 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**]
Pregabalin 150 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**]
Levothyroxine Sodium 88 mcg QMOWEFR (MO,WE,FR) PO [**2139-6-15**] @
Levothyroxine Sodium 88 mcg QTUTHSA (TU,TH,SA) PO [**2139-6-16**]
Discharge Medications:
1. hospital bed
2. one-step mattress
3. standard wheelchair
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
Decadron 2 mg Q8H PO
Dolasetron Mesylate 12.5 mg Q8H:PRN IV [**2139-6-13**] @ 1900
Insulin - Sliding Scale Sliding Scale 0 UNIT ASDIR SC [**2139-6-13**]
Pantoprazole 40 mg Q24H PO [**2139-6-13**] @ 1900
Prochlorperazine 10 mg Q6H:PRN IV [**2139-6-13**] @ 1900
Prochlorperazine Maleate 10 mg Q6H:PRN PO [**2139-6-13**] @ 1900
Senna 1 TAB [**Hospital1 **]:PRN PO [**2139-6-13**] @ 1900
Docusate Sodium 100 mg [**Hospital1 **] PO [**2139-6-13**] @ [**2132**]
Clotrimazole 1 TROC QID PO [**2139-6-13**] @ 2200
Olanzapine (Disintegrating Tablet) 5 mg QHS PO [**2139-6-13**] @ 2200
Levothyroxine Sodium 44 mcg QSUN ([**Doctor First Name **]) PO [**2139-6-14**] @ 1300
Pregabalin 50 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**]
Pregabalin 150 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**]
Levothyroxine Sodium 88 mcg QMOWEFR (MO,WE,FR) PO [**2139-6-15**] @
Levothyroxine Sodium 88 mcg QTUTHSA (TU,TH,SA) PO [**2139-6-16**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CSF infection.
Discharge Condition:
Stable.
Discharge Instructions:
Please complete the prescribed antibiotics as prescribed.
Please call or return for headache, vision changes, redness,
swelling or drainage from wound, fever, chills, or any other
concern. You also have a decubitus ulcer that should be cared
for by a wound nurse. We are providing you a referral for that
service.
Followup Instructions:
Please return for removal of sutures [**7-4**].
2 weeks after completion of antibiotics, please return for
clinic visit with Dr. [**Last Name (STitle) **] and MRI. Please call Brain [**Hospital 341**]
Clinic to set up an appointment time. ([**Telephone/Fax (1) 6574**].
You will have an appointment with Dr. [**Last Name (STitle) 4253**] on Tuesday
morning at the Infusion Center for intrathecal Depocyte. Her
assistant will call you with the appointment time.
Completed by:[**2139-6-26**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4858
} | Medical Text: Admission Date: [**2158-10-16**] Discharge Date: [**2158-10-19**]
Date of Birth: [**2080-6-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
melena, drop in hct
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo male, h/o recently diagnosed metastatic pancreatic cancer,
presenting from rehab with melena and dropping hct. Pt was
recently admitted here at [**Hospital1 18**] with FTT (weight loss 30 lb,
diarrhea, abdominal pain. Work up at this time included CT scan
of the abdomen which showed a 3.5x5.5 cm mass in the head of the
pancreas with erosion into the duodenal wall, with multiple
mesenteric and hepatic metastases. EGD during this
hospitalization showed gastritis, antral erosions, duodenitis,
and metastatic pancreatic cancer encircling the GDA. He
required transfusions at that time to keep his hct>30. He was
discharged to rehabilitation, to follow up with Dr. [**Last Name (STitle) **]
for further oncologic management.
.
Pt has been at [**Hospital3 **] since that time; labs checked
today showed a hematocrit of 24.5 (29.4 on [**10-9**]) and WBC of
16.5. Pt denies melena or BRBPR, but he states that NH staff
found blood in his stool. He reports diarrhea x 1-2 days ([**11-20**]
loose BM per day) and some lightheadedness with standing. He
denies CP/SOB/PND/orthopnea/fever/chills.
Past Medical History:
1. HTN
2. DM 2
3. Hypercholesterolemia
4. Enlarged prostate, elevated PSA (?biopsy)
5. DJD of right hip
6. Large, left, reducible inguinal hernia
7. CRI, baseline 1.1-1.5
8. Metastatic pancreatic cancer, with hepatic and mesenteric
mets, elevated CA [**71**]-9
9. Gastritis on EGD [**2158-9-16**]:
Stenosis of the gastroesophageal junction
Erosion in the stomach
Erythema in the second part of the duodenum and third part
of the duodenum compatible with duodenitis
Stenosis of the second part of the duodenum
On scope withdrawal a hematoma was seen in cervical
esophagus, just below upper esophageal sphincter.
Social History:
Living at [**Hospital3 **] currently, no family in area, remote
smoking ([**12-22**] yrs) but quit 50 yrs ago, no alcohol/drugs, retired
postal worker; never been married, no kids, has cousin living on
west coast. No health care proxy and has no family or friends to
appoint.
Family History:
Mother died in 70s [**12-21**] unknown causes, father died in 70s [**12-21**]
MI, no siblings
Physical Exam:
VS: 98.9 76 99/54 17 100% RA
Gen: elderly male, somewhat disheveled, poor dentition, A&Ox3,
pleasant
HEENT: PERRL, OP clear, poor dentition, MMM; with some asymmetry
of right eyelid/droop
Neck: no LAD, no JVD
Lungs: CTA bilat, no w/r/r
CV: irreg rhythm, nl s1/s2, no m/r/g appreciated
Abd: soft, nt/nd, nabs, no reb/guard
Extr: no c/c/e, PT 1+ bilat
Neuro: CN II-XII intact with lid droop as above, 4+/5 strength
diffusely, toes downgoing bilaterally, MS as above
Skin: multiple nevi diffusely, especially on torso/back, ?SKs
(?sign of [**Last Name (un) **]-Trelat)
Pertinent Results:
Labs:
[**2158-10-16**] 06:58PM WBC-18.2*# RBC-2.77* HGB-8.0* HCT-22.5*
MCV-81* MCH-28.8 MCHC-35.4* RDW-16.0*
[**2158-10-16**] 06:58PM GLUCOSE-354* UREA N-44* CREAT-1.5* SODIUM-133
POTASSIUM-5.3* CHLORIDE-93* TOTAL CO2-27 ANION GAP-18
[**2158-10-16**] 06:58PM CK(CPK)-64
[**2158-10-16**] 06:58PM CK-MB-NotDone cTropnT-0.1*
[**2158-10-16**] 06:58PM PT-13.2 PTT-18.9* INR(PT)-1.2
.
Imaging:
CXR: no infiltrate, perhaps small bilateral effusions
.
CT Abdomen: large pancreatic head mass, slightly larger; still
with encasement of gastroduodenal artery (unchanged); small
filling defect in base of right lung
.
EKG: NSR 68, LAD, ST depr in I, II, AVL, V5, V6; unchanged from
prior
Brief Hospital Course:
1. UGIB: In the ED, he was hemodynamically stable, and his hct
was 22.5. He was transfused 2 U PRBC. A CT abdomen was obtained
and was unchanged except slight in crease in the pancreatic
mass. The pt was monitored overnight in the MICU. He was given
[**Hospital1 **] proton pump inhibitor. He was transfused an additional 1U
and given bicarbonate in his IVF for renal protection. He was
then transfered to the floor.
On the floor the pt continued to have slow blood loss. GI was
consulted but an EGD was deferred because no therapeutic options
were seen and the pt was reluctant to have a procedure done. The
pt was hemodynamically stable. He was thought to have chronic
bleeding most likely from multiple small lesions in the duodenum
and erosive gastritis. He received one more unit of PRBC on the
floor. The pt will probably continue to require transfusions if
the hct continues to fall. Plan was coordinated between Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] at the [**Hospital3 2558**] to have
hematocrits drawn every 4 days as long as he does not have
grossly bloody stools and will be scheduled for regular blood
transfusions through the pheresis unit at [**Hospital1 18**] with scheduling
through [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 46376**].
2. Goals of Care: The pt was addressed regarding the goals of
his care. Palliative care was involved in this discussion. It
seemed that the pt was not able to make a decision for CMO at
this point. He wanted to continue receiving blood transfusions
but opposed chemotherapy.
3. Leukocytosis: The pt initially presented with leukocytosis.
The source was unclear source, and it may originated from a
stress response or might be due to malignancy. The pt did not
have any localizing symtpom. Urine and blood cultures were
negative at time of discharge.
4. Chronic renal insufficiency. The pt was thought to be
slightly volume depleted due to blood loss and resolved after
resuscitation. The pt was given post-CT hydration with sodium
bicarbonate and his creatinine was monitored and remained
stable.
5. NSTEMI: The pt was noted to have an asymptomatic NSTEMI with
elevated cardiac enzymes (0.12->0.15). This likely occurred in
the setting of demand ischemia. Atenolol was stopped initially
but then was restarted at half dose 12.5mg.
6. Communication: Has cousin in [**Name (NI) 36413**]; states does not know
her address or phone number and would not want her contact[**Name (NI) **] in
an emergency/change in status; no HCP designated
Medications on Admission:
Meds on Admission:
Lipitor 40 mg
MVI
Atenolol 50 mg
Prilosec 40 mg
Insulin SS
Mylanta PRN
No known allergies
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO
BID:PRN as needed.
Disp:*30 Capsule(s)* Refills:*0*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
Disp:*qs * Refills:*2*
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
Disp:*100 ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Metastatic pancreatic cancer
Upper GI bleeding
NSTEMI
Discharge Condition:
Fair, hematocrit stable for >24 hours
Discharge Instructions:
Please come back to the hospital if you experience any
lightheadedness, chest pain, shortness of breaths or any
concerns. If you develop black or bloody stools you should also
inform your doctors [**First Name (Titles) **] [**Hospital3 **] immediately.
Followup Instructions:
please follow up with Dr. [**Last Name (STitle) **] in the [**Hospital3 **].
ICD9 Codes: 5859, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4859
} | Medical Text: Admission Date: [**2173-7-20**] Discharge Date: [**2173-8-16**]
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Cephalosporins / Gabapentin /
Quinolones / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Emergent ascending aorta and hemiarch replacement
Open J-tube
Tracheostomy
History of Present Illness:
Mrs. [**Known lastname 67952**] is an 82 yo F who was transferred from [**Hospital **]
Hospital with a diagnosis of type A dissection, obtained by CT
scan in the course of work-up for shortness of breath and chest
pain. She was taken to the operating room urgently for repair
of her type A dissection.
Past Medical History:
HTN
DMII
Hypercholesterolemia
osteoporosis
R. breast ca, s/p mastectomy
R. arm lymphedema
Spondylolisthesis
s/p TAH
Social History:
Lives with husband
Denies tobacco or EtOH
Family History:
NC
Physical Exam:
At time of discharge:
Alert, follows commands, moves all 4 extremities, however very
minimal on left
PERRL, does not open eyes spontaneously
RRR, no murmurs appreciated
Lungs with coarse BS b/l, no w/r/r
Abd soft, NT/ND, +bs, J-tube in place
LE with trace edema b/l, UE with 2+ edema
Pertinent Results:
CTA head [**7-22**]: 1. Subacute ischemic infarction in the area of
the R. central gyrus, likely related to the recent aortic repair
surgery. No embolus, thrombus, or areas of significant stenosis
seen.
2. Moderate-sized pleural effusion with compressive atelectasis
in the left lung.
[**2173-8-16**] 03:13AM BLOOD WBC-4.8 RBC-3.24* Hgb-9.6* Hct-28.1*
MCV-87 MCH-29.7 MCHC-34.4 RDW-15.3 Plt Ct-286
[**2173-8-16**] 03:13AM BLOOD Glucose-115* UreaN-12 Creat-0.2* Na-139
K-4.1 Cl-99 HCO3-36* AnGap-8
Brief Hospital Course:
On [**2173-7-20**], Ms. [**Known lastname 67952**] was transferred from [**Hospital **] Hospital
to the cardiac surgery service under the care of Dr. [**Last Name (STitle) **]
with a diagnosis of a Type A aortic dissection. She underwent
emergency ascending aortic arch and hemi arch replacement with a
24mm Gelweave graft. Cross clamp time was 70 mins., total
bypass time was 110 mins., and circ. arrest time was 22 mins.
Post-operatively she was transferred to the CSRU in stable
condition. On POD 1 she was noted to have left sided weakness,
was not opening her eyes spontaneously, and a neurology consult
was obtained. A CTA of her head revealed ischemia in the right
precentral gyrus. She continued to be in afib and was placed on
amiodarone, ASA, and heparin ggt. A dobhoff feeding tube was
placed on POD 3 and she was started on enteral nutrition. She
was extubated, but required agressive respiratory therapy for
management of secretions.
She had a bronch on POD#5 which revealed mucous plugging. She
remained lethargic and required intermittent bronchs. She was
also unable to complete a swallowing evaluation and had tube
feeds. Her neuro status gradually improved, but she still
remains quite lethargic. On POD#15 she underwent placement of
an open J tube.
She continued to progress and did continue to require aggressive
respiratory therapy, and eventually had a trach on POD#21. She
had not had afib for 10 days and did not require further
anticoagulation. Neuro was in aggreement with this as well. On
POD#22 she had a R thoracentesis and 700cc of straw colored
fluid was obtained. An bilateral ultrasound of the chest showed
minimal effusions on [**2173-8-13**]. She continued to progress and on
POD#26 she was discharged to rehab in stable condition.
Medications on Admission:
Vasotec 2.5", zocor 40', oscal 500"', actonel 35mg Wqk,
glucophage 500"
Discharge Medications:
1. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H (Every 3 to 4 Hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Captopril 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP <100, HR <60.
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO BID (2 times
a day).
13. Metoclopramide 5 mg IV Q6H:PRN nausea/vomiting
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for temperature >38.0.
16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Type A aortic dissection
Right sided CVA
AFib
DMII
HTN
Discharge Condition:
Stable
Discharge Instructions:
Call your doctor or go to the ER if you experience any of the
following: severe pain, increasing nausea/emesis, worsening
shortness of breath, fevers >101.5, pus draining from wound, or
any other concerning symptoms. Continue chest PT, suctioning as
needed, and tube feeds at goal.
Followup Instructions:
Dr. [**Last Name (STitle) **] - call for an appointment [**Telephone/Fax (1) 170**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) 13090**] for 2-3 weeks
Completed by:[**2173-8-16**]
ICD9 Codes: 5180, 9971, 5185, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4860
} | Medical Text: Admission Date: [**2101-10-30**] Discharge Date: [**2101-11-3**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 yo female s/p fall while walking down concrete steps at
church; fell approx. 6 ft hitting her head; No LOC per EMS
report. She was transported from scene to [**Hospital1 18**] for further
care.
Past Medical History:
CVA on Coumadin since [**2-4**]
Hypertension
Right shoulder surgery
Social History:
Resides in an [**Hospital3 **] facility
Has a son and 2 grandchildren
Family History:
Noncontributory
Pertinent Results:
[**2101-10-30**] 10:15PM HCT-23.6*#
[**2101-10-30**] 10:15PM PT-16.0* INR(PT)-1.5*
[**2101-10-30**] 12:46PM GLUCOSE-170* UREA N-35* CREAT-1.1 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-25 ANION GAP-18
[**2101-10-30**] 12:46PM CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-2.1
[**2101-10-30**] 12:46PM WBC-24.0* RBC-3.95* HGB-10.9* HCT-32.1*
MCV-81* MCH-27.7 MCHC-34.1 RDW-15.2
[**2101-10-30**] 12:46PM PLT COUNT-258
[**2101-10-30**] 12:46PM PT-16.1* PTT-33.6 INR(PT)-1.5*
CT HEAD W/O CONTRAST
Reason: r/o bleed
[**Hospital 93**] MEDICAL CONDITION:
89 year old woman s/p fall
REASON FOR THIS EXAMINATION:
r/o bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 89-year-old woman on Coumadin status post fall,
evaluate for bleed.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: There are areas of increased hyperdensity along the
sulci in the right temporal and insular regions, suggesting
subarachnoid hemorrhage versus contusion. Asymmetric extra-axial
fluid collections, greater on the left side are seen, possibly
representing sequelae of old subdural hematoma. There is a
component of hypodensity within the left extra-axial collection
consistent with acute subdural hemorrhage. The left extra-axial
collection measures approximately 1.1 cm in greatest diameter.
There is associated rightward shift of approximately 7 mm. Low
density seen within the right thalamus possibly represents old
infarct. Ventricles appear relatively symmetric and the basal
cisterns remain patent. Soft tissue hematoma is noted along the
right scalp. Visualized portions of the paranasal sinuses appear
normally aerated.
IMPRESSION:
1. Areas of hyperdensity along the sulci in the right temporal
and insular regions, suggest subarachnoid hemorrhage versus
contusion.
2. Asymmetric extra-axial fluid collection, left greater than
right, with hypodense component suggesting acute subdural
hemorrhage. There is associated rightward shift of approximately
7 mm pelvis. This could possibly be chronic and correlation with
patient's history is recommended.
3. Right-sided scalp hematomas.
CT HEAD W/O CONTRAST
Reason: r/o expanding bleed
[**Hospital 93**] MEDICAL CONDITION:
89 year old woman s/p 5 foot fall today.
REASON FOR THIS EXAMINATION:
r/o expanding bleed
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL HISTORY: 89-year-old female status post five-foot fall.
Evaluate for expanding bleed.
COMPARISON: Non-contrast CT head from [**2101-10-30**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There are prominent bifrontal extra-axial collections,
which appears increased (especially on the right) compared to
one day prior. Given acuity of increase of the size of this
extra-axial collection, which is of CSF density, this most
likely reflects an acute subdural hygroma. There is a small area
of hyperdensity along the along the dural surface of the right
parietal region, which is unchanged and may represent a small
subdural hematoma. The small amount of subarachnoid blood in the
right sylvian fissure is largely unchanged. No new focus of
hemorrhage. There is no shift of normally midline structures,
however, there is slight mass effect on the on the bilateral
convexities secondary to the extra- axial collections. The
ventricles and cisterns are normal. The soft tissue
hematoma/laceration along the right scalp is noted once again.
The visualized paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION: Increased size of bifrontal extra-axial collections
likely representing acute subdural hygroma. Stable appearance of
small subarachnoid blood in the right sylvian fissure. Probable
small left parietal subdural hemorrhage, unchanged. No new focus
of hemorrhage.
CT C-SPINE W/O CONTRAST
Reason: r/o fx.
[**Hospital 93**] MEDICAL CONDITION:
89 year old woman s/p fall
REASON FOR THIS EXAMINATION:
r/o fx.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 89-year-old woman status post fall.
COMPARISON: None.
TECHNIQUE: Non-contrast axial scans of the cervical spine were
obtained. Coronal and sagittal reformatted images were also
displayed.
FINDINGS: There is no evidence of acute fracture or abnormal
prevertebral soft tissue swelling. Severe degenerative changes
are noted throughout the cervical spine with mild grade-I
retrolisthesis of C5 on C6, with disc space loss at multiple
levels. CT does not provide intrathecal detail comparable to
MRI, however, the thecal sac grossly appears intact. Visualized
portions of the lung apices appear clear.
IMPRESSION:
1. No evidence of acute fracture or abnormal prevertebral soft
tissue swelling.
2. Cervical spondylosis.
Cardiology Report ECG Study Date of [**2101-10-30**] 12:44:38 PM
Sinus rhythm with PVCs
Cannot rule out septal infarct - age undetermined
Left ventricular hypertrophy
Lateral ST-T changes are probably due to ventricular hypertrophy
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 176 96 368/388.42 32 14 83
ECHO [**2101-11-2**]
Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D
or color Doppler. Left ventricular wall thickness, cavity size,
and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is
normal. Right ventricular chamber size and free wall motion are
normal. The
ascending aorta is moderately dilated. The aortic valve leaflets
are severely
thickened/deformed. There is severe aortic valve stenosis. No
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to
moderate ([**1-31**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Severe/critical aortic stenosis with preserved LVEF.
At least mild
to moderate mitral regurgitation with moderate MAC.
Brief Hospital Course:
She was admitted to the Trauma service. Her forehead laceration
was sutured. She received FFP and tetanus in the Emergency
department. Neurosurgery was consulted because of her injuries;
these were nonoperative. She was loaded with Dilantin and will
continue on Keppra for a total of 4 weeks at which time she will
follow up with Dr. [**Last Name (STitle) 548**] for repeat head imaging. There have
been no observed or reported seizure activity.
Orthopedics was consulted because of her right humerus fracture;
this was nonoperative. She is to remain non weight bearing on
her right arm and will follow up next week with Dr. [**Last Name (STitle) 1005**],
Orthopedics for repeat films.
She underwent ECHO; her EF 65% (see full report in Pertinent
results section).
Speech and Swallow were also consulted because of dysphagia; she
initially failed her bedside swallow evaluation. As her mental
status improved she was re-evaluated; her diet was upgraded and
she is tolerating this without difficulty.
Physical nad Occupational therapy were consulted and have
recommended short term rehab stay.
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
twice a day as needed for constipation.
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily): hold fro
HR <60; SBP <110.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day as needed for per sliding scale.
9. Colace 150 mg/15 mL Liquid Sig: Fifteen (15) ML's PO twice a
day: hold for loose stools.
10. Milk of Magnesia 800 mg/5 mL Suspension Sig: Ten (10) ML's
PO once a day as needed for constipation.
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 days.
12. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 weeks: begin on [**2101-11-6**] a.m. dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p Fall (5 ft)
Subarachnoid hemorrhage
Acute on chronic subdural hematoma
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you develop any fevers, severe
headaches, visual disturbances, seizure activity, nausea,
vomiting and/or any other symptoms that are concerning to you.
DO NOT bear any weight on your right arm because of your
fracture
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 4 weeks. Call
[**Telephone/Fax (1) 2992**] for an appointment; inform the office that you will
need a repeat head CT scan for this appointment.
Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics, in 1 week, call
[**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2101-11-3**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4861
} | Medical Text: Admission Date: [**2195-12-23**] Discharge Date: [**2195-12-31**]
Date of Birth: [**2119-6-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tetracycline / Codeine
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
left upper lobe nodule.
Major Surgical or Invasive Procedure:
76 yo F s/p Left thoracotomy, Left upper Lobectomy [**12-23**]
Past Medical History:
CAD s/p stenting, hypothyroid, hyperchol, GERD, sciatica
Social History:
lives alone. Former smoker- one ppd quit [**2152**].
no etoh
Family History:
non-contributory
Physical Exam:
general: well appearing elderly female in NAD.
Reap: CTA bilat.
cor: RRR S1, S2
abd: soft, NT, Nd, +BS
Extrem: no C/C/E
neuro: A+OX3. no focal deficits.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2195-12-29**] 05:20AM 7.5 3.15* 9.4* 25.8* 82 29.7 36.2* 14.1
246
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2195-12-29**] 05:20AM 91 12 1.0 141 4.2 106 231 16
Brief Hospital Course:
Pt was admitted on [**2195-12-23**] and taken to the OR for bronch, left
VATS wedge biopsy proceeding to left mini thoracotomy for left
upper lobectomy for nodule.
PT was admitted to the PACU intubated d/t hypothemia nd slow
awakening. Once recovered, she was extubated. Left chest tube
and [**Doctor Last Name **] to wall sxn w/o leak draining moderate amts serosang
drainage. CXR w/o PTX. Pain control in initial post op period
unrelieved requiring increased epidural and toradol.
POD#[**11-30**] Chest tubes water seal. Improved pain control. [**Last Name (un) **] Reg
diet.
POD#[**1-30**] pain well controlled. temp spike 103. pan cultured.
Lethargic w/ mottled LE. HR and BP stable. CT obatined to eval
for INfection vs. PE.
Chest CT w/ IMPRESSION:
1. No evidence for pulmonary embolus.
2. Left hydropneumothorax, as described. Infection of this
collection cannot be excluded.
3. The presumed residual left upper lobe has an abnormal
appearance, as described. There is probable mucous plugging to
the bronchus in this region. Differential diagnosis includes
infection, post-obstructive pneumonitis, and re-expansion edema
post-operatively. Given the probable mucous plugging,
bronchoscopy could be considered.
4. Interval increase in the size of the largest right upper lobe
nodule from the prior PET- CT from [**2195-11-11**]. The band-
like parenchymal opacity also has a more nodular component on
the current study. These findings may relate to interval
progression of an infectious/inflammatory process, though a
neoplastic process cannot be excluded. Correlation with the
pathology findings from the left upper lobe is recommended.
5. Small-moderate right pleural effusion.
6. Left renal cyst, incompletely characterized on this study.
Based on these findings pt was transferred to the CSRU and was
bronched for large mucous plug at take off of LUL. started on
Zosyn.
POD#5 Mental status improved. Vanco added to zosyn. Repeat
bronch w/ bloody secretions- lavaged until clear. Transferred
from CSRU to floor. Epidural d/c'd.
POD#[**5-4**] Cont's to improve. Chest tube and [**Doctor Last Name **] d/c'd. improved
ambulation and activity tolerance.
POD#8 d/c'd to daughter -in law's home w/ VNA and PT services.
Also will be on po augmentin x 2weeks. Follow up w/ Dr. [**Last Name (STitle) **]
in 2weeks.
Medications on Admission:
fosamax 70 qweek, nexium 20', crestor 10', toprol 100',
synthroid 100'
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 15-30 MLs PO
Q4H (every 4 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
8. 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*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Coronary artery disease s/p stents [**2189**] normal EF, hypothyroid,
gastric esophogeal reflux disease
left thoracotomy, left upper lobectomy
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office/ Throacic Surgery office [**Telephone/Fax (1) 170**]
for: fever, shortness of breath, chest pain, excessive foul
smelling drainage at chest tube site.
Take regular medications as prior, take new medications as
directed.
No driving if taking narcotic pain medication
no tub baths for 4 weeks.
You may shower 2 days after chest tube removed.
VNA Services through Caritas Home Care.
Followup Instructions:
Call Dr.[**Doctor Last Name 4738**] office/ Throacic Surgery office [**Telephone/Fax (1) 170**]
for appointment in [**9-10**] days.
please arrive for your follow up appointment 45 minutes early
and report to the [**Hospital Ward Name 23**] Clinical center [**Location (un) **] radiology
for a follow up CXR before your appointment.
Completed by:[**2195-12-31**]
ICD9 Codes: 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4862
} | Medical Text: Admission Date: [**2192-8-29**] Discharge Date: [**2192-9-4**]
Date of Birth: [**2119-8-5**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 y.o. male with a h/o COPD (6-7LO2 at home) and CHF, presents
after losing consciousness while moving from his wheelchair into
a car. Mr [**Known lastname **] noticed that his oxygen tank was empty while
in a parking garage. He does not know how long it had been
empty. He attempted to begin to start another tank, but lost
consciousness before he was succesful. He reports no prodrome:
he only comments that he noticed his oxygen was gone and then
passed out. His wife states that a concerned samaritan then
helped drag her husband out of the car onto the ground. He
apparently had a pulse and was breathing. Together, they
restarted his oxygen. She reports that he was probably
non-responsive for ~5min. She thinks he was mostly motionless
but one of his arms might have been shaking. After the episode,
he was brielfy "groggy", but was coherent, and was brought to
the ED.
.
His baseline COPD is 6L O2 at rest, 7L with exertion; he is
fatigued after walking ten feet. He has had no recent change in
his exertional capacity and has not noticed an increase in his
baseline cough. He has been producing clear phelgm. At baseline,
he has orthopnea and PND, requiring him to sleep with his bed
elevated and two pillows. He has a h/o of Afib with a pacemaker
placed in 6/[**2192**]. He has no other h/o of cardiac disease. He has
no h/o of seizures or prior syncope.
.
He denies bowel or bladder incontinence. He has not had recent
nausea, vomiting, diarrhea, or decreased PO intake. He has not
noticed increased edema. He denies chest pain, palpitations,
pleurisy, fever, chills, and sweats.
.
In the ED, he was somnolent but repsonisive. He was given
Furosemide (40mg IV), Methylprednisone (125mg IV), and started
on Nebulizers (Ipratropium, Albuterol). He initially had a
non-rebreather with 100%O2. proBNP returned at 15,123 (baseline
not known). Initial ABG was 7.33/46/68. WBC was increased to
15.0. On weaning to 6L NC, his O2 sat decreased to 81-82%
Past Medical History:
Illnesses/Hospitalizations
- COPD: diagnosed ~20 yrs ago; 7L O2 with exertion; Reportedly
desats into 70s with exertions while on O2. 3 Hospitlizations
for "COPD flares" since [**2192-1-7**]. Recently hospitalilzed
when 20mg QD Prednisone was decreased to 10mg Prednisone QD.
- CHF: EF?, reports being hospitlaized for CHF in [**2190**]
- Atrial Fibrillation: diagnosed in [**6-/2192**]; has pacemaker; on
warfarin
- Herpes Zoster: aggravated with Prednisone
- Anxiety/Depression
- Cataract in right eye; "torn retina (?)" in left eye
- DVT/PE in the past
- cath 3 years ago- clean coronary
Social History:
Mr. [**Known lastname **] lives with his wife in a private one-story home in
[**Location (un) 5450**], NH. He had left an eye appointment at [**Hospital3 **]
Associates before his LOC. He did not receive any medication at
that appointment, except for having his pupils dilated.
He has ~100 pack-year history and has not smoked in 20 years. He
denies EtOH and recreational drug use. Last ETOH 32 years ago.
Family History:
- Colon CA: Father, Brother
- Brother: "Ht Valve", AAA
- Sister: Died from massive brain hemorrhage at 70
Physical Exam:
-Gen: Resting comfortably on O2 non-rebreather. Responsive but
somnolent. Able to speak in full sentences without dyspnea. No
use of accesory muscles or respiration.
- HEENT: Pupils Minimally reactive (Dilated at Ophtho Appt),
Fundi: Corneal opacities seen bilaterally
- Neck: No JVD
- CVS: RRR; Distant Heart sounds; Nl S1 and S2; 2/6 SEM best at
LLSB
- Resp: Decreased breath sounds throughout; Expiratory wheezes;
No crackles
- Abdomen: Protuberant. Midline scar. +BS. Non-tender. No
apparent hepatosplenomegaly. there is firmness at midline of the
abdomen (site of previous mesh placement)
- Extremities: Compression stockings on; 1+ pitting edema
bilaterally; No clubbing or cyanosis
- Skin: Ecchymoses on elbows, no rashes; Radial and PT pulses 2+
and symmetric
-neuro: alert and oriented x 3. somnolent but arousable
Pertinent Results:
Blood cultures- NG
Urine culture- NG
Sputum Contaminated
CXR- emphysema, possible LLL opacity, no effusion
CTA- possible tiny central filling defect in RUL pulmonary
artery- artifact vs small nonocclusive thrombus
CK: 36 MB: Notdone Trop-*T*: 0.02
CK: 43 MB: Notdone Trop-*T*: 0.02
Brief Hospital Course:
1. Pneumonia: Mr. [**Known lastname **] was placed back on oxygen as
described once admitted to the ICU, though he required more
oxygen than was his baseline. Postulated to be secondary to
pneumonia, likely aspiration given patient's leukocytosis,
initial CXR consistent with LLL pneumonia (although it is hard
to interpret in the setting of prior lung surgery). During his
stay, he had increased sputum production, but remained afebrile.
With presumed pneumonia in the setting of syncope, the
possibilty of aspiration was considered, and for this reason, he
was started on levofloxacin 500 mg po daily and flagyl 500 mg po
TID for a 7 day course, all of which were completed in the [**Hospital1 18**]
MICU.
.
2. COPD: Albuterol and atrovent nebs were continued, patient was
placed on prednisone taper, tapered to 20 mg prednisone daily
with plans for a 30 day course (started on [**2192-9-2**]). In
evaluating other causes for Mr. [**Known lastname 62449**] increased oxygen
reqirement, pulmonary embolism was considered and ruled out by
CT angiogram as well as a negative lower extremity ultrasound.
On discharge, he required 6L of O2 via NC (which is his
baseline), as well as 12 L face-tent. He is able to transition
from bed to chair and feels that his dyspnea is at baseline
despite some increased oxygen need. The patient desires to be
closer to his home in NH, and in discussion with case
management, it was felt that he needed to be transferred to an
acute rehabilitation facility that could accommodate his
increased oxygen requirement. Apparently, the patieny has also
been bridging to hospice care over the last month and is in
actively on the path to transitioning to hospice care.
.
3. Pulmonary Hypertension: Given syncope in the setting of known
CHF and dyspnea, an echocardiogram was obtained which showed
severe global right ventricular free wall hypokinesis. There was
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. Moderate [2+] tricuspid
regurgitation was seen. There was also severe pulmonary artery
systolic hypertension (60-80 mmHg).
.
4. CHF: LVEF on Echo >55%, though patient has known CHF. During
his ICU stay, he had several episodes of acute shortness of
breath with lung crackles that responded well to lasix. Cardiac
enzymes were negative and EKG has been unchanged. Isordil was
started to improve congestion. Lisinopril was also started. He
will also continue on lasix.
.
5. ARF: Pt's creatinine was initially 1.9 on admission trended
down to 1.2 on discharge with diuresis.
.
6. Atrial fibrillation/increased INR: Patient on coumadin for
atrial fibrillation, though coumadin doses have been gradually
decreased and then held due to patient's rising INR. This is
postulated to be due to the fact that patient has been taking
levofloxacin for pneumonia. INR on day of discharge was 2.1, and
coumadin was restarted 1 day prior to discharge at 2 mg daily.
Medications on Admission:
Nebulizers (DuoNeb) 4Xday
- Flovent 2 puffs [**Hospital1 **]
- Prednisone 10mg [**Hospital1 **]
- Acyclovir 400mg QD
- Ketoconazole 400mg ONCE/WK (Dose due today [**8-28**])
- HCTZ 25mg QD
- Furosemide 40mg [**Hospital1 **]
- Coumadin: 3mg Wednesday/Satruday, 2mg all other days
- Citalopram 20mg [**Hospital1 **]
- Mirtazapime 45mg QD
- Lorazepam 1mg TID PRN
- Guafinesin 600mg QD
- Solifenacin 5mg QD
- Pantoprazole 40mg QD
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebs
Inhalation Q4H (every 4 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
8. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
9. VESIcare 5 mg Tablet Sig: One (1) Tablet PO daily ().
10. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO MTTHFSUN
().
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
13. Ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO 1X PER
WEEK ().
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
15. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
18. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
19. Aspirin 325 mg Tablet Sig: One (1) Tablet PO ONCE (once) for
1 doses.
20. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
21. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
22. Prednisone 20 mg po daily x 27 days (at least).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
1. Aspiration pneumonia
2. COPD: diagnosed ~20 yrs ago; 7L O2 with exertion; Reportedly
desats into 70s with exertions while on O2. 3 Hospitlizations
for "COPD flares" since [**2192-1-7**].
3. CHF, LVEF >55% on ECHO
4. Pulmonary hypertension
5. Acute Renal Failure
.
Secondary:
1. Atrial Fibrillation: diagnosed in [**6-/2192**]; has pacemaker; on
warfarin, increased INR in-house secondary to quinolone use.
2. Herpes Zoster: aggravated with Prednisone
3. Anxiety/Depression
Discharge Condition:
stable
Discharge Instructions:
PLease return to the hospital ot let your doctor knows if you
have increased oxygen requirement, chest pain or if there are
any concerns at all
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge
from the hospital.
ICD9 Codes: 5070, 496, 4280, 5849, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4863
} | Medical Text: Admission Date: [**2126-3-21**] Discharge Date: [**2126-5-19**]
Date of Birth: [**2126-3-21**] Sex: F
Service: NEONATAL
HISTORY: Baby Girl [**Known lastname 49805**] was the 955 gram product of a
28-2/7 week gestation, born to a 37 year old gravida 2, para
2 mother. Pregnancy was uncomplicated until mother presented
on the day of delivery with severe right upper quadrant pain.
Laboratory results showed increased liver function tests and
slight decrease in platelets, one plus proteinuria and high
blood pressures. She was diagnosed with pre-HELLP syndrome
and labor was induced by pitocin. Mother was given one dose
of betamethasone and magnesium sulfate. Cord prolapsed but
infant delivered vaginally alongside cord. The infant
emerged without spontaneous respiratory effort but responded
well to 15 second bag mask ventilation. The infant was
transported to the Newborn Intensive Care Unit with
spontaneous respirations and blow-by O2. Apgars were
assigned at 6, 7 and 8.
PHYSICAL EXAMINATION: Unremarkable. Anterior fontanel open
and flat. Palate intact. Positive red reflex bilaterally.
Breath sounds equal with inspiratory crackles and grunting,
flaring and retracting noted. Normal S1, S2. No audible
murmurs. Pink and well perfused. Abdomen benign with three
vessel umbilical cord. Normal external female genitalia.
Infant appropriate for gestational age. Birth weight was 955
grams, length was 35 centimeters.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: [**Known lastname 8254**] was initially
intubated on admission to the Newborn Intensive Care Unit for
management of respiratory distress syndrome. Her maximum
ventilator settings were 18/5, with rate of 5. She received
two doses of Surfactin and was extubated at 24 hours of age
to CPAP of 5 centimeters. She remained on CPAP for
approximately 24 hours and was transitioned at that time to
room air where she had remained throughout her hospital
course. She was empirically started on caffeine citrate for
management of apnea and bradycardia of prematurity and
caffeine citrate was discontinued on [**Month (only) 956**] ....., [**2126**].
Her last episode of apnea of bradycardia was on [**2126-3-11**].
2. CARDIOVASCULAR: She has been cardiovascularly stable
throughout her hospital course without issue. The patient
has an intermittent murmur consistent with peripheral
pulmonary stenosis.
3. FLUID AND ELECTROLYTES: Birth weight was 955 grams.
Discharge weight is 2680. The infant was initially
started on 80 cc. per kilo per day of D10W. Enteral feedings
were initiated on day of life two. The infant advanced to
full enteral feedings by day of life ten and maximum enteral
intake was 150 cc. per kilo per day of premature Enfamil of
30 calorie with ProMod. She is currently ad lib feeding of
Enfamil 26 calorie taking in adequate amounts. $ calories are
added via concentration 2 by corn oil.
4. GASTROINTESTINAL: Peak bilirubin was on day of life two
of 7.5 over 0.3. She was treated with phototherapy for a
total of six days. Rebound bilirubin was 2.6/0.3 in the
infant and this issue has resolved.
5. HEMATOLOGY: Hematocrit on admission was 57.1. The
infant has not required any blood transfusions during this
hospital course and her most recent hematocrit and
reticulocyte count were 33.6 with a reticulocyte count of
6.3% on [**2126-3-21**]. She is currently receiving
Fer-In-[**Male First Name (un) **] supplementation of 2 mg per kg per day in addition
to enteral feedings.
6. INFECTIOUS DISEASE: A CBC and blood culture obtained on
admission was CBC benign. Antibiotics were initiated with
Ampicillin and Gentamicin and at 48 hours blood cultures
remained negative and antibiotics were discontinued at that
time. The infant has not had any further issues with sepsis
during this hospital course.
7. NEUROLOGIC: Head ultrasounds were performed on day of
life seven and day of life 30 and they are within normal
limits and physical examination is appropriate for
gestational age.
Hearing screen was performed with automated auditory brain
stem responses and the infant passed both ears.
Car seat test passed.
Ophthalmology: The infant has been seen
by Ophthalmology and
her most recent examination was on [**2126-5-8**], stage 1
O3, o.u. with follow-up in three weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] in [**Location (un) 745**],
[**State 350**]. His telephone number is [**Telephone/Fax (1) 41277**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Continue ad lib feeding, Enfamil 24
calories.
2. Medications: Fer-In-[**Male First Name (un) **] with administration of 2 mg per
kg per day.
3. Car Seat Position Screening has been performed and the
infant.......................
4. State Newborn Screen has been sent per protocol.
5. Immunizations received: Hepatitis B vaccine on [**2126-5-10**]. Received her DTPA, HIB, IPV, Pneumococcal 7 valiance
on [**2126-5-18**].
6. Immunizations recommended: Synagis RSV Prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
that meet any of the three criteria: 1) Born at less than 32
weeks; 2) born between 32 and 35 weeks with plans for day
care during RSV season, with a smoker in the household, or
with preschool siblings or 3) with chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Former 28-3/7 weeker.
2. Status post respiratory distress syndrome.
3. Status post rule out sepsis with antibiotics.
4. Status post apnea and bradycardia of prematurity.
5. Status post anemia of prematurity.
6. Status post hyperbilirubinemia.
7. Retinopathy of prematurity.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 38444**]
MEDQUIST36
D: [**2126-5-17**] 17:09
T: [**2126-5-17**] 21:47
JOB#: [**Job Number 49806**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4864
} | Medical Text: Admission Date: [**2133-8-3**] Discharge Date: [**2133-8-15**]
Date of Birth: [**2085-6-19**] Sex: M
Service: [**Last Name (un) **]
PRESENT ILLNESS: The patient is a 48 year old male who
presented [**7-24**], at which time the patient had a
laparoscopic cholecystectomy, a laparoscopic intraoperative
ultrasound, and attempted laparoscopic segment 5 resection
converted to open segment 5 resection adjacent to the
gallbladder. The operative note is dictated in detail by Dr.
[**First Name (STitle) **]. At that point the patient was transferred to the
intensive care unit and eventually transferred to the floor
and discharged home. The patient re-presented to the
emergency room on [**2133-8-3**] with lethargy and severe
dehydration. His [**Location (un) 1661**]-[**Location (un) 1662**] drain which he was sent home
with was putting out approximately 1800 cc per day. His
admission creatinine was 4.1. His admission white blood cell
count was 30.6. His AST was 233. His ALT was 142. His
alkaline phosphatase was 131. Bilirubin was 1.4. Blood
cultures were sent upon admission and revealed 4 out of 4
positive vials of methicillin sensitive staph aureus. Fluids
sent from the JP also revealed methicillin sensitivity staph
aureus.
PAST MEDICAL HISTORY: Morbid obesity, hypertension, NIDDM,
sleep apnea.
PAST SURGICAL HISTORY: Left knee surgery.
MEDICATIONS: Admission medications of Metformin, Lisinopril,
Hydrochlorothiazide, Nifedipine, Reglan and Glipizide.
HOSPITAL COURSE: The patient was admitted to the transplant
surgery service and hydrated. Over the course of the next 5
days his creatinine improved back to his baseline of 1.0. The
[**Location (un) 1661**]-[**Location (un) 1662**] drain was removed on hospital day 4. However,
on hospital day 8 the patient had a bump in creatinine to 1.8
and a guaiac positive stool. An NG tube was placed which
revealed a significant amount of blood. A significant drop in
hematocrit was also seen. The patient was transferred to the
intensive care unit and had an endoscopy performed. Three
collapsed varices were banded by Dr. [**Last Name (STitle) **],
gastrointestinal service. The patient became rapidly
unstable, was intubated in the intensive care unit. His
hemodynamics were completely off and they were requiring
pressors. His LFTs significantly increased to an AST of 4567
and an ALT of 923, alkaline phosphatase of 653 and a
bilirubin of 8.7. His INR at that time was also significantly
elevated at 2.5. Mr. [**Known lastname **] at that point was requiring a
significant amount of support. He was paralyzed with a Swan
Ganz catheter in place. He had maximum pressors with Levophed
and Octreotide, as well as Vasopressin. He was on maximum
ventilation support which was eventually switched to pressure
control ventilation with continued maximal oxygenation. He
was also started on CVH for significant acidosis and volume
overload. He was placed on broad spectrum antibiotics, which
included Vancomycin, Zosyn, Fluconazole and Flagyl.
The patient's status continued to deteriorate despite the
maximal support. On [**8-14**] the patient had multiple coding
episodes with V-tach, asystole, pulseless electrical activity
in which ACLS protocol was initiated. This happened 4 times.
After discussion with the family and the intensive care unit
attending, as well as the surgical attending, it was decided
the patient should be made DNR.
The morning of [**8-15**] at 7:20 a.m. the patient expired.
CONDITION ON DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. Status post segment 5 liver resection.
2. Morbid obesity.
3. Hypertension.
4. Non-insulin dependent diabetes mellitus.
5. Sleep apnea.
The patient's family agreed to postmortem, which was
performed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2133-8-15**] 17:11:35
T: [**2133-8-15**] 18:39:21
Job#: [**Job Number 62223**]
ICD9 Codes: 5845, 5715, 2851, 4275, 4019, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4865
} | Medical Text: Admission Date: [**2100-9-26**] Discharge Date: [**2100-10-1**]
Date of Birth: [**2026-12-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Patient is 73M with PMH sig. for lung cancer s/p lobectomy,
bilateral PEs on coumadin who presented with an acute episode of
hemoptysis. Pt reports that he was watching TV yesterday evening
when he started coughing up blood into his tissue. He feels the
blood is running down the R side of his throat. He persisted to
cough for about an hour for a total of 2 cups, and drive himself
to OSH. He noted that walking from the parking lot to the ED, he
felt SOB. However, this is chronic for him. He also had one
episode of hemoptysis about 2.5 weeks ago. A CTA from OSH showed
a new 3.9x2.7 x 2.8 cm L suprahilar mass impinging upon or
invading the left pulmonary artery and obstructing L apical
segmental bronchus with either tumor or mucus plugging in the
adjacent segmental bronchi. INR was 1.9. Pt was reversed with 10
mg of vitamin K and 4 units of FFP at OSH.
In the ED, initial VS: 98.6 103 158/98 20 97 on 3L. CXR shows no
infiltrate. IP was made aware.
ROS: He has DOE, feeling SOB after walking 15 feet. He has a
chronic clear cough. Denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
DM2
HTN
COPD
HL
Lung cancer s/p RUL resection 5 years ago
Bilateral PEs 5 years ago, on coumadin
h/o neurofibroma
Social History:
Pt usually lives alone but his son has recently moved in with
him. Retired truck driver. Previous smoker of 4ppd x 50 years,
quit 5 years ago 2 mo before lung cancer diagnosis. No ETOH or
drug use.
Family History:
FAMILY HISTORY: Breast cancer--daughter died of metastatic
breast cancer at age 35 yo.
Physical Exam:
Vitals - T: 98.2 BP:115/87 HR:123 RR:22 02 sat:92% on 2L
GENERAL: NAD; seems to have trouble catching his breath
HEENT: PERRL; EOMI; mucous membranes moist; neck supple; no
lymphadenopathy.
CARDIAC: tachycardic; irregular rhythm
LUNG: CTAB; decreased breath sounds over upper chest division
b/l
ABDOMEN: NT ND nl BS
EXT: 2+ DP; no edema
NEURO: CN II-XII intact; normal sensation; 5/5 strength although
easily winded.
DERM:no rashes or ecchymoses
Pertinent Results:
Admission Labs:
[**2100-9-26**] 01:40AM WBC-9.9 HGB-15.1 HCT-43.0
[**2100-9-26**] 01:40AM NEUTS-77* BANDS-0 LYMPHS-16* MONOS-5 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2100-9-26**] 01:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
[**2100-9-26**] 01:40AM PLT COUNT-224
[**2100-9-26**] 01:40AM GLUCOSE-201* UREA N-18 CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-23 ANION GAP-18
[**2100-9-26**] 12:29PM PT-14.9* PTT-21.3* INR(PT)-1.3*
.
CXR [**9-26**] - 1. Post-surgical changes, with volume loss of the
right hemithorax.
2. Likely small bilateral pleural effusions.
3. Increased reticular opacities in the lung bases bilaterally,
could reflect a chronic interstitial abnormality.
4. Rounded opacity projecting over the left superior hilus, may
reflect a
vessel or a pulmonary nodule.
Spirometry:
SPIROMETRY 10:35 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 3.40 4.89 70
FEV1 1.37 3.21 43
MMF 0.42 2.71 16
FEV1/FVC 40 66 61
LUNG VOLUMES 10:35 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 5.58 7.76 72
FRC 3.25 4.47 73
RV 1.96 2.87 68
VC 3.73 4.89 76
IC 2.33 3.30 71
ERV 1.29 1.60 81
RV/TLC 35 37 95
He Mix Time 1.38
DLCO 10:35 AM
Actual Pred %Pred
DSB 13.49 25.51 53
VA(sb) 4.72 7.76 61
HB 14.10
DSB(HB) 13.69 25.51 54
DL/VA 2.90 3.29 88
[**2100-9-30**] Radiology FDG TUMOR IMAGING (PET-
IMPRESSION: 1. FDG-avid left suprahilar mass, difficult to
separate from the
hilus. 2. Small left apical ill-defined opacity is also
FDG-avid, raising
concern for a second site of neoplastic involvement. 3.
Multifocal opacities predominate at the right lung base, likely
reflecting infection or aspiration. Component of mild volume
overload, as described. 4. Extensive coronary artery
atherosclerotic calcifications.
[**2100-9-27**] Pathology Tissue: ENDOBRONCHIAL BX, LUL
Squamous cell carcinoma, likely invasive.
[**2100-9-27**] Cytology TBNA LYMPH NODE STATION 4L
Rare groups of atypical epithelial cells with prominent
nucleoli present in a background of many bronchial cells and
scattered lymphocytes; no definite evidence of lymph node
sampling.
Brief Hospital Course:
73M with PMHx sig. for lung cancer s/p lobectomy, bilateral PEs
on coumadin who presented wtih acute SOB followed by coughing up
2 cups of hemoptysis. He was admitted to the MICU where he
received a bronchoscopy that initially showed blood in the L
bronchus. He was stabilized and transferred to the medicine
floor. A brief description of his hospital stay according to
problem is described below:
# Hemoptysis: His hemoptysis was likely due to his endobronchial
lesion and its proximity/involvement with the pulmonary artery.
This lesion was found to be squamous cell carcinoma. His
coumadin was stopped and he was treated with vit K and FFP at
the outside hospital before coming in. His INR was 1.1 on
admission to [**Hospital3 **]. He had a bronchoscopy that revealed
that the bleeding had stopped and he did not have hemoptysis
during his hospitalization. He had serial coags for goal INR
<1.5, serial HCT q8-12 hrs, an active type and screen. Tessalon
pearls to prevent coughing that could exacerbate the bleed.
#Lung cancer: Patient mass found to be a squamous cell
carcinoma. He received a PET with CT scan for staging. He was
put into contact with the oncology team to discuss his treatment
options.
#Atrial Fibrillation: patient found to have AFib in the
bronchoscopy suite after his procedure. He was rate controlled
with diltiazem while in the hospital. Cardiology was consulted
and agreed with his discarge dose of diltiazem 480 ER once a
day. Given his recent episode of hemoptysis, anticoagulation
was not started given the risk of severe bleeding. He will see
in PCP 3 days after discharge to check his rate and adjust the
medicine as needed.
# DM2: Patient's home medication was stopped and he was put on
a humalog ISS while in house.
# COPD: Patient found to have severe emphysema on CT scan and
with PLT's. His home advair was continued and he was treated
with xoponex and ipratropium nebulizers. This improved his
symptoms subjectively. He still required 2-4L of O2 to maintain
O2 sats in the 90's and was discharged home with O2 tank.
# Hyperlipidemia: we continued his home lovastatin
# Code: DNR/DNI
# CONTACT: [**Name (NI) **] (separated wife, [**Name (NI) 382**] [**Telephone/Fax (1) 84557**]
Medications on Admission:
Warfarin 5 mg daily
Metformin 500 mg [**Hospital1 **]
Gemfibrozil 600 mg [**Hospital1 **]
Glyburide 10 mg qam, 7.5 mg qpm
Mucinex 600mg [**Hospital1 **]
Advair 500 mcg-50 mg inh [**Hospital1 **]
Lovastatin 40 mg daily
Iron 325 mg
MTV
Discharge Medications:
1. Oxygen
2-4L continous pulse dose for portability
2. Nebulizer machine
Please provide patient with nebulizer machine and supplies for
at home.
Dx: lung cancer and COPD
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea, cough.
Disp:*28 nebulizers* Refills:*0*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
10. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
Disp:*500 ML(s)* Refills:*0*
11. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
12. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) solution Inhalation q 4 hrs () as needed for wheeze,
cough.
Disp:*120 solution* Refills:*0*
13. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day.
18. Glyburide 5 mg Tablet Sig: 1-2 Tablets PO once a day: Take
two tablets in the morning and 1.5 in the evening.
19. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
20. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Lung cancer
Discharge Condition:
Stable; Atrial fibrillation, rate controlled with diltiazem
Discharge Instructions:
You are being sent home with a couple of important medicine
changes.
.
1. Diltiazem 480mg long acting before bed. This medication is
for your fast heart rate. Whenever you are not taking this,
your heart rate increases to an alarming level. It is important
that you remember to take every dose of this and that you do not
miss a dose.
.
2. Robitussin with codeine. You can take [**4-18**] ml of this
whenever you have a cough. Preventing a coughing fit can
prevent you from coughing blood again, it is important that you
have good control of this.
.
3. Nebulizer machine with ipatropium and xoponex. This
treatment helped your breathing. Please do this treatment every
six hours.
.
4. Home oxygen. Please keep the oxygen on at home.
.
5. Your coumadin is being stopped due to your risk of bleeding.
.
6. Levofloxacin 750mg daily for 7 more days. You have an
infection, please take this to treat the pneumonia.
.
You have the following appointment with Dr. [**Last Name (STitle) **] to make
sure that your heart rate is being controlled on the medicine
given.
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Date and time: Tuesday, [**10-5**] at 2:15pm
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **], ONE PEARL
ST, [**Apartment Address(1) 84558**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone number: [**Telephone/Fax (1) 10381**]
.
Your information has been given to the oncology team and they
will call you for an appointment to discuss your diagnosis and
treatment options.
Specialty: Oncology
Phone number: [**0-0-**]
Special instructions if applicable: You will be called with an
appt date, time and oncologist name for an appt. If you do not
hear from the office by Monday, [**10-4**] please call above
number.
.
Please return to the ER or call your doctor if you cough blood,
have increasing shortness of breath, chest pain, fever, or any
other alarming symptoms.
Followup Instructions:
You have the following appointment with Dr. [**Last Name (STitle) **] to make
sure that your heart rate is being controlled on the medicine
given.
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Date and time: Tuesday, [**10-5**] at 2:15pm
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **], ONE PEARL
ST, [**Apartment Address(1) 84558**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone number: [**Telephone/Fax (1) 10381**]
Your information has been given to the oncology team and they
will call you for an appointment to discuss your diagnosis and
treatment options.
Specialty: Oncology
Phone number: [**0-0-**]
Special instructions if applicable: You will be called with an
appt date, time and oncologist name for an appt. If you do not
hear from the office by Monday, [**10-4**] please call above
number.
Please return to the ER or call your doctor if you cough blood,
have increasing shortness of breath, chest pain, fever, or any
other alarming symptoms.
Completed by:[**2100-10-9**]
ICD9 Codes: 486, 2762, 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4866
} | Medical Text: Admission Date: [**2138-11-20**] Discharge Date: [**2138-11-29**]
Date of Birth: [**2065-11-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
fevers and mental status change
Major Surgical or Invasive Procedure:
pleural tap
History of Present Illness:
72 yo Mandarin speaking female with metastic breast CA who had a
hip fx 2 months ago with a prolonged hospital course and long
recovery at rehab, presents with MS [**First Name (Titles) 767**] [**Last Name (Titles) 1501**] on [**2138-11-20**]. She
also complained of sharp right sided chest pain.
.
Her temp in ED was 102. She received 1L NS, tylenol,
vancomycin, ceftrioxone, [**Date Range **], lopressor and plavix. She was
aditted to [**Hospital1 1516**] for rule out MI and fevers.
Past Medical History:
-- R. breast cancer s/p mastectomy no chemotx /
radiation[according to records from [**Hospital1 **]--pt had 1.9cm
infiltrating, poorly differentiated ductal carcinoma; 8 axillary
nodes (-). ER/PR negative & HER-2/Neu 3+. Pt reportedly lost to
follow-up after mastectomy - 10 years ago per notes. Chest CT
from [**2138-10-14**] shows "extenisive tumor mass involving the right
anterior chest wall & ribs...there appears to be increase in the
extent of . The lesion extends from the level of the aortic arch
caudally to the inferior costal margin." ]
-- s/p excisional bx of right neck lymph node [**10-3**] (for purpose
of assessing recurrance of breast CA via tumor markers
-- Stage 4 sacral decubitus ulcer
-- Osteoarthritis (according to son)
-- Anemia NOS
-- Pulmonary nodule (6mm) seen on [**10-3**] CT, unchanged from prior
scan
-- Calcified lung granuloma (? remote h/o TB)
--- choledolithiasis - 3 months ago @ MWH, had subsequent
sphintorectomy and biliary duct stenting placed with improvement
in n/v -> subsequent functional decline with overall weakness
leading to R hip Fx after a fall at home.
--- R hip replacement - 6 weeks ago - s/p ORIF, subsequent care
at [**Hospital1 **]
--- SI/attempt [**1-30**] to hip fx and associated pain
Social History:
Pt moved from [**Country 651**] to US 10yrs ago to live w/ her son & his
children. She has served as primary care giver for them. Has two
sons in [**Name (NI) 651**]. Hopes to move back one day.
Family History:
NC
Physical Exam:
Vitals: T: 97.4 BP:84/51 P:89 R:12 SaO2: 98% 2L
General: appropriate, answering question in chinese, cachetic
woman.
HEENT: NC/AT, temporal wasting, anicteric, dry MM, clear OP
without lesions.
Neck: no JVD, flat neck veins
Pulmonary: Lungs CTA bilaterally;
Cardiac: RRR, nl. distant HS; S1S2, no M/R/G noted
Abdomen: + BS x 4 quadrants, soft, NT/ND, no masses or guarding
Rectal: Guiac positive in ED. Large area of skin breakdown with
necrotic area, exposed bone, area ~ 5 cm diameter with minimal
surrounding erythema.
Extremities: No edema, no cyanosis.
Skin: no rashes or lesions noted, no extremity skin breakdown
Pertinent Results:
CXR [**2138-11-20**]: Right lower lobe pneumonia with a small
parapneumonic effusion.
.
EGK [**11-20**]: 99bpm Sinus rhythm. Low limb lead voltage. There is
diffuse slight ST segment elevation.
.
TTE:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
Moderate tricuspid regurgitation.
.
MR head:
Moderate brain atrophy. No enhancing brain lesions to indicate
metastatic disease.
.
MR [**Name13 (STitle) **]:
1. There is no spinal cord compression.
2. There are STIR and T1 hyperintense lesions in C7 and T2 most
consistent
with hemangiomas.
.
MR [**Name13 (STitle) 2854**]:
There is no evidence of metastatic disease to the thoracic spine
or thoracic spinal cord compression.
.
MR [**Name13 (STitle) **]:
1. No lesion is seen that suggests a lumbar spine metastasis.
2. There is moderate degenerative stenosis at L4-5 where there
is grade 1
spondylolisthesis and posterior element hypertrophy.
.
CT chest, Abd, pelvis:
1. Large right breast/anterior chest wall soft tissue mass,
measuring
approximately 7.4 cm in size, eroded the adjacent sternum.
Associated right lateral chest wall 1.2 cm subcutaneous deposit.
Moderate-sized layering right pleural effusion with three right
upper lobe/right middle lobe nodules. No primary lung mass
identified. No additional osseous metastatic lesions seen.
2. Calcified lung nodule with associated multiple calcified
mediastinal nodes suggest prior tuberculosis exposure.
3. Pneumobilia with distended intra- and extra-hepatic biliary
ducts. No
hepatic metastases visualized.
4. Large right sacral decubitus ulcer extending to the
sacrum/coccyx, chronic osteomyelitis cannot be excluded.
5. Right total hip replacement without evidence for loosening.
No acute
fracture or dislocation.
.
Pleural fluid Cytology: PND
.
Bone scan:
Patchy uptake involving the anterior right ribs and sternum
correlates with right chest wall osseous tumor invasion on CT
scan.
Uptake around the trochanteric portion of the right hip
prosthesis may relate to surgery, but if there had been a
pathologic fracture initially, residual osseous tumor cannot be
excluded.
Brief Hospital Course:
72 YO mandarin speaking woman with metastatic breast cancer and
recent hospitalization for hip fracture, state IV ulcer, and
recent suicide attempt who presents with fevers, N/V and found
to have pneumonia, UTI, bacteremia, Stage IV decubitus ulcer,
pleural effusion.
.
# Fever: Has multiple sources of infection including RLL PNA
treated with a course of azithromycin and at time of discharge
no cough or sputum production, lungs are clear. UTI with
enterococcus, Strep milleri bacteremia. At time of discharge,
she was afebrile, normal WBC count. Stage IV decubitus ulcer
dressing changes and family teaching. Will complete a 14 day
course of antibiotics with moxifloxacin per ID recommendations.
Pleural effusion was tapped and showed exudate negative for
bacterial culture. AFB stain was negative. Cytology is pending
at the time of discharge. It is thought the pleural effusion is
most likely associated with her malignancy but await cytology
results.
.
# ID: During her hospitalization, the infectious disease service
was concerned about active tuberculosis. Her pleural effusion
was negative for AFB stain. Pulmonary does not believe that
further evaluation is needed. Infectious disease and infection
control have cleared patient for active TB; she does not need to
wear mask at home OR have contact TB precautions when
hospitalized (unless she develops new symptoms suspicious for
TB) at which point this will need to be reevaluated.
.
# HYPOTENSION: Likely [**1-30**] [**Month/Day (2) **] dose. She only had low grade
temperatures and her lactate was normal which argues against
sepsis. However, she currently has multiple infections and a
dramatic stage IV decubitus ulcer which puts her at high risk
for sepsis. She responded to IVF and is currently at her
low-normal baseline. (Her son reports that her SBP runs between
100-105.)
.
# MS CHANGE: She is back to baseline currently, confirmed with
son. This was likely from her multiple infections. MRI head
was negative for metastatic disease
.
# ANEMIA: She had a HCT drop from 27 to 22 and responded to 32
after 1u of pRBC. She denies blood in stool but was guaiac + is
ED. She has iron panel suggesting anemia of chronic disease.
She takes iron at home. She was continued on iron and her HCT
was monitored and PPI continued. At the time of discharge her
HCT was stable in the mid 30s.
.
# CARDIAC: She has small (if even present) ST elevations in II,
II, AVF and no old EKGs to compare. Cardiology saw patient in
ED and recommended [**Last Name (LF) 30474**], [**First Name3 (LF) **] and plavix. Three sets of
cardiac markers were unremarkable. The family refused cath.
[**First Name3 (LF) **] and plavix discontinue. [**First Name3 (LF) **] discontinued [**1-30**]
hypotension. Echo showed normal L and R ventricular function
with moderate TR.
.
# BREAST CA: She has metastatic disease to chest wall and ribs.
MRI is negative for mets to brain. She received mastectomy in
the past but has never received chemo or radiation per OSH
records. Of note, her decline in the past 7 weeks is quite
dramatic. Per family, she was cooking and cleaning 7 weeks ago
and now she cannot walk and has urinary incontinence. MRI of
spine was negative for evidence of cord compression. CT showed
large right breast/anterior chest wall soft tissue mass, eroded
the adjacent sternum. Associated right lateral chest wall 1.2
cm subcutaneous deposit. Moderate-sized layering right pleural
effusion with three right upper lobe/right middle lobe nodules.
No primary lung mass identified. No additional osseous
metastatic lesions seen. Pleural effusion tapped and cytology is
pending. Pain control provided. Lymph node cytology obtained
from OSH revealing metastatic disease.
.
# CODE STATUS: At time of discharge, patient is DNR/DNI. The
status has been changed throughout the hospitalization to await
family arrival from [**Country 651**]. Currently DNR/DNI per patient and
family.
Medications on Admission:
Pantoprazole 40 mg qd
remeron 7.5 mg po qd
Fragmin 2500U qd
iron
Discharge Medications:
1. Hospital Bed
Needs hospital bed, this is a medical necessity.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain: [**Month (only) 116**] cause
drowsiness. .
Disp:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY (): Apply to
hip. Leave for 12 hours, then take off for 12 hours. .
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
8. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for loose stools.
Disp:*60 Tablet(s)* Refills:*2*
10. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 5 days: Begin on [**11-30**]. .
Disp:*5 Tablet(s)* Refills:*0*
11. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
12. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for nausea: Take as needed for nausea.
Disp:*100 Tablet(s)* Refills:*2*
13. Sterile Gauze Bandage Sig: As Directed Topical twice a
day: 4x4 size
Wound care as directed.
Disp:*2 boxes* Refills:*2*
14. Aquacel Hydrofiber Dressing Bandage Sig: As directed
Topical twice a day: 4x4 size
Wound care as directed.
Disp:*2 boxes* Refills:*2*
15. Aloe Vesta 2-n-1 Protective Ointment Sig: As directed
Topical twice a day: Wound care as directed.
Disp:*1 Tube* Refills:*2*
16. Normal saline
Normal saline for wound irrigation
17. Dressing Sponges Bandage Sig: As directed. Topical
twice a day: Wound care as directed.
Disp:*2 Boxes* Refills:*2*
18. Medfix Tape Sig: As directed Topical twice a day:
Wound care as directed.
Disp:*2 Rolls* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
UTI
Bacteremia-S. milleri
Metastatic breast cancer
Stage 4 sacral decubitus ulcer
.
SECONDARY DIAGNOSIS:
Osteoarthritis
Anemia NOS
Pulmonary nodule, per report unchanged from prior exam
Calcified lung granuloma
Sphintorectomy and biliary duct stenting
Suicide ideation/attempt
Discharge Condition:
Stable, afebrile, respiratory status stable
Discharge Instructions:
Please take all medication as prescribed.
.
If you develop a fever, cough, night sweats, or weight loss, or
any other symptoms that care concerning to you, call you primary
care doctor.
.
Continue to eat and drink as tolerated. Ensure Plus is a good
supplement that you should drink three times daily as tolerated.
Followup Instructions:
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **], phone: [**Telephone/Fax (1) 70737**]
.
Follow up pleural fluid cytology with your primary care
physician.
ICD9 Codes: 7907, 486, 5990, 2761, 2767, 2930, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4867
} | Medical Text: Admission Date: [**2130-3-10**] Discharge Date: [**2130-3-24**]
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
weight loss and no appetite
Major Surgical or Invasive Procedure:
[**2130-3-16**]
Right DL PICC
[**2130-3-20**]
1. Laparoscopic reduction of hiatal hernia.
2. Repair of diaphragm with pledgets.
3. Suture repair of gastric perforation.
4. Peg tube placement.
History of Present Illness:
Mr. [**Known lastname **] is a pleasant 87 years old man, previously relatively
healthy, who developed anorexia and had a 15 lbs weight loss
over the past 6 weeks. He states that he had his last full
"real" meal about 6 weeks ago after which he "lost interest" in
eating. He specifically denies any problems with dysphagia, pain
with eating or swallowing, choking, food getting stuck, early
satiety, nausea or vomiting. He also denies any fevers or
chills, and continues
to have small bowel movements. Over the past 6 weeks he has been
only taking liquids to stay hydrated, no solid food, and has
lost at least 15 lbs as a result. He has a very mild shortness
of breath but in general aside from "not wanting to eat" denies
anything else that is bothering him at present.
He has visited his PCP several times and was finally referred
for admission to [**Hospital **] Hospital due to failure to thrive. He
had a CT today which shows a large left diaphragmatic hernia
with abdominal contents in the left chest, with organo-axial
volvulus. He received zosyn and Protonix 40 at [**Hospital1 **] and was
transferred here for further management of this complex surgical
problem.
Past Medical History:
PMH: afib, chf, HTN, High Cholesterol
PSH: midline incision for stone retrieval from ureter
Social History:
No tobb/etoh/drugs, retired professor of biology at a local
community college.
Family History:
non contributory
Physical Exam:
Temp: 98.5 HR: 89 BP: 100/62 RR: 20 O2 Sat: 97% RA
GENERAL [ ] All findings normal
[ ] WN/WD [x] NAD [x] AAO [x] abnormal findings: cachectic
man
HEENT [x] All findings normal
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[ ] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [ ] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[x] Abnormal findings: dry mucous membranes
RESPIRATORY [x] All findings normal
[x] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [x] No spine/CVAT
[x] Abnormal findings: decreased breath sounds at left lung base
CARDIOVASCULAR [x] All findings normal
[x] RRR [ ] No m/r/g [x] No JVD [ ] PMI nl [x] No edema
[x] Peripheral pulses nl [ ] No abd/carotid bruit
[x] Abnormal findings:
GI [x] All findings normal
[x] Soft [x] NT [x] ND [x] No mass/HSM [ ] No hernia
[x] Abnormal findings: well healed lower midline abdominal
incision
GU [x] Deferred [ ] All findings normal
[x] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings: poor historian
Pertinent Results:
[**2130-3-10**] 06:11PM WBC-10.6 RBC-3.58* HGB-9.3* HCT-28.0* MCV-78*
MCH-25.9* MCHC-33.2 RDW-18.0*
[**2130-3-10**] 06:11PM NEUTS-89* BANDS-0 LYMPHS-6* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2130-3-10**] 06:11PM PLT SMR-HIGH PLT COUNT-575*
[**2130-3-10**] 06:11PM PT-14.2* PTT-31.4 INR(PT)-1.3*
[**2130-3-10**] 06:11PM GLUCOSE-102* UREA N-19 CREAT-0.6 SODIUM-138
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-25 ANION GAP-18
[**2130-3-10**] 06:11PM ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-69 TOT
BILI-0.7
[**2130-3-14**] CXR :
Patient's condition required examination in upright sitting
position using AP frontal and left lateral views. The heart
shadow is
difficult to delineate in detail because of overlapping
mediastinal structures including a large left-sided hiatal
hernia. Significant cardiac enlargement is unlikely and the
pulmonary vasculature is not congested. Relative prominence of
the central pulmonary vessels is identified but more attenuated
appearance of the periphery does not demonstrate any evidence of
advanced CHF.
There are some old parenchymal scars in the apical area but no
active
abnormalities are seen. Bilaterally, the lateral pleural spaces
are blunted probably by pleural effusions mild-to-moderate
degree. There is a large sized hiatal hernia with typical
air-fluid level in retrocardiac position. No other pulmonary or
cardiovascular abnormalities can be identified. Our records do
not include previous chest examinations available for
comparison. An outside chest CT has been transferred in to our
PACS system and shows the presence of a large hiatal hernia.
[**2130-3-23**] CXR post left thoracentesis
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the hospital, kept NPO and hydrated
with IV fluids. Based on his symptoms and anatomy, repair of his
large paraesophageal hernia was recommended. Unfortunately he
became delirious after having low dose Ativan which was given
preoperatively to reduce his anxiety. He was taken to the
Operating Room for surgery on [**2130-3-15**] but immediately refused
the surgery when he arrived in the Operating Room. He appeared
confused and delirious, the surgery was cancelled and he
returned to the floor.
The Psychiatry service evaluated him and felt that the confusion
and delirium was prompted by Ativan in combination with poor
nutritional status and his age. At that point the patient wanted
surgery again. A decision was made to place a PICC line and
give TPN for 4-5 days prior to operating with the attempt to
help improve his nutritional status. A PICC line was placed on
[**2130-3-16**] and TPN began.
In the mean time he worked with Physical Therapy and had no more
episodes of confusion or delirium.
On [**2130-3-20**] he was taken to the Operating Room and underwent a
laparoscopic paraesophageal hernia repair with PEG tube
placement. He tolerated the procedure well and returned to the
PACU in stable condition. He maintained stable hemodynamics and
his pain was well controlled. Following transfer to the
Surgical floor he continued to make good progress. His pain was
controlled with Tylenol alone and his mental status was intact.
His TPN continued and eventually tube feedings were started and
well tolerated. He was maintained on 2 cal HN 1 can TID. His
TPN was weaned off [**2130-3-23**] and his PICC line was removed.
His chest xray on admission to the hospital was notable for
bilateral pleural effusions but his respiratory status was not
compromised. His effusions did increase in size and on [**2130-3-23**]
he has a left thoracentesis for 1 liter of serosanguinous fluid.
He tolerated it well and his subsequent chest xray demonstrated
no pneumothorax and a clear diaphram. He was breathing
comfortably off of oxygen and had room air saturations of 95%.
He continued to work with Physical Therapy who recommended that
he go to a short term rehab prior to returning home to increase
his mobility and endurance. From a surgical standpoint he
continued to do well. His post sites were healing well and his
PEG site was dry. After a long hospital stay he was discharged
to rehab on [**2130-3-24**].
Medications on Admission:
diltiazem ER 360', ramipril 5', lovastatin 40', lasix 40', asa
81', ? celebrex (unknown dose) -
Discharge Medications:
1. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] PRN
() as needed for hemorrhoid pain.
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. ramipril 5 mg Capsule Sig: One (1) Capsule PO once a day.
5. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for SBP < 100.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Milk of Magnesia 400 mg/5 mL Suspension Sig: Two (2) tbsp PO
at bedtime as needed for constipation.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Giant paraesophageal hernia.
Delirium secondary to medications
Severe protein-calorie malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting
-Increased shortness of breath
Pain
-Take stool softners with narcotics
-No driving while taking narcotics
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2130-4-4**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Completed by:[**2130-3-24**]
ICD9 Codes: 5119, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4868
} | Medical Text: Admission Date: [**2161-7-4**] Discharge Date: [**2161-7-25**]
Date of Birth: [**2091-8-28**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 57860**] is a 69-year-old
female, who has developed sudden onset of abdominal pain,
which was band like and sharp on the day of admission. She
complains of flank and back pain. She states she has had
vomiting, which is nonbilious. She was brought to the [**Hospital1 1444**], and an ultrasound was
performed in the emergency department, which was consistent
with gallstone pancreatitis. The patient denies fevers,
chills, or loose stools.
PAST MEDICAL HISTORY: Significant for hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Toprol XL 50 mg q.d.
2. Norvasc 10 mg q.d.
SOCIAL HISTORY: The patient lives alone at home. She denies
any drug history.
FAMILY HISTORY: The patient is adopted.
PHYSICAL EXAMINATION: Vital Signs: Temperature 98.1 degrees
Fahrenheit, heart rate 60, blood pressure 117/66, respiratory
rate 18, and oxygen saturation 97 percent on room air. In
general, the patient is alert and oriented, and in no
apparent distress. HEENT is normocephalic and atraumatic.
Pupils are equal, round, and reactive to light and
accommodation. Extraocular muscles are intact. Sclerae are
anicteric. Cardiovascular: Regular rate and rhythm, with no
murmurs, rubs, or gallops. No jugular venous distention.
Respiratory: Clear to auscultation bilaterally. No
crackles. Abdomen: Soft, nondistended, with mild bilateral
subcostal tenderness, and epigastric tenderness. There is no
rebound, rigidity, or guarding. No [**Doctor Last Name 515**] sign. Rectal
exam: Negative. Extremities: Warm.
LABORATORY DATA: EKG: Slight ST segment changes in the
precordial leads less than 1 mm, but enzymes are negative
(outside hospital). EKG here unremarkable with sinus rhythm
at 75. Labs obtained in the emergency department: Sodium
144, potassium 3.9, chloride 107, bicarbonate 25, BUN 17,
creatinine 0.7, and glucose 160. White blood cell count
10.2, hematocrit 40.2, and platelets 202,000. AST 320, ALT
268, alkaline phosphatase 319, total bilirubin 2.7, amylase
4514, and albumin 4.8.
HOSPITAL COURSE: Ms. [**Known lastname 57860**] was admitted to the Platinum
Surgery Service on [**2161-7-4**] and underwent an ERCP. The ERCP
demonstrated periampullary edema. There was also dilation of
the distal pancreatic duct. There was minor common bile duct
dilation to 9 mm, and a single 5 mm stone was seen within the
common bile duct that was causing partial obstruction. A
sphincterotomy was performed, and the stone was extracted
successfully using a balloon. The patient was kept n.p.o.
and started on imipenem. On [**2161-7-6**], the patient spiked a
fever to 102.7 degrees Fahrenheit, and was complaining of
shortness of breath with diffuse upper quadrant abdominal
pain. She denied chest pain or nausea and vomiting. An ABG
was drawn, which was essentially normal. The patient's
oxygen was increased to 4 liters, and she was placed on a
facemask. A chest x-ray was obtained, which showed a pleural
effusion, most likely from her pancreatitis. On the morning
of [**2161-7-7**], the patient's oxygen requirements had increased
to 6 liters by facemask and she was still short of breath.
She had decreased breath sounds bilaterally in her lung
bases. Another EKG was done, which showed no change from her
previous EKG. Another ABG was drawn, which was again within
normal limits. Due to increased oxygen demand and shortness
of breath, she was transferred to the ICU for closer
observation. On [**2161-7-9**], a central line was placed and
total parenteral nutrition was started. She was diuresed
with Lasix, and her right chest was tapped. Her blood sugars
were consistently elevated in the 200 range. She was
therefore on an insulin drip for a short time, and then
insulin was added to her TPN, which kept her blood sugars
within the normal range. At one point, she required 180
units of insulin in her TPN per day. She also required BiPAP
for a short while, while in the ICU. On [**2161-7-15**], her pain
had improved to the point where she was able to start sips of
clears. On [**2161-7-15**], she was only requiring 2 liters of
oxygen per nasal cannula, her pain had improved, and she no
longer had shortness of breath. She was therefore
transferred to the floor. On [**2161-7-18**], her imipenem was
discontinued, as she had completed a 14-day course. She
remained on TPN while on the floor. On [**2161-7-20**], the patient
underwent a laparoscopic cholecystectomy for gallstone
pancreatitis. There were no complications. Also, see the
operative note. The patient was kept on TPN postoperatively,
but her diet was advanced as tolerated. Throughout her
hospital course, her liver enzymes had continued to decrease.
However, on [**2161-7-22**], her amylase, alkaline phosphatase, and
total bilirubin all slightly increased. She was therefore
made n.p.o. and restarted on her TPN. When rechecked the
following morning, however, the enzymes had all again fallen.
She was therefore restarted on a low-fat diet. On [**2161-7-23**],
it was noted that there was slight erythema and purulence of
her umbilical port incision. The wound was therefore opened,
and wet-to-dry dressing changes were started 3 times a day.
She was also started on a 7-day course of Keflex. On
[**2161-7-25**], the patient's pain was very well controlled with
oral pain medications, her liver enzymes were still falling,
and she was tolerating a regular diet and p.o. medications.
She was therefore discharged to home with visiting nurses to
assist her with her dressing changes.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Gallstone pancreatitis.
Hypertension.
Status post laparoscopic cholecystectomy.
Status post endoscopic retrograde cholangiopancreatography.
DISCHARGE MEDICATIONS:
1. Percocet 5-325 mg tablets, 1 to 2 tablets p.o. q.4-6h.
p.r.n. for pain.
2. Cephalexin 500 mg capsule, 1 capsule p.o. q.6h. for 5
days.
3. Atenolol 50 mg tablet, 1 tablet p.o. q.d.
4. Multivitamin with minerals, 1 caplet p.o. q.d.
FOLLOWUP PLANS: The patient is to follow up with Dr.
[**Last Name (STitle) **] in 1 to 2 weeks. She is to call his office for an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 11988**]
MEDQUIST36
D: [**2161-7-25**] 14:21:21
T: [**2161-7-26**] 06:27:59
Job#: [**Job Number 57861**]
ICD9 Codes: 5119, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4869
} | Medical Text: Admission Date: [**2166-3-20**] Discharge Date: [**2166-3-24**]
Date of Birth: [**2114-3-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
Melena, hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
51 yo M with HCV, s/p interferon/ribavirin with sustained
virologic response, cirrhosis, liver AVM, GIII esophageal
varices presents with one-2 day of melena and hematemesis.
.
The patient was admitted to [**Hospital1 18**] from [**2-24**] to [**2166-3-4**] for
abdominal pain of unclear etiology. During that admission his
work up EGD with G3 esophageal varices which were not seen on
EGD [**2162**]. He also underwent a liver MRI which showed a liver AVM
which was believed to be worsening his portal hypertension. He
was scheduled for a planned IR coiling of his AVM tomorrow.
However, yesterday he had an episode of melena/BRBPR and today
had what he describes as one cups of hematemesis. He denies
dizziness or lightheadedness but does endorse crampy abd pain.
In the ED, initial VS were: 112 119/85 18 98%. He was given on
liter of fluid and was given a dose of ceftriaxone, pantoprazole
and was started on a octreotide gtt. Hepatology was consulted
who recommended admission and likely endoscopy in the AM. His
tachycardia resolved to HR 77 with 119/56 prior to transfer.
.
On arrival to the MICU, inital vitals were: HR 77 BP 135/77 16
97% on RA . He is complaining of abdominal pain that he says is
severe. The pain started in the ED, is epigastric, associated
with nausea, not associated with SOB or CP.
.
Past Medical History:
Hepatitis C cirrhosis
-s/p interferon with SVR
GIII esophageal varices
GERD
HTN
Diverticulosis ([**12/2163**])
RBBB
Hiatal Hernia
Esophogeal Spasm
eczema
herpes simplex
s/p lipoma removal
MRSA buttock abscess
s/p tonsillectomy
s/p lap CCY ([**2164-1-16**])
PML fissure s/p botox and perianal dermatitis
Social History:
Used to smoke 1-1.5 ppd x 30 years, now just smokes cigars on
occassion. Former EtOH user 20 years ago. Former IVDU (heroin)
18 yrs ago. Currently going through a divorce. He is sexually
active with multiple female partners, always uses condoms except
with his wife.
Family History:
History of CVA in his family. Mother being treated for stomach
cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: HR 77 BP 135/77 16 97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, minimally-tender in RUQ, minimally-distended,
bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
ADMISSION LABS:
[**2166-3-20**] 06:45PM WBC-8.3 RBC-3.98* HGB-12.0*# HCT-37.3* MCV-94
MCH-30.1 MCHC-32.1 RDW-14.5
[**2166-3-20**] 06:45PM NEUTS-76.2* LYMPHS-17.8* MONOS-4.1 EOS-1.6
BASOS-0.2
[**2166-3-20**] 06:45PM PLT COUNT-180
[**2166-3-20**] 06:45PM GLUCOSE-169* UREA N-19 CREAT-0.6 SODIUM-140
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-24 ANION GAP-12
[**2166-3-20**] 06:45PM ALT(SGPT)-56* AST(SGOT)-58* ALK PHOS-63
AMYLASE-114* TOT BILI-0.8
[**2166-3-20**] 06:45PM LIPASE-108*
[**2166-3-20**] 06:45PM ALBUMIN-3.3*
[**2166-3-20**] 06:45PM PT-14.1* PTT-27.7 INR(PT)-1.3*
.
DISCHARGE LABS:
[**2166-3-24**] 05:30AM BLOOD WBC-7.3 RBC-3.32* Hgb-9.9* Hct-30.6*
MCV-92 MCH-30.0 MCHC-32.5 RDW-14.8 Plt Ct-152
[**2166-3-24**] 05:30AM BLOOD PT-12.0 PTT-29.6 INR(PT)-1.1
[**2166-3-24**] 05:30AM BLOOD Glucose-105* UreaN-16 Creat-1.0 Na-136
K-3.5 Cl-102 HCO3-27 AnGap-11
[**2166-3-24**] 05:30AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.0
.
IMAGING:
[**2166-3-21**] EGD:
Findings: Esophagus:
Protruding Lesions 4 cords of grade III varices were seen in
the lower third of the esophagus. There were stigmata of recent
bleeding. 3 bands were successfully placed.
Stomach:
Contents: Clotted blood was seen in the fundus. There was no
gastric varix underneath.
Duodenum: Normal duodenum.
Impression: Varices at the lower third of the esophagus
(ligation)
Blood in the fundus
Otherwise normal EGD to second part of the duodenum
.
[**2166-3-21**] Hepatic Angiogram by IR:
1. High flow arterioportal fistula supplied by the right hepatic
arteryinvolving the border zone parenchyma between the segments
VII and VIII of the right hepatic lobe.
2. Successful deployment of a 6-mm Amplatzer endovascular plug
effectively shutting down the flow through the arterioportal
fistula.
3. Variant early origin of the right hepatic lobar artery
directly from the celiac trunk.
4. Successful deployment of 6 French Angio-Seal closure device
in the right common femoral artery.
Brief Hospital Course:
51 yo M with HCV, s/p interferon/ribavirin with sustained
virologic response, cirrhosis, liver AVM, GIII esophageal
varices presents with one day of melena and hematemesis.
.
.
ACTIVE ISSUES:
# UGIB: Likely UGIB given hematemesis and known varices. He
underwent EGD which showed four cords of grade 3 varices with
stigmata of recent bleeding, but no active bleeding. Three bands
were applied. Hct was 37.3 in ED, baseline low 40s. Was
tachycardic in ED but resolved with 1 L IVF. He was placed on an
octreotide drip and a pantoprazole drip at the time of
admission. His HCTs were trended and stabilized. He was then
transferred to the floor, where his Hct remained stable. Hct at
the time of discharge was 20.6. Patient was started on nadolol
40 mg daily to reduce risk of further variceal bleeding. He
tolerated this well. Additionally, he was treated with 5 days of
ceftriaxone IV to prevent development of SBP.
.
# Liver AVM: Patient was scheduled for planned ablation during
the time period of this hospitalization. He did receive this
procedure on [**2166-3-21**] with successful closure of arterioportal
fistula by amplatzer plug deployment by interventional
radiology. This procedure was uncomplicated.
.
# Abdominal pain: Patient developed epigastric pain on the first
night of this admission. Etiology of epigastric pain is unclear;
may be related to esophageal spasm (as patient believes) vs.
banding of varices vs. coiling of AVM vs. gastropathy. No noted
gastritis on EGD Differential diagnosis also includes
pancreatitis, but amylase only mildly elevated (108). Pain was
well-controlled with morphine IV initially, then oxycodone PO.
Prior to discharge, he was not requiring any PRN pain meds.
.
.
CHRONIC ISSUES:
# HCV Cirrhosis: HCV treated successfully with ribivarin and
interferon in [**2163**]-[**2164**] with sustained response. HCV viral load
undetectable in 3/[**2165**]. Cirrhosis complicated by portal
hypertension and GIII varices which may be exacerbated by AVM.
MELD 9 on admission. Received thourough imaging last admission
including RUQ US, Liver MRI, EGD and [**Last Name (un) **]. This issue was stable
throughout his admission.
.
# Herpes simplex: History of genital herpes. No noted lesions at
present. Patient continued valacyclovir 1000 mg PO daily.
.
.
TRANSITIONAL ISSUES:
# Patient should be scheduled for follow-up EGD to ensure
improvement of varices.
# CODE: Full (confirmed)
# HCP: wife, [**Name (NI) **] - [**Telephone/Fax (3) 13135**]
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. niacin 500 mg Capsule, Extended Release Sig: Two (2) Capsule,
Extended Release PO HS (at bedtime).
3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
4. cholestyramine (with sugar) 4 gram Packet Sig: One (1) PO
once a day.
5. Zofran 4-8 mg po q8h prn nausea/vomiting(called in) disp 30
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. niacin 500 mg Capsule, Extended Release Sig: Two (2) Capsule,
Extended Release PO at bedtime.
3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
4. cholestyramine (bulk) Powder Sig: Four (4) g
Miscellaneous once a day.
5. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
6. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Esophageal variceal bleed
.
Secondary diagnosis:
Liver AVM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 5730**],
It was pleasure to participate in your care here at [**Hospital1 771**]! You were admitted with an upper
gastrointestinal bleed, from esophageal varices, which were
banded in your upper endoscopy procedure. Your blood count
stabilized after this procedure, and you did not require any
blood transfusions. While you were here, you also had the
arterial-venous malformation in your liver coiled by
Interventional Radiology. This procedure went very well.
Please note, the following changes have been made to your
medications:
- START nadolol 40 mg by mouth daily
Resume all of your other outpatient medications.
It is important that you keep your follow-up appointments, as
listed below.
Wishing you all the best!
Followup Instructions:
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2166-3-26**] at 9:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2166-4-2**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: THURSDAY [**2166-4-3**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: TUESDAY [**2166-4-15**] at 7:30 AM [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
ICD9 Codes: 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4870
} | Medical Text: Admission Date: [**2173-2-25**] Discharge Date: [**2173-3-4**]
Date of Birth: [**2106-8-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Naproxen
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
s/p Coronary artery bypass graft (Left internal mammary artery >
left anterior descending, saphenous vein graft > diagonal,
saphenous vein graft > obtuse marginal 1, saphenous vein graft >
obtuse marginal 2) [**2173-2-25**]
History of Present Illness:
66 year old male with alzheimers dementia and history of
coronary artery disease, silent myocardial infarctions with
multiple interventions.
Past Medical History:
Coronary artery disease s/p CABG
Hypercholesterolemia
Hypertension
Venous insufficiency
GERD
Mitral Regurgitation
Dementia
Depression
Obstruction sleep apnea
Pseudogout
Hyperuricemia
Arthritis
Social History:
Retired
Lives with spouse who is primary caretaker
[**Name (NI) 1139**] 50 pack year history quit 25 years ago
Alcohol rare
Family History:
Father deceased at 54 yo from myocardial infarction
Physical Exam:
General Comfortable HR 59, RR 19, b/p 173/94 rt, 183/88 lt
Skin unremarkable
HEENT unremarkable
Neck Supple full ROM
Chest Lungs CTA bilateral
Heart RRR
Abdomen soft, nondistended, nontender, + bowel sounds
Extremeties warm well perfused
Varicosities none
Neuro grossly intact
Pulses palpable
Pertinent Results:
[**2173-3-3**] 04:15PM BLOOD WBC-8.7 RBC-3.56* Hgb-10.5* Hct-28.7*
MCV-81* MCH-29.5 MCHC-36.6* RDW-15.1 Plt Ct-241
[**2173-2-25**] 12:19PM BLOOD WBC-13.6*# RBC-3.49*# Hgb-10.0*#
Hct-28.0* MCV-80* MCH-28.6 MCHC-35.7* RDW-14.1 Plt Ct-160
[**2173-3-3**] 04:15PM BLOOD Plt Ct-241
[**2173-3-1**] 12:01AM BLOOD PT-14.0* PTT-32.4 INR(PT)-1.2*
[**2173-2-25**] 12:19PM BLOOD Plt Ct-160
[**2173-2-25**] 12:02PM BLOOD PT-35.8* PTT-150* INR(PT)-3.80*
[**2173-2-25**] 12:02PM BLOOD Fibrino-52.5*
[**2173-3-3**] 11:10AM BLOOD Glucose-79 UreaN-19 Creat-0.9 Na-143
K-4.4 Cl-111* HCO3-26 AnGap-10
[**2173-2-25**] 01:03PM BLOOD UreaN-13 Creat-0.8 Cl-115* HCO3-24
[**2173-3-1**] 12:01AM BLOOD ALT-21 AST-30 AlkPhos-41 TotBili-1.6*
[**2173-2-26**] 05:41PM BLOOD ALT-15 AST-28 LD(LDH)-269* AlkPhos-35*
TotBili-0.5
[**2173-3-1**] 09:29AM BLOOD Glucose-96 K-3.9
[**Known lastname 13640**],[**Known firstname **] SR [**Medical Record Number 13641**] M 66 [**2106-8-23**]
Radiology Report CHEST (PA & LAT) Study Date of [**2173-3-2**] 10:40
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2173-3-2**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 13642**]
Reason: evaluate for effusion
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p CABG - hx alzeiheimers with
confusion please limit
time in radiology
REASON FOR THIS EXAMINATION:
evaluate for effusion
Provisional Findings Impression: ARHb [**First Name8 (NamePattern2) **] [**2173-3-2**] 12:38 PM
Left lower lung opacity demonstrates interval improvement which
may represent
atelectasis. Small bilateral pleural effusions.
Final Report
INDICATION: History of Alzheimer's with confusion.
COMPARISON: CXR, [**2173-2-25**].
FRONTAL AND LATERAL CHEST: Patient is status post CABG and
median sternotomy.
The cardiomediastinal silhouette appears unchanged. The
pulmonary vascularity
appears stable. Left lower lung opacity, likely representing
atelectasis,
demonstrates mild improvement with small bilateral pleural
effusions noted.
The right lung appears clear and there is no pneumothorax.
IMPRESSION: Improved left lower lung opacity with small
bilateral pleural
effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: WED [**2173-3-3**] 9:20 AM
[**Known lastname 13640**],[**Known firstname **] SR [**Medical Record Number 13641**] M 66 [**2106-8-23**]
Cardiology Report ECG Study Date of [**2173-3-2**] 10:59:26 AM
Sinus rhythm
Prolonged QT interval
T wave abnormalities
Since previous tracing of [**2173-2-25**], ST segment elevation in the
lateral leads
are less
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 140 104 458/475 28 8 61
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 13640**], [**Known firstname **] SR [**Hospital1 18**] [**Numeric Identifier 13643**]
(Complete) Done [**2173-2-25**] at 9:08:48 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-8-23**]
Age (years): 66 M Hgt (in): 70
BP (mm Hg): 140/70 Wgt (lb): 220
HR (bpm): 72 BSA (m2): 2.18 m2
Indication: Chest pain. Coronary artery disease. Left
ventricular function. Right ventricular function. Valvular heart
disease.
ICD-9 Codes: 440.0, 413.9, 414.8, 424.0
Test Information
Date/Time: [**2173-2-25**] at 09:08 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.17
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Lipomatous hypertrophy
of the interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH with normal cavity
size and global systolic function (LVEF>55%). Normal regional LV
systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta. Normal aortic arch diameter. Mildly dilated descending
aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Mild MVP.
Eccentric MR jet. Mild to moderate ([**2-5**]+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: No PS. Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Regional
left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta.
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 myxomatous. There is mild mitral
valve prolapse of the P2 region. An eccentric, posteriorly
directed jet of Mild to moderate ([**2-5**]+) mitral regurgitation is
seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on Mr
[**Known lastname **], P at 8AM before incision.
Post-Bypass:
Preserved biventricular systolic function.
Normal LVEF 55%,
Intact thoracic aorta.
Mild to moderate MR>
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2173-2-25**] 16:13
Brief Hospital Course:
Admitted same day as surgery and underwent coronary artery
bypass graft surgery. Received cefazolin for perioperative
antibiotics. See operative report for further details. He was
transferred to the intensive care unit for hemodynamic
monitoring. In the first twenty four hours he was weaned from
sedation, awoke with confusion but has baseline dementia, and
was extubated without complications. He remained in the
intensive care unit on nitroglycerin drip and management of
confusion receiving haldol. With his confusion at times he
became aggressive with staff. On post operative day four he was
transferred to the floor for the remainder of his care.
Physical therapy worked with him on strength and mobility. He
continued to progress but remained on haldol due to confusion
although no aggressive behavior toward staff. He was confused
with environment, getting in and out of bed frequently,
forgetting were things were in the room which may be due to the
unfamiliar environment. He was ready for discharge home on post
operative day seven with services.
Sternal incision clean no erythema no drainage
Left leg EVH sites no erythema, no drainage
Lower extemeties with +1 edema which is progressively decreasing
Plan to follow up with Dr [**Last Name (STitle) 1683**] on [**3-10**], he has been prescribed
haldol for 1mg at bedtime with repeat dose of 0.5mg once if
needed, wife has been instructed to call Dr [**Last Name (STitle) 1683**] with any
concerns about confusion, agitation, and aggression. Spoke with
Dr [**Last Name (STitle) 1683**] and she will monitor him and manage the haldol dosing,
prescription given for only 20 tablets of 0.5mg.
Social work meet with Wife [**Location (un) **] Elder services and
Alzheimers association were contact[**Name (NI) **] on Mr [**Name (NI) **] behalf.
Medications on Admission:
Atenolol 50 mg daily
Lipitor 70 mg daily
Citalopram 60mg daily
Plavix 75mg daily
Colchicine 0.6 mg daily
Donepezil 10 mg daily
Zetia 10 mg daily
Felodipine 10 mg daily
Fluticasone 50 mcg 2 sprays each nostril daily
HCTZ 25 mg daily
Lisinopril 20 mg daily
Prilosec 20 mg daily
Aspirin 325 mg daily
Tylenol 1000mg twice a day
NTG SL prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily): to each nostril.
Disp:*qs qs* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
7. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime:
1 mg at bedtime, if needed may repeat with 0.5mg one time
no more than 1.5 mg in 24 hours.
Disp:*20 Tablet(s)* Refills:*0*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO once a day:
total dose 60mg .
Disp:*90 Tablet(s)* Refills:*0*
12. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) for 5 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p CABG
Acute Delirium
Hypercholesterolemia
Hypertension
Venous insufficiency
GERD
Mitral Regurgitation
Dementia
Depression
Obstruction sleep apnea
Pseudogout
Hyperuricemia
Arthritis
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-9**] weeks
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2173-3-4**] 2:15
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB)
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2173-3-10**] 11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2173-3-17**] 2:00
Completed by:[**2173-3-4**]
ICD9 Codes: 2930, 2720, 4240, 311, 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4871
} | Medical Text: Admission Date: [**2118-11-15**] Discharge Date: [**2118-11-22**]
Date of Birth: [**2044-8-14**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
74M w/bilateral renal masses
Major Surgical or Invasive Procedure:
[**11-15**] PROCEDURES: Left laparoscopic radical nephrectomy and left
laparoscopic para-aortic lymph node dissection.
[**11-16**] PROCEDURE: Open splenectomy for splenic rupture
History of Present Illness:
1. Peripheral vascular disease.
2. 2.5 cm right renal mass.
3. 3.2 and 1.6 solid left renal masses.
4. [**1-18**] MRI left kidney: 3.1 and 2.1 solid lesion suspicious
for papillary RCC, right kidney: 1.9-cm solid lesion in the mid
kidney suspicious for RCC.
5. [**9-18**] MRI, significant increase in mass, 4.9 cm with
perinephric nodules.
Past Medical History:
PMH: HTN, bilateral renal masses, HLD
PSH: splenectomy [**2118**], lap left radical nephrectomy [**2118**], R CEA
([**Doctor Last Name **]) [**2116**], hernia repair x 2
Social History:
He is a senior project coordinator for the Department of Mental
Health, specializes in [**Doctor First Name **] networks. He has a 50-pack-year
smoking history, continues to smoke one pack per day, occasional
alcohol, no drug use.
He drinks rare alcohol. He is retired but still works two days
a week.
Family History:
Not available at time of dictation
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, appropriately tender along incisions
Incisions c/d/i w/out evidence hematoma, infection
Foley catheter in place, urine yellow/clear
JP to [**Doctor Last Name 14837**] bulb in place.
Extremities w/out edema or pitting and no report of calf pain
Pertinent Results:
[**2118-11-21**] 3:25 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2118-11-22**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2118-11-22**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2118-11-8**] 11:00 am URINE Site: CLEAN CATCH CLEAN CATCH.
**FINAL REPORT [**2118-11-9**]**
URINE CULTURE (Final [**2118-11-9**]): <10,000 organisms/ml.
[**2118-11-21**] 05:20AM BLOOD WBC-17.9* RBC-2.90* Hgb-9.0* Hct-26.3*
MCV-91 MCH-31.0 MCHC-34.2 RDW-13.5 Plt Ct-555*
[**2118-11-20**] 03:06AM BLOOD WBC-18.5* RBC-3.04* Hgb-9.0* Hct-27.6*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.4 Plt Ct-549*
[**2118-11-19**] 03:47AM BLOOD WBC-18.8* RBC-2.82* Hgb-8.5* Hct-25.4*
MCV-90 MCH-30.2 MCHC-33.4 RDW-13.8 Plt Ct-371
[**2118-11-21**] 05:20AM BLOOD Glucose-151* UreaN-14 Creat-1.0 Na-134
K-4.0 Cl-97 HCO3-29 AnGap-12
[**2118-11-20**] 03:06AM BLOOD Glucose-75 UreaN-18 Creat-1.1 Na-137
K-4.1 Cl-98 HCO3-28 AnGap-15
[**2118-11-19**] 03:47AM BLOOD Glucose-81 UreaN-15 Creat-1.2 Na-138
K-4.1 Cl-103 HCO3-28 AnGap-11
[**2118-11-20**] 03:06AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 82579**] was admitted to Urology after undergoing
laparoscopic Left nephrectomy. There was splenic bleeding
intra-op with 50-100cc extravasation, controlled with packing
and dry at the end of the case. Post-operatively Mr. [**Known lastname 82579**]
had hypotension, poor urine output, and 10-point drop in Hct
over 3 hours, so he was taken for emergent splenectomy. Total
received 3u PRBC and 2L crystalloid resuscitation. Excellent
hemostasis at the end of splenectomy but had 350cc bloody JP
output immediately post-op. Remained asymptomatic and JP output
slowed. The patient received perioperative antibiotic
prophylaxis. The patient was transferred to the intensive care
unit from PACU in stable condition. On POD1 he was hydrated for
urine output >30cc/hour, provided with pneumoboots and incentive
spirometry for prophylaxis. He was monitored with serial
hematocrits. He was eventually transferred from the ICU to the
general surgical floor where he made a gradual recovery and was
advanced with diet. Basic metabolic panel and complete blood
count were checked, pain control was transitioned from PCA to
oral analgesics, diet was advanced to a clears/toast and
crackers diet. Abdominal drain output was monitored and checked
for creatinine and amylase and at discharge was left in place.
Urethral foley was removed on day prior to discharge but he
failed the voiding trial so it was replaced. Diet was slowly
advanced but by discharge he was on a regular house diet. The
remainder of the hospital course was relatively unremarkable.
The patient was discharged in stable condition, eating well,
ambulating independently, and with pain control on oral
analgesics. On exam, incision was clean, dry, and intact, with
no evidence of hematoma collection or infection. The patient was
given explicit instructions to follow-up in clinic with Dr.
[**Last Name (STitle) 3748**] for trial of Void and staple removal and with Dr. [**Last Name (STitle) **]
for abdominal drain removal.
Medications on Admission:
Metoprolol 25 mg PO bid
Simvastatin 20 mg PO qhs
Vitamin b12 1000 mcg PO daily
ASA 325 mg PO 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. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): DO NOT SMOKE WHILE CONCURRENTLY
WEARING PATCH.
Disp:*14 Patch 24 hr(s)* Refills:*2*
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: DO
NOT RESUME until cleared by Dr. [**Last Name (STitle) 3748**] &/or Dr. [**Last Name (STitle) **].
11. Outpatient Lab Work
-Please empty and MEASURE AND RECORD the daily output of the
drain and be prepared to share these findings with Dr. [**Last Name (STitle) **] at
your appointemnt.
Discharge Disposition:
Home
Discharge Diagnosis:
[**11-15**]: Renal Cell Carcinoma
[**11-16**]: Splenic Rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please also refer to the provided written instructions on
post-operative care, instructions and expectations made
available from Dr. [**Last Name (STitle) 3748**]??????s office.
-The DRAIN will remain in place until your follow-up appointment
with Dr. [**Last Name (STitle) **] and the Foley will be removed when you see Dr.
[**Last Name (STitle) 3748**] later this week.
-Please empty and measure AND RECORD the daily output of the
drain and be prepared to share these findings with Dr. [**Last Name (STitle) **] at
your appointemnt.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-DO NOT RESUME your pre-admission dose of ASPIRIN 325mg PO DAILY
until explicitly cleared by Dr. [**Last Name (STitle) 3748**] &/or Dr. [**Last Name (STitle) **]
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Resume all of your pre-admission/home medications except as
noted. Do not take Aspirin or Non-steroidal anti-inflammatories
(ibuprofen, etc.) unless advised to do so.
-Call your Urologist's office today to schedule/confirm your
follow-up appointment in 3 weeks AND if you have any questions.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-If you have been prescribed IBUPROFEN (the ingredient of Advil,
Motrin, etc.) , you may take this and Tylenol together
(alternating) for additional pain control---please try TYLENOL
FIRST and take the narcotic pain medication as prescribed if
additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark tarry stools)
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
-Please call Dr.[**Name (NI) 11306**] office to arrange for TRIAL OF VOID
and surgical skin clip removal for Thursday this week;
[**2118-11-24**].
-The DRAIN will remain in place until your follow-up appointment
with Dr. [**Last Name (STitle) **]. Your appointment has been made for [**2118-11-29**] at
10:30 AM.
-Call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for follow-up AND if
you have any urological questions. Dr. [**Last Name (STitle) 3748**]??????s Nurse
Practitioner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22714**] may be reached at the same
number.
Completed by:[**2118-11-25**]
ICD9 Codes: 2851, 5180, 2724, 4019, 3051, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4872
} | Medical Text: Admission Date: [**2117-10-29**] Discharge Date: [**2117-11-9**]
Date of Birth: [**2059-10-30**] Sex: M
Service: MEDICINE
Allergies:
Terazosin / Carbamazepine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Upper GI Bleed and Hypotension
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy x 2
Tracheal Intubation/Mechanical Ventilation
Central venous catheter placement
Arterial line placement
History of Present Illness:
Mr. [**Known lastname 88028**] is a 57 year old man with h/o afib on Coumadin,
pacemaker, CAD s/p stents x2, CVA, seizures, HLD, HTN, asthma,
arthritis on NSAIDs, who was transferred from an OSH with chest
pain after choking, found to have atrial flutter, hypotension,
acute renal failure, and hematemesis.
.
The patient was in his usual state of health when he choked on
some canned tuna in the morning. He later felt fatigued and
developed substernal chest pain. He also had epigastric
discomfort. He initially presented to [**Hospital3 **] around
3pm, where he was found to be in aflutter with RVR (HR 140s). He
was given Metoprolol 5mg with subsequent hypotension (SBP 60s).
BP did not improve with 1LNS. At 6:45PM, the patient vomited a
large amount of bright red blood. NGT was placed with bloody
output. He was pale and continued to be hypotensive. Labs were
notable for WBC 19.3, HCT 35.7, INR 3.1, Cr 1.9 (baseline 0.9),
Trop I <0.06, Lactate 6.9. He was given Vitamin K 10mg SC x1,
Protonix 40mg IV, 1unit pRBCs, and 1unit FFP.
.
Of note, he has a several month h/o epigastric discomfort in the
setting of NSAID use (Aleve x years). He had an EGD 4 months ago
that was unremarkable. He continued to use NSAIDs during this
time.
.
In the ED, initial vs were: T 97.2 HR 107 BP 88/41 RR 34 O2sat
100%4LNC. The patient appeared very pale on arrival. He
continued complaining of epigastric pain. Exam notable for
pallor and abdominal distension. Labs notable for HCT 18.4, INR
3.9, Cr. 1.5. Patient was given 3units pRBCs, 1unit FFP, 2 packs
of platelets, 2LNS. Repeat HCT 24.3. Patient was seen by GI in
the ED - will hold on scope until AM given stable BP. Also had
an episode of dark red bowel movement. Vitals prior to
transfer: HR 120 BP 116/87 RR 21 O2sat 100% *LNC.
.
On the floor, the patient was hemodynamically stable. He
complained of large amounts of gas in his abdomen. He had
another dark bloody bowel movement. No fevers, chills, abdominal
pain, nausea, vomiting, shortness of breath, chest pain. No h/o
GI bleeds, no known h/o cirrhosis. Does have past h/o EtOH use.
Past Medical History:
Afib/flutter
s/p pacemaker x13years
CAD s/p stents x2
CVA
Seizure
HLD
HTN
Asthma
Colonic polyps
Arthritis
Bipolar/Manic d/o
Social History:
Lives with his girlfriend. Uses walking stick when hiking.
- Tobacco: none
- Alcohol: past use, quit 7 years ago, 2-6 beers/day
- Illicits: past marijuana, rare cocaine use
Family History:
Dad and 3 siblings with DM
Physical Exam:
Admission Physical Exam:
Vitals: T 97.4 HR 102 BP 126/73 RR 22 O2sat 100% 4LNC
General: alert, oriented, shallow quick breaths
HEENT: sclera anicteric, dry MM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops
Abdomen: distended, tympanic, nontender, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: 2+ pulses, no clubbing, cyanosis or edema
.
Discharge Physical Exam:
Vitals: T 99.8, HR 74, BP 110-120/68-72, RR 18, SO2 100%RA
GEN: AAOx2-3, comfortable appearing, NAD
HEENT: pupils equal and reactive to light
CV: RRR, normal S1, S2 with no m/r/g
RESP: unlabored breathing, mild patch wheezing
ABD: S/NT/ND, BS+, no TTP
EXT: warm, well-perfused, non-erythematous LUE
NEURO: CN II-XII intact, moving all extremities
Pertinent Results:
Admission Results:
.
[**2117-10-29**] 08:40PM BLOOD WBC-11.6* RBC-2.15* Hgb-6.4* Hct-18.4*
MCV-86 MCH-29.9 MCHC-34.9 RDW-13.9 Plt Ct-183
[**2117-10-29**] 09:45PM BLOOD WBC-12.7* RBC-2.72*# Hgb-8.2*# Hct-24.3*#
MCV-89 MCH-30.0 MCHC-33.6 RDW-14.1 Plt Ct-149*
[**2117-10-29**] 08:40PM BLOOD PT-37.6* PTT-37.0* INR(PT)-3.9*
[**2117-10-29**] 08:40PM BLOOD Plt Ct-183
[**2117-10-30**] 01:29AM BLOOD Fibrino-159
[**2117-10-30**] 05:07AM BLOOD Fibrino-140*
[**2117-10-29**] 08:40PM BLOOD Glucose-120* UreaN-29* Creat-1.5* Na-144
K-4.4 Cl-118* HCO3-15* AnGap-15
[**2117-10-30**] 01:29AM BLOOD Glucose-108* UreaN-35* Creat-1.3* Na-142
K-5.2* Cl-115* HCO3-21* AnGap-11
[**2117-10-29**] 08:40PM BLOOD ALT-15 AST-20 AlkPhos-31* Amylase-40
TotBili-0.4
[**2117-10-30**] 03:38PM BLOOD LD(LDH)-245 CK(CPK)-522* TotBili-1.4
[**2117-10-30**] 05:07AM BLOOD cTropnT-0.04*
[**2117-10-30**] 03:38PM BLOOD CK-MB-12* MB Indx-2.3 cTropnT-0.06*
[**2117-10-31**] 04:19AM BLOOD cTropnT-0.03*
[**2117-10-29**] 08:40PM BLOOD Albumin-2.2* Calcium-6.4* Phos-1.8*
Mg-1.4*
[**2117-10-30**] 03:38PM BLOOD Hapto-<5*
[**2117-10-29**] 08:50PM BLOOD Glucose-117* Lactate-5.1* Na-139 K-4.2
Cl-119* calHCO3-15*
[**2117-10-29**] 09:49PM BLOOD Glucose-134* Lactate-3.9* K-6.0*
[**2117-10-30**] 01:35AM BLOOD Lactate-2.4*
[**2117-10-30**] 05:23AM BLOOD Lactate-2.0
[**2117-10-31**] 04:37AM BLOOD Lactate-1.3
.
EKG ([**10-29**]): Atrial tachycardia or flutter with variable block.
Non-specific ST-T wave
changes. A single ventricular premature beat is noted. No
previous tracing available for comparison.
.
CXR ([**10-29**]): No focal consolidation. Nasogastric tube is seen
in the upper esophagus, but cannot be followed reliably into the
stomach due to underpenetration.
.
CXR ([**10-30**]): As compared to the previous radiograph, there is a
newly appeared complete left lower lobe atelectasis. In
addition, a small left pleural effusion is seen.
Otherwise, the radiograph is unchanged. The monitoring and
support devices
are constant. Unchanged size of the cardiac silhouette.
Unchanged absence of
parenchymal opacities in the right lung.
.
EKG ([**11-1**]): Probable atrial flutter with 4:1 block. Early R
wave progression. Since the
previous tracing of [**2117-10-31**] the ventricular rate has decreased.
Otherwise, findings are unchanged.
.
CXR ([**11-3**]): Left lower lobe aeration is improving, small left
pleural effusion stable. Upper lungs clear. Mild cardiomegaly
unchanged. ET tube and transvenous right atrial and right
ventricular pacer leads in standard placements. No pneumothorax.
.
EKG ([**11-4**]): Atrial flutter with ventricular paced rhythm. Since
the previous tracing of [**2117-11-1**] ventricular paced rhythm is now
present.
.
EKG ([**11-5**]): Atrial flutter with rapid ventricular response.
Diffuse non-specific ST-T wave
changes. Compared to the previous tracing of [**2117-11-4**]
ventricular pacing is not seen on the current tracing.
.
CXR ([**11-4**]): As compared to the previous radiograph, there is
minimally increasing mainly perihilar opacity, potentially
reflecting mild-to-moderate pulmonary edema. As compared to the
previous radiograph, there has also been an increase in the
extent of the retrocardiac atelectasis. The presence of a small
left pleural effusion cannot be excluded.
.
CXR ([**11-5**]): Mild pulmonary edema which developed on [**11-4**]
and perihilar consolidation in the left mid lung have both
cleared. Although the heart size is normal
there is still pulmonary vascular engorgement suggesting
elevated left atrial pressure. There is no pneumothorax or
pleural effusion. Nasogastric tube passes into the stomach and
out of view. Transvenous right atrial and ventricular pacer
leads are in standard placement.
.
EKG ([**11-7**]): Atrial flutter with controlled ventricular
response. Compared to tracing #1
ventricular response is slower.
.
Discharge Labs:
.
[**2117-11-9**] 06:23AM BLOOD WBC-8.5 RBC-3.43* Hgb-9.9* Hct-29.9*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.3 Plt Ct-296#
[**2117-11-9**] 06:23AM BLOOD PT-12.7 PTT-22.8 INR(PT)-1.1
[**2117-11-9**] 06:23AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-139
K-4.0 Cl-107 HCO3-24 AnGap-12
[**2117-11-9**] 06:23AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9
Brief Hospital Course:
57 year old man with h/o afib/flutter on Coumadin, pacemaker,
CAD s/p stents x2, prior CVA, seizures, HLD, HTN, asthma,
arthritis on NSAIDs, who was transferred from an OSH with
hematemsis.
.
#. GIB: Pt with brisk upper GI bleed - HCT dropped from 35 at
the OSH to 18 here, despite transfusion of 1unit pRBCs. Initial
thought to be peptic ulcer disease, given h/o epigastric
discomfort and long term NSAID use. No h/o GI bleeds or
cirrhosis. Pt has received Pt has received 18 units pRBCs, 9
units FFP, and 3 packs of platelets during the admission.
Recieved 2 EGD's which failed to visualize a lesion, therefore a
gastric dieulafoy lesion was on top of the differential.GI
placed the patient as high risk for bleeding on anticoagulation
and the decision to restart anticoagulation should be made by
cardiology. The patient was placed on a PPI gtt which was later
transitioned to the IV BID. Held Coumadin, ASA, Plavix. Upon
transfer to the floor, the patient was transitioned to an oral
PPI, which he was discharged on. ** The patient should follow up
with his outpatient cardiologist to determine which
anti-platelet agents and anti-coagulants should be restarted **
.
# Citrobacter Pneumonia: The patient was intubated early in his
hospitalization for airway protection. Several days into his
hospital course the patient developed fevers and sputum, urine
and blood cultures were performed. The initial sputum culture
grew Citrobacter koseri that was sensitive to Cefepime, which
the patient was started on. CXR demonstrated evidence concerning
for a left-sided infiltrate but also a small pleural effusion.
The patient was treated with Cefepime throughout his
hospitalization. Repeat CXR prior to discharge revealed
resolution of the pulmonary edema and only minimal evidence of
the possible infiltrate seen early in his hospitalization. The
patient needed an additional seven days of Cefepime following
discharge to complete his course of antibiotics for his
hospital-acquired pneumonia and was discharged to an extended
care facility where his antibiotics would be completed.
.
#. Blood Pressure: The patient was initially hypotensive on
admission in the setting of his upper gastrointestinal bleed.
His hypotension improved with fluid and blood products. Post
extubation, the patient SBP reached the 170s and his HR reached
the 120s. The patient was started on Metoprolol 25mg PO TID
prior to transfer to the medicine service. Blood pressure and
heart rate control were achieved on this regimen, which the
patient was discharged on.
.
#. Chest pain: Patient had atypical chest pain prior to
admission admission. Trop-I were less than 0.06 at OSH. Repeat
troponin testing at [**Hospital1 18**] were 0.01 on admission with the
following subsequent changes while in the medical ICU, 0.03 -->
0.06 --> 0.03. These mild elevations were seen in the setting of
acute renal failure and the patient's upper GI bleed. Repeated
EKG testing revealed non-specific ST-T changes that persisted
throughout the patient's hospitalization. No outside/old EKGs
were available for comparison. The patient remained chest pain
free throughout his hospitalization. No acute interventions were
sought. As per below, the patient's anti-coagulation was held
but the patient was started on Aspirin 81 mg daily. Of note, the
patient had known CAD with 2 bare metal stents in place that
were from several years prior. Of concern, the patient was
admitted on Coumadin, Aspirin and Clopidogrel. Given the timing
of the patient's stent placement and apparent duration of
Clopidogrel therapy, this medication was not restarted during
this hospitalization. The patient was given a follow up
appointment the day after discharge with his Cardiologist to
discuss what anti-coagulation and anti-platelet therapies the
patient needed to be continued on.
.
#. Afib/flutter: The patient's home Metoprolol was discontinued
on arrival to the hospital because of hypotension. The patient
was started on Metoprolol Tartrate 25 mg PO TID once his
hypotension resolved and his gastrointestinal bleeding resolved.
The patient was intermittently in atrial fibrillation/flutter in
the throughout his stay. The patient's Coumadin was held given
recent GI bleed. Per above, the patient was discharged with a
follow up appointment with his cardiologist the day after
discharge.
.
#. UTI: Given the patient's fevers, his urine was cultured early
in his hospitalization at the same time his sputum was cultured.
Klebsiella pneumoniae was cultured and grew 10,000 to 100,000
CFU/mL. The patient most likely acquired the infection from his
foley. The baceria was sensitive Cefepime, which the patient
would complete the appropriate course for while being treated
for his pneumonia as per above.
.
#. Acute Renal Failure: The patient's serum creatinine was
elevated to 1.9 at OSH from a baseline 0.9. Given the patient's
UGIB and hypotension on admission, the most likely etiology was
pre-renal renal failure. The patient's renal failure responded
to volume resuscitation with intravenous fluids and blood
products. His serum creatinine was 0.8 at discharge.
.
#. Hyperlipidemia: Stable. Simvastatin was restarted on transfer
to the floor.
.
#. Psych: Stable. The patient's anti-psychotics were restarted
on transfer to the floor. ** The patient's anticipated time in
rehabilitation is less than one month. **
Medications on Admission:
Coumadin 7.5mg PO qhs
ASA 81mg PO daily
Plavix 75mg PO daily
Toprol 50mg PO daily
Lisinopril 10mg PO daily
Ziprasidone 80mg PO BID
Adderall 10mg PO daily
Lamictal 100mg PO daily
Simvastatin 40mg PO daily
Abilify 5mg PO
Buspirone 10mg PO TID
Glucosamine
Aleve x several years
MSM (methylsulfonylmethane)
Discharge Medications:
1. cefepime 2 gram Recon Soln Sig: One (1) infusion Intravenous
every twelve (12) hours for 7 doses.
Disp:*7 doses* Refills:*0*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Abilify 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Glucosamine Oral
7. methylsulfonylmethane Oral
8. Adderall 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day). Tablet(s)
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnoses:
Upper GI bleed
Pneumonia
.
Secondary Diagnoses:
Asthma
Hyperlipidemia
Bipolar Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 88028**]:
.
You were brought to the hospital because of a upper
gastrointestinal bleed which caused your blood pressure to
decrease. You were cared for in the medical ICU and received
blood transfusions and respiratory assistance with mechanical
ventilation. You improved with these therapies. Two endoscopies
could not visualize a source for your bleeding from your
stomach. You will need to follow up with the gastroenterology
department as an outpatient. There was also some concern over
the Coumadin, Plavix and Aspirin that you were taking when you
were admitted to the hospital as these increase your risk of
gastrointestinal bleeding. You need to follow up with your
cardiologist to determine which of these medications should be
continued.
.
We made the following changes to your home medication list:
.
1. Stop Coumadin 7.5 mg by mouth at night until you follow up
with your outpatient cardiologist.
2. Stop Plavix 75 mg by mouth daily until you follow up with
your outpatient cardiologist.
3. Stop Toprol XL 50 mg by mouth daily.
4. Start taking Metroprolol tartrate 25 mg by mouth three times
a day. Your outpatient cardiologist may adjust this medication.
5. Start taking Omeprazole 40 mg by mouth once a day. This
medication will help to protect your stomach.
6. Start Cefepime 2 gram solution. Give one infusion
intravenously every twelve hours for 7 doses. Begin the evening
of [**11-9**].
.
No other changes were made to your medications.
Followup Instructions:
Please keep all follow up appointments as below.
.
1.
Cardiology
Dr. [**Last Name (STitle) **]
[**Hospital3 **]
3:45 PM
([**Telephone/Fax (1) 40360**]
.
2.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2117-11-23**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2117-11-13**]
ICD9 Codes: 5849, 5990, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4873
} | Medical Text: Admission Date: [**2140-6-28**] Discharge Date: [**2140-7-12**]
Date of Birth: [**2083-10-9**] Sex: F
Service: MICU
CHIEF COMPLAINT: Chest pain and shortness of breath.
HISTORY OF THE PRESENT ILLNESS: This is a 56-year-old female
with a history of sickle cell hemoglobin SC disease with a
baseline hematocrit between 17 and 21, also with chronic
renal failure due to FSGS as well as diastolic CHF, as well
as cirrhosis due to iron overload, who was in her usual state
of health until four to five days prior to admission when she
started to feel increased shortness of breath and
intermittent "band-like" nonpleuritic chest pain. According
to the patient's daughter, the chest pain was nonradiating
with a question of nausea that was present. The patient did
received a blood transfusion on the day prior to admission.
On the next day, the day of admission, the shortness of
breath was worse with increased dyspnea on exertion, making
it difficult to walk more than a few steps. The patient had
chest pain again which was relieved by supplemental 02. In
the Emergency Room, she had a temperature of 99.8 with a
blood pressure of 199/101, pulse 97, respirations 24, 100% on
nonrebreather. There, in the Emergency Room, she was given
Lasix and started on a nitroglycerin drip. She was then
transferred to the medical floor where she became acutely
dyspneic and was found to be extremely hypoxic. She had a
blood gas on face mask which was 7.30 with a PC02 of 52 and a
P02 of 99. She continued to get more somnolent and was
intubated for respiratory failure and was admitted to the
MICU.
PAST MEDICAL HISTORY:
1. Sickle cell hemoglobin SC disease for 20 years.
2. Pulmonary hypertension, on home 02, with pulmonary
infarcts present on chest CT.
3. Diastolic CHF with an EF of 70%, 1+ MR, 2+ TR.
4. Chronic renal failure secondary to focal segmental
glomerulosclerosis.
5. Cirrhosis secondary to iron overload with ascites but no
history of spontaneous bacterial peritonitis.
6. Gout.
7. Hypertension.
8. Depression.
9. Reactive airways disease.
10. History of neutropenia due to hydroxyurea.
11. Status post cholecystectomy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Celexa.
2. Norvasc.
3. Folate.
4. Albuterol.
5. Hydralazine 40 q.i.d.
6. Protonix.
7. Sodium bicarbonate 1,300 q.d.
8. Senna.
9. Ursodiol 300 q.d.
10. Hydroxyurea 1,000 mg q.d.
11. Renagel 800 mg p.o. t.i.d.
12. Calcitriol.
13. Morphine sulfate immediate release p.r.n.
14. Ultram p.r.n.
15. Colace 100 b.i.d.
16. Epo 10,000 units three times a week.
17. Tylenol p.r.n.
SOCIAL HISTORY: The patient lives with her granddaughter.
She denied alcohol or smoking.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.8, blood pressure 140/80, pulse 106, respirations 24, 02
saturation 93% on 5 liters. General: This is an elderly
woman who appeared tachypneic and uncomfortable initially and
became somnolent after being sedated and intubated. HEENT:
The pupils were equally round and reactive to light with
muddy sclerae. Her neck veins revealed JVP that was
difficult to assess but appeared elevated. Cardiovascular:
Rapid but regular rate with normal S1, S2, with a grade
III/VI systolic murmur. Lungs: Remarkable for crackles at
the bases one-third of the way up bilaterally. Abdomen:
Large and distended but soft with some shifting dullness.
There was no guarding or rebound. Extremities: There was 2+
pitting edema, 2+ dorsalis pedis pulses bilaterally.
Neurologic: The patient was initially alert and oriented
times three, became increasingly somnolent and at the time of
admission to the MICU was sedated for intubation.
LABORATORY/RADIOLOGIC DATA: A chest x-ray revealed a
cardiomegaly with prominent pulmonary arteries as well as
pulmonary vascular engorgement and pleural effusions. There
was also persistent patchy linear opacities of lung bases and
at the retrocardiac region.
An EKG was done which showed a normal sinus rhythm at a rate
of 91 beats per minute with evidence of LAD, LVH, and poor R
wave progression. T wave inversions were present in leads I,
aVL, V5 and V6, as well as lead II which was unchanged from
[**2140-5-26**].
White count 9.7, hematocrit 18.5, platelets 86,000 with an
MCV of 96, neutrophils 72%, 48% nucleated RBCs. The Chem-7
was 141, potassium 5.1, chloride 108, bicarbonate 23, BUN 62,
creatinine 3.7, glucose 89. CK 24, troponin less than 0.3.
Her coagulation studies were normal. A U/A was significant
for 400 mg/deciliter of protein on the urinalysis.
HOSPITAL COURSE: 1. RESPIRATORY FAILURE: The patient was
presumed to have a diastolic CHF. It was noted that several
admissions ago, the patient had been discontinued off her
standing Lasix with the thought that it may contribute to
more rapid worsening of her renal failure. It seems to be
that the patient has been admitted a few more times since
that time in [**Month (only) 547**] when she presented with increased ascites
and CHF. Her chest x-ray did seem consistent with cardiac
failure and she was placed on Lasix boluses which did not
result in a negative net diuresis. She then was tried on a
Lasix drip with Zaroxolyn as well as Diuril. All of these
treatments also failed to make her negative.
The Heart Failure Service was consulted and she was tried on
a Nisiritide drip for four days. She did urinate roughly
1,500 cc per day on this regimen. However, she did not make
herself net negative even while her medications were
maximally concentrated by the pharmacy. She continued to
progress in worsening of her creatinine clearance.
The Renal Service was consulted to ask the question whether
dialysis should be instituted. After trying to optimize the
blood pressures and trying medical diuresis, it was
determined that the patient's respiratory status depended on
her fluid overload and both teams agree that the patient
should go to hemodialysis for fluid removal. She was kept on
assist control for most of this time on the mechanical
ventilator and improved her respiratory status after
hemodialysis was initiated.
While on the ventilator, she did develop secretions and
fevers and later grew out Acinetobacter and MRSA from the
sputum for which she had been treated with vancomycin and
ceftazidime. There appeared to be a correlating left lower
lobe infiltrate that seemed to be the focus of the pneumonia.
After the third dialysis, the patient did become length of
stay negative and was prepared for weaning and extubation.
She was finally extubated on [**2140-7-10**] and tolerated this well
and immediately did well on 2 liters of nasal cannula. She
will continue to be treated for a total of 14 days of
vancomycin and ceftazidime for the Acinetobacter and MRSA
pneumonia. She has been afebrile for the past 48-72 hours in
the MICU and will be transferred to the medical floor when a
bed becomes available.
2. CONGESTIVE HEART FAILURE: As mentioned, the patient's
respiratory failure was thought to be due mostly to fluid
overload and diastolic dysfunction. She did have episodes of
labile hyper and hypotension; mainly hypertension which was
controlled by intermittent labetalol and nitroglycerin drips.
In addition, she did have a troponin leakage in the face of
renal failure and hypertension. She initially had been
started on Hydralazine and then later was switched to her
usual Norvasc which is what she was taking at home. She did
have some episodes of hypotension and in order to protect
renal perfusion, all hypertensives were discontinued until
the patient went on dialysis.
At this time, the patient is now back on a beta blocker for
heart failure. For the troponin leak, she was put on a
low-dose aspirin, although keeping a vigilant eye on the
thrombocytopenia she presented with, the aspirin use should
be monitored, especially given the fact that the patient had
a normal coronary catheterization in [**2136**] showing normal
coronary arteries.
In addition, the Renal Service will be asked whether starting
an ACE inhibitor would be okay at this time given that she
does have heart failure and might benefit from this regimen.
3. RENAL FAILURE: As mentioned, the patient did progress in
terms of her worsening of creatinine clearance. The
patient's daughter was notified and was aware that the
patient would need renal replacement in the coming one to two
months irrespective of this acute episode. The patient did
start hemodialysis using a temporary femoral Quinton
catheter. This was discontinued on after her third
hemodialysis. She then received a tunnel dialysis catheter
on [**2140-7-11**] without any incident. She is now, I
believe, scheduled to undergo regular renal replacement
therapy to be dictated by the Nephrology Team and her
nephrologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She will be started on Renagel
as she is now tolerating a diet and appears to be
hyperphosphatemic. She should undergo eating a
phosphate-restricted diet where the potassium is strictly in
her diet which seems to be less crucial for her since she has
been on the hypokalemic side. She will also continue her
Calcitriol and Epo administration starting on dialysis.
PhosLo should be instituted at this time given the latest
renal recommendations.
4. SC DISEASE AND THROMBOCYTOPENIA: The patient's
thrombocytopenia was puzzling because on admission the
platelets were between 60s and 70s and the liver synthetic
function appeared to be fine. Given that the patient had a
history of pancytopenia due to hydroxyurea, Hematology was
consulted and they recommended discontinuing the Hydroxyurea
and famotidine which she was receiving in the ICU for
prophylaxis. She did continue to have low-grade
thrombocytopenia that did not resolve immediately after
discontinuation of those medicines. She did receive a
platelet transfusion for initiation of a femoral Quinton
catheter for dialysis and since then her platelets have
remained above 100,000 with no clinical signs of bleeding.
As mentioned, aspirin has been started but she may require
discontinuation of this medicine depending on how the
Hematology/Oncology Team feels about her thrombocytopenia.
5. FEVERS: As mentioned, the patient did spike fevers
throughout her hospital course. She did receive
ultrasound-guided paracentesis of which only 8 cc of
peritoneal fluid was removed and the fluid analysis was not
consistent with spontaneous bacterial peritonitis. It was
also felt that her peripheral IVs could be contributing to
fevers and those were discontinued in place of a new left
subclavian catheter which was inserted without difficulty.
She also did undergo right DVT ultrasound to look for
evidence of clot because right IJ was initially attempted and
this was not successful. The study showed no evidence of
clot.
When she initially spiked fevers, she was started empirically
on vancomycin, ceftazidime, and Flagyl. She has had diarrhea
which has been negative for C. difficile times three. Her
antibiotic regimen was paired down to just vancomycin and
ceftazidime. A CT scan of the belly was done prior to dispo
from the ICU to look for evidence of intra-abdominal abscess
or ongoing infection given that her previous abdominal
ultrasound was negative and that LFTs were mildly elevated at
one point. A right upper quadrant ultrasound showed absence
of gallbladder and normal hepatopetal flow in the portal
vein. She also had no evidence of abscesses in the abdomen.
As mentioned, the fevers were likely due to a
ventilator-associated pneumonia as the Gram's stain on the
sputum did return Acinetobacter and MRSA for which she is now
being treated and has been afebrile.
This dictation including discharge diagnoses and medicines
will be dictated at a later date.
DR [**First Name (STitle) **] CLARY12.AEW
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2140-7-11**] 01:05
T: [**2140-7-11**] 13:46
JOB#: [**Job Number 106567**]
ICD9 Codes: 5715, 2875, 2761, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4874
} | Medical Text: Admission Date: [**2201-1-27**] Discharge Date: [**2201-1-31**]
Date of Birth: [**2143-3-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
HEMOPTYSIS
Major Surgical or Invasive Procedure:
[**2202-1-27**] Emergent MVRepair with 27 mm [**Company **] duran ring and
resection P2 leaflet.
History of Present Illness:
57 yo M with recently discovered heart murmur. Echo showed MR
and cardiac MRI showed severe MR [**First Name (Titles) **] [**Last Name (Titles) 61102**] forward EF. He
presented to the ED at MWMC a few weeks PTA with hemoptysis and
was worked up for pulmonary problems. Outpatient Cath at MWMC
the day of admission showed severe MR [**First Name (Titles) 151**] [**Last Name (Titles) **] leaflet and
ruptured chordae. He became hypotensive and hypoxic. He was
intubated and transferred to [**Hospital1 18**] for emergent surgery.
Past Medical History:
MR
[**First Name (Titles) **]
[**Last Name (Titles) 71504**]
anal fissure repair
Social History:
married, lives with wife
smokes cigars
2 etoh/week
works as electrician
Physical Exam:
intubated, in NAD
opens eyes to command, MAE well
bibasilar crackles
RRR holosystolic murmur
Abd benign
Extrem warm, no edema
Rt groin dressing C/D/I
Brief Hospital Course:
He was taken emergently to the operating room on [**2201-1-27**] where
he underwent an emergent MV repair. He was transferred to the
ICU in critical but stable condition. He was extubated on POD
#1, weaned from his vasoactive drips and transferred to the
floor on POD #1. He was started on a beta blocker and diuretic.
He has done well with ambulation, and has remained
hemodynamically stable. He is ready to be discharged home on
POD #4.
Medications on Admission:
asa, vitamin E, piroxicam, SBE proph
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*060 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. 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*
6. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO twice a day for 5 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of greater [**Location (un) **]
Discharge Diagnosis:
MR [**First Name (Titles) 151**] [**Last Name (Titles) **] leaflet/ruptured chordae
MR
[**First Name (Titles) 20441**]
[**Last Name (Titles) 71504**]
anal fissure repair
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting (>10 pounds) or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 8049**] 2 weeks
Dr. [**Last Name (STitle) 32255**] 2 weeks
Completed by:[**2201-1-31**]
ICD9 Codes: 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4875
} | Medical Text: Admission Date: [**2121-10-29**] Discharge Date: [**2121-11-10**]
Date of Birth: [**2086-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Nsaids / Levaquin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Right and left heart catheterization.
Endomyocardial biopsy.
History of Present Illness:
Mrs. [**Known lastname **] is a 34 year old woman with a history of
hypertrophic cardiomyopathy, hypertension, SVT, s/p PEA arrest
x3, s/p pericardial effusion/window who was transferred to [**Hospital1 18**]
from [**Hospital 1474**] Hospital for CHF exacerbation and work up for
constrictive pericarditis. She reports she developed bilateral
back pain with inspiration about 2 days ago that is consistent
with her prior CHF exacerbation. She also reports that she
noticed that her face and lips became cyanotic with exertion at
home. Of note, she reports she has a baseline variable 02
requirement at home from 0-2L. She otherwise denies f/c/change
in appetite, CP/palp/SOB/+dyspnea, -abd
pain/n/v/d/c/melena/brbpr, paresthesias/weakness.
.
At [**Hospital 1474**] Hospital, she underwent CT angiogram that was
negative for PE. She was treated for CHF exacerbation with
diuresis. She was noted to be bradycardic to the 40's and
amiodarone briefly dc'd. She had a CT scan of the chest showing
hilar and mediastinal adenopathy. RHC showed question of
constrictive pericarditis with equalization of diastolic
pressures in all four [**Doctor Last Name 1754**] (RAP 27, RVP 25, wedge 27).
.
During this hospitalization at the [**Hospital1 18**], she had multiple
bursts of SVT to HR 150s-160s. Most recently this morning she
had several minutes of SVT to 160s x 3. During these episodes,
she was noted to have undopplerable blood pressure per report.
She was treated with carotid massage and converted to her native
rhythm. She was also given 1 L of IVF with SBP 100.
.
Cardiac review of systems is notable for absence of chest pain,
+dyspnea on exertion, paroxysmal nocturnal dyspnea, +orthopnea
chronic 2 pillows, -ankle edema, -palpitations, -syncope or
presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, + Hypertension
.
Percutaneous coronary intervention: None
.
Pacemaker/ICD: None
.
Cardiac history, compiled from OMR: taken from last discharge
summary.
Age:
12: Initial presentation with syncope
13: Seen at [**Hospital3 1810**] for history of syncope, chest
pain and progressive exercise intolerance; diagnosed with
hypertrophic cardiomyopathy, and underwent catheterization in
which LVEDP was found to be 20. Started on ongoing verapamil
therapy.
16: Cardiac arrest secondary to complex tachycardia,
successfully resuscitated. Repeat catheterization showed left
ventricular end diastolic pressure of 36-40 without outflow
tract obstruction. EP showed inducible atrial flutter with a
rapid ventricular blood pressure; dx'ed w/rapid antegrade
conduction and possible pre-excitation. Started on Norpace
(dysopyramide); kept on verapamil and Norpace for many years.
Had occasional palpitations, chest pain and light headedness.
25: Appendicitis during pregnancy, with post-op course
complicated by congestive heart failure, intubated and then
eventually extubated without difficulty; delivered son at 25
weeks.
RECENT HISTORY:
* [**2121-2-8**]: Atrial arrythmias (MAT diagnosed at [**Hospital1 18**],
Afib/flutter seen at OSH), started on amiodarone.
* [**2121-3-1**]: Admitted from [**Hospital 1474**] Hosp w palpitations,
diagnosed as AVNRT, discharged with increased dose of verapamil,
made long-acting.
* [**2121-3-18**]: Pulmonary vein isolation procedure. Post-procedure
atrial tachycardia w/multiple morphologies-->cardioversion.
Respiratory distress and post-procedure
re-intubation<--pulmonary edema and possible contribution of
pan-sensitive klebsiella PNA. Ongoing fevers, ?PE treated with
heparin. Discharged on amiodarone 200 mg TID.
* [**2121-4-5**]: Dyspnea, chest pain, possible pneumomediastinum;
diagnosed with large pericardial effusion; pericardial window
done; post-op atrial tachycardia. During post-op course, had
difficult-to-assess fluid status and was taken to the cath lab;
in holding area had PEA arrest, coded for 1 hour; intubated for
6 days and put on CVVH after cath confirmed volume overload;
extubated; and then reintubated 2 days later for aspiration and
hypoxia, then had pneumothorax as complication of intubation;
ultimately extubated again, treated for pneumonia. Admission
also notable for ARF and pancreatitis.
* [**2121-5-12**]: Admitted from rehab with dyspnea and chest pain,
anemia and mild CHF symptoms; having atrial tachycardia with
varying 2:1 and 3:1 conduction. Discharged [**5-15**].
* [**2121-5-18**]: Admit for shortness of breath, coded for 30 minutes
while being evaluated in ED: PEA w wide-complex near-sine-wave
tachycardia [**3-15**] hyperkalemia; regained pulse in 30 minutes,
after which she had NSR w RBBB; then had wide complex tachy and
BP drop; defibrillated x1 200J, briefly on dopamine gtt.
Admission notable for ongoing fluid overload and
weakness/apparent deconditioning. Source of hyperkalemia was
never clear. Pt discharged on [**5-25**] to home after refusing
placement to rehab. Pt had been at home until her most recent
admission to [**Hospital1 1474**].
Social History:
Lives at home with her husband and 15y/o son.
-Tobacco history:Quit [**2121-2-6**] (former 2ppdx20yrs).
-ETOH:denies
-Illicit drugs:denies
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
VS: T97.7, B P 100/67, HR 105, RR 16, sat 96% on 2L Pulsus:
difficult to assess due to faint pulses ~8
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Able to
speak in full sentencnes.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: JVP ~8 cms
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2, +S4, [**3-19**] diastolic murmur loudest rusb.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were slightly labored, no accessory muscle use. Crackles bases
to mid lung fields b/l.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
..
PHYSICAL EXAM AT DISCHARGE:
Pertinent Results:
EKG ([**2121-10-30**]) demonstrated atrial tachycardia to 164, left
axis deviation, RBBB, biatrial enlargement.
..
CXR PA AND LAT ([**2121-10-30**]):
FINDINGS: Two views of the chest are compared to [**2121-6-15**].
There are bilateral small-to-moderate pleural effusions (right
greater than left), but much improved from [**2121-6-15**]. There is
a cephalization of engorged pulmonary vasculature, but no overt
pulmonary edema. There is no new
superimposed consolidative process identified. Cardiomegaly and
mediastinal
contours are stable.
IMPRESSION: Bilateral loculated pleural effusions, improved from
[**2121-6-15**]. Mild pulmonary overload, but no overt interstitial
edema.
..
CARDIAC MRI ([**2121-10-31**]):
IMPRESSION:
1. The pericardium demonstrates patchy late gadolinium
enhancement and maybe tethered to the myocardium; the
pericardial thickness is normal. Abnormal septal motion was not
seen. Together, these findings are consistent with but not
diagnostic of constrictive pericarditis.
2. Moderate asymmetric hypertrophy with mildly depressed
biventricular
function due to septal akinesis.
3. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
4. Moderate to severe biatrial enlargement.
5. Moderate bilateral pleural effusion. Patchy opacity is noted
in the right middle lobe. Correlation with other chest imaging
studies is advised.
..
ENDOMYOCARDIAL BIOPSY ([**2121-11-3**]):
DIAGNOSIS:
Heart, intraventricular septum, biopsy (A): Cardiomyocyte
disarray, hypertrophy and increased amount of interstitial
fibrosis consistent with hypertrophic cardiomyopathy.
Thickening of the endocardium present. All findings could
account for clinical picture. No evidence of amyloid or
inflammation. Masson trichrome done.
..
CORONARY CATH ([**2121-11-3**]):
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated no
angiographically apparent coronary artery disease. The LMCA,
LAD, LCx,
and RCA were free of apparent flow-limiting lesions.
2. Resting hemodyamics revealed moderately elevated right and
left sided
filling pressures (RA mean and RVEDP both 28 mm Hg, and PCWP
mean 40 mm
Hg, LVEDP 33 mm Hg, respectively). There were prominent x and y
descents
and concordance of left and right ventricular pressures with
respiration, consistent with restriction. Pulmonary pressures
were
moderately elevated (PASP 59 mm Hg). Cardiac index was mildly
depressed
at 1.6 l/min/m2. Systemic and pulmonary vascular resistance were
normal
(SVR 1368 dynes-sec/cm5, PVR 52 dynes-sec/cm5). There was no
gradient
upon pullback of the catheter from the LV into the aorta.
3. Left ventriculography was deferred.
4. Endomyocardial biopsy was performed (2 samples) from the RV
interventricular septum. RV contraction appeared normal, there
was no
pulmonic outflow obstruction, and prominent trabeculation was
evident.
FINAL DIAGNOSIS:
1. No angiographically apparent coronary artery disease.
2. Elevated right and left heart pressures consistent with
diastolic
dysfunction.
3. Possible restrictive cardiomyopathy.
4. Mildly depressed cardiac index.
5. Successful endomyocardial biopsy.
..
ECHOCARDIOGRAM ([**2121-10-30**]):
The atria are moderately dilated. There is moderate 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 right
ventricular free wall is hypertrophied and RV cavity is mildly
dilated, with mild global free wall hypokinesis. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion or pericardial
thickening. There is no evidence of pericardial constriction.
Brief Hospital Course:
In summary, this is a 34-year old female with a history of
hypertrophic cardiomyopathy, SVT, hypertension, COPD s/p
multiple PEA arrests who is admitted with CHF exacerbation and
work up for constrictive pericarditis versus restrictive
cardiomyopathy. She is transferred to the CCU due to runs of
atrial tachycardia to the 160s and associated hypotension.
..
# RHYTHM: She has a history of multiple SVTs including atrial
fibrillation, atrial tachycardia, MAT and AVNRT. She was
transferred to the CCU after bursts of what appeared to be MAT.
Due to her hemodynamic compromise in this rhythm, she was
reloaded with amiodorone at a dose of 400 mg [**Hospital1 **]. She was then
loaded with digoxin and had a subsequent decrease in her
ventricular rate to 70s with 2:1-3:1 atrioventricular
conduction. Her metoprolol was uptitrated as blood pressure
would tolerate.
.
Plan for AV nodal ablation and permanent pacemaker placement was
delayed by symptomatic candidal UTI being tx with 2 week course.
However, at time of discharge her rate was well controlled on
the combination of amiodorone, digoxin, and metoprolol. Pt will
return for elective procedure in 1 to 2 weeks after repeat UA is
clear.
..
# PUMP: She has a history of hypertrophic cardiomyopathy with
preserved EF and moderate symmetric LVH. Right heart
catheterization at [**Hospital 1474**] Hospital prior to transfer showed
equalization of pressures concerning for constrictive
pericarditis. However, right and left heart catheterization at
[**Hospital1 18**] showed prominent x and y descents and concordance of left
and right ventricular pressures with respiration, all consistent
with a restrictive cardiomyopathy. Endomyocardial biopsy was
performed and pathology was consistent with hypertrophic
cardiomyopathy. Cardiac MR was done with full report above.
.
On physical exam and chest x-ray, it was clear that she was
volume-overloaded and her symptoms of shortness of breath,
fatigue were consistent with her usual heart failure
exacerbations. She was therefore started on a Lasix drip with
goal diuresis 1 to 1.5 L per day. At time of discharge, her net
diuresis is negative. Her oxygen requirements are 2L.
.
# CAD: There was no evidence of coronary disease on cardiac
catheterization during this or previous hospitalizations. Blood
pressure and heart rate control were achieved with metoprolol,
amio, and digoxin for primary prevention.
.
# URINARY TRACT INFECTION: During the hospital course, she
started complaining of burning with urination. A urine culture
grew out yeast, 100,000 colonies, and because she was
symptomatic we decided to treat with a 14 day course of
fluconazole. A renal ultrasound was performed to look for
perinephric abscess; this showed no hydronephrosis or
perinephric abcess, it did show a small left pleural effusion.
Her symptoms resolved on fluconazole and is to have a repeat Ua
in [**2-12**] weeks. Patient can have ablation once UTI resolves.
.
# COPD: We continued her outpatient regimen of Xopenex,
Montelukast, and ipratropium.
.
# DEPRESSION / ANXIETY: We continued her outpatient regimen of
bupropion, clonazepam, sertraline.
.
She was maintained on a heparin drip due to her underlying
atrial dysrrhythmia; this was switched to lovenox instead of
coumadin at time of discharge because there was concern fo
interactions with digoxin and amiodarone. She had a cardiac
heart-healthy diet. There was no indication for GI prophylaxis.
Medications on Admission:
MEDICATIONS AT TIME OF TRANSFER FROM [**Hospital1 **]:
lopressor 12.5mg [**Hospital1 **]
amiodarone 100mg daily
lasix 80mg IV BID
aldactone 25mg [**Hospital1 **]
singular 10mg daily
trazadone 100mg daily
zoloft 50mg TID
wellbutrin 75mg daily
IV dilaudid q4hprn
percocet 5/325 [**Hospital1 **] prn
potassium chloride 40meq [**Hospital1 **]
folic acid 1mg daily
iron 300mg daily
klonapin 1mg QID
tylenol.
..
MEDICATIONS AT TIME OF TRANSFER FROM FLOOR:
Albuterol prn
Amiodarone 200
Metoprolol Tartrate 37.5 TID
Wellbutrin 75
Monteleukast
Clonazepam
Iron
Folic acid
Lasix 40 IV BID
Dilaudid prn
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Atrial Tachycardia
Atrial Fibrillation/Atrial Flutter
Hypertrophic Obstructive Cardiomyopathy
ASthma
Depression
anxiety
Fungal Urinary Tract Infection with right flank pain
Discharge Condition:
Stable
Right groin with tiny tender nodule under puncture site, no
bruising swelling or erythema.
Discharge Instructions:
You had an episode of congestive heart failure with high
pressures within your heart at [**Hospital 1474**] Hospital. We increased
the amount of fluid medicine (spironolactone) to take with the
Furosemide. We also started you on Digoxin and increased your
Metoprolol to control your heart rate. You have a urinary tract
infection and we started you on fluconazole for a total of 14
days. You will need an AV node ablation and pacemaker after your
urinary tract infection is cleared.
Stop taking your warfarin for now, you will give yourself
Lovenox twice daily until the nurse who arranges the pacemaker
tells you to stop taking it.
We started Lisinopril to control your blood pressure better and
help your heart pump. We also started Spiriva to help with your
breathing.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:[**2113**] cc
.
Congratulations on quitting smoking. Information was given to
you on admission regarding smoking cessation and preventing
relapses.
Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] Phone: ([**Telephone/Fax (1) 2037**] Date/time: Monday [**12-29**] at 3:30pm.
.
Primary Care: [**Hospital1 **] HealthCare
[**Last Name (un) 5935**], MA
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5936**], MD
Wednesday [**11-12**] at 10 am
Please do EKG at this time and e-mail [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], MD [**First Name (Titles) 151**] [**Last Name (Titles) 5937**]
results.
.
Pt will need AV ablation and pacemaker after Urine culture is
clear. This will be done by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2121-11-10**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4876
} | Medical Text: Admission Date: [**2181-12-10**] Discharge Date: [**2181-12-18**]
Date of Birth: [**2109-5-30**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old white
male with a history of cardiomyopathy, history of myocardial
infarction 15 years ago, and a five vessel coronary artery
bypass graft 10 years ago, who is transferred from [**Hospital 11066**]
[**Hospital 107**] Hospital after presenting with two weeks of
progressive shortness of breath, chest heaviness, right
scapular pain, and palpitations. Patient says that for one
or two weeks before presenting to the outside hospital, he
was experiencing shortness of breath mostly at night
associated with bilateral chest tightness. He denies any
substernal chest pain, diaphoresis, presyncope, or dizziness.
He does admit to having paroxysmal nocturnal dyspnea, which
is improved with keeping his head elevated. He sleeps with
one pillow. He denies any orthopnea. Patient says
previously he has never had these symptoms. He denies any
history of chest pain or shortness of breath. He denies any
exertional symptoms with good exercise tolerance in the past
without chest pain or shortness of breath. Denies any pedal
edema or abdominal distention.
He has been experiencing episodes of palpitations, which have
lasted a few minutes, relieved with rest, and associated with
shortness of breath. No chest pain, diaphoresis, or syncope.
Presented to outside hospital on [**12-2**]. Over the
course of the hospitalization, the patient continued to have
shortness of breath, but he ruled out for a myocardial
infarction. He had an echocardiogram which showed an
ejection fraction of [**10-15**]% with severe mitral regurgitation.
He had a stress thallium which showed minimal no liability of
apical and septal segments. The patient experienced
supraventricular tachycardia. He was diagnosed as having
atrial fibrillation/atrial flutter.
He had been taking Quinidine which had been discontinued. He
was started on amiodarone. He is also started on ACE
inhibitor. He had an episode of decreased urine output, and
his creatinine went from 1.5-2.6. Has decreased by 7.5,
likely secondary to decrease cardiac output and renal
perfusion.
PAST MEDICAL HISTORY:
1. Coronary artery disease with a myocardial infarction 15
years ago, coronary artery bypass graft 10 years ago five
vessels.
2. Dyslipidemia.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lasix 40 mg po bid.
2. Coumadin 5 mg po q day.
3. Amiodarone 200 mg po q day.
4. Flomax 0.4 mg po q hs.
5. Captopril 12.5 mg po tid.
6. Digoxin 0.125 mg po q day.
7. Aspirin one tablet po q day.
8. Nitroglycerin transdermal 0.2 mg q am.
9. K-Dur 20 mg po q day.
10. Sucralfate 1 gram qid.
FAMILY HISTORY: Mother had breast cancer. No history of
hypertension, coronary artery disease, diabetes, or heart
disease. No history of thyroid disease.
SOCIAL HISTORY: Patient is retired. He lives with his wife.
[**Name (NI) **] denies any tobacco, social ethanol use, or intravenous
drug abuse.
PHYSICAL EXAMINATION: Temperature 97.3, heart rate 100,
blood pressure 90/40, respiratory rate 22, oxygen saturation
97% on room air. In general, the patient is lying
comfortable in no apparent distress. HEENT: Pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Conjunctivae pink. Throat
has moist mucous membranes. Neck: Jugular venous distention
to angle of the jaw approximately 12-15 cm. No carotid
bruits. Chest was clear to auscultation bilaterally. Poor
inspiratory effort. Cardiac: Point of maximal pulse is
enlarged. It is mid axillary. He had a [**3-6**] holosystolic
murmur that radiates from the apex to the axilla. Abdomen:
Normal bowel sounds, soft, nontender, and nondistended. No
hepatomegaly. Back: No costovertebral angle tenderness.
Extremities: No clubbing or cyanosis, trace pitting edema of
the lower extremities bilaterally. Femoral 2+ pulses, no
bruits, 1+ dorsalis pedis pulse bilaterally. Neurologic:
Awake, alert, and oriented times three. Cranial nerves II
through XII intact. Muscle strength in upper and lower
extremities [**5-5**] bilaterally. He had 2+ patellar reflexes.
LABORATORIES: White count is 15.6, hematocrit 37.9,
platelets 224,000. INR of 1.4, PTT 30.1, sodium 135,
potassium 4.2, chloride 98, bicarbonate 30, BUN 42,
creatinine 1.8, glucose 115, digoxin level 1.2.
Electrocardiogram showed sinus rhythm with a left bundle
branch block pattern.
IMPRESSION: This is a 72-year-old white male who has
coronary artery disease who presents with symptoms of
congestive heart failure.
HOSPITAL COURSE BY SYSTEMS: 1. Cardiac. The patient was in
overt congestive heart failure. Based on the previous
echocardiogram at the outside hospital, he had a very low
ejection fraction. Physical examination was significant for
jugular venous distention and peripheral edema. He did have
some crackles at the base of the lungs. The initial plan was
for the patient to have a cardiac catheterization on the
second day of admission.
Initially his medications were continued including the
digoxin, the ACE inhibitor. The Coumadin was held because of
the consenting of a potential procedure. His aspirin,
nitroglycerin patch, and Lipitor were also continued. He was
given Mucomyst prior to the catheterization. He was also
sent for an echocardiogram.
He had a cardiac catheterization on the second day of
admission. Results from the Catheterization Laboratory are
as follows: The coronary arteries show a right dominant
system, left main coronary artery had an 80-90% ostial
lesion. The left anterior descending artery had severe
proximal diffuse disease and then a mid total occlusion.
Left circumflex showed proximal occlusion with the distal A-V
groove vessels filled by left collaterals. The right
coronary artery was not engaged.
The grafts are as follows: The saphenous vein graft to the
left anterior descending artery was patent and supplied one
collateral to distal right coronary artery. The saphenous
vein graft to the first branch of the obtuse marginal was
patent, supplied a large branching vessel collaterals to the
LPL. Saphenous vein graft to the second obtuse marginal
arteries showed diffuse severe disease but supplied tiny
obtuse marginal. Saphenous vein graft to the acute marginal
showed diffuse irregularities with ostial 50% stenosis and
the saphenous vein graft to the PDA showed diffuse stenoses
to 60%, but good flow.
Left ventriculography showed 3+ mitral regurgitation with an
left ventricular ejection fraction of 20%. The aortography
showed 3+ aortic regurgitation with a left ventricular
ejection fraction of 20%.
His pressures were as follows: His right atrial pressure
mean of 14. His right ventricle had a pressure of 72/14.
Pulmonary artery was 81/45. Pulmonary capillary wedge
pressure was 29. Aortic pressure was 106/61. His cardiac
index was 1.8 with a cardiac output of 3.75.
Because of his elevated filling pressures, he was given Lasix
80 mg IV and started on dobutamine to improve his cardiac
output. The End Catheterization Laboratory post dobutamine
numbers were as follows: The aortic pressure was 113/57 and
the pulmonary artery pressure was 79/38 entirely different to
the numbers previous to the dobutamine. The cardiac output
after dobutamine was 7.72 and the cardiac index was 2.26
which were substantial increase in both numbers.
Because he was started on dobutamine, he was transferred from
the Catheterization Laboratory to the CCU for post-cath
management. In the CCU, the patient was managed. He had a
transthoracic echocardiogram done at the [**Hospital1 346**] which showed left atrial
enlargement, ejection fraction of 20%, and moderate aortic
regurgitation, 4+ mitral regurgitation, mild aortic stenosis,
and moderate pulmonary hypertension, and severe left
ventricular and right ventricular global hypokinesis.
The patient did not have any interventions in Catheterization
Laboratory. He did not have a balloon pump because of the
severity of his aortic regurgitation. He was on the
dobutamine to improve diuresis by improving his
contractility. He was given additional 40 mg IV of
furosemide in the CCU. He responded well to the furosemide
and diuresed well.
He was initially continued on his captopril 12.5 mg po tid.
He was also continued on his amiodarone, Lipitor, and
aspirin. He was also continued on digoxin. On the day after
cardiac catheterization in the unit, the patient had diuresed
approximately 2.5 liters. His blood pressure though was
between systolic of 88-114 and his diastolic was 42-77. He
had a femoral line. Pulmonary artery pressure was 78/34. It
was decided that since he was diuresing fairly sufficiently,
the dobutamine will be weaned off the day after his cardiac
catheterization. It was weaned off gradually.
Because of his severe valvular disease, the patient was seen
by CT Surgery for possible surgical intervention. However,
they felt that his substantial surgical risk and at this time
was not a surgical candidate. Instead medical management was
felt to be more appropriate at this time. The goal had been
to wean dobutamine the first day after cardiac
catheterization. However, with the totality of his input and
output, he was found to be even. Subsequently the dobutamine
was continued for a day, and he was given the standing dose
of 80 mg of IV Lasix every six hours. He was nearly even
because of the fluid from the Catheterization Laboratory.
Because he was producing large amounts of urine, it was
decided to wean off the dobutamine on the second day after
his cardiac catheterization. His furosemide was continued at
80 mg IV tid. The captopril and digoxin were continued. His
blood pressure remained borderline low, but he could easily
tolerate the captopril at low doses. He was weaned off the
dobutamine and transferred out of the unit on the [**12-15**].
On the [**12-13**], he did have one episode of left
lateral chest pain. He was given one sublingual
nitroglycerin which relieved the pain. In the night of the
13th, he had an episode of dyspnea which resolved with
furosemide.
On the 14th, his furosemide was changed to 80 mg po bid from
the IV formulation. He was also started on metolazone 5 mg
[**Hospital1 **] to be given prior to the furosemide. His diuresis on the
14th, had been approximately a liter. At times, his
captopril was held because of blood pressure less than 110,
however, it was then changed to less than 90. His blood
pressure remained in the high 90-100s for systolic blood
pressure.
On [**12-15**], he had been approximately 1.5 liters
negative. He had an improving chest x-ray. On [**2181-12-16**], his creatinine had increased to 2.7. It was mainly due
to the seeing of the diuresis.
In a 24 hour period on [**12-16**], he had been nearly 3
liters negative and had lost about 3 lb. Consequently, his
Lasix was discontinued at this point. With the goal was to
have an even fluid balance. His blood pressure remained
approximately the same at this time. His captopril was also
discontinued at this time. Consequently, since it was
thought that he had an increase in his creatinine due to
overdiuresis, he was given a liter of 0.5 normal saline. His
creatinine did improve to 2.2 from 2.7.
His creatinine on the [**12-18**] was 2.1. At this time
his captopril was restarted at 12.5 mg po tid and his
furosemide was restarted at 80 mg po bid, but no metolazone.
During this admission, he had been diuresed to the point
where his kidneys started to show an increase in creatinine.
It was felt that he had been diuresed well, but would need a
maintenance diuresis. Consequently, he was continued on the
afterload reduction contractility [**Doctor Last Name 360**] with digoxin and
Lasix for maintaining diuresis. His Lasix dose may need to
be adjusted as an outpatient. It was decided that his volume
status needed to be balanced against his renal function. His
creatinine may need to be slightly increased to have improved
volume status.
For his valvular disease, it was decided that medical
management might not be best as he was not a surgical
candidate at this time. His coronary arteries, though having
some evidence of disease, did not have any slow limiting
stenoses and did not require any intervention at this time.
2. Renal. The patient has a history of chronic renal
insufficiency. His baseline creatinine had been 1.5. At the
outside hospital, his creatinine had increased to 2.6 due to
diuresis and hypertension. Over the course of this
admission, the patient's creatinine also increased. He did
receive Mucomyst prior to the cardiac catheterization. His
creatinine increased to 1.8 on the 11th on the second day of
his admission.
On the third day of his admission, his creatinine was again
1.5. On the fourth day of admission, it was 1.7. Lasix was
still continued. On fifth day of admission, it was 1.9. On
the sixth day of admission it was 2.1. But on the seventh
day of admission, it increased to 2.7. At this time his
Lasix and metolazone and captopril were discontinued
temporarily. It was felt that his acute renal failure was
secondary to overdiuresis. He was given a liter of 0.5
normal saline. His creatinine responded to decrease of 2.2.
On date of discharge, it was 2.1. It was felt that he may
have a new baseline creatinine at his new volume status.
His furosemide was restarted at 80 mg po bid and the
metolazone was stopped. His captopril was also restarted at
12.5 mg po tid to improve the patient's afterload reduction.
3. Infectious disease. The patient had an elevated white
count that increased from 11 to 16 on second day of
admission. However, he had no fevers during the course of
his admission. His urine culture did not reveal any
suspicious findings. He also had blood cultures to assess
for any evidence of endocarditis, and at time of discharge,
the cultures were still negative.
4. Heme. The patient had a decrease from 38 to 31 in his
hematocrit. This has occurred on the third day of his
admission and was thought merely to the hydration he received
during the Catheterization Laboratory prior to and during his
cardiac catheterization. His hematocrit on the sixth day of
admission was 34.5. His hematocrit was managed throughout
the rest of his admission. On the day of discharge, his
hematocrit was 33.7.
The patient was discharged to home with his family.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg po q day.
2. Furosemide 80 mg po bid.
3. K-Dur 20 mEq po q day.
4. Captopril 12.5 mg po tid.
5. Digoxin 0.125 mg po q day.
6. Flomax 0.4 mg po q day.
7. Sucralfate 1 gram po qid.
8. Amiodarone 200 mg po q day.
9. Atorvastatin 10 mg po q day.
FOLLOWUP: He will follow up with his cardiologist for
further adjustments in his diuretic medications and
concerning possibility of restarting Coumadin. He did not
have any further episodes of atrial fibrillation or atrial
flutter during this admission.
DISCHARGE STATUS: The patient can be discharged back to
home.
FOLLOWUP: He will have followup with his cardiologist within
the next week.
CONDITION ON DISCHARGE: The patient is in fair condition.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Mitral regurgitation, severe.
3. Moderate aortic regurgitation.
4. Acute exacerbation of chronic renal insufficiency.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2182-3-11**] 15:24
T: [**2182-3-13**] 11:22
JOB#: [**Job Number 39457**]
ICD9 Codes: 4280, 4254, 5849, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4877
} | Medical Text: Admission Date: [**2135-8-30**] Discharge Date: [**2135-9-20**]
Date of Birth: [**2094-3-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Coiling of P-Comm Aneurysm
Placement of EVD
VP Shunt
History of Present Illness:
41 y/o female presented to OSH after taking her son to the [**Name (NI) **]
for a viral rash when she had a sudden onset headache, nausea,
and vomiting. She returned to the ED where a CT was done. CT
scan revealed spontaneous SAH and she was transferred to [**Hospital1 18**]
for further neurosurgical workup. She was medflighted to [**Hospital1 **] and
intubated in route for worsening mental status. She has a
history of cocaine abuse.
Past Medical History:
HTN
Cocaine abuse
Social History:
Drug abuse
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
T:97 BP:134/70 HR: 56 R:18 O2Sats: CMV
Gen: Patient is intubated and sedated on fentanyl
HEENT: Atraumatic, normocephalic
Pupils: 4-2mm bilaterally EOMs: UTA
Neuro:
Mental status: patient was intubated and sedated on fentanyl
Orientation: unable to access
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally.
V, VII: Facial symmetric at rest.
Positive cough and gag.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. BUE weak attempt to localize to noxious stimuli, LLE
triple flexion to noxious stimuli, and RLE no movement to
noxious
stimuli.
Discharge exam:
A&O to self
EOMs intact
face symmetrical
tongue midline
Motor B T D IP [**Initials (NamePattern5) 12643**] [**Last Name (NamePattern5) **] AT [**Last Name (un) 938**]
R 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5
Incision: clean, dry, and intact
Physical Exam on discharge: A&O to name, hospital, unable to
tell date. Speech clear, No drift, motor [**5-3**].
Pertinent Results:
CTA HEAD W&W/O C & RECONS Study Date of [**2135-8-30**] 12:00
1. Diffuse subarachnoid hemorrhage, increased from earlier
today. Increased
intraventricular hemorrhage with increased hydrocephalus.
2. 4.5 x 2 x 2 mm aneurysm at the junction of the right ACA and
anterior
communicating artery. Conventional angiography is already
planned at the time of this dictation.
TRANSCATH EMBO THERAPY Study Date of [**2135-8-30**] 1:02 PM
1. Successful coiling of 2.3mm x 4 mm right anterior
communicating artery
origin aneurysm.
2. No additional aneurysms identified. Pressure held at right
groin access
site with adequate hemostasis obtained.
CT HEAD W/O CONTRAST Study Date of [**2135-8-30**] 3:58 PM
1. Unchanged extensive subarachnoid and intraventricular
hemorrhage.
2. Status post ventriculostomy with questionable minimal
decreased size of
the temporal horns of the lateral ventricles. Otherwise, no
significant
change in hydrocephalus.
CT HEAD W/O CONTRAST [**2135-9-12**]
1. New right frontal approach ventriculostomy terminates near
the left
foramen of [**Last Name (un) 2044**]. No appreciable change in size of ventricles.
2. Expected evolution of intracranial blood products. No new
hemorrhage.
[**2135-9-19**] 05:00AM BLOOD WBC-6.6 RBC-3.70* Hgb-12.0 Hct-34.8*
MCV-94 MCH-32.3* MCHC-34.5 RDW-14.1 Plt Ct-489*
[**2135-9-16**] 05:00AM BLOOD WBC-8.8 RBC-3.37* Hgb-11.3* Hct-32.9*
MCV-97 MCH-33.4* MCHC-34.2 RDW-13.2 Plt Ct-531*
[**2135-9-15**] 05:00AM BLOOD WBC-8.4 RBC-3.63* Hgb-11.7* Hct-35.3*
MCV-97 MCH-32.1* MCHC-33.0 RDW-13.1 Plt Ct-555*
[**2135-9-19**] 05:00AM BLOOD PT-11.9 PTT-28.2 INR(PT)-1.0
[**2135-9-19**] 05:00AM BLOOD Glucose-102 UreaN-17 Creat-0.6 Na-152*
K-4.1 Cl-114* HCO3-30 AnGap-12
[**2135-9-18**] 06:30AM BLOOD Glucose-107* UreaN-17 Creat-0.5 Na-150*
K-4.3 Cl-112* HCO3-24 AnGap-18
[**2135-9-16**] 12:25PM BLOOD Glucose-136* UreaN-13 Creat-0.5 Na-147*
K-3.7 Cl-108 HCO3-28 AnGap-15
[**2135-9-19**] 05:00AM BLOOD Calcium-10.2 Phos-4.4 Mg-2.3
Brief Hospital Course:
Patient presented to [**Hospital1 18**] from OSH s/p severe sudden onset of
headache and n/v. Head CT revealed a spontaneous SAH. She was
intubated on route to [**Hospital1 **] and taken to CTA immediately upon
arrival and exam completed. CTA revealed a R ACOM aneurysm which
was coiled in angiogram. An EVD was also placed to reduce
hydrocephalus. Patient was then transferred to ICU where her
intracranial pressures were measured. She was extubated on [**8-31**]
and her exam was stable. She periods of increasing ICP which
required Mannitol and tpa administration. She failed two
clamping attempts and eventually required a VP shunt on [**9-12**]. VP
shunt in place, patient alert and oriented to self and full
strength. On [**9-16**], sodium level was noted to be 153 in the
morning, 250cc bolus of D5W was started. Sodium level in the
afternoon was 147 after administration of D5W.
She had no ID issues with exception of MRSA+ found on admission
in her nose she was placed on precautions.
Follow up CTAs showed good positioning of the coils and
questionable periods of vasospasm for which she did not exhibit
any clinical symptoms.
Free water was encourage for Na 150 on [**2135-9-18**]. She was on a
regular diet. [**9-19**] changed to low sodium diet and encouraged to
free water. Please follow sodium at rehab. A sodium is pending
on discharge.
Patient has been screened for a rehab facility and will be
discharged on [**2135-9-20**]. Her neurological exam on discharge was
she was awake, alert and orientated to self and hospital. She
has short term memory issues and rarely remembers the date. Her
face is symmetric she has no drift and she is full strength.
Medications on Admission:
unknown
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain fever.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
SAH with A-Comm Aneurysm
Hydrocephalus
Discharge Condition:
Neurologically stable
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? You may resume sexual activity.
?????? Gradually increase your activities and distance walked as you
can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Follow up 4 weeks with Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1669**] to set up an appointment, you will need a
non-contrast CT scan of the head prior to the appointment which
can be scheduled at the same time as your office appointment.
Completed by:[**2135-9-20**]
ICD9 Codes: 431, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4878
} | Medical Text: Admission Date: [**2124-4-1**] Discharge Date: [**2124-4-1**]
Date of Birth: [**2046-8-6**] Sex: F
Service: CARD ICU
HISTORY OF PRESENT ILLNESS: The patient is a 77 year old
female with a history of significant coronary artery disease,
status post numerous interventions, aortic valve replacement,
hypertension, hypercholesterolemia, who presented to an
outside hospital intubated after she was found to have
hypoxic respiratory failure which required intubation by EMS
in the field. Post intubation EMS noted the patient had an
episode of asystole requiring resuscitation. The patient was
brought to the outside hospital where EKG noted the patient
had new wide left bundle branch block morphology. The
patient was also significantly acidotic. The patient's
acidemia was reversed and the patient was transferred to
[**Hospital1 18**] for acute cardiac intervention. The patient arrived at
[**Hospital1 18**] at approximately 7:30 a.m. by Life Flight. She was
intubated, but responsive. Her abdomen was benign. Her EKG
changes had resolved with resolution of acidemia. However,
the patient ruled in significantly with cardiac enzymes,
positive CKMB and positive troponin. Given the known tenuous
nature of her previous vein grafts, specifically patent SVG
to D1 which was supplying the majority of the myocardium,
plan was made to take the patient to cardiac catheterization.
In addition, the patient was noted to have a new wall motion
abnormality in the inferior lateral walls which further
supported the decision to take the patient to the cardiac
cath lab.
HOSPITAL COURSE: In the cardiac cath lab, the patient's vein
graft from SVG to D1 was noted to be patent. There was mild
ostial lesion, but no clear obstruction of the flow. The
patient became hypotensive in the middle of the
catheterization. The patient required initiation of three
pressor agents. In addition, decision was made to place an
intra-aortic balloon pump. In order to place the
intra-aortic balloon pump, several stents had to be placed in
the iliac artery. The balloon pump was successfully placed
which transiently improved her cardiac output. However, the
patient continued to deteriorate.
At this point labs showed that the patient was acutely
bleeding, given that her hematocrit had dropped from
approximately 33 on admission to 12.9 post procedure. The
patient was taken for CT scan for visualization of possible
retroperitoneal or femoral bleed. During the CT scan, the
patient became hemodynamically unstable. Pressure had
dropped. Attempts were made to resuscitate the patient with
multiple units of blood. She required multiple doses of
epinephrine.
At one point the patient's rhythm was noted to ventricular
fibrillation and she required cardioversion back to paced
rhythm. The CT scan did not demonstrate an obvious source of
bleeding. However, it did note evidence of mesenteric
ischemia with portal venous gas. Vascular surgery was
consulted regarding whether or not acute surgical
intervention would benefit the patient. Given her
deteriorating condition on three pressors, it was felt that
she was an extremely poor surgical candidate.
At this time the patient's family was consulted regarding her
deteriorating clinical status and the decision was made to
withdraw care. The patient was transferred back to the
cardiac intensive care unit where pressure support was
discontinued. The patient passed away within the hour at
approximately 9:00 p.m. The medical examiner was notified of
this case and declined autopsy.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36
D: [**2124-4-2**] 12:26
T: [**2124-4-3**] 14:26
JOB#: [**Job Number 49977**]
ICD9 Codes: 4280, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4879
} | Medical Text: Admission Date: [**2138-3-18**] Discharge Date: [**2138-3-25**]
Date of Birth: [**2062-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Decreased exercise tolerance with dypsnea on exertion
Major Surgical or Invasive Procedure:
AVR (23mm CE pericardial))/MVR (29mmCE, pericardial)/TV Repair
(32mm ring)/CABG X 1 (SVG > OM) on [**2138-3-18**]
History of Present Illness:
75 y/o african american male with known rheumatic heart disease
with recent shortness of breath and hospital admission for
congestive heart failure. Also c/o decreased exercise tolerance,
DOE, and fatigue.
Past Medical History:
Aortic Stenosis
Mitral Regurgitation and Stenosis
Tricuspid Regurgitation
Coronary Artery Disease
Rheumatic Heart Disease
congestive Heart Failure
Hypercholesterolemia
Diverticulitis
?GERD
h/o Prostate Cancer s/p prostatectomy
s/p testicular surgery
Social History:
Retired parking officer. Lives with wife.
Quit smoking [**9-28**] after 1/2ppd x 35 yrs.
Rare ETOH
Family History:
Non-contributory
Physical Exam:
VS: 84 20 160/84 160/80 5'[**41**]" 112#
General: 75 y/o male in NAD
Skin: Unremarkable, W/D
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR 3/6 syst. murmur
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, few varicosities bilat R>L
Neuro: A&Ox3, MAE, non-focal
Pertinent Results:
Echo [**3-18**]: Prebypass: The right atrium is markedly dilated.
There is moderate global left ventricular hypokinesis. Overall
left ventricular systolic function is moderately depressed.
Resting regional wall motion abnormalities include moderately
depressed inferior wall basal and mid portions. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis. Moderate to severe (3+)
aortic regurgitation is seen. Aortic annulus measures 23 mm. The
mitral valve leaflets are severely thickened/deformed. The
mitral valve shows characteristic rheumatic deformity. There is
moderate mitral stenosis. Moderate (2+) mitral regurgitation is
seen. Severe [4+] tricuspid regurgitation is seen. Moderate
sized left pleural effusion. Post bypass: Biventricular systolic
function is unchanged. Bioprosthetic valve seen in the mitral
position. Valve appears well seated and the leaflets move well.
Trace mitral regurgitation. Bioprosthetic valve seen in the
aortic position. Leaflets move well and the valve appears well
seated. Trace aortic regurgitation present. Annuloplasty ring
seen in the tricuspid position. Trace to mild tricuspid
regurgitation present.
CXR [**3-24**]: Resolution of failure. Cardiomegaly persists.
[**2138-3-18**] 02:05PM BLOOD WBC-17.6*# RBC-2.95*# Hgb-8.9*#
Hct-25.9*# MCV-88 MCH-30.3 MCHC-34.5 RDW-13.3 Plt Ct-106*
[**2138-3-20**] 03:36AM BLOOD WBC-19.2* RBC-2.85* Hgb-8.6* Hct-24.4*
MCV-86 MCH-30.3 MCHC-35.4* RDW-15.2 Plt Ct-126*
[**2138-3-24**] 09:00PM BLOOD WBC-10.8 RBC-3.66* Hgb-11.2* Hct-31.3*
MCV-86 MCH-30.5 MCHC-35.6* RDW-14.0 Plt Ct-171
[**2138-3-18**] 02:05PM BLOOD PT-18.8* PTT-58.3* INR(PT)-1.8*
[**2138-3-22**] 03:17AM BLOOD PT-13.0 PTT-30.8 INR(PT)-1.1
[**2138-3-18**] 03:20PM BLOOD UreaN-13 Creat-0.7 Cl-114* HCO3-23
[**2138-3-24**] 06:09AM BLOOD Glucose-120* UreaN-16 Creat-0.7 Na-138
K-3.2* Cl-101 HCO3-26 AnGap-14
[**2138-3-24**] 06:09AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 131**] was seen initially as an outpatient and had his entire
pre-operative work-up done prior to hospital admission for
surgery. He was a same day admit on [**2138-3-18**] and was brought to
the operating room where he underwent a aortic valve repair,
mitral valve repair, tricuspid valve replacement and coronary
artery bypass graft x 1 by Dr. [**Last Name (Prefixes) **]. Please see op note
for surgical details. Following surgery patient was transferred
to the CSRU in stable condition receiving Epinephrine,
Milrinone, and Propofol. Early on post-op day one he was weaned
from sedation, awoke neurologically intact and extubated. He was
weaned off of all pressors/inotropes by post-op day two. Beta
blockers and diuretics were started and he was gently diuresed
towards his pre-operative weight. He was slightly anemic with a
Hgb of 24.4 and was transfused 1u PRBC's. At time of discharge
his Hgb was 31. Chest tubes and epicardial pacing wires were
removed per protocol. Had sleep study on post-op day 3 secondary
to difficulty swallowing. He became febrile between post-op day
3 and 4 and was empirically started on Vancomycin and Levaquin.
Multiple cultures came back negative but was found to have LLL
consolidation (presumed PNA). He was transferred to the cardiac
surgery step down unit on post-op day four. His temperature
decreased on pod#5, but had elevated WBC. PT worked with patient
during entire post-op course for strength and mobility. Patient
became confused and psychiatric consult was done. Infectious
disease was also consulted secondary to fever/WBC/PNA. Over next
couple of days patient was stable with normal exam, vital signs,
and stable labs. He was discharged home with VNA services on
post-op day seven and the appropriate follow-up appointments.
Medications on Admission:
Aspirin 81mg qd, Lisinopril 20mg qd, Simvastatin 40mg qd,
Antacids prn
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-25**]
Puffs Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
Disp:*1 MDI* Refills:*2*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then 200 mg daily until d/c'd by Dr. [**Last Name (STitle) 3659**].
Disp:*60 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO twice a day for 7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Aortic Stenosis/Mitral Regurgitation and Stenosis/Tricuspid
Regurgitation/Coronary Artery Disease s/p Aortic Valve
Replacement, Mitral Valve Replacement, Tricupid Valve Repair,
Coronary ARtery Bypass Graft x 1
Rheumatic Heart Disease
Hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) **] in [**12-27**] weeks
with Dr. [**Last Name (STitle) **] in [**12-27**] weeks
with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2138-3-25**]
ICD9 Codes: 5070, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4880
} | Medical Text: Admission Date: [**2131-9-5**] Discharge Date: [**2131-9-14**]
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right colectomy, ileocolic anastomosis,
open cholecystectomy and transgastric feeding jejunostomy.
History of Present Illness:
This is a [**Age over 90 **] yo F with complicted past medical history but no
abdominal operations, comes in with 3 days history of "feeling
lousy." States she cannot recall the onset, but for the past
few days she has felt weak, tired and generally unwell. Denies
fevers, chills, sweating. Has had some nausea, and vomited a
small amount last night, though she could not describe it.
Denies abdominal pain, but endorses discomfort. Normal
urination, normal BM (yesterday), no diarrhea. No chest pain or
SOB.
Of note, she is DNR, DNI and states she has no intention of
having any operations even if it were to save her life. In
addition, she states her lawyer drafted a document to this
effect. She has no proxy and no family memebers in the area.
Dr. [**First Name (STitle) 2819**] has seen the patient and discussed the diagnosis with
the patient and family. The patient was previously DNR/DNI and
was initially refusing surgery. However, after discussion with
Dr. [**First Name (STitle) 2819**], who explained the benefits, alternative, and risks to
the patient and her family, the decision to proceed with surgery
was made. Her DNR/DNI order will be suspended for the
perioperative period.
Past Medical History:
PMH: Afib, CHF, diabetes, asthma, coronary artery disease, hx of
falls.
PSgH: status post left cataract, B/L shoulder surgery, R hip
surgery.
Social History:
Lives in [**Location (un) **] [**Hospital3 400**] for 8 years.
Family History:
Non-contributary
Physical Exam:
AAO x 3, NAD
RRR no MRG
CTA B/L, some ronchi at bases. ? emphysema
Soft, NT, ND, no tympany, mildly protuberant (patient states it
is baseline) + B/S, no hernias
Rectal exam: NT, no masses, no stool in rectal vault, guaiac
negative, + edema B/L
Pertinent Results:
[**2131-9-6**] 02:25PM BLOOD WBC-13.2*# RBC-3.61* Hgb-11.3* Hct-33.2*
MCV-92 MCH-31.4 MCHC-34.2 RDW-13.9 Plt Ct-327
[**2131-9-11**] 04:16AM BLOOD WBC-10.4 RBC-3.60* Hgb-11.2* Hct-33.5*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.0 Plt Ct-292
[**2131-9-12**] 04:05AM BLOOD Glucose-136* UreaN-22* Creat-0.7 Na-135
K-3.7 Cl-107 HCO3-25 AnGap-7*
[**2131-9-11**] 04:16AM BLOOD Calcium-7.6* Phos-3.4 Mg-1.6
[**2131-9-11**] 03:51PM BLOOD Digoxin-1.3
.
Portable TTE (Complete) Done [**2131-9-7**] at 8:32:16 AM FINAL
Conclusions
The left atrium is elongated. The patient is mechanically
ventilated. The IVC is small, consistent with an RA pressure of
<10mmHg. Left ventricular wall thicknesses and cavity size are
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Probably low normal overall systolic function. Mild
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension.
.
Radiology Report UNILAT UP EXT VEINS US Study Date of [**2131-9-10**]
10:28 AM
IMPRESSION: No evidence of right upper extremity DVT.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-9-10**]
10:56 AM
The right internal jugular line tip is most likely at the
cavoatrial junction.
The cardiomediastinal silhouette is difficult to appreciate
given the
bilateral increase in pleural effusion and perihilar opacities
consistent with worsening of pulmonary edema. Aspiration can
also be included in differential diagnosis. The patient is after
recent abdominal surgery. Contrast material is demonstrated in
the bowel.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2131-9-10**]
11:58 AM
IMPRESSION: No acute intracranial process.
.
**FINAL REPORT [**2131-9-10**]**
URINE CULTURE (Final [**2131-9-10**]):
GRAM NEGATIVE ROD(S). ~1000/ML.
STAPHYLOCOCCUS SPECIES. ~1000/ML.
Brief Hospital Course:
This is a [**Age over 90 **] year old female with abdominal pain, nausea,
vomiting. Imaging at
[**Location (un) 620**] noted an ileocolic intussuception that is likely due to
a lead point of tumor or polyp. This is causing a small bowel
obstruction. She agreed to surgery and went to the OR on [**2131-9-6**]
for: Exploratory laparotomy, right colectomy, ileocolic
anastomosis, open cholecystectomy and transgastric feeding
jejunostomy
Post-op Acute Respiratory Failure: Post-operatively she went
into respiratory failure mid day. TTE done by fellow [**Last Name (un) 16997**] Tan
showed mild global hypokinesis and worsened TR (baseline 2+).
She received 1U PRBC for acute post-op blood loss anemia.
She was reintubated.
Post-op Atrial Fibrillation/Tachycardia: She was cardioverted in
PACU for chronic afib with RVR to 120s as her BP dropped to 70s.
She was flipping between sinus 40-60s and afib with slow
ventricular response to 40-60s. She eventually was in sinus
rhythm. Once on the floor, she had episodes of post-op
bradycardia and so her Lopressor was held. On POD 8, her
Lopressor was restarted secondary to tachycardic episodes.
She went to the ICU post-op for close monitoring.
She was transferred out of ICU on [**9-8**].
Post-op UTI: On [**9-9**]: UA+-->GNR & Staph <1000/mL. She was
treated with Cipro for a UTI.
Difficult to Arouse: The patient was triggered for nursing
concern. The patient was hard to arouse and not waking to
sternal rub, but had stable vital signs. She went for imaging on
[**9-10**] HEAD CT: No hemmorhage. CXR: incr b/l effusion, worseing
pulm edema vs. aspiration.
This episode passed and she was alert and oriented and back at
her baseline.
FEN: She was NPO with IVF. She was started on trophic
tubefeedings and the tubefeedings were ramped up to goal. Once
more awake and alert, her diet was slowly advanced and she was
tolerating a regular diet at time of discharge. Her tubefeedings
should continue for at least 3 months.
Abd: Her abdomen was soft and nontender. The staples were
removed prior to discharge and steri strips applied.
Medications on Admission:
digoxin 0.125', furosemide 40', MVI', toprol XL 12.5', enalapril
2.5", plus calcium supplementation, metformin 500"
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for delerium.
5. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Ileocolic intussusception secondary to submucosal mass, chronic
cholecystitis with cholelithiasis.
Post-op Bradycardia
Post-op Tachycardia
Acute Respiratory Failure
Discharge Condition:
Good
Tolerating a regular diet
Tolerating tubefeedings
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 take all new meds as ordered.
* No heavy lifting (>10lbs) for 6 weeks.
* Continue to increase activity daily
* Monitor your incision for signs of infection (redness or
drainage).
* Continue tubefeedings
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**11-29**] weeks. Call to schedule an
appointment.
Please follow-up with Dr. [**First Name (STitle) 2819**] on [**2131-9-24**] at 9:45am in [**Location (un) 620**].
Call ([**Telephone/Fax (1) 6347**] with questions or concerns.
Completed by:[**2131-9-14**]
ICD9 Codes: 5185, 5849, 9971, 5990, 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4881
} | Medical Text: Admission Date: [**2175-5-16**] Discharge Date: [**2175-5-19**]
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo female s/p fall down stairs; unknown LOC. Taken to an area
hospital, found to have a left temporal subarachnoid hemorrhage.
She was transferred to [**Hospital1 18**] for continued trauma care.
Past Medical History:
CAD
CRI
AAA s/p repair
COPD
PVD
CHF
AFib
h/o DVT
Social History:
Married, lives with husband who reportedly has some Dementia.
Has a son and daughter.
Family History:
Noncontributory
Physical Exam:
VS upon admission to the trauma bay:
GCS 15
BP 144/palp HR 80 RR 16
EOMI, occipital laceration, TM's clear, clotted blood in
pharynx, mid face stable
Cervical collar, no crepitus
Midthoracic tenderenss, no stepoffs, BS clear
Abdomen soft, nontender, reducible hernia
Pelvis stable
Normal rectal tone, guaiac negative
Extr no deformities
Pertinent Results:
[**2175-5-16**] 04:59PM GLUCOSE-149* LACTATE-1.7 NA+-135 K+-7.7*
CL--98* TCO2-23
[**2175-5-16**] 04:50PM UREA N-49* CREAT-3.1*
[**2175-5-16**] 04:50PM AMYLASE-101*
[**2175-5-16**] 04:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-5-16**] 04:50PM WBC-11.3* RBC-5.10 HGB-12.9 HCT-39.7 MCV-78*
MCH-25.3* MCHC-32.5 RDW-16.6*
[**2175-5-16**] 04:50PM PT-34.8* PTT-41.1* INR(PT)-3.8*
[**2175-5-16**] 04:50PM PLT COUNT-331
CT HEAD W/O CONTRAST [**2175-5-17**] 9:56 AM
CT HEAD W/O CONTRAST
Reason: F/u head bleed
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with AH/SDH
REASON FOR THIS EXAMINATION:
F/u head bleed
CONTRAINDICATIONS for IV CONTRAST: renal failure
CT OF THE HEAD WITHOUT CONTRAST, DATED [**2175-5-17**]
HISTORY: 81-year-old female with known intracranial hemorrhage
after trauma; followup.
TECHNIQUE: Contiguous 5-mm axial tomographic sections were
obtained from the skull base through the vertex and viewed in
brain and bone window. Much of the study is significantly
degraded by patient motion artifact and several sections were
repeated.
FINDINGS: The study is compared with the examination obtained
approximately 17 hours earlier. Allowing for the
motion-degradation, there has been no significant change in the
bifrontal parenchymal hemorrhages, likely representing
hemorrhagic contusions. There is no interval increase in
adjacent edema, mass effect or associated shift of the midline
structures. Assessment of the small hemorrhagic focus in the
anterior aspect of the right middle cranial fossa is limited,
but this, too, is not grossly changed, and no new hemorrhagic
focus is identified. Again demonstrated are large right
occipital scalp subgaleal hematoma with underlying right
basiocciput fracture and fluid layering in the right sphenoid
sinus, with no definite sphenoid fracture seen.
IMPRESSION: Motion-limited study, with no significant change
since the admission examination obtained on the preceding day.
CT C-SPINE W/O CONTRAST [**2175-5-16**] 4:45 PM
CT C-SPINE W/O CONTRAST
Reason: ? fx
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman s/p fall on coumadin
REASON FOR THIS EXAMINATION:
? fx
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 82-year-old female with status post fall, on
Coumadin. Evaluate for fracture.
No prior studies for comparison.
TECHNIQUE: Axial non-contrast images of the cervical spine were
obtained. Sagittal and coronal reconstructions were performed.
FINDINGS: On sagittal images, the base of the occiput to the T2
vertebra is clearly visualized. The prevertebral soft tissues
are unremarkable. There is slight grade 1 retrolisthesis of C4
on C5. A C4 inferior endplate deformity most likely represents a
Schmorl node, although inferior endplate fracture cannot be
definitively excluded. Moderately severe degenerative changes of
the cervical spine. Facet joint proliferative changes and
posterior osteophytes result in mild spinal canal narrowing,
most marked at C5/6. There are emphysematous changes of the
lungs with scarring of the right lung apex. MRI is better in the
evaluation of the thecal sac, but there are no gross thecal sac
abnormalities.
IMPRESSION:
1. Grade 1 retrolisthesis of C4 on C5. A C4 inferior endplate
deformity likely represents a Schmorl's node, although inferior
endplate fracture cannot be definitively excluded. Clinically
correlate.
2. Degenerative changes of the cervical spine.
NOTE ADDED IN ATTENDING REVIEW:
1. Right basiocciput fracture well seen in coronal reformatted
images; exits at the jugular foramen but spares the occipital
condyle, and atlanto- occipital relationship is maintained.
2. Moderately severe degenerative changes, particularly at the
C5/6 > C4/5, with moderate canal stenosis and slight indentation
of the thecal sac (and cord). Might be at risk for "central
cord" injury at these levels (with appropriate mechanism). b/l
neural foraminal narrowing at these levels.
3. Evidence of severe bullous emphysema, w/irreg, focal
pleuroparench thickening, R lung apex; a pleural-based mass is a
consideration.
4. D/W Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] (Trauma [**Doctor First Name **]), 0915h, [**2175-5-17**].
CT CHEST W/CONTRAST [**2175-5-16**] 4:45 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: ? bleeding
Field of view: 50 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman s/p fall on coumadin
REASON FOR THIS EXAMINATION:
? bleeding
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 82-year-old female status post fall, on Coumadin.
Comparison to prior CT abdomen/pelvis of [**2169-4-7**].
TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis
were obtained after the administration of IV Optiray contrast.
Multiplanar reformatted images were also obtained.
CT CHEST WITH IV CONTRAST: Heart and great vessels are
unremarkable. There are scattered mediastinal lymph nodes. A
pretracheal lymph node measures 1.2 cm. There is apical
scarring. A right upper lobe pulmonary nodule measures 4 mm.
There is bibasilar atelectasis. Incidental note is made of a
1-cm spiculated right breast opacity concerning for malignancy.
CT ABDOMEN WITH IV CONTRAST: The liver, pancreas, adrenal
glands, and left kidney are unremarkable. Right kidney
hydronephrosis and ureteral stent is seen. A right kidney
hypodensity likely represents a cyst, but cannot be further
characterized on this examination. The spleen is heterogeneous
likely secondary to the phase of filling. There is a small
gallstone. Again seen is a suprarenal abdominal aortic aneurysm
measuring 3.7 cm. This has decreased in size compared to the
prior examination and there is evidence of surgical
intervention. There are bilateral common iliac artery grafts
with partial thrombosis. No free fluid or free air within the
mesentery.
CT PELVIS WITH IV CONTRAST: The rectum is normal. There is
sigmoid diverticulosis without evidence of diverticulitis. A 1.5
x 1.0 cm cystic structure is seen within the uterus. There is a
moderate amount of high- attenuation fluid within the pelvis,
likely representing hematoma. Incidental note is made of left
internal iliac aneurysm.
OSSEOUS WINDOWS: Demonstrate a partially displaced sacral
fracture.
IMPRESSION:
1. Partially displaced sacral fracture with adjacent presacral
pelvic hematoma.
2. Suprarenal abdominal aortic aneurysm measuring 3.7 x 3.2 cm,
decreased in size compared to the previous examination. There
are common iliac artery grafts with partial thrombosis.
3. Right-sided hydronephrosis with right ureteral stent.
4. Gallstone.
5. Spiculated opacity in the right breast concerning for
malignancy, for which mammogram is recommended.
6. Cystic density within the uterus, for which pelvic ultrasound
is recommended.
Brief Hospital Course:
Patient admitted to the trauma service. Neurosurgery and
Orthopedic surgery were consulted because of her injuries. Her
SAH was managed non operatively; she was loaded with Dilantin
and will continue for the next 4 weeks until follow up with Dr.
[**Last Name (STitle) **], Neurosurgery in 3 months at which time she will have a
repeat head CT scan.
Her Coumadin should not be restarted until [**2175-5-25**].
Her Orthopedic injuries were managed conservatively as well.
There were no cervical spine fractures identified and so her
cervical collar was removed. She can be WBAT with her sacral
fracture. For pain control she was placed on ATC Tylenol and prn
Dilaudid 1 mg for breakthrough pain.
Geriatrics was consulted because of her age and mechanism of
injury. Several recommendations regarding her medication
regimine were made; she was also started on Calcium and Vit D
prophylaxis. Her HCTZ was restarted at a lower dose; was on 50
mg QD at home.
There was an incidental finding on her chest CT scan; a
spiculated opacity right breast was noted and on exam there is a
palpable mass. Her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30106**] was contact[**Name (NI) **] regarding
this; a copy of the CT report was forwarded to him as well. She
will need to follow up with him after discharge from rehab.
Physical and Occupational therapy were consulted and have
recommended short term rehab stay.
Medications on Admission:
Verapamil 180'
HCTZ 50'
Dig .125'
Coumadin 2'
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold fro HR <60 and/or SBP <110.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day): Continue for 4 weeks then
discontinue.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p Fall
Left Temporal Subarachnoid Hemorrhage
Transverse Sacral Fracture
Discharge Condition:
Stable
Discharge Instructions:
DO NOT restart your Coumadin until [**2175-5-25**]
Follow up in 2 months with Orthopedics
Follow up with Neurosurgery in 3 months
Followup Instructions:
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30106**] regarding the finding on
chest CT; you will also need a mammogram scheduled within the
next 1-2 weeks.
Call [**Telephone/Fax (1) 1228**] for an appointment in 2 months with Dr.
[**Last Name (STitle) 1005**], Orthopedics.
Call [**Telephone/Fax (1) 2731**] for an appointment with Dr. [**Last Name (STitle) **],
Neurosurgery. Infrom the office that you will need a repeat head
CT scan for this appointment.
Completed by:[**2175-5-19**]
ICD9 Codes: 496, 4280, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4882
} | Medical Text: Admission Date: [**2186-10-31**] Discharge Date: [**2186-11-3**]
Date of Birth: [**2114-1-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
coronary catheterization - stents x 2 to graft to OM2 and LAD.
History of Present Illness:
72 yo M h/o 3VD s/p CABG in [**2171**] (cath in [**2181**] with chronically
occluded SVG to OM1), HTN, hyperlipidemia, COPD, DM (diet
controlled), and CRI presents as tx from [**Hospital3 1443**] for
CP. The CP began Mon morning ([**10-30**]) while the pt was in bed. He
describes one week of angina with increasing frequency that
responded to nitro 1-2 tabs SL. The angina was generally
associated with exertion, though some episodes occurred while
the patient was in bed. He called EMT's on Monday because the
pain did not respond to nitro SL x 3. At [**Hospital3 1443**] he
was found to have EKG with ST depression in inferior and
anterior leads and a trop I of 0.47 (0.04 ULN). He had an
episode of CP at OSH that resolved with SL nitro x 1. He was
tx'd to [**Hospital1 18**] for coronary cath on [**10-31**]. On the morning of
[**10-31**] he went to cath and was stented in his graft to OM2 and
his LAD distal to the LIMA touch down with good restoration of
flow. (SVG to OM1 remained occluded.) EKG changes were resolving
but not gone. After catheterization, when the sheath was pulled,
the pt had a vagal episode that did not resolve with atropine
promptly. He was started on dopa for pressure and was taken back
to the cath lab as he developed substernal CP in the face of EKG
changes re-emerging. In the cath lab he was noted to have patent
stents. No further intervention was done.
.
The patient had a Creat of 2.0 from OSH - he received 180cc
contrast in first cath and 30cc in second cath.
Past Medical History:
PMH:
- CAD s/p CABG after MI in [**2171**] with LIMA to LAD, SVG to OM1 and
SVG to OM2 - [**2181**] cath found OM1 graft to be occluded and not
amenable to PCI.
- Hyperlipidemia
- COPD: asthma
- DM, diet controlled (pt denies)
- obesity
- AFlutter [**2183**]
- CRI (baseline Creat 2.0)
- Bilateral cataract surgery
.....
PSH:
- [**2171**] CABG ([**Hospital1 18**])
- [**5-21**] colon surgery (?resection). No malignancy per pt - done
at [**Hospital3 1443**]).
- appy
.....
Allergies: NKDA
Social History:
SHx: Machinist - retired. 50 pck yr hx smoking quit in [**2171**]
after MI and CABG. EtOH only very occasionally. Ambulates
independantly,
uses a cane prn. Lives in [**Location 1468**] with wife, [**Name (NI) 2013**], and son,
[**Name (NI) 401**].
......
FHx: Father died of MI age 71, 2 sisters have "heart problems."
Physical Exam:
Gen: NAD, in bed comfortable.
VS: 113/58, 80, AF.
Head: EOMI, NCAT
Neck: No bruits, thick neck, poorly visualized JVD, Supple.
Lungs: Crackles bilaterally laterally.
Heart: RRR, S1 and S2 present, II/VI SEM at USB
Abd: soft, NTND +BS, no HSM
Groin: R groin with gauze in place, small ooze, no bruit, no
hematoma. L groin with gauze (s/p angioseal) with some oozing,
no bruit, no hematoma.
Extr: Pulses dopplerable bilat at DP and PT. Toes cool
bilaterally, legs and feet warm. No skin color changes.
Pertinent Results:
Day of Admission:
[**2186-10-31**] 05:24PM BLOOD WBC-14.7*# RBC-4.28* Hgb-13.1* Hct-36.5*
MCV-85 MCH-30.7 MCHC-36.0*# RDW-13.8 Plt Ct-256
[**2186-10-31**] 08:30AM BLOOD INR(PT)-1.2
[**2186-10-31**] 05:24PM BLOOD PT-12.8 PTT-25.2 INR(PT)-1.1
[**2186-10-31**] 05:24PM BLOOD Glucose-135* UreaN-30* Creat-1.7* Na-136
K-3.7 Cl-96 HCO3-30 AnGap-14
[**2186-10-31**] 05:24PM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9
[**2186-11-1**] 04:10AM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE
.
Cardiac Enzymes:
[**2186-10-31**] 05:24PM BLOOD CK(CPK)-50
[**2186-10-31**] 10:50PM BLOOD CK(CPK)-80
[**2186-11-1**] 04:10AM BLOOD CK(CPK)-65
[**2186-10-31**] 05:24PM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2186-10-31**] 10:50PM BLOOD CK-MB-NotDone cTropnT-0.54*
[**2186-11-1**] 04:10AM BLOOD CK-MB-NotDone cTropnT-0.63*
.
Day of Discharge:
[**2186-11-2**] 07:05AM BLOOD WBC-10.0 RBC-3.53* Hgb-10.7* Hct-30.2*
MCV-86 MCH-30.4 MCHC-35.5* RDW-13.9 Plt Ct-206
[**2186-11-2**] 07:05AM BLOOD Glucose-119* UreaN-33* Creat-1.9* Na-139
K-3.8 Cl-98 HCO3-33* AnGap-12
.
.
EKG: [**10-31**] - pre-cath:
Sinus bradycardia. Inferolateral T wave inversions with ST
segment depression consistent with an acute ischemic process.
Compared to the previous tracing of [**2183-5-4**] no definite change.
Cardiac Cath #1:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
three vessel native CAD, a patent LIMA, a chronically occluded
SVG to
OM1 and a stenotic SVG to OM2. The LMCA had diffuse mild
disease. The
LAD had a subtotal ostial occlusion and was totally occluded
after the
first septal branch. The distal vessel filled by a patent LIMA
but
there was an 80% native LAD lesion after the touchdown of the
LIMA.
There was a very distal 80% apical lesion. The Lcx had severe
diffuse
disease throughout its length and in its branches. It was
occluded
after the OM2. The distal vessel filled via left to left and
right to
left collaterals. The SVG to Om1 was known to be occluded. The
SVG to
OM2 had a distal 90% lesion within the SVG. The native LAD and
this SVG
were stented (see below).
2. Limited hemodynamics revealed normal central aortic blood
pressures.
3. Left ventriculography was not performed.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA to LAD.
3. Occluded SVG to OM1
4. 90% stenosis of SVG to OM2.
.
.
Cardiac cath #2:
Stents Patent
.
.
EKG [**11-1**] - post-cath:
Sinus bradycardia. First degree atrio-ventricular conduction
delay.
P-R interval 0.24. Lateral T wave inversion with ST segment
depression.
Compared to the previous tracing of [**2186-10-31**] repolarization
abnormalities are
somewhat less prominent.
.
.
Echocardiogram (Post-Cath):
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Preserved global biventricular systolic function..
Mild mitral regurgitation.
Brief Hospital Course:
# Cardiac: 72 yo M with known CAD, s/p NSTEMI/ +troponin.
Admitted for cath from OSH. During cath, had 2 vessel
intervention (LAD and graft to OM2). Afterward, during sheath
pull, developed severe and symptomatic hypotension and chest
pain. Pt was taken for re-look procedure. The stents were found
to be patent. Overnight had dopamine weaned and BP remained low
normal. The patient was initially very confused but gradually
became more oriented overnight. HCT was stable. The next day,
metoprolol was started at low dose for cardioprotection and the
pat tolerated this well. The patient was known to have
extensive 3VD, so was followed with daily ekg that showed
resolution of small ischemic area. Echo showed a preserved EF,
small focal WMA, and no effusion. CE's trended down (CK) while
troponins increased. The patient diuresed well after the volume
load in the cath lab and was euvolemic at discharge. The
patient has a history in his chart of A flutter and had an
episode of narrow complex tachycardia at this hospitalization
that probably represented AT. This never recurred. The patient
was treated for diastolic heart failure with intermittent
diuresis diet control, wt and BP monitoring.
.
# Hypotension: The pt was hypotensive after catheterization and
was on dopamine for pressor for 12 hours. Thereafter pressures
were low stable. Metoprolol was started at a low dose and
titrated up as BP tolerated. The patient was changed back to
atenolol on discharge at a lower dose than on admission. His BP
was to be checked regularly so that his atenolol could be
titrated up as an outpatient. Imdur was also restarted as an
OP. Diltiazem was held and the pt was instructed to f/u with
PMD to restart this medication and titrate other BP meds as his
BP returned to his previous state of controlled hypertension.
.
# ? Cholesterol Emboli - on the day after cath, the pt was
thought to have had mottled toes that were cool. Interventional
cards was called and suggested a vascular consult. Vascular
recommended no treatment for this symptom. By two days
post-cath, there was no further evidence of emboli nor tissue
damage.
.
# PVD - Vascular suggested at w/u for PVD given the pt's history
of claudication. LE dopplers showed ABI > 1 but some slowed
flow to LLE. The pt was instructed to f/u with vascular surgery
to follow his symptoms and ABI's.
.
# CRI: The patient is noted to have a baseline creat in 2.0. Was
1.8 at OSH. Likely etiology was DM and HTN.
- Bicarb infusion per protocol was given prior to cath, but held
post-cath as pt was volume overloaded.
- Observed Creat/BUN for 72 hours. Dye load was relatively large
given 2 caths (210cc). No acute contrast nephropathy developed.
There was no evidence of cholesterol emboli to the kidneys.
.
# Gout: The patient developed L MTP joint tenderness two days
after catheterization. He has a history of gout but did not
recall being treated for this. He was treated with colchicine
for the acute flair. He would likely benefit from long-term
allopurinol therapy, as his serum uric acid was elevated to over
10 and he has had repeated episodes.
.
# Leukocytosis: Pt had an elevated WBC in setting of cath x 2 on
day of admission. This was thought to be due to demargination
from stress, however, to be sure of this diagnosis she was given
a UA and UCx, which were negative for infection. BCx and CXR
were also negative for infection..
.
# MS changes - The pt arrived in the CCU after cath with MS
changes - trying to get out of bed, generally disoriented. These
symptoms improved with time, and were likely were due to
atropine.
.
# Hyperlipidemia
- Continued lipitor at home dose.
.
# COPD
- Continued advair and albuterol at home doses.
.
# DM
- HbA1C was <7. Pt was placed on SSI but sugars were well
controlled.
.
# Ppx: The patient was maintained on sq heparin throughout the
hospitalization.
Medications on Admission:
Home Meds:
ASA 325 mg po daily
atenolol 100 mg po QD
lipitor 80 mg po daily
HCTZ 25 mg po daily
Imdur 60 mg po daily
diltiazem CD 120 mg po daily
bumex 1 mg po daily
advair 100/50
albuterol 2 puffs
flovent 220 mcg
colace 100 mg po BID
--------
Meds on Tx:
mucomyst started at OSH
heparin gtt started at OSH
integrilin gtt at OSH
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): To prevent stent closure.
Disp:*90 Tablet(s)* Refills:*4*
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain: Take
one tablet under tongue for chest pain. Wait 5 minutes and
repeat as needed. Take a total of 3 tablets and if pain does
not resolve, seek medical attention.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day: For
blood pressure. .
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet
Sustained Release 24HR PO once a day.
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day:
To reduce cholesterol.
7. Bumex 1 mg Tablet Sig: One (1) Tablet PO once a day: To
prevent water retention.
8. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-18**] puff Inhalation
once a day as needed for shortness of breath or wheezing.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed for gout: In case of gout pain - take one
tablet every 2 hours until the pain resolves or you develop
diarrhea. Do not take more than 7 doses.
Disp:*7 Tablet(s)* Refills:*0*
11. Flovent 220 mcg/Actuation Aerosol Sig: One (1) spray
Inhalation once a day.
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
NSTEMI
s/p 2 stents
HTN
hypercholesterolemia
PVD
gout
CKD
COPD
Discharge Condition:
Good - free of chest pain.
Discharge Instructions:
You were admitted with chest pain and taken to the coronary cath
lab. You received 2 stents. Afterward, you had more chest pain
and returned to the cath lab where it was found that the stents
were in place.
You are being discharged and will have a nurse come to your home
to help you with your medications and to monitor your blood
pressure and pulse.
You should follow up with your primary care doctor, Dr. [**Last Name (STitle) **]
within 2-3 weeks. You can call him to make an appointment by
calling: [**Telephone/Fax (1) 39260**].
You should follow up with your cardiologist, Dr. [**Last Name (STitle) 5686**],
within 4 weeks. You can schedule an appointment at
[**Telephone/Fax (1) 11554**].
You should follow up with vascular surgery for an appointment to
evaluate your leg pain. The circulation to your legs is
somewhat impaired and the vascular surgeon will assess your
blood flow to determine what the best therapy will be to reduce
your pain. You have an appointment with Dr. [**Last Name (STitle) 39261**] on [**11-22**] at 4:15pm. You can call if you need to change your
appointment: ([**Telephone/Fax (1) 1798**].
Followup Instructions:
Dr. [**Last Name (STitle) **] within 2-3 weeks. -Pt's atenolol dose was decreased and
diltiazem has been held as he was hypotensive in the hospital.
These medications should be adjusted based on BP readings as an
outpatient. He was previously on 100mg atenolol and 120mg
diltiazem.
Pt may benefit from allopurinol therapy as an outpatient.
Dr. [**Last Name (STitle) 5686**] within 4 weeks.
Dr. [**Last Name (STitle) 39261**] - [**11-22**], 4:15pm
Completed by:[**2186-11-4**]
ICD9 Codes: 5859, 4019, 2720, 412, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4883
} | Medical Text: Admission Date: [**2195-4-6**] Discharge Date: [**2195-4-13**]
Service: MEDICINE
Allergies:
Niacin / Lovastatin
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation ([**0-0-**])
History of Present Illness:
87 year-old female with COPD, Alzheimers, prior ESBL UTI,
non-verbal at baseline, transferred from [**Hospital 100**] Rehab with
fever, tachypnea, and hypoxia. She has had productive cough,
fever to 103 x2 days. On day prior to admission, chest
radiograph was negative for infiltrate, and she was started on
levofloxacin for concern for aspiration pneumonia. Received
several neb treatments without relief, and morphine 4mg IV x1
for respiratory distress. Prominent upper airway congestion,
cough. Prior to transfer to [**Hospital1 18**], 101.6, RR 42, 90% NRB. Per
call-in sheet, had pneumococcal vaccination [**2192-7-13**], no record
of influenza vaccination, and prior ESBL UTI. Also on aspiration
precautions.
.
Of note, she was inpatient [**Date range (1) 93603**] for COPD exacerbation,
pyelonephritis, and [**Last Name (un) **] secondary to urinary retention. She was
treated initially with vancomycin, levofloxacin, and ceftriaxone
and transitioned to Bactrim on discharge.
.
In the ED, 99.5 78 107/56 40 100%NRB. Triggered for tachypnea.
Physical examination notable for dyspnea, use of accessory
muscles, and diffuse rhonchi on auscultation. Laboratory data
significant for WBC 7.7, hematocrit 32.6, normal chemistry
panel, troponin-T 0.03; lactate 1.1; positive UA. CXR reportedly
unremarkable for acute process. EKG with NSR 90, PVC/PAC, no
evidence of ischemia. Received vancomycin, Zosyn, levofloxacin;
Duonebs; solumedrol; IVF 1.5L NS. On transfer to MICU, RR
improved to 20s; 81, 94/55, 29, 95% 6L NC. Access PIV x1. Prior
to transfer she was confirmed full code with family.
.
In the MICU, patient is nonverbal. She responds to daughter's
voice.
Past Medical History:
1. End-stage Alzheimers Dementia, non-verbal
2. COPD
3. Pulmonary nodules
4. ?CAD ?MI in [**2171**]; normal dipyridamole thallium in [**2173**].
5. Osteoarthritis
6. Cataracts.
7. Chronic back pain and hip pain
8. Hearing loss
9. Varicose veins
10. Heart murmur
11. Breast cancer in the left breast back in [**2183**] treated with
radiation and tamoxifen, which was later changed to Arimidex.
12. Osteopenia with history of atraumatic vertebral fracture.
13. Abnormal endometrial, worked up by OB/GYN in the past.
14. Hypercholesterolemia.
15. Status post cholecystectomy in [**2164**].
16. Status post umbilical hernia repair.
17. Rib fractures.
18. Actinic keratoses.
19. Posterior vitreous detachment.
20. Hypertension.
21. History of vertigo.
22. Headaches with negative workup in the past.
Social History:
Former criminal lawyer. [**Name (NI) **] 3 children. Quit smoking 30 years
ago; previously was heavy smoker. No alcohol, illicit drug use.
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
99.0, 75, 104/65, 28, 94%6L
General: Responds with movement to verbal, painful stimuli;
tachypneic
[**Name (NI) 4459**]: Dry mucous membranes; oropharynx clear
Neck: JVP below angle of mandible
Lungs: Coarse breath sounds with expiratory wheezes throughout;
no appreciable rhonchi or crackles
CV: Difficult auscultation given loud breath sounds; RRR, normal
S1/S2, no appreciable murmurs
Abdomen: Normoactive bowel sounds; soft, nontender; mildly
distended
GU: Foley in place
Ext: Warm, well-perfused; radial pulses 2+, symmetric;
diminished DP/PT pulses; no lower extremity edema
Neuro: Pupils equal and slowly reactive to light; responds to
voice, painful stimuli with movement; biceps reflexes 2+,
symmetric; unable to ellicit patellar reflexes
.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.0 169/65 63 24(20-30 in last 24hrs) 96%RA
GEN: elderly female, tahypnic, non-verbal, does not follow
commands or make eye contact
[**Name (NI) 4459**]: [**Name2 (NI) 2994**], EOMI, OP clear
NECK: supple, no JVD
PULM: tachypnic to 24, mild wheezing throughout all lung fields,
improved from prior exam, no focal findings
CV: RRR, normal S1/S2, no appreciable murmurs
Abdomen: naBS, NT/ND, soft
GU: Foley in place
Ext: WWP, 1+ DP/PT/radial pulses, no c/c/e
Pertinent Results:
Blood Counts
[**2195-4-6**] 05:27AM BLOOD WBC-7.7 RBC-4.01* Hgb-10.3* Hct-32.6*
MCV-81*# MCH-25.7* MCHC-31.6 RDW-14.8 Plt Ct-280
[**2195-4-7**] 01:55AM BLOOD WBC-7.9 RBC-3.83* Hgb-9.7* Hct-31.8*
MCV-83 MCH-25.3* MCHC-30.5* RDW-14.7 Plt Ct-243
[**2195-4-12**] 05:00AM BLOOD WBC-7.8 RBC-4.15* Hgb-10.4* Hct-32.4*
MCV-78* MCH-25.0* MCHC-32.0 RDW-15.0 Plt Ct-200
[**2195-4-13**] 04:51AM BLOOD WBC-6.9 RBC-4.04* Hgb-10.1* Hct-31.6*
MCV-78* MCH-24.9* MCHC-31.9 RDW-15.3 Plt Ct-230
Chemistry
[**2195-4-6**] 05:27AM BLOOD Glucose-160* UreaN-18 Creat-0.6 Na-141
K-4.3 Cl-102 HCO3-30 AnGap-13
[**2195-4-9**] 07:57PM BLOOD Glucose-266* UreaN-25* Creat-0.4 Na-139
K-4.0 Cl-102 HCO3-33* AnGap-8
[**2195-4-13**] 04:51AM BLOOD Glucose-162* UreaN-17 Creat-0.4 Na-140
K-3.0* Cl-99 HCO3-35* AnGap-9
Micro
- [**2195-4-6**] Blood Culture - negative
- [**2195-4-6**] - Respiratory Viral Antigen Screen:
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
- [**2195-4-6**] - Respiratory Virus Identification
REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor First Name 50967**] #[**Numeric Identifier 56433**] @1600, [**2195-4-6**].
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Viral antigen identified by immunofluorescence.
- [**2195-4-6**] URINE CULTURE (Final [**2195-4-7**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging
[**2195-4-6**] - TTE
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-1**]+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a prominent fat pad.
[**2195-4-11**] RUE Doppler
No evidence of DVT in the right upper extremity.
Brief Hospital Course:
HOSPITAL COURSE
87yo F w COPD on chronic prednisone, Alzheimer's, prior ESBL
UTI, non-verbal at baseline, a/w fever and respiratory distress,
now s/p intubation for hypoxia, found to have UTI and flu swab
positive for Influenza A, now s/p tamiflu, abx for HCAP,
extubated, stable, discharged to rehab.
.
ACTIVE
# Influenza / Health Care Associated Pneumonia / COPD
Exacerbation: Patient was a/w fever and acute respiratory
distress, with positive nasal swab for influenza. Patient sent
to ICU for hypoxia requiring intubation. She treated with
oseltamivir, as well as azithro/vanco/meropenem for presumed
HCAP (given h/o ESBL Ecoli). Course was complicated by presumed
COPD exacerbation, for which the patient had chronic steroids
increased to stress doses. Respiratory status improved and
patient was extubated. Patient completed eight day course of
vancomycin and meropenem, five day course azithromycin, five day
course oseltamivir. She was continued on nebulizers.
.
# UTI: UA on admission suggestive of UTI; given h/o ERBL Ecoli
colonization w indwelling foley, patient started on empiric
coverage (as described above).
.
# End-Stage Alzheimers Demetia: Patient at baseline is nonverbal
with poor functional status. Post-extubation she passed a
speech and swallow examination to return to baseline diet ground
solids / nectar liquids. Given end-stage dementia, patient
condition is likely expected to continue to deteriorate. Family
was counseled on this, and that complications from aspirations
(such as pneumonia) were likely. The family was not yet ready
to make further decisions regarding goals of care.
.
# Right Upper Extremity Swelling: Likely related to PICC Line.
DVT ruled out with upper extremity ultrasound. Swelling and
erythema stable.
.
INACTIVE
# Osteoporosis: Continued vitamin D and calcium.
.
TRANSITIONAL
1. Code status: Full code confirmed with family; discussed end
of life issues with the family and they are reluctant to make
any decisions as the patient's daughter (health care proxy) is
currently away on vacation; given poor functional status of
patient, discussed what to expect from this degenerative disease
process with the family; believe that goals of care discussion
regarding their thoughts on DNR/DNI vs "do not rehospitalize"
would be of utility once the [**Hospital 228**] health care proxy returns
from vacation.
2. Pending labs: Blood culture from [**2195-4-8**] was pending at
discharge and will need to be followed up by the patient's
physicians at her rehabilitation center.
3. Transfer of Care: Discharge summary sent with patient to
rehabilitation.
4. Barriers to Care: As described above, patient has end-stage
dementia with poor functional status; believe that family will
benefit from future counseling on end of life decision-making.
Medications on Admission:
1. Albuterol neb Q4 hours
2. ASA 81mg PO daily
3. Bisacodyl suppository 10mg PR daily except Sunday
4. Vitamin D 1000 units PO daily
5. Ipratropium neb Q4 hours
6. Levofloxacin 500mg PO x1 [**2195-4-5**], then 250mg PO daily ([**4-6**]-)
7. Miralax 17g PO daily
8. Prednisone 10mg PO daily ([**2194-7-10**]-present)
9. Acetaminophen prn
10. Morphine 4mg SL [**2195-4-6**] at 0245
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours).
2. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
daily except Sunday.
4. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every four (4) hours.
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
7. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 3 days: 40mg daily to continue for 3 days.
8. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day:
20mg daily to continue for 3 days after 40mg daily completes.
9. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
10mg daily to continue after completion of 20mg daily, ongoing.
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
11. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day). mL
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
PRIMARY
Viral Influenza
SECONDARY
Pnuemonia
COPD Exacerbation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Vital signs: Persistently tachypnic 24-30, afebrile, satting
high 90s room air
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted with cough and fever. You
were found to have influenza and a urinary tract infection. You
were having trouble breathing and needed to be intubated to help
you breathe. You were treated with antibiotics and an antiviral
medication. You were able to be extubated and are now stable
and ready to return to your rehabilitation facility.
During your hospitalization, the following changes were made to
your medications:
-STARTED colace
-INCREASED prednisone (now being tapered back to your chronic
dose)
Followup Instructions:
Your care will be provided to your by your rehabilitation
facility.
ICD9 Codes: 486, 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4884
} | Medical Text: Admission Date: [**2177-10-1**] Discharge Date: [**2177-10-14**]
Service: HEPATOPANCREATIC BILIARY SERVICE
HISTORY OF PRESENT ILLNESS: The patient is status post
extensive lysis of adhesions secondary to recurrent adhesive
small bowel obstruction and status post anticoagulation from
left upper extremity deep venous thrombosis.
PHYSICAL EXAMINATION: Vital signs: T-max 100.4??????, T-current
100.1??????, blood pressure 104/64, pulse 90, respirations 22,
current oxygen saturation 95% on room air. General: The
patient is an 84-year-old female with appearance appropriate
for age. The patient was in no acute distress. HEENT: No
evidence of scleral icterus. Extraocular movements intact.
Moist mucous membranes. No evidence of ulcers. No cervical
lymphadenopathy. Cranial nerves II-XII intact. Chest:
Clear to auscultation bilaterally. Cardiovascular:
Irregularly, irregular beats without evidence of cardiac
murmurs. Abdomen: Vertical incision noted with staples
intact. Inferior aspect of the wound site is currently
packed with new gauze. There was mild erythema along the
inferior aspect of the wound. There were small and resolving
indurations also noted on palpation. The patient's abdomen
is soft and nondistended and minimally tender to palpation
with no evidence of rebound or hepatosplenomegaly or masses
palpated. Bowel sounds present on auscultation in all four
quadrants. Extremities: Bilateral pretibial edema extending
up to one-eight above the ankle with 2+ pedal edema present.
LABORATORY DATA: White count 9.7, hematocrit 34.3, platelet
count 313; sodium 134, potassium 4.1, bicarb 28, chloride
100, BUN 6, creatinine 0.4, glucose 121; PT 17, PTT 101.4,
INR 2.0; magnesium 1.7, phosphate 3.1.
Upper extremity duplex on [**2177-10-8**], showed
occlusive thrombus in the subclavian axillary and brachial
veins. PICC line was seen at the center of the thrombus.
HOSPITAL COURSE: The patient is an 84-year-old female with a
history of atrial fibrillation, status post low anterior
resection, radiation therapy for T3N1 rectal cancer,
presenting to our service for exploratory laparotomy after
being nutritionally supplemented times two weeks. The
patient's operative course was remarkable for an extensive
adhesive bowel which required six hours to lyse. During the
postoperative course in the PACU, the patient's pressure
remained persistently low between the 80s/50s with
tachycardia heart rates greater than 120 and atrial
fibrillation. The patient was aggressively resuscitated with
fluids and received concomitant evaluation by the Cardiology
Service regarding the patient's status.
An emergent echocardiogram done by the cardiologist revealed
an ejection fraction greater than 50%, and a recommendation
was made to continue to aggressively fluid resuscitate the
patient. When urine output continued to remain low with low
pressures, the decision was made to transfuse 2 U packed red
blood cells. The patient's pressure rose to 120/70 without
any pressors, and the patient was then transferred to the
Intensive Care Unit for continuous cardiac and fluid
management.
After adequately resuscitating the patient in the Intensive
Care Unit, the patient was transferred to the floor for
continued diuresis. On postoperative day #7, the patient
began complaining of asymmetric edemas, left arm greater than
the right despite the heavy diuresis. The patient underwent
an emergent ultrasound which revealed an occlusive thrombus
in the subclavian, axillary, and brachial veins with PICC
line at the center. The PICC line was removed, and the
patient was immediately initiated on Heparin anticoagulation.
After the patient achieved adequate anticoagulation level
with subsequent Coumadin therapy and was able to tolerate
adequate p.o. intake without difficulty, the patient was
discharged to rehabilitation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post extensive lysis of adhesions.
2. Status post 2 U transfusion secondary to hypotension.
3. Status post left upper extremity deep venous thrombosis.
4. Status post occlusive thrombus in the subclavian,
axillary, and brachial veins on the left.
5. Atrial fibrillation with rapid ventricular response.
6. Nutritional support with total parenteral nutrition.
7. Hypokalemia.
DISCHARGE MEDICATIONS: Keflex 500 mg p.o. q.i.d., Warfarin 2
mg p.o. q.h.s., Digitalis 0.125 mg p.o. q.d., Lopressor 10 mg
IV q.6 hours, Albuterol nebulizer, Furosemide 20 mg q.a.m.,
10 mg q.p.m., Dilaudid p.r.n. for pain, Protonix.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 468**] in
[**11-3**] days in his surgical office.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 40628**]
MEDQUIST36
D: [**2177-10-14**] 12:56
T: [**2177-10-14**] 13:16
JOB#: [**Job Number 40629**]
ICD9 Codes: 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4885
} | Medical Text: Admission Date: [**2102-4-4**] Discharge Date: [**2102-4-17**]
Date of Birth: [**2055-6-22**] Sex: M
Service: OME
The patient's date of discharge is pending. This dictation
covers the hospital course from admission, [**2102-4-4**] until
[**2102-4-17**]. The remainder of the hospital course will be
dictated by the next intern taking over care for this
patient.
CHIEF COMPLAINT: AML with increased blasts on a CBC.
HISTORY OF PRESENT ILLNESS: This is a 46 year old male who
developed dyspnea on exertion, palpitations and left
abdominal pain and was diagnosed with pancytopenia in [**2100-11-17**]. Bone marrow aspirate was consistent with
myelodysplastic syndrome, MDS. He was started on Procrit at
the time and Aranesp and treated with arsenic which was
discontinued in [**2101-9-17**]. White blood cell count
increased to 300,000 with 87 percent myeloblasts and he was
treated with leukophoresis followed by induction chemotherapy
7 Plus 3, in [**2102-1-16**], without infectious complications.
A repeat bone marrow biopsy on [**2101-2-8**], showed
hypercellular marrow with myeloid maturation and diffuse
reticular fibrosis. He was given another course of
chemotherapy in [**2102-2-16**], and went home on [**2102-3-6**]. He received platelets and blood transfusions during
this time.
On [**2102-4-3**], he saw Dr. [**Last Name (STitle) **] in Clinic where he was
noted to have increasing blast count. He was asked to come
into the hospital for admission of chemotherapy. His
appetite has been good and he has had improving energy
recently. He denies fevers, chills, nausea, vomiting,
shortness of breath, cough, chest pain, diarrhea or dysuria
and his weight has increased by five pounds in the past week.
PAST MEDICAL HISTORY: AML as described above with induction
chemotherapy 7 plus 3 in [**2102-1-16**].
Vocal cord polyps removed in [**2077**].
History of optic disc elevation, right greater than left.
MEDICATIONS:
1. Valtrex one gram q. Day.
2. Diflucan 100 mg p.o. q. Day.
3. Ciprofloxacin 500 mg p.o. q. Day.
4. Neupogen.
5. Neumega 7 cc subcutaneously q. Day.
6. Procrit subcutaneously weekly.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father with alcoholic cirrhosis. No history
of malignancy.
SOCIAL HISTORY: He is married and lives with his wife in
[**Name (NI) 1727**]. Quit alcohol at 28 years old. Quit tobacco
approximately five months ago. Quit marijuana approximately
one year ago. Exposure to barium and lead in the past.
PHYSICAL EXAMINATION: In general, well dressed, well
nourished man in no apparent distress appearing slightly
fatigued. Vital signs are temperature of 98.3 F.; heart rate
95; blood pressure 160/80; respiratory rate 20; saturation of
100 percent on room air. HEENT: Pupils equal, round and
reactive to light. Extraocular muscles intact. Oropharynx
is clear. Chest is clear to auscultation bilaterally with no
wheezes, rales or rhonchi. Heart is regular rate and rhythm,
normal S1, S2, II/VI systolic murmur, question flow murmur.
Abdomen soft, nontender, nondistended, positive bowel sounds,
positive hepatosplenomegaly. Extremities with no clubbing,
cyanosis; one plus pitting edema bilateral lower extremities.
Neurological: Five out of five strength in all extremities.
Cranial nerves II through XII intact. Back tender over the
bone marrow biopsy sites. No hematoma.
PERTINENT LABORATORY DATA: Hematocrit is 24.0; white blood
cell count is 4.7 with 51 percent polys, 2 bands, 34 lymphs,
19 monos, one eo, 29 percent blasts. Platelets of 195. INR
is 1.3, fibrinogen 297, LDH 393, uric acid 6.8, creatinine
0.8, potassium 3.9, ANC is 959, ALT 73, AST 30, alkaline
phosphatase 86.
HOSPITAL COURSE:
1. ONCOLOGY: The patient presented with AML with increasing
blasts on smear. The patient underwent chemotherapy with
the FLAG protocol, which included Fludarabine, Ara-C and
GCSF. The patient had an echocardiogram on presentation
which was normal. He had an uncomplicated course during
his hospitalization stay. He got GCSF continual and his
hematocrit continued to drop during the hospitalization
course.
2. HEMATOLOGY: The patient's transfusion hematocrit
threshold was 25.0. He was given blood transfusions in-
house to maintain a hematocrit of greater than 25 as well
as platelet transfusions to be greater than 10. He had an
episode where he required steroids, Decadron times one,
prior to platelet transfusion as this had been occurring
during his previous hospitalization stay at an outside
hospital.
3. INFECTIOUS DISEASE: The patient was maintained on
Bactrim, Diflucan and Acyclovir for prophylaxis. Levaquin
was added once his ANC was less than 500.
4. DIET, FLUID, ELECTROLYTES AND NUTRITION: The patient was
maintained on a neutropenic diet. When counts decreased,
then he was maintained on intravenous fluids. Once his
hydration reached an equilibrium after chemotherapy, he
was switched to KVO during the day and maintenance fluids
at night times one liter.
5. ACCESS: The patient had a left Portacath already in place
on admission. He received a right triple lumen catheter
at the Interventional Radiology in the right subclavian.
He had some pain associated at the site and got Oxycodone
as needed.
6. VERTIGO: The patient experienced a one time episode of
vertigo while getting blood and while getting high dose
ARA-C. Otoscopic examination was unremarkable. He had an
MRI with gadolinium which was negative for any
abnormalities except for mastoid and sphenoid fluid.
Vertigo resolved.
7. OPHTHALMOLOGY: The patient had a history of a visual
field cut defect and optic disc swelling right greater
than left. The patient had Ophthalmology consulted in-
house. They recommended an orbital MRI to rule out
leukemic infiltrate. The patient had a fine cut MRI of
the orbits which was negative for a leukemic infiltrate or
mass effect.
Followup of a lumbar puncture that was performed in the
patient prior to admission was obtained from the outside
hospital and was negative for malignant cells or any
infectious process.
The remainder of the [**Hospital 228**] hospital course will be
dictated in a future discharge addendum summary by the next
intern taking care of this patient.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 55010**]
Dictated By:[**Last Name (NamePattern1) 12481**]
MEDQUIST36
D: [**2102-4-17**] 14:31:07
T: [**2102-4-17**] 19:02:19
Job#: [**Job Number **]
ICD9 Codes: 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4886
} | Medical Text: Admission Date: [**2174-10-20**] Discharge Date: [**2174-10-25**]
Date of Birth: [**2108-5-9**] Sex: F
Service: MEDICINE
Allergies:
Latex / Benadryl / Penicillins / Clindamycin / Shellfish Derived
/ Ibuprofen / Codeine / Bactrim / Aspirin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath and fevers
Major Surgical or Invasive Procedure:
PICC line insertion
History of Present Illness:
66 yo F with PMH of morbid obesity, PAF, DM2, COPD on 2L home
oxygen, CAD and recent diagnosis of PE who presents from OSH
with SOB and fevers. She was taken from rehab to [**Hospital3 **]
hospital with SOB and fever to 100. She was recently at [**Hospital1 18**] in
the beginning of [**Month (only) **] with SOB. It was thought that she likely
had PE. Given her shellfish allergy, she had a VQ scan rather
than a CTA. This returned indeterminant and the decision was
made to treat her with coumadin for presumed PE. She also had a
cellulitis on her pannus and was sent to rehab on vancomycin and
ceftazidine which ended on [**2174-10-13**].
.
In the ED, her initial vitals were T 101.8, HR 94, BP 166/30, RR
28, O2sat 95% 3L NC. She was noted to have a subtherapeutic [**Date Range 263**]
of 1.8 and she was started on a heparin gtt. She also complained
to RUQ pain and had an ultrasound which was negative. A CXR was
also negative. A U/A was positive and it was thought she had a
UTI from a foley catheter. She was admitted to CC7 for further
work up. On admission there, she was in no acute distress. She
noted her SOB was improved but was still having fevers. She was
given vancomycin and ceftriaxone for UTI antibiotics and the
plan was to likely send her home in the AM.
.
A trigger was called shortly after admission for hypoxia and
tachypnea. She was found to have blue lips and SOB. She also
felt chest pain that was across her entire chest wall and around
to her back. She had an EKG which was unchanged, given
nitroglycerin which did not change her pain. She was also given
nebulizers for wheezing, and given lasix but did not put out
much to it. Another CXR was performed which was largely
unchanged. She had an ABG which was 7.26/65/339 on NRB. She was
changed to a 35% face mask. She was transferred to the ICU for
further care.
.
Currently, she feels her breathing is slightly improved but
still not at baseline. She still has some chest pain as well.
+nausea. No vomiting. No abdominal pain currently. +fevers. No
chills. Can not assess dysuria given foley in place. No
diarrhea.
Past Medical History:
PMHx: per patient and OSH records:
-spina bifida repair at 10days old
-atrial fibrillation
-DM2
-COPD on home oxygen of 2L NC
-asthma
-CAD
-h/o pulmonary embolisms
-GERD
-depression
-angiodysplasia
-anxiety
-h/o cellulitis
-multiple ICU admissions for sepsis, cellulitis, anaphylaxis
-skin graft for ulcers
-benign left breast mass
-OSA uses BiPAP 12/8 with 2L oxygen
Social History:
Smoked in the past but quit 20 years ago. Currently wheelchair
bound and oxygen depended on 2L NC from COPD. Has a sister who
is next of [**Doctor First Name **]. Currently lives at nursing home on the [**Hospital **].
Family History:
Noncontributory.
Physical Exam:
VS - T 102, BP 134/84, RR 35, HR 86 O2Sat 94% on 3L
GENERAL: morbidly obese, NAD, mildly tachypnic. Using some
excessory muscles when breathing.
HEENT: PERRL, EOMI, anicteric sclera. Clear conjunctiva. Dry
mucous membranes.
CVS: irregular,irregular, no m/r/g
PULM: bibasilar scattered rales, no wheezing or rhonchi
ABD: Obese. +BS, soft, moderate tenderness at epigastrum, no
rebound or guarding, some tenderness to percussion over RUQ. No
lesions or ulcerations under abdominal panus.
EXT: 2+ pitting edema bilaterally, venous stasis changes in
lower calfs at medial margins. Skin breakdown in folds of
posterior calf bilaterally. Small sacrul ulcer. Mild erythema of
L posterior thigh.
Pertinent Results:
Admission Labs:
WBC-7.3 RBC-3.67* Hgb-10.1* Hct-31.1* MCV-85 MCH-27.6 MCHC-32.5
RDW-15.1 Plt Ct-140*
Neuts-89.4* Lymphs-7.4* Monos-2.1 Eos-0.6 Baso-0.4
PT-19.7* PTT-27.3 [**Hospital 263**](PT)-1.8*
Glucose-98 UreaN-18 Creat-0.8 Na-138 K-4.4 Cl-97 HCO3-30
ALT-13 AST-22 CK(CPK)-17* AlkPhos-82 Amylase-45 TotBili-0.3
Calcium-8.7 Phos-2.4* Mg-1.7
cTropnT-<0.01
TSH-4.5*
BLOOD Type-ART pO2-339* pCO2-65* pH-7.26* calTCO2-31* Base XS-0
Glucose-94 Lactate-2.4* Na-140 K-4.4 freeCa-0.45*
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
URINE Blood-MOD Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-0
[**2174-10-20**] 2:20 pm URINE Site: CATHETER
**FINAL REPORT [**2174-10-23**]**
URINE CULTURE (Final [**2174-10-23**]):
ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| ENTEROBACTER CLOACAE
| |
CEFEPIME-------------- 2 S 8 S
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
PIPERACILLIN---------- =>128 R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
[**2174-10-20**] 11:05 am BLOOD CULTURE FROM PICC LINE # 1.
**FINAL REPORT [**2174-10-23**]**
Blood Culture, Routine (Final [**2174-10-23**]):
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2174-10-21**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 1:39A [**2174-10-21**].
GRAM NEGATIVE RODS.
Anaerobic Bottle Gram Stain (Final [**2174-10-21**]): GRAM
NEGATIVE RODS.
Studies:
[**2174-10-20**] EKG: Sinus rhythm with premature ventricular
contractions. Prolonged A-V conduction. Left axis deviation.
Right bundle-branch block with left anterior fascicular block.
Lateral ST-T wave changes. Compared to the previous tracing of
[**2174-10-5**] the premature ventricular contractions are new.
[**2174-10-20**] RUQ ultrasound: IMPRESSION:
1. Normal-appearing gallbladder without gallstones or signs
suggestive of cholecystitis.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
[**2174-10-20**] CXR - Right PICC line has been replaced or advanced to
the low SVC. Lung volumes are low, but aside from mild linear
scarring or atelectasis at the right base, clear. Moderate
cardiomegaly is stable. Mediastinal vascular engorgement is
persistent, either an indication of elevated central venous
pressure or anatomic variant.
[**2174-10-21**] bilateral LE veins: IMPRESSION: No evidence of deep
vein thrombosis in either leg.
[**2174-10-22**] CXR - IMPRESSION: Probable right lower lobe pneumonia.
[**2174-10-22**] CT abdomen & pelvis - IMPRESSION:
1. Nonobstructed subcentimeter right intrarenal calculus. No
evidence for
hydronephrosis. No ureteral calculus.
2. No evidence for acute bowel pathology.
3. Severe degenerative changes of the spine.
Brief Hospital Course:
66 yo F with PMH of morbid obesity, PAF, DM2, COPD on 2L home
oxygen, CAD and recent diagnosis of PE who presents from OSH
with SOB and fevers.
.
# SOB: Most likely due to aspiration given coughing with food
observed on morning rounds. PNA is unlikely, but was started on
ceftriaxone and vancomycin in the setting of fevers and GNR
bacteremia. LENIs were negative for DVT. Steroids, vancomycin
and ceftriaxone were stopped on [**10-22**]. The patient was placed
on BiPAP at night per her home regimen. Her shortness of breath
was likely due to a combination of COPD and aspiration of
secretions. She was evaluated by speech and swallow who
determined that she was not aspirating food or liquids but did
have thick secretions which she was aspirating. She can eat a
regular, heart healthy diet and should have appropriate COPD
treatment as per her home regimen.
.
# GNR Bacteremia: Likely from a urine source. Blood is growing
Enterobacter that is ceftriaxone/cephalosporin resistant. On
[**10-22**] she was switched to ciprofloxacin when sensitivities
became available. She should complete a 14 day course of cipro
for her bacteremia. This will end on [**2174-11-4**]. She also had an
abdominal CT that was negative for perinephric abscess given
bacteremia from presumed pyelonephritis.
.
# Hypocalcemia: On presentation the patient had acute
hypocalcemia on venous blood gas. She was repleted with 4g
calcium gluconate and her calcium has remained stable since.
Ionized calciums were trended.
.
# COPD: The patient was initially treated for a COPD flare, but
this was stopped as it was felt that her SOB was more likely
related to aspiration. She was continued on her home regimen of
advair and singular.
.
# PE: Unclear if the patient actually had a PE on prior
admission given that her area of mismatch on V/Q scan was in the
same location as a pleural effusion. She was started on a
heparin gtt on admission and it was stopped on [**10-22**] when she
was therapeutic on warfarin. She became supratherapeutic on
Warfarin due to her antibiotics and it was stopped on [**2174-10-24**].
Please see below for further instructions regarding
anticoagulation.
.
# Afib: The patient was continued on metoprolol. She had some
episodes of RVR on [**10-23**] and her metoprolol dose was increased
to 75 mg PO TID. Her anticoagulation was managed as discussed
below with heparin and coumadin.
.
# Anticoagulation: The patient was subtherapeutic on warfarin on
admission ([**Month/Year (2) 263**] 1.8). She was started on heparin gtt and
warfarin was continued. Heparin was stopped when [**Month/Year (2) 263**] became
therapeutic. The patient was started on ciprofloxacin for
bacteremia from a urine source on [**10-22**]. As fluoroquinolone
antibiotics interact with warfarin and prolong the [**Month/Year (2) 263**] ([**Month/Year (2) 263**] 3.5
on [**2174-10-25**], the morning of discharge), her warfarin dose should
be decreased from 3 mg to 2mg daily and her [**Date Range 263**] more closely
monitored on discharge so that her warfarin dose can be adjusted
accordingly. When she finishes her course of ciprofloxacin her
warfarin dose will need to be increased accordingly so that she
does not become subtherapeutic.
.
# CAD: not on asa given allergy. Continue BB as above. Not on
statin, unclear why.
.
# DM2: The patient was placed on an insulin sliding scale and
metformin was held for imaging.
.
# Depression: Sertraline was continued per home regimen.
.
# Chronic pain: Gabapentin and tramadol continued per home
regimen.
.
# FEN: Regular diet, not aspirating per speech and swallow
evaluation.
.
# PPX: warfarin for anticoagulation. H2 blocker per home regimen
for GI ppx. bowel regimen.
.
# Access: PICC line placed and then removed given bacteremia.
.
# Code: pt was DNR/DNI but reversed her code status to full code
during her trigger on the floor. Her code status should be
reassessed.
Medications on Admission:
Per last d/c summary:
-Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
-Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
-Levothyroxine 237 mcg daily
-Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID
-Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
-Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for oversedation or RR<10 .
-Insulin Lispro 100 unit/mL Solution Sig: AS DIR
Subcutaneous ASDIR (AS DIRECTED): Continue prior SSI coverage:
Start at 6 Units for 201-250, 8 Units for 251-300, 10 Units for
301 to 350 range and 12 Units for 351-400 range FSG levels at
mealtime and reduce each level by 2 for qhs scale .
-Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
-Os-Cal 500 + D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO twice a day.
-Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
-Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
-Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
-Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
-Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H as needed for wheeze.
-Azo Cranberry [**Medical Record Number 18595**] mg-mg-million Tablet Sig: One (1)
Tablet PO twice a day.
-Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 2 weeks.
-Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three times
a day as needed.
-Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet 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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
10. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 14 days. Start date = [**2174-10-22**], Last day =
[**2174-11-4**]
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
14. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for wheezing.
16. Miconazole Nitrate Powder Sig: One (1) application
Miscellaneous twice a day.
17. Outpatient Lab Work
Please check [**Month/Day/Year 263**] daily. Resume Coumadin dosing when [**Month/Day/Year 263**] between
2 and 3.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38380**] Skilled Nursing nad Rehab
Discharge Diagnosis:
Primary Diagnoses:
1. Urinary Tract Infection
2. Bacteremia due to Enterobacter
3. Aspiration of Secretions
4. Atrial fibrillation with rapid ventricular rate
5. Chronic obstructive pulmonary disease
Secondary Diagnoses:
1. Type 2 diabetes
2. Asthma
3. Gastroesophageal reflux disease
4. History of pulmonary embolisms
5. Obstructive sleep apnea
6. Depression
Discharge Condition:
Stable, at baseline O2 requirements, afebrile.
Discharge Instructions:
You were admitted to the hospital for shortness of breath and
fevers. You were found to have bacteria in your blood, likely
because you had a urinary tract infection which spread to the
blood. You are being treated with the antibiotic ciprofloxacin
and will need to complete a total of 14 days of treatment with
this antibiotic. Because this antibiotic interacts with
warfarin, your [**Location (un) 263**] will need to be monitored and your warfarin
dose adjusted accordingly.
You were also noted to have difficulties breathing while you are
eating. You had a special swallow study and you are not
aspirating food at this time, however, you are aspirating some
of your secretions and this may be contributing to your
shortness of breath and chest discomfort. Please eat all meals
sitting upright and continue to wear your BiPAP machine at
night. Please attend to oral hygiene to reduce the bacteria in
your mouth.
The following changes were made in your medications.
Please take ciprofloxacin 750 mg Q12H through [**2174-11-4**].
Your metoprolol dose was increased to 75 mg TID.
Your warfarin dose was decreased to 2 mg while you are on
ciprofloxacin but your [**Month/Day/Year 263**] is still high so your coumadin was
held. Once your [**Month/Day/Year 263**] is between 2 and 3, you should re-start
coumadin at 2mg, and it should be increased back to 3 mg when
you are finished with the ciprofloxacin. You should have your
[**Month/Day/Year 263**] checked every day to determine the proper dosing of
Coumadin.
Please call your physician or return to the hospital if you
develop fevers > 100.4, chills, night sweats, worsening
shortness of breath, productive cough or other symptoms that
concern you.
Followup Instructions:
Please follow-up with your primary care provider within the next
2 weeks.
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4887
} | Medical Text: Admission Date: [**2168-1-9**] Discharge Date: [**2168-1-14**]
Date of Birth: [**2122-10-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 yo M with a PMH Of DMII, HTN, morbid obesity, and sleep apnea
who presents with SOB. He states that he [**Doctor Last Name **] had worsening
dyspnea on exertion for approximately one month. States he was
previously able to walk up three flights of stairs, but can now
only go up about 1.5 flights. This week he was unable to walk to
the bathroom without SOB. Also notes increased orthopnea
requiring [**3-19**] pillows, and prior to 9 months ago was able to
sleep on his back. He also notes increasing LE edema and
decreased urination over an unclear duration of time. He also
notes edema in his back and increasing abdominal girth over the
past month. Has seen PCP on this issue, and has his had lasix
uptitrated recently to 120mg QAM and 80mg QPM. He states he is
medically compliant. On ROS he denies cough, CP, rhonorrhea,
leg pain, nausea, vomiting, diarrhea. He denies tobacco use but
smokes marijuana daily. Has also been diagnosed with severe
OSA, requiring him to quite his job [**1-16**] to daytime somnolence
and an MVA while at work.
.
In the ED, his vitals were: 97.5, 201/117, 102, 22 and (?)67% on
RA. He was noted to have LE edema. He was placed on CPAP and
received NTG 0.3 SL tab x1, [**12-16**] inch of nitro paste,
Albuterol/atrovent nebs, azithromycin 500 mg po x1, and CTX 1 gm
IV x1. CXR was notable for assymetric pulmonary edema, cannot
r/o infiltrate. His BNP was 856. He was placed on BIPAP with
improved O2 sats. He refused A-line and they were unable to
obtain an ABG. He had c/o mild chest discomfort (although he
denies that he complained of this) but denies palpitations. Has
started taking aspirin one week PTA, but denies ever being
instructed to do so by a physician. [**Name10 (NameIs) **] leaving the ED, this
O2 sat had improved to 96%/4L NC with these interventions.
Past Medical History:
-Hypertension
-Morbid Obesity
-Type 2 diabetes Mellitus --hgb A1c 6.9 in [**8-21**]
-sleep apnea, mixed sleep disorder: per Dr.[**Name (NI) 935**] note from
[**2167-12-25**]: "On [**2167-12-16**] he had a split study, which showed
severe mixed sleep-disordered breathing. Sleep efficiency was
decreased in the 50 percentage level at that time with also
evidence of obstructive events as well as periodic breathing and
the baseline oxygen saturation while awake was in the 80s,
suggesting hypoventilation, although carbon dioxide level was
not checked. He was subsequently evaluated on CPAP and BiPAP
with BiPAP destabilizing him and an effective pressure of CPAP
was not found. He had a AHI of 130, desaturation to 53%, CPAP
and BiPAP failed in [**12-22**]; He was placed empirically on cpap auto
with a pressure of 15cm and a flex of 2. O2at 2L/min ; the past
six years, he has been having worsening symptoms of excessive
daytime sleepiness, nocturnal awakenings along with even
problems functioning at work. He also has on occasion fallen
asleep or even just dozed off and most recently rear-ended
vehicle in front of him at a stoplight."
Social History:
Denies tobacco, etOH, or drug use current or past
Occ: previously employed driving trucks but now unable to due to
health problems
[**Name (NI) **]: lives with wife and kids in [**Location (un) 686**]
Family History:
Mother died of cancer
Father died of unknown causes
.
Physical Exam:
Physical Exam on MICU admission:
VS: Temp: 97.8 BP: 173/97 HR: 91 RR: 22 O2sat 96/6L NC
GEN: obese, pleasant, comfortable, NAD speaking in short
sentences
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: distant heart sounds, RR, S1 and S2 wnl, no m/r/g
ABD: obese, +b/s, soft, nt, cannot assess masses or
hepatosplenomegaly [**1-16**] to body habitus
EXT: 1+ peripheral edema to distal thigh, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3.
Pertinent Results:
ABG pH 7.38 / pCO 257 / pO2 67 / HCO3 35
.
EKG: Sinus tachycardia = 100bpm, nml axis, frequent PVCs, no TW
abnormalities
.
CXR:
AP UPRIGHT RADIOGRAPH OF THE CHEST: The exam is extremely
limited by poor penetration and technique. Increased
interstitial marking of the pulmonary edema is visualized. The
lungs are difficult to evaluate; however, patchy consolidation
is noted at the right lower lobe which might represent
asymmetric pulmonary edema or pneumonia/atelectasis. No pleural
effusion or pneumothorax is noted. Cardiac silhouette is mildly
enlarged. The hilar contours are prominent. The osseous
structures of the thorax appear normal.
IMPRESSION: Findings consistent with interstitial pulmonary
edema. Focal consolidation at the right lung base cannot be
excluded. This appearance is suggestive of asymmetric alveolar
pulmonary edema or less likely pneumonia/atelectasis.
Brief Hospital Course:
The pt is a 45 yo AA male with a PMH significant for DMII, HTN,
morbid obesity, and sleep apnea who presents with SOB and
increased swelling in his LE.
.
# Hypoxia/Hypercarbia: Multifactorial. Most likely [**1-16**] CHF: BNP
elevated and subsequent TTE showed LVEF of 35%. However, other
etiologies likely contributed to hypoxia as well:
hypoventilation and pulm HTN [**1-16**] severe OSA and obesity. ABG on
admission was c/w chronic retention at 7.38/57/67. Ruled-out for
MI with negative enzymes. PE and PNA unlikely given lack of
clinical or laboratory signs. On the floor, pt diuresed well
with lasix, and symptoms improved. The patient remained stable
throughout the hospitalization and reported no
SOB/CP/palpitations on day of discharge.
.
# CHF (acute on chronic systolic) - Although has had signs and
symptoms of CHF dating back to [**2162**] in prior notes. There is no
echo in our system. Echo done here showed EF of 35%. Serum
studies were ordered to eval for secondary causes of CHF: Iron
studies (hemochromatosis), CBC (anemia), TSH(hypothyroid) and
returned within normal limits. A stress test was ordered to
evalute for ischemia, however, given patient's weight it had to
be a two day stress and patient could not stay in the hosptial.
Most likely etiology of CHF is severe OSA however stress test
should be done to rule out ischemia as a possible etiology as an
outpatient. Patient discharged home on 160mg PO lasix [**Hospital1 **] and
advised to f/u with PCP next week for chem 7 check.
# Severe OSA: Recently found to have very severe mixed sleep
apnea, AHI of 130, desaturation to 53%, CPAP and BiPAP failed.
Patient states poorly tolerated mask at home. We gave
noninvasive mechanical ventilation with CPAP at 15 at night,
tolerated well. Pt was counseled to continue using CPAP at home
and he is scheduled for an overnight sleep titration study with
sleep lab.
.
# Lower extremity edema: Most likely [**1-16**] CHF and non-compliance
with meds. Low suspicion for DVT given symmetry on exam,
nontender & no history of prolonged recumbency. Improved with
lasix during hospitalization, and was significantly improved by
day of discharge.
.
# HTN: Hypertensive on admission to SBP > 200. Confirms mild
CP, but denies HA or other symptoms of hypertensive urgency.
Discontinued Norvasc due to CFH. Maintained BP with lasix,
lisinopril, metoprolol, hydralzaine, while inpatient. The pt's
BP improved significantly with these measures and was stable
throughout this hospitalization. Stopped hydralazine on day of
discharge and changed over to hydrochlorthiazide. Pt was
instructed to follow up with PCP in next few days re: HTN
management.
.
# DM: Per patient is on glipizide and metformin and ASA as an
outpatient. While hospitalized, we held the pt's glipizide and
metformin, and instead used an insulin sliding scale. Restarted
glipizide and metformin on day of discharge.
.
# CRI: BL Cr 1.4. Cr and UO were monitored throughout
hospitalization: pt remained at his baseline.
.
# ?BPH - Pt on Doxazosin 4 mg qhs as outpatient. Continued
while inpatient.
Medications on Admission:
atenolol 100 mg daily
glipizide 10 mg daily
valsartan 320 mg daily
lasix 120 mg in AM and 80 mg in PM
lisinopril 40 mg daily
metformin 1000 mg [**Hospital1 **]
norvasc 10 mg daily
Doxazosin 4 mg qhs
.
Allergies: NKDA
Discharge Medications:
1. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
every twelve (12) hours.
Disp:*180 Tablet(s)* Refills:*1*
5. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Contact your physician if you begin to experience
muscle cramps, nausea, vomiting .
Disp:*30 Tablet(s)* Refills:*11*
6. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*1*
7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Congestive Heart Failure
Obstructive sleep apnea
Hypertension
Diabetes Mellitus
Secondary:
Chronic Kidney Disease
Lower extremity edema
Discharge Condition:
Stable, improving.
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
were seen by the intensive care specialists and the medicine
team. We gave you IV diuretics to take off some fluid. An Echo
was done which showed 35% of ejection fraction.
Please continue to take all medications as prescribed, and
attend all of your appointments.
If you have chest pain, shortness of breath, lightheadedness
please return to the emergency room.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11528**] [**Telephone/Fax (1) 7976**]
in 2 weeks. You can also call [**Telephone/Fax (1) 250**] to setup an
appointment with another PCP at Health [**Name9 (PRE) **] Associate.
Please call Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at [**Telephone/Fax (1) 3512**] for an appointment
in the heart failure clinic.
You have the following upcoming appointments:
-Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 9529**] & DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2168-2-12**] 4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2168-1-16**]
ICD9 Codes: 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4888
} | Medical Text: Admission Date: [**2106-6-16**] Discharge Date: [**2106-6-21**]
Date of Birth: [**2054-7-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2106-6-16**] Coronary artery bypass grafting x4 left internal mammary
artery to left anterior descending coronary; reverse saphenous
vein single graft from aorta to the 1st diagonal coronary
artery; reverse saphenous vein single graft from aorta to the
1st obtuse marginal coronary artery; as well as reverse
saphenous vein single graft from aorta to the distal right
coronary artery
History of Present Illness:
The patient is a 51-year-old gentleman who presented with
unstable angina. Cardiac catheterization revealed severe 3-
vessel coronary disease with preserved left ventricular
function. The patient was therefore referred for coronary artery
bypass grafting.
Past Medical History:
1) CAD, as above, [**2106-5-31**] exercise MIBI with fixed inferior
defect, associated hypokineses. EF reported at 57%.
2)Kidney stones
3)Colonic Polyps - s/p polypectomy
Social History:
He works as teacher in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] Public School. He does not have
any smoking or drinking history.
Family History:
Mother- died of SCD at age 62
Father- died of bladder cancer
Physical Exam:
AFVSS
NEURO:PERRL / [**Last Name (LF) 3899**], [**First Name3 (LF) 2995**] equally, Answers simple commands, Neg
pronator drift, Sensation intact to ST, 2 plus DTR, Neg [**Name2 (NI) **]
HEENT: NCAT, Neg lesions nares, oral pharnyx, auditory
NECK: Supple / FAROM, neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2106-6-16**] Intra-op TEE for CABG
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal
(LVEF>55%).
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic function is normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
1. Regional and global left ventricular systolic function are
normal. Right ventricular systolic function is normal.
2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]
3. Aorta is intact post decannulation
[**2106-6-20**] 04:00AM BLOOD WBC-6.7 RBC-2.96* Hgb-9.3* Hct-25.9*
MCV-88 MCH-31.4 MCHC-35.9* RDW-13.9 Plt Ct-208
[**2106-6-19**] 04:05AM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-140
K-4.0 Cl-103 HCO3-32 AnGap-9
[**2106-6-18**] 02:32AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
[**2106-6-18**] Chest x-ray: Interval development of a small-to-moderate
left pleural effusion.
Brief Hospital Course:
Mr [**Known lastname 15848**],[**Known firstname 1112**] was admitted on [**2105-6-16**] for an elective
surgery.
Pre-operatively, he was consented, prepped, and brought down to
the operating room for surgery.
He underwent the below procedure:
PROCEDURE:
1. Coronary artery bypass grafting x4 left internal mammary
artery to left anterior descending coronary; reverse
saphenous vein single graft from aorta to the 1st
diagonal coronary artery; reverse saphenous vein single
graft from aorta to the 1st obtuse marginal coronary
artery; as well as reverse saphenous vein single graft
from aorta to the distal right coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
Intra-operatively, he was closely monitored and remained
hemodynamically stable. He tolerated the procedure well without
any difficulty or complication. Post-operatively, transferred to
the CSRU for further stabilization and invasive monitoring.
Within 24 hours, he awoke neurologically intact and was
extubated without any sequele. After extubation he was
transfered to the floor in stable condition. On the floor, he
remained hemodynamically stable with his pain controlled. He
remained in a normal sinus rhyth without atrial or ventricular
arrhythmias. He progressed with physical therapy to improve his
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home with services on
postoperative day five.
Medications on Admission:
ASA 81', Lipitor 80', plavix 600' (stopped [**6-7**]), metoprolol
12.5", SL NTG prn
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:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day for 2 weeks: Take with food.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
ulcer dz w/history of UGI bleed
Asthma
HTN
dyslipidemia
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. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Call your PCP schedule an appointment for 2 weeks. [**Last Name (LF) **],[**First Name3 (LF) **]
M. [**Telephone/Fax (1) 2393**].
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2106-6-29**]
3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2106-7-2**] 11:00
Call Dr[**Name (NI) 9379**] office and schedule an appointment for 4
weeks. ([**Telephone/Fax (1) 1504**].
Completed by:[**2106-6-22**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4889
} | Medical Text: Admission Date: [**2153-4-30**] Discharge Date: [**2153-5-23**]
Date of Birth: [**2103-2-21**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Bowel obstruction and respiratory failure POD12 from emergent
right hemicolectomy
Major Surgical or Invasive Procedure:
[**2153-5-12**]: Tracheostomy and PEG ([**Doctor Last Name 853**])
[ prior to admission - [**2153-4-18**]: Exlap right hemicolectomy
([**Doctor Last Name **]) ]
History of Present Illness:
Ms [**Known lastname 46117**] is a 50F with steroid-dependent COPD known to the
ACS service from recent admission for free air & extensive
pneumatosis now s/p ex-lap and R colectomy ([**4-18**]) who returns on
transfer from OSH for bowel obstruction and respiratory failure.
Pt was discharged in good condition with functioning bowels. Hx
obtained from daughter as pt is intubated: She has been
increasingly distended and nauseated since discharge. She has
been keeping her pills down but has been regurgitating into her
mouth. This AM at home she looked ill and her lips were blue.
She was taken to [**Hospital3 **] where CXR and KUB showed
massive gastric dilatation and small bowel dilatation with
stool/contrast in the rectum. An NGT was placed with hurricane
spray and pt aspirated. She went into respiratory failure and
was intubated prior to transfer. Post intubation film confirmed
the NGT well within the stomach, which was decompressed, and
appropriate positioning of the NGT.
Past Medical History:
PMH: duodenal ulcers, COPD on chronic steroids, asthma, tobacco
dependence, hypothyroidism, chronic constipation, multiple
T-spine compression fxs, depression w/hx suicidal ideation and
suicide attempts/psych hospitalizations
PSH: open R hemicolectomy ([**2153-4-18**]), C-Sxn, endoscopic "repair"
of duodenal ulcers
Social History:
Lives with nephrew in [**Hospital1 487**], +tob 30 PY, no ETOH, no drugs
Family History:
Non-contributory
Physical Exam:
ADMISSION: Vitals: HR 110's, BP 140's
GEN: Intubated, no sedation since before transfer and pt is not
moving or responding to stimuli, pt is cachectic, ill-appearing,
w/skin changes c/w lonterm steroid use
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Coarse b/l
ABD: Soft, distended, retention sutures and surgical staples to
midline abdominal wound, no erythema hypoactive bowel sounds, no
palpable masses
Ext: No LE edema, L calf ulcer, venous stasis changes to b/l LEs
CBC: 2.5 > 36.7 < 279 [N:63 Band:25 L:5 M:5 E:1 Bas:0 Metas:
1]
140 / 92 / 46
Chem: --------------< 134 Ca: 8.7 Mg: 7.8 P: 3.5
3.4 / 36 / 1.4
ALT 21; AP 118; Tbili 0.7; Alb 3.4; AST 37; Lip 42; Trop-T:
0.02
PT: 11.0 PTT: 22.8 INR: 0.9 Lactate:3.5
- UCG Negative
- pH 7.43/pCO2 56/pO2 423/HCO3 38/BaseXS 11/MetHb 16/O2Sat: 83
Imaging:
CXR (OSH): massively dilated stomach, dilated loops of SB, no
free air
KUB (OSH): Dilated SB, gastric distension, stool w/contrast in
rectum
Pertinent Results:
[**2153-4-30**] 05:20PM BLOOD WBC-2.5* RBC-3.71* Hgb-11.7* Hct-36.7
MCV-99* MCH-31.4 MCHC-31.8 RDW-18.1* Plt Ct-279
[**2153-5-22**] 02:07AM BLOOD WBC-35.3* RBC-3.48* Hgb-10.4* Hct-32.1*
MCV-92 MCH-29.8 MCHC-32.3 RDW-16.5* Plt Ct-534*
[**2153-5-22**] 02:07AM BLOOD Glucose-131* UreaN-20 Creat-0.3* Na-137
K-4.7 Cl-94* HCO3-32 AnGap-16
[**2153-5-19**] 06:31AM BLOOD Type-ART Temp-37.6 PEEP-5 pO2-64*
pCO2-59* pH-7.42 calTCO2-40* Base XS-10 Intubat-INTUBATED
[**2153-5-19**] 06:31AM BLOOD Lactate-2.6*
[**5-21**]: CT torso:
1. Increased number and confluence of cavitary lesions noted in
the left
lower lobe consolidation. Other previously reported diffuse
cavitary lesions and ground-glass opacities appear relatively
stable. These findings are consistent with necrotizing pneumonia
or septic emboli with superimposed necrotizing lobar pneumonia;
fungal infection such as invasive aspergillosis is also
considered.
2. Interval resolution of pleural effusion.
3. Stable ileocolic anastomosis without evidence of anastomotic
leak or bowel
obstruction.
4. Minimal residual debris at site of prior pigtail drain
without evidence of
reaccumulated or new focal abscess.
5. Stable thoracic spine compression fractures.
6. Pancreatic calcifications consistent with chronic
pancreatitis.
Brief Hospital Course:
Ms [**Known lastname 46117**] was admitted to the ICU upon her arrival to the
[**Hospital1 18**] Emergency Department. She arrived from [**Location **]
intubated/sedated on mechanical ventilation. During her 3 week
ICU stay, her primary issues were pulmonary and infectious. In
brief, we were unable to wean her from the ventilator but her
mental status normalized and her gut tolerated tube feeds. A
detailed hospital course is below.
Neuro: CT head ([**4-30**]) was performed at presentation as
neurologic status could not be adequately assessed and
precipitating insult was not confirmed. This showed no acute
intracranial pathology.
CV: She had an intermittent pressor requirement. She underwent
trans-thoracic echocardiogram on [**5-9**] and [**5-17**], both studies
showed good cardiac function (EF 65%). There was question of
valve vegetation, but no TEE was performed.
PU: CT Chest on admission showed left lower lobe consolidation
and peribronchial ground glass opacities bilaterally, thought to
be due to infection with possible aspiration. She remained
ventilator dependent during the stay. On HD3, she self-extubated
and soon became tachypnic and hypoxic so was re-intubated.
Repeated attempts to wean pressure support were limited by
tachypnea, tachycardia and hypoxia. She underwent multiple
bronchoscopies to remove secretions and mucous plugs. Repeat
Chest CT on [**5-8**] showed interval worsening of the large left
lower lobe consolidation and interval increase of innumerable
small cavitary lesions compatible with diffuse dissemination of
infection. Once apparent she would likely never wean from the
vent, she underwent tracheostomy [**2153-5-12**]. Repeat chest CT on [**5-21**]
was consistent with worsening necrotizing pneumonia.
GI: She arrived with an NGT in place given her sedation and risk
for aspiration. Tube feeds were started [**5-7**]. Repeat CT abd/pelv
on [**5-8**] showed the anastamosis to be intact, no evidence of
bowel obstruction and near-complete resolution of abdominal
ascites and resolution of deep pelvic collection. Percutaneous
gastrostomy tube was placed on [**5-12**] and feeds were begun the
following day.
GU: Urine culture from [**5-7**] showed >100k yeast. Renal ultrasound
on [**5-18**] showed no evidence of fungal infection. Foley was kept in
place, and urine output remained adequate.
FEN: She required few IV boluses. She was started on TPN [**2153-5-1**]
and continued until could tolerate tube feed nutrition.
HEM: She exhibited an initial rise then persistently elevated
WBC. On admit, was 2.5, rose to 13.0 by HD6, peaked at 35.3
[**2153-5-22**]. She was transfused 2 units PRBC on HD 4 and required
pressors and was not responding sufficiently to crystalloid
resuscitation. However, once adequately rescusitated, the
patient was weaned off of pressors, and did not require
additional blood transfusions.
ID: In summary of her infectious course, she had a pelvic
abscess growing C. perfringens and [**Female First Name (un) 564**] that was treated. She
then developed findings concerning for cavitary pneumonia with
mucocutaneous candidiasis in bladder, esophagus and lungs. She
never had fungemia. Possible fungal reservoir include heart
valves, which would require amphoteracin treatment. On HD2, she
underwent IR-guided drain placement of the pelvic abscess. This
drain was removed after 8 days and CT pelvis showed resolution
of abscess. Her antibiotic therapy changed frequently based on
recommendations from the Infectious Disease consult team and her
culture data.
pip-tazo [**Date range (1) 73789**]
vanco [**Date range (1) 89420**]
cefepime [**Date range (1) 73635**]
metronidazole [**5-1**]-
meropenem [**Date range (1) 89421**]
gent [**Date range (1) 85269**]
fluc [**5-7**]-
micafungin [**Date range (1) 89422**]
levoflox [**5-18**]-
She had many microbiology studies performed. Of note, all
[**Female First Name (un) **] growths were fluconazole sensitive and Klebsiella was
pan-sensitive. There were no positive blood cultures.
[**5-1**] | pelvic abscess: C. perfringens, C. albicans
[**5-5**] | BAL: yeast
[**5-7**] | urine: C. albicans
[**5-7**] | "peritoneal fluid" (abscess drainage): C. albicans
[**5-8**] | BAL: C. albicans, C. dublinensis, Klebsiella PNA
[**5-16**] | urine: >100K yeast pending spp.
[**5-17**] | BAL: yeast, GNR pending spp. (requested [**5-18**])
The patient overall was not improving clinically. Her white
count continued to rise, and she was unable to be weaned off of
the vent. Her necrotizing pneumonia continued to worsen and it
was decided that recovery for her was unlikely. A family meeting
was held on [**2153-5-22**], and it was determined that patient should be
made CMO. The patient expired on [**2153-5-23**].
Medications on Admission:
duloxetine 60mg daily, albuterol nebs q4H, ipratropium nebs q6H,
levothyroxine 50mcg daily, quetiapine 25mg qHS, pantoprazole
40mg daily, fluticasone 110mcg
[**Hospital1 **], latanoprost 0.005% qHS, montelukast 10mg qHS, clonazepam 1
mg TID, Colace 100mg [**Hospital1 **], prednisone 15mg daily, Ferrex 150mg
daily, Symbicort 160-4.5mcg INH [**Hospital1 **], Bactrim DS 800-160mg 3x
weekly, Miralax 17g prn, oxycodone 5-10mg q6H, lactulose 20g prn
constipation
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
- Severe COPD
- Right colon perforation leading to pelvic abscess
- necrotizing pneumonia
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2153-6-4**]
ICD9 Codes: 5070, 0389, 5849, 5180, 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4890
} | Medical Text: Admission Date: [**2100-8-22**] Discharge Date: [**2100-9-6**]
Date of Birth: [**2064-8-1**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
Cerebral angiogram
Cerebral aneurysm clipping
Lumbar drain
History of Present Illness:
36 y/o female in previously good health until approximately
4:30pm [**2100-8-21**] when she experienced sudden onset severe headache
along the suboccipital and left temporal regions. This was
accompanied by nausea/vomiting, photophobia, and nuchal
rigidity.
Upon admission to an outside ER, head CT revealed subarachnoid
hemorrhage [**Doctor Last Name 957**] grade 2, with blood in prepontine cistern and
bilateral Sylvian fissures. The patient remained neurologically
stable (Hunt-[**Doctor Last Name 9381**] 2) and was transferred to [**Hospital1 18**] ER where
neurosurgery was consulted.
Past Medical History:
UTI
GERD
Social History:
occupation: retail services
Family History:
Non contributory
Physical Exam:
T:98.3 BP: 122/88 HR: 90 R 19 O2Sats 98% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-12**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-13**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors - speaks
Portugese only.
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2100-8-21**] 10:45 PM
Routine CTA of the head was performed with contrast using
standard departmental protocol.
On the unenhanced head CT, note is made of mild subarachnoid
hemorrhage in the left sylvian fissure, and in the suprasellar
cistern with possible minimal subarachnoid hemorrhage also
anterior to the pons and the medulla.
Evaluation of the CTA demonstrates a 3 mm left supraclinoid ICA
aneurysm, which appears to be distal to the takeoff of the
posterior communicating artery. This appears to be pointing
posterolaterally.
No other aneurysms seen.
No evidence for vasospasm.
IMPRESSION:
Possible 3-mm left supraclinoid ICA aneurysm pointing
posterolaterally. Mild subarachnoid hemorrhage as detailed
above.
[**Numeric Identifier 75057**] VERT/CAROTID A-GRAM [**2100-8-22**] 10:51 AM
Reason: aneurysm, possible embolization
Contrast: OPTIRAY
The patient was brought to the interventional neuroradiology
suite and placed on the biplane table in the supine position.
Prior to the start of the procedure, a time out was performed
which confirmed the patient's identity, procedure, and access
site. Both groins were prepped and draped in the usual sterile
fashion. Access to the right common femoral artery was obtained
using a 19 gauge single wall needle, under local anesthesia
using 1% Lidocaine mixed with Sodium Bicarbonate with aseptic
precautions. Through the needle, a 0.35 [**Last Name (un) 7648**] wire was
introduced and the needle was taken out. Over the wire, a 5
French vascular sheath was placed and connected to a saline
infusion (mixed with heparin 500 units and 500 cc of saline)
with a continuous drip. Through the sheath, a 4 French
Berenstein catheter was introduced and connected to a continuous
saline infusion (with heparin mixture: 1000 units of heparin and
1000 units of saline). The following vessels were selectively
catheterized and arteriograms were performed from these
locations. After review of films, the catheter and/or sheath
were withdrawn. Hemostasis was achieved using a boomerang device
and pressure applied on the groin. The procedure was uneventful
and the patient tolerated the procedure well without any
immediate complications. The patient was sent to the floor with
orders.
The following blood vessels were selectively catheterized and
arteriograms were obtained in the AP and lateral projections.
1) Left internal carotid artery.
2) Left common carotid artery.
3) Left vertebral artery.
4) Right internal carotid artery.
5) Right common carotid artery.
6) Right vertebral artery.
FINDINGS: There is an approximately 1.5 mm in size broad-based
aneurysm arising from the left internal carotid artery
immediately superior to the origin of the left posterior
communicating artery. Additionally, there is a small
infundibulum at the origin of the left ophthalmic artery.
No evidence of aneurysm or vascular malformation arising from
the right internal carotid artery and its major branches. There
is a small infundibulum at the origin of the right posterior
communicating artery.
There are no aneurysms or vascular malformations arising from
the bilateral vertebral arteries and their major branches. Note
is made of a right anterior inferior cerebellar and posterior
inferior cerebellar artery complex. Additionally, there is a
prominent left posterior cerebral artery.
IMPRESSION: Approximately 1.5 mm broad-based aneurysm arising
from the left internal cerebral artery just superior to the
origin of the left posterior communicating artery. Additionally,
small infundibula of the origin of the left ophthalmic artery
and the origin of the right posterior communicating artery.
[**Location (un) **]/CERB UNI [**2100-8-26**] 8:09 AM
Reason: post clipping angio
Contrast: OPTIRAY
IMPRESSION: Status post clipping of the previously identified
left internal carotid artery aneurysm, just superior to the left
posterior communicating artery origin. No residual aneurysm
filling.
CT HEAD W/O CONTRAST [**2100-9-1**] 3:12 PM
Reason: interval changes
There is only a minimal amount of residual pneumocephalus
remaining.
There are no new intracranial hemorrhages.
There is a small subdural collection over the left frontal lobe
unchanged from the prior study which may represent sequela of
the surgery. There is overlying craniotomy change with multiple
surgical skin staples causing streak artifact which obscures on
the adjacent brain.
A left paraclinoid aneurysm clip is again seen. The ventricles
are unchanged. The previously seen intraventricular blood is not
well seen on today's study. The [**Doctor Last Name 352**]/white matter
differentiation is maintained.
IMPRESSION:
1. Decrease in pneumocephalus with only minimal remaining.
2. Previously seen intraventricular blood is not well seen on
today's study.
3. No new intracranial hemorrhages.
4. Small subdural collection over the left frontal lobe which
likely is sequela of the overlying craniotomy.
Brief Hospital Course:
Patient is a 36 F admitted to Neurosurgery ICU on [**2100-8-22**] for
nontraumatic SAH. Her initial neurological exam was no focal
deficits. CTA and angiogram revealed 3mm left aneurysm. She
underwent aneurysm clipping and lumbar drain placement on
[**2100-8-25**]. Post-op CTA and cerebral angiogram showed good clipping
and no residual aneurysm/no vasospasm. Her lumbar drain was
d/ced on POD1.
[**8-28**]: her HCT dropped to 21.5 and she received 2units of PRBC;
post transfusion HCT was 27.4. She was found left pupil was 6mm
and right pupil 4mm. Repeat head CT was stable.
[**8-30**]: TCD showed mild vasospasm; repeat daily TCD from [**8-31**] -
[**9-2**] was negative for vasospasm.
[**9-2**] she was transferred out of ICU to stepdown. She was
transferred to regular floor on [**9-4**]. Diet and activity were
advanced.
PT was consulted and recommended pt to be discharged home.
Upon discharge, patient is neurologically stable, tolerating
diet, ambulating without assistance. Her pain is under control
with po medication.
Medications on Admission:
Motrin prn
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take while on narcotics.
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Cerebral aneurysm
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
You will need repeat angio in follow up in 3 months.
Completed by:[**2100-9-6**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4891
} | Medical Text: Admission Date: [**2182-1-17**] Discharge Date: [**2182-1-20**]
Date of Birth: [**2108-9-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Phenobarbital / Sulfa (Sulfonamide Antibiotics) /
Latex / Gluten
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
# Right total hip arthroplasty
# Blood transfusion
History of Present Illness:
Ms. [**Known lastname 83788**] is a 73 year-old woman now status-post hip
replacement being transferred to the cardiology service for
continued evaluation of hypotension.
Was initially admitted on [**1-17**] for right hip replacement.
Post-operatively, at ~06:40 her systolic blood pressures fell to
the high 80s systolic by aline (90s by cuff); she was
asymptomatic at that time. In response to the BP and a HCT of
27.4, she was transfused 2 units of pRBC. Also received two
250cc bolus of IVF. She was evaluated by the cardiology team
who found that her BP was improved (109/45) with a PA pressure
of 37/16 and a wedge of 13mmHg.
Currently, she is feeling well and is without complaint. She
walked with PT and feels strong.
ROS:
(+) weight loss (100 lbs a few years back; since then, stable)
(-) fevers/chills
(-) CP/SOB/palps
(+) urinary frequency (chronic); no dysuria
(+) shoulder pain (chronic)
(+) calf pain, right (chronic)
All other ROS negative.
Past Medical History:
1. Hypertension
2. Diabetes
3. Hyperlipidemia
4. Aortic stenosis
- 0.5-0.6 cm2, peak grad 50 mmHg, mean grad 23 mmHg
5. Congestive heart failure, EF 30%
- BiV pacemaker
6. Atrial fibrillation
- Multiple DCCV
- AVJ ablation
7. LBBB
8. Hypothyroidism
9. Traumatic brain injury
Social History:
Prior smoking history (quit in [**2133**]; smoked 2ppd x 10-15 years).
No alcohol or drug use. Divorced; lives alone and has 3 sons.
Writing a memoir of a life s/p traumatic brain injury. Uses a
walker at baseline.
Family History:
Mother had multiple MIs. No other heart disease, sudden death or
dysrhythmia in other relatives.
Physical Exam:
Vitals - BP 99/70, HR 70, RR 18, 100% on room air
General - Lying in bed, comfortable.
Eyes - Anicteric; no pallor
[**Year (4 digits) 4459**] - Right neck bandaged; no carotid bruits noted
CV - Sounds regular; systolic murmur heart loudest at RUSB but
noted throughout including at apex; S2 heard; no radiation to
carotids
Pulm - Clear; no rales/wheeze
Abdomen - Soft; non-tender
Ext - Warm; right hip bandaged with edema noted; trace bilateral
lower extremity edema; DP pulses palpable bilaterally
Integument - No rashes
Neuro - Alert and oriented; able to provide clear history.
Strenght exam somewhat limited by pain. Left arm and leg appear
to have full strength; right arm is limited by pain, especially
at shoulder. Right leg also limited given post-operative hip
Psych - Appropriate
Pertinent Results:
Admission Labs: [**2182-1-17**]
.
WBC-6.3 RBC-3.37* Hgb-10.9* Hct-31.8* MCV-94 MCH-32.3* MCHC-34.2
RDW-15.2 Plt Ct-134*
Neuts-81* Bands-5 Lymphs-7* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0
Myelos-0
PT-14.1* INR(PT)-1.2*
Glucose-124* UreaN-21* Creat-0.7 Na-136 K-3.9 Cl-104 HCO3-28
AnGap-8
.
[**1-17**] TEE (intra-operative):
No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is
moderately depressed (LVEF= 30 - 35 %). Basal segments contract
well, but all mid-segments are HK, and the apex is akinetic.
There is moderate global free wall hypokinesis. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is critical aortic valve stenosis (valve area
<0.8cm2). No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild to moderate ([**2-10**]+)
mitral regurgitation is seen. There is no pericardial effusion.
Pacing leads are seen in the right atrium and coronary sinus.
.
[**1-19**] TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. There is mild regional left
ventricular systolic dysfunction with infero-lateral
hypokinesis. RV with borderline normal free wall function. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are moderately thickened.
There is moderate to severe aortic valve stenosis (valve area
0.9 cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2181-10-16**],
LVEF and RVEF have increased.
.
ECG: Atrial rhythm is afib; ventricular pacer with QS in lead I
likely due to BiV.
.
Imaging:
[**1-17**] Pelvis:
IMPRESSIONS: Expected post-operative changes after total right
hip arthroplasty.
.
[**1-19**] Hip:
FINDINGS: Complete right hip replacement. The prosthetic
components are in correct position. No evidence of fracture.
.
Discharge labs:
[**2182-1-20**] 05:20AM BLOOD WBC-5.1 RBC-2.93* Hgb-9.6* Hct-27.7*
MCV-94 MCH-32.6* MCHC-34.6 RDW-15.5 Plt Ct-105*
[**2182-1-20**] 05:20AM BLOOD Plt Ct-105*
[**2182-1-20**] 05:20AM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-138
K-3.6 Cl-102 HCO3-30 AnGap-10
[**2182-1-20**] 05:20AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.8
Brief Hospital Course:
73 year-old woman with AS (0.5-0.6cm2), sCHF (EF 30%) s/p BiV
PM, and AF, who underwent total right hip replacement this
hospitalization and whose course was complicated by fluid
responsive post-operative hypotension treated with 2 units of
pRBCs.
.
ACTIVE ISSUES:
.
# Right total hip replacement: At the time of this discharge
summary, an operative note is not in OMR. On discharge the
patient is able to ambulate and there is no evidence of hematoma
at the incision site.
.
# Post-operative Hypotension and Anemia: The patient had an
episode of post-operative hypotension in the PACU and received 2
units of pRBC in conjunction with IVF, with an appropriate bump
in her Hct and resolution of her hypotension. Her Hct is stable
at about 28 on discharge. Repeat TTE was stable.
.
# Post-operative Thrombocytopenia: Patient's plt count was
steadily trending in low 100s post-operatively and the etiology
remains unclear, but it is likely related to intraoperative
bleeding. **Plts will need to be followed after discharge.**
.
INACTIVE ISSUES:
.
# Atrial fibrillation: Remained hemodynamically stable in AF and
rate controlled on metoprolol, unchanged from outpatient dosing.
Anticoagulated with enoxaparin as an inpatient and bridged to
unchanged warfarin dosing on discharge. **INR will need to be
closely followed after discharge.**
.
# Chronic sCHF: Lisinopril was held in the acute setting of
hypotension, but restarted unchanged from outpatient dosing. TTE
as detailed above showed improved RVEF and LVEF.
.
# Hypothyroidism: Unchanged home dosing of levothyroxine.
.
Remained full code for the duration of the hospitalization.
.
TRANSITIONAL ISSUES:
As above in **.
Medications on Admission:
Furosemide 20 mg when weight >142 lbs
Levoxyl 37.5 mg daily
Lisinopril 5 mg daily
Prandin 0.5 mg daily
Simvastatin 10 mg daily
Klor-Con 10 mEq daily
Trazodone 25 mg daily
Warfarin
Tylenol PRN
Ascorbic acid
Probiotic
Calcium
Ferround gluconate
Glucosamine/chondroitin
Guaifenesin
Magnesium
MVI
DHEA
Psyllium
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for When weight greater than 142 lbs.
4. Klor-Con 10 10 mEq Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day as needed for Take with
furosemide when weight greater than 142 lbs.
5. Weigh yourself daily
Weigh yourself daily:
-Take Furosemide as prescribed if weight greater than 142 lbs
-Call your cardiologist if your weight does not decrease with
this medication
6. warfarin 6 mg Tablet Sig: One (1) Tablet PO once a week: Take
Saturdays.
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 6 days per
week; not Saturdays: Daily dose 6 days per week is 4.5 mg. One
2.5 mg tablet plus one 2 mg tablet equals 4.5 mg.
8. warfarin 2 mg Tablet Sig: One (1) Tablet PO 6 days per week;
not Saturdays: Daily dose 6 days per week is 4.5 mg. One 2.5 mg
tablet plus one 2 mg tablet equals 4.5 mg.
9. levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
10. Prandin 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
11. ferrous gluconate Powder Miscellaneous
12. DHEA Oral
13. ascorbic acid Oral
14. Calcium+D Oral
15. Probiotic Oral
16. Glucosamine Sulf-Chondroitin Oral
17. guaifenesin Oral
18. magnesium Oral
19. multivitamin Oral
20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
21. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**7-17**]
hours as needed for pain.
Disp:*60 Capsule(s)* Refills:*0*
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
23. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
24. ondansetron 4 mg Film Sig: One (1) film PO every eight (8)
hours as needed for nausea.
25. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 7 days: Until INR between [**3-14**].
Disp:*7 syringes* Refills:*0*
26. Check INR
[**1-21**]: Check INR, fax results to rehab physician
[**1-22**]: Check INR, fax results to rehab physician
[**1-23**]: Check INR, fax results to rehab physician
[**Name Initial (PRE) **].
Continue to check INR until between [**3-14**]; at that time Enoxaparin
shots may be stopped as directed by rehab physician
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
Right total hip arthroplasty
Post-operative hypotension
.
SECONDARY:
Chronic Systolic Heart Failure
Atrial Fibrillation
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:
It has been a privilege to take care of you at the [**Hospital1 771**] ([**Hospital1 18**]).
.
You were hospitalized to undergo a total right hip replacement.
The surgery went well.
.
After the surgery, you had an episode of low blood pressure in
the recovery room. You received a blood transfusion and IV
fluids, which raised your blood pressure into the normal range.
Given your known heart conditions, the cardiology service
followed you very closely during your episode of low blood
pressure and you were subsequently transferred to the cardiology
floor from the recovery room.
.
On the cardiology floor, no changes were made to your heart
medicines. They continue to be the following:
# CONTINUE: Lisinopril 10 mg daily
# CONTINUE: Simvastatin 10 mg daily
# CONTINUE: Warfarin 6 mg Saturday, 4.5 mg 6 days/week
# CONTINUE: To weigh yourself daily; [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
# CONTINUE: Furosemide 20 mg when weight >142 lbs
# CONTINUE: Klor-Con 10 mEq daily when you take Furosemide
.
You will also need to continue on a blood thinning medication
until your coumadin reaches therapeutic levels in your body.
# START: Enoxaparin until INR between [**3-14**]
.
.
It is normal to experience pain after a major surgery like a hip
replacement. You are being discharged with the following pain
regimen.
# START: Tylenol 650 mg every 8 hours whether you are in pain or
not
# START: Oxycodone 5 mg every 4 to 6 hours as needed for pain
# STOP: Tylenol with Codeine
# START: Senna to prevent constipation that can result from
oxycodone
# START: Colace to prevent constipation that can result from
oxycodone
.
Please continue to take your other medications as previously
prescribed; they were not changed this hospitalization.
.
Please attend all of your follow-up appointments as detailed
below.
Followup Instructions:
Department: ORTHOPEDICS
When: FRIDAY [**2182-2-22**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], PA [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2182-3-1**] at 3:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2182-7-16**] at 2:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280, 4241, 2859, 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4892
} | Medical Text: Admission Date: [**2101-9-16**] Discharge Date: [**2101-10-5**]
Date of Birth: [**2101-9-16**] Sex: F
Service: NB
HISTORY: This interim summary is covering from [**9-16**] to
[**10-5**]. This is a 30-2/7-weeks gestational age infant, who
was born to a 36-year-old G1 P0, whose past medical history
was notable for benign thyroid nodule treated with partial
thyroidectomy and had a history of fibroids. Her prenatal
laboratories were A positive, Coombs' negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune,
HIV negative, cystic fibrosis negative, GC negative,
chlamydia negative, and an unknown GBS.
The pregnancy was complicated by first trimester bleeding
attributed to a partial abruption, a shortened cervix, and
preterm labor initially at 22 weeks. At this time, it was
treated with Indomethacin and she had admission to the
hospital. At 25 weeks gestation, she received a full course
of betamethasone and had normal serial ultrasounds. She had
no fever or other evidence of chorioamnionitis due to her
preterm prolonged rupture of membranes on [**2101-9-1**]. The
infant progressed with continuing labor and because she was a
footling breech, had a cesarean section under spinal
anesthesia.
The infant emerged with fair tone, but inconsistent
respiratory effort. She was admitted to the ICU and after
Apgars of six at one minute and eight at five minutes. She
was admitted and placed on CPAP in the Newborn ICU, but
subsequently had to be intubated.
PHYSICAL EXAMINATION: On physical exam, her weight was 1755
grams in the 90th percentile. Length 43 cm in the 75th-90th
percentile. OFC 29-1/4 cm (75th percentile). Otherwise, on
physical exam, she had moderate respiratory distress with
retractions, flaring, and grunting. She had regular, rate,
and rhythm without any murmur. Abdomen was soft and
nondistended, and otherwise her exam was normal.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory:
Initially, the infant was started on CPAP, but subsequent to
increasing FIO2 into the 40 percent range, she was intubated
and given Surfactant subsequently x3. She required a large
amount of support and continues to have problems with both
ventilation and oxygenation requiring up to 70 percent
oxygen. After two days of these therapies, she was switched
to the oscillatory ventilator, which significantly improved
her lung volumes on chest x-ray and her oxygenation, and she
was switched back to the conventional. Again, she
deteriorated and on day of life four, she was switched back
to the oscillatory ventilator.
She improved slowly, but surely over the next several days
and was extubated to nasal CPAP on day of life seven from the
high frequency oscillatory ventilator. At that time, she
required between room air and 26 percent. She subsequently
has done quite well on nasal cannula ranging between 25-50 cc
of oxygen and has very rare apneic and bradycardic spells.
She has not had apneic or bradycardic spells since [**9-28**].
She has never had any caffeine and has done quite well
without it.
Cardiovascular: Initially, because of difficulty in
oxygenation and a murmur heard and a metabolic acidosis, she
was treated with Indocin one course and had subsequent
followup, and echocardiogram showed no PDA. This problem
resolved with time. Her blood pressures were good and since
then, she has done well from a cardiovascular standpoint
without any issues.
FEN: The infant was initially made NPO, started on D10W and
changed over to PN in the next several days. She started
feeds on day of life five, and advanced very slowly until she
reached full feeds of Special Care 20. On day of life 12, at
this time, she was fortified and is currently on Special Care
24 being gavage fed over two hours at a total fluid of 140
cc/kg/day.
GI: She had problems with hyperbilirubinemia and max
bilirubin was that of 10 on day of life seven and she was
treated with phototherapy; and subsequently the bilirubin has
decreased on its own and she is not clinically jaundiced at
this time.
Hematology: Her initial hematocrit was 55, and she had a
subsequent hematocrit of 35.5, and she has not had a
transfusion. The infant was started on iron at two weeks of
life.
ID: The infant was initially started on ampicillin and
gentamicin, and was treated for a full seven day course for
possible pneumonia because of her difficult respiratory
status. She did not have any positive blood cultures. Had a
LP that was normal appearing without any growth on culture.
Antibiotics were stopped on the [**8-23**] after a seven
day course.
Neurology: The infant had a head ultrasound screening exam
on day of life seven, [**9-23**], which was normal. She will need
a followup head ultrasound at 30 days of age.
Sensory: The infant will need a hearing screen and
ophthalmologic screening.
Primary pediatrician is [**Last Name (un) 58115**] in [**Location (un) 16848**]. Phone number is
([**2101**].
DISCHARGE DIAGNOSES: Prematurity.
Respiratory distress.
Pneumonia.
Hyperbilirubinemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 58116**]
MEDQUIST36
D: [**2101-10-5**] 12:52:49
T: [**2101-10-5**] 13:29:05
Job#: [**Job Number **]
ICD9 Codes: 769, 7742, 4280, 2762, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4893
} | Medical Text: Admission Date: [**2152-5-25**] Discharge Date: [**2152-5-30**]
Date of Birth: [**2069-11-7**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Evaluate for IPH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 yo ambidextrous man with HTN, CAD, CRF who presented to ED
from OSH (medflighted for IPH), for evaluation.
He lives in TN with his wife. [**Name (NI) **] came to [**Location (un) 86**] yesterday for
family reunion. Last night when he slept, he was asymptomatic.
When he woke up this am at 7 am or so, he noted that his left UE
felt funny. He didnt think it was weak then but felt it was
"heavy". He had breakfast at 7.45-8 am. He ate doughnut and had
coffee with left hand without any trouble and his wife was with
him. Then he went up the stairs and took a shower. After coming
from shower, he noted that he was not able to dress especially
with the left hand which was "very weak". He kept on fumbling
with the buttons of his jeans with the hand. When his wife went
to see him, she noted that his left UE was weak, but she did not
notice any other weakness, facial asymmetry or any different
speech. He did not have any trauma , headache, fevers, or any
other symptom.
He was taken to OSH, where he was noted to be afebrile, BP
230/120, and noted to have "left UE weakness". He was given
labetalol 20 IV followed by drip and underwent CT head which
showed 3 cm right parietal bleed. He underwent EKG which did not
show any new ST/T changes, CBC was normal, chem 10 showed BUN 42
Cr 2.4 and ca of 10.6. After recieving labetelol, his blood
pressure dropped to high 90s. It was stopped and his BP came up
again to 130's. In the meantime he recieved ativan 0.5 Iv for
unclear reasons. There is no history of seizures or agitation.
He was medflighted to [**Hospital1 18**]. Neurology consult was called after
arrival.
After coming to [**Hospital1 18**] ED, his blood pressure became high at
170/90 and he was started on nicardipine drip.
Of note, he has h/o unexplained weight loss of 25 pounds in last
6 months. He was admitted for pna in TN few weeks ago and
recieved IV abx. Metoprolol dose was decreased from 50 [**Hospital1 **] to 25
[**Hospital1 **] few weeks ago. other review of systems is negative.
Past Medical History:
HTN
Dyslipidemia
CAD s/p stents
cognitive decline over last few years
Glaucoma
CRF ? etiology (likely HTN)
BL inguinal hernia
s/p prostate operation 20-30 years ago for BPH
Social History:
Retd. Lives with wife in TN, quit smoking 25 years ago, about 30
pack years before that. Non alcoholic, No drugs.
Family History:
No strokes but h/o DM and HTN in many members.
Physical Exam:
Exam:
Vitals- 98.6 66 134/66 19 99
Gen: Lying in bed, supine, not in any acute distress
HEENT: NCAT, moist mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Please note that patient was given ativan this am at OSH and
hence the examination was difficult as he was becoming drowsy
during the examination.
Mental status: Awake,cooperative with exam, somewhat drowsy and
flat affect. Oriented to person, place, and date. inattentive,
unable to say [**Doctor Last Name 1841**] backwards but able to say it forwards. able to
say DOW in backward fashion. Speech is fluent with normal
comprehension and
repetition; naming intact. No Dysarthria noted. He doesnt attend
to objects on the left side of page while [**Location (un) 1131**] or while
looking at the picture on the stroke card. He missed the kids
stealing cookies on the left side of picture. Registers [**2-9**],
recalls 0/3 in 5 minutes. No evidence of apraxia. He was
somewhat
inattentive towards left side. He kept on calling the right arm
as his "left arm' even after reminding him. However, he was able
to touch right thumb to left ear and was able to identify the
fingers.
Cranial Nerves:
Pupils equally round and slugggishly reactive to light, 4 to 3
mm
bilaterally. he has BL cataracts. has left visual field cut.
Extraocular movements intact bilaterally, no nystagmus.
Sensation
intact V1-V3. Face symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally.
Motor:
Normal bulk bilaterally. Tone decreased on the left upper
extremity. No observed myoclonus or tremor
Has pronator drift in left upper arm
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 4- 4 5 4 4 4 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, temparature, vibration and
proprioception on the right. He has extinction to DSS in the
left
arm more so than the left leg. Intact JPS and vibration. He has
loss of cortical sensations on the left hand. RAMs are clumsy on
left side.
Reflexes:
Reflexes are +1 on the right and left, except ankle jerks which
are absent.
Right toe is downgoing, left toe is mute
Coordination: finger-nose-finger normal on right, difficult to
test on left, KHS test normal.
Gait: deferred
Pertinent Results:
[**2152-5-29**] 06:21PM BLOOD WBC-7.9 RBC-4.17* Hgb-11.8* Hct-35.1*
MCV-84 MCH-28.3 MCHC-33.7 RDW-15.5 Plt Ct-269#
[**2152-5-29**] 06:55AM BLOOD WBC-7.0 RBC-3.90* Hgb-10.9* Hct-32.3*
MCV-83 MCH-27.9 MCHC-33.6 RDW-15.5 Plt Ct-163
[**2152-5-29**] 06:21PM BLOOD PT-13.2 PTT-28.3 INR(PT)-1.1
[**2152-5-29**] 06:21PM BLOOD Plt Ct-269#
[**2152-5-29**] 06:21PM BLOOD Glucose-114* UreaN-54* Creat-2.7* Na-137
K-5.1 Cl-103 HCO3-24 AnGap-15
[**2152-5-29**] 06:55AM BLOOD Glucose-105* UreaN-45* Creat-2.6* Na-138
K-4.0 Cl-107 HCO3-19* AnGap-16
[**2152-5-28**] 04:02AM BLOOD Glucose-105* UreaN-41* Creat-2.5* Na-144
K-3.8 Cl-111* HCO3-24 AnGap-13
[**2152-5-27**] 02:50AM BLOOD Glucose-110* UreaN-39* Creat-2.3* Na-143
K-4.4 Cl-108 HCO3-22 AnGap-17
[**2152-5-25**] 11:40AM BLOOD cTropnT-0.03*
[**2152-5-26**] 01:04AM BLOOD CK-MB-3 cTropnT-<0.01
[**2152-5-26**] 01:04AM BLOOD PEP-NO SPECIFI
Imaging:
CT [**5-25**]:
Overall, this examination is unchanged. A 2.7 x 2.0 right
parietal
intracerebral hemorrhage is stable. There is surrounding edema
as well as
some extension of hemorrhage through the cortex into the
subarachnoid space
(2:21). No new hemorrhage is identified. No midline shift or
evidence of
herniation is seen. There is prominence of the ventricles and
sulci,
reflecting generalized atrophy, age related. Lacunes are seen in
the
bilateral caudates.
No concerning osseous lesion is seen. The visualized paranasal
sinuses are
clear. No evidence of mass effect is seen.
IMPRESSION: Overall unchanged examination with right parietal
ICH,
surrounding edema and subarachnoid extension. No midline shift.
MRI/A: As seen on the recent CT there is an approximately 2.9 x
2.1 cm
acute to subacute right parietal hematoma with surrounding
vasogenic edema.
There is no shift of normally midline structures. There is
minimal mass
effect on the occipital [**Doctor Last Name 534**] of the right lateral ventricle.
There are no
other areas of susceptibility artifact apart from a small focus
within the
left middle cerebellar peduncle. There is no definite evidence
of acute
infarct. There is a focus of high signal on diffusion-weighted
images in the
periventricular white matter of the right frontal lobe which
appears to
correspond to a focus of FLAIR signal hyperintensity and may be
related to T2
shine-through as it is not resolvable on the ADC map. Otherwise
there is no
evidence of acute infarct. The ventricles and sulci are
prominent likely
related to age-related involutional change. The major
intracranial flow voids
appear maintained.
MRA OF THE BRAIN: There is no abnormal vascular structure in the
area of the
hemorrhage. There is hypoplasia of the A1 segment of the right
anterior
cerebral artery, normal variant. The posterior cerebral arteries
bilaterally
are somewhat attenuated which may be related to atherosclerosis
but there is
no evidence of flow-limiting stenosis, occlusion, or aneurysm in
the vessels
of the anterior or posterior circulation.
IMPRESSION:
1. No findings on the MRI or MRA to suggest underlying vascular
malformation
in the area of the right parietal hematoma.
2. Punctate focus of susceptibility artifact in the left middle
cerebellar
peduncle is non-specific and could be a calcification,
microhemorrhage or
cavernoma.
CT [**5-26**]:
There is a 2.7 x 1.8-cm right parietal intracerebral
hemorrhage, stable from prior exam with similar perilesional
edema. There is
no significant midline shift. Minor subarachnoid extension
exists. There is
no new intraparenchymal hemorrhage. Prominence of ventricles and
sulci relate
to age-related atrophy. Lacunes are redemonstrated on the right.
Mastoid air cells are clear. Visualized paranasal sinuses are
unremarkable.
IMPRESSION: Stable appearance to right parietal intracerebral
hemorrhage. No
midline shift.
EEG:
This telemetry captured no pushbutton activations; however,
it captured frequent sharp activity in the right parasagittal
area which
sometimes became more rhythmic and evolving suggestive of
electrographic
seizures without clear clinical correlate. The background
activity was
also slower in the right parasagittal area suggestive of
subcortical
dysfunction in the region.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to neurology ICU service for evaluation
of IPH. He was closely monitered in unit and was transfered to
neurology floor after initial stabilisation.
Neuro
He was closely monitered with neuro checks initially Q1h. Signs
of new deficits as well as that of raised ICP such as headache,
vomiting, visual blurring were monitered and he did not have any
of those. Antiplatelets and heparin SC was avoided given IPH. He
was put on comtinuous LTM EEG for 2 days given history of IPH,
however he did not have any clinical seizures but had few
discharges on EEG in the area on right parasaggital region c/w
IPH location. He underwent repeat CT scan after 24 hrs which did
not show any evidence of edema or increasing bleed or new bleed.
he underwent MRI to evaluate for any underlying mass or other
areas of bleed which was negative for the above.
The mechanism of bleed was thought to be HTN or amyloid.
Cards
He was closely monitered on telemetry. He was ruled out for
cardiac ischemia by EKG and cardiac enzymes. Heart healthy diet
was given.
Renal
Creatinine was closely watched. I/O was monitered. nephrotoxic
agents and dyes were avoided. SPEP and UPEP were done to
evaluate for myeloma which was negative
Endo
close watch over blood sugars was kept and he was on RISS.
FEN- Nutrition
He was closely monitered and underwent swallow test..
Rehab
he was seen by OT/PT who felt that the patient needed rehab.
Medications on Admission:
Clonidine 0.1 [**Hospital1 **]
Metoprolol 25 [**Hospital1 **]
Travast eye drops
aspirin 81 /day
Fish oil
MVI
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) 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. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic QHS (once a
day (at bedtime)).
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Right parietal bleed
Discharge Condition:
awake, alert, follows commands (1 and 2 steps), able to say days
of week backward, oriented to person, place, year, but not
month, day, spatial memory intact, mild naming difficulty to low
frequency objects, comprehension and repition intact,
calculation intact, attends to both side
CN: EOMI, visual fields appear full, occ inattentive on left,
but no extinction to DSS, tongue midline, face symmetric
Motor: slight left sided drift, weakness ([**3-13**])at the left
delt/tricep/ finger extensors, strong at biceps, full at RUE,
full at legs
[**Last Name (un) **]: reports slight decreased to light touch and pinprick,
astereognosis and agraphasthesia on the left hand
Discharge Instructions:
You were admitted with the onset of left upper extremity
weakness. You were brought to an outside hospital where an
image of your head was performed and you were noted to have a
bleed in your brain a small area in the right side called the
parietal lobe. You were medflighted to [**Hospital1 18**] for further
evaluation. Here you were admitted to the neuro ICU for blood
pressure controll and frequent monitoring. You did well and
were transferred out to the floor for further monitoring. You
were seen by physical therapy who recommended rehab.
Your medications were changed as follows:
You clonidine was increase to 0.2 TID
You were started on amlodipine 10mg daily
Your aspirin was stopped
Please take all medications as prescribed. Please make all
follow up appointments. If you have any new weakness or any of
the symptoms listed below please call your doctor or return to
the nearest emergency room.
Followup Instructions:
Patient lives in [**Location **], he will need to follow up with his
primary care provider when he gets released from rehab and be
set up with a neurologist in his home area.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 2930, 5859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4894
} | Medical Text: Admission Date: [**2113-1-12**] Discharge Date: [**2113-1-15**]
Date of Birth: [**2033-5-6**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Fatigue, Anuria
Major Surgical or Invasive Procedure:
Intraaortic Balloon Pump Placement
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
79 year old man with diastolic heart failure, chronic afib, CHF,
CRI, male breast cancer s/p masectomy with two recent admissions
presents with anuria and malaise. He was hospitalized from
[**Date range (1) 18845**] with a CHF exacerbation, and was diuresed 30 lbs (to
dry weight of 155 lbs). He was then hospitalized from [**11-29**]-
[**12-6**] with e coli urosepsis, treated with 4 weeks IV
ceftriaxone. Recent echo concerning for endocarditis due to ?
endocarditis. Seen in [**Hospital **] clinic [**1-10**]. No evidence of active
infection at time of visit. Culture neg endocaritis panel
pending at this time - sent as pt had persistent fever after
treatment for e.coli infection. At cardiology visit on [**1-11**] pt
found to be in ARF with Cr of 3.3 and evidence of worsening
volume overload. He was advised to come into the hospital.
Metolazone was discontinued and he was advised to hold his
torsemide. His digoxin and allopurinol were also held.
On admission today the patient reports increased edema of LE as
well as increasing abdominal distention. No urine output today.
His wife notes he has become increasing somnulent. The patient
denies dyspnea and states he has been able to walk around his
home. Does not climb stairs - utilizes chair lift. His wife adds
that he has required a walker for ambulation over the past few
days. He has had increased loose stools [**2-28**] daily for past days,
worse than his baseline. He is complaining of thirst and reports
good appetite.
On arrival to the ED the patient has an intial SBP in 90s and HR
60s, then pressure dipped to mid 70s but he continued to mentate
well. He was started on lasix gtt at 20mg/hr and received diuril
250mg.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative. Complains of fatigue and loose
stools as above.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations. The patient does report intermittent
lightheadedness with standing.
Past Medical History:
diastolic CHF
atrial fibrillation
male breast cancer s/p R mastectomy in [**2104**]
hypertension
dyslipidemia
gout
.
Cardiac Risk Factors: - Diabetes, + Dyslipidemia, + Hypertension
.
Cardiac History: No prior CABG. No history of PCI.
Social History:
Social history is significant for the absence of current tobacco
use, last smoked [**2069**]. There is no history of alcohol abuse, he
currently drinks 1 drink per night. Prior [**University/College **] professor.
.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
PHYSICAL EXAMINATION
VS - Tc 97.4, HR 61, BP 88/42, RR 14, 95%RA, 0
Gen: Elderly male in NAD. Oriented x3. Irritable. Dyspneic with
speaking
HEENT: Sclera anicteric. PERRL, EOMI. Dry MM, clear OP.
Neck: Supple with JVP at earlobe
CV: Irregularly irregular, normal S1, S2. 2/6 SEM at RUSB. [**3-2**]
systolic murmur over mitral area with radiation to axilla. No
thrills, lifts. No S3 or S4.
Chest: Resp were slightly labored. decreased BS at RLL with
dullness to percussion.
Abd: Soft, +distention and fluid wave
Ext: 1+ ankle edema, 3+ thigh edema b/l. DP and PT dopplerable
Skin: + stasis changes bilateral LE. No ulcers, scars, or
xanthomas. Warm extremities
Pertinent Results:
EKG demonstrated atrial fibrillation with ventricular rate
60bpm. LAD. QRS126 - IVCD. Low voltage in leads II,III, AVF with
q waves in III and AVF. Poor R wave progression. Non specific
diffuse twave flattening. No ST changes with no significant
change compared with prior dated [**2113-12-1**].
.
[**2113-1-12**] 03:30PM WBC-6.3 RBC-4.27* HGB-13.3* HCT-40.2 MCV-94
MCH-31.1 MCHC-33.0 RDW-17.9*
[**2113-1-12**] 03:30PM NEUTS-74.2* LYMPHS-17.2* MONOS-7.8 EOS-0.4
BASOS-0.3
[**2113-1-12**] 03:30PM PLT COUNT-108* LPLT-3+
[**2113-1-12**] 03:30PM PT-28.2* PTT-37.8* INR(PT)-2.8*
[**2113-1-12**] 03:30PM CALCIUM-8.6 PHOSPHATE-8.5*# MAGNESIUM-3.3*
[**2113-1-12**] 03:30PM CK-MB-8 cTropnT-0.04*
[**2113-1-12**] 03:30PM ALT(SGPT)-17 AST(SGOT)-48* CK(CPK)-104 ALK
PHOS-167* AMYLASE-91 TOT BILI-0.4
[**2113-1-12**] 03:30PM LIPASE-123*
[**2113-1-12**] 03:30PM GLUCOSE-167* UREA N-169* CREAT-4.5*#
SODIUM-127* POTASSIUM-5.4* CHLORIDE-85* TOTAL CO2-28 ANION
GAP-19
[**2113-1-12**] 03:43PM LACTATE-1.7 K+-4.8
[**2113-1-12**] 05:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2113-1-12**] 05:07PM URINE RBC-[**3-1**]* WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2113-1-12**] 05:07PM URINE GRANULAR-0-2 HYALINE-[**6-6**]*
[**2113-1-12**] 05:07PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
.
CXR [**2113-1-12**] - AP UPRIGHT CHEST: There has been interval removal
of a left-sided PICC. Moderate enlargement of the cardiac
silhouette is stable. Mediastinal and hilar contours are
unchanged. Mild vascular engorgement and redistribution is again
identified, consistent with mild volume overload. There is a
stable moderate right pleural effusion with chronic right volume
loss and right basilar opacity, likely atelectasis. No
pneumothorax is identified. Visualized bony structures of the
thorax are stable.
IMPRESSION:
1. Enlarged cardiac silhouette with pulmonary vascular
redistribution consistent with mild volume overload.
2. Stable moderate right pleural effusion with right basilar
opacity, likely atelectasis, although underlying pneumonia is
not excluded.
.
Renal US [**2113-1-13**]
FINDINGS: The right kidney measures 12.3 cm and the left kidney
measures 13.4 cm. Again seen are multiple simple cysts on each
of the kidneys. The largest cyst on the right kidney measures
6.3 x 7.0 x 7.8 cm. The largest cyst on the left kidney measures
14.0 x 12.4 x 11.6 cm. There is no hydronephrosis seen and no
solid masses or stones are identified in either kidney. There is
ascites noted within the abdomen and a right pleural effusion is
also seen. A Foley catheter is identified within the minimally
distended bladder. The bladder wall is noted to be thickened.
IMPRESSION:
1. No hydronephrosis.
2. Multiple simple renal cysts.
3. Ascites with right pleural effusion.
4. Thickened bladder wall.
.
Cath [**1-13**]:
FINAL DIAGNOSIS:
1. Severe left and right ventricular diastolic dysfunction.
2. Severe pulmonary arterial hypertension.
3. Successful insertion of an intra-aortic balloon pump, albeit
with
minimal systolic unloading.
4. Atrial fibrillation.
5. Catheter-induced ventricular tachycardia.
.
TTE [**1-14**]:
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 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. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is partial anterior mitral
leaflet flail. There is small vegetation on the mitral valve
(remnant of prior endocarditis). An eccentric, posteriorly
directed jet of Moderate (2+) mitral regurgitation is seen (due
to the eccentric nature of the mitral regurgitation, the
volumetric assessment (based on color flow imaging) of mitral
regurgitation may be underestimated. The tricuspid valve
leaflets are mildly thickened. The supporting structures of the
tricuspid valve are thickened/fibrotic. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. Significant pulmonic regurgitation is seen. The
main pulmonary artery is dilated. The branch pulmonary arteries
are dilated. There is a small pericardial effusion. The effusion
appears circumferential. There are no echocardiographic signs of
tamponade.
Compared to the previous study of [**2112-12-28**], the mitral
regurgitation is reduced, the forward stroke volume is
increased, and the aortic regurgitation is unchanged.
Brief Hospital Course:
79M with diastolic heart failure, 4+ TR and 3+ MR afib, RF in
past related to obstruction, prostate ca, CKD (baseline Cr ~1.5)
admitted with hypotension and anuria.
.
1. Decompensated Diastolic Heart Failure/Valvular Heart Disease:
The patient presented with severe decompensated diastolic heart
failure; likely precipitated by multivalvular disease. He was
anuric on admission and was started on a lasix gtt overnight
with minimal improvement in urine output. Renal consultation was
obtained and anuria felt to be prerenal in etiology. Lasix gtt
was discontinued. The patient underwent IABP placement on [**1-13**]
with subsequent improvement in urine output and Cr. The patient
then underwent TTE and evaluation for valvular surgery as his
condition was unlikely to resolve without repair of TR and MR.
The patient refused consideration for surgery and also elected
to have the IABP removed. After discussion with the patient and
family, the patient requested to transition his care to comfort
measures. He expired on [**1-15**] at 15:15, shortly after IABP
removal.
.
2. Rhythm - Atrial fibrillation; induced Vtach during placement
of balloon but no intervention required and returned to Afib. Pt
remained well rate controlled.
.
3. Valves - Moderate (2+) AR, Moderate to severe (3+) MR,
Severe [4+] tricuspid regurgitation. Pt declined consideration
of valvular repair/replacement.
.
4. ARF: Pt presented with anuria. Cr 4.5 from 1.9 on [**1-5**].
Etiology consistent with prerenal. Treatment with lasix gtt and
IABP as above.
Medications on Admission:
CURRENT MEDICATIONS: (Per wife's medication list)
Torsemide 100 mg Tablet [**Hospital1 **]
Metolazone 5 mg T/Th/Sat - stopped
Losartan 25 mg daily
MAGNESIUM OXIDE 400 mg daily
Toprol XL 100 mg SR daily
Finasteride 5 mg daily
Tamsulosin 0.4 mg daily
Warfarin 2 mg daily T,W,Th,Sat, 1mg M,F
Femora 2.5mg daily
Gemfibrozil 600mg daily
Allopurinol 75mg daily - stopped
Lipitor 5mg daily
Digoxin 0.4mg daily - stopped
Discharge Disposition:
Expired
Discharge Diagnosis:
Diastolic Congestive Heart Failure
Valvular Heart Disease
Discharge Condition:
Expired
ICD9 Codes: 5849, 4271, 9971, 4280, 4240, 2749, 2724, 2875, 5859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4895
} | Medical Text: Admission Date: [**2160-9-8**] Discharge Date: [**2160-9-20**]
Service: CARDIOTHORACIC
Allergies:
Atenolol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2160-9-16**] Coronary Artery Bypass graft x 3 (left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the first marginal branch and the terminal circumflex
coronary artery)
History of Present Illness:
87 yo male with a history of coronary artery disease status post
multiple stents and endarterectomy more than 10 years ago at
[**Hospital1 18**], Hypertension, dyslipidemia, prostate cancer treated with
XRT, COPD/chronic bronchitis with bronchoreactive airway
disease, chronic pain issues treated with steroids-seen by pain
clinic presents to OSH with substernal chest pain and EKG
changes. Cardiac cath performed shows significant critical
multivessel coronary artery disease. Pt was transferred on
Integrilin and Nitroglycerin drips to [**Hospital1 18**] for
surgical revascularization with Dr.[**Last Name (STitle) **].
Past Medical History:
Coronary Artery Disease status post multiple stents,
Hypertension, Dyslipidemia, Prostate cancer treated with XRT,
Chronic obstructive pulmonary disease/chronic bronchitis with
bronchoreactive airway disease, Chronic pain issues chronic pain
issues treated with steroids, Hematuria
Social History:
Lives with:wife
Occupation:full time employee in motor coach industry with
Celtics and [**Company **]
Tobacco:distant HX of cigar use. Denies cigareete use
ETOH:denies
Family History:
Noncontributory
Physical Exam:
Skin: Dry [] intact []: (L)thigh
cellulitis/indurated/warm/erythemarous area
HEENT: PERRLA [] EOMI [x]
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: Left:
Carotid Bruit Right: Left:
Pertinent Results:
[**2160-9-9**] Carotid Ultrasound: Right ICA stenosis <40%. Left ICA
stenosis <40%.
[**2160-9-9**] PFT's:
SPIROMETRY 2:21 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.71 3.95 69 2.93 74 +8
FEV1 1.53 2.39 64 1.68 70 +10
MMF 0.54 1.89 28 0.55 29 +2
FEV1/FVC 56 61 93 57 95 +2
DLCO 2:21 PM
Actual Pred %Pred
DSB 17.05 22.03 77
VA(sb) 4.65 6.78 69
HB 11.80
DSB(HB) 18.71 22.03 85
DL/VA 4.03 3.25 124
[**2160-9-15**] Echo: Prebypass: No mass/thrombus is seen in the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses are
normal. There is mild regional left ventricular systolic
dysfunction with LVEF of 45%. Overall left ventricular systolic
function is mildly depressed (LVEF= 45 %). There is hypokinesia
of the apex, apical and mid portions of the anterior wall and
anterior septum. Right ventricular chamber size and free wall
motion are normal. with normal free wall contractility. 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 (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results on [**2160-9-15**] at 815am.
Post bypass: Patient is a paced and receiving an infusion of
phenylephrine and epinephrine. LV sytolic function is slightly
improved. RV systolic function is unchanged. Mild mitral
regurgitation persists. Aorta is intact post decannulation.
[**2160-9-20**] 05:21AM BLOOD WBC-12.4* RBC-3.09* Hgb-9.3* Hct-27.9*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.4 Plt Ct-418
[**2160-9-15**] 11:16AM BLOOD PT-13.1 PTT-36.1* INR(PT)-1.1
[**2160-9-20**] 05:21AM BLOOD Glucose-100 UreaN-22* Creat-1.1 Na-139
K-4.2 Cl-100 HCO3-29 AnGap-14
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 93843**] was transferred on
Integrilin and Nitroglycerin drips to [**Hospital1 18**] for surgical
revascularization. Her underwent appropriate surgical work-up
which included carotid U/S, pulmonary function tests and echo.
He was medically managed which included Nitroglycerin and
Heparin gtt, along with antibiotics for cellulitis on left
thigh. Surgery also was delayed for a work-up of GI bleed. On
[**9-15**] he was cleared for surgery by GI and brought to the
operating room where he underwent a coronary artery bypass graft
x 3. Please see operative note for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. He was
disoriented to place post-operatively, but his exam was
non-focal. He also experienced paroxysmal atrial fibrillation
which resolved. He was transferred to the floor to begin
increasing his activity level. Beta blockade titrated and he was
gently diuresed toward his preop weight. Chest tubes and pacing
wires removed per protocol. He was cleared for discharge by Dr.
[**Last Name (STitle) 914**] to rehab on post-operative day five.
Medications on Admission:
ASA 325mg qd, Simvistatin 80mg qd, Lopressor 12.5mg [**Hospital1 **], Cozaar
50mg qd, Allopurinol 100mg qd, Spiriva [**Hospital1 **], Vicodin 1mg [**Hospital1 **]
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:*2*
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day) for 10 days.
Disp:*400 mg* Refills:*0*
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
Disp:*qs * Refills:*0*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*qs * Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever/pain.
Disp:*40 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. 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:
Extended Care
Facility:
tba
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass graft x 3
PMH: status post multiple stents, Hypertension, Dyslipidemia,
Prostate cancer treated with XRT, Chronic obstructive pulmonary
disease/chronic bronchitis with bronchoreactive airway disease,
Chronic pain issues chronic pain issues treated with steroids,
hematuria,radiation colitis, GI bleed
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 from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 1295**] in [**1-29**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 1270**] in 2 weeks. [**0-0-**]
Scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2161-3-25**] 9:30
Completed by:[**2160-9-20**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4896
} | Medical Text: Admission Date: [**2120-11-8**] Discharge Date: [**2120-11-15**]
Date of Birth: [**2066-10-13**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
fever / mental status changes
Major Surgical or Invasive Procedure:
Arterial Line - [**2120-11-8**] 10:37 PM
Presep Catheter - [**2120-11-8**] 10:39 PM
History of Present Illness:
54 yoF w/ a h/o OSA, obesity hypoventilation syndrome with
multiple admissions for hypercarbic respiratory failure, ASD w/
R to L shunt, HTN and pan hypopit presents with a fever and
mental status changes / depression, found to have a PaCO2 of 105
on initial ABG.
.
Per her daughter the patient woke up in the a.m. did not eat
breakfast, did not take her medications, but she was awake and
alert. Her daughter then left for a period of time and then
returned home she was sleeping during conversation. She was
complaining of a headache but this has been present for years
and unchanged. She was also coughing, productive of yellow
sputum, also she had chills x 24hours. The day prior to
admission she felt completely fine and was at her baseline. She
did use her CPAP overnight and has used her nebulizer, she has
been using it more frequently. She had not been complaining of
any urinary symptoms such as urinary frequency or dysuria;
however she felt that she gets tired of urinary frequency with
lasix.
.
Initially in the ER had a Temp of 102.6 HR 82 BP 132/71 and
was 95% on a non rebreather. (initial O2 sat in the field was
73% by EMS) In ER was unable to articulate any sentances. SBP
initially 132 then trended down to 80s systolic. Attempted CPAP
initially without success. R IJ, arterial line and intubated in
ER with a Bougie. Rec'd 6 liters NS and 0.09 of Levophed, CVP
of 23. Rec'd levo / ctx / vanco and nebs as well as solumedrol
125mg IV x 1.
Past Medical History:
1)Obstructive Sleep Apnea on home CPAP, 16cm H20
2)Obesity Hypoventilation
- Multiple admissions for hypercarbic respiratory failure; PFT's
consistent with a restrictive defect
- PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO reduced
3)ASD with right-left shunt (12% shunt fraction documented in
nuclear study from [**2116-3-30**])
4)Pulmonary artery hypertension: Echo in [**10/2118**] demonstrated a
TR gradient of 33mmHg ?????? followed by [**Location (un) 4507**]
5)Hypertension
6)Pan-hypopituitarism with partially empty sella on
desmopressin, levothyroxine, prednisone ?????? followed by Dr.
[**Last Name (STitle) **]
7)Diastolic CHF with dilated RA/LA on previous echo
8)Angioedema (unclear history, possibly related to ACE-I)
Social History:
Lives with daughter and 3 grandchildren [**Location (un) 6409**].
Originally from [**Male First Name (un) 1056**]. Goes to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Program
History of tobacco use, no h/o ETOH or IVDU
Family History:
Non-contributory
Physical Exam:
Tmax: 37.7 ??????C (99.8 ??????F)
Tcurrent: 37.6 ??????C (99.7 ??????F)
HR: 91 (81 - 91) bpm
BP: 117/67(86) {102/61(75) - 150/87(344)} mmHg
RR: 15 (12 - 24) insp/min
SpO2: 97%
GEN: NAD
HEENT: EOMI, PERRL 2mm to 1mm. MMM, JVP 12cm
COR: RRR, no M/G/R, soft heart sounds
PULM: Lungs CTAB anteriorly and laterally
ABD: Soft, obese, NT, ND, +BS, no HSM, no masses
EXT: 2+ pitting pedal edema bilaterally symmetric
NEURO: responds to painful stimuli appropriately, does not
respond to verbal stimuli. toes are upgoing bilaterally,
patellar tendon DTRs diminished bilat symmetrical. PERRL.
Pertinent Results:
[**2120-11-10**] 03:00AM BLOOD WBC-8.0# RBC-3.14* Hgb-8.5* Hct-27.9*
MCV-89 MCH-27.1 MCHC-30.5* RDW-17.1* Plt Ct-109*
[**2120-11-10**] 03:00AM BLOOD Neuts-75.3* Lymphs-15.7* Monos-7.4
Eos-1.3 Baso-0.2
[**2120-11-10**] 03:00AM BLOOD Plt Ct-109*
[**2120-11-10**] 03:00AM BLOOD PT-16.4* PTT-32.8 INR(PT)-1.5*
[**2120-11-10**] 03:00AM BLOOD Glucose-92 UreaN-18 Creat-1.3* Na-149*
K-4.0 Cl-109* HCO3-34* AnGap-10
[**2120-11-9**] 04:54AM BLOOD ALT-11 AST-24 LD(LDH)-243 AlkPhos-85
TotBili-0.5
[**2120-11-10**] 03:00AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.2
[**2120-11-8**] 05:45PM BLOOD cTropnT-0.02*
[**2120-11-8**] 05:45PM BLOOD CK-MB-NotDone
[**2120-11-8**] 11:30PM BLOOD Cortsol-29.0*
[**2120-11-10**] 10:20AM BLOOD Type-ART Temp-37.8 Rates-/15 PEEP-0
FiO2-40 pO2-91 pCO2-69* pH-7.31* calTCO2-36* Base XS-4
Intubat-INTUBATED
[**2120-11-10**] 03:10AM BLOOD Lactate-1.1
[**2120-11-10**] 03:10AM BLOOD freeCa-1.11*
Brief Hospital Course:
Pt's a 54 yo F with h/o OSA, obesity hypoventilation syndrome
with multiple admissions for hypercarbic respiratory failure,
ASD w/ R to L shunt, HTN and pan hypopit presents with a fever
and mental status changes found to have a PaCO2 of 105 on
initial ABG in basic hypercarbic respiratory failure and
triggered by sepsis - initially tx for pulm source but later
evident to be more urospepsis with E. Coli. (Initially covered
with vanc/zosyn/levo - later switched to to just levofloxicin.
Dosing has been challeging with pt admitted with ARF. Pt with
period of hypotension - tx with levophed - off pressors and now
extubated 2 days ago - still with mild low grade temps am of tx
to floor. Currently without complaints, breathing comfortably
on BiPAP (during night).
# Urosepsis/UTI - Patient admitted with fever and possible
pulmonary infiltrate as well as hypotension, so she was treated
for sepsis due to a pulmonary source (vanc/ zosyn/ levofloxacin
for legionella coverge). Pt has had recent hospitalization so
at risk for HAP. Additionally, pt UA was positive and urine
culture growing E. Coli that was resistent to Amp. Pt blood
culture and sputum cx were no growth to date. The patient was
stablized in the ICU. Her coverage was reduced to levofloxacin
250mg q24 for urinary source of infection, but noted still with
low grade temps morning of ICU tx. Patient's levofloxacin was
increased to 500 mg po qd. She developed a leukocystosis to 16K
on [**2120-11-13**] with low-grade fevers to with a tmax of 100.3. Her
right IJ CVC was removed on [**11-13**] with tip cultured. The
patient subsequently was completely afebrile for over 24 hours
with improvemnt of her leukocytosis. All studies to evaluate
for ongoing infection were negative to date. Patient had rash
on leg and arms but not cellulitic in appearance. The patient
was completely asymptomatic. Of note, the patient is on
prednisone 5 mg po qd.
-patient to complete 5 more days of levofloxacin 500 mg po qd at
home. Note made of hx of prolonged Qtc interval.
-Would recommend cbc check at f/u PCP visit in 2 weeks.
# Hypercarbic Respiratory Failure: Multiple hospitalizations
related to hypercarbic respiratory failure thought to be due to
obesity hypoventilation syndrome. At this admission, initial
PCO2 was 105 with improvement on mechanical ventilation. The
patient was successfully extubated on [**11-11**] and tolerated it
well. Patient was continued on bipap at night. Patient was
ambulated by PT with ambulatory sats in mid 90s.
-outpatient consideration of chronic trach or intermittant NIPPV
(this was brought up by the ICU attending). Patient should f/u
with her pulmonologist.
# HTN: Pt BP medication were initially held due to hypotension.
She was restarted on her home clonidine, valsartan, and
metoprolol as outpatient.
#Acute on chronic, Diastolic CHF: Pt was restarted on her home
lasix.
#ARF: Resolved during admission. Baseline creatinine is 0.9.
#Hypernatremia: Serum Na 155 on am of discharge. Repeat sodium
checked. Likely secondary to free water deficit and/or steroid
replacemnt for pan-hypo pit.
# Panhypopituitarism: Partially empty sella, currently on
desmopressin, levothyroxine, prednisone at home.
- continuing these medications at the current dosage
(replacement dosing).
#Anemia: MCV normocytic. Stable.
# Comm: Daughter [**First Name4 (NamePattern1) **] [**Name (NI) 1005**] [**Telephone/Fax (1) 110404**]
Medications on Admission:
Clonidine 0.1 mg po daily
Aspirin 81 mg po daily
Levothyroxine 150mcg po daily
Desmopressin 0.1 mg po daily
Prednisone 5 mg po daily
Lasix 40mg po daily
Cholecalciferol (Vitamin D3) 400 unit po daily
Calcium Carbonate 500 mg po tid
Miconazole Nitrate 2 % Powder prn
Valsartan 80 mg po qpm, 40mg po qam
Metoprolol Tartrate 25 mg po bid
Pantoprazole 40 mg po daily
albuterol nebs q6hrs prn
Omeprazole 20mg po daily
cefpodoxime 200mg x 2 months (1+ month left)
2L NC oxygen
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
3. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Apply to inner thighs.
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
12. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing. neb
Discharge Disposition:
Home With Service
Facility:
Physicians home care
Discharge Diagnosis:
Hypercarbic respiratory Failure
UTI with possible urosepsis
Acute Renal Failure
Obesity Hypoventilation
Obstructive Sleep Apnea
Rash
Leukocytosis
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to ED if having fevers, chills, significantly worsening
rash, shortness of breath.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2120-11-25**] 4:30
Patient to arrange f/u appointment with her PCP [**First Name8 (NamePattern2) 3296**]
[**Last Name (NamePattern1) 3297**],[**Name9 (PRE) 3295**] I. [**Telephone/Fax (1) 608**] in [**1-31**] weeks.
Patient to f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**] of pulmonary at [**Hospital1 18**].
Patient to discuss with Dr. [**Last Name (STitle) 4507**] role for trach given multiple
repeated hospitalizations and intubations.
ICD9 Codes: 5849, 5990, 2760, 4589, 4019, 311, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4897
} | Medical Text: Admission Date: [**2163-7-25**] Discharge Date: [**2163-8-25**]
Date of Birth: [**2102-6-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
61 year-old female diagnosed with primary amyloidosis in [**Month (only) 958**]
[**2163**], recently harvested after Cytoxan chemotherapy, being
admitted for melphalan therapy followed by auto-BMT as a
palliative measure.
Major Surgical or Invasive Procedure:
Triple lumen catheter placement ([**2163-7-25**])
Esophagogastroduodenoscopy ([**2163-7-26**] and [**2163-8-13**])
Right femoral line cordis placement ([**2163-8-4**])
Endotracheal intubation ([**2163-8-4**] to [**2163-8-5**])
History of Present Illness:
Ms. [**Known lastname **] is a 61 year-old woman diagnosed with primary
amyloidosis in [**2162-3-6**]. At that time, she presented with
progressive lower extremity edema. Work-up revealed significant
proteinuria. A renal biopsy was then performed and showed lambda
light chain deposits. She was also found to have lambda light
chain in her urine. A diagnosis of primary [**Doctor Last Name **] amyloidosis was
subsequently made. She was recently harvested after Cytoxan
therapy and is now being admitted for melphalan chemotherapy
followed by autologous stem cell transplant. Her screening
evaluation revealed normal pulmonary function and no significant
cardiac dysfunction. Except for the proteinuria, her renal
function is normal.
Other than her leg edema, Ms. [**Known lastname **] complains of increasing
weakness and fatigue. She denies SOB, cough, headache, syncope,
chest pain or palpitation, abdominal pain or dysuria. She also
denies any recent febrile illness.
Past Medical History:
1) Primary amyloidosis diagnosed in [**3-10**] following clinical
proteinuria. Renal biopsy demonstrated a predominance of lambda
light chains. Bone marrow biopsy in [**5-10**] showed low level (5-10%
of the cellularity) monoclonal lambda plasmacytosis.
2) Multiple bilateral breast cysts: Biopsies negative for
cancer.
3) History of premature ventricular complexes
4) History of duodenal ulcer
5) Surgery to right leg ligamentin [**2139**]'s
Social History:
She currently lives with her husband and has three children. Her
younger son had [**Name (NI) 1932**] disease approximately 3-4 years ago.
She has a 20 pack-year smoking history and reports occasional
alcohol consumption, no drugs.
Family History:
Significant for [**Name (NI) 1932**] disease in her son. She ahd a brother
with renal cell carcinoma. Her mother is alive at the age of 93.
Her father died at the age of 84 of "old age".
Physical Exam:
GENERAL: Pleasant woman in NAD.
VITAL SIGNS: Temp 97, HR 104, BP 110/64, RR 20, oxygen
saturation 96% on RA
HEENT: PERRL, EOMI. no sinus tenderness. Clear oropharynx.
NECK: No JVD. No carotid bruit.
RESP: Clear to auscultation bilaterally
CVS: Normal S1, S2. No murmur/rub or gallop. Left subclavian
triple lumen in place.
GI: Normal BS. Soft and non-tender. No hepatosplenomegaly.
EXt: 3+ pitting edema to thighs. No clubbing, no cyanosis.
NEURO: AAO X3. CN II-XII intact. Strenght [**5-11**] thoughout.
Pertinent Results:
Pertinent laboratory results on admission include WBC-12.5*
(NEUTS-82.6* LYMPHS-11.5* MONOS-4.0 EOS-0.7 BASOS-1.2),
HGB-12.0, HCT-34.5*, PLT 588*. Chemistry reveals GLUCOSE-153*,
UREA N-21*, CREAT-0.6, SODIUM-141, POTASSIUM-3.8, CHLORIDE-106,
HCO3-25, CALCIUM-8.5, PHOSPHATE-3.8, MAGNESIUM-1.6, URIC
ACID-9.5*, ALBUMIN-2.8*. Liver enzymes show ALT-16, AST-18,
ALP-115 with normal bilirubin profile. LDH 276.
Imaging:
CXR ([**2163-6-3**]): Normal
Skeletal survey ([**2163-5-26**]): Normal
Echo ([**2163-6-14**]): LVH with low normal LVEF (50-55%), 1+ MR.
Brief Hospital Course:
Her hospital course will be reviewed by problems:
1) Primary amyloidosis: Ms [**Known lastname **] was treated with 2 days of high
dose Melphalan, followed by one rest day. Stem cells were
reinfused on [**2163-7-29**]. Her ANC reached a nadir on [**2163-8-3**],
then was above 500 on [**2163-8-9**]. She was given Neupogen from
[**2163-8-2**] until [**2163-8-11**]. She tolerated the chemo well.
2) CNS: On [**2163-7-30**] (day +1), the patient developed a transient
right visual field defect which resolved spontaneously after one
hour with no recurrence. Neurology was consulted. MRI head on
[**7-30**] revealed a hyperintense region in the left temporal lobe
consistent with acute infarction. Work-up for an embolic focus
was initiated and was negative. EKG revealed NSR. Echo (TTE)
showed no evidence of a thrombus, moderate symmetric LVH and
LVEF low-normal 50-55%. TEE was not performed given low ANC and
low platelets. Carotid doppler ([**2163-8-2**]) showed no stenosing
lesion. She was also placed on telemetry for evaluation of
arrhythmia (see CVS). Decision was taken not to administer ASA
given thrombocytopenia post reinfusion. Heparin was also not
indicated in her case, given negative embolic work-up and high
risk of heparinization. She was IV hydrated to maintain her BP
at a higher level, and continued on Lipitor. Her CVA was
subsequently felt to be possibly related to hypercoagulability
secondary to her nephrotic syndrome.
During her hospital stay, Ms [**Known lastname **] was also found to have a
fluctuating mental status, mostly at night, starting around day
+18. Infectious and metabolic work-ups were negative, including
TSH, B12, and RPR. Psychiatry was consulted, with an impression
of delirium. All BDZ, anticholinergics and cognitive depressant
medications were held. Patient's mental status subsequently
improved. She will follow-up with psychiatry as an out-patient
to evaluate for underlying depression in setting of her medical
condition.
3) GI: On day 6 post BMT, patient developped some hematuria,
followed by a small volume of hematemesis. This was followed by
massive hematochezia and hematemesis ~450cc total. Platelets
were 37. With each episode, she became more fatigued and
hypotensive, with SBP decreasing to 70's (baseline 100's) and
decreased mentation. Agressive IVF and blood product support
were initiated. She was transferred to the [**Hospital Unit Name 153**] for hemodynamic
instability. GI was consulted emergently. The patient was
electively intubated for endoscopy. EGD revealed a smooth,
non-bleeding, 12 cm mass in the mid-body of the greater
curvature, but no evidence of active bleeding. She was started
on Protonix IV. She overall received 2L NS, 1L LR, 4U PRBC's, 2U
FFP, 6hr pressor support with levophed over initial
stabilization. HCT initially dropped from 25-->16, then
increased to 29 after 4U PRBC's. A repeat CT head showed no
bleed. She returned to the floor on [**2163-8-7**].
On [**2163-8-13**], a repeat EGD was performed to assess
prognostication prior to anticoagulation for a subclavian
catheter-related thrombosis. It revealed Grade 2 esophagitis in
the lower third of the esophagus and a segment suspicious for
Barrett's esophagus. More importantly, it showed a 10 cm X 1,5
cm cratered ulcer in the stomach body. Given high-risk of
rebleeding, decision was taken not to anticoagulate. The line
was pulled out with no complications. High dose Protonix was
started along with Carafate. Her hematocrit remained stable
while on the floor. She was last transfused on [**2163-8-11**].
Helicobacter pylori serology negative. She will follow-up with
GI as an out-patient and will need a repeat EGD.
4) Respiratory: After extubation, Ms. [**Known lastname **] required supplemental
oxygen up to 4L via NP to maintain her oxygen saturation above
92 %. She was gradually weaned off oxygen on the floor and
supplemental oxygen was discontinued on [**2163-8-24**]. At discharge,
her oxygen saturation is 92-94 % on room air. Serial CXRs
revealed fairly stable bilateral pleural effusions and vascular
congestion consistent with pulmonary edema. No evidence of
pneumonia or pulmonary infiltrate.
5) CVS: As mentionned, patient was placed on telemetry following
CVA/TIA. She had a few asymptomatic episodes of NSVT, up to 12
beats, without hemodynamic instability. Her primary cardiologist
was contact[**Name (NI) **] (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**]) and an EP consult was obtained.
As per EP, she was started on Metoprolol 12.5 mg PO BID. We were
unable to increase the dose to a target of 25 mg PO BID given
patient's borderline low BP (SBP in 90s-100s). A repeat cardiac
echo on [**2163-8-15**] showed mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mild symmetric LVH
with low normal LVEF (55%) and a small pericardial effusion was
seen.
EKGs revealed sinus tachycardia, probable prior anterior and
inferior MI and non-specific lateral ST-T changes were noted. Of
note, her QTc is slightly prolonged and should be followed. She
will follow-up with her primary cardiologist at D/C.
6) GU: Patient's volume status remained a major issue during her
hospital stay. She has anasarca secondary to her primary
condition, proteinuria and hypoalbuminemia. She was gently
diuresed with Lasix with good results. Her creatinine remained
normal throughout. Her electrolytes were repleted as needed. A
24-hour urine collection revealed a total protein of 232 mg/dL,
Ucreat of 25. Her albumin remains low at 2.3 at discharge. She
will be discharged on Lasix 20 mg PO BID and should have
biweekly Chem 10 with electrolyte repletion as necessary.
She experienced multiple episodes of incontinence while on the
floor, both of urine and feces, felt secondary to reduced
mobility and access. She reports a history consistent with
stress incontinence prior to her admission. On the floor, a
foley was inserted for a short period of time. U/A and urine
cultures were negative. She also complained of bladder spasms,
controlled with Ditropan. No further incontinence at D/C. Off
Ditropan.
Nutrition: She was started on TPN upon return from the [**Hospital Unit Name 153**]
status post massive UGI bleed. diet was advanced slowly and TPN
was D/C'd on [**2163-8-13**].
7) ID: Patient had some diarrhea while in hospital. Flagyl was
started on [**8-8**] and D/C'd on [**8-9**] given C.diff negative on 3
occasions. Her diarrhea was felt to be most likely secondary to
erythromycin, started post UGI bleed to increase GI motiliy. She
also had a low-grade temperature starting on [**2163-8-10**] (100.1).
She was continued on her prophylactic Levoquin (started on day
-2). Vancomycin was added. Levo switched to Cefepime. All
antibiotics were D/C'd on [**8-15**] given no longer neutropenic and
negative work-up.
8) Skin: While in hospital, Ms. [**Known lastname **] had a severe candidal rash
involving her groins, genitalia and buttocks. Fluconazole and
Miconazole powder were prescribed. The rash improved on the
above regimen and with a foley catheter which kept the area dry
(patient incontinent at times). She also has 2 groin lesions
from previous femoral sticks/cordis in the ICU. Plastic Surgery
was consulted, who felt that the lesions were superficial and
required no antibiotics. Wound care with wet-to-dry dressings
were recommended.
She was followed by OT and PT in hospital and will benefit from
continued services at D?C. She will be discharged to a skilled
nursing facility. COndition stable at discharge.
Medications on Admission:
ASA 81 mg PO once daily
Ranitidine 150 mg PO once daily
Lipitor 20 mg PO once daily
Toprol 20 mg PO once daily
Discharge Medications:
1. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Carafate 1 g Tablet Sig: One (1) Tablet PO every six (6)
hours: Please take on an empty stomach.
Disp:*120 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: Half Tablet PO twice a
day: Take 12.5 mg PO twice daily.
Disp:*30 Tablet(s)* Refills:*2*
4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
5. Protonix 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:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Life Care Facilities
Discharge Diagnosis:
1) Primary amyloidosis
2) Gastric ulcer
Discharge Condition:
Patient discharged to skilled nursing facility in stable
condition.
Discharge Instructions:
Please call your primary oncologist or return to the clinic if
you develop fever or chills, or if you experience worsening
shortness of breath or increased leg swelling.
Please follow-up with Dr [**Last Name (STitle) 11493**], Dr [**Last Name (STitle) 410**], Dr [**Last Name (STitle) 2161**]
(gastroenterology) and psychiatry as indicated below.
Followup Instructions:
1) Please follow-up with Dr [**Last Name (STitle) 410**] in the next 3 weeks. Please
call his office at [**Telephone/Fax (1) 3760**] to schedule an appointment in
early [**Month (only) **].
2) Please follow-up with gastroenterology for your stomach
ulcer. Your appointment is scheduled for [**2163-9-16**] at
0900 with Dr [**Last Name (STitle) 2161**] as indicated below:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2163-9-16**] 9:00
3) Please call your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] and schedule an
appointment to see him in the next 1 month.
4) You may call the psychiatry [**Hospital 6669**] clinic to schedule an
appointment at [**Telephone/Fax (1) 1387**].
Completed by:[**2163-8-25**]
ICD9 Codes: 9971, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4898
} | Medical Text: Admission Date: [**2180-8-28**] Discharge Date: [**2180-8-31**]
Date of Birth: [**2106-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
1. Esophogealduodenoscopy (EGD)
2. Flexable Sigmoidoscopy
History of Present Illness:
74 year old man with CAD, valvular disease, GERD, PVD, and
recent admission for rectal bleeding from radiation proctitis,
presents with BRBPR for weeks. He reports some amount of GI
bleeding since the radiation treatment one year ago, but states
this was worsened since he was started on blood thinners for a
planned vascular surgery. Per his last discharge summary, he had
BRBPR requiring 2u+1u PRBC after being started on heparin gtt
for graft instability on [**8-6**]. During that admission, he had a
colonoscopy that showed radiation changes. She had bleeders
cauterized and was discharged. Since then, he had some mild
continued bleeding. His PCP sent him in for his low Hct of 25
from Hct 32 on [**8-17**].
In the ED, initial vs were: 97.4 51 137/70 18 99. He was alert
but ashen. He was seen by GI. He was started on one unit of PRBC
and had an 18G and 16G placed. He complained of some mild chest
dyscomfort and had an EKG that was "at baseline", and CE sent
for chest dyscomfort. Prior to transfer, BP 142/41 and HR 53.
Currently, he feels normal. Denies weakness or dizziness.
Past Medical History:
1. HTN
2. Hyperlipidemia (pt denies)
3. GERD (pt denies)
4. PVD s/p L CFA to DP bypass graft, s/p R CFA to peroneal
bypass for popliteal artery aneurysm, s/p redo R CFA to peroneal
bypass using nonreversed R basilic/cephalic veins, s/p B/L LE
angio ([**7-2**]), s/p LLE angio ([**8-3**])
5. CAD, s/p DES to LCX/OM1 in [**2168**]. On [**2180-8-10**] cath: LAD 50%
stenosis, D1 80% ostial stenosis, Cx had a 90% stenosis, RCA 70%
stenosis, lateral 80% stenosis in the med region of the vessel
and a subbranch of the PL had a 70% stenosis at its origin.
6. DM (pt denies)
7. Prostate cancer s/p radiation therapy
8. Aortic stenosis (0.8-1.19cm2)
9. CKD, baseline Cr 1.3
10. Anemia, baseline Hct upper 20s-low 30s
Social History:
Spanish speaking. He is married and lives with his wife. [**Name (NI) **]
continues to smoke [**4-30**] cigs/day, h/o 1ppd since age 15. Denies
EtOH for years, but history of heavy drinking. No drug use.
Family History:
Brother died of colon CA at age 70. No sudden cardiac death.
Physical Exam:
On MICU Admission
Vitals: 97 56 136/47 18 96%/RA
General: Alert, pale, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
loudest at base
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Rectal: in ED, small BRB G+
Pertinent Results:
ON ADMISSION:
[**2180-8-28**] 11:10AM BLOOD WBC-7.2 RBC-2.53*# Hgb-6.8*# Hct-22.3*#
MCV-88 MCH-26.9* MCHC-30.6* RDW-16.3* Plt Ct-404
[**2180-8-28**] 11:10AM BLOOD Glucose-114* UreaN-30* Creat-1.3* Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
[**2180-8-29**] 03:02AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.4
HCT TREND
[**2180-8-28**] 09:00PM Hct-25.1*
[**2180-8-29**] 03:02AM Hct-27.3*
[**2180-8-29**] 01:56PM Hct-27.8*
[**2180-8-29**] 09:00PM Hct-29.8*
[**2180-8-30**] 05:30AM Hct-30.0*
[**2180-8-30**] 05:30AM Hct-30.4*
ROMI
[**2180-8-28**] 11:10AM BLOOD CK(CPK)-31* cTropnT-<0.01
[**2180-8-28**] 09:00PM BLOOD CK(CPK)-28* CK-MB-NotDone cTropnT-<0.01
[**2180-8-29**] 03:02AM BLOOD CK(CPK)-32* CK-MB-NotDone cTropnT-<0.01
[**2180-8-29**] 01:56PM BLOOD CK(CPK)-32* CK-MB-NotDone cTropnT-<0.01
IRON STUDIES
[**2180-8-28**] 11:10AM BLOOD Iron-25* calTIBC-267 Hapto-261*
Ferritn-24* TRF-205
Brief Hospital Course:
74yo male with history of radiation proctitis with 1 year hx of
BRBPR with recent LGIB during pre-op hospitalization, GERD, PVD,
and severe aortic stenosis who presents with drop in Hct and
BRBPR.
.
# GI Bleed: Patient describes chronic, low-level bleeding that
is likely from angioectasias from radiation proctitis. Low
suspicion for upper GI bleed given slow nature, history, and
absence of nausea/vomiting. In the emergency room, he was
transfused 1 unit PRBCs and 2 large bore IV's placed. Due to
active GI bleed, he was admitted directly to the MICU. In the
ICU, he was given 3 units packed red blood cells. He maintained
hemodynamic stability. The patient does have a drug eluding
stent, but given he was one year out from stent placement, his
aspirin and beta-blocker were held in setting of his bleed.
Patient has a history of iron deficiency, he was loaded with
iron with his blood transfusions. Given his hemodynamic
stability, he was transferred to the floor for ongoing medical
managment and planned scopes by GI. He arrived to the floor
with stable hemodynamics and aysmptommatic. He still had BRBPR,
but per pt and nursing reports, it was greatly decreased from
admission. He was followed with serial hematocrits, and aspirin
was held. Outpatient iron replacement regimen was held as to
not mask melena. Due to GI bleed, DVT prophylaxis consisted of
ambulation. The GI consult team planned for a flex
sigmoidocscopy and EGD on day 2 of the floor and patient was
prepped with 2L Go-lytely for his procedures. Flex
sigmoidoscopy identified a large rectal ulcer at site of
previous cautery with no active bleeding to explain patient's
drop in hematocrit. EGD showed z-line abnormality and biopsy
was taken, otherwise unremarkable. Small bowel imaging was
planned in the outpatient setting. The patient continued to be
hemodynamically stable on the floor with a stable hematocrit x48
hours priors to discharge. The patient was to have his
hematocrit checked by VNA and faxed to his PCP on day 1 and 4
after discharge.
.
# CAD: Due to active GI bleed, Mr. [**Known lastname 16709**] aspirin and beta
blocker were held on admission and throught is hospital stay.
Due to patient > 1 year out from DES, low risk for in-stent
thrombosis. His statin was continued. Patient was instructed
to follow-up with his PCP after discharge to re-evaluate the
reintroduction of these medications.
.
# Hypertension: Due to active bleeding on admission, Mr.
[**Known lastname 16709**] anti-hypertensive medications were discontinued.
After becoming hemodynamically stable and transfer to the floor,
the patient was kept NPO in preparation for GI procedures. Mr.
[**Known lastname **] was normotensive for most of his admission, with his
Lisinopril and Nifedipine resstarted prior to discharge. He was
instructed to follow-up with the arranged PCP appointment for
blood pressure evaluation.
.
# Anemia: Iron studies, hypochromia, and microcytosis consistent
with iron deficiency. Mr. [**Known lastname **] was iron loaded in the ICU
with his transfusions and instructed to follow-up with PCP [**Last Name (NamePattern4) **]:
future iron replacement.
.
# FEN: No IVF, replete electrolytes, regular diet
.
# Code: Full
.
# Communication: Patient (spanish speaking, some english)
Medications on Admission:
Aspirin 325 mg PO daily
Clonazepam 1 mg PO QHS
Hydrochlorothiazide 25 mg PO daily
Lisinopril 20 mg PO daily
Nifedipine 90 mg PO daily
Pantoprazole 40 mg PO Q24H
Hydrocortisone Acetate 25 mg suppository
Atorvastatin 80 mg PO daily
Citalopram 10 mg PO daily
Ferrous Sulfate 325 mg PO daily
Metoprolol Succinate 50 mg PO daily
Discharge Medications:
1. Hydrocortisone Acetate 25 mg Suppository Sig: One (1)
Suppository Rectal DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia for 10 days.
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
8. Outpatient Lab Work
Please Check CBC on [**Last Name (NamePattern4) 2974**] [**2180-9-1**] and fax results to PCP.
[**Name10 (NameIs) 357**] check CBC on Monday [**2180-9-4**] and fax results to PCP
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Rectal Ulcer
2. Lower GI Bleed
Secondary:
1. Hypertension
3. Radiation Proctitis
Discharge Condition:
Stable. Vitals stable.
Discharge Instructions:
You were admitted to the hospital for active bleeding and a drop
in your blood levels. You were admitted to the Intensive Care
unit to monitor your closely until you were stabilized. You
revieved a total of 5 blood transfusions during your admission.
During your admission, your blood pressure medication was
stopped since you were losing blood. You also had a a
sigmoidoscopy sigmoid colon and and EGD to look at your
esophagus, stomach and part of your duodenum.
Medication changes:
1. Stop Hydrochlorothiazide
2. Stop Metoprolol
3. Stop Aspirin
4. Stop Ferrous sulfate
5. Pantoprazole now 40 mg every 12 hours
3. Take all other medications as prevoiusly prescribed
If you experience increased bleeding per rectum please contact
your PCP or go to the Emergency Room or call 911. Additionally,
if you get a Temperature > 102, light headedness, chest pain,
severe headache, decreased urine output, fainting or any other
syptom that concerns you please call you PCP or visit an
emergency room.
Followup Instructions:
PCP [**Last Name (NamePattern4) **]:
MD: Mr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**]
Specialty: PCP
Date and time: [**Last Name (LF) 2974**], [**9-8**] at 9:20AM
Location: [**Hospital 16710**] HEALTH CARE, INC., [**Street Address(2) 16711**], [**Location (un) **],[**Numeric Identifier 6809**]
Phone number: [**Telephone/Fax (1) 1792**]
Capsule Endoscopy:
Provider: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2180-9-6**] 11:30
Gastroenterology [**Name8 (MD) **]
MD: [**Doctor First Name 4370**] [**Doctor Last Name **]
Date/Time: [**2180-9-19**] 2:00pm
Location: [**Hospital1 18**] [**Hospital Ward Name **], RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX), [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 2724, 5859, 412, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4899
} | Medical Text: Admission Date: [**2117-7-12**] Discharge Date: [**2117-7-22**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Intracerebral hemorrhage
Major Surgical or Invasive Procedure:
PERCUTANEOUS PLACEMENT JEJUNOGASTROSTOMY TUBE
CT HEAD W/O CONTRAST
Neurophysiology EEG
CTA HEAD W&W/O C & RECO
History of Present Illness:
Pt is a 83 yo RHF with h/o pacemaker, AF, multiple valve
replacements, COPD, and anemia who is transferred with a large
ICH.
She was reportedly in her USOH this morning and then was noted
around 11:30 am to be confused and not herself. She was still
able to walk with her walker though. She went to an OSH and CT
showed 4x4.3 cm ICH in the right parietal lobe without
ventricular spread. She is on coumadin and her INR was 3. She
was given FFP (either 2 or 4 units, records are unclear),
vitamin
K, and then transferred here. INR here was 1.8. Head CT here
showed a fairly stable hemorrhage, shift of 2mm(up from 1mm
earlier) with increased effacement of right lateral ventricle,
and no herniation. She was given Profilnine and started on
Nipride for her BP. She was loaded with dilantin.
Her family felt she was more tired and groggy than at the OSH,
but otherwise unchanged. She was switched to labetalol for BP
control and admitted to the ICU. Neurosurgery saw her as well.
ROS: Patient denies HA, but is unable to go through full ROS
Past Medical History:
s/p L craniectomy for traumatic SDH 30 yrs ago
s/p pacemaker placement
s/p porcine aortic valve replacement
s/p porcine mitral valve replacement
atrial fibrillation
COPD
h/o thyroid nodules
iron deficiency anemia
B12 deficiency
hyperlipidemia
osteoporosis
Social History:
Lives with her daughter. Several other family members in the
area. Walks with a walker.
Family History:
Unknown
Physical Exam:
Vitals:T:97.2 BP:192/83-->140s/70s HR: 101 R 16 O2Sats 93
on 4L
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
Neurologic examination:
Mental status: Awake and alert, moderately cooperative with
exam.
Orientation: Oriented to person, and [**Hospital 1474**] Hospital.
Attention: Somewhat inattentive.
Language: Fluent with good comprehension and repetition. Naming
moderately intact. No dysarthria or paraphasic errors
No apraxia
Dense left sided neglect
[**Location (un) **] intact to the right [**2-9**] of sentences.
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. She a left hemianopsia vs hemineglect. Fundi
normal bilaterally.
III, IV, VI: She has right eye deviation and will not look to
even midline. She does have some up and downgaze.
V, VII: Facial sensation intact and symmetric. Face symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor
Full strength on right UE and LE. She has Left sided paresis vs
neglect(slight withdraw of LE to nox and minimal withdrawal of
UE
to nox).
Sensation: Intact to light touch, pinprick throughout all
extremities.
Reflexes: B T Br Pa Ankle
Right 2 2 2 1 0
Left 2 2 2 1 0
Toes were downgoing on right, up left.
Coordination: Normal on finger-nose-finger on right.
Gait: Unable
Pertinent Results:
[**2117-7-12**] 06:40PM BLOOD WBC-8.9 RBC-3.96*# Hgb-13.2# Hct-38.4#
MCV-97 MCH-33.4* MCHC-34.5 RDW-14.9 Plt Ct-175
[**2117-7-12**] 06:40PM BLOOD Neuts-68.9 Lymphs-20.6 Monos-6.4 Eos-3.9
Baso-0.1
[**2117-7-12**] 06:40PM BLOOD PT-18.9* PTT-29.4 INR(PT)-1.8*
[**2117-7-12**] 06:40PM BLOOD Glucose-180* UreaN-25* Creat-0.8 Na-138
K-3.8 Cl-100 HCO3-31 AnGap-11
[**2117-7-12**] 06:40PM BLOOD CK(CPK)-66
[**2117-7-14**] 03:40AM BLOOD CK(CPK)-49
[**2117-7-12**] 06:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2117-7-14**] 03:40AM BLOOD CK-MB-4 cTropnT-<0.01
[**2117-7-13**] 03:23AM BLOOD Phos-2.9 Mg-2.4
[**2117-7-14**] 03:40AM BLOOD Albumin-3.6 Calcium-7.3* Phos-1.3*#
Mg-2.4
[**2117-7-13**] 03:23AM BLOOD Phenyto-9.4*
[**2117-7-13**] 03:28AM BLOOD Type-ART pO2-128* pCO2-51* pH-7.39
calTCO2-32* Base XS-5
138 100 25 180
------------<
3.8 31 0.8
CK: 66 MB: Notdone Trop-T: <0.01
8.9\13.2/175
/38.4\
N:68.9 L:20.6 M:6.4 E:3.9 Bas:0.1
PT: 18.9 PTT: 29.4 INR: 1.8
CTA:4.3 x 4.6 cm intraparenchymal right parietal bleed, with
effacement of the right ventricle (increased from outside
study),
minimal midline shift (2 mm).
No obvious AVM or mass, though large bleed limits evaluation of
underlying structural and vascular abnormalities.
Brief Hospital Course:
Patient is a 83RHW with h/o pacemaker, AF, multiple valve
replacements with porcine aortic and mitral valves, on coumadin,
COPD, and anemia with a large right parietal bleed. Exam is
significant for inattention, left neglect and left sided
weakness arm>leg.
.
1. Neuro: Patient was admited to neuro ICU [**7-12**] -> transferred
to stepdown [**7-13**]. Q2h neuro checks. Kept head of bed >30
degrees. Repeat head CT in am [**7-13**] showed area of hemorrhage was
stable. Neurosurgery was following and no surgical intervention
was indicated. Dilantin was continued for 1 week as seizure
prophylaxis. EEG [**7-14**] was negative for epileptiform features.
She was started on Provigil to improve her alertness with good
effect. Patient will need a follow up CT with contrast after
she recovers from this admission. Mechanism of bleed was likely
secondary to amyloid angiopathy.
.
2. Cards: Kept systolic BP<150 with metoprolol 5 IV Q6 + hydral
PRN. Continued Lasix with strict I/Os keeping fluid status
-500cc over 24 hours. Ruled out for MI. Atrial fibrillation
was well rate controlled on metoprolol.
.
3. Heme: Patient received additional FFP to keep INR<1.3 and
Vitamin K 10 mg daily x3 days. Patient was resumed on aspirin
81 after 1 week as stroke prophylaxis in setting atrial
fibrillation given risk of bleeding on warfarin.
.
4. Pulm: Continued Advair and Nebs PRN. Received additional
Lasix 20mg IV as needed to keep fluid status negative for mild
CHF.
.
5. Endo: Covered insulin sliding scale. TSH and T4 were
normal.
.
6. FEN: Kept NPO and placed GJ tube due to failing swallow
evaluation.
.
7. GU: Continued Ditropan
.
8. PPX: RISS. PPI. Tylenol prn. Pneumoboots
.
9. CODE: Full code per discussion with her daughters tonight
.
10. Other: History of Etoh nightly so on CIWA, thiamine, MVI,
folate replacement
Medications on Admission:
coumadin
lasix 80 daily
calcium 1g [**Hospital1 **]
ditropan 5 daily
magnesium oxide 250 daily
verapamil 360 daily
potassium 30 daily
iron 325 daily
colace
vitamin B12
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: PER SLIDING
SCALE UNITS Injection ASDIR (AS DIRECTED).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 325-650 mg PO Q4-6H
(every 4 to 6 hours) as needed: Not to exceed 4g/day of APAP.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Last Name (STitle) **]: Ten
(10) ML PO BID (2 times a day).
9. Magnesium Oxide 140 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO DAILY
(Daily).
10. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Cyanocobalamin 100 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY
(Daily).
13. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for groin rash.
14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO BID (2 times a day): Dc on [**7-22**].
15. Furosemide 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
16. Modafinil 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QD ().
17. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100 or HR<55.
18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Year (2) **]: One (1)
Neb Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
19. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) Neb
Inhalation Q6H (every 6 hours).
20. Strict I/Os daily
Goal negative 500cc daily. Give additional Lasix 20mg IV x1 PRN
to achieve fluid goal.
21. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Right parietal hemorrhage
Amyloid angiopathy
Secondary diagnosis:
Atrial fibrillation
History of left subdural hemorrahge status post craniotomy
Status post pacemaker placement
Status porcine aortic and mitral valve replacement
Chronic obstructive pulmonary disease
History of thyroid nodules
Iron deficiency anemia
B12 deficiency
Hyperlipidemia
Osteoporosis
Discharge Condition:
Vocalizes with moderate dysarthria. Inattentive. Exam is
significant for left neglect and left sided weakness arm>leg
Discharge Instructions:
You have bled into your head. You will need to follow-up with a
stroke neurologist.
Please take medications as prescribed and keep your follow-up
appointments.
Do not take aspirin or motrin.
If you have any worsening headaches, weakness, numbness/tingling
or any other worrying symptoms, please call your primary care
physician or return to the emergency department.
Followup Instructions:
PCP: [**Name10 (NameIs) 29557**] [**Last Name (NamePattern4) 29558**], MD Phone: [**Telephone/Fax (1) 3183**] Date/Time: [**2117-7-30**]
11:15am
Stroke neurologist: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2117-8-18**] 3:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2117-7-22**]
ICD9 Codes: 496, 5990, 2724 |
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