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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4900
} | Medical Text: Admission Date: [**2115-1-14**] Discharge Date:[**2115-1-29**]
Date of Birth: [**2115-1-14**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 21991**] was the 2.995 kg product of a 37
week gestation born to a 24-year-old G2, P1, now 2 woman.
Prenatal screens - AB positive, antibody negative, rubella
immune, RPR nonreactive, hepatitis surface antigen negative,
GBS negative.
Prior OB history notable for prior preterm delivery at 32
weeks. The child is now 3 years old, alive and well. This
pregnancy uncomplicated with spontaneous onset of labor. No
interpartum maternal fever or other sepsis risk factors. The
infant born by spontaneous vaginal delivery. Nuchal cord
noted at delivery. Apgars were 7, and 9.
The infant delivered by cesarean section, routine neonatal
resuscitation with Apgars of 7 and 8.
PHYSICAL EXAMINATION: Nondysmorphic female in room air.
Warm, dry skin. Color pink. Bruise on right arm. Anterior
fontanel open level. Sutures apposed. Palate intact. Positive
red reflex bilaterally. Ears normal. Occipital caput. CHEST:
Breath sounds equal. Fair aeration. Intermittent audible
grunting. CARDIOVASCULAR: Soft systolic murmur left sternal
border. Normal S1, S2. Femoral pulses 2+. ABDOMEN: Soft,
full, no masses. Positive bowel sounds. Cord unclamped. GU:
Normal female. Spine straight. Normal sacrum. EXTREMITIES:
Moving all limbs. Hips stable. Clavicles intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The
infant was admitted to the newborn intensive care unit for
monitoring of transitional grunting, flaring and retracting.
Chest x-ray was obtained and was consistent with transitional
tachypnea of the newborn. The infant was placed on nasal
cannula. She remained on nasal cannula until [**2115-1-27**]. She
initially required nasal cannula continuous but gradually
progress to only with feeds and then not at all. At the time of
discharge, she was comfortable in room.
CARDIOVASCULAR: She has been cardiovascularly stable. She was
noted to have a heart murmur the day before discharge. She was
evaluated with a normal EKG, 4 extremity blood pressures, and pre
and post ductal saturations. The murmur was consistent with PPS
and could be followed by the primary care pediatrician.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 2.995
kg. She has been ad lib feeding Similac 20 calorie, taking in
adequate amounts. Her discharge weight is 3135 grams. Discharge
head circumference is 33 cm. Discharge length is 48 cm.
GASTROINTESTINAL: Peak bilirubin was 9.3/0.3. The infant has
not required any interventions.
HEMATOLOGY: Hematocrit on admission was 42.4. The infant has
not required any blood transfusions.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign with a white count of 19.1,
platelets 289, 75 poly's, 0 bands. The infant received 48
hours of ampicillin and gentamycin which were discontinued
after 48 hours with a negative blood culture.
NEUROLOGIC: The infant has been appropriate for gestational
age.
SENSORY: Hearing screen was performed with automated auditory
brain stem responses and the infant passed both ears.
PSYCHOSOCIAL: The family has been invested and involved.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 5602**]. Telephone No.:
[**Telephone/Fax (1) 71954**] fax [**Telephone/Fax (1) 71955**].
CARE RECOMMENDATIONS:
1. Feedings: Continue ad lib feeding Similac 20 calorie.
2. Medications: None.
3. Car seat position screening was performed for 90 minute
screening. The infant passed.
4. State newborn screen was sent on [**1-17**] and 27, [**2114**]
that has been within normal limits.
5. Immunizations received: The infant received Hepatitis B
vaccine on [**2115-1-18**].
DISCHARGE DIAGNOSIS:
1. 37 week gestational infant with transitional respiratory
distress.
2. Rule out sepsis with antibiotics.
3. Heart murmur c/w PPS.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) **]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2115-1-21**] 23:51:05
T: [**2115-1-22**] 01:35:23
Job#: [**Job Number 71956**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4901
} | Medical Text: Admission Date: [**2157-12-22**] Discharge Date: [**2158-1-1**]
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Resp distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
81 yo M with COPD, HTN, end stage dementia with alzheimers
(averbal baseline) who presented from [**Hospital3 **] with
respiratory distress and intubated in ambulance on way here. He
has had a recent hospitalization at [**Hospital1 336**] for ?L. wrist fx and
per [**Hospital3 **] rn was started on baclofen yesterday for
contractures. He was noted after starting baclofen to retain
food in his mouth more and then he began to have temps 101-103
on the day prior to admission. He then desated to 80's at
[**Hospital3 **] and with increased RR's was intubated on way to
[**Hospital1 18**].
-
Pt also had a picc line placed on the day prior to admission for
trying to begin clindamycin for unknown source of fever.
Past Medical History:
HTN
BPH
COPD
Dementia
PUD
GI bleed in [**2146**]
Social History:
Pt nonverbal
Family History:
Pt nonverbal
Physical Exam:
On Xfer from MICU:
97.8 158/82 88 25 99% shovel mask @ FIO2 .4
Gen: Lying in bed with obvious contractures, mouth gaping open,
breathing his own secretions in and out, unresponsive to verbal
or tactile stimuli
HEENT: Right surgical pupil, left reactive, mouth with dry
crusted blood and mucus, JVD flat
Chest: Coarse, loud, ronchorous breath sounds diffusely
CV: Faint heart sounds above respiratory noise; regular on pulse
examination
Abd: Diffuse guarding, nd, decreased BS
Ext: Warm X 4, obvious contractures
Neuro: Unresponsive to verbal or tactile stimuli
Pertinent Results:
INDICATION: 81 year old with respiratory failure, post
intubation.
PORTABLE SUPINE FRONTAL RADIOGRAPH. No prior studies.
FINDINGS:
The cardiac and mediastinal contours are normal. The lungs
appear grossly
clear. There is no evidence of CHF. No pneumothorax is
identified. An
endotracheal tube is seen with its tip in the mid trachea at the
level of the
clavicles.
IMPRESSION:
No focal pneumonic consolidation or evidence of CHF. No
pneumothorax. ET
tube with its tip in the mid trachea.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: [**First Name8 (NamePattern2) **] [**2157-12-22**] 10:18 AM
Procedure Date:[**2157-12-22**]
-
-
INDICATION: 81 year old with respiratory distress with
anisocoria.
TECHNIQUE: CT brain without IV contrast. No prior studies for
comparison.
FINDINGS:
Extensive hypodensity is seen in the periventricular and
subcortical white
matter consistent with chronic small vessels infarctions. There
is no acute
intracranial hemorrhage. [**Doctor Last Name **]-white matter differentiation
appears preserved.
The ventricles and sulci are prominent, though the ventricles
including
lateral, third, fourth, and temporal horns appear somewhat more
prominent than
the degree of sulcal prominence. No prior studies are available
for
comparison. Incidental note is made of a cavum septum
pellucidum. Dense
arterial calcifications are seen in the vertebral and internal
carotid
arteries. Calcifications are also seen in both right and left
basal ganglia.
The osseous structures and soft tissues are unremarkable. A
fluid level is
seen within the sphenoid sinus. The patient has been intubated.
The
remaining paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
Extensive hypodensity consistent with small vessel ischemic
changes and
chronic infarction. No acute intracranial hemorrhage. Marked
prominence of
the ventricles may be related to age related atrophy, but no
comparison is
available. An element of communicating hydrocephalus is not
excluded.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**]
Approved: [**First Name8 (NamePattern2) **] [**2157-12-22**] 9:43 AM
Procedure Date:[**2157-12-22**]
-
-
CLINICAL HISTORY: An 81-year-old male with aspiration pneumonia
status post
central line placement.
TECHNIQUE: Portable AP chest.
COMPARISON: Examination performed 12 hours prior.
FINDINGS:
Endotracheal tube remains in stable, satisfactory position.
There has been
interval placement of a right subclavian central venous
catheter, which
terminates within the distal SVC. There is no definite
associated
pneumothorax. Cardiac and mediastinal contours are stable and
within normal
limits. Lung fields appear grossly clear. Osseous structures are
unremarkable.
IMPRESSION:
Satisfactory positioning of subclavian central venous catheter
without
evidence of pneumothorax.
-
-
INDICATION: An 81-year-old male with aspiration pneumonia,
status post right
subclavian line placement. Verify placement of nasogastric tube.
COMPARISON: Made with a prior AP supine portable chest x-ray,
dated [**2157-12-22**]
at 1711.
FINDINGS:
AP supine portable chest x-ray: A nasogastric tube is seen
extending below
the diaphragm in the fundus of the stomach. An endotracheal tube
seen in
place approximately 4 cm superior to the carina. A right
subclavian central
venous catheter terminates in unchanged position in the middle
superior vena
cava. There is no evidence of pneumothorax on the supine chest
x-ray. Cardiac
and mediastinal contours are stable and within normal limits.
Lung fields
appear grossly clear bilaterally. The osseous structures are
unremarkable.
IMPRESSION:
Placement of the nasogastric tube tip in the fundus of the
stomach.
Endotracheal tube, and right subclavian central venous catheter
in unchanged
position.
-
-
CLINICAL INDICATION: Respiratory failure.
Endotracheal tube, central venous catheter and nasogastric tube
remain in
place. Cardiac and mediastinal contours are stable. The right
lung is clear
except for minimal discoid atelectasis at the left lung base.
Within the left
lung, there is minimal hazy opacity in the left infrahilar
region. This
appears not significantly changed.
IMPRESSION:
Stable radiographic appearance of the chest.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SAT [**2157-12-24**] 9:37 AM
Procedure Date:[**2157-12-24**]
-
-
INDICATION: An 81-year-old with this respiratory failure,
increased white
blood cell.
TECHNIQUE: Portable AP chest radiograph.
Comparison is made with a prior chest radiograph dated
[**2157-12-24**].
FINDINGS:
The right IJ line is terminating at the junction of SVC and
right atrium. No
pneumothorax. Left costophrenic angle is not included in the
present study.
Thoracic aorta is tortuous. Note is made of opacity in the right
lower lobe,
probably representing pneumonia. However, please evaluate by
repeated PA and
lateral chest x-ray with better view. No CHF is noted.
IMPRESSION:
Patchy opacity in the right lower lobe, probably representing
pneumonia. Left
costophrenic angle is not included. Please further evaluate
repeated PA and
lateral chest x-ray with better quality.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**]
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: WED [**2157-12-28**] 5:10 PM
Procedure Date:[**2157-12-28**]
-
-
INDICATION: An 81-year-old man with respiratory failure, status
post
extubation, now with increased white blood cell and neutrophil
count.
Comparison is made with a prior AP portable chest x-ray dated
[**2157-12-28**], at 8:20.
AP UPRIGHT PORTABLE CHEST X-RAY: A right subclavian central
venous catheter
is seen with the tip terminating in the distal superior vena
cava. The
cardiac, mediastinal, and hilar silhouettes remain stable. A
tortuous aorta
is seen with mural calcifications. The appearance of bilateral
pulmonary
vessels appears normal. The left lung is grossly clear. Within
the right
lung, there is interval worsening opacification of the right
cardiac border.
Surrounding soft tissue and osseous structures are unremarkable.
IMPRESSION:
1) Findings consistent with right middle lobe pneumonia.
2) Right subclavian central venous catheter with the tip in good
position in
the distal superior vena cava/right atrium.
3) No evidence of pneumothorax.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
-
-
Brief Hospital Course:
In the ED, he was given one dose of ceftriaxone prior to
discovery of cephalosporin [**Last Name (un) **]. Hw as also given flagyl,
tylenol, propofol/versed gtt. His PE at the time was notable for
multiple ulcers everywhere, cachexia, contractures, and
anisocoria (R. pupil >L pupil size).
-
He was admitted to the ICU febrile to 103.8 on [**12-22**] and was
treated with levo/flagyl, PO prednisone, alb/iprat. Head CT was
obtained for anisocoria which demonstrated small vessel ischemic
changes and
chronic infarction but no acute changes. He was emaciated and
appeared dehydrated; his labs reflected hypernatremia to 151 and
his BUN/Creat was 62/1.4.
-
On the day following admission, the patient was seen by
dermatology who felt that his bullous pemphigoid was not active
and recommended tpaer when HD stable. The patient was given IVF
transfused 2U PRBC. On the third hospital day, vanco was added
for broader coverage and to cover UTI in pen allergic patient.
Captopril was added for SBP in 180s. AC was changed to PS and
the patient was then extubated. His ARF had resolved w/fluid
resucitation and was thus felt to be [**1-4**] pre-renal. His
hypernatremai also resolved and it was thus felt that it's
original etiology was failure of PO intake in response to
hypovolemic hypernatremia. Hydralazine was added for improved
BP control. Haldol was used as needed for agitation.
-
Given HD stability and lack of improved rehabilitation potential
from MICU level of care, the patient was called out to the floor
on the fourth hospital day.
-
His respiratory failure was felt likley secondary to aspiration
event. He failed S&S eval today. His respiratory status did
not change during the course of his floor stay.
-
His BPs remained high and his enalaprilate and hydralazine were
titrated up.
-
His Staph aureus UTI was resistant to Levo/ PCN. [**Last Name (un) 36**] ox/ gent
and given PCN allergy, was treated w/vancomycin.
-
The patients crit remained stable through his floor course.
-
His steroids were tapered through his time on the floor and will
continue to be tapered as OP. We continued aggressive wound
care bandages and pertolatum dressing and mupirocin ointment as
ppx. and recommend the same @ ECF.
-
The patient's anisocoria did not change and his head CT was
negative for acute changes.
-
The patient's hypernatremia was felt likely secondary to
dehydration and resolved w/IVF which were maintained on the
floor.
-
The patient's ARF resolved w/IVF and was thus likely due to
pre-renal state.
-
The patient was averbal w/ end stage dementia/alzheimers @
baseline and remained so.
-
Discussion was had w/family regarding PEG. Given lack of clear
morbidity or mortality benefit, family elected to not place PEG
and pursue comfort measures and discuss Hospice care
possibilities at facility.
-
On xfer from unit, pt was cpr not indicated but full code.
Attending re-adressed w/family and pt became DNR/DNI.
-
Comm was made when possible with daughter: [**Name (NI) **] [**Name (NI) 59408**]
[**Telephone/Fax (1) 59409**], [**Hospital3 **] RN [**Telephone/Fax (1) 7233**]
-
Pt was discharged to ECF.
Medications on Admission:
Combivent
Colace
Lopressor
Albuterol
Prednisone
Heparin
Ultram
Cipro
Protonix
MVI
Dulc
Zestril
Cardura
Discharge Medications:
1. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
[**Hospital1 **] (2 times a day) as needed for agitation.
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Methylprednisolone Sodium Succ 2,000 mg Recon Soln Sig: One
(1) dose of 20mg Injection once a day for 4 days: To be followed
by four days of 10mg per day as separately written.
6. Methylprednisolone Sodium Succ 2,000 mg Recon Soln Sig: One
(1) dose of 10mg Injection once a day for 4 days: Following four
days of 20mg.
7. Hydralazine HCl 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
8. Enalaprilat 1.25 mg/mL Injectable Sig: One (1) Intravenous
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration pneumonitis, UTI
Discharge Condition:
DNR/DNI
Discharge Instructions:
Please administer all medications as directed.
Followup Instructions:
In case of difficulties, call your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 59410**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5070, 5849, 2760, 5990, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4902
} | Medical Text: Admission Date: [**2131-11-12**] Discharge Date: [**2131-11-30**]
Date of Birth: [**2062-6-28**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Aspirin / Compazine / spironolactone
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
Right total knee arthroplasty
initiation of hemodialysis
placement of tunneled hemodialysis catheter
History of Present Illness:
From orthopedics:
Mr. [**Known lastname **] returns. Her orthopedic history is well
documented. The shots that I give her improve her symptoms
significantly, so that she can walk around without pain.
Unfortunately, the pain returns. It is the pain in her right
knee that is keeping her from ambulating as pain in the right
knee that is keeping her from doing all her activities of daily
living and it is the pain that keeps her intermittently in a
wheelchair. She also has chronic lower back issues, which hurt
as well.
[**Hospital Unit Name 92800**]:
69 yo F with CKD stage 4, CAD with CABG, morbid obesity, who was
admitted for right TKR, s/p TKR on [**2131-11-12**], transferred to
the [**Year (4 digits) **] floor given [**Last Name (un) **] on CKD and volume overload.
Per report, patient had a right TKR on [**2131-11-12**]. Per
orthopedics, patient would need to be on Lovenox for DVT/PE
prophylaxis in the setting of recent TKR. They were concerned
about patient's cardiac function and underlying CAD.
Med Consult was consulted POD2 given hypoxia, decreased uop, and
acute on chronic renal disease. Patient was noted to require 3L
of O2 from a baseline of only intermittent 1-2 L NC. Patient
was feeling very fatigued. Patient was noted to be 6.7 L net
positive on [**2131-11-14**]. She was ultimately transferred to the
[**Year (4 digits) **] Hospitalist Service for further management. It was
thought that patient was volume overloaded. Nephrology was
consulted on [**2131-11-15**] for acute on chronic kidney disease and
thought that patient should continue with diuresis.
MICU consult was called on [**2131-11-16**] given altered mental
status. Patient was noted to be lethargic on [**2131-11-15**] in the
setting of getting diuresis, pain medications, and home
gabapentin. Her pain medications were stopped. She was found
to be sobbing in the morning of [**2131-11-15**] from pain at the
surgical site. Patient was given 2.5 mg po oxycodone and 160 mg
IV lasix and metolazone. She was then found to be somnolent and
difficult to arouse from the sternal rub. When evaluated
patient's vitals were 97.8, 107/50, 69, 20, 96% on 2L NC
(although the oxygen was not turned on upon my entering to the
room).
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG ([**2129-7-27**]): LIMA-LAD, SVG-OM1, SVG-OM2 c/b non-healing
sternal incision wound
- MI in [**2128**] and [**2129**]
- Diastolic heart failure (EF >55%)
- PERCUTANEOUS CORONARY INTERVENTIONS: None in [**Hospital1 18**] records
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Cerebrovascular accident with L residual hemiparesis ([**10-30**])
-T2DM on insulin (last A1c=6.4%)
-Chronic kidney disease with microalbuminuria (stage III)
-Hyperlipidemia
-Hypertension
-Asthma - intubated "many years ago." Per patient last
exacerbation requiring hospitalization was 2-3 years ago.
-Morbid obesity
-UGIB [**7-31**] suspected d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
Social History:
The patient lives in [**Hospital3 4634**] and is very
limited in terms of her physical mobility. Has severe right knee
pain, is winded & tires very easily. No ETOH, smoking or
illicit
drug use. Has children, originally from Barbados, has home
services.
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: Diabetes, unsure of cause of death, no reported CAD
- Father: Died in 30s from trauma after falling off a horse
Physical Exam:
Orthopedics Admission exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples, no erythema
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* 5/5 strength
* SILT, NVI distally
* Toes warm
[**Hospital Unit Name 153**] admission exam:
Vitals: 98.3, 66, 127/55, 18, 99% 2L.
General: Alert, oriented x 2 (knows in [**Hospital1 18**], knows president
[**Last Name (un) 2753**], but thought it is [**2124**] [**Month (only) 404**]), sobbing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP difficult to assess due to body habitus but EJ
is prominent, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diminished breath sounds in the basis, difficult exam due
to pain and inspiratory effort, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: + Foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis,
trace edema
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
limited exam in the RLE given pain, grossly normal sensation,
gait deferred
Discharge Exam:
General: alert, oriented x3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: RRR, 3/6 systolic murmur LUSB; pt with R tunneled HD
catheter C/D/I
Lungs: diminished breath sounds at bases, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis,
trace ankle edema. Right knee with staples in place, no
erythema, or warmth
Neuro: CNII-XII intact, gait deferred, moving all extremities
Pertinent Results:
Admission labs:
[**2131-11-12**] 05:37PM BLOOD WBC-6.9 RBC-3.06* Hgb-9.8* Hct-29.2*
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.9 Plt Ct-254
[**2131-11-12**] 05:37PM BLOOD Glucose-119* UreaN-72* Creat-2.4* Na-140
K-4.3 Cl-106 HCO3-22 AnGap-16
[**2131-11-16**] 07:55AM BLOOD ALT-5 AST-33 AlkPhos-100 TotBili-0.2
[**2131-11-12**] 05:37PM BLOOD Calcium-8.9 Phos-4.3 Mg-1.7
[**2131-11-17**] 04:04AM BLOOD CRP-200.3*
[**2131-11-16**] 01:40PM BLOOD Type-ART pO2-78* pCO2-35 pH-7.37
calTCO2-21 Base XS--3
[**2131-11-16**] 01:40PM BLOOD Lactate-0.6
Discharge labs:
[**2131-11-30**] 05:41AM BLOOD WBC-10.1 RBC-2.59* Hgb-8.0* Hct-25.4*
MCV-98 MCH-30.8 MCHC-31.5 RDW-16.8* Plt Ct-135*
[**2131-11-30**] 05:41AM BLOOD Glucose-101* UreaN-34* Creat-3.1* Na-138
K-4.1 Cl-101 HCO3-25 AnGap-16
[**2131-11-30**] 05:41AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1
RELEVANT LABS:
[**2131-11-22**] 03:18AM BLOOD calTIBC-241* Ferritn-454* TRF-185*
[**2131-11-27**] 05:13AM BLOOD PTH-383*
[**2131-11-20**] 02:19AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2131-11-27**] 05:13AM BLOOD 25VitD-LESS THAN
Micro:
[**2131-11-16**] 10:30 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2131-11-22**]**
Blood Culture, Routine (Final [**2131-11-22**]): NO GROWTH.
[**2131-11-16**] 5:27 pm URINE Source: Catheter.
**FINAL REPORT [**2131-11-17**]**
URINE CULTURE (Final [**2131-11-17**]): NO GROWTH.
[**2131-11-23**]
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 8 I
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
[**2131-11-26**] 1:54 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2131-11-27**]**
C. difficile DNA amplification assay (Final [**2131-11-27**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Imaging:
[**11-12**] R KNEE TISSUE PATH:
Bone, right knee, right total knee replacement (A-B):
Trabecular bone and overlying articular cartilage with
degenerative changes. Dense fibroadipose tissue with focal
chronic inflammation, fat necrosis, and dystrophic
calcification.
[**11-12**] R KNEE XR
1. Status post right knee total arthroplasty. Surgical
hardware intact with no evidence for hardware failure.
2. Expected post-operative changes.
[**11-13**] CXR
Bilateral hazy opacifications likely represent a component of
pulmonary edema. Heart size is unchanged since prior study. No
large pleural effusion or pneumothorax.
[**11-15**] ECHO
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (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
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Elevated LVEDP and mild pulmonary hypertension.
[**11-15**] RENAL US
No evidence for urinary obstruction.
[**11-16**] CXR
In comparison with study of [**11-13**], there is continued
enlargement
of the cardiac silhouette with pulmonary vascular congestion.
In the
appropriate clinical setting, supervening pneumonia would be
difficult to
exclude.
[**11-17**] B/L LE Venous
Extremely limited examination in the postoperative setting due
to
patient body habitus and discomfort. Diminished respiratory
variation on the left greater than the right may be related to
body habitus; however, upstream venous occlusion cannot be
entirely excluded.
[**11-19**] CXR
As compared to the previous radiograph, the patient shows
unchanged
alignment of sternal wires. A right PICC line is in correct
position.
Moderate cardiomegaly with signs of mild-to-moderate pulmonary
edema, but
without evidence of pleural effusions or pneumonia. Mild
tortuosity of the thoracic aorta.
Venous mapping [**2131-11-23**]:
FINDINGS: Some asymmetric decreased phasicity in the right
subclavian vein is noted, which could imply some impaired flow
centrally however this may simply be secondary to the right
internal jugular large-caliber dialysis catheter currently in
place.
RIGHT SIDE: The right cephalic vein caliber ranges from 1.5 mm
proximally to 0.8 mm distally. At the antecubital fossa, it is
not well seen secondary to an intravenous catheter. The right
basilic vein caliber ranges from 2.7 mm proximally to 1.9 mm
distally. The right brachial artery appears duplicated.
The smaller caliber vessel measures 1.9 mm and large caliber
vessel measures 2.9 mm and has some calcification which appears
mild. The right radial artery measures 1.1 mm in caliber and
has mural calcification.
LEFT SIDE: The left cephalic vein in the upper arm has a caliber
ranging from 1.7 mm to 1.9 mm. In the antecubital fossa, it
measures 2.8 mm. In the forearm, the caliber ranges from 1.5 mm
proximally to 1.2 mm distally. The caliber of the left basilic
vein ranges from 1.7 mm proximally to 1.5 mm distally. The left
brachial artery appears duplicated with a smaller vessel
measuring 2.5 mm in caliber and the larger vessel measuring 3.5
mm in caliber.
The left radial artery measures 1.9 mm in caliber. No
significant
calcification of left-sided arteries.
CONCLUSION:
Bilateral vein mapping as above with patent cephalic and basilic
veins as
described. Asymmetric decreased phasicity in the right
subclavian vein may in part relate to an indwelling right
internal jugular vein large bore IV catheter.
Right Tunneled line placement [**2131-11-27**]:
CONCLUSION: Uncomplicated placement of a tunneled hemodialysis
catheter, 23 cm tip-to-cuff, with tip in the right atrium.
Brief Hospital Course:
Brief Course:
69 yo F diastolic heart failure with pulmonary hypertension, CAD
with CABG, morbid obesity, CKD, who was admitted for TKR, s/p
TKR on [**2131-11-12**], transferred to the [**Year (4 digits) **] floor given [**Last Name (un) **]
on CKD and volume overload, then transferred to [**Hospital Unit Name 153**] for altered
mental status. She underwent dialysis and mental status improved
and transferred to the floors. A tunneled line was placed and
transplant surgery was consulted for possible AV graft after
discharge. Pt was discharged to rehab.
ACTIVE ISSUES:
# Delirium: Likely multifactorial given recent surgery,
hospitalization, pain medications, and possibly uremia. Pain
medications were adjusted in respect to renal clearance and
oversedation, and pt's somnolence improved. Per PCP, [**Name10 (NameIs) **] was
having trouble with self-care at baseline and it is possible she
has some baseline cognitive deficits. A UA on [**2131-11-23**] was
concerning for a UTI and the patient was started on ceftriaxone.
The urine culture grew pseudomonas aeruginos sensitive to cipro
and pt was switched to complete 7 day course of cipro, last day
on [**2131-12-2**]. On discharge, her MS was improved and she was
oriented to person, place, month and year but had difficulties
with the date, though she could recall the date as [**2131-11-30**] on
the day of discharge.
Pt also with anxiety and concern for mental status throughout
course. Would suggest neurocognitive evaluation on discharge
from rehabilitation.
# Acute on chronic renal failure: Baseline Crt 2.5-2.9. Her Cr
had been trending up since surgery. Obstructive etiologies ruled
out with renal U/S. Nephrology was consulted, who felt that
granular casts, hyaline casts, and tubular epithelial cells seen
on sediment could be the result of fluctuating BPs or mild ATN.
It is thought that perhaps the amount of fluid she received led
to acute exacerbation of dCHF, leading to poor forward flow. She
was initially started on IV lasix for diuresis per renal recs,
and her Cr began to improve. On [**11-18**], the patient's UOP dropped
despite furosemide gtt and 80 torsemide PO. This also proved
refractory to another 80 torsemide and 25 chlorthalidone. A
temporary dialysis catheter was placed on [**11-20**] and she was
started on CVVH for volume overload. Patient was called out of
the [**Hospital Unit Name 153**] and was started on hemodialysis. She was evaluated by
renal transplant and the left arm was preserved. The patient
was continued on HD and a tunneled HD line was placed on [**2131-11-27**]
without complication. Transplant surgery recommended left AV
graft. Her plavix was held on discharge in anticipation of
surgery on Wednesday [**2131-12-5**]. She will continue on HD TuThSat.
She was started on Sevalmer, iron with HD, and high-dose Vitamin
D repletion.
PPD placed in house was negative.
# Acute on chronic diastolic CHF: Pt was grossly fluid
overloaded in the [**Hospital Unit Name 153**]. Echo showed normal EF without wall
motion abnormality. Previous chest imaging showed cardiomegaly.
Likely a diastolic component of CHF. CXR was consistent with
pulmonary vascular congestion as well and pt was initially
hypoxic in the ICU. Pt was diuresed with IV lasix until HD was
started. The patient underwent HD with good effect and improved
respiratory status. She was placed on Metoprolol (held on HD
days given low BP). Pt's weight on discharge was 119.2kg.
# S/p right total knee replacement & persistent knee pain:
Elective surgery on [**11-12**]. Patient continued to have significant
pain despite pain medication. Patient received SQH TID for
prophylaxis. Persistent knee pain was concerning for possible
development of hematoma, hemorrhagic effusion (given also
dropping Hct), or post-op infection (giving rising WBC). A
repeat knee XRay revealed small suprapatellar effusion but no
evidence of acute complication. Her pain was managed with
tylenol TID and morphine prn. LENIs were performed to r/o DVT,
which were inconclusive because they were limited by body
habitus. Pain persisted during her hospital course. Her pain
control improved with standing tylenol and low dose oxycodone
prn. She will follow-up with orthopedics as an outpatient on
[**2131-12-4**].
# Anemia, normocytic: Chronic in nature. Baseline Hct usually
in the 28-30. Most likely has some degree of anemia from
chronic kidney disease which is now worsened by acute on chronic
KD and recent acute blood loss from TKR. Her Hct was monitored
with a transfusion threshold of 21. Her stools (x3) were
hemoccult negative. On [**11-20**], patient received 1u pRBC during
CVVH. She was given an additional unit of blood on [**2131-11-23**]. She
was started on iron with HD.
# Coronary artery disease with CABG surgery in [**2129**] complicated
by nonhealing sternal incision wound, MI in [**2128**] and [**2129**]. Pt
had rise in troponin during ICU stay, most likely due to renal
failure and decreased clearance. Plavix was held pre-IR guided
tunneled line, and continued to hold on discharge in
anticipation of AV graft procedure as discussed above. She was
continued on metoprolol, rosuvastatin, and isosorbide. Her
Plavix should be restarted after the AVG placed on [**2131-12-5**].
# Thrombocytopenia: Mild drop to 130s, low concern for HIT given
not consistent with time course, and no evidence of thrombosis.
4T score calculated at 2. Her platelets remained stable and were
135 on discharge with no signs or symptoms of bleednig.
# Hypertension: BP well-controlled in house. She had mild drop
in BP with dialysis after UF. She also had brief period of
hypertension [**2-22**] anxiety associated with procedure. Her BP on
discharge was in systolic 120s.
INACTIVE ISSUES:
# CVA in [**2128**].
# Insulin-dependent diabetes: Difficult to dose insulin
appropriately given flux in renal function and desire to avoid
hypoglycemic episode in vasculopathic cardiac pt. ISS adjusted
in house.
# Hyperlipidemia: Continued on rosuvastatin.
TRANSITIONAL ISSUES:
# CODE: FULL
# CONTACT: Name of health care proxy: [**Name (NI) 1670**] [**Known lastname **]
Relationship: daugther
Phone number: [**Telephone/Fax (1) 106689**]
Cell phone: [**Telephone/Fax (1) 106688**]
# Follow-up:
- Orthopedics [**2131-12-4**]
- PCP after discharge from rehab
- Transplant surgery - planned AV graft placement on Weds
[**2131-12-5**]
# Medications:
- Restart Plavix after AVG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol 100 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
hold for SBP < 110
3. Carvedilol 6.25 mg PO BID
hold for SBP < 110
4. Clopidogrel 75 mg PO DAILY
5. Famotidine 20 mg PO Frequency is Unknown
6. Gabapentin 100 mg PO BID
7. HydrALAzine 50 mg PO BID
hold for SBP < 110
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Start: In am
hold for SBP < 110
9. Lidocaine 5% Patch 1 PTCH TD DAILY
Discharge Medications:
1. Allopurinol 100 mg PO EVERY OTHER DAY
2. Gabapentin 100 mg PO BID
HOLD if sedated or confused
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
hold for SBP < 110
4. Lidocaine 5% Patch 1 PTCH TD DAILY
5. Acetaminophen 1000 mg PO Q6H
6. Rosuvastatin Calcium 10 mg PO DAILY
7. Heparin 5000 UNIT SC TID
8. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) Duration: 1 Months
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. OxycoDONE Liquid 2.5 mg PO Q6H:PRN pain
11. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
12. Metoprolol Tartrate 12.5 mg PO BID
HOLD for SBP<100, HR<60
13. Senna 2 TAB PO HS:PRN constipation
14. Docusate Sodium 100 mg PO BID
15. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
16. Ciprofloxacin HCl 250 mg PO Q24H Duration: 2 Days
to be completed on [**2131-12-2**]
17. Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line
flush
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Total knee arthroplasty
Acute on chronic renal failure
Complicated cystitis
Acute on chronic diastolic heart failure
Secondary:
Coronary artery disease
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during this admission. You
were admitted for knee replacement which was done with the
surgeons. The surgery went well, however, you weren't breathing
well and required transfer to the intensive care unit. Your
kidney function was worse and you were started on dialysis. You
were intermittently confused but this improved with dialysis.
The transplant surgeons saw you and recommend a graft in the
future for continued dialysis.
Please see the attached medication list.
Followup Instructions:
Please keep the following appointments:
- TRANSPLANT surgery [**2131-12-5**]. The transplant surgery
coordinator will call the rehabilitation center to give the time
for transport.
***PLEASE ENSURE PT IS NPO FOR PROCEDURE ON [**2131-12-5**].
Department: ORTHOPEDICS
When: TUESDAY [**2131-12-4**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], 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: PODIATRY
When: MONDAY [**2132-1-7**] at 2:15 PM
With: [**Hospital 1947**] CLINIC (SB) [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2131-12-2**]
ICD9 Codes: 5845, 2851, 5990, 4280, 4168, 2767, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4903
} | Medical Text: Admission Date: [**2134-3-14**] Discharge Date:
Date of Birth: [**2069-6-10**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old woman
who has a history of migraine headaches, atrial fibrillation
not on Coumadin, and hypercholesterolemia. She was in her
usual state of health until Friday. She, at that point,
noticed an acute onset of left sided arm and neck pain at
around 1:30 p.m. No history of trauma. It was thought at
this time that this could be cardiac and she was admitted to
[**Hospital3 3583**], where she had an elevated. The date of the
troponin was [**2134-3-11**]. The troponin was 6.78 with a peak CK
of 260 and MB fraction of 37.9. She went to [**Hospital3 3583**],
where she got sublingual nitroglycerin with partial relief of
pain and Morphine, which completely relieved the pain. The
EKG at that point showed subtle inferior changes and she was
pain free. She was then transferred to [**Hospital1 190**] for a cardiac catheterization, which showed
50% mid LAD lesion, distal left circumflex lesion, no
intervention. She was found to be in atrial fibrillation the
day after the catheterization and discharged home with some
headache. She went home and she was found to have headaches
on the way home. Her husband left her around 6:15 a.m. on
[**2134-3-14**] to pick up something from the pharmacy. When he
returned at 6:45 he found her responsive and not moving her
right side. At that point they went to [**Hospital3 3583**],
which saw a dense MCA sign on CT. She was then transferred
to [**Hospital1 69**]. She arrived at [**Hospital1 1444**] intubated, sedated, and
paralyzed. MRI done around 11 p.m. showed striatocapsular on
the left side. She was then taken to angiography, where she
had an angiogram suggestive of left internal carotid artery
dissection and distal occlusion after the ophthalmic artery.
The MCA was occluded, but there was collateralization with
meningeal branches. It was decided not to give TPA since the
distal ICA and MCA were closed. The patient was greater than
six hours and the proximal ICA appeared to be dissected. The
family was in agreement with this and they did not wish to
have an experimental procedure done. At that point, the
examination was limited secondary to intubation, sedation,
and paralysis. Vital signs were stable, however.
She was admitted to the Neurological Intensive Care Unit.
The head of bed was flat and her blood pressure was
controlled between 140 and 160. A head CT was done the next
day to evaluate for hemorrhage since the stroke was large.
Repeat head CT showed evolution of the stroke, but no
hemorrhage. At that point, Heparin was started on the
patient and her sedation was decreased. The patient was in
the Intensive Care Unit, had episodes of bradycardia when in
sinus rhythm. But, the patient remained neurologically
intact, able to move her left side. The patient was
intermittently in atrial fibrillation. Cardiology was
consulted and she was started on an Amiodarone drip and
Esmolol for rate and blood pressure control. She was
extubated on [**2134-3-15**] and she did well following extubation,
maintaining her oxygenation. She was still in intermittent
atrial fibrillation, however, by [**2134-3-16**] she was deemed to
be stable for transfer to the floor. She was able to be
weaned off the Esmolol drip. However, there were no floor
beds at that time.
On [**2134-3-16**] she had a repeat MRI, which showed increase in
diffusion abnormality extending laterally to the inferior
cortex, slightly more edema, and a small amount of
hemorrhagic transformation. However, just by this, the
heparin was continued, not only for the dissection, but also
the atrial fibrillation. By this time, she was sleepy, but
arousable in terms of her physical examination. She was not
speaking, but able to follow commands with difficulty with
her oral buccal movements with decreased blink to threat on
her right side and continued hemiparesis of her right arm and
leg.
On [**2134-3-17**], the patient was noted to have spiked a fever to
101.8. She had blood. Arterial line was changed as was the
line in her neck.
Fever workup was done showing a positive urinalysis with
greater than 50 WBCs and moderate bacteria. She was started
on Levaquin for that. Sensitivities on the blood cultures
came back as coagulase positive, Staphylococcus aureus
sensitive to Oxacillin. She was started on Oxacillin and
defervesced. She had hematoma at the site of her radial A
line. The Department of Plastic Surgery was consulted,
recommending Silvadene cream.
The patient was transferred out of the unit on [**2134-3-18**],
after she appeared stable. She had a NG tube placed prior to
transfer and she was started on tube feeds. In addition, at
the time of transfer it was determined that she was not being
rate controlled by the Amiodarone, nor was she being kept in
sinus rhythm, so that was discontinued. She was continued on
an aspirin for her heart and beta blockers for rate control,
which she did well. She continued to become more alert and
awake. However, repeated studies by Speech and Swallow
Department revealed that she was still unable to take in
enough nutrition by mouth to maintain her nutritional status,
thus, she will be getting a PEG tube placed on [**2134-3-23**].
She has been maintained on Heparin, and she will start on
Coumadin after PEG placement.
DISCHARGE DIAGNOSIS:
1. Left MCA stroke with a left internal carotid dissection.
2. Urinary tract infection.
3. Coagulase positive Staphylococcus bacteremia.
DISCHARGE CONDITION: The patient is to go to rehabilitation.
An addendum will need to be dictated for her medications.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], M.D. [**MD Number(1) 37533**]
Dictated By:[**Last Name (NamePattern1) 8853**]
MEDQUIST36
D: [**2134-3-22**] 16:09
T: [**2134-3-22**] 16:25
JOB#: [**Job Number 37941**]
ICD9 Codes: 7907, 5119, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4904
} | Medical Text: Admission Date: [**2173-3-30**] Discharge Date: [**2173-4-6**]
Date of Birth: [**2091-9-8**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Sulfa (Sulfonamide Antibiotics) / Promethazine
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Dialysis
History of Present Illness:
81 year old woman with ESRD from hypertensive glomerulonephritis
s/p bilateral nephrectomy on dialysis, s/p recent admission for
"multilobar pneumonia", admitted on [**2173-3-25**] after developing
chest pain at rest. Patient was admitted to LGH two weeks prior
to this admission with fevers, AMS, and CXR consistent with
multifocal PNA. At that time she was also have chest pain that
was thought [**1-18**] GI etiology. She had a barium swallow that
showed marked dysmotility of the esophagus with tertiary
contractions but no GERD or strictures. For the PNA she was
started on levoquin and her fevers trended down. She was then
transitioned to rocephin and sent back to [**Location (un) **] House.
She was home for one day and then developed chest pain at rest.
This responded to nitroglycerin at home. She was then taken to
the ED at LGH.
In the ED at LGH she had an EKG that showed ST depressions in
the lateral and anterior leads which was unchanged from prior
EKGs. Her troponin I was 4.15. CK was negative.
She was admitted to LGH for NSTEMI. While admitted she remained
painfree for several days. Cardiology was consulted the next day
and recommended cardiac cath as in retrospect it seemed that the
multifocal PNA may have been acute CHF exacerbation that could
have been related to ischemia. Therefore the patient was started
on heparin gtt, plavix, and aspirin and transferred to the LGH
CCU to await catheterization. She received last dialysis
Saturday [**2173-3-27**](removed 2.6 liters) via left arm fistula.
She remained chest pain free for the next few days. On [**2173-3-30**]
she underwent cath where she was found to have an 85% LAD
stenosis and a 95% lesion in a small RCA. Meds in cath lab
included 0.5mg versed80cc contrast, 50 cc NS. Sheaths were
pulled as there were plans for her to have dialysis and then
transfer to [**Hospital1 18**] tomorrow for PCI. However, following cath, pt
developed 10/10 chest pain that was treated with 6mg morhine,
zofran, ativan, SL nitro, IV nitro at 30mcg/min and was
transferred to [**Hospital1 18**] for PCI (painfree).
.
Vitals on transfer: HR 60SR, BP 150/50, Satting 96% on 2L.
.
Patient underwent second cardiac cath at [**Hospital1 18**] during which she
received 12mg fentanyl, 5mg IV hydralazine, and a nitro gtt for
elevated BP. She had cypher stent placed in LAD distally and
second cypher stent placed in LM into proximal LAD as well.
.
On admission to the CCU patient was somnolent but arousable. She
was unable to answer complicated questions. She was not in pain.
.
As above patient was too somnolent to answer ROS questions.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes(-), Dyslipidemia(+),
Hypertension (+)
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
Cath at LGH [**2173-3-30**]:
LAD ostial 85%
small RCA 90%
LV s/d/e: 162/-[**2-18**]
AO s/d/m: 119/22/51
.
-PACING/ICD: None
- ADmission for acute LV failure in [**2-22**]. Adenosine test
reportedly negative for ischemia at that time with EF 56%.
3. OTHER PAST MEDICAL HISTORY:
- Hypertension
- ESRD on dialysis
- Nephrectomy bilaterally for severe htn
- PAF
- Hx of GIB from diverticuli and hemorrhoids (off
anticoagulation)
- Rheumatoid arthritis
- Multiple joint replacements
- Anxiety/depression requiring ECT
Social History:
Widowed. Was at [**Location (un) **] House rehab center. Patient normally
lives with her daughter [**Name (NI) **] [**Name (NI) **] who is the primary care
giver.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T: 97.1 BP146/39 HR 76 RR 13 O@ 100% 2L
GENERAL: Elderly female in NAD.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: RR, Unable to hear clear S1. Soft S2 [**1-22**] SM at RUSB
early peaking. radiating to carotids.
LUNGS: CTAB, no crackles, wheezes or rhonchi anteriorly
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: lethargic but arousable.
Pertinent Results:
[**2173-3-30**] 09:40PM GLUCOSE-131* UREA N-70* CREAT-8.5* SODIUM-138
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-23 ANION GAP-20
[**2173-3-30**] 09:40PM CK(CPK)-12*
[**2173-3-30**] 09:40PM CK-MB-NotDone
[**2173-3-30**] 09:40PM CALCIUM-10.4* PHOSPHATE-5.1* MAGNESIUM-2.9*
[**2173-3-30**] 09:40PM WBC-21.0* RBC-3.38* HGB-9.7* HCT-30.4* MCV-90
MCH-28.6 MCHC-31.8 RDW-22.7*
[**2173-3-30**] 09:40PM NEUTS-91.2* LYMPHS-4.4* MONOS-2.6 EOS-1.7
BASOS-0.2
[**2173-3-30**] 09:40PM PLT COUNT-366
[**2173-3-30**] 09:40PM PT-17.4* PTT-44.8* INR(PT)-1.6*
[**2173-3-30**] 06:00PM GLUCOSE-158* UREA N-68* CREAT-8.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-21*
[**2173-3-30**] 06:00PM cTropnT-1.10*
EKG:
[**2173-3-23**]: NSR STD I,avL,V3-V6
[**2173-3-26**]: NSR STD V4-V6
[**2173-3-27**]: NSR STD <1mm V4-V6
[**2173-3-30**]: NSR STD II,III,aVF, V4-V6
[**2173-3-30**] at [**Hospital1 18**]: NSR STD I,V4,V5. <0.5mm STD V6. TWI aVL
.
CARDIAC CATH:
LMCA: diffuse moderate disease approx 50%
LAD: ostial 90%; proximal 70%, small D1 with 90% ostial disease
LCx: Large dominant with no significant disease
RCA: Not injected. Known small non-dominant with severe disease
Cypher stent placed in more distal proximal LAD lesion and then
second stent placed from LM ostium into proximal LAD.
.
HEMODYNAMICS:
AO pressure: 186/46 Mean:100
TTE:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Left ventricular
systolic function is hyperdynamic (EF>75%). 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 are mildly
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. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric LVH with hyperdynamic LV systolic
function. Diastolic dysfunction with elevated filling pressures.
Mild aortic valve stenosis with mild aortic regurgitation.
Brief Hospital Course:
81yo F with h/o ESRD on HD, HTN, HL, acute CHF exacerbation 1
month ago, admitted from OSH with NSTEMI now s/p cath with DES
in LAD and LMCA
# CORONARIES: S/P NSTEMI and DES to LMCA and LAD. Unclear timing
of NSTEMI and may have been on prior admission (see below).
Continued aspirin, statin, increased beta blocker. No role of
ACE as had bilateral nephrectomies. She will need to continue
plavix for at least 1 year. Throughout her stay she continued to
complain of chest pain, but admitted that this was very mild
([**12-26**]) and remained stable without intervention.
# PUMP: Had EF 56% on adenosine stress test at OSH per report
less than one month ago. In retrospect admission for "multifocal
PNA" was more likely for acute CHF exacerbation. With trops
elevated on this admission but CKs not more likely that she had
an ischemic event on last admission leading to acute CHF and now
the only enzyme elevated is troponin because 1) its half life is
longer than CK and 2) she had renal failure. TTE the day after
cath showed diastolic dysfunction and LVH consistent with her
history of HTN but no WMA.
# RHYTHM: NSR during but h/o AF. Was continued amiodarone. Not
on coumadin because of history of GIB. ASA for anti-coagulation
# Hypertensive Emergency: Patient with h/o severe HTN and
elevated pressures in cath lab so was started on nitro gtt. Was
weaned off nitro gtt quickly, however, because of hypotension.
During dialysis the next day no fluid was removed and her BPs
afterward were severely elevated. In this setting the patient
had chest pain and lateral ST depressions. She was replaced on
the nitro drip with good bp response and resolution of the chest
pain and EKG changes. She was placed on higher [**Month/Year (2) 4319**] of
nifedipine CR and labetalol with better bp control. She became
hypotensive after dialysis and large bowel movements, thus
labetalol was decreased to 100mg twice daily. Her long-acting
nifedipine was also discontinued as it was felt that better
titration could be achieved with short acting agents in the
short term. She is being discharged on labetalol 100 [**Hospital1 **]. Please
monitor bp especially in the peridialysis period. If severely
hypertensive may attempt nitroglycerin 2% TP on an as needed
basis, per physician [**Name Initial (PRE) 8469**]. Please note that she had
episodes of asymptomatic hypotension after dialysis.
# AMS: On admission there were multiple etiologies for AMS but
most likely were: 1. multiple sedating medications during both
caths, 2. No dialysis for 3 days (longest she's ever gone
without dialysis), 3. Pseudodementia from depression. LFTs were
wnl. Sedating medications were held overnight. In the morning
patient was back to baseline. Had dialysis and then her hearing
aid batteries were replaced the next morning and after these
interventions she was able to mentate appropriately. Did
continue to be tearful and psych/social work were consulted.
They did not feel there was an acute psychiatric problem and did
not change any medications. The patient's mental status
continued to improve and she was discharged at her baseline
mental status.
#. C. Diff: Patient developed large amounts guaiac positive
loose stools and leukocytosis. Stool was positive for C. Diff.
She was started on PO vancomycin as flagyl would be dialyzed off
in HD. Her abdominal exam remained benign and the diarrhea
resolved quickly. A two week course is planned for vancomycinin
(D0=[**2173-4-5**])
#. ESRD: Was continued on T/Th/Sat HD schedule.
#. GERD: continued PPI and added GI cocktail for pill-dysphagia.
#. HL: continued statin
ACCESS: peripheral line in foot and Right IJ triple lumen which
was placed at OSH [**2173-3-30**], a-line
PROPHYLAXIS:
-DVT ppx with pneumoboots
-Bowel regimen with colace, lactulose per home regimen
CODE: DNR/DNI - confirmed with daughter. Reversed only for cath.
Communication: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone #[**Telephone/Fax (1) 82674**]; #[**Telephone/Fax (1) 82675**]
Medications on Admission:
MEDICATIONS at home:
Zoloft 150mg QHS
Amiodarone 200mg daily
Aspirin 81mg daily
Phoslo 667mg three times daily
Colace 100mg daily
Lactulose 30mL daily
Nephrocaps one tablet daily
Nifedipine XL 60mg twice daily
Protonix 40mg daily
REquip 0.25mg QHS
Albuterol PRN
Metoprolol 75mg twice daily
Renagel 1600mg three times daily
Neurontin 200mg qhs
Requip 0.25mg PO qhs
MEDICATIONS ON TRANSFER:
Amiodarone 200mg daily
Nephrocaps 1 tab daily
Phoslo 667mg PO TID before meals
Plavix 75mg daily
Clotrimazole 10mg 5X daily
Metoprolol Tartrate 75mg three times daily
Nifedipine SR 60mg twice daily
Pantoprazole 40mg daily
Prednisone 10mg daily
Ropinirole 0.25mg QHS
Sertraline 150mg daily
Renagel 1600mg three times daily
Aspirin 81mg daily
Colace 100mg twice daily
Senokot 2 tabs QHS
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking unless instructed
by Dr. [**Last Name (STitle) **].
4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: 15-30cc
MLs PO QID (4 times a day) as needed for chest pain.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for evidence of thrush.
12. Nitroglycerin 2 % Ointment Sig: One (1) inch Transdermal Q8H
(every 8 hours) as needed for SBP> 160.
13. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks: first dose [**2173-4-5**].
16. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Hold SBP<100, HR <60.
17. Neurontin 100 mg Capsule Sig: Two (2) Capsule PO at bedtime.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Non-ST elevation Myocardial Infarction
End Stage Renal Disease with Hemodialysis
Depression
Discharge Condition:
stable
Discharge Instructions:
You were admitted because you had a heart attack. We evaulated
the arteries that supply your heart and placed stents in the
ones that were occluded. You were also found to have an elevated
blood pressure and were given medications to treat this. We
continued your dialysis regimen. You were found to have an
infection of your large bowel cousing you to have diarrhea and
we gave you oral antibiotics.
Please call your regular doctor or return to the emergency room
if you have fevers, chills, diarrhea, low or high blood
pressure, chest pain or any other concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Primary Care:
[**Last Name (LF) 10000**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 53192**] Date/time: Please call the
office to schedule an appt 1 week after you are discharged from
rehabilitation
Cardiology:
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
[**Apartment Address(1) 82676**]
[**Hospital1 3597**], [**Numeric Identifier 82677**]
([**Telephone/Fax (1) 29073**] Date/time: [**4-26**] at 1:45pm.
Completed by:[**2173-4-7**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4905
} | Medical Text: Admission Date: [**2111-1-5**] Discharge Date: [**2111-1-10**]
Date of Birth: [**2030-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Weakness, shoulder/neck pain
Major Surgical or Invasive Procedure:
[**2111-1-5**]: right heart cath, pericardial tap, arterial puncture
History of Present Illness:
80 yo M with HTN, who presents with weakness and shoulder/neck
pain. Of note, he was recently observed in the [**Hospital1 18**] ED on
[**12-16**] with similar complaints and had a MIBI that showed
no reversible defect. He reports 4 weeks of gradually worsening
weakness, waxing and [**Doctor Last Name 688**], without any sensory neurologic
symptoms. On the day prior to presentation, he felt that he was
unable to move at all prompting him to come to ED. He does also
report neck/throat tightness with radiation to the shoulders for
the last 5 days. It waxes and wanes, lasting 30-60 minutes, it's
pleuritic without an exertional component. Patient does report
SOB, palpitations, a "trembling chest", and five days' of a dry
cough.
.
In ED: patient received ASA 325 on [**12-4**], Lasix 20 mg IV and 1 x
SLNTG. EKG nsr @ 87, nl axis, IVCD, TWI in III, aVF; q in III -
old; no new ST changes, no new Q waves. CE's flat x 2. A V/Q
scan was low likelihood for pulmonary embolism.
.
On the floor, he developed progressively worsening dyspnea and
hypoxia. He was noted to have a pulsus of 22 and a bedside echo
showed RV collapse; he was taken urgently for pericardial
drainage with removal of 400cc of serosanguinous fluid and drain
placement.
.
ROS: No dysuria/hematuria, no abdominal pain, no back pain, no
n/v/d, no diaphoresis. Does report transient lightheadedness
this AM, with a headache that resolved. Patient denies any
urinary retention or fecal incontence. He does report
hematochezia x1 approx 2 wks ago after straining for a hard BM;
denies known hx of hemorrhoids.
Past Medical History:
?previous silent MI
Incomplete LBBB
Neuropathy with footdrop
Hypertension
Diverticulosis
Esophageal ring
Gout
Social History:
No smoking, occasional alcohol, no drug use.
Family History:
Non-contributory
Physical Exam:
T 100.4 BP 161/60 HR 83 RR 24 Sat 98% on NRBM
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no carotid
bruits, JVP approx 10cm
RESP: CTA b/l; no w/r/r
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: trace [**Name (NI) **] PT/DP pulses b/l; no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact.
RECTAL: guaiac negative in ED
Pertinent Results:
V/Q scan ([**1-5**]):
Low likelihood ratio for recent pulmonary embolism.
.
MRA Chest ([**1-5**]):
No evidence of aortic dissection. Questionable area of wall
thickening in the ascending aorta at the level of the main
pulmonary artery. Although the finding is potentially
artifactual, further assessment with a dedicated non-contrast
chest CT is recommended to exclude an intramural hematoma. No
evidence of aneurysm. Moderate pericardial effusion. Small
bilateral pleural effusions with associated bilateral lower lobe
atelectasis.
.
ECG ([**2111-1-5**]): ECG: nsr @ 87, nl axis, IVCD, TWI in III, aVF; q
in III - old; no new ST changes, no new Q waves
.
Bedside TTE ([**2111-1-5**]): There is a moderate sized pericardial
effusion. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology. Left
ventricular systolic function is grossly preserved.
.
Cardiac cath ([**2111-1-5**]): Resting hemodynamics were performed. The
femoral arterial pressures had a pulsus of 41mmHg at the
beginning of the procedure. The right sided filling pressures
were significantly elevated (mean RA pressures were 25mmHg). The
PCWP pressures were elevated at 25-30mmHg. The pericardial
pressures were elevated at 20mm Hg. Successful
pericardiocentesis was performed with appx 300cc of
serosanguinous fluid removed. Drain left in place. Post
pericardiocentesis, there was resolution of respiratory
variation of the femoral arterial tracing. The right sided
filling pressures were mildly elevated (mean RA pressures was
12mmHg). The left sided filling pressures have improved (mean
PCW pressures were 21mmHg). The cardiac index improved to 3.2
l/min/m2. The pericardial pressures were appx 0mmHg.
.
Pericardial fluid cytology ([**2111-1-5**]): negative for malignant
cells
.
CT Chest ([**2111-1-6**]): Tracheomalacia with narrowing of the main
stem bronchi.
Pericardial effusion. Bilateral pleural effusions. Increased
pulmonary parenchymal density most likely representing mild
edema. Compressive atelectasis. Hepatic cyst.
.
TTE ([**2111-1-8**]): The estimated right atrial pressure is 5-10 mmHg.
There is symmetric left ventricular hypertrophy. The left
ventricular cavity is small. Left ventricular systolic function
is hyperdynamic (EF>75%). The right ventricular cavity is
dilated. Right ventricular systolic function appears depressed.
There is a small pericardial effusion subtending the lateral
wall of the left ventricle. There are no echocardiographic signs
of tamponade.
.
[**2111-1-4**] 09:15PM WBC-10.3 RBC-2.88* HGB-9.5* HCT-27.3* MCV-95
MCH-32.9* MCHC-34.7 RDW-14.7
[**2111-1-4**] 09:15PM GLUCOSE-172* UREA N-65* CREAT-3.1*#
SODIUM-136 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-18* ANION
GAP-20
[**2111-1-4**] 09:15PM CK-MB-NotDone proBNP-778
[**2111-1-4**] 09:15PM cTropnT-0.04*
Brief Hospital Course:
Shortly after admission to the floor for hypoxia, Mr. [**Known lastname **] MRI
from the ED was noted to show a moderate-sized pericardial
effusion. Although his ECG did not show electrical alternans or
low voltages, a pulsus was checked and found to be elevated at
22 mm Hg. An urgent cardiology consultation was obtained and a
bedside TTE showed RV collapse and tamponade physiology. He was
taken directly to cardiac catheterization where 400cc of
serosanguinous fluid was removed and a pericardial drain was
placed; he was sent to the CCU for further care. All studies
(including Gram stain, culture, and cytology) returned as
negative. He experienced relief of his dyspnea with the removal
of this fluid but remained hypoxemic requiring 100% NRB
facemask.
.
On hospital day 2, his percardial drain showed no fluid output
and a followup TTE showed no evidence of reaccumulation so his
drain was pulled. A chest CT showed no evidence of malignancy
or any other pathology that could potentially explain his
tamponade.
.
Due to a fever spike and concern for an infiltrate on his CXR,
he was started on a 7-day course of empiric levofloxacin and
metronidazole for suspected pneumonia. He was aggressively
diuresed with a gradual decrease in his oxygen requirements over
the course of his hospital stay. A V/Q scan in the ED was low
probability for PE and LENIs were negative for DVT. A pulmonary
consultation was obtained and agreed that his pneumonia and
fluid overload were the most likely cause of his hypoxemia. By
discharge, he was saturating 92-94% on room air.
.
Of note, on admission, he was found to be in acute-on-chronic
renal failure, though to be secondary to renal hypoperfusion
from his tamponade. His meds were renally-dosed, his [**Last Name (un) **] was
held, and his creatinine gradually improved with diuresis and
improvement of his cardiac functioning.
.
He was also noted to have an acute-on-chronic anemia, though no
source of acute bleeding could be identified. Iron studies were
consistent with an anemia of chronic inflammation, although his
very low serum iron also suggested some component of iron
deficiency. He was started on iron repletion and further causes
of anemia should be worked up as an outpatient.
Medications on Admission:
Omeprazole 20mg
Proscar 5mg daily
Felodipine 10mg daily
Allopurinol 300mg daily
Folic Acid 1mg daily
Gabapentin 1200mg qhs at 7pm; 400mg prn for restless legs
Mirapex 2.25mg qhs at 7pm
Gemfibrozil 600mg twice daily
Losartan 25mg daily
Terazosin 10mg daily
ASA 325mg daily
Vit C 1000mg
MVI
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Felodipine 5 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO DAILY (Daily).
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for leg/foot pain.
7. Pramipexole 1 mg Tablet Sig: One (1) Tablet PO hs ().
8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
14. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours) as needed for SOB/wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
pericardial effusion with tamponade
.
Secondary diagnosis:
Hypoxia
Acute on chronic renal failure
Hypertension
Coronary artery disease
Neuropathy
Gout
Discharge Condition:
Good, ambulatory, respiratory status stable off oxygen
Discharge Instructions:
Please take all medications as directed. You will be taking two
antibiotics (levofloxacin and flagyl to complete a 7 day
course). Your gabapentin dose has been decreased to 600mg by
mouth at night. You should not take losartan due to your kidney
function until your primary doctor or cardiologist tell you to
restart it.
.
If you develop shortness of breath, chest pain, dizziness,
fever, or any other symptom that concerns you, call your doctor
or go to the emergency room.
.
Go to all of your follow up appointments.
Followup Instructions:
You have the following follow up appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2111-1-16**] 11:40
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to make an appointment for [**1-22**].
Phone:([**Telephone/Fax (1) 5909**]. Tell the office that Dr. [**Last Name (STitle) **] said it
was okay to double book.
You will also need to call to make an appointment for an
Echocardiogram prior to your visit with Dr. [**Last Name (STitle) **]. The phone
number is ([**Telephone/Fax (1) 19380**].
You will need a follow up chest CT in 2 months to evaluate lung
parenchyma. CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-3-10**]
10:00. This is located in [**Hospital Ward Name 23**] [**Location (un) **]. Do not eat or
drink for 3 hours prior to this exam.
You will need to have your doctor follow up on your cytology and
pericardial cultures.
ICD9 Codes: 4280, 5849, 5859, 486, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4906
} | Medical Text: Admission Date: [**2115-1-26**] Discharge Date: [**2115-3-2**]
Date of Birth: [**2062-9-7**] Sex: F
Service: SURGERY
Allergies:
Codeine / Demerol
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
52F ESLD due to EtOH cirrhosis
Major Surgical or Invasive Procedure:
S/p Liver transplant on [**2115-1-27**]
History of Present Illness:
Pt is a 53 yr old female with ESRD due to ETOH cirrhosis with
h/o Variceal bleeding, SBP, thrombocytopeniacoagulopathy,
hyponatremia on Tovaptan trial. Recently admittee on [**2115-1-18**]
and d/c on [**2115-1-21**] for nausea and hyponatremia-(NA 129).
Placed on fluid restriction with slight impropvement. Patient
discharged home. No history of fevers, chills, nausea, vomiting
diarrhea. nor abdominal pain. Na level on [**2115-1-25**] was 118.
Past Medical History:
1. Heavy ETOH abuse since age 20 for about 30 years. Used to
drink pint a day. Unsuccessful detox treatment in the past. No
h/o DTs, or seizures.
2. Liver cirrhosis with portal HTN, thrombocytopenia,
coagulopathy. (hepatologist Dr. [**First Name (STitle) **]
2. H/o upper and lower GI bleeding in [**2111**] with EGD positive for
varices which were ?banded .
3. h/o HTN
4. h/o low back pain
5. s/p tubal ligation [**2093**]
6. Ectopic pregnancy [**2099**]
Social History:
Tobacco ?????? [**3-15**] cigarettes/dayEtOH ?????? Stopped drinking on [**3-15**],
previously [**4-12**] vodka drinks per day for 30 years.IVDU ??????
deniesLives w/husband, [**Name (NI) **]
Family History:
Strong hx of alcohol abuse and cirrhosis. Father died from MI at
53. Mother died at 57 from alcohol abuse, brother died in the
last two years from alcohol abuse
Physical Exam:
Patient A+Ox3 in NAD
T=97.4 BP 75/58 HR=74 RR=16 on RA at 99%
RRR S1 S2 SEM III/VI
lungs:CTA
Abd: soft, mildly distended
extremities:edema to knees b/l
petecchia/eccymosis to Right Arm
Pertinent Results:
[**2115-1-25**] 10:02AM BLOOD WBC-7.1 RBC-2.96* Hgb-10.7* Hct-32.3*
MCV-109* MCH-36.2* MCHC-33.2 RDW-18.9* Plt Ct-79*
[**2115-1-25**] 10:00AM ALBUMIN-2.7*
[**2115-1-25**] 10:02AM PT-20.0* PTT-66.5* PLT COUNT-79* INR(PT)-2.5
[**2115-1-25**] 10:02AM ALT(SGPT)-31 AST(SGOT)-57* TOT BILI-13.5*
[**2115-1-25**] 10:02AM GLUCOSE-187* UREA N-18 CREAT-1.0 SODIUM-118*
POTASSIUM-4.8 CHLORIDE-88*
[**2115-1-26**] 04:15PM FIBRINOGE-102*
Brief Hospital Course:
On [**2115-1-26**] Patient admiitted and was given fluids, 10PRBC,
10FFP, 10plts. Chest x-ray demonstrated no acute process, and
EKG-NSR with no ST elevations. Pt. went to the OR on
[**1-27**]/04for a liver transplant. Please see OR note for details.
[**Name (NI) **] pt. went to the SICU. Patient was intubated,
on an insulin drip, Neoral, on a steroid taper and changed from
valcycte to gancyclovir. On [**2115-1-27**] pt. had a duplex U/S
demonstrating normal portal venous and hepatic venous blood flow
with moderately elevated velocity in the main hepatic artery. On
[**1-29**] an angiogram was performed demonstrating no evidence for
hepatic artery stenosis. Patient coninued draining from the JP
drain. Patient was on a fluid restriction for a sodium of 128
on [**2115-1-30**]
Patient transferred to regular floor. Pt had a left upper
extremity u/s on [**1-31**]
/04 due to arm swelling which demonstrated a thrombus within
the left basilic vein. The remainder of visualized left upper
extremity veins were normal.
On [**2115-2-3**] Pt. became slightly confused with decrease po
intake. Psychiatry was consulted and recommended Haldol 2.5 [**Hospital1 **]
prn.
Patient weight was slowly increasing requiring intermitent Lasix
for diuresis. PT/OT and nutrition was consulted. Patient's MS
did improve and Haldol was discontinued and Risperidol was
started. Patient did improve with her nutritional status,
eating well. Patient will be leaving tomorrow for [**Hospital1 **].
Medications on Admission:
Tolvaptan 30', Aldactone 100', Lasix 40', Nadolol 20', Protonix
40', Mirtazapam 45', Lactulose 30"", Trazodone 50', Rifaximin
400", Cipro
Discharge Medications:
Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Fluconazole 400 mg PO/NG Q24H
Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Heparin 5000 UNIT SC TID
Docusate Sodium 100 mg PO BID
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Pantoprazole 40 mg PO Q24H
Mycophenolate Mofetil 1000 mg PO BID
Prednisone 15 mg PO DAILY Start: In am
[**2-6**] am
traMADOL 50 mg PO Q4-6H:PRN
Valganciclovir HCl 450 mg PO BID Start: In am
start [**2-11**]
Sarna Lotion 1 Appl TP QID:PRN
Risperidone 0.5 mg PO BID
CycloSPORINE Modified (Neoral) 125 mg PO Q12H Duration: 2 Doses
give 125mg for pm dose 1/4 and am dose [**2-13**]
Furosemide 20 mg PO DAILY
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:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
ESLD due to ETOH cirrhosis s/p orthotopic liver transplant
[**2115-1-27**]
h/o GI bleed, encephalopathy, portal htn, esoph varices
Steroid induced psychosis post tx, resolved with haldol. now on
risperdal
HTN
s/p ectopic pregnancy/tubal ligation.
LBP
Discharge Condition:
Stable
Discharge Instructions:
notify transplant office [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, inability to take medications, jaundice, lethargy or
delusions/psych
Completed by:[**2115-2-12**]
ICD9 Codes: 5119, 5990, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4907
} | Medical Text: Admission Date: [**2117-5-11**] Discharge Date: [**2117-5-15**]
Date of Birth: [**2061-4-24**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 69838**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 56 yo M with long h/o ETOH abuse who presented
to AJH today intoxicated requesting detox. He states that he has
not had amnything to eat or drink in four days. He began
vomiting with brown emesis yesterday. He was feeling very
depressed and had abdominal pain and presented c/o suicidal
ideation. He had an admission to AJH in Jamnuary with
diverticulitis and had part of his colon removed. He had been
doing well since but began to have recurrence of abdominal pain
this past week which he associated with increased ETOH. He
drinks only vodka and denies any other ingestions including
toxic alcohol ingestion. His last drink was on morning of
admission. On presentation to AJH, he was noted to be in
metabolic acidosis with bicarb of 7. his lactate was 8, acetone
50 and eoth 247. CT head was negative as was CXR. He had one
episode of coffee grounds episode and was started on a protonix
gtt and transferred here for further evaluation. He had one
additional episode of coffee grounds emesis en route here. On
arrival here, initial vs were: 115 116/71 18 95% 4L NC . Patient
was given diazepam (total 30mg IV), zofran and pantoparzole gtt
was continued. Also received 2L LR and D5NS @125 was started. He
has had no emesis since arrival here. NG lavage with coffee
grounds that cleared. lactate trended down to 5.0 here. hct
stable. gi requested full abd us. vitals on transfer T 100 HR
112 125/78 13 97 3L.
.
On arrival he is tremulous to the point that he has difficulty
speaking. He states that he has both lower abdominal pain
similar to his prior diverticulitis pain and also epigastgric
pain. He also reports visual but no auditory hallucinations. He
denies chest pain but does feel some shortness of breath but no
cough or sputum production. He has history of withdrawal
symptoms but no history of seizures.
Past Medical History:
diverticulitis s/p partial colectomy in [**12-29**]
bipolar
lyme
babesiosis
erhlichia
ADHD
Social History:
Drugs: none
Tobacco: none
Alcohol: vodka daily
Other: lives as tenant in house of woman who lives with her son.
has four children. only in contact with older 2. closest
relative is his sister who he does not want to know he is here.
Family History:
Noncontributory
Physical Exam:
On Admission:
General Appearance: Anxious, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, thrush, acetone breath
Cardiovascular: (S1: Normal), (S2: Normal), No(t) Rub, (Murmur:
No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : right base)
Abdominal: Soft, Bowel sounds present, Tender: r and l LQs ,
midline scar
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Not assessed, No(t) Rash: , No(t) Jaundice. No stigmata
of liver disease
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Not assessed, Tone: Normal
DRE: no blood, sml brown OB - stool
Pertinent Results:
[**2117-5-11**]
WBC-7.8 > Hgb-12.4* / Hct-35.5* < Plt Ct-164
Neuts-82.8* Lymphs-9.7* Monos-7.0 Eos-0.4 Baso-0.2
.
PT-12.2 PTT-20.2* INR(PT)-1.0
.
132 | 94 | 10 < 208
3.8 | 12 | 0.7
.
ALT-70* AST-144* AlkPhos-86 TotBili-0.6
Lipase-36
.
ASA-NEG Ethanol-68* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
[**Last Name (un) **] pO2-179* pCO2-22* pH-7.35 calTCO2-13* Base XS--11
Lactate-5.0*
.
URINE
Protein-30 Glucose-300 Ketone-150
bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG
mthdone-NEG
Abdominal ultrasound:
IMPRESSION:
1. Echogenic liver consistent with fatty change. Other forms of
liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. No sequelae of portal hypertension seen.
Brief Hospital Course:
56 yo with history of ETOH abuse who presented with ETOH
intoxication and coffee ground emesis.
.
# UGIB: More likely gastritis than MWT given he initially had
emesis that was brown and never had bright red blood. Low
suspicion for variceal bleed. No stigmata of liver disease. No
lab abnormalities suggesting impaired hepatic function. GI
consulted and felt patient likely had gastritis due to EtOH
abuse. Patient was initially started on IV PPI, which was
transitioned to PO. HCT stable on serial checks. GI recommended
endoscopy for when patient's alcohol withdrawal stabilized. EGD
showed mild esophagitis, mildly irregular squamocolumnar
changes, erosions in the gastric antrum, and erosions in the
duodenum. Biopsy pending at time of discharge for work up of
GAVE. [**Month (only) 116**] be followed up as an outpatient. He was continued on
ppi and advised to avoid alcohol and nsaids.
.
# ETOH withdrawal: On admission pt was noted to be tremulous
with ongoing symptoms of withdrawal, without seizure activity.
Initially treated with ativan CIWA scale, which was transitioned
to valium CIWA scale when liver synthetic function determined to
be intact. Patient's symptoms improved and his CIWA check
frequency spaced further apart to q4. Social work and psychiatry
both evaluated the patient and felt patient would be appropriate
for dual diagnosis treatment once stabilized. Pt was continued
on thiamine, folate, and multivitamin. On the floor he stopped
[**Doctor Last Name **] on the CIWA scale and did not require additional
diazepam.
.
# Transaminitis: Patient had AST greater than ALT consistent
with alcoholic hepatitis. Abdominal ultrasound showed fatty
liver and no evidence of portal hypertension. Transaminases have
been consistently trending back down since his admission on
Tuesday, [**2117-5-11**].
.
# Bipolar disorder: Patient restarted on home medications:
tegretol, risperdal and buspirone. Psychiatry recommended
discharge to dual diagnosis program.
.
#Lip laceration: Patient given triple antibiotic ointment for
application to his lacertion which alleviated some discomfort. A
swab for HSV was sent for testing, and remains pending.
Follow up for PCP
1. Biopsy pending at time of discharge for work up of GAVE
Medications on Admission:
Trazodone 300mg qhs
Risperdal 3mg QHS
Tegretol 200mg QAM, 400 mg QPM
buspar 10 TID
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for Constipation.
4. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4 () as needed
for CIWA >10 for 3 days.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
8. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. buspirone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
11. risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. neomycin-bacitracnZn-polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed
for lip lesion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Hematemesis
Acute gastritis
Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for vomiting blood and alcohol
withdrawal. You were transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital to
[**Hospital1 **] ICU for management and then to the general
wards for additional care. You were treated with medication to
protect your stomach from acid, and diazepam (valium) to prevent
symptoms of alcohol withdrawal. You had a scope test to look at
your stomach and it showed that you have some erosions in your
stomach and in the first part of your small intestine. These
erosions are caused by alcohol.
.
Regarding your alcohol use and depression, psychiatry was
consulted and they recommend inpatient psychiatric management.
.
The following changes were made to your home medications:
STARTED thiamine, folate, and multivitamin
STARTED neosporin ointment to your lip
STARTED pantoprazole for alcohol gastritis
STARTED bowel regimen: senna colace and miralax
Followup Instructions:
Once you are released from your psychiatric facility, please
follow up with your primary care doctor and your pscyhiatrist.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 69841**]
ICD9 Codes: 2851, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4908
} | Medical Text: Admission Date: [**2162-8-26**] Discharge Date: [**2162-9-9**]
Date of Birth: [**2093-4-1**] Sex: M
Service: SURGERY
Allergies:
Indocin / Clinoril / naproxyn / allopurinol / sodium thiosulfate
/ probenecide / suldinac / indomethacine / Heparin Agents /
Sulfa(Sulfonamide Antibiotics) / furosemide / sulfonamides /
Tylenol
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2162-8-28**]:
Right hip hemiarthroplasty
[**2162-8-31**]:
Exploratory laparotomy with sigmoid colon
resection and Hartmann pouch
[**2162-9-3**]:
Reopening of recent laparotomy.
Resection and revision of colostomy.
Mesh repair of incisional hernia.
V.A.C. closure midline wound 60 cm square.
History of Present Illness:
Mr. [**Known lastname **] is a 69 year old man with severe psoraitic
arthritis, Crohn's disease (on prednisone) and recent bilateral
DVT (on coumadin) presents with atraumatic right femoral neck
fracture. He was exercising Sunday, 6 days prior to admission
and felt a [**Doctor Last Name **] in his left hip and noticed a burning pain and
required a crutch to help him walk afterwards. Pain increased
throughout the week and eventually left him bedbound. One day
prior to admission, he stepped out of bed and felt severe pain
in his right anterior hip area and fell to the ground. He
continued to have full range of motion of his ankle and did not
have any numbness or tingling. He was on the ground for about 4
hours before he was brought into the ED by ambulance.
In the ED, he was afebrile with stable vitals, labs revealed INR
of 4.5. CT head was normal, CT pelvis/hip/femur were notable for
diffuse osteopenia and acute femoral neck fracture. He was seen
by ortho who planned on admission to medicine and surgery in the
morning.
Of note, patient has had multiple admissions in the past several
months. He was admitted from [**2162-4-23**] - [**2162-5-7**] for diarrhea
likely from Crohn's flare and was started on 40 mg prednisone at
that time. His platelets fell during that admission, which was
thought to be due to heparin induced thrombocytopenia from SQH,
so he was switched to fondaparinux, which resulted in rectal
bleeding, likely complication of Crohn's. His PF4 Ab came back
positive during that admission, so he was continued on
fondaparinux for prophylaxis. He was discharged to rehab, where
he developed large volume rectal bleeding and was readmitted on
[**2162-5-11**] requiring transfusion. A seratonin release assay was
negative during that admission, so it was felt that he did not,
in fact, have HIT. He was discharged on continued prednisone and
mesalamine.
He was admitted again on [**2162-7-20**] - [**2162-8-2**] for bilateral leg
swelling and redness and found to have bilateral posterior
tibial DVTs. He was started on IV heparin and bridged to
coumadin. Labs were notable for a pancytopenia, though it is
unclear if that was due to heparin. He has been on coumadin 4
mg daily since that time and LENIs in the ED on [**8-26**] were
negative for DVTs.
Denies fever, chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough. Denied chest pain or tightness, palpitations.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Past Medical History:
- Crohn's disease
- Psoriasis
- Psoriatic arthritis
- Hypertension
- Obesity
- GERD
- Hyperuricemia
- Anxiety
- Cholelithiasis
- Multiple liver hypodensities seen on CT, most likely cysts
- Left renal cyst
- Impaired glucose tolerance
- Ascending colon adenoma, removed ([**2161-2-5**])
- Long history of liver problems since [**2131**] in Atrius records-
has had 2 liver biopsies at [**Location (un) 2274**] (In [**2137**] and [**2144**]) that showed
? methotrexate induced toxicity or ? gold reaction.
- Gastrointestinal bleed
- h/o DVT in upper extremity after PICC line insertion
- h/o bilateral LE DVTs ([**7-/2162**])
- s/p right hip arthroplasty ([**8-/2162**])
Social History:
Lives by himself in [**Location (un) **]. Ambulates with crutch. Worked for
Department of Defense. Quit drinking 15 years ago, used to drink
[**7-16**] drinks/weekend. Denies hx of tobacco smoking or any other
drug use. Has son in [**Name (NI) **] who helps him out.
Family History:
Dad [**Name (NI) **]-Arthritis, CHF
Mom [**Name (NI) **]-HTN, brain aneurysms
Sister-CLL, [**Name (NI) **] disease
Physical Exam:
Admission physical exam:
Vitals: 98.4 125/76 82 20 93-100%RA FSBG: 172
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Skin: Diffuse erythematous patches appox 0.5-1cm with scale
distributed over his back, chest, abdomen, upper arms, and legs.
Lesions on legs appear to be coalescing and with more scale.
Ext: Warm, well perfused, 1+ pulses, pitting edema bilaterally
with chronic venous changes. Hands with shortened digits,
especially thumbs.
Neuro: CNII-XII intact, moving right extremity distally, but
deferred proximal exam given recent fx. Otherwise moving all
extremities equally with good strength.
Physical examination upon discharge: [**2162-9-9**]:
Vital signs: t=98.8, hr=74, rr=20, oxygen sat=97% room air,
bp=98/60- 110/68
General: Resting comfortable, conversant
HEENT: scleral anicteric
CV: ns1, s2, -s3, -s4, no murmurs
LUNGS: Clear
ABDOMEN: soft, mild tenderness, mid-line wound open, edges pink,
pink granuation tissue, no exudate, ostomy left side abdomen,
stoma red, marroon liquid in bag, stoma slightly retracted
EXT: hyperpigmentation lower ext. bil., feet cool, + dp bil.,
contracture hands bil.
SKIN: fine macular rash back, upper thigh, abdomen, macular
hemorrhagic area both arms, skin abrasion dorsal surface of
right hand ( DSD), stage 2 abrasion coccyx
MENTATION: alert, oriented x3, speech clear, no tremors
Pertinent Results:
[**2162-9-9**] 05:02AM BLOOD WBC-9.3 RBC-2.52* Hgb-7.5* Hct-24.7*
MCV-98 MCH-29.6 MCHC-30.3* RDW-16.6* Plt Ct-372
[**2162-9-8**] 02:33PM BLOOD WBC-14.5* RBC-2.96* Hgb-8.8* Hct-28.9*
MCV-98 MCH-29.9 MCHC-30.5* RDW-16.3* Plt Ct-519*
[**2162-9-8**] 04:50AM BLOOD WBC-11.9* RBC-2.59* Hgb-7.8* Hct-25.2*
MCV-97 MCH-30.1 MCHC-31.0 RDW-16.3* Plt Ct-444*
[**2162-8-26**] 04:45PM BLOOD WBC-8.9 RBC-4.07* Hgb-12.7* Hct-38.5*
MCV-95 MCH-31.1 MCHC-32.9 RDW-16.4* Plt Ct-175
[**2162-8-30**] 08:00AM BLOOD Neuts-84.8* Lymphs-11.1* Monos-3.8
Eos-0.2 Baso-0.1
[**2162-9-9**] 05:02AM BLOOD Plt Ct-372
[**2162-9-9**] 05:02AM BLOOD PT-13.4* INR(PT)-1.2*
[**2162-9-8**] 02:33PM BLOOD Plt Ct-519*
[**2162-9-8**] 04:50AM BLOOD Plt Ct-444*
[**2162-9-8**] 04:50AM BLOOD PT-14.8* INR(PT)-1.4*
[**2162-9-8**] 04:50AM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-140
K-4.1 Cl-104 HCO3-30 AnGap-10
[**2162-9-7**] 04:54AM BLOOD Glucose-80 UreaN-6 Creat-0.4* Na-139
K-3.8 Cl-103 HCO3-30 AnGap-10
[**2162-9-3**] 01:44AM BLOOD ALT-7 AST-16 CK(CPK)-26* AlkPhos-65
Amylase-10 TotBili-0.8
[**2162-8-26**] 04:45PM BLOOD CK(CPK)-41*
[**2162-9-3**] 01:44AM BLOOD CK-MB-1 cTropnT-<0.01
[**2162-9-3**] 03:39AM BLOOD freeCa-1.14
[**2162-8-31**] 07:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
[**2162-9-3**] 05:33PM BLOOD Lactate-1.0
[**2162-9-3**] 03:39AM BLOOD Hgb-8.3* calcHCT-25 O2 Sat-96
[**2162-9-3**] 03:39AM BLOOD freeCa-1.14
[**2162-8-26**]: ct of the head:
IMPRESSION: No intracranial hemorrhage or fracture; sinus
disease as
described above.
[**2162-8-26**]: bil. lower ext. veins:
IMPRESSION: No bilateral deep vein thrombosis evident.
Specifically, the posterior tibial vein thrombosis identified on
prior study are not seen today. Left peroneal vein is not
visualized.
[**2162-8-26**]: pelvis:
Transcervical right femoral neck fracture.
[**2162-8-31**]: cat scan of abdomen and pelvis:
IMPRESSION: Large amount of free intraperitoneal air with
stranding adjacent to the sigmoid colon in the right lower
quadrant, suggesting sigmoid colon perforation. Urgent surgical
consultation is recommended.
[**2162-9-3**]: CTA of head and neck:
1. Questionable area of decreased blood flow with normal blood
volume, and mildly increased mean transit time in the left
frontal lobe, which are nonspecific and may represent an
artifact. No acute territorial infarct or intracranial
hemorrhage.
2. Unremarkable MRA of the head and neck
[**2162-9-3**]: chest x-ray:
Moderate cardiomegaly is stable. There are low lung volumes.
Increasing opacities in the left lower lobe could be due to
increasing atelectasis but aspiration could also be present.
There is a small left pleural effusion.
The right IJ catheter tip is in the lower SVC. NG tube tip is
out of view below the diaphragm. Widened mediastinum is stable.
Brief Hospital Course:
The patient was admitted to the hospital after a fall. Upon
admission, he was made NPO, given intravenous fluids, and
underwent imaging. An x-ray of the pelvis showed a
transcervical right femoral neck fracture.
The patient had supratherapeutic INR on admission from
anticoagulation for DVT which was diagnosed on [**2162-7-21**], so
arthroplasy was delayed one day while the patient was reversed
with IV vitamin K 5 mg x 2. On [**8-28**], the patient underwent
uncomplicated right hip surgical fixation with orthopedics. No
blood was required peri-operatively. Post-operative pain was
controlled with oxycodone and home oxycontin. The patient
remained hemodynamically stable on the floor. Because of the
patient's history of DVT the patient was given IV heparin to
bridge to coumadin. A pantocytopenia was noted, and it was
unclear if it was related to heparin use, but possibly related
to ? HIT. PF4 antibodies were positive, but serotonin release
assy was negative. The patient was started on fondaparinux on
POD #1 in order to bridge to coumadin. On POD #1, 5 mg of
coumadin was started. Physical therapy was ordered and began
evaluating the patient in preparation for discharge.
Over the course of the next 3 days, the patient began to notice
a dull progressing to sharp and extreme pain in his right lower
quadrant. A cat scan of the abdomen was performed on [**2162-8-31**],
which showed free intraperitoneal air. He was evaluated by the
acute care service and based on the ct findings, the patient was
emergently taken to the operating room for exploratory
laparotomy, sigmoidectomy and [**Doctor Last Name **] pouch. During the
operative course, there was a 50cc blood loss and a 2 liter
fluid requirement. He did not require any vasopressor infusions
and was actually hypertensive requiring treatment with
labetalol. He was successfully extubated and then transferred to
the intensive care unit for monitoring.
Upon arrival to the intensive care unit, the patient complained
of incisional pain but was otherwise well. He was alert,
oriented and conversant. He was able to move all extremities
with good peripheral pulses and no evidence of shock/sepsis.
His pain was controlled with a dilaudid PCA and he remained NPO
with intravenous hydration. There were no acute events
overnight, and on [**9-1**] he was deemed stable for transfer to the
surgical floor for additional recovery.
After arrival to the surgical floor the patient was reported to
have an episode of unresponsiveness. The Neurology service was
consulted and a cat scan of the head was ordered which showed no
evidence of acute ischemia or vessel occlusion. [**Last Name (un) **] this
imaging, he had continuous EEG monitoring to look for evidence
of seizure activity after an apparent significant effect of
lorazepam to his mental status. In 24 hours, he returned to his
baseline mental status. He was however found on the morning
after the episode to have a necrotic, ischemic colostomy and
went to the operating room on [**2162-9-3**] for reopening of recent
laparotomy, resection and revision of colostomy and mesh repair
of incisional hernia A vac dressing was placed on the wound.
The patient returned to the surgical floor in stable condition
with an intact neurological status. The patient receive
intravenous analgesia after the surgery. Once tolerating clear
liquids, the patient was transitioned to oral analgesia.
The GI service was consulted regarding tapering of his
prednisone dose. On HD # 14, his prednisone taper was started.
He will be tapered 2.5 mg weekly. The patient was maintained on
arixtra with a bridge to coumadin. He has received coumadin x 3
days, current INR is 1.2. He has received arixtra 2.5, but was
increased to 7.5mg daily to provide him with the treatment dose
for DVT. His INR was closely monitored. Once he attains INR of
2.0, arixtra can be discontinued. On POD #6 from the ostomy
revision, the patient was noted to have frank blood from the
ostomy. He remained hemodynamically stable with a stable
hematocrit.
During the hospitalization, the ostomy nurse provided
instruction to the patient in caring for the ostomy. Physical
therapy evaluated the patient's mobility status and his
capability of caring for himself at discharge. He was reported
to have a skin breakdown on his coccyx for which mepilex has
been applied. Recommendations were made for discharge to a
rehabilitation facility.
On HD #15 , the patient was discharged to a rehabilitation
facility with stable vital signs. Appointments for follow-up
were made with the acute care service, orthopedics, and his GI
provider.
*********
VAC dressing removed prior to discharge and moist to dry
dressing applied: needs reapplication of VAC dressing
Providers: GI Dr. [**Last Name (STitle) **] at [**Location (un) 2274**] ([**Telephone/Fax (1) 106179**])
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Repaglinide 1 mg PO WITH LUNCH
2. Warfarin 4 mg PO/NG DAILY16
3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
4. Ascorbic Acid 500 mg PO BID
5. Atenolol 25 mg PO DAILY
Hold for SBP<100 or HR<60
6. Ferrous Sulfate 325 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Hold for oversedation
11. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
12. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
13. DiCYCLOmine 40 mg PO TID
14. Calcium Carbonate 1500 mg PO BID
15. Colchicine 0.6 mg PO DAILY
16. Atovaquone Suspension 1500 mg PO DAILY
17. Apriso *NF* (mesalamine) 1.5g Oral daily
18. Calcipotriene 0.005% Cream 1 Appl TP [**Hospital1 **]
Apply to psoriatic areas twice daily. Do not apply below mid
thighs.
19. Coal Tar 3% Shampoo 1 Appl TP DAILY
20. Ethacrynic Acid 50 mg PO BID
Hold for SBP<100
21. Lidocaine 5% Patch 1 PTCH TD DAILY
22. Loperamide 2-4 mg PO QID:PRN Diarhhea
4mg following first loose stool of day, 2mg afterwards
23. Thiamine 100 mg PO DAILY
24. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Hold for oversedation or RR<10
Discharge Medications:
1. Atenolol 25 mg PO DAILY
Hold for SBP<100 or HR<60
2. Calcipotriene 0.005% Cream 1 Appl TP [**Hospital1 **]
Apply to psoriatic areas twice daily. Do not apply below mid
thighs.
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Hold for oversedation
4. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Hold for oversedation or RR<10
5. PredniSONE 17.5 mg PO DAILY Duration: 1 Weeks
last dose 10/8
6. Pantoprazole 40 mg PO Q24H
7. Sarna Lotion 1 Appl TP QID:PRN pruritis
8. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
9. Colchicine 0.6 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
hold for diarrhea
11. Fondaparinux Sodium 7.5 mg SC DAILY
please start [**9-10**]
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Ascorbic Acid 500 mg PO BID
14. Calcium Carbonate 1500 mg PO BID
15. FoLIC Acid 1 mg PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD DAILY
17. Multivitamins 1 TAB PO DAILY
18. Thiamine 100 mg PO DAILY
19. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
20. PredniSONE 15 mg PO DAILY
start [**9-14**], last dose 10/15
21. PredniSONE 12.5 mg PO DAILY
start [**9-21**], last dose 10/22
22. PredniSONE 10 mg PO DAILY
start [**9-28**], last dose 10/29
23. PredniSONE 7.5 mg PO DAILY
start [**10-5**], last dose [**10-11**]
24. PredniSONE 5 mg PO DAILY
start [**10-12**], last dose 11/12
25. PredniSONE 2.5 mg PO DAILY
start [**10-19**], last dose 11/19
26. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
27. Coal Tar 3% Shampoo 1 Appl TP DAILY
28. Ferrous Sulfate 325 mg PO DAILY
29. DiCYCLOmine 40 mg PO TID
30. Repaglinide 1 mg PO WITH LUNCH
31. Ethacrynic Acid 50 mg PO BID
Hold for SBP<100
32. Warfarin 7.5 mg PO ONCE Duration: 1 Doses
please give 4pm [**9-9**]...daily coumadin as per INR monitoring
33. Atovaquone Suspension 1500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnoses:
- Atraumatic right hip fracture
- Prior bilateral DVT
- Perforated colon
- Ischemic ostomy
Secondary diagnoses:
- Severe psoriatic arthritis
- Crohn's disease on prednisone
- Heparin induced thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Right leg anterior weight bearing precautions.
Discharge Instructions:
You were admitted to hospital after you fell and fractured your
hip. You had your hip repaired. Three days after the surgery,
you had abdominal pain. You underwent a cat scan and you were
found to have a perforation in your colon. You were taken to
the operating room where you had a portion of your colon removed
and a colostomy. You returned to the operating room because the
color of your ostomy had change and underwent an exploratory
laparotomy. You were monitored in the intensive care unit, and
were transferred to the surgical floor. While on the surgical
floor, you had a change in your mental status and there was a
concern for a stroke. A cat scan was done which was normal. You
gradually improved and returned to the surgical floor. You are
now slowly getting better and you are preparing for dishcarge to
a rehabilitation facility where you can further regain your
strength and mobility.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2162-9-14**] at 9:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2162-9-14**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD
Specialty: Endocrinology
[**Location (un) 2274**] [**Location (un) **]
[**Location (un) 2129**]
[**Location (un) 86**] [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 89288**]
When: [**9-16**] at 3:30pm
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], MD
Specialty: Gastroenterology
[**Hospital1 **]
[**Location (un) 4363**]
[**Location (un) 86**] [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 89288**]
When: We are working on a follow up appointment. You will be
contact[**Name (NI) **] with an appointment. If you have not heard in two
business days, please call above number for status
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2162-9-23**] at 2:15 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] in the ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2162-9-10**]
ICD9 Codes: 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4909
} | Medical Text: Admission Date: [**2144-12-3**] Discharge Date: [**2144-12-5**]
Date of Birth: [**2069-8-30**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hematemesis and melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
75 year old female presenting to OSH with about 24 hours of
hemetemesis and melena. Patient was found by daughter this
morning to be lethargic and less responsive. Patient has hx of
significant NSAID use for her chronic back pain. Upon
presentation to the ED she was oriented and alert. She had 2 IVs
started and given 1L crystalloid bolus. She was noted to have
large amount of melena in the ED. She was given a protonix bolus
and started on IV infusion. At the OSH the patient denied any
chest pain, shortness of breath with mild abdominal discomfort.
The mild abd pain has been present for a couple of weeks.
Patient was initially tachycardic and hypotensive to 90
systolic.
At OSH pt underwent EGD after elective endotracheal intubation
for airway protection. The EGD showed large clot in the stomach
with gastric varices. No esophageal varices were identified. no
evidence of ulcer in duodenum. No intervention was performed.
She was transferred here for tertiary care. At OSH she received
a total of 7 units pRBC, 6 FFP, and 4L of crystalloid. She was
started on an octretide drip. Patient's blood pressure remained
relatively stable and required a short time of peripheral
pressor support.
.
On arrival to the MICU, patient was intubated but arousable. She
was hemodynamically stable with normal blood pressure. She was
on sedation as well as an octreotide drip.
.
Review of systems:
(+) Per HPI
Past Medical History:
Right Breast cancer [**2139**] with lumpectomy, Type 2 DM, HTN,
hyperlipidemia, hyperthyroidism, depression, anxiety, COPD
Tubal ligation, appendetomy, hysterectomy, tonsillectomy
Social History:
- Tobacco: Significant hx of previous tobacco use, quit about 3
yrs ago
- Alcohol: Denies
- Illicits:
Family History:
Not able to obtain currently
Physical Exam:
Vitals: T:99.5 BP:134/58 P:92 R: 18 O2:
General: Intubated, arousable to verbal stimuli, does not appear
to be in distress
HEENT: Sclera anicteric, PERRL
Neck: supple, JVP not elevated,
CV: A. fib; no M,R,G
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly; active melena
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: intubated and sedated. Patient is moving extremities.
Pertinent Results:
[**2144-12-3**] 09:39PM PT-14.7* PTT-27.1 INR(PT)-1.3*
[**2144-12-3**] 09:39PM PLT COUNT-190
[**2144-12-3**] 09:39PM NEUTS-79.0* LYMPHS-16.9* MONOS-3.8 EOS-0.2
BASOS-0.2
[**2144-12-3**] 09:39PM WBC-10.0 RBC-2.60* HGB-7.8* HCT-22.8* MCV-88
MCH-29.9 MCHC-34.1 RDW-15.8*
[**2144-12-3**] 09:39PM ALBUMIN-2.7* CALCIUM-6.7* PHOSPHATE-2.8
MAGNESIUM-1.4*
[**2144-12-3**] 09:39PM cTropnT-<0.01
[**2144-12-3**] 09:39PM LIPASE-20
[**2144-12-3**] 09:39PM ALT(SGPT)-11 AST(SGOT)-25 LD(LDH)-174 ALK
PHOS-39 TOT BILI-0.3
[**2144-12-3**] 09:39PM estGFR-Using this
[**2144-12-3**] 09:39PM GLUCOSE-167* UREA N-24* CREAT-0.7 SODIUM-146*
POTASSIUM-3.4 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13
AP chest reviewed in the absence of prior chest imaging:
ET tube ends no less than 4 cm above the carina in standard
placement. Right internal jugular introducer ends in the upper
SVC. No pneumothorax, pleural effusion, or mediastinal widening.
Heart size top normal. Diminished pulmonary vasculature
suggests emphysema. No pneumonia or pulmonary edema.
CT abdomen/pelvis:
IMPRESSION:
1. Bilateral pleural effusions, bibasilar atelectasis and mild
interstitial edema.
2. Splenic vein thrombosis. Multiple varices noted in the region
of the spleen and anterior to the stomach.
3. Thrombosed aneurysm at the origin of the SMA, with
reconstitution of the distal SMA from adjacent vessels.
EGD:
Esophagus:
Contents: Old blood was seen along the mucosa of the lower third
of the esophagus.
Mucosa: Normal mucosa was noted in the whole esophagus. There
was no evidence of esophageal varices or esophagitis.
Stomach:
Contents: A large amount of clotted blood was seen in the
fundus. Thirty minutes were spent trying to suction and remove
the clot to visualize the fundus, however the fundus could not
be fully visualized. The GE junction was carefully examined and
there was no evidence of gastro-esophageal varices. Isolated
fundal varices could not be ruled out.
Duodenum:
Mucosa: Old blood was noted in the whole duodenum, however the
mucosa was normal without ulcers
Brief Hospital Course:
75 year old female with history of HTN, hyperlipidemia, breast
cancer s/p lumpectomy in remission transferred from OSH with
significant active upper GI bleed. Patient required multiple
packed red cell transfusions with continued instability upon
admission. Emergent EGD showed extensive hemorrhage in the
stomach; a lesion could not be localized. Patient underwent a
massive transfusion protocol, and received 14 units of packed
red cells at the outside hospital and [**Hospital1 18**]. Octreotide and
pantoprazole gtts were continued. CT abdomen suggested gastric
varix due to splenic vein thrombosis was possible source of
bleeding.
.
#Diabetes- monitored finger sticks
.
#COPD- Continued home meds (ventolin and adviar)
.
#Hyperlipidemia- Held Crestor
.
#Hypertension- held lisinopril until hemodynamically stable
.
# FEN: IVF, NPO
# Prophylaxis: Pneumaboots
# Access: peripherals x 3, right IJ trauma line was placed
# Communication: HCP [**Name (NI) **] [**Name (NI) 732**] [**Telephone/Fax (1) 91259**]; discussed case
# Code: DNR
.
Following initial stabilization, patient had another episode of
significant hematemesis and melena on the afternoon of [**2144-12-4**],
and was hemodynamically unstable, requiring additional packed
red cell transfusions. An emergent conference was held
involving attending physicians from the hepatology,
interventional radiology, ICU and surgical services to discuss
possible therapeutic interventions. It was felt that no
endoscopic options were possible and that, due to multiple
varices and very difficult/calcified/aneurysmal anatomy, IR
options were not optimal. Surgery was felt possible but
extremely high risk and with a low likelihood of long-term
control. [**Hospital **] health care proxy, [**Name (NI) **] [**Name (NI) 732**] (daughter),
was involved in the process. She expressed that patient would
not wish to undergo major surgery. After an informed
discussion, the decision was made to transition the patient to
comfort care. No further interventions were pursued. With
family at her bedside, the patient expired peacefully on
[**2144-12-5**] at 2:07 a.m.
Medications on Admission:
Ventolin 2puffs Q4H, crestor 40mg qd, lisinopril 20mg qd,
arimidex 1mg qd, vicodin 5-500 q6h prn pain, naproxyn 375 mg
[**Hospital1 **], methimazole 5mg TID, metformin 1000mg [**Hospital1 **], advair q12h,
aspirin 81mg QD
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 2851, 4019, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4910
} | Medical Text: Admission Date: [**2121-10-25**] Discharge Date:
Service: CARD/[**Last Name (un) **]
ATTENDING:[**Last Name (STitle) 36538**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old
female status post CABG in [**2103**], and PTCA in [**2115**]. She
presented with chest pain and positive stress test to the ER.
The catheterization showed LIMCA 40% ostia occluded, 40% to
59% distally occluded, LAD 100% occluded, LCX proximally at
90% occluded, RCA 100% occluded. Ejection fraction was 45%.
PAST MEDICAL HISTORY: History is significant for coronary
artery disease, status post CABG in [**2103**], PTCA in [**2115**],
hypercholesterolemia and GERD.
MEDICATIONS: (home).
1. Hydrochlorothiazide.
2. Lipitor.
3. Imdur.
4. Accupril.
5. Lopressor.
6. Aspirin.
HOSPITAL COURSE: The patient was taken by Dr. [**Last Name (STitle) 5873**] to the
ER for CABG times three on [**2121-10-28**]; LIMA to LAD,
SVG to OM and SVG to RPDA.
Postoperatively, the patient did very well being extubated
and weaned off drips. The chest tube was discontinued
without incident.
On postoperative day #2, the patient was transferred to the
floor and ambulating and working with the physical therapist
without any problems. The patient achieved physical therapy
level III.
On postoperative day #3, the patient would express a desire
to leave and a rehabilitation facility was arranged for the
patient.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o.b.i.d.
2. Lasix 20 mg p.o.b.i.d. times five days.
3. [**Doctor First Name 233**]-Ciel 20 mEq p.o.b.i.d. times five days.
4. Aspirin 81 mg p.o.q.d.
5. Lipitor 10 mg p.o.q.d.
Upon discharge, the patient was in regular rate and rhythm,
normal sinus. Chest was clear to auscultation. Incision was
clean, dry, and intact, no drainage, no pus, sternum stable.
The patient was ambulating with assistance at level III. The
patient was discharged to rehabilitation with instruction to
followup with Dr. [**Last Name (STitle) 5873**] in three to four weeks.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] E. 02-248
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2121-10-31**] 10:45
T: [**2121-10-31**] 10:49
JOB#: [**Job Number 36539**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4911
} | Medical Text: Admission Date: [**2190-1-16**] Discharge Date: [**2190-1-18**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is an 82-year-old woman,
resident at [**Hospital3 **], who
presented to the Emergency Department on the day of admission
following an episode of hematemesis. She also had a few days
of dark stools prior to this.
In the Emergency Department, the patient underwent an NG tube
lavage which was positive for coffee-ground and blood. Her
hematocrit on admission was 35 with an INR of 3.9, and as she
is on Coumadin for deep venous thrombosis.
The patient was admitted to the Medical Intensive Care Unit
for treatment of her gastrointestinal bleeding.
PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2.
Dementia. 3. History of cerebrovascular accident. 4.
History of lower gastrointestinal bleed in [**2185**]. 5. Status
post colectomy for above. 6. History of recurrent deep
venous thromboses on Coumadin. 7. Status post
cholecystectomy. 8. Anemia. 9. Hypertension. 10.
Gastroesophageal reflux disease.
SOCIAL HISTORY: The patient lives at [**Hospital3 **]
Home for the Aged. She does not smoke or drink. Her son is
one of her primary caregivers, and his name is [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 26375**].
MEDICATIONS: Coumadin, Vitamin C, Pepcid, Glucotrol,
Trazodone.
ALLERGIES: BACTRIM.
PHYSICAL EXAMINATION: Vital signs: Afebrile, heart rate 110
and regular, respirations 22, blood pressure 138/82, oxygen
saturation 98% on room air. General: The patient was found
lying in bed, asleep but arousable. HEENT: Significant for
dry mucous membranes. Neck: Supple. Heart: Regular, rate
and rhythm. S1 and S2 normal. No murmurs. Lungs: Clear to
auscultation bilaterally. Abdomen: Soft but tender to
palpation and nondistended. She had bowel sounds.
Extremities: There was no lower extremity edema, but there
were nodules on her left lower extremity.
ASSESSMENT AND PLAN: The patient is an 82-year-old woman
transferred to [**Hospital6 256**] after one
episode of hematemesis. NG tube lavage revealed some
coffee-grounds. The patient also had leukocytosis to 24.9,
as well as increased INR of 3.9.
Differential diagnosis at the time of admission included an
upper gastrointestinal bleed secondary to gastritis, peptic
ulcer disease, AV malformation, or an esophageal tear.
LABORATORY DATA: White count 24.9, hematocrit 35.4; INR 3.9,
glucose 344; sodium 142, potassium 5.1, chloride 109, bicarb
23, BUN 40, creatinine 0.8; LFTs within normal limits.
Chest x-ray showed no pneumonia.
HOSPITAL COURSE: The patient was admitted to the SICU for
further management. She was kept NPO and had good access
throughout her hospital stay. She was started on intravenous
Protonix. She received volume resuscitation with intravenous
fluids and blood. Her INR was reversed using FFP.
EGD was performed on [**1-17**] which revealed esophagitis in
the lower third of the esophagus and a medium hiatal hernia
but otherwise normal EGD to the third part of the duodenum.
Recommendations by the Gastrointestinal Staff, who had been
asked to consult on the patient, were to continue b.i.d.
protime pump inhibitor for two weeks and then taper to one
time a day and then repeat EGD in eight weeks to ensure
healing.
The patient did well after her EGD with her hematocrit
remaining stable around 30 and her heart rate returning back
to normal and her Coumadin still held, given the risk of
gastrointestinal bleed.
With respect to her diabetes, the patient was taken off of
her Glucotrol and placed on a regular sliding scale. Her
fingersticks were checked four times a day.
Her code status of DNR/DNI was respected throughout her stay.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To [**Hospital3 26376**].
DISCHARGE DIAGNOSIS:
1. Upper gastrointestinal bleed secondary to Coumadin and
esophagitis.
2. Diabetes mellitus type 2.
3. Dementia.
4. History of anemia.
5. History of cerebrovascular accident.
6. History of lower gastrointestinal bleed status post
colectomy.
7. History of deep venous thrombosis with recurrence, on
Coumadin.
8. Status post cholecystectomy.
DISCHARGE MEDICATIONS: Tylenol 325-650 mg p.o. q.4-6 hours
p.r.n. pain and fever, Lansoprazole oral suspension 30 mg
p.o. b.i.d. until [**1-29**], and then 30 mg p.o. q.d. after
that, Trazodone 50 mg p.o. q.h.s. p.r.n. sleep, regular
Insulin sliding scale as per attached form, until the patient
is able to take full p.o. intake, after which the regular
Insulin sliding scale should be discontinued, and the
patient's Glucotrol should be restarted.
FOLLOW-UP: The patient is to continue her protime pump
inhibitor until [**1-29**] at b.i.d. dosing and then q.d.
afterwards. The patient needs to undergo a repeat EGD in
eight weeks to ensure healing; this needs to be arranged by
calling [**Hospital6 256**]
Gastrointestinal, [**Telephone/Fax (1) 1954**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], M.D. 12.ADN
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2190-1-18**] 13:45
T: [**2190-1-18**] 13:50
JOB#: [**Job Number 26377**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4912
} | Medical Text: Admission Date: [**2152-10-5**] Discharge Date: [**2152-10-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
s/p fall --> [**Last Name (un) 94409**] transfer from [**Hospital 8641**] Hospital, arrived
in the ED at [**Hospital1 18**] around 3 pm for acute SDH
Major Surgical or Invasive Procedure:
Left Craniotomy with evacuation of acute SDH
PEG tube placement [**10-17**]
History of Present Illness:
Ms. [**Known lastname **] is an 87yo woman with h/o paroxysmal AFib on coumadin
who presented to [**Hospital1 18**] on [**10-5**] with subdural hemorrhage after a
fall the day before.
.
History obtained from the daughter, [**Name (NI) **] [**Name (NI) 94410**]: her mother
is usually articulate, and lives with her husband. Yesterday, at
around 2:30 pm, her husband and herself got back from eating
lunch out. She bent down to pick a piece of paper, tripped and
fell, and hit the left side of her head. The apartment that she
and her husband live in face the beach, and two boys came
running to her aide, dialled 911, and she refused to go. The
following day, another one of her daughters came to pick her up
to go out for the day, but she was still in bed. According to
her daughter [**Name (NI) **], she normally does not sleep well at
night, but ended up having a good night of sleep.
.
INR was 3.5 on admission and was reversed with FFP. She
underwent craniotomy with evacuation of hematoma SDH s/p
craniotomy with evacuation of hematoma. Her hospital course was
complicated by fevers felt to be due to hospital acquired
pneumonia. She then developed respiratory distress in the
setting of her pneumonia and volume overload and was transferred
to the MICU [**10-10**] for further management.
.
In the MICU, she was diuresed with IV lasix gtt, during which
time she has developed a contraction metabolic alkalosis. TTE
demonstrated hyperdynamic LV with grade II diastolic
dysfunction. Lasix gtt was discontinued in the AM of [**10-14**] and
she has been euvolemic on 80mg IV lasix daily, currently with
sat's of 99% on a face mask (she is a mouth breather). She had
AFib with RVR in the setting of her infection, but her heart
rate has been well controlled over the past several days. Her
mental status has remained poor (apparently "very articulate" at
baseline and is primary caregiver for her husband, who has
dementia). She is minimally responsive to voice and touch and is
non-verbal. She was having witnessed apneas, so the MICU team
repeated her head CT [**10-14**], but there was no evidence of
progressive bleed. She also had a CT of her pelvis to evaluate
for fracture; the preliminary read shows no evidence of
fracture.
.
She has been called out to the medicine floor for further care.
Of note, she continues to have fevers and leukocytosis. Her
course of vanc and zosyn for HAP is supposed to be completed
[**10-15**]. She also received 5 days of bactrim for E coli UTI per UCx
from [**10-5**]. Repeat cultures are unrevealing at this time, though
UA did have trace leukocytes. C diff is pending; she has had [**2-16**]
loose BMs/day.
Past Medical History:
PMHx:
1. Paroxysmal Atrial Fibrillation
2. CHF
3. HTN
4. Osteoporosis
PSx
1. Hysterectomy
2. Pelvic fracture 2.5 y ago
3. Appendicectomy
4. Cholecystectomy
Social History:
Lives with her husband in a [**Location (un) 448**] apartment,
normally highly articulate. A retired right handed personnel
employee officer. Non-smoker, no alcohol, no other drugs. Her
power of attorney is her daughter [**Name (NI) **] [**Name (NI) 94410**] cell [**2152**]. Her husband's name is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 94411**]. her PCP is
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94412**] [**Telephone/Fax (1) 94413**]
Family History:
Positive for strokes. This current presentation is not
relevant as it is a traumatic SDH.
Physical Exam:
O: T:97.5 BP: 165/92 HR:97 R 18 O2Sats 98% on room air
Gen: Left sided bruise on the head, right hematoma. Confused,
GCS 13.
HEENT: Pupils: 3-2 mm B/L EOMs full
Neck: In a C-collar
Lungs: poor air entry bilaterally.
Cardiac: HS+S4
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status:Unable to assess due to confusion, is verbalizing,
but speech is nonsensical and she is perseverating.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Left side - hearing aid
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 difficult to assess as she has difficulty
following one step commands. She is able to elevate both her
arms
off the bed, her grip is -5 bilaterally. Her right leg movements
are limited by pain, she is kicking her left leg around in the
bed. Right sided pronator drift
Sensation and coordination: Unable to assess reliably.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Positive Babinski on the right
Pertinent Results:
LABS ON ADMISSION:
.
[**2152-10-5**] 03:15PM WBC-6.9 RBC-3.76* HGB-10.8* HCT-31.4* MCV-84
MCH-28.8 MCHC-34.5 RDW-17.0*
[**2152-10-5**] 03:15PM PLT COUNT-221
[**2152-10-5**] 03:15PM PT-30.4* PTT-37.7* INR(PT)-3.1*
[**2152-10-5**] 03:15PM GLUCOSE-121* UREA N-32* CREAT-1.0 SODIUM-141
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15
[**2152-10-5**] 09:58PM GLUCOSE-118* LACTATE-0.8 NA+-141 K+-3.7
[**2152-10-20**] 05:20AM BLOOD WBC-15.8* RBC-2.85* Hgb-8.4* Hct-25.3*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.9* Plt Ct-356
[**2152-10-18**] 09:50AM BLOOD WBC-19.7* RBC-3.25* Hgb-9.1* Hct-28.2*
MCV-87 MCH-28.1 MCHC-32.4 RDW-17.0* Plt Ct-623*
[**2152-10-16**] 07:05AM BLOOD WBC-19.6* RBC-3.16* Hgb-9.0* Hct-27.1*
MCV-86 MCH-28.5 MCHC-33.2 RDW-17.4* Plt Ct-506*
[**2152-10-14**] 03:24PM BLOOD WBC-18.8* RBC-3.33* Hgb-9.8* Hct-28.1*
MCV-84 MCH-29.4 MCHC-34.8 RDW-16.5* Plt Ct-437
[**2152-10-13**] 02:44AM BLOOD WBC-14.8* RBC-3.39* Hgb-9.8* Hct-29.0*
MCV-86 MCH-29.0 MCHC-33.9 RDW-16.7* Plt Ct-369
[**2152-10-7**] 03:08AM BLOOD WBC-10.7 RBC-3.30* Hgb-9.6* Hct-27.6*
MCV-84 MCH-29.1 MCHC-34.8 RDW-16.3* Plt Ct-154
[**2152-10-17**] 06:00AM BLOOD PT-13.0 PTT-28.7 INR(PT)-1.1
[**2152-10-12**] 02:15AM BLOOD PT-15.3* PTT-43.6* INR(PT)-1.4*
[**2152-10-20**] 05:20AM BLOOD Glucose-131* UreaN-61* Creat-0.9 Na-145
K-3.7 Cl-101 HCO3-33* AnGap-15
[**2152-10-16**] 07:05AM BLOOD Glucose-147* UreaN-39* Creat-0.9 Na-136
K-3.1* Cl-93* HCO3-34* AnGap-12
[**2152-10-13**] 03:19PM BLOOD Glucose-117* UreaN-30* Creat-0.8 Na-138
K-3.2* Cl-92* HCO3-38* AnGap-11
[**2152-10-9**] 01:03AM BLOOD Glucose-161* UreaN-24* Creat-0.7 Na-146*
K-3.7 Cl-114* HCO3-25 AnGap-11
[**2152-10-15**] 06:00AM BLOOD ALT-30 AST-30 LD(LDH)-366* AlkPhos-117
TotBili-0.9
[**2152-10-12**] 02:15AM BLOOD ALT-31 AST-34 LD(LDH)-297* AlkPhos-98
TotBili-1.0
[**2152-10-10**] 02:43AM BLOOD CK-MB-5 cTropnT-0.06* proBNP-GREATER TH
[**2152-10-5**] 03:15PM BLOOD cTropnT-0.01
[**2152-10-20**] 05:20AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.8*
[**2152-10-14**] 03:24PM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.2 Mg-2.0
[**2152-10-19**] 05:02AM BLOOD Type-ART pO2-61* pCO2-41 pH-7.55*
calTCO2-37* Base XS-11
[**2152-10-9**] 11:02AM BLOOD Type-ART FiO2-95 pO2-59* pCO2-33*
pH-7.47* calTCO2-25 Base XS-0 AADO2-611 REQ O2-96
[**2152-10-6**] 02:19PM BLOOD Type-ART Temp-36.5 PEEP-5 FiO2-40 pO2-84*
pCO2-34* pH-7.44 calTCO2-24 Base XS-0 Intubat-INTUBATED
Vent-SPONTANEOU
[**2152-10-19**] 05:02AM BLOOD Lactate-1.3
[**2152-10-14**] 12:59PM BLOOD Lactate-1.0
Brief Hospital Course:
In summary, Ms [**Known lastname **] is an 87-y/o F w HTN, paroxysmal a-fib (on
home Coumadin), acute on chronic diastolic CHF, who was very
functional until a recent fall resulting in subdural hematoma
(SDH), now s/p craniotomy with poor mental status (though
improving per family), s/p treatment for hospital acquired PNA
and s/p diuresis for acute diastolic CHF in MICU, off abx.
Neurosurgery course: INR was 3.5 on admission and was reversed
with FFP. She underwent craniotomy with evacuation of hematoma
SDH s/p craniotomy with evacuation of hematoma. Her hospital
course was complicated by fevers felt to be due to hospital
acquired pneumonia. She then developed respiratory distress in
the setting of her pneumonia and volume overload and was
transferred to the MICU [**10-10**] for further management.
.
MICU course: Respiratory distress was multifactorial from
pulmonary edema/acute-on-chronic CHF (diastolic with EF 75%,
BNP>70,000) and likely aspiration/hospital-acquired pneumonia.
Cardiac enzymes were NL. Changed labetalol to short-acting
metoprolol and changed diltiazem XR to short-acting diltiazem
for better rate control to aid in diuresis. Held atenelol since
this can worsen CHF. Started on lasix drip and transitioned to
IV lasix with goal balance -100mL/hour. Continued valsartan and
lisinopril for afterload reduction. Started empiric vancomycin
and piperacillin/tazobactam for hospital-acquired/aspiration
pneumonia.The patient was diuresed with IV lasix gtt, during
which time she has developed a contraction metabolic alkalosis.
TTE demonstrated hyperdynamic LV with grade II diastolic
dysfunction. Lasix gtt was discontinued in the AM of [**10-14**] and
she has been euvolemic on 80mg IV lasix daily, currently with
sat's of 99% on a face mask (she is a mouth breather). She had
AFib with RVR in the setting of her infection, but her heart
rate has been well controlled over the past several days. Her
mental status has remained poor (apparently "very articulate" at
baseline and is primary caregiver for her husband, who has
dementia). She is minimally responsive to voice and touch and is
non-verbal. She was having witnessed apneas, so the MICU team
repeated her head CT [**10-14**], but there was no evidence of
progressive bleed. She also had a CT of her pelvis to evaluate
for fracture; the preliminary read shows no evidence of
fracture. After resolution of her respiratory distress, she was
called out to the medicine floor for further care.
On the Medicine Floor her course is as follows:
.
# Acute SDH: She presented via [**Last Name (un) **]-flight from [**Hospital 8641**] hospital
with a large left hyperacute subdural hematoma with rightward
subfalcine herniation and early uncal herniation, and brought to
the ICU and loaded with dilantin. She was taken to the OR that
day for craniotomy and evacuation of hematoma. No evidence of
progressive bleed on head CT [**10-14**]; will need f/u CT as outpt.
Dilantin was switched to keppra on the medicine floor. On
discharge she was opening her eyes, occasionally lateralizing to
voice, smiling when family speaking to her, wincing to pain and
trying to vocalize.
.
# Respiratory failure: Pulmonary toilet and suctioning were
continued on the floor. Completed abx course on [**10-15**], but still
requiring regular suctioning. On [**10-17**] she had a witnessed
aspiration event during her PEG tube placement. Her 02 sat
dropped to 88% but rose to >95% on 8L, she was quickly weaned
back to RA and f/u CXR showed no new infiltrate. She was kept
on strict aspiration precautions on the floor. On the morning
of [**10-19**] she was found to be tachypenic with ABG 7.55/41/61. The
tachypnea resolved with albuterol nebs, 2L 02 via facemask, and
morphine. Was felt to be due to cheynes-[**Doctor Last Name 6056**] breathing. Of
note, patient breathes predominantly through her mouth and has
been aided by humidified oxygen.
.
# Fevers: Was febrile in the MICU likely due to aspiration
pneumonia as UA and blood cultures negative to date. Completed
a course of empiric vancomycin and piperacillin/tazobactam for
hospital-acquired/aspiration pneumonia; D/Ced on [**2152-10-15**] after 7
days of treatment given negative cultures. WBCs continued to
trend up so patient was recultured. Blood cultures were
negative and urine grew only yeast. C. Diff was negative, her
foley was changed and vanc/zosyn was stopped (due to concern for
drug fever). Urine culture was negative after foley was
changed, she remained afebrile for >72 hours and her WBC trended
down.
.
# Hypernatremia: likely from poor free water intake and ongoing
fevers. Treated with free water via Peg tube starting [**10-19**]. Would
consider increasing free water as needed.
.
# Hyperglycemia: unclear if she has baseline glucose
intolerance, or if this is from acute illness; has required
significant sliding scale insulin, ultimately adding glargine 6
units qhs with q6h sliding scale.
.
# Atrial fibrillation: Held anticoagulation given her
highly-morbid intracranial bleed. Her rate was originally
difficult to control but eventually well managed with
nodal blocking agents (metoprolol and diltiazem).
# Nutrition: Patient received tube feeds per NGT while in MICU.
On the floor, a family meeting occurred and it was decided to
place a PEG tube for feeding. This was done on [**10-17**] and feeds
were started on [**10-18**]. Changed to fibersource HN.
Medications on Admission:
Labadalol 200 mg THREE TIMES A DAY (she??????s taken this for many
years!!)
Lisinopril 40 mg ONCE A DAY
Cardia (cardizemCD) 300 mg ONCE A DAY (new as of [**2152-4-15**])
Terazozin 1 mg ONCE A DAY
Diovan 320 mg ONCE A DAY
Bumex 1 mg ONCE A DAY (new as of [**2152-4-15**])
Norvasc 5 mg ONCE A DAY (new as of [**2152-4-15**])
Coumadin 6 mg ONCE A DAY at 7 p.m. (new as of [**2152-7-16**])
Potassium Ch 20meq (two 10 meq pills) TWICE A DAY) (new as of
[**2152-4-15**])
Ecotrin 81 mg ONCE A DAY
One-a-Day "Essential" Vitamin ONCE A DAY
Tylenol 625 mg ONCE A DAY Rapid Release
Tylenol PM 500 mg AT BEDTIME Rapid Release
Percocet [oxycodone] as needed for pain, 7.5 mg/325 mg
Discharge Medications:
1. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
unity Injection TID (3 times a day).
1. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
unity Injection TID (3 times a day).
13. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
14. Insulin Regular Human 100 unit/mL Solution Sig: Two (2) unit
Injection every six (6) hours as needed: Use Sliding Scale
(orders come with the patient) as follows:
Give 2 units regular insulin for FSG >120. Increase inuslin
dose by 2 units for every increase of 20 in FSG. Please see
attached.
15. Tube Feeds
Tubefeeding: Fibersource HN Full strength;
Starting rate: 50 ml/hr; Do not advance rate Goal rate: 50 ml/hr
Residual Check: q4h Hold feeding for residual >= : 150 ml
Flush w/ 100 ml water q6h
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 15852**] at Rye
Discharge Diagnosis:
Traumatic brain injury [**3-18**] subdural hematoma
Discharge Condition:
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 sutures and/or 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
?????? 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.[**First Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST
in 4 weeks
ICD9 Codes: 4019, 5070, 5990, 5849, 2760, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4913
} | Medical Text: Admission Date: [**2147-9-19**] Discharge Date: [**2147-9-21**]
Service: MEDICINE
Allergies:
Morphine / Mirtazapine / Ambien
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Chest pain and ICD firing at home
Major Surgical or Invasive Procedure:
defibrillation: 35 J succesfully out of VT
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in
[**2136**], chronic AFib with V-pacing, chronic systolic CHF with EF
20%, recently discharged from CCU for ICD firing, coming with
recurrant ICD firing. He initially presented on [**2147-8-29**] with
recurrent ICD firing in the setting of sustained VTach and was
admitted to our hospial, where he was loaded with amiodarone and
discharged to [**Hospital 100**] Rehab on amiodarone 400 Daily. He was
followed by EP service and it was decided not to pursue ablation
or further hospitalizations given patient preferences and code
status (DNR/DNI). Recently patient was in his normal state of
health until yesterday afternoon, when he had sudden oppressive
substernal chest pain that lasted a 1-2 seconds, that he
charachterized as being "shocked". He felt three more episodes
like this one and decided to come to our ER.
.
His VS were T 98.3 F, BP 110 74 mmHg, HR 76 BPM, RR 20 X', SpO2
99%. He did not receive any medications in the ER and was
admitted to [**Hospital Unit Name 196**]. A soon as he arrived on the floor he went into
VTach at 150s and code blue was called. Initially his SBP was 88
and improve with trendelenburg. He was mentating well throughout
the episode. Pads were put in place, but patient ATPx3 and then
shocked 35 J succesfully out of his VT. He received 150 mg of IV
amiodarone x1. He was transfered to the ICU for further care.
.
In the ICU he had another episode. Amiodarone 150 mg IV x1 and
then infusion at 1 mg/min was started, metoprolol 5 mg IV x1 and
then 25 mg of PO metoprolol. Attending was notified and it was
discussed with team that knows him that he has been DNR/DNI in
the past and that he was made "do not hospitalized". Multiple
attempts to contact the family were unsuccessfull.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He does endorses recent constipation for the past two days. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion (though poor exercise capacity), paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations.
Past Medical History:
MI X2 (inferior and anteroseptal)
- CABG: LIMA to LAD, SVG to OM/PDA ([**Hospital1 112**] [**2136**])
- Afib w/o anticoag (fall risk)
- Sustained VTach in [**2146**] s/p admission
- PACING/ICD: BiV ICD ([**2122**]?). ICD generator changed to
[**Company 1543**] Concerto in [**2145**].
.
3. OTHER PAST MEDICAL HISTORY:
- legally blind secondary to glaucoma
- Hiatal hernia
- Hepatic cysts/hemangioma and lipoma in hepatic flexure
- s/p Lt BKA (WWII trauma [**2078**])
- BPH s/p suprapubic prostatectomy ([**2131**])
- s/p cholecystectomy ([**2110**])
- Chronic low back pain
- Osteoarthritis
- Positive PPD in past
- Depression and anxiety
Social History:
The patient immigrated from [**Country 532**] 20 years ago; lives at [**Hospital1 100**]
Senior Center w/ wife. Former oncology surgeon w/ one daughter
and grandaughter in [**Name (NI) 86**].
-Tobacco history: None currently
-ETOH: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 96.3, P 120, BP 112/70, R 27, O2 97% on RA
.
GENERAL - well-appearing man in NAD, Oriented x3, comfortable,
Mood, affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-20**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
EKG:
AV paced 100% with ventricular rate of 70 BPM, no ST TW changes
compared to prior 07/[**2147**].
.
Telemetry:
Pt with sustained wide-complex tachycardia at rate of 150s.
Started suddenly, cannot see PVCs.
On [**9-21**], has been 48-72 hours without VT.
.
On discharge, Na 135, K 3.8, Cl 99, bicarb 24, BUN 17, Cr 1.0
.
On discharge, CBC 10.3, Hb 14.1, Hct 42.4, plt 204
.
PT: 13.3 PTT: 29.1 INR: 1.1
.
CXR [**2147-9-21**]:
FINDINGS: As compared to the previous radiograph, there is no
evidence of
pneumonia. Unchanged course and position of the pacemaker leads.
Unchanged
moderate cardiomegaly without signs of overhydration. No
left-sided pleural effusion, the right sinus is not included on
the image. Unchanged tortuosity of the thoracic aorta.
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in
[**2136**], chronic AFib with V-pacing, chronic systolic CHF with EF
20%, recently discharged from CCU with ICD firing, now returns
with recurrent VT on PO amiodarone.
.
#. Rhythm - Pt with known VTach and s/p ICD, presented due to
ICD firing. Patient went into VT and defibrillated to sinus
with 35 J on this admission in the ED. He is on amiodarone at
home and was bolused. He was also initially kept on IV lidocaine
gtt. Patient was kept on telemetry, had a short run of VT, which
resolved, and was not noted to have further events. On prior
admission, extensive discussion with patient, family, and
cardiology physicians took place, where patient refused
ablation, and corroborated DNR/DNI status. Patient stated that
he does not want CPR, shocks, intubation. During this
admission, we were not able to reach family despite multiple
attempts. Patient does not wish to pursue aggressive care, and
is NOT TO BE SHOCKED unless his code status changes. We
recommend that a family meeting be called when his family is
home to discuss goals of care and possibly a "do not
hospitalize" plan. He does not wish to have his ICD turned off
at this time or to pursue an ablation.
.
#. Pump - No signs of CHF at this time. Pt with known chronic
systolic heart failure with EF of 20%. He was continued on
statin, ASA, and metoprolol. ACEi and Lasix were held in
setting of hypotension but Lasix was restarted at previous dose
at discharge. Please restart Captopril as BP allows.
.
#. CAD - Pt with known CAD s/p CABG. Chest pain free, other than
his VT and shocks. ASA, statin, BB were continued as above.
ACEi held as above, due to hypotension.
.
#. OA - pain was well controlled on Tylenol and oxycodone.
.
# Low grade temperature: T max 100.4 PO on [**2147-9-20**]. WBC is flat,
temp [**Month (only) **] to 98 without Tylenol. BC, urine CX is pending at time
of this summary. Urinalysis is negative. CXR shows no acute
process. Mild fever likely [**3-20**] atelectasis and immobility. No
further workup is warranted unless temp rises again.
#. Anxiety - Continued on Ativan home-dose.
.
#. Code - patient is DNR/DNI. Not to be shocked. Has declined
ablation therapy.
Medications on Admission:
Aspirin 81 mg PO Daily
Atenolol 12.5 mg PO Daily
Digoxin 125 mcg QOD
Dorzolamide 2% Both eyes [**Hospital1 **]
Escitalopram 10 mg PO Daily
Lasix 120 mg PO BID
Isosorbide Mononitrate SR 30 mg Daily
Brimonidine 0.15% Both eyes [**Hospital1 **]
Latanoprost 0.005% QHS
Lorazepam 1.5 mg PO QHS
Polyethylene Glycol 3350 100% Powed Daily
Simvastatin 10 mg Daily
Nitroglycerin 0.3 mg SL PO PRN chest pain
Captopril 12.5 mg PO TId
Amiodarone 200 mg PO Daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Dorzolamide 2 % Drops Sig: Two (2) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO once a day.
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO at bedtime as
needed for anxiety / agitation.
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Ventricular Tachycardia
Chronic Systolic Congestive Heart Failure: EF 20%
Hypertension
Coronary artery disease
Discharge Condition:
stable, no VT for 72 hours
Discharge Instructions:
YOu had a reoccurance of your ventricular tachycardia. We
started intravenous amiodarone while you were in the hospital
and changed you back to your previous dose of amiodarone on
discharge. We talked to you with an interpreter and you stated
that you did not want an ablation procedure and did not want
your ICD turned off.
.
Medication changes:
1. Atenolol was changed to Metoprolol twice daily
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: none
Followup Instructions:
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) 93240**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 285**] Date/Time:[**2147-11-3**] 11:30
Completed by:[**2147-9-21**]
ICD9 Codes: 4271, 412, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4914
} | Medical Text: Admission Date: [**2102-7-8**] Discharge Date: [**2102-7-14**]
Service: TRAUMA
NOTE: Please complete the dictation that was previously
interrupted. There was a disconnection from the phone
system.
ADDENDUM CONTINUATION:
By hospital day #7, Mrs. [**Known lastname 97816**] was found to be much more
awake and oriented. The epidural catheter was discontinued
and her pain was well controlled on a po regimen. She was
reevaluated by physical therapy who thought at that time she
might benefit from a short term rehabilitation course in
order to better recover.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg po bid
2. Percocet 1 to 2 tablets po q 4 to 6 hours prn
3. Ferrous sulfate 325 mg po q day
4. Colace 100 mg po bid
5. Dulcolax 10 mg per rectum q hs prn
6. Nifedipine 60 mg po bid
7. Carbamazepine chewable tablets 100 mg po tid
8. Tylenol 650 mg po q 4 to 6 hours prn
9. Protonix 40 mg po q 24 hours
10. Sertraline hydrochloride 100 mg po q day
11. Folic acid 1 mg po q day
12. Calcium carbonate 500 mg po qid
FOLLOW UP: The patient should make follow up appointment on
the trauma clinic in approximately two weeks.
DISCHARGE CONDITION: Stable
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2102-7-14**] 13:23
T: [**2102-7-14**] 14:24
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4915
} | Medical Text: Admission Date: [**2155-9-8**] Discharge Date: [**2155-9-10**]
Date of Birth: [**2101-6-17**] Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Fevers, leukocytosis, tachycardia
Major Surgical or Invasive Procedure:
Ultrasound-guided percutaneous cholecystostomy with catheter
placment
History of Present Illness:
54yo female with T-cell lymphoma transferred from [**Hospital **]
Hospital with diagnosis of presumed cholecystitis. She was
initially admitted [**8-31**] with fevers at home to 101.9 without
localizing symptoms and was admitted overnight, labs drawn,
negative CXR and discharged on [**9-1**] apparently without
intervention. She was home for 5 days and continued to have
fevers up to 103, and re-presented to [**Hospital1 **] on [**9-6**]. Again she
had no localizing symptoms. On the day of admission her WBC was
found to be 21.8 (50% PMNs, 13% bands) up from WBC 0.8 two days
prior. She was started on vancomycin and cefepime. She had a
CXR on [**9-7**] which showed bilateral intersititial opacity slightly
worse on the right. She was additionally found to have elevated
LFTs with Tbili 2.4, Dbili 2.2, ALT initially 188, AST 130,
increasing to 245 on day of transfer. Alk phos 521.
Given the LFT abnormalities she had an abdominal ultrasound,
which showed gallbladder wall thickening, distention of
gallbladder and multiple 10mm mobile gallstones, trace
pericholecystic fluid, but no CBD dilatation (4mm). This was
thought to be consistent with cholecystitis. After the RUQ
ultrasound, this was changed to Zosyn and vanc was dc'd.
On exam she had a positive [**Doctor Last Name 515**] sign was tachycardic and
initially borderline hypotensive (unclear exact pressures),
however, received fluid resuscitation with an unclear amount of
fluid and blood pressures responded, by report systolics in the
low 100s (105/68) upon transfer, HR 140s regular sinus tach, RR
20, 95% on RA.
On arrival to the MICU, patient's VS. T 97.8 HR 134 BP 85/58 RR
24 94% 2L NC
Review of systems:
(+) Per HPI, as well as nausea, new nonproductive cough,
slightly short of breath
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies wheezing. Denies chest pain, chest pressure,
palpitations. Denies constipation, abdominal pain, diarrhea,
dark or bloody stools. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
ONCOLOGY:
[**11/2154**]: Screening colonoscopy negative.
[**2154-12-10**]: Screening PET showed no avid lesions though some low
avidity uptake at surgical margins.
[**2-/2155**]: Abdominal discomfort.
[**3-/2155**]: CT demonstrated new liver lesions. A biopsy
was performed which demonstrated a lymphoma. Limited tissue, a
clear diagnosis was not possible but pathology was consistent
with Hodgkin lymphoma.
[**2155-4-3**]: Staging PET showed enlarged right subocciptal node,
intensely avid, with avidity of the posterior paraspinal
musculature. Multiple enlarged right supraclavicular nodes.
Asymmetric thickening of right supraspinatus muscle. Multiple
intensely avid masses within the liver. Enlarged and intensely
avid aortocaval node and multiple enlarged left midabdomen
mesenteric nodes. Circumferential masslike thickening of a
portion of small bowel with an expanded lumen.
Bone marrow biopsy demonstrated no disease.
[**4-/2155**]: Right-sided neck pain; right arm pain, numbness and
weakness; night sweats. Given rapid progression of symptoms, a
second biopsy was performed on the neck lymph node and she was
started on treatment with steroids and ABVD. Pathology from
lymph node demonstrated a peripheral T-cell lymphoma. Chemo was
changed for her second cycle to CHOEP. She received 3 cycles of
CHOEP. CT following those scans demonstrates progression.
[**2155-7-28**]: ICE cycle #1.
[**2155-8-6**]: Admitted for neutropenic fever.
[**2155-8-18**]: ICE cycle #2.
.
PMH:
- Colon cancer s/p right hemicolectomy [**2153**]. 2 tumors. One
5cm,
low grade through the muscularis propria into the pericolonic
adipose tissue (t4), no lymphatic invasion. second tumor 4cm
with some lymphatic invasion. 25 negative nodes.
Microsatellite
instability negative. No adjuvant treatment.
- Celiac disease, dx at investigation of weight loss following
colectomy. Managed with diet.
PSX:
- Hemicolectomy as above.
Social History:
Started smoking in her teens, quit 2 years ago /rare ETOH/no
illicits. Works in IT.
Family History:
Mother died of breast cancer at 54. Grandmother died at 52.
Father died in 80s with CAD. 2 healthy sisters. Daughter has
celiac disease.
Physical Exam:
Admission:
Vitals: T 97.8 HR 134 BP 85/58 RR 24 94% 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, reg rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at bases bilaterally, breath sounds decreased
[**1-6**] way up right lung field, no wheezes
Abdomen: soft, minimally tender to palpation diffusely,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding, no [**Doctor Last Name 515**] sign
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge: Deceased
Pertinent Results:
Admission:
[**2155-9-8**] 08:52PM BLOOD WBC-25.8*# RBC-2.44*# Hgb-7.8*#
Hct-23.1*# MCV-94 MCH-31.8 MCHC-33.7 RDW-19.0* Plt Ct-129*#
[**2155-9-8**] 08:52PM BLOOD Neuts-83* Bands-1 Lymphs-9* Monos-5 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2155-9-8**] 08:52PM BLOOD PT-17.0* PTT-42.7* INR(PT)-1.6*
[**2155-9-8**] 08:52PM BLOOD Fibrino-470*
[**2155-9-8**] 08:52PM BLOOD Glucose-48* UreaN-11 Creat-0.8 Na-137
K-3.7 Cl-109* HCO3-11* AnGap-21*
[**2155-9-8**] 08:52PM BLOOD ALT-145* AST-112* AlkPhos-520*
TotBili-2.6* DirBili-2.4* IndBili-0.2
[**2155-9-8**] 08:52PM BLOOD Albumin-2.2* Calcium-7.3* Phos-2.1*
Mg-2.0
[**2155-9-8**] 09:59PM BLOOD Type-MIX pO2-44* pCO2-24* pH-7.29*
calTCO2-12* Base XS--12
[**2155-9-8**] 09:59PM BLOOD Lactate-7.4*
Discharge:
[**2155-9-9**] 06:45PM BLOOD WBC-62.5*# RBC-2.58* Hgb-8.0* Hct-25.9*
MCV-101* MCH-30.9 MCHC-30.7* RDW-20.5* Plt Ct-115*
[**2155-9-9**] 02:41AM BLOOD Neuts-80* Bands-0 Lymphs-2* Monos-15*
Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-1* NRBC-1*
[**2155-9-9**] 06:45PM BLOOD PT-21.8* PTT-53.6* INR(PT)-2.1*
[**2155-9-9**] 06:45PM BLOOD Glucose-145* UreaN-23* Creat-2.0* Na-133
K-4.5 Cl-98 HCO3-6* AnGap-34*
[**2155-9-9**] 06:45PM BLOOD ALT-137* AST-186* LD(LDH)-4300*
AlkPhos-478* TotBili-2.5*
[**2155-9-9**] 06:45PM BLOOD Albumin-2.6* Calcium-7.5* Phos-5.1*
Mg-2.1
[**2155-9-9**] 02:41AM BLOOD Cortsol-37.7*
[**2155-9-9**] 07:25PM BLOOD Type-ART Temp-36.7 Rates-22/4 Tidal V-550
PEEP-10 FiO2-40 pO2-97 pCO2-26* pH-7.02* calTCO2-7* Base XS--23
-ASSIST/CON Intubat-INTUBATED
[**2155-9-9**] 07:25PM BLOOD Lactate-15.1*
Microbiology:
[**2155-9-8**] 8:52 pm BLOOD CULTURE: pending
[**2155-9-9**] 2:43 am MRSA SCREEN: pending
[**2155-9-9**] 2:39 am URINE CULTURE: pending
[**2155-9-9**] 11:15 am FLUID,OTHER GALLBLADDER DRAINAGE.
GRAM STAIN (Final [**2155-9-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): Pending
ANAEROBIC CULTURE (Preliminary): Pending
Imaging:
[**9-9**] Liver/Gall Bladder Ultrasound:
IMPRESSION:
1. Circumferentially thickened gallbladder wall in the setting
of ascites. Tiny 5-mm gallbladder calculus.
2. Slightly prominent common bile duct, measuring 6 mm.
3. Small amount of ascites and right pleural effusion.
[**9-9**] CT Abd/Pelvis w/ Contrast:
IMPRESSION:
1. Circumferential wall thickening of the gallbladder in the
setting of
anasarca and free fluid within the abdomen and pelvis with no
significant
distension of the gallbladder. These findings are not classic
for cholecystitis, however, if clinical suspicions remain high,
an ultrasound and a HIDA scan is recommended to further evaluate
for acute cholecystitis. No evidence of intrahepatic biliary
dilatation.
2. Supraclavicular, mediastinal, and retroperitoneal lymph
nodes, which are not particularly enlarged by CT criteria,
however, demonstrate FDG avidity in a recent PET-CT, dated
[**2155-9-4**].
3. 1-cm hypoenhancing lesion within the segment VI of the liver,
which has
demonstrated FDG avidity on the prior PET-CT.
4. Mild splenomegaly.
5. Distal small bowel, eccentric, centrally hypoenhancing
nodule, measuring 1.9 x 1.9 cm, which is suspicious for small
bowel lymphomatous involvement or mesenteric implant.
[**9-9**] CTA: No PE
[**9-9**] Echo: IMPRESSION: Grossly preserved biventricular systolic
function. No pericardial effusion seen. Limited study due to
suboptimal acoustic windows and persistent tachycardia.
[**9-8**] CXR:
CONCLUSION:
1. New interstitial pulmonary edema is mild to moderate.
2. Bilateral mild-to-moderate pleural effusion is unchanged.
Brief Hospital Course:
Brief Course:
54yo female with T-cell lymphoma transferred from [**Hospital **]
Hospital for fever, tachycardia, leukocytosis, elevated LFTs
with suspicion for cholecystitis vs. cholangitis. Patient
developed septic shock and required 3 pressors. She also
developed respiratory failure and was intubated and ventilated.
She was covered broadly with antibiotics. She underwent
ultrasound guided cholecystoscopy and catheter placement,
however her lactate continued to increase and the patient
continued to clinically decompensate. Her family was made aware,
and decided to pursue DNR code status with comfort measures
only. Patient was taken off pressors and antibiotics and was
extubated. She expired the follwing morning.
Active Issues:
#Septic Shock: Patient was hypotensive requiring 3 pressors,
tachycardic, and febrile with leukocytosis. Source is most
likely acute cholecystitis. Patient underwent ultrasound guided
cholecystostomy with catheter placement, as she was not stable
enough to undergo cholecystectomy. Despite intervention and
broad spectrum antibiotic coverage with meropenem and zosyn,
patient's lactate continued to trend up to a peak of 15 and she
continued to be tachycardic, hypotensive, and acidotic despite
optimizing ventilator settings. In light of clinical
decompensation, the family decided to make the patient DNR, with
comfort measures only. Therefore she was extubated and pressors
and antibiotics were stopped. She was made comfortable with
morphine drip until she expired.
#Respiratory failure: Likely secondary to fluid overload or
flash pulmonary edema which is supported by bilateral pleural
effusions seen on CT and crackles on exam. PE was ruled out with
CTA. Patient's oxygenation was maintained on the ventilator, but
she continued to be acidotic despite maximizing her settings.
She was subsequenty extubated for comfort per the family's
wishes.
#Metabolic acidosis: Secondary to lactic acidosis in setting of
sepsis. Patient could not compensate respiratory wise initially
and was subsequently intubated. Acidosis could not be corrected
despite optimizing vent settings and patient was subsequently
extubated per family's wishes as mentioned above.
#Coagulopathy: INR 1.5. No signs of active bleeding. [**Month (only) 116**] be
secondary to malnutrition or liver dysfunction.
#Elevated LFTs: CT very suggestive of acute cholecystitis.
Direct bilirubinemia with elevated alk phos suggestive of
obstruction. AST and ALT also elevated may be from adjacent gall
bladder inflammation or cholangitis. Baseline at last check ALT
47, AST 22, Tbili 0.5. Patient underwent ultrasound guided
cholecystostomy, however her lactate continued to trend up and
she continued to be septic. Further intervention and antibiotics
were withheld when the patient was made comfort measures only.
# Hypoglycemia: Noted to be hypoglycemia in the 40s and 50s. She
was replaced with D50 as needed. [**Month (only) 116**] be due to liver dysfunction
and inadequate gluconeogenesis.
#Anemia: Has been running baseline in range of Hgb [**7-14**], Hgb
24-26. This is likely to be related to chemotherapy or anemia of
chronic inflammation in setting of cancer.
#T cell lymphoma: Status post one cycle of ABVD and 3 cycles of
CHOEP with
progression and C2D9 from ICE salvage. PET showing multiple
areas with lymphadenopathy and increased uptake in liver.
Patient had expressed that she did not want to continue
treatment.
Inactive Issues:
#Celiac disease: Controlled with diet.
Transitional Care Issues:
1. Code Status: DNR
2. Contact: Sister [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 44304**]
3. Pending studies: Blood and urine cultures, MRSA screen
4. Medication changes: N/A
5. Follow up: N/A
Medications on Admission:
Zosyn 3.375 gram q6h
Acyclovir 400mg PO BID (prophylaxis)
Bactrim SS one PO daily (prophylaxis)
Advair 250/50 one inhalation daily
Zofran 4mg q6h PRN nausea
Acetaminophen 1000mg q6h PRN fever
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Septic Shock
Respiratory failure
Secondary:
Acute cholecystitis
Discharge Condition:
Expired
Discharge Instructions:
Dear Ms. [**Known lastname 11084**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
with a severe infection likely from your gall bladder. We
supported you with antibiotics, and medications to help with
your blood pressure. You also had difficulty breathing so we
supported your breathing with a ventilator. We put a drain into
your gall bladder, however your infection was very severe and
all of our measures did not seem to be helping. Your family
wanted to make you comfortable, so stopped the breathing
machine. You passed away with your family at your bedside.
Followup Instructions:
None
Completed by:[**2155-9-11**]
ICD9 Codes: 0389, 2762, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4916
} | Medical Text: Admission Date: [**2103-10-1**] Discharge Date: [**2103-10-6**]
Date of Birth: [**2056-12-25**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old male
with a history of alcohol abuse and a history of cholecystectomy
at [**Hospital 4415**] on [**2103-1-17**]; during which
time a biliary stent was placed. The postoperative course was
complicated by multiple problems including a small-bowel
The patient has had chronic abdominal pain since the surgery but
now presents with diffuse worsening of the abdominal pain. The
patient describes the onset of abdominal pain four to five days
prior to admission without nausea or vomiting, without bright red
blood per rectum, without constipation, without melena. No
fevers, chills, sick contacts, or any other symptoms.
The patient says that two to three days prior to admission,
he went on an alcohol binge (which he was unable to quantify) in
order to dull the pain. He also noted watery diarrhea of about
two to three times per days for the two days prior to
presentation. These symptoms were similar to an admission to
[**Hospital1 69**] in [**2103-8-19**], but
the patient states the abdominal pain has increased in severity,
and the patient also noted substernal chest pain for two days
without radiation, without shortness of breath, without
diaphoresis, and not related to exertion.
Initially, in the Emergency Room, the patient's temperature
was 99.4, his blood pressure was 203/119, heart rate was 120,
oxygen saturation of 98% on 2 liters. He received aspirin and
nitroglycerin for concern of an acute coronary syndrome as well
as morphine sulfate intravenously times one. He also reported to
be nauseous and received and droperidol, Zofran, and Pepcid.
An electrocardiogram showed sinus tachycardia with no acute
ischemic changes; however, a CT of the abdomen showed bowel wall
thickening, inflammation of the terminal ileum as well as the
ascending colon, as well as evidence that the stent in the common
bile duct had migrated and was largely present in the duodenum
now. The patient was evaluated by Surgery who felt that
mesenteric ischemia was unlikely, and the patient was admitted to
the Medicine Service.
PAST MEDICAL HISTORY:
1. Alcohol abuse with a history of prior detoxifications;
the patient denies a history of delirium tremens or seizures.
2. Cholecystectomy with biliary stent placement.
3. Small-bowel obstruction, status post exploratory
laparotomy.
4. Enterocutaneous fistula during same admission for
small-bowel obstruction.
5. Asthma.
6. Alcoholic ketoacidosis in [**2103-8-19**] during
admission at [**Hospital1 69**].
7. Left lower leg surgery.
8. Seasonal allergies.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Albuterol as needed, thiamine,
folate, ibuprofen (it was not clear how much of each the
patient had been taking).
SOCIAL HISTORY: The patient is currently homeless. He has been
living at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House in the past. The patient denies
smoking or intravenous drug use and states he has only been using
alcohol; however, was unable to quantify.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's temperature was 99.4 degrees,
blood pressure was 115/64, heart rate was 92, respiratory
rate was 16, and oxygen saturation was 98% on room air. On
general examination, he was an awake and alert male who was
agitated and uncomfortable appearing as well as tremulous.
On head, eyes, ears, nose, and throat examination his pupils
were equal, round, and reactive. His extraocular movements
were intact. His sclerae were anicteric. His mucous
membranes were moist and without oral lesions. His
cardiovascular examination revealed tachycardic. Normal
first heart sound and second heart sound. No murmurs, rubs,
or gallops. The lungs showed diffuse wheezes without
crackles. His abdomen was soft, diffusely tender, with
voluntary guarding. Active bowel sounds were present. A
well-healed midline scar was present. Extremities revealed
2+ pulses. No edema. On rectal examination, he was
guaiac-positive in the Emergency Department. On neurologic
examination, he was alert and oriented times three. His
motor examination was [**4-22**] in all extremities. He did have a
resting tremor, but no asterixis.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
studies revealed the patient's white blood cell count was 4,
with a hematocrit of 41.6, and platelets were 344. Sodium
was 140, potassium was 3.2, chloride was 102, bicarbonate
was 22, blood urea nitrogen was 6, creatinine was 0.7, and
blood glucose was 99. Calcium was 8.6. His ALT was 128
(increased from 40 in [**Month (only) **]), his AST was 163 (increased
from 63), his alkaline phosphatase was 174, total bilirubin
was 0.4, lipase was 80. Urinalysis revealed protein of 13,
ketones of 15, and 0 to 2 white blood cells.
RADIOLOGY/IMAGING: A chest x-ray showed hyperinflation, but
no acute cardiopulmonary process.
A CT of the abdomen revealed diffuse fatty infiltrate of the
liver. No biliary ductal dilatation. No free fluid.
Gallbladder thickening from the terminal ileum extending into
the cecum and descending colon with fat stranding.
HOSPITAL COURSE:
1. GASTROINTESTINAL SYSTEM: The etiology of the patient's
abdominal pain was thought to be multifactorial. The CT
suggested an acute ileitis/colitis with a differential diagnosis
of infectious versus inflammatory versus ischemic.
The Surgical Service was following during this admission and did
not feel this was consistent with ischemic bowel.
The abdominal pain was felt to be partially due to acute
alcoholic hepatitis as well as potential pancreatitis given the
elevated lipase.
The patient was placed on a n.p.o. diet and given intravenous
fluids. Stool culture were sent which were negative at the time
of discharge. However, given the concern for potential
infectious ileitis/colitis or diverticulitis the patient was
started on a 10-day course of levofloxacin and metronidazole on
[**10-3**]. The patient's pancreatic enzymes normalized by
hospital day two, and pancreatitis was considered to be unlikely.
The patient's liver function tests remained stable throughout the
hospitalization, and it was felt that his liver involvement was
stable. The patient was given morphine sulfate as needed for
pain control.
The Biliary Service was consulted, who felt that the biliary
stent placed earlier in the year at [**Hospital 4415**]
needed to be removed given that it was mostly located in the
duodenum now, and the patient was scheduled for endoscopic
retrograde cholangiopancreatography on [**10-3**]; however, he
refused on that day feeling he was not ready; and the patient
underwent endoscopic retrograde cholangiopancreatography on
[**10-5**].
At endoscopic retrograde cholangiopancreatography, a plastic
stent in the major papilla had migrated was found and was pulled
out and sent for cytology. A filling defect in the distal common
bile duct was felt to be likely representing intra-ampullary
sphincter muscle which was treated with a successful
sphincterotomy. No stones or biliary sludge were removed.
The patient's morphine sulfate was discontinued, and he was
placed on ibuprofen for pain control. On [**10-6**], he was
started on a clear diet and advanced to solid food as tolerated
prior to discharge. The patient was to be discharged on a total
10-day course of levofloxacin and metronidazole.
Of note, given the initial concern for ischemic colitis, the
patient's lactate level was checked during the first few days
of hospitalization and was 1.9 and 1.2; respectively.
2. ALCOHOL ABUSE: On admission, the patient's blood alcohol
level was 260. The remainder of the serum toxicology and urine
toxicology screens were negative. He was placed on a CIWA scale
for withdrawal to be treated with Valium. He did require several
doses of Valium during the first day or two; however, he had not
required Valium throughout the rest of the hospitalization and
had not shown any signs of withdrawal or delirium tremens.
The Addiction Service was consulted and met with the patient.
The patient has had several periods of sobriety in the past
and did state that he was planning to remain sober after this
hospitalization and wanted to go to the [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **]
House.
CONDITION AT DISCHARGE: Stable.
CODE STATUS: Full code.
DISCHARGE DIAGNOSES:
1. Alcohol intoxication.
2. Filling defect in the distal common bile duct; likely
intra-ampullary sphincter muscle, status post sphincterotomy
on [**2103-10-5**].
MEDICATIONS ON DISCHARGE:
1. Metronidazole 500 mg p.o. t.i.d. (last day on [**2103-10-13**]).
2. Levofloxacin 500 mg p.o. q.d. (last day on [**2103-10-13**]).
3. Ibuprofen 600 mg p.o. q.4-6h. as needed.
4. Thiamine 100 mg p.o. q.d.
5. Folate 1 mg p.o. q.d.
DISCHARGE FOLLOWUP: If the patient's abdominal pain does not
improve, he will require a colonoscopy in the future to assess
for potential right-sided inflammatory bowel disease. This should
be scheduled in about six to eight weeks by calling the
[**Hospital **] Clinic at telephone number [**Telephone/Fax (1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**], M.D.
Dictated By:[**Last Name (NamePattern1) 423**]
MEDQUIST36
D: [**2103-10-5**] 22:49
T: [**2103-10-6**] 02:40
JOB#: [**Job Number 33312**]
ICD9 Codes: 2761, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4917
} | Medical Text: Admission Date: [**2170-5-22**] Discharge Date: [**2170-6-12**]
Date of Birth: [**2131-2-16**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male with a history of ETOH abuse. By report, he was found
groggy while speaking on the phone with his girlfriend. When
she came home, she found him asleep on the lawn near
midnight. She got him into the car and took him to [**Hospital 8641**]
hospital. A head CT showed intraventricular blood. He became
progressively more somnolent and was then intubated and
transferred to [**Hospital1 69**] for
further management. His blood pressure at the time was in the
240's.
PAST MEDICAL HISTORY: ETOH abuse. Allergy to shellfish.
The patient came intubated, no eye opening; pupils three,
down to two and briskly reactive. Minimal horizontal eye
movement to dull movements. No corneals. Positive gag. No
withdraw to nail bed pressure times four in the extremities.
Fundi with some obstruction of the nasal disks. Engorged
vessels on fundi but no frankly swollen disks. Head CT shows
small amount of blood in the right caudate; massive
intraventricular blood in the right lateral, left third
ventricle.
HOSPITAL COURSE: The patient was admitted to the neurologic
Intensive Care Unit. He promptly had a ventricular drain
placed and was monitored in the Intensive Care Unit.
Neurologically, the patient became more alert with frequent
dosing, oriented to person, oriented to the hospital here at
times. Conversation was confused at times. Pupils are
equal, round, and reactive to light and accommodation.
Moving all extremities with normal strength in bilateral arms
and legs weaker but able to lift them off the bed. Follows
commands. Vent training remained at 10 cms above the tragus
and opened with pink colored cerebrospinal fluid drainage.
His ICP was 4 to 16.
Over the next 24 hours, the patient was oriented times one,
moving all extremities, was following commands. His drain
was raised to 20 cms above the tragus. He had an attempted
arteriogram to look at the question of an
arteriovenous malformation.
The patient had a trial of clamping his drain, although he did
not tolerate it, and he was taken to the operating room on
[**2170-6-4**] for VP shunt placement, which he tolerated without
complications. Postoperatively, his vital signs were stable. He
was afebrile. He was awake, alert,
complaining of headaches with no drift. Grasp was strong and
equal bilaterally. The cerebrospinal fluid has been negative
to date. He was then transferred to the regular floor. His
dressings were clean, dry and intact. He was awake, alert
and oriented, no drift. Smile was symmetric. His strength
was [**4-9**] in all muscle groups. He was evaluated by physical
therapy and occupational therapy. It was determined that he
would be safe for discharge to home with 24 hour supervision;
not safe to be discharged home alone. He will require
aggressive outpatient occupational therapy for cognitive
therapy. Physical therapy cleared him for safe discharge
home, independently walking.
He will follow-up for staple removal on [**6-15**] and
follow-up with Dr. [**Last Name (STitle) 1132**] in one month. His condition was
stable at the time of discharge.
MEDICATIONS AT DISCHARGE:
Hydromorphone 2 to 4 mg p.o. q. four hours prn.
Metoprolol 50 mg p.o. twice a day.
Captopril 25 mg p.o. three times a day.
Famotidine 20 mg p.o. twice a day.
The patient's condition was stable at the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2170-6-12**] 09:17
T: [**2170-6-12**] 08:25
JOB#: [**Job Number 47649**]
ICD9 Codes: 431, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4918
} | Medical Text: Admission Date: [**2151-3-22**] Discharge Date: [**2151-4-2**]
Date of Birth: [**2081-3-22**] Sex: M
Service: CCU
CHIEF COMPLAINT: Elective cardiac catheterization.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 69 year old man
with a past medical history significant for congestive heart
failure, ejection fraction of 20%, atrial fibrillation, acute
coronary syndrome in [**2151-1-16**], intermittent left and
right bundle branch block, ACS303, treated with heparin drip
alone, hypertension, and increased lipids. He now presents
from [**Hospital3 **] for elective cardiac
catheterization and ventricular mapping for a possible
pacemaker placement.
The patient initially presented to [**Hospital1 190**] on [**2151-2-9**], with right sided weakness,
elevated cardiac enzymes consistent with a watershed
infarction of left anterior cerebral, middle cerebral artery
and increased dyspnea on exertion and orthopnea.
Cardiac catheterization could not be performed at that time
secondary to the acute cerebrovascular accident so it was
decided to postpone and the decision was made to delay to an
elective procedure. Given the patient's history of
intermittent left bundle and right bundle branch block it was
decided to perform an electrophysiology study at the time of
admission as well for a possible pacemaker for placement.
Since last discharged to [**Hospital1 **], he has recovered much of
his speech, although he has residual right sided weakness.
PAST MEDICAL HISTORY:
1. Left cerebrovascular accident in [**1-/2151**], secondary to
cardiac embolic event with residual.
2. Dilated cardiomyopathy and congestive heart failure with
ejection fraction of 20%, global hypokinesis.
3. Acute coronary syndrome, 03/[**2150**].
4. Intermittent left bundle branch block, right bundle
branch block.
5. Atrial fibrillation on Coumadin.
6. One to two plus mitral regurgitation.
7. Hypertension.
8. Hypercholesterolemia.
9. Pituitary adenoma status post resection with secondary
pan hypopyon.
10 Transitional cell carcinoma of the bladder status post
carboplatin and gemcitabine.
MEDICATIONS ON ARRIVAL:
1. Pravachol 20 mg q. day.
2. Coumadin 2.5 mg q. day.
3. Lopressor 50 mg q. a.m. and 37.5 q. p.m.
4. Synthroid 50 micrograms q. day.
5. Axid 150 mg twice a day.
6. Zoloft 25 mg q. day.
7. BHEA 25 mg p.o. twice a day.
8. Prednisone 4 mg p.o. q. day.
9. Lasix 60 mg p.o. q. day.
10. Aspirin 325 mg p.o. q. day.
ALLERGIES: No known drug allergies.
LABORATORY: White blood cell count 11.7, hematocrit 34.9,
platelets 194, INR of 1.2. Sodium of 138, potassium 4.4,
chloride 101, bicarbonate 25, BUN 21, creatinine 1.0, glucose
1.8, calcium 9.8, magnesium 1.9, phosphorus 4.8.
CK 31, troponin less than 0.3.
HOSPITAL COURSE:
1. CARDIOVASCULAR: The patient was admitted to the [**Hospital Unit Name 196**]
service for an elective catheterization. On [**2151-3-23**], the
patient underwent a cardiac catheterization with successful
percutaneous transluminal coronary angioplasty to the left
anterior descending and right coronary artery lesions.
Hemodynamics demonstrated markedly elevated filling pressures
with mean capillary wedge pressure of 30 and a cardiac index
of less than 2.0. Left ventriculography demonstrated a mild
mitral regurgitation, left ventricular ejection fraction of
20%, inferior and global hypokinesis.
Given the patient's severe heart failure as well as volume
overload, he was transferred to the Cardiac care unit for
further management.
2. PUMP: The patient was maintained on Milrinone for
inotropic support with subsequently improvement in his blood
pressure and cardiac index. The patient was waiting
electrophysiology evaluation on a milrinone holiday when on
[**2151-3-25**], he developed a temperature spike to 102.4 F. His
central venous line from cardiac catheterization in his right
groin had been removed early in the morning of [**2151-3-25**],
for concerns of possible contamination. However, given the
patient's hypotension when temperature spiked and hemodynamic
instability, a line was replaced on the night of [**2151-3-25**].
Two hours subsequently, blood cultures came back four out of
four positive for Gram positive cocci and the patient was
initiated on treatment with Vancomycin. The patient
continued to require milrinone for inotropic support over the
next six days.
Eventually, the patient was started on treatment with digoxin
and tolerated a slow wean on milrinone on [**2151-3-31**]. The
[**Hospital 228**] medical regimen for his congestive heart failure
was tailored to include Carvedilol 12.5 mg p.o. twice a day;
Captopril 6.5 mg p.o. twice a day; digoxin 0.25 mg p.o. q.
day; spironolactone 25 mg p.o. q. day.
3. ISCHEMIA: The patient underwent successful PCI to his
left anterior descending and right coronary artery lesions.
He was maintained on his medical regimen including aspirin,
Plavix, Carvostatin, Carvedilol. The patient was maintained
anti-coagulated throughout his hospitalization on heparin GTT
for his atrial fibrillation.
4. RHYTHM ISSUES: The patient continued to experience
intermittent left and right bundle branch block. Initially
the patient was atrial fibrillation with poor rate control,
however, this improved dramatically after initiation of
digoxin treatment.
5. INFECTIOUS DISEASE ISSUES: The patient with a single
temperature spike on [**2151-3-25**], with hemodynamic
instability. The patient started empirically on Levofloxacin
and Flagyl for concerns of right lower lobe infiltrate on
chest x-ray. Subsequent blood cultures drawn [**2151-3-25**],
four out of four bottles for Methicillin resistant
Staphylococcus aureus. The patient was initiated on
treatment of Vancomycin at that time. Surveillance cultures
on [**2151-3-27**], demonstrated one out of four bottles positive
and subsequent cultures on [**3-28**] and [**3-29**], demonstrated no
growth. The patient underwent removal of right internal
jugular line placed at the time of temperature spike on
[**2151-4-1**]. PICC line was placed for access for Vancomycin
treatment.
The Infectious Disease Service was consulted and recommended
a two week course of Vancomycin prior to any further
intervention.
In addition to rhythm issues, the patient was evaluated by
the Electrophysiology Service for possible biventricular
pacemaker and/or AICD. The placement of this device was
delayed, however, given bacteremia. The patient will plan to
return in two weeks time for further evaluation.
Psychiatry was consulted as the patient was with very labile
mood and strong evidence for depression. They recommended
increasing his Zoloft to 50 mg q. day and to increase it by
25 mg every two to three days as tolerated. They also
recommended the addition of Remeron 7.5 mg q. h.s to help
with insomnia.
HEMATOLOGIC: The patient did experience some decrease in
platelets with a prolonged treatment with heparin GGT
therapy. HIT antibodies were sent and were negative.
Heparin was re-introduced without incident. The patient was
continued on his Prednisone level of 4 mg p.o. q. day and
Levoxyl. During episode of hypertension associated with high
grade bacteremia, the patient also received stress dosed
steroids for two days.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post cardiac
catheterization with successful PCI to an left anterior
descending and right coronary artery lesion.
2. Methicillin resistant Staphylococcus aureus bacteremia.
3. Intermittent left and right bundle branch block.
4. Class IV congestive heart failure.
5. Depression.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Plavix 75 mg p.o. q. day times one month.
3. Carvedilol 12.5 mg p.o. twice a day.
4. Captopril 6.25 mg p.o. twice a day.
5. Pravastatin 20 mg p.o. q. day.
6. Digoxin 0.25 mg p.o. q. day.
7. Spironolactone 25 mg p.o. q. day.
8. Warfarin, dose to be titrated to keep INR between 2.0 and
3.0. The patient will need frequent monitoring of his INR.
9. Vancomycin one gram intravenously q. 24 hours through
[**2151-4-16**].
10. Protonix 40 mg p.o. q. day.
11. Domipizone 5 mg p.o. q. h.s.
12. Trazodone 15 mg p.o. q. h.s. p.r.n.
13. DHEA 25 mg p.o. twice a day.
14. Levothyroxine 50 micrograms p.o. q. day.
15. Sertraline 15 mg p.o. q. day.
16. Tylenol 650 mg p.o. q. four to six p.r.n.
17. Colace 100 mg p.o. twice a day.
18. Maalox 30 cc. q. six hours p.r.n.
19. Senna two tablets p.o. twice a day.
20. Miconazole 2% powder applied three times a day p.r.n.
21. Lasix 10 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. Follow-up for monitoring of INR.
2. Increase sertraline by 25 mg q. two to three days, up to
100 mg for desired affect.
3. Diet less than 2 gram sodium diet with 1500 cc. fluid
restriction, heart healthy.
4. Specific treatments include daily weights; need Telemetry
monitoring and Methicillin resistant Staphylococcus aureus
precautions.
5. Follow-up with Cardiology, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2151-4-2**] 15:35
T: [**2151-4-2**] 20:57
JOB#: [**Job Number 107880**]
ICD9 Codes: 4280, 4254, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4919
} | Medical Text: Admission Date: [**2132-12-7**] Discharge Date: [**2132-12-19**]
Date of Birth: [**2064-2-9**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
malaise, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 68 year-old man with a history of T cell lymphoma
s/p five cycles of CHOP (last dose [**2132-11-28**]) and recently
admitted for pneumonia/sepsis and Capnocytophaga bacteremia
([**2132-11-13**] - [**2132-11-26**], [**Hospital Unit Name 153**] admission) and abdominal pain
([**2132-12-1**] - [**2132-12-3**], no etiology identified) who presents with
malaise and fevers. He was in his USOH after his last discharge
until this morning when he awoke with malaise and fever to 100.7
at home, along with some worsening of his chronic abdominal pain
associated with antibiotic ingestion (levo and clinda for
capnocytophagia bacteremia) and right flank pain. He denied
cough, dyspnea, nausea, vomiting, and loose stools. After
consultation with his oncologist, he presented to the ED.
.
In the ED, vital signs were initially: 99.6 90 115/66 18 90%ra.
He was given vancomycin, levoflox, doxy, and clinda for presumed
infection/recurrence of his capnocytophagia bacteremia and a
chest/abdominal CT demonstrated increased bibasilar
consolidation in the lung bases concerning for progressive
lymphoma vs pneumonia, but no acute findings in the abdomen.
Labs were notable for lactate of 3. He was initially signed out
to BMT but then became hypotensive to SBPs in the 80s. He also
spiked to 101.6. His pressures responded to 4L IVFs and he was
transferred to the [**Hospital Unit Name 153**] for further management. Of note that he
completed courses of levoflox and clinda on [**12-3**].
.
REVIEW OF SYSTEMS:
(+) as above. No chest pain, shortness of breath, nausea,
vomiting, diarrhea.
Past Medical History:
1. Melanoma, right arm excised in [**2129**].
2. Question of history of histoplasmosis.
3. Right shoulder surgery for fracture and dislocation [**2129**].
4. Kidney stones 40 years ago.
Oncologic History:
Mr. [**Known lastname **] developed left inguinal swelling in [**5-17**] while in
[**Country 4194**], where it was attributed to a hernia. Upon his return to
the US in early [**Month (only) 216**], his PCP suspected left inguinal
lymphadenopathy and arranged for excisional biopsy of a part of
a lymph node. This revealed reactive changes. He was admitted to
the [**Hospital1 18**] on [**2132-9-7**]
with worsening left groin swelling and pain related to worsening
lymphadenopathy, abdominal pain and nausea. Laboratory data
remarkable for elevated LDH and significant eosinophilia (as
high as 30%.) CT imaging demonstrated bilateral basilar
pulmonary nodules and significant lymphadenopathy involving the
retroperitoneal, pelvic, and left iliac chains. Infectious
disease work-up was unremarkable. The CT findings, along with
elevated LDH, raised concern about a lymphoproliferative
disorder. SPEP revealed monoclonal gammopathy, which was
comprised of IgG lambda and constituted 1600 mg/dl. PET scan
demonstrated intensely FDG avid in the left cervical (SUV 18),
right axillary (SUV 5), left supraclavicular (SUV 17), left
paratracheal (SUV 13), retroperitoneal (SUV 22,) and left
inguinal (SUV 25) lymph node groups.
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] repeat excisional biopsy of an FDG-avid
inguinal lymph node on [**9-13**]. Flow cytometry revealed atypical
lymphohistiocytic infiltrate highly suggestive of peripheral
T-cell lymphoma NOS. On histological examination, the lymph node
architecture was completely effaced with a background of
epithelioid histiocyte granulomatoid aggregates. Intermingled
was an atypical lymphoid population that stained positive for
CD2, 3, and 5 with dual loss of CD4 and CD8 and loss CD7. The
combined morphologic and immunophenotypic picture was most
consistent with peripheral T-cell lymphoma, NOS. [**Last Name (un) **] staining
was negative. IgH gene rearrangement failed to show
monoclonality. TCR rearrangement, on the other hand, was
monoclonal. On further review of BM, he was found to have 5-10%
plasma cells in BM c/w plasma cell dyscrasia.
Social History:
Typically splits his time between [**First Name9 (NamePattern2) 82914**] [**Last Name (un) **], [**Country 4194**] and
[**Last Name (un) 51768**]. Spent the majority of the past five years in
[**Country 4194**] where his wife of several years works as a physician. [**Name10 (NameIs) **]
frequently traveled to [**Country 4194**] over the past 25 years. Patient
also has a strong social support network of friends in [**Name (NI) 108**].
Patient has traveled to Western Europe; used to smoke a pipe, 5
bowls per day x30 years. Currently living with his son and
[**Name2 (NI) 41859**] in law plus their children here in [**State 350**]. He
used to be an alcoholic but has been sober since [**2098**]. He is a
retired school teacher and used to teach in [**Last Name (un) 51768**],
[**State 108**]. He has one healthy pet dog.
Family History:
Breast cancer in mother, throat cancer in father,
and coronary artery disease in brothers.
Physical Exam:
VS: 101.6 94/54 83 96%2l 20
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
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:
CT Abd/pelv [**2132-12-7**]:
1. Interval progression of the bibasilar consolidation, with new
involvement of the right middle lobe and lingula. Given the
relative long time course and slowly progressing disease from
foci of centrilobular nodules to frank enlarging consolidation
over several months, the likelihood of an acute infectious
process (in this immuncompromised patient) seems less likely.
Therefore, progression of malignant disease is favored. However,
superimposed infectious process cannot be entirely excluded.
2. No renal calculus or hydroureteronephrosis. No acute
intra-abdominal
process. Interval decrease of inguinal lymphadenopathy.
.
CXR PA and LAT [**2132-12-7**]:
Bilateral basilar opacities, given chronicity question if
possibly indicative of progression of underlying known
malignancy over
infectious process. However, given slight increase in opacities
in
retrocardiac left lower lobe, a coincident pneumonia cannot be
excluded.
CT chest ([**2132-12-9**]): Improved mediastinal lymphadenopathy,
persistent bronchiectasis, small nodules have improved in the
lingula and right middle lobe. Also there has been improvement
in bibasilar consolidation. No areas of acute abnormalities.
1. Marked improvement of bilateral lower lobe opacities.
2. Grossly stable mediastinal lymph nodes with minimal
enlargement of AP
window lymph node, which measures up to 9 mm, previously
measured 7 mm.
3. Probable left renal cyst, stable.
4. Moderate centrilobular emphysema.
CT sinus ([**2132-12-11**]): Minimal sinus disease as described above
TTE ([**2132-12-11**]): Left ventricular wall thicknesses are normal. 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 mildly dilated
with borderline normal free wall function. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
Mr. [**Known lastname **] is a 68 year-old man with T cell lymphoma s/p five
cycles of CHOP (last dose [**2132-11-28**]) and recently admitted for
pneumonia/sepsis and Capnocytophaga bacteremia
([**Date range (1) 82915**]) who presented with malaise, progressive
fatigue and fevers and was initially admitted to [**Hospital Unit Name 153**] for
hypotension.
Sepsis/Hypotension: The patient initially met SIRS criteria with
hypotension, fever and leukocytosis. Tamiflu was initially
started but stopped when nasopharyngeal swab for influenza came
back negative. Blood and urine cultures did not yield any
organisms. Antibiotic treatment with Vancomycin, Aztreonam and
Levaquin was initated. IV fluid boluses were provided as needed
for MAP>60. TSH was wnl. The patient remained hemodynamically
stable and did not require pressors. He was called out of the
ICU the following day. CT abdomen/pelvis on admission revealed
interval progression of the bibasilar consolidation, with new
involvement
of the right middle lobe and lingula. After 5 days of empiric
coverage with Vancomycin, Aztreonam and Levaquin despite
continually negative culutres did not improve daily febile
episodes, they were discontinued. Given the credible story of
prior acute Histoplasmosis, we initiated empiric treatment with
Ambisome for re-activated chronic Histoplasmosis on [**2132-12-13**].
This resulted in resolution of febrile episodes. The patient
reported significant symptomatic improvement. CT chest was
performed and revealed marked improvement of bilateral lower
lobe opacities, grossly stable mediastinal lymph nodes. The
patient was discharge home with the plan to complete a 14 day
course of Ambisome, followed by a PO course of Itraconazole to
complete treatment for Histaplasmosis.
T cell lymphoma: The next cycle of CHOP therapy was not
initiated during this admission due to concern for active
infectious process. The patient will follow up with his
oncologists Dr. [**Last Name (STitle) 4613**] and Dr. [**First Name (STitle) **] for further management of
his T cell lymphoma upon discharge. PCP Prophylaxis was
continued.
Chronic epgastric abdominal pain: the patient had several months
of chronic abdominal epigastric pain. He was seen by GI service
on admission and [**First Name (STitle) 1834**] EGD, which did not reveal any
abnormalities in his esophagus, stomach or duodenum. The
patient was started on Carafate and Mylanta prior to his
discharge with some improvement in his symptoms.
DVT: The patient with a history of a provoked DVT being
anticoagulated with Levenox as outpatient. The patient was
Lovenox was held trasiently given possibility of invasive
diagnostic procedure, but was re-started once all procedures
were complete. The patient will continue on Lovenox for
anticoagulation upon discharge.
Medications on Admission:
MEDICATIONS AT HOME (per last discharge summary):
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous DAILY
2. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime))
prn
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H prn
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H prn
5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet Q6H
prn
6. Tamsulosin 0.4 mg Capsule, SR 1 tab po qhs
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
8. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for
nausea/vomiting.
9. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 5 days: Last day: Monday, [**12-8**].
10. Protonix 40 mg Tablet, Delayed Release (E.C.) One (1) tab
[**Hospital1 **]
11. Maalox/Diphenhydramine/Lidocaine, Sig: [**5-23**] mL qid prn
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours).
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 epigastic pain.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
7. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime)).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. AmBisome 50 mg Suspension for Reconstitution Sig: Two
Hundred (200) mg Intravenous once a day for 7 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Peripheral T-cell lymphoma, Acute pulmonary infectious
process, likely Histoplasmosis, Epigastric Abdominal Pain
Secondary: None
Discharge Condition:
Afebrile, vitals stable, able to ambulate without difficulty.
Discharge Instructions:
You were admitted to the hospital because you developed fevers
and progressive weakness and shortness of breath. You were
admitted to Intensive Care Unit because there was a concern
about your blood pressure. You received a 5 day course of oral
antibiotics, which were discontinued because they did not seem
to help with fevers. Because of the history of suspected
infection with Histoplasmosis, and your immunocompromised state,
you were started on treatment for chronic Histoplasmosis
infection. After initiation of treatment, your symptoms have
improved and your fevers resolved. You also had an endoscopy to
evaluate your chronic abdominal pain. Your esophagus, stomach
and first part of small intestine looked normal. You were
prescribed Carafate and Mylanta to help with abdominal
discomfort.
You need to continue to receive daily IV antibiotic medication
Ambisome for the next week. After that, you will be switched to
an oral medication called Itraconazole. We set up daily
appointments for you to come to the clinic to receive Ambisome
as well as Lovenox (see below).
You have follow-up appointment with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 4613**] next
week (see below). You will also be called with an appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] (infectious diseases).
1. Carafate 1gram 4 times a day
2. Mylanta 15-20ml every 4 times a day as needed for abdominal
pain
3. Ambisome 200mg IV daily for 7 days (in clinic), after which
you will be switched to oral medicine for Histoplasmosis
You should continue to take all your other medications as
previously prescribed.
Followup Instructions:
You have an appointment to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4613**] on Wednesday, [**2132-12-24**] at 1:30 pm at
[**Hospital Ward Name 23**] [**Location (un) 436**] clinic.
You will follow up with infectious disease specialist Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. You will be called with an appointment on Monday.
If you do not hear back by Tuesday, please call [**Doctor First Name 43395**] at
[**Telephone/Fax (1) 31305**].
You will need to come in daily to 7 [**Hospital Ward Name 1826**] outpatient clinic
or [**Hospital Ward Name 23**] [**Location (un) 436**] clinic for administration of Ambisome (IV
antibiotic) and Lovenox for the next week.
Your appointments are as follows:
7 [**Hospital Ward Name **] Date/Time: Saturday, [**2132-12-20**] at 11:00 am
7 [**Hospital Ward Name **] Date/Time:Sunday, [**2132-12-21**] at 11:00 am
[**Hospital Ward Name **] 7 CLINIC Date/Time:Monday, [**2132-12-22**] at 1:00 pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Tuesday, [**2132-12-23**] at 2:00 pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Wednesday, [**2132-12-24**] at 1:00 pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Thursday, [**2132-12-25**] at 12:00pm
[**Hospital Ward Name **] 7 CLINIC Date/Time:Friday, [**2132-12-26**] at 12:00 pm
Completed by:[**2133-2-13**]
ICD9 Codes: 0389, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4920
} | Medical Text: Admission Date: [**2190-3-5**] Discharge Date: [**2190-3-12**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an 85 year-old right-handed man with a PMH of PD and
dementia who was transferred from [**Hospital3 10310**] hospital with
an ICH. This history is obtained from the patients wife, OSH
records and the patient. Per the records, he reported a fall 1
week ago in the bathtub. This morning he woke up and his wife
heard him walk to the bathroom and back (they sleep in separate
rooms). She
then went to check on him around 4:30am and found him
complaining that he was cold. She noticed that he wasn't really
moving the L side. She made him coffee and put him back to bed.
Later that morning she was trying to get him changed out of
pajamas and when he stood up he fell forward onto his face.
There was no LOC. They therefore took him to an OSH. There his
BP was highest at 206/87.
He had screening labs including an INR of 1.1 and platelets of
177. A head CT was done which showed a R parietal bleed, he was
give Cerebryx 1gm and he was transferred here for further care.
Of note, he has a history of falls and slipped in the bathroom
1-2 weeks ago, but had no LOC and was baseline afterward
ROS: (per wife)
Denied headache, loss of vision, dysarthria, dysphagia,
lightheadedness. Denied difficulties producing or comprehending
speech. + chronic constipation. denied recent fever or chills.
No night sweats or recent weight loss or gain. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied arthralgias or myalgias. Denied rash.
Past Medical History:
- HTN
- Hx of falls
- Hernia bilaterally (?)
- cataracts surgery
- glaucoma
- vein stripping
- GI polyps
- "Prostate problems", not CA per wife
Social History:
-lives with his wife and is independent in his ADLS
-Alcohol: denies
-tobacco: denies
-drugs: denies
Family History:
non contributory
Physical Exam:
Vitals: T: 98.4 P: 56 R: 16 BP: 158/73 SaO2: 100
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: decreased ROM in all directions, no carotid bruits
appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema.
Skin: scars over knees
Neurologic:
-Mental Status: Alert, requesting repeatedly to go to the
bathroom and insisting that he cannot use a bed pan. Oriented to
person, hospital and [**Month (only) 958**] but not day or year. Unable to
provide details of history. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt does not cooperate with all aspects of the
exam but is able to name high frequency objects and follow
simple commands. Reads without difficult as well. Pt always
looking to the R side of room but when prompted does attend to
the L side and is able to turn head to look to the L. Does not
move the L hand or leg spontaneously. When asked why he is here
he notes that there is something wrong with the L side but does
not understand why he can't get up to go to the bathroom and
says he can walk "fine".
CN
I: not tested
II,III: blinks to threat inconsistently, does not cooperate with
VF testing. pupils ovid and surgical bilaterally, unable to
visualize fundi
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-13**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk, increased tone (?paratonia vs rigidity) in
all extremities w/ + cogwheeling in R wrist. R resting tremor.
Pt does not cooperate with formal strength testing but is
briskly antigravity on the L arm and leg. The R arm falls to the
bed when picked up and the L leg moves antigravity < 5 seconds
when prompted. However with nox stim, the pt moves his L fingers
and flexes at the elbow. He does not improve however when his
hand is shown to him.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 0 0 Up
R 2 2 2 0 0 Up
-Sensory: No deficits to nox stim throughout, does not cooperate
with other modalities consistently. + extinction to DSS on the L
-Coordination: pt does not cooperate with testing.
-Gait: deferred given weakness
Pertinent Results:
[**2190-3-5**] 01:20PM BLOOD WBC-9.4 RBC-4.31* Hgb-13.8* Hct-39.9*
MCV-92 MCH-32.0 MCHC-34.6 RDW-14.3 Plt Ct-187
[**2190-3-5**] 01:20PM BLOOD PT-13.2 PTT-29.4 INR(PT)-1.1
[**2190-3-5**] 01:20PM BLOOD Glucose-109* UreaN-15 Creat-1.0 Na-145
K-4.0 Cl-107 HCO3-27 AnGap-15
[**2190-3-5**] 01:20PM BLOOD ALT-20 AST-21 CK(CPK)-59 AlkPhos-202*
TotBili-0.4
[**2190-3-5**] 01:20PM BLOOD cTropnT-<0.01
[**2190-3-6**] 02:30AM BLOOD Triglyc-63 HDL-39 CHOL/HD-2.7 LDLcalc-53
[**2190-3-6**] 02:30AM BLOOD %HbA1c-5.6
CT HEAD ([**3-6**]): 1. Right parieto-occipital intraparenchymal
hemorrhage, with moderate surrounding edema and local mass
effect.
2. Small overlying subarachnoid hemorrhage.
MRI/A of HEAD ([**3-6**]): Limited study with only FLAIR T1 and
diffusion images acquired. Right parietal hematoma is
visualized. No underlying infarct seen.
Somewhat most-limited MRA of the head without significant
abnormalities.
CT HEAD ([**3-8**]): No new areas of hemorrhage.
Brief Hospital Course:
The pt is an 85 year-old RH man with a PMH of PD and dementia
who was transferred from an OSH after being found to have a R
parietal bleed. He reportedly was in his USOH yesterday and was
able to walk this morning, however when his wife checked on him
around 4:30 he was unable to move his L side. He then fell later
in the morning while trying to change clothing. He was found to
have a large R parietal superficial
bleed with a small amount of SAH. He was also hypertensive
initially.
On exam, he has L sided weakness, neglect and possible agnosia.
Given his presentation and location of bleeding plus his age,
this is most likely amyloid angiopathy. Underlying abnormal
vessels or mass were ruled out with MRI/A of the head. Although
he did not require intubation, given bleed he was initially
admitted to the ICU where he remained stable overnight then
subsequently transferred to the step down unit.
Patient was also enrolled in the Deferoxime in ICH trial for
which he received total 3 days of Deferoxime infusion from
3/27~[**3-7**] without adverse reaction. He is being followed up for
these studies by his stroke physician, [**Initials (NamePattern5) **] [**Last Name (NamePattern5) **].
Patient was admitted to the stepdown unit for 3 days. Systolic
blood pressure was in the range of 170-150. On [**2190-3-8**] Atenolol
was discontinued and Metoprolol was started.
Constipation was an issue on the floor, he was put on an
aggressive bowel regimen which helped his bowels, and he has had
bowel movements daily over the past 3 days. He was sleepy on
Keppra, therefore, it was stopped, he had no seizures on the
floor.
Medications on Admission:
Simvastatin 40 mg daily
Atenolol 25 mg daily
Aspirin 81 mg daily
Seroquel 25 mg daily
Exelon patch
Xalatan 0.005% 2.5 drops each eye daily
Combigan 0.2/0.05% 1 drop each eye daily
Miralax
Colace Osteo Biflex
Centrum Silver
"Sleeping pill"
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) Transdermal
Qday ().
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily).
9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
10. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 511**] [**Hospital 62289**] Hospital at [**Location (un) 4047**]
Discharge Diagnosis:
Primary
Right parietal hemorrhage
Presumed Amyloid angiopathy
Constipation
Secondary
Hypertensive disorder
Parkinson's Disease
Dementia
Discharge Condition:
Left hemiparesis with neglect
Discharge Instructions:
you were admitted to the hospital after sudden onset of left
sided weakness. You had a head CT which showed large bleeding in
the right side of your brain. You were admitted to the ICU for a
few days and then transferred to the floor, subsequent CT showed
stable hemorrhagic lesion.
If you have worsening of your symptoms, please go to your
nearest ER.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2190-4-7**] 1:00
Completed by:[**2190-3-12**]
ICD9 Codes: 431, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4921
} | Medical Text: Admission Date: [**2131-4-16**] Discharge Date: [**2131-4-19**]
Date of Birth: [**2069-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2131-4-16**] Coronary artery bypass grafts x3 (LIMA-LAD, SVG-OM,
SVG-PDA)
History of Present Illness:
Mr. [**Known lastname **] is a 62 year old male with known coronary artery
disease and insulin dependent diabetes mellitus for the last 50
years. He has history of prior inferior myocardial infarction
and underwent RCA stenting back in [**2124**]. Despite medical
therapy, he has recently noted an increase in his anginal
symptoms. On the morning of admission, he awoke with "heart
burn" which was relieved with sublingual Nitro. He presented to
[**Hospital3 **] and was eventually transferred to the [**Hospital1 18**] for
cardiac catheterization. Cardiac cath revealed severe three
vessel coronary artery disease and surgical revascularization
was recommended. Given patient was on Plavix, surgery was
delayed to allow for washout.
Past Medical History:
Coronary artery disease
Insulin dependent diabetes mellitus
History of Myocardial Infarction [**2119**]
Prior RCA stent [**2124**], [**2125**]
Hypertension
Hyperlipidemia
Carotid Disease
H/o Grave's disease( s/p ablation)
Bipolar disorder - type I
s/p cervical laminectomy
s/p carpal tunnel surgery
s/p rotater cuff repairs
Social History:
Lives with friend who helps him with his medications.
-Tobacco history: None
-ETOH: none
-Illicit drugs: none
Family History:
Father with MI at 57, GF with MI in 50s.
Physical Exam:
BP 126/56, HR 67, RR 18
Height 71 inches
Weight 171 pounds
General: Well appearing male in no acute distress
Skin: unremarkable
HEENT: oropharynx benign
Neck: supple, no JVD
Chest: lungs clear bilaterally
Heart: regular rate and rhythm, normal s1s2, [**1-5**] soft systolic
ejection murmur
Abdomen: benign
Ext: warm, no edema
Neuro: grossly intact
Pulses: 2+ bilaterally, bilateral carotid bruits noted
Pertinent Results:
[**2131-4-16**] Intraop TEE:
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium or left atrial appendage. No
thrombus is seen in the left atrial appendage. No spontaneous
echo contrast is seen in the body of the right atrium or right
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 30 cm
from the incisors. There are simple atheroma in the ascending
aorta. There are simple atheroma in the aortic arch.
5. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation. Trivial mitral regurgitation is seen.
7. There is no pericardial effusion.
POST-CPB: On infusion of phenylephrine. A-pacing for slow sinus
rhythm. Preserved biventricular systolic function. Trivial MR.
Aortic contour is normal post decannulation.
[**2131-4-19**] 05:45AM BLOOD WBC-8.2 RBC-3.54* Hgb-12.1* Hct-33.7*
MCV-95 MCH-34.1* MCHC-35.9* RDW-14.0 Plt Ct-159
[**2131-4-19**] 05:45AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-136
K-4.3 Cl-96 HCO3-32 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) 914**]. For surgical details, please
see operative note. Following the operation, he was brought to
the CVICU for invasive monitoring. Within several hours, patient
awoke neurologically intact and was extubated without incident.
He maintained stable hemodynamics and transferred to the step
down floor on post-operative day one. Chest tubes and pacing
wires were removed without complication. Beta blockade and
psychiatric medications were resumed. Over several days, he
continued to make clinical improvement with diuresis. By
post-operative day three he was ready for discharge to home.
Medications on Admission:
Aspirin 81 qd, Lantus Insulin, Clonazepam 5 [**Hospital1 **], Amlodipine 5
qd, Strattera 40 [**Hospital1 **], Lipitor 80 qd, Lamictal 100 qd, Toprol 25
[**Hospital1 **], Euthyroid 150 qd, Zoloft 100 qd, Plavix - stopped
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. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atomoxetine 40 mg Capsule Sig: Two (2) Capsule PO daily ().
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed. Tablet(s)
10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous once a day.
12. Lamictal 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease, s/p cornary artery bypass grafts
Insulin dependent diabetes mellitus
History of Myocardial Infarction
Prior RCA stent [**2124**]
Hypertension
Hyperlipidemia
Carotid Disease
H/o Grave's disease( s/p ablation)
Bipolar disorder
Discharge Condition:
Good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in 2 weeks ([**Telephone/Fax (1) 62**]
Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4127**] in [**12-1**] weeks ([**Telephone/Fax (1) 8894**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Please call for appointments
Completed by:[**2131-4-19**]
ICD9 Codes: 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4922
} | Medical Text: Admission Date: [**2165-12-11**] Discharge Date: [**2165-12-17**]
Date of Birth: [**2105-8-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 18627**] is a 60 year old female with a hx of DM2, HTN, and CVA
who presents with dyspnea x 3 days. Pt states that her symptoms
began acutely on Sunday evening when she was lying supine. She
stated that she has previously never had similar symptoms. She
states that her shortness of breath is worse at night when she
lays down and is relieved with sitting up. This AM, she was
noted at her PCP's office to be in afib with RVR (140s) and also
had TWI in lateral leads that were new.
.
In the ED, VS were BP 108/72 HR 115 O2sat 95%RA. Given her RVR,
patient recieved IV dilt 10mg x 4 and dilt 30mg po. Her HR
decreased to the 110s and she remained HD stable during the
entire episode. Patient also had SOB and chest pressure in the
ED and responded to nitro. In addition, the patient received a
dose of cipro for a positive UA, though she denies dysuria. She
was also found to be in ARF with a Cr of 1.4 (b/l 0.8) and
received 2L of NS. However, her BNP was later found to be
significantly elevated to 7600.
.
Pt was initially admitted to the floor. She was initially rate
controlled with PO Metoprolol and IV Lopressor with 1 dose of
Diltiazem. In addition a Bedside ECHO done (given low voltage on
EKG, ? muffled heart sounds and possible concern for pericardial
ffusion)-->showed EF 15% that was new and no evidence of
effusion. In addition, her BP remained low 70-80s and thus
decision made to transfer to CCU for closer monitoring and
inotropic support with dobutamine.
.
Patient denies having any recent colds, but admits to allergies
associated with rhinorrhea and watery eyes.
.
Denies fever or chills. Admits to nausea and vomiting. No
diarrhea, constipation or abdominal pain. No melena or BRBPR.
Past Medical History:
PMH:
- Type 2 diabetes
- History of cerebrovascular accident
- Depression
- Remote history of necrotizing fasciitis
Social History:
Social Hx: Lives with nieces and nephew. Non-[**Name2 (NI) 1818**], rare
alcohol use. Practicing Catholic.
Family History:
Family Hx: Father died of MI at age 50. Positive for lung and
throat cancer in siblings who smoked.
Physical Exam:
Vitals: T: 98.9, 113, 127/75, 85, 25, 97%RA
General: Alert and oriented x 3, NAD
HEENT: ATNC, EOMI, no aniscoria
Neck: supple, 12 cm JVD. No carotid bruits
Pulmonary: CTAB, no wheezes or rhonchi.
Cardiac: irreg irreg, distant HS, no murmurs, rubs, or gallops.
RV heave, laterally displaced PMI.
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly
Extremities: 1+ LE edema, 2+ PT/DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no echymoses. Extremities were cool on examination prior
to transfer to CCU.
Neuro: CN grossly intact
.
Pertinent Results:
[**2165-12-11**] 07:30PM CK(CPK)-60
[**2165-12-11**] 07:30PM CK-MB-NotDone cTropnT-0.03*
[**2165-12-11**] 07:30PM HBsAg-NEGATIVE HBs Ab-NEGATIVE
[**2165-12-11**] 07:30PM HCV Ab-NEGATIVE
[**2165-12-11**] 12:30PM URINE HOURS-RANDOM CREAT-350 SODIUM-33
[**2165-12-11**] 12:30PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.029
[**2165-12-11**] 12:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-MOD
[**2165-12-11**] 12:30PM URINE RBC-0-2 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-[**7-16**]
[**2165-12-11**] 12:30PM URINE HYALINE-0-2
[**2165-12-11**] 12:00PM estGFR-Using this
[**2165-12-11**] 12:00PM ALT(SGPT)-74* AST(SGOT)-45* CK(CPK)-62 ALK
PHOS-132* TOT BILI-0.6
[**2165-12-11**] 12:00PM cTropnT-0.02*
[**2165-12-11**] 12:00PM CK-MB-NotDone proBNP-7612*
[**2165-12-11**] 12:00PM ALBUMIN-4.0 CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-1.5* IRON-40
[**2165-12-11**] 12:00PM calTIBC-307 FERRITIN-270* TRF-236
[**2165-12-11**] 12:00PM TSH-1.2
[**2165-12-11**] 12:00PM FREE T4-1.3
[**2165-12-11**] 12:00PM WBC-10.7# RBC-3.68* HGB-11.5* HCT-34.1*
MCV-93 MCH-31.2 MCHC-33.7 RDW-14.4
[**2165-12-11**] 12:00PM NEUTS-81.2* LYMPHS-14.4* MONOS-3.8 EOS-0.3
BASOS-0.2
[**2165-12-11**] 12:00PM PLT COUNT-240
[**2165-12-11**] 12:00PM D-DIMER-2381*
[**2165-12-11**] 12:00PM RET AUT-2.6
ECHO [**12-11**]:
The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF =15-20 %). Transmitral Doppler
imaging is consistent with Grade III/IV (severe) LV diastolic
dysfunction. The right ventricular cavity is markedly dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-6**]+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Severe global biventricular systolic dysfunction.
Elevated filling pressures. Mild to moderate mitral
regurgitation. Moderate tricuspid regurgitation.
Brief Hospital Course:
ASSESSMENT: 60 year old female with a hx of DM2, HTN, and CVA
who presents with dyspnea x3 days, AFib, and new dilated CM with
EF 15-20%.
.
# Atrial fibrillation: Patient presented in a. fib with RVR and
was managed in the ED with IV and po diltiazem, though she
required high doses of each. On the floor, she again became
tachycardic with afib with RVR and was given IV and po
lopressor. A bedside ECHO was performed for concern of
pericaditis, as the patient had low voltage on her EKG and there
was some concern that she may have had a pericardial effusion.
The study revealed acute, decomponsated CHF, with a dilated
cardiomyopathy and an EF of 15%, compared to a baseline EF of
56% on [**5-14**]. She also became hypotensive with SBPs in the 80s
and was transferred to the CCU. It was thought that she had
received too much negatively inotropic medication.
In the CCU, the patient was started on dobutamine gtt with goal
SBP > 100. This [**Doctor Last Name 360**] was rapidly weaned. TEE was done which
did not reveal any [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] or echo contrast. Therefore,
cardioversion was attempted. However, this failed. She was
started on amio and lisinopril were started. Dig was
subsequently added for further rate control. Carvedilol was up
titrated and she was started on coumadin for anticoagulation.
#CHF, systolic, new diagnosis: Stable. Patient's BPs when she
reached the CCU was 60-80s systolic. On exam, patient's lungs
were CTAB, 12 cm JVD, cool extremities, c/w cardiogenic shock.
Patient's BPs have been low, likely compounded with AFib with
RVR. The pt briefly required pressors, but was off dobutamine by
the morning following admission. Pt was started on a lasix drip
and diuresed well and was transitioned to stable lasix dose. Sx
of hf and pressor requirement resolved completely.
.
# Dilated Cardiomyopathy: Though the etiology of the patient's
dilated CMP cannot be determined definitively, her toxicology
screen was found to be positive for cocaine and she endorses
ETOH use. Of note, the patient's ECHO did not show evidence of
amyloid and her iron studies and TSH were all normal, with the
exception of an elevated ferritin. Viral studies have been
negative: HIV, CMV, EBV (Igm neg).
.
# ARF: Patient was found to be in ARF with a Cr that peaked at
2.0 compared to a b/l of 0.8. Pt was thought to be prerenal
from poor systolic function and Cr decreased to 1.4 by the time
of discharge.
.
# UTI: Positive UA. Started on cipro in ED for ?UTI,
asymptomatic. Urine sample contaminated with epithelial cells.
Repeat UA was negative and cipro was stopped.
.
# Transaminitis: Pt had elevated LFTs on admission with ALT and
AST that peaked at 1100 and 1900. LFT's trended down as
pressures and forward flow improved.
.
# DM2: HbA1C <6% on recent evaluation. Patient was managed with
an ISS and oral hypoglycemics were held. Given new diagnosis of
heart failure pt was swiched to glyburide 5mg po bid (actos,
metformin were dc'd given CHF).
Medications on Admission:
CLOPIDOGREL 75 mg daily
FLUOXETINE - 20 mg Capsule - 1 Capsule(s) by mouth m,w,f. 2 on
t,t,s,s for depression
METFORMIN - 1000mg [**Hospital1 **]
PIOGLITAZONE [ACTOS] - 45 mg Tablet - [**2-6**] Tablet(s)(s) by mouth
once a day for sugar
PRAVASTATIN [PRAVACHOL] - 20 mg Tablet - 1 Tablet(s) by mouth
once a day for cholesterol
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply twice a day as
needed for rash
ASA 81
Discharge Medications:
1. Outpatient Lab Work
Please check INR on Thursday [**12-19**] and call results to Dr.
[**Last Name (STitle) 8499**] at [**Telephone/Fax (1) 7976**]
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO QMWF ().
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO QTTSS ().
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed for RASH.
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): start [**2165-12-17**].
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
11. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Atrial fibrillation
Acute dilated cardiomyopathy
Acute congestive Systolic Heart Failure
.
Secondary:
Type 2 diabetes
Cerebrovascular accident
Depression
History of necrotizing fasciitis
Discharge Condition:
Good
Discharge Instructions:
You were admitted because of shortness of breath. We diagnosed
you with a heart arrhythmia called atrial fibrillation. We also
determined that you had heart failure, as your heart was
dilated. You had congestive heart failure which means that your
heart is weak. To treat you for these conditions, we gave you
medications to slow your heart rate down and improve its pump
function.
You will need to start warfarin (coumadin) to prevent blood
clots and strokes. Both the atrial fibrillation and weak heart
function put you more at risk for a stroke or clot.
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
.
New Medicines:
1. Warfarin: to prevent blood clots and strokes. The goal blood
level of warfarin is [**3-10**]. You will need to have your blood drawn
frequently until we have you on the right dose of warfarin.
Please see the sheet given to you about taking and monitoring
warfarin. Do not take warfarin tonight, resume taking 2mg
tomorrow [**12-18**].
2. Furosemide: a diuretic to prevent fluid accumulation
3. Lisinopril: to help you heart beat stronger and lower blood
pressure
4. Carvedilol: to lower your heart rate and help your heart beat
stronger
5. Amiodarone: to keep your heart rate low
6. Glyburide: to replace Actos and Metformin for your diabetes.
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet: information was given to you.
Fluid Restriction: 1.5L or about 7 cups per day.
.
You will need your liver function and thyroid function rechecked
in about 1 month.
Followup Instructions:
Scheduled Appointments :
Primary Care:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2165-12-30**] 8:30(Group diabetes Visit)
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2165-12-19**] 9:30 (personal visit with doctor)
Cardiology:
Provider:
[**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone: [**Telephone/Fax (1) 62**] Tuesday [**1-7**] at
1:00pm.
Completed by:[**2165-12-25**]
ICD9 Codes: 4254, 5849, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4923
} | Medical Text: Admission Date: [**2165-6-25**] Discharge Date: [**2165-7-6**]
Date of Birth: [**2101-2-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Barrett's esophagus with high-grade dysplasia.
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy.
Transhiatal esophagectomy with left cervical
esophagogastrostomy.
Feeding jejunostomy.
Left sided chest ultrasound and diagnostic and therapeutic
paracentesis.
History of Present Illness:
Mrs. [**Known lastname 696**] is a 64 year-old female with known [**Doctor Last Name 15532**]
esophagus found to have high-grade dysphasia on screening EGD.
Past Medical History:
[**Doctor Last Name 15532**] Esophagus
Hiatal Hernia
Hypothyroidism
Social History:
Married with 4 healty children. Waitress
Tobacco: never. ETOH rare
Family History:
Mother died age [**Age over 90 **] s/p hip fracture
Father died age 84 of DMT2 complication
Siblings: 2 sisters, 3 brothers 1 died ag 50 of degenerative
neuro disease
Physical Exam:
Afebrile, AVSS
NAD
RRR
CTAB
SNTND BS+
Wound CDI
No c/c/e
Pertinent Results:
Tissue Pathology [**6-25**]
I. Esophagus and proximal stomach, esophagogastrectomy (A-Y):
1. Barrett's esophagus with small foci of intramucosal
carcinoma, arising in a background of extensive high grade
glandular dysplasia; see synoptic report.
2. No submucosal invasion is identified; examined esophageal
and gastric resection margins are free of malignancy and
dysplasia.
3. Squamous epithelium with mild active esophagitis.
4. Gastric segment with unremarkable fundic mucosa.
5. Eight (8) regional lymph nodes with no carcinoma identified
(0/8).
II. Left gastric lymph nodes, regional resection (Z-AC):
Six (6) lymph nodes with no carcinoma identified (0/6).
.
Pleural fluid [**7-1**] NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells and histiocytes.
.
[**6-25**] CXR
IMPRESSION:
1. Endotracheal tube entering right mainstem bronchus and likely
associated left basal atelectasis/consolidation and probable
pleural effusion.
2. Nasogastric tube passes below the diaphragm with its sidewall
hole at the level of the diaphragm.
[**6-28**] CXR
NG tube tip is in unchanged position. Left lower lobe
retrocardiac opacity is persistent, corresponding to atelectasis
or pneumonic consolidation. Right lung remains clear. There is
no pneumothorax. Small left pleural effusion is unchanged as is
cardiomediastinal silhouette
[**7-1**] CXR
Decreased small left pleural effusion. Left lower lobe
atelectasis. Dilated neo esophagus with air-fluid level.
Brief Hospital Course:
Pt was admitted to Thoracic surgery s/p transhiatal
esophagectomy on [**2165-6-25**]. The patient tolerated the procedure
well without complications and with an EBL of 600. Post
operatively, the patient was transfered to the ICU per
esophagectomy protocol and was tranfused 1 u PRBC. The patient
was extubated on the night of POD#0. On POD#2, tolerated trophic
tube feeds at 30cc/hr. On POD#3, NGT was dc'd without issues.
On POD#6, epidural was d/c'd, tube feeds were held [**12-21**] nausea,
and pleural fluid was tapped by IP [**12-21**] increasing left sided
pleural effusion. On POD#9 pt passed the grape juice swallow
test and tolerated clears without nausea. On POD#10, JP was
dc'd and TF were advanced to goal, both without any
complications. On POD#11, staples were removed from her wound
and steristrips placed. Upon discharge, the patient was
afebrile with all vitals stable, tolerating full liquid diet,
ambulating well, and with pain controlled on po pain meds.
Medications on Admission:
Prilosec 40 mg once daily
Synthroid 75 mcg once daily
Discharge Medications:
1. Replete/Fiber Liquid Sig: 55 (fifty-five) cc PO every
hour: Please attach to pump so she gets a continuous flow of
tube feeds running at 55cc/hr. Thanks.
Disp:*60 bottles* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 5ml packs* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: please take while you are using pain meds.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
Barrett's esophagus with high-grade dysplasia s/p
esophagogastroduodenscopy & feeding jejunostomy
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you experience chest
pain, shortness of breath, fever, chills, nausea, vomiting,
diarrhea, or abdominal pain.
If your feeding tube sutures become loose or break, please tape
the tube securely and call the office [**Telephone/Fax (1) 170**]. If your
feeding tube falls out, save the tube, call the office
immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a
timely manner because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Flush your feeding tube with 50cc of water every 8 hours if not
in use and before and after every feeding.
Followup Instructions:
Please call to schedule your follow-up appointment with Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] on the [**Hospital Ward Name 517**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) **].
Please report to the [**Location (un) **] radiology department a chest
x-ray 45 minutes before your schedule appointment.
Also, please call the office about your barium swallow study the
morning of your appointment.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**]
ICD9 Codes: 5180, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4924
} | Medical Text: Admission Date: [**2117-6-28**] Discharge Date: [**2117-7-16**]
Service: BLUE SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 82 year-old
Chinese gentleman who presented with a chief complaint of
constipation. He is a gentleman with a past medical history
of Parkinsonism, hypertension who started reporting change in
bowel habits since [**2117-1-13**]. He has had multiple
episodes of diarrhea and fecal incontinence and had an
episode of bright red blood per rectum in [**2117-5-13**]. He
was evaluated in the Emergency Department and was found to
have fissure on ______________. In [**2117**] Mr. [**Known lastname **] started
reporting symptoms of constipation and underwent colonoscopy
on [**6-28**]. A colonoscopy done by Dr. [**First Name (STitle) **] [**Name (STitle) **] and Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 111702**] found a circumferential nonbleeding mass of
malignant appearance at the rectum causing near complete
obstruction. The patient was consulted for possible surgical
treatment.
On admission the patient's heart rate was in the 70s. The
blood pressure 127/70. Respirations comfortably and
saturating 99% on 2 liters. The patient was awake, alert and
able to follow commands. The patient was not able to speak
consistent with his past medical history of Parkinson's
disease. His cardiac examination was significant for
irregularly irregular heart rate, which is consistent with
his past medical history of atrial fibrillation. His lung
examination was clear. The abdomen was soft, but slightly
distended and full in the lower quadrants. There was no
distance masses palpated. Bowel sounds were present. On
digital rectal examination at approximately 3 cm deep a firm
circumferential mass was palpated and examiner could not pass
the digit beyond the mass.
The patient was preoped and was taken to the Operating Room
on [**2117-7-1**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**]. Please see the
operative report for the detailed information. The patient
underwent end sigmoid colostomy. The patient was stable upon
completion of the operation and was bolused according to
anesthesia and he was taken to the Intensive Care Unit as a
prophylacting measure. During the Intensive Care Unit stay
the patient did not pass any flatus or gas out of the stoma
and was getting progressively distended. The patient
experienced respiratory distress presumably due to his
increasing abdominal distention. The patient was intubated
and sedated and put on mechanical ventilation. The patient
underwent a gastrograph and stoma study in which the flow of
grafting was seen going to the rectum instead of into the
proximal bowel. The patient was emergently brought back to
the Operating Room on [**2117-7-5**]. Upon exploration of the
abdomen the distal sigmoid was looping through the lower
right quadrant confusing the anatomy. In addition, there was
significant adhesions of the sigmoid colon making it to
appear as if going into the rectum. A new stoma was created
and mature and upon entrance gas and stool were released.
Please see the operative report for surgery dated [**2117-7-5**] for
further details. At the end of the operation the patient was
brought back to the Intensive Care Unit. The patient's
descended abdomen gradually decreased through his Intensive
Care Unit stay. The patient was successfully weaned off the
ventilator and successfully extubated. The patient left the
Intensive Care Unit on the [**7-9**] and was transferred
to the regular floor.
The patient recovered well on the floor without any
respiratory difficulties. The new colostomy produced fecal
contents and gas. The patient was supported via DP and
nutrition and was advanced to clears and then to solid foods
as tolerated. On postoperative day 15 and 11 respectively,
the patient fully tolerated full diet and was no longer
needing total parenteral nutrition. The patient had a very
active bowel sounds. The abdomen was soft, nontender,
nondistended with colostomy working well producing adequate
amounts of stool and gas. The patient was discharged to
[**Hospital3 **] Center.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to [**Hospital3 **].
DISCHARGE DIAGNOSES:
1. Rectal carcinoma undifferentiated type.
2. Lower gastrointestinal obstruction.
3. Parkinson's disease.
4. Polyrheumatica myalgia.
5. Hypertension.
6. Chronic atrial fibrillation.
7. Glaucoma.
FOLLOW UP PLANS: The patient is to be followed as an
outpatient by the Oncology Service and the Radiation Oncology
Service at [**Hospital1 69**]. The patient
is also to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**] Department of
Surgery for surgical treatment after chemotherapy and
radiation therapy. Please call Dr.[**Name (NI) 6275**] office for an
appointment.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2117-7-16**] 11:52
T: [**2117-7-16**] 12:06
JOB#: [**Job Number 111703**]
ICD9 Codes: 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4925
} | Medical Text: Admission Date: [**2190-11-23**] Discharge Date: [**2190-12-6**]
Date of Birth: [**2110-1-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
5.6-cm infrarenal abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2190-11-23**] Resection and repair of abdominal aortic aneurysm
with 20-mm Dacron tube graft.
History of Present Illness:
This 80-year-old gentleman has a juxtarenal, 5.6-cm, infrarenal
abdominal aortic aneurysm, enlarging over the last year. His
anatomy was not suitable for endovascular repair due to a lack
of a proximal neck, and he was electively scheduled open repair
via a retroperitoneal approach.
Past Medical History:
Hyperlipidemia
COPD
Possible CAD based on nuclear imaging stress test (2 months
prior to admission, small mild fixed perfusion abnormality of
the inferior wall with hypokinesis and an EF of 53%)
Left internal carotid stenosis 70-90%
Dysphagia
Aortic aneurysm -measured at 4.2 x 3.9cm by U/S dated [**2189-7-7**]
Right common iliac artery aneurysm measuring 1.9cm from study
dated [**11-30**]
cataract surgery bilaterally [**11-2**]
Skin cancer removed left ear
Left hand growth removed
Eczema
Social History:
-Tobacco history: 62 pack year history of smoking, quit 3
months ago
-ETOH: on wednesdays
Family History:
father died at 87, mother died of 89. 1 of 14 siblings.
Brother with MI in 40s.
Physical Exam:
T: 99 HR: 68 BP: 122/73 RR: 18 Spos: 96%
NAD, Alert and oriented x3
Neuro: CN II-XII
Cardiac: RRR
Lungs: CTA bilaterally
Abd: soft, NT, mildly distended, + BS x 4, + BM [**12-5**]
Abdominal incisions open to air, staples removed. Steri strips
intact. NO s/sx of infection.
Pulses: Fem DP PT
Left palp palp palp
Right palp palp palp
Pertinent Results:
[**2190-12-6**] 05:01AM BLOOD WBC-9.2 RBC-3.07* Hgb-9.5* Hct-28.8*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 Plt Ct-265
[**2190-12-5**] 05:27AM BLOOD WBC-9.3 RBC-3.02* Hgb-9.5* Hct-28.7*
MCV-95 MCH-31.3 MCHC-33.0 RDW-13.6 Plt Ct-250
[**2190-12-6**] 05:01AM BLOOD Plt Ct-265
[**2190-12-5**] 05:27AM BLOOD Plt Ct-250
[**2190-12-6**] 05:01AM BLOOD Glucose-86 UreaN-33* Creat-1.0 Na-135
K-4.3 Cl-106 HCO3-22 AnGap-11
[**2190-12-5**] 05:27AM BLOOD Glucose-94 UreaN-35* Creat-0.9 Na-136
K-4.6 Cl-107 HCO3-23 AnGap-11
[**2190-12-4**] 06:00AM BLOOD Glucose-121* UreaN-35* Creat-0.9 Na-138
K-4.4 Cl-107 HCO3-25 AnGap-10
[**2190-11-26**] 05:34AM BLOOD ALT-33 AST-59* LD(LDH)-302* AlkPhos-46
Amylase-24 TotBili-0.7
[**2190-11-23**] 12:55PM BLOOD CK(CPK)-136
[**2190-12-6**] 05:01AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0
[**2190-12-5**] 05:27AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
[**2190-12-4**] 06:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
[**2190-12-3**] 05:10AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1
[**2190-11-26**] 05:34AM BLOOD calTIBC-168* Ferritn-565* TRF-129*
[**2190-11-29**] 03:00AM BLOOD Triglyc-153*
[**2190-11-24**] 05:28AM BLOOD Type-ART pO2-75* pCO2-38 pH-7.36
calTCO2-22 Base XS--3
[**2190-11-23**] 08:10PM BLOOD Type-ART pO2-85 pCO2-36 pH-7.39
calTCO2-23 Base XS--2
[**2190-11-23**] 08:10PM BLOOD O2 Sat-95
[**2190-11-24**] 05:28AM BLOOD freeCa-1.12
[**2190-11-23**] 08:10PM BLOOD freeCa-1.16
Brief Hospital Course:
On [**2190-11-23**] The patient was taken to the OR for a open AAA
repair. Tolerated procedure without complications. He was
transferred to the CVICU post op. He was kept intubated and
sedated overnight and was on a nitroglycerin drip for blood
pressure management. Epidural was placed for pain management
with morphine as needed. No acute issues overnight. [**2190-11-24**] The
patient was extubated POD #1. Continued with a-line monitoring,
epidural infusing and ICU management. Transferred to VICU status
[**2190-11-25**]
[**2190-11-25**]-Vitals stable. Epidural intact. Keep npo. OOB to chair.
Abdomen distended with discomfort and nausea. Abdominal Xray
confirmed an ileus. The patient was kept NPO and an NGT was
placed. [**2190-11-26**] Continued abdominal girth. NGT to low
continuous wall suction. Nutrition was consulted and started on
TPN. Abdominal wound stable and epidural was discontinued. On
[**2190-11-28**] a rectal tube was placed. Repeat KUB showed dilation in
the small and large bowel. The patient had multiple small BMS.
Bowel regimen was continued. On [**2190-11-29**] NG tube was removed.
Continued on TPN and kept NPO. PICC Line placed and confirmed
with Xray. Physical therapy following Mr. [**Known lastname **] and initially
recommended Rehab. On [**2190-11-30**] the patient was continued to be
diuresised with daily TPN with lipids. NGT was removed and the
patient was having small bowel movements but continues to have
abdominal distention. On [**2190-12-1**] Colorectal surgery was
consulted for continued [**Last Name (un) 3696**] syndrome with non improving
KUBs. They recommended continuing rectal tube, discontinuing
narcotics and repleted electrolytes as needed. The plan included
a dose of Neostigmine if no improvement of colonic distention.
On [**2190-12-2**] a dose of Neostigmin was given with positive results
of flatus and bowel movement. Abdominal distention improved. On
[**2190-12-3**] the patient was slowly started on a clear liquid diet
and by the evening was increased to full diet. The patient
tolerated this well without nausea and vomiting. Tolerated
regular diet on [**12-4**] and [**12-5**]. On [**2190-12-6**] the patient was re
screened by Physical therapy which cleared him for home. He was
discharged home on post op day 13. He will follow up with Dr.
[**Last Name (STitle) **] in 2 weeks. Abdominal staples were removed prior to
discharge and the patient was in stable condition.
Medications on Admission:
albuterol sulfate 90 mcg HFA Aerosol Inhaler 2 puffs QID,
fluticasone-salmeterol 250 mcg-50 mcg/Dose Disk with Device 2
puffs [**Hospital1 **], simvastatin 20, tiotropium bromide 18 cg Capsule,
w/Inhalation Device 1 puff PRN, aspirin 81, calcium
carbonate-vitamin D3, multivitamin omega-3 fatty acids-vitamin E
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take as needed .
Disp:*60 Capsule(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
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.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take as needed for GERD.
Disp:*60 Tablet(s)* Refills:*2*
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Omega 3-6-9 Fatty Acids 400-400-200 mg Capsule Sig: One (1)
Capsule PO once a day: Resume home dose.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
AAA (preop)
Postoperative ileus/ogilvies
PMH:
Hyperlipidemia
COPD
Right common iliac artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-1**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**1-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2191-1-6**] 3:00
Completed by:[**2190-12-6**]
ICD9 Codes: 496, 2724, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4926
} | Medical Text: Admission Date: [**2122-7-12**] Discharge Date: [**2122-7-24**]
Date of Birth: [**2077-7-1**] Sex: M
Service: SURGERY
REASON FOR ADMISSION: The patient was admitted
preoperatively for a pancreas transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old
male with a history of end stage renal disease due to type I
[**2114**] with a baseline creatinine of 1.8. He also had a
history of deep vein thrombosis and pulmonary embolus. He
had an inferior vena cava filter in place. He also had a
cerebrovascular accident in [**2121-11-26**].
On [**2122-7-12**], the patient was taken to the operating room and
underwent a pancreatic transplant by Dr. [**Last Name (STitle) **]. Cold
was 15 minutes. Please see the detailed operative report for
any details of his intraoperative course. He was stable
intraoperatively without a need for any pressors. The
pancreas transplant was from a 19-year-old donor and he
underwent a hand-sewn, double-layered anastomosis of the
allograft. The patient subsequently was taken to the
intensive care unit for tight blood pressure control as well
as to minimize the chance of thrombosis.
PAST MEDICAL HISTORY: The past medical history was
significant for pulmonary embolus, deep vein thrombosis, type
I diabetes, hypertension and status post cerebrovascular
accident.
PAST SURGICAL HISTORY: The past surgical history was
significant for a living related kidney transplant in [**2114**],
inferior vena cava filter and uvulectomy for sleep apnea.
MEDICATIONS ON ADMISSION: His medications at the time of
admission to the intensive care unit were thymoglobulin,
Solu-Medrol, fluconazole, Unasyn, Zantac, heparin drip and
pamidronate as well as Dilaudid PCA.
HOSPITAL COURSE: Postoperatively, the patient did very well.
There were no complications. He continued on a Dilaudid PCA.
He received a perioperative course of Unasyn for 48 hours and
was on a heparin drip until postoperative day #10. For his
immunosuppression, he received a thymoglobulin, rapamycin and
Solu-Medrol taper and he was subsequently started on Prograf.
His creatinine remained stable in the 1.2 to 1.4 range. He
was able to tolerate a regular diet. His amylase on
postoperative day #1 was 69 and his hematocrit remained
stable. His heparin drip was at 250 units/hour.
For our records, the donor was cytomegalovirus positive and
the patient will receive six weeks of ganciclovir. In terms
of immunosuppression, the patient initially was on
thymoglobulin and Solu-Medrol and rapamycin and Prograf were
started on postoperative day #3.
The patient was transferred to the regular floor from the
intensive care unit on postoperative day #2. Norvasc was
started for blood pressure control. His blood sugars
remained in the 90 to 120 range initially postoperatively.
Thyroglobulin was stopped after four doses. Subsequently,
the patient developed constipation and his narcotics were
minimized and he was started on a bowel regimen.
The patient had a rise in his blood sugars on postoperative
day #7 in the 170 to 210 range and, due to this, he underwent
an allograft ultrasound, which showed normal patency of his
vessels. His amylase and lipase were normal. Subsequently,
on postoperative day #8, the patient underwent a CT scan of
the abdomen, which showed no pancreatic bleed and no abscess.
Following that, he underwent a CT guided biopsy of the
allograft, which did not show any abnormalities. There was
no rejection. After the biopsy, the patient developed pain
in the left lower quadrant at the site of biopsy of the
allograft site.
On postoperative day #10, his abdominal pain slightly
improved and he was able to tolerate p.o. intake. His
heparin drip was changed to subcutaneous heparin and his
Rapamune level on [**2122-7-22**] was 13.
On postoperative day #11, the patient developed increasing
abdominal pain and underwent another CT scan with intravenous
contrast, which showed some fluid around the head of the
allograft, but no abscess and no fluid collections at the
tail of the allograft, where the biopsy had been taken. His
abdominal pain subsequently improved and he was able to
tolerate p.o. intake.
The patient was discharged in stable condition on
postoperative day #12. His Prograf level on during the last
couple of days of his admission ranged from 8 to 12.
DISCHARGE MEDICATIONS:
Rapamycin 5 mg p.o. q.d.
Prednisone 20 mg p.o. q.d.
Prograf 3 mg p.o. b.i.d.
Ganciclovir 500 mg p.o. t.i.d. for six weeks.
Reglan.
Neutra-Phos.
Bactrim single strength p.o. q.d.
Enteric coated aspirin.
Norvasc.
Zantac.
Peri-Colace.
Mycelex.
Percocet for pain.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) **] as an outpatient.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 27423**]
MEDQUIST36
D: [**2122-7-27**] 11:56
T: [**2122-7-27**] 16:48
JOB#: [**Job Number 27424**]
ICD9 Codes: 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4927
} | Medical Text: Admission Date: [**2121-9-11**] Discharge Date: [**2121-9-26**]
Date of Birth: [**2073-6-11**] Sex: F
Service: Medicine [**Location (un) **]
HISTORY OF PRESENT ILLNESS: A 48-year-old woman with primary
pulmonary hypertension who awoke on the day of admission with
a fever of 101.6 accompanied with aches, chills which mildly
improved upon taking Tylenol. When the patient became more
symptomatic however, the patient came to the Emergency Room.
She did not have any localizing complaints except a
generalized whole body achiness as well as flu-like symptoms.
She denies shortness of breath, cough, sputum production.
She denies dysuria, increased frequency, or urgency. She
denies any neck pain, nausea, vomiting, diarrhea,
constipation, or upper respiratory tract like symptoms. She
denies any sick contacts and has not eaten any suspicious
foods. She has not taken any new medications. She denies
any joint pains or rash.
PAST MEDICAL HISTORY:
1. Primary pulmonary hypertension: The patient has been
taking Flolan which is a continuous prostacyclin infusion for
the past 2.5 years ([**11/2118**]). The patient says that she has
not had any history of line infection and sees Dr. [**Last Name (STitle) **],
who is on medical leave currently. The patient's baseline
blood pressure is 80-110. She says she only gets shortness
of breath with exertion. She is also on Coumadin and sees
Dr. [**Last Name (STitle) **] in Cardiology for her primary pulmonary
hypertension as well.
2. History of supraventricular tachycardia/ventricular
tachycardia: The patient sees Dr. [**Last Name (STitle) **] and has had
three ablations done in the past. The patient is currently
on amiodarone for management of her arrhythmias.
3. Glaucoma.
4. Status post appendectomy.
5. Status post cesarean section.
MEDICATIONS:
1. Coumadin 2.5 mg po q day except half a tablet on Thursday
and Sunday.
2. Prostacyclin 18 ng/kg/min.
3. Multivitamin.
4. Claritin.
5. Cosopt one drop OS [**Hospital1 **].
6. Xylatan one drop OS q hs.
ALLERGIES: Vancomycin causes an itchiness/redness at the
head and neck.
FAMILY HISTORY: Father died of a myocardial infarction at
age 53.
SOCIAL HISTORY: Patient is married and has two children.
She lives at home. She denies any alcohol, or tobacco, or
drug use. She manages her Flolan infusion on her own.
PHYSICAL EXAMINATION: General: Patient is a thin woman in
no acute distress. Temperature is 99.3 F, blood pressure
80/40, heart rate 105, respiratory rate 16, oxygen saturation
97% on room air. HEENT: Pupils are equal, round, and
reactive to light. Extraocular movements are intact. No
scleral icterus. Oropharynx clear. Skin: No peripheral
embolic signs, or rash, or splinter hemorrhages. Chest:
Clear to auscultation bilaterally with faint fine and
inspiratory crackles. Cardiovascular: Regular, rate, and
rhythm with S1 and variable splitting S2, systolic murmur,
visible carotid pulsations were present to the ear. Abdomen:
Soft, nontender, and nondistended, positive bowel sounds.
Extremities: No clubbing, cyanosis, or edema. Neurologic:
Grossly intact.
LABORATORIES: White count 6.6 with a differential of 77
neutrophils, 18 bands, 4 lymphocytes, hematocrit of 41.3,
platelets of 141,000. PT of 23, INR of 3.7. Sodium of 139,
potassium 38, chloride 105, bicarb of 22, BUN of 11,
creatinine of 1.0, glucose of 107. Urinalysis was negative.
A TSH 3.3, free T4 1.2, ALT 13, AST of 16, total bilirubin of
0.7.
Chest x-ray showed no evidence of pneumonia, prominent main
pulmonary arteries consistent with primary pulmonary
hypertension. No pleural effusions. Blood cultures and
urine cultures were drawn in the Emergency Room. In the
Emergency Room the patient also received linezolid x1 dose.
HOSPITAL COURSE:
1. Infectious Disease: The patient has [**3-17**] positive blood
cultures growing Pseudomonas aeruginosa, the source of which
was likely to be from the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] line for the
patient's Flolan infusion. The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] line was
removed and the catheter tip culture was positive for
Pseudomonas.
The patient was started immediately on intravenous
ceftazidime and Tobramycin. A left subclavian line was
placed on [**2121-9-13**]. The patient also had a further
Infectious Disease workup to identify the source of
bacteremia including a transthoracic echocardiogram and a
transesophageal echocardiogram which showed no evidence of
vegetations, but increased pulmonary artery pressures with
new bidirectional flow across the patent foramen ovale.
An abdominal ultrasound was performed because the patient
complained of some lower abdominal pain which was negative, a
urinalysis and urine culture were negative, and a renal
ultrasound was also found to be negative.
On [**2121-9-12**], the patient became progressively more
hypoxic and complained of severe right sided pleuritic chest
pain with oxygen desaturation into 79%, which subsequently
increased to 100% on 100% nonrebreather. A chest CTA was
performed to look for evidence of pulmonary emboli, which was
negative, but did show evidence of a right lower lobe
consolidation with effusion, as well as suspected early
cavitation which was thought to be secondary from the
patient's Pseudomonal bacteremia.
On repeat chest CT scan done on [**2121-9-22**], there was
a persistence of the right lower lobe consolidation with
effusion as well as an increased fluid density opacity within
the right lower lobe which was thought secondary to entrapped
fluid or early abscess formation. The patient had an
ultrasound guided diagnostic thoracentesis performed on
[**2121-9-23**], which revealed an exudative fluid,
representative of an uncomplicated parapneumonic effusion.
The pleural fluid Gram stain was negative for any organisms
or white cells, however, the fluid culture was positive for
rare bacterial growth. It was thought however, that the
effusion was still uncomplicated and that the Tobramycin with
ceftazidime antibiotic treatment, the pneumonia and effusion
would resolve after a three week course.
On [**2121-9-25**], a PICC line was placed for outpatient
antibiotic and Flolan treatment, and the subclavian line was
removed and the tip was sent for culture. The patient is to
continue a full three-week course of Tobramycin and
ceftazidime and if the patient remained afebrile and has no
symptoms of infection after stopping the antibiotics for at
least one week, the patient will be able to have a permanent
central line placed for her continuous Flolan infusion.
2. Pulmonary: As noted, the patient became progressively
more hypoxic during her hospital course with right sided
severe pleuritic chest pain. As noted again, the chest CTA
performed at that time revealed no evidence of pulmonary
emboli, but did show right lower lobe pneumonic consolidation
and effusion secondary to septic emboli. The patient was
transferred to the Medical Intensive Care Unit on [**2121-9-12**] for her worsening hypoxia. The patient was initially
placed on nonrebreather mask ventilation, and then required
BiPAP.
Because the patient's hypoxia did not improve, elective
intubation occurred on [**2121-9-15**]. The patient was
extubated on [**2121-9-19**] and developed post-extubation
stridor which was successfully treated with a brief course of
steroids. The patient was transferred out of the Medical
Intensive Care Unit on [**2121-9-23**]. Her breathing
improved remarkably and the patient no longer required oxygen
upon transfer out of the MICU. Her oxygen saturation
remained excellent at 97-99% postextubation. Additionally, a
repeat chest x-ray which was performed on [**2121-9-25**]
showed an improving right lower lobe consolidation.
It terms of the patient's pulmonary hypertension, the patient
was continued on her Flolan infusion during her entire
hospital stay. The patient had her Coumadin stopped while in
the hospital, and the plan is to restart the patient's
Coumadin for her primary pulmonary hypertension once the
permanent tunnel catheter is placed approximately two weeks
after discharge. The patient will follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**] in approximately one month.
3. Cardiovascular: The patient was continued on amiodarone
throughout her hospital stay given her history of ventricular
tachycardia and supraventricular tachycardia. Her potassium
was repleted to a level greater than or equal to 4.5 for
prophylaxis against any arrhythmias. As noted above, a TTE
performed on [**2121-9-12**] revealed a patent foramen ovale
with bidirectional shunt across the interatrial septum at
rest.
The overall left ventricular systolic function was mildly
depressed, and the right ventricular cavity was markedly
dilated. There was severe global right ventricular free wall
hypokinesis. Mild dilation of the aortic root. Trivial
mitral regurgitation was seen.
A transesophageal echocardiogram was also performed which
revealed similar findings as well as no evidence of
endocarditis and presence of tricuspid regurgitation which
could not be quantified.
4. GI: The patient complained of mild right upper quadrant
tenderness during her hospitalization along with loose
stools. The amylase and lipase levels were found to be
elevated with peak levels of an amylase of 473 and a lipase
of 513. Patient's abdominal discomfort subsided with bowel
rest, and the patient was placed on Prevacid 30 mg po q day
for gastrointestinal prophylaxis. The patient's amylase and
lipase trended downwards, and the patient remained
asymptomatic of pancreatitis. It was thought that the
patient's pancreatitis was secondary to a brief use of Flagyl
which was empirically started on [**2121-9-15**] for
diarrhea. Clostridium difficile toxin studies were sent and
were all negative.
5. Disposition: The patient will be discharged home with
nursing services for home antibiotic treatment as well as
Flolan. The patient will continue her full three-week course
of intravenous antibiotics, and will require Tobramycin
trough and peak levels drawn during administration. If
patient remains asymptomatic and well for one week after
discontinuation of antibiotics, she will be eligible for
surgical placement of a central catheter for Flolan infusion.
The patient will follow up with Dr. [**Last Name (STitle) 217**] in
approximately one month, with Dr. [**Last Name (STitle) 4390**] in approximately
two weeks. The patient will schedule her own surgical
appointment for placement of a central line.
6. Dermatology: During the [**Hospital 228**] hospital course she
experienced the development of painful, erythematous nodules
on her arms and back as well as lower legs. Dermatology was
consulted and biopsies were obtained which showed evidence of
panniculitis most consistent with erythema nodosum and no
evidence of septic emboli. Dermatology recommended
symptomatic relief. Upon discharge, these lesions had been
improving.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with services.
DIAGNOSES:
1. Pseudomonal line sepsis with septic emboli to the lung.
2. Right lower lobe pneumonia with fusion, secondary to
septic emboli.
3. Asymptomatic pancreatitis secondary to Flagyl use.
4. Primary pulmonary hypertension.
5. History of ventricular tachycardia, supraventricular
tachycardia.
6. Glaucoma.
DISCHARGE MEDICATIONS:
1. Ceftazidime 2 grams IV q8 hours for a total of 21 days
(seven days more).
2. Tobramycin 250 mg IV q day for 21 days total (seven days
more).
3. Flolan 18 ng/kg/min IV continuous infusion.
4. Loratadine 10 mg po q day.
5. Amiodarone 100 mg po q day.
6. Dorzolamide 2%/Timolol 0.5% ophthalmic solution one drop
OU q hs.
7. Lansoprazole 30 mg po q day.
8. Latanoprost 0.005% one drop OU q day.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2121-9-25**] 15:44
T: [**2121-10-2**] 06:24
JOB#: [**Job Number **]
ICD9 Codes: 486, 5185, 4271, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4928
} | Medical Text: Admission Date: [**2118-4-14**] Discharge Date: [**2118-4-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD x2 ([**2118-4-14**] and [**2118-4-21**])
Colonoscopy ([**2118-4-21**])
Endotracheal Intubation
History of Present Illness:
88 yo man with h/o A fib on coumadin and CHF presents to ED c/o
3 days of black stools. Denied lightheadedness, CP or SOB at
home. Has chronic DOE which is unchanged from baseline. Denies
hematemesis. Mild nausea. Patient denies NSAID use. In the
ED, digital rectal exam revealed maroon stool in rectal vault
and NG Lavage was negative. EGD done showed esophagitis,
gastritis, duodenitis as well as Shatzki's ring. Patient was
hemodynamically stable on admission.
Past Medical History:
CHF - diastolic dysfxn (EF > 65% on Echo [**12-16**])
Chronic A fib x 15 years (failed cardioversion) on coumadin
AS with valve area 1.0 cm2
Gout
Disc surgeries
BPH
HTN
OSA
Social History:
Lives alone. Denies tobacco, alcohol, illicit drugs. Worked as
a lab technician. Is independent of all ADL's. Drives, cooks,
and shops for himself. He has no family that he is close to.
Family History:
NC
Physical Exam:
T 97.4, 140/70, 91, 24, 100% on 2L
GEN - NAD, A&Ox3, slurred speech
HEENT - PERRLA, EOMI, MMM
NECK - no JVD
HEART - nl s1s2, RRR, III/VI holosystolic murmur at apex and
II/VI SEM at LUSB radiating to carotids
LUNGS - CTAB
ABD - soft, mildly distended, NT, NABS, no masses
EXT - no edema
Pertinent Results:
Labs on admission:
[**2118-4-14**] 11:30 am Hct 31.5, WBC 4.3, Plts 128, INR 1.9
Na 146, K 4.0, Cl 112, CO2 22, BUN 27, Creat 0.9
CK 93, Trop T 0.01
UA negative
Studies:
CXR [**2118-4-14**] Heart size is unchanged; bilateral small pleural
effusion with atelectasis. No CHF noted. No PNA.
EGD [**2118-4-14**]:
Schatzki's ring.
Erosions in the gastroesophageal junction.
Esophagitis in the gastroesophageal junction.
Gastric deformity.
Erythema in the antrum compatible with gastritis.
Ulcers in the duodenal bulb.
Erythema in the duodenal bulb compatible with duodenitis.
Head CT [**2118-4-15**]:
Stable appearance of the brain parenchyma from earlier in the
day. No intracranial hemorrhage.
KUB [**2118-4-16**]:
Features of mechanical small-bowel obstruction.
CT abd [**2118-4-17**]:
1. Findings consistent with ileus. There are dilated loops of
small bowel with air-fluid levels without transition point.
2. Gallstone.
3. A small amount of fluid around the liver, around the
gallbladder and in the pelvis.
4. Cirrhotic liver.
5. Persistent native portosystemic shunt. (right posterior
portal vein to right hepatic vein)
EEG [**2118-4-19**]:
This is an abnormal portable EEG due to the presence of
intermittent, focal delta frequency slowing involving the right
anterior
quadrant. This finding suggests subcortical dysfunction in this
region
and is a relatively non-specific finding with regard to an
evaluation
for seizures. In addition, the background rhythm is slowed with
occasional generalized delta frequency slowing. This finding
suggests
deep, midline subcortical dysfunction and it is consistent with
an
encephalopathy. Note was made of an irregular rhythm with
occasional
ectopy on the cardiac monitor. No epileptiform abnormalities
were seen.
CXR [**2118-4-21**]:
1) OG tube terminating in the distal esophagus. It should be
advanced to appropriately lie within the stomach.
2) Retrocardiac left lower lobe atelectasis/consolidation.
EGD [**2118-4-21**]:
- Ulcer in the upper third of the esophagus, Schatzki's ring,
grade II esophagitis in the gastroesophageal junction.
A. Upper esophagus, mucosal biopsy:
1.) Squamous epithelium with active esophagitis and ulceration.
2.) No neoplasm identified.
3.) Periodic acid-Schiff (PAS) stain for fungi is negative
(positive control slide).
Colonoscopy [**2118-4-21**]:
multiple non-bleeding diverticula in the entire colon and rectal
varices.
Video Swallow [**2118-4-25**]:
Video oropharyngeal swallow study: The study was performed in
conjunction with the Speech and Swallow Service. Please refer to
their note for recommendations and full details in the online
medical record. Various consistencies of barium were
administered to the patient. There was premature spillover of
thin liquids through straw to the level of the piriform sinuses.
There is prolonged AP transport piecemeal swallow for all
consistencies. Bolus propulsion is mildly impaired. There is a
small amount of ground solid residue in puree consistent in the
valleculae, which clears after a subsequent swallow. There was
penetration noted for consecutive straw sips of nectar thick
liquid. A chin tuck maneuver effectively prevents penetration of
straw sips. The barium pill passes freely without holdup.
IMPRESSION: No aspiration observed for all consistencies.
However, there is moderate oral and mild pharyngeal dysphagia as
described
Brief Hospital Course:
88 yo man with A fib on coumadin and CHF presents with melena
and maroon stool in rectal vault. EGD done in the ED revealed
gastritis, esophagitis, and duodenitis with signs of recent
bleeding but no active bleeding. He was hemodynamically stable
and transferred to the floor. He was noted to be obtunded on
HD#2 and was transferred to the ICU.
Patient transferred from floor after being intubated for airway
protection secondary to altered mental status. Felt that
patient may have encephalopathy secondary to GI bleed. Patient
started on lactulose while in unit. Patient had CT scan of head
and EEG which were both negative. He was given 6 liters of prep
for a colonoscopy and put out very minimal stool. Felt that
patient may have partial bowel obstruction. Patient's Hct
stabalized felt that c-scope not urgent. Patient after 2 days
in the unit started to produce stool. Felt better to have
c-scope procedure done while patient on sedation and intubated.
Patient had c-scope and EGD with push enteroscopy which was
negative for any active bleeding. Rectal varacies were
indentified. After scope patient was weaned off sedation and
exubated. During ICU course patient had witnessed aspiration
after coughing out trach tube. Patient was started on
antibiotic course for asp. PNA after temperature spike and
positive sputum cultures for Klebsiella, E. Coli, and
Pseudomonas. PAtient was initially put on levo/ceftaz and
flagyl. Later patient kept on just ceftaz and flagyl.
Patient's mental status gradually improved while in the ICU and
he was transferred back to the floor.
1) Esophagitis, Gastritis, Duodenitis - No signs/symptoms of
active bleeding. Etiology unknown. Patient denies recent NSAID
use. H.pylori IgG negative. He was Continued on Protonix. He
initially receieved 2 units of PRBC in the ED, Hct remained
stable during the rest of his hospital course.
2) Delirium. Likely related to encephalopathy precipitated by
GIB (elevated ammonia) vs meds from EGD done in ED. Likely with
continued delirium after prolonged intubation and ICU stay. His
mental status is somewhat improved since starting lactulose
although not at baseline. As per PCP, [**Name10 (NameIs) **] was independent of all
ADL's, cooking, and driving.
- Head CT negative.
- EEG done on [**4-19**] with right anterior bursts of delta slowing
amidst theta/delta background consistent with encephalopathy. No
epileptiform activity.
- He was continued on lactulose for a goal of 3 BM's per day.
3) Cirrhosis noted on Abd CT (Abd CT from [**6-15**] with some
evidence of cirrhosis). Etiology unclear. Liver Team was
involved in his care.
DDX includes EtOH (although no known history of EtOH abuse),
autoimmune (not likely given [**Doctor First Name **] 1:40, IgG 1210, anti-smooth
muscle 1:20), hemachromatosis (Fe studies WNL), infectious
(unlikely given negative Hep B and C viral load), Celiac Sprue
(TTG WNL), PBC (IgM WNL, AMA pending at discharge ), cardiac
congestion.
- RUQ U/S ([**4-16**]) w/o ascites
- unconjugated bili not elevated, therefore less likely related
to cardiac congestion as per liver
- continued on lactulose for goal of 3 BM's per day
4) Pneumonia - likely aspiration event when pt extubated.
Patient with sputum culture positve for pansensitive Pseudomonas
and Klebsiella. Patient remains afebrile, WBC slowly trending
down.
- He received 7 days of Ceftaz, changed to po levo at discharge.
He will continue an additional 7 day course.
- Received 4 days of Flagyl, d/c'ed [**4-26**] given sputum culture
results
5) Atrial fibrillation. He was moinitored for complete heart
block, as pt has significant underlying conduction disease. His
HR was well controlled on Metop 12.5 [**Hospital1 **]. His coumadin was
d/c'ed given recent GI bleed (last INR 1.7). Decision to restart
coumadin to be decided by PCP.
6) CHF - known diastolic dysfunction, treated as outpt with
lasix and lisinopril. Currently not in CHF. His lasix was
dosed on a prn basis during this admission. He was euvolemic to
volume deplete on discharge. His lasix should be restarted if he
appears fluid overloaded.
7) BPH - Terazosin restarted at discharge.
8) OSA. Pt is not on BiPAP. SHould have outpt eval.
9) Hypernatremia and contraction alkalosis. Na and Bicarb
trending down on day of discharge. Continue to hold lasix as pt
appears volume deplete. To be restarted by PCP if indicated.
10) Ileus noted on KUB while in ICU, resolved. Pt had NGT to
suction with bilious output in ICU. Tolerating po diet.
11) HTN. BP well controlled. Started on Metoprolol 12.5 mg [**Hospital1 **].
Lisinopril restarted at discharge. Lasix being held as above.
12) FEN - Pt underwent video swallow. He did well on a ground
diet with thickened liquids.
Medications on Admission:
Lisinopril 10 mg po qd
Lasix 40 mg po qd
Coumadin
Terazosin
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO three times
a day: please titrate to
[**3-17**] BM's per day.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
6. Terazosin HCl 1 mg Tablet Sig: One (1) Tablet PO once a day:
please titrate up as needed. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
GI Bleed
Aspiration Pneumonia
Hepatic encephalopathy
Discharge Condition:
Stable
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience bleeding, confusion, shortness of
breath, fever >101,4, or any other concerns.
Please assess volume statis and consult PCP regarding lasix. Pt
was on lasix 40 mg daily as an outpt. Currently being held
secondary to volume depletion.
Please consult PCP regarding coumadin. Pt was on coumadin as an
outpt for Afib, however currently being held for recent GI
Bleed.
Followup Instructions:
1. Please follow up with Dr. [**First Name (STitle) 6164**] when you leave rehab.
[**Telephone/Fax (1) 5723**]
You have the following appointments scheduled:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2118-8-30**] 1:15
2. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2118-10-13**] 2:00
ICD9 Codes: 5070, 5715, 4241, 4280, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4929
} | Medical Text: Admission Date: [**2116-4-8**] Discharge Date: [**2116-4-14**]
Date of Birth: [**2052-10-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
capsule endoscopy
History of Present Illness:
History of Present Illness: 63 y/o M on coumadin for h/o mitral
stenosis now with St. Jude's valve (initially with mv prolapse
causing [**First Name3 (LF) 1902**] treated with bioprostethic valve and then developed
MV stenosis from valve), TR, HTN, OSA and pulmonary hypertension
who presents for a low hematocrit. Patient reports that
beginning several weeks ago he had vague abdoinal discomfort
with mild nausea (no emesis). His stools at this time were dark
brown and tarry in quality. He noted no BRBPR. Beginning a few
days ago he had new dizziness and weakness. Also with some
exertional fatigue where he was unable to complete his usual
work-out. Patient went to his cardiologist were he was noted to
have a Hct of 23 and he was referred to the ED for evaluation.
.
Denies any history of NSAID use. Does take a baby aspirin.
Drinks etoh rarely if ever. Occasionally uses omeprazole for
heartburn (1x per month). No previous history of UGIB/LGIB or
other issues.
.
In the ED, initial vs were: T99.4 P68 BP107/61 R18 O2 100%RA
sat. Lungs clear. Guaiac -> dark brown positive. NG lavage -> no
blood, no coffee grounds. INR 3.8 -> 4.1. Type and Crossed and
started on 2 units PRBC's. Protonix bolus and gtt given. Patient
was not reversed as bleed felt to be subacute and clinically
stable.
.
Last VS were HR 64, BP 110/91, RR 24, 98% RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes
Past Medical History:
1) s/p St. Jude's valve [**1-8**] for bioprosthetic MV Stenosis.
Original MVR in [**2107**] for MVP/MR [**First Name (Titles) **] [**Last Name (Titles) 1902**] sx's
2) 4+ Tricuspid Regurgitation s/p TVR [**1-8**]
3) s/p Permanent Pacemaker in [**2110**], DDI for bradycardia during
apneic episodes.
4) Hypertension
5) mod Pulmonary hypertension
6) Obstructive Sleep Apnea - on BiPAP
7) BPH
8) h/o urethral meatal stricture s/p dilatation
9) GERD
10) Gout - as above
11) h/o Hep C, s/p interferon, reportedly "cured".
12) Depression/Anxiety
13) H/o Postop Atrial Fibrillation,
14) H/o Urosepsis
15) Diastolic HTN
Social History:
-smokes [**2-5**] three cigarettes per day over last year, down from
2ppd habit x 20yrs, occasional marijuana
-ETOH: 0.5 pint per month
-Previous notes mention occasional cocaine and marajuana use.
-Works for Youth Development Council --used to be a detective
-Divorced w/ 2 grown children
Family History:
-Father: died of cerebral hemorrhage ([**2-4**] aneurysm)in his 60's,
h/o stroke
-No history of premature arthrosclerotic CVD or sudden cardiac
death
-Mother: HTN
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Exam on discharge:
afebrile, BP 130s/80s, HR 50s, 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2116-4-8**] 10:48AM PT-37.1* INR(PT)-3.8*
[**2116-4-8**] 10:48AM PLT COUNT-323
[**2116-4-8**] 10:48AM WBC-6.2 RBC-3.29*# HGB-6.6*# HCT-23.3*#
MCV-71* MCH-20.2* MCHC-28.4* RDW-15.8*
[**2116-4-8**] 10:48AM MAGNESIUM-2.2
[**2116-4-8**] 10:48AM estGFR-Using this
[**2116-4-8**] 10:48AM UREA N-27* CREAT-1.2 SODIUM-140 POTASSIUM-4.6
CHLORIDE-102 TOTAL CO2-30 ANION GAP-13
[**2116-4-8**] 10:48AM GLUCOSE-117*
[**2116-4-8**] 03:55PM PT-39.5* PTT-35.8* INR(PT)-4.1*
[**2116-4-8**] 03:55PM PLT COUNT-306
[**2116-4-8**] 03:55PM NEUTS-64.4 LYMPHS-26.0 MONOS-6.7 EOS-2.2
BASOS-0.8
[**2116-4-8**] 03:55PM WBC-7.3 RBC-3.10* HGB-6.1* HCT-20.9* MCV-67*
MCH-19.7* MCHC-29.2* RDW-16.0*
[**2116-4-8**] 03:55PM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.1
[**2116-4-8**] 03:55PM cTropnT-<0.01
[**2116-4-8**] 03:55PM estGFR-Using this
[**2116-4-8**] 03:55PM GLUCOSE-83 UREA N-31* CREAT-1.3* SODIUM-138
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11
Studies:
ECG:
Sinus rhythm. Tracing is without diagnostic abnormality
Chest AP portable:
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: There is unchanged
moderate
cardiomegaly, with midline intact sternal wires and vascular
clips from prior CABG. A left chest pacing device is in
unchanged position. A mechanical valve is also apparently
unchanged. Lung volumes are low and there is mild atelectasis at
the lung bases, but no focal consolidation. Overall, vascular
congestion appears similar to the prior study.
IMPRESSION: No significant change since [**2114-6-3**].
Colonoscopy [**2-/2115**]:
Diverticulosis of the descending colon and sigmoid colon
Otherwise normal colonoscopy to cecum
EGD [**4-/2116**]:
Patchy erythema of the mucosa was noted in the duodenal bulb
compatible with mild duodenitis.
Impression: Erythema in the duodenal bulb compatible with mild
duodenitis
Otherwise normal EGD to third part of the duodenum
Capsule endoscopy results pending at time of discharge
Labs at discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
6.0 3.55* 8.2* 26.4* 74* 23.0* 30.9* 19.0* 273
PT PTT INR(PT)
25.5* 92.8* 2.5*
Glucose UreaN Creat Na K Cl HCO3 AnGap
90 12 1.2 141 4.5 105 30 11
calTIBC Ferritn TRF Fe
433 46 333 16
retic count 4.6, retic index 2.6
Brief Hospital Course:
Assessment and Plan: 63 year old male with history of mitral
valve prolapse s/p MVR with [**Hospital3 9642**] valve on coumadin
presented with GI bleed.
# GIB: Mr. [**Known lastname 10881**] symptoms were felt to be most consistent with
UGIB. He was admitted to the MICU for monitoring. He was
evaluated by the gastroenterology service, who recommended
waiting for endoscopy until the patient's INR came < 3. He
underwent endoscopy on [**2116-4-10**] which showed erythema in the
duodenal bulb compatible with mild duodenitis, but otherwise
normal study. There was no active bleeding noted. He received a
total of 7 units of packed RBCs to maintain his hematocrit
during this admission. Aspirin was held. Following transfer
from the ICU to the floor, the patient remained hemodynamically
stable with stable Hct, but continued to have melanic stools. A
capsule endoscopy was thus performed on [**2116-4-14**], with the
results pending at the time of discharge. The patient then
received two more units of PRBCs on [**2116-4-14**] for symptomatic
treatment. A colonoscopy had been performed about one year ago
which had shown sigmoid diverticulosis. The patient was
counseled at discharge to continue to monitor for recurrence of
melena, worsening shortness of breath, pre-syncope, or chest
pain. If his GI bleed should recur, the patient should be
considered for enteroscopy to further evaluate the small bowel
if the capsule endoscopy proves to be unremarkable, as an EGD
has already been performed. A tagged red cell scan and
colonoscopy could also be considered. The patient will follow
up with his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **], to review the capsule endoscopy
report and follow on repeated CBC and INR. Iron studies were
checked, and were not consistent with iron deficiency anemia.
# Prosthetic Valve: The patient's INR was initially allowed to
drift down (no administration of vitamin K). Antibiotics
peri-EGD were discussed, but not given as not currently
indicated by AHA guidelines for prosthetic valve. When INR
became < 2.5, a heparin drip was started as a bridge to
warfarin. Warfarin was started on [**2116-4-11**] at 50 mg daily. INR
at time of discharge was 2.5. Patient received warfarin 50 mg
on [**2116-4-14**], and will continue with his outpatient regimen of 40
mg 4x/week and 30 mg 3x/week. He will have his INR checked
within the next 5 days.
# HTN: Home anti-hypertensives were held in the setting of acute
bleed. Given several elevated BPs, patient was restarted on ACE
and BB, and alpha blockade. Amlodipine was not restarted at
discharge.
# OSA: Patient uses BIPAP at home and was continued on an
in-house unit, which he reported worked well for him.
# Gout: Stable.
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: coumadin therapeutic
# Access: peripherals
# Communication: Patient
# Code: Full (discussed with patient)
Medications on Admission:
Medications as outpatient
(from [**2115-10-3**])
Carvedilol 25 mg twice daily,
amlodipine 5 mg daily,
lisinopril 40 mg daily,
oxazepam 15 mg three times daily as needed for anxiety,
potassium chloride 20 mEq daily,
aspirin 81 mg daily,
warfarin 5 mg daily,
multivitamin daily, omeprazole 20 mg daily,
gabapentin 300 mg at bedtime as needed for restless legs
syndrome, colchicine twice daily as needed for gout flare,
terazosin 10 mg daily,
Spiriva inhaler one puff daily as needed,
zinc
.
As per patient
Amlodipine 10
Carvedilol 25 [**Hospital1 **]
Lisinopril 40mg daily
Terazosin 10mg daily
Tiotropium 1 puff daily prn
Warfarin 50mg (?) daily
Aspirin EC 81mg daily
Vitamin D
MVI
Fish Oil
Omeprazole prn
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily) as needed for shortness of
breath or wheezing.
2. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
8. Warfarin 5 mg Tablet Sig: Eight (8) Tablet PO every other
day: please start on [**2116-4-15**], continue taking every other day.
9. Warfarin 5 mg Tablet Sig: Ten (10) Tablet PO every other day:
please start on [**2116-4-16**].
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Outpatient Lab Work
please check INR and CBC on [**2116-4-16**], and fax results to Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **], [**Telephone/Fax (1) 64448**]
12. Compazine 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
occult and overt GI bleed, unknown etiology
Secondary Diagnosis:
MVP s/p MVR, on chronic anti-coagulation
HTN
OSA
Discharge Condition:
alert and oriented x 3
ambulatory without assist
stable condition
Discharge Instructions:
You were admitted to the hospital with a GI bleed. Given the
concern for bleeding from you stomach or esophagus, in the
setting of an elevated INR, you were initially cared for in the
ICU. You had an EGD performed which showed mild inflammation in
the duodenum, the first part of your small intestine, but the
EGD did not show a cause of your bleeding. You were then
transferred to the medicine floor, where you continued to be
closely monitored. You continued to have a small amount of
blood in your stool, and your blood count did not improve.
Therefore, you had another study performed, a capsule endoscopy,
the results of which were pending at the time of your discharge.
You were discharged on [**2116-4-14**] in stable condition.
Please see below for your follow up appointment.
The following changes have been made to your medications:
Please stop taking amlodipine and aspirin.
Please start taking pantoprazole 40 mg twice a day.
No other changes have been made to your medications.
Please call your PCP or the Emergency Room if you develop
worsening shortness of breath, lightheadedness, feeling like
your going to pass out, or chest pain; please also seek medical
attention if your stools turn black or if you have any amount of
blood in your stool. Your discharge paperwork has specified the
appropriate next step if your bleeding recurs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 251**] R.
Location: [**Hospital **] [**Hospital **] HEALTH CENTER
Address: [**Last Name (un) **], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 14050**]
Appt: [**4-21**] at 4:15pm
ICD9 Codes: 5789, 2851, 4280, 4019, 4168, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4930
} | Medical Text: Admission Date: [**2124-11-5**] Discharge Date: [**2124-11-8**]
Date of Birth: [**2075-5-30**] Sex: M
Service: CCU
CHIEF COMPLAINT: Anterior myocardial infarction.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old
gentleman with no known history of coronary artery disease
who presented to an outside hospital complaining of
substernal chest pain. The pain began at 10:00 a.m. and was
substernal without radiation described as a dull ache
different from the usual GERD. The patient preceeded to the
local Emergency Room given the persistent and worsening pain
at 10:30 a.m. At the outside hospital Emergency Department
the patient also complained of diaphoresis and now of [**9-28**]
chest pain. An electrocardiogram revealed ST elevation and
peaked T waves. The patient was given sublingual
nitroglycerin, morphine, Lopressor, aspirin and the pain
decreased to [**5-29**], but never went away completely. The
patient was then transferred to [**Hospital1 188**] for cardiac catheterization. Catheterization revealed
that right dominant system normal, normal LMCA, LCX with mild
disease, right coronary artery with 40% mid and 50% posterior
descending coronary artery stenosis, left anterior descending
coronary artery with 70% stenosis at the origin and 99%
stenosis due to thrombotic occlusion distally with slow TIMI
two flow. An angiojet coronary thrombectomy was performed
followed by stenting of the left anterior descending coronary
artery at the origin and distally.
PHYSICAL EXAMINATION AT PRESENTATION: Pulse 65. Blood
pressure 120/58. Respirations 18. Oxygen saturation 100%.
General appearence in no acute distress, alert and awake.
HEENT mucous membranes are moist. Pupils are equal, round
and reactive to light. Oropharynx clear. No JVD.
Cardiovascular regular rate and rhythm. Normal S1 and S2.
No murmurs. Lungs clear to auscultation anteriorly and
laterally. Abdomen is soft, nontender, nondistended. Normal
bowel sounds. Extremities no clubbing, cyanosis or edema.
Right groin there is an arterial venous sheath in place. No
bruit or hematoma. Good distal pulses bilaterally.
LABORATORIES AT OUTSIDE HOSPITAL: White blood cell 6.2,
hematocrit 46.4, platelets 141, sodium 143, potassium 3.9,
chloride 106, bicarb 21, BUN 16, creatinine .7, glucose 81,
CK 130, and troponin less then 0.01. Electrocardiogram at
outside hospital showed normal sinus rhythm with a heart rate
of 70, normal intervals, right axis, ST elevation in V1
through V4, peaked T waves in V1 through V4 and flat Ts.
After stent placement at [**Hospital1 69**]
electrocardiogram showed normal sinus rhythm with a heart
rate of78, normal intervals, normal axis, ST elevation in V2
through V4 is still present, but decreased and there is a Q
wave in V3 of questionable significance and normal T waves.
Peak CPKs was 2600 and peak troponin was more then 50. Total
cholesterol was 206, HDL 46, LDL 142, triglycerides 89.
Echocardiogram showed an EF of 30%, apical akinesis,
anteroseptal and free anterior wall hypokinesis.
PAST MEDICAL HISTORY: 1. Depression. 2. Gastroesophageal
reflux disease. 3. Mild hypercholesterolemia.
ALLERGIES: Penicillin, which causes a rash.
MEDICATIONS AT HOME: Prozac, Protonix occasionally.
FAMILY HISTORY: No history of coronary artery disease,
cerebrovascular accident or diabetes mellitus.
SOCIAL HISTORY: No smoking, occasional alcohol intake.
Prior marijuana use in [**2091**]. He leads an active lifestyle
and recently picked up scuba diving. He is divorced and he
is a pharmacist.
HOSPITAL COURSE: Mr. [**Known lastname **] is a 49 year-old gentleman
with no prior history of coronary artery disease who
presented to an outside hospital with substernal chest pain
and diaphoresis and anterior ST elevation on
electrocardiogram consistent with an anterior myocardial
infarction and was transferred to [**Hospital1 190**] for catheterization, which revealed left
anterior descending coronary artery stenosis 70% at the
origin and 99% mid distally, now status post stent of the
left anterior descending coronary artery at the origin and
distally.
Coronary artery disease, Mr. [**Known lastname **] is status post anterior
myocardial infarction and stenting of the left anterior
descending coronary artery times two. He received Integrilin
for eighteen hours and then was started on aspirin 325 mg,
Plavix 75 mg. A lipid panel was drawn and LDL was found to
be 142, which is significantly higher then the goal of 100
for him, therefore Atorvastatin 10 mg po q.d. was also
started. An echocardiogram showed an EF of 30% with akinesis
at the inferior wall and hypokinesis V3 and septal inferior
wall. An ace inhibitor was started and titrated up. The
patient also was started on heparin for anticoagulation due
to akinesis and decreased EF. The anticoagulation was
supposed to be performed with heparin for a few days until
Coumadin was provided with a therapeutic INR, however, after
only one hour of being on heparin the right groin hematoma
enlarged and heparin was immediately discontinued and the
patient was never started on Coumadin. Mr. [**Known lastname **] had a
few runs of nonsustained ventricular tachycardia during the
24 hours after the anterior myocardial infarction and
catheterization. He then had no more arrhythmias. A beta
blocker was started and titrated up as tolerated. He was
randomized to the cooling arm of the cool myocardial
infarction protocol trial. His hospital stay was otherwise
unremarkable. Mr. [**Known lastname **] was evaluated by physical therapy
who gave information about the amount of exercise that he
should perform and how to pace himself. He was deemed fit to
go home by the physical therapy.
MEDICATIONS AT DISCHARGE: Atorvastatin 10 mg po q day,
Toprol XL 50 mg po q day, Lisinopril 10 mg po q day, Plavix
75 mg po q day to continue for thirty days, aspirin 325 mg po
q day.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
FOLLOW UP: Mr. [**Known lastname **] to follow up with his cardiologist
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46763**] on [**2124-11-15**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 6831**]
MEDQUIST36
D: [**2124-11-8**] 10:39
T: [**2124-11-9**] 12:08
JOB#: [**Job Number 46764**]
ICD9 Codes: 4271, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4931
} | Medical Text: Admission Date: [**2190-10-17**] Discharge Date: [**2190-10-22**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization and bare metal stent placement
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo F with history of inferior STEMI in [**5-22**]
complicated by hypotension and bradycardia requiring temporary
pacing during RCA stenting who presents with inferolateral
STEMI. She awoke from sleep with severe CP that did not resolve
with 3 NTG and called EMS. Per EMS, she was bradycardic to the
30s requiring atropine enroute.
.
In the ER, she received levophed, dopamine, heparin drip, [**Date Range 4532**]
load, zofran and morphine. Her HR was persistently low
requiring two more doses of atropine. The cath [**Date Range **] was
activated, and she underwent cath showing stent thrombosis of
proximal RCA BMS that was treated with Export thrombectomy, PTA
and stenting with BMS. Her course was complicated by
bradycardia requiring temporary pacer wire placement. She was
weaned off pressors while in the [**Date Range **].
.
In the CCU, she reports feeling much better now. Patient denies
any CP other than last night but her son reports an episode
angina last week that resolved with two NTG.
.
On review of systems, she has a history of CVA and is recovering
from a bout of bronchitis causing cough. She denies any prior
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains or hemoptysis. She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2186-5-23**] ulcerated 60%
RCA lesion x 3 BMS here, s/p LAD stents on [**2186-6-6**] at [**Hospital1 112**]
- PACING/ICD: temporary pacing wire [**5-22**] for transient CHB
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
h/o CVA, no residual deficit
GERD
h/o parathyroid adenoma s/p removal
Social History:
She does not currently smoke. No alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=...BP= 129/81 HR= 90 RR= 16 O2 sat= 97% 2L NC
GENERAL: Elderly female with increased psychomotor activity,
difficulty lying still
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. S3 heard throughout
precordium. No S4.
LUNGS: No chest wall deformities noted. Resp were unlabored, no
accessory muscle use. Poor inspiratory effort but CTAB without
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e, slightly cool feet and hands with good
cap refill
SKIN: Small skin tear over R lower shin.
PULSES: R and L DPs dopplerable, 1+ PTs
.
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
[**2190-10-17**] 05:45AM BLOOD WBC-13.7* RBC-2.99* Hgb-9.4* Hct-26.2*
MCV-88 MCH-31.4 MCHC-35.8* RDW-13.3 Plt Ct-230
[**2190-10-17**] 05:45AM BLOOD Neuts-83.5* Lymphs-12.4* Monos-3.2
Eos-0.8 Baso-0.2
[**2190-10-17**] 09:30AM BLOOD PT-15.3* PTT-76.2* INR(PT)-1.3*
[**2190-10-17**] 05:45AM BLOOD Glucose-184* UreaN-14 Creat-0.7 Na-135
K-4.0 Cl-101 HCO3-22 AnGap-16
[**2190-10-17**] 09:30AM BLOOD ALT-39 AST-63* CK(CPK)-356* AlkPhos-328*
TotBili-0.4
[**2190-10-17**] 05:45AM BLOOD cTropnT-0.18*
[**2190-10-17**] 09:30AM BLOOD Albumin-3.6 Calcium-8.2* Phos-3.1 Mg-2.0
[**2190-10-17**] 09:30AM BLOOD %HbA1c-7.3* eAG-163*
[**2190-10-17**] 10:40AM BLOOD Lactate-0.9
.
DISCHARGE LABS
.
MICROBIOLOGY
[**2190-10-18**] Urine culture (final): No Growth
[**2190-10-19**] Urine culture (final): No Growth
[**2190-10-19**] Blood culture: NGTD
.
IMAGING
[**2190-10-17**] CARDIAC CATHETERIZATION:
1. Selective coronary angiography of this right dominant system
revealed single vessel coronary artery disease. The LMCA had no
angiographically apparent disease. The LAD had mild luminal
irregularities and a patent stent. The LCx had mild luminal
irregularities. The RCA was found to be totally occluded very
proximally/ostially.
2. Limited resting hemodynamics revealed severe hypotension with
initial
blood pressure of 73/50 and bradycardia with heart rate of
40bpm. She
was receiving Levophed and Dopamine from the ED. An urgent
temporary
pacing wire was placed and set with rate of 80bpm with
successful
capture.
3. Successful PCI and stenting of a mid-RCA 100% occlusive
culprit
lesion with a 3.0 x 12 mm Integrity bare metal stent with no
residual
stenosis. Minimal residual stenosis in the distal RCA stent and
in the
RPL branch following POBA (to ensure adequate outflow from the
mid-RCA
stent).
FINAL DIAGNOSIS:
1. STEMI due to stent thrombosis of the proximal RCA bare metal
stent
placed in [**2186**].
2. Successful placement of temporary pacer wire for bradycardia
associated with hemodynamic compromise.
3. Initial hemodynamic compromise improved with pacing,
pressors, and
revascularization. Patient was able to be weaning off pressors
by end of
case with hemodynamic stability.
4. Aspirin 325mg daily x3 months then 162mg daily x12 months.
[**Year (4 digits) **]
75mg daily for minimum 3 months, likely longer.
.
[**2190-10-17**] ECG: Sinus rhythm. A-V conduction delay. There are ST
segment elevations in leads II, III and aVF with corresponding T
wave inversions, as well as T wave inversions in leads V5-V6
consistent with acute transmural ischemia in the inferolateral
territory. Compared to the previous tracing of [**2186-5-25**] inferior
injury pattern is new. Clinical correlation is suggested.
.
[**2190-10-18**] ECG: Sinus rhythm. Deep T wave inversions in leads II,
III and aVF. T wave flattening in leads V5-V6. Compared to the
previous tracing of [**2190-10-17**] ST segment elevations have resolved.
However, T wave inversions are deeper consistent with evolution
of acute myocardial infarction.
.
[**2190-10-17**] ECHO
LV systolic function appears depressed (ejection fraction 40
percent) secondary to severe hypokinesis of the inferior and
posterior walls. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. Aortic stenosis is present (not quantified). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**1-17**]+) mitral regurgitation is
seen (may be underestimated due to technically suboptimal
imaging). There is no pericardial effusion.
.
[**2190-10-18**] ECHO
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild to moderate regional left
ventricular systolic dysfunction with hypokinesis of the basal
half of the inferior and mid inferolateral walls. The remaining
segments contract normally (LVEF = 50%). 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). Trace aortic regurgitation is seen. The mitral
valve appears structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**1-17**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (PDA distribution). Mild-moderate
mitral regurgitation. Mild aortic valve stenosis. Pulmonary
artery hypertension.
Compared with the prior study (images reviewed) of [**2190-10-17**],
global left ventricular systolic function is minimally improved.
.
[**2190-10-18**] CHEST (PORTABLE AP): There is a new inferior approach
pacing lead with its tip in the region of the right ventricle.
There is unchanged dense calcification of the aortic arch and
the descending aorta. There are low lung volumes with small
bilateral pleural effusions and retrocardiac and left basilar
atelectasis. There is marked prominence of the pulmonary
vasculature. No pneumothorax is present. The heart is top normal
in size.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **]yo F with history of inferolateral STEMI in
[**5-22**] who presents with inferior STEMI from RCA stent thrombosis
complicated by bradycardia, s/p BMS placement to the mid-RCA.
.
.
ACTIVE ISSUES
# Inferior STEMI: Patient has a history of prior RCA STEMI in
[**2186**] with 3 BMS and presented with thrombosis of the stents now
causing STEMI. This was ballooned open with improvement in her
hemodynamics. There was successful PCI and stenting of a mid-RCA
100% occlusive culprit lesion with a 3.0 x 12 mm Integrity bare
metal stent with no residual stenosis. She was [**Year (4 digits) 4532**] loaded
and will continue on Integrillin for the next 18 hours. Her
HbA1C was 7.3 and TTE showed mild to moderate regional left
ventricular systolic dysfunction (EF= 50%) with hypokinesis of
the basal half of the inferior and mid inferolateral walls. She
was continued on [**Last Name (LF) 4532**], [**First Name3 (LF) **], valsartan, metoprolol, and
switched to atorvastatin from simvastatin.
.
# RHYTHM: She was bradycardic to the 30s likely from increased
vagal tone during STEMI and hypotensive in the ED. Temporary
pacer was inserted in the cath [**First Name3 (LF) **] and left in for monitoring.
Her native rate improved after intervention and the pacer was
pulled, but she was given small dose beta blocker (25mg Toprol
XL) to avoid withdrawal.
.
# Esophageal pain: Pt reported pain in her esophagus and
epigastrum, especially when eating. She was given GI cocktail
along with famotidine. Etiology of the pain is unclear. She had
no evidence of [**Female First Name (un) **] in her oropharynx. GERD is a possibility
though it is likely she would have improved with famotidine.
Pill esophagitis is a possibility. Eventually the pain subsided.
Would recommend outpatient GI follow-up if symptoms continue.
.
.
CHRONIC ISSUES
# CHF: No echo in our system but suspect she has component of
ischemic cardiomyopathy given her history and daily use of
lasix. No current signs of failure on exam and had transient S3
on physical exam. TTE showed moderate regional left ventricular
systolic dysfunction with hypokinesis of the basal half of the
inferior and mid inferolateral walls. LVEF = 50% with pulmonary
artery hypertension. She had some crackles bilat on day of
discharge and her lasix was increased to 20 mg daily from 10 mg
daily. She was advised to check her weight daily and to stop the
increased dose if she has signs of dehydration.
.
# Shoulder pain: Patient continued to have bilateral shoulder
pain secondary to previous rotator cuff injuries. She will
continue to have home physical therapy for this pain.
.
# HTN: Once BP (and HR) tolerated it, she was continued on her
beta-blocker amlodipine. She was from her home [**Last Name (un) **] to valsartan
while in-house.
.
# HLD: Her calculated LDL was 87 on [**10-4**]. She was switched to
80mg atorvastatin from simvastatin to achieve goal <70.
.
# GERD: She was switched from omeprazole to famotidine given
[**Month/Year (2) 4532**] use.
.
# Hypothyroidism: She was continued on home Levoxyl.
.
.
TRANSITION ISSUES
1. Perform full anemia work-up as an outpatient, including iron
studies, B12 and folate.
2. VNA to send labs on Tuesday to check electrolytes on new
medicines.
Medications on Admission:
AMLODIPINE [NORVASC] 5 mg daily
BUPROPION HCL 75 mg daily
FUROSEMIDE 10mg daily
IRBESARTAN [AVAPRO] 300 mg daily
ISOSORBIDE 30 mg daily
METOPROLOL SUCCINATE 50 mg qAM, 25mg qHS
POTASSIUM CHLORIDE 15 mEq daily
ASPIRIN 325 mg daily
OMEPRAZOLE 20 mg daily
Levoxyl 50 mcg daily
Simvastatin 80mg daily
Ocuvite
MVI
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): take 2 tablets on [**2190-10-22**].
Disp:*30 Tablet(s)* Refills:*11*
5. irbesartan 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. isosorbide mononitrate 30 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*
7. metoprolol succinate 50 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*
8. potassium chloride 15 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
9. Outpatient [**Date Range **] Work
Check Chem-7 on Monday [**2190-10-25**] with results to Dr. [**Last Name (STitle) 1968**] at
[**Telephone/Fax (1) 3329**]
10. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. potassium & sodium phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO BID (2 times a day) for
3 doses.
Disp:*3 Powder in Packet(s)* Refills:*0*
14. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ST elevation myocardial infarction
Hypertension
Gastro-esophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a small heart attack because there was a clot in the
stent that blocked blood flow to your heart. The clot was
removed and you had another bare metal stent placed in the right
coronary artery. You will be on a full dose aspirin and
clopidogrel for the next few months and possibly longer. It is
extremely important that you take the aspirin and clopidogrel
every day without fail to keep the stent from clotting off again
and causing another heart attack. Do not stop taking aspirin or
clopidogrel unless Dr. [**Last Name (STitle) **] tells you it is OK. Your heart rate
was low during your heart attack and you needed a temporary
pacer to help your heart beat. Your heart rate is now normal.
Your echocardiogram showed good heart function and should
improve in the next moonth. You had some stomach upset that we
think is not related to your heart. You were started on some
medicines to help and can stop taking the medicines if you
stomach feels better. Weigh yourself every morning, call Dr.
[**Last Name (STitle) **] if weight increases more than 3 pounds in 1 day or 5
pounds in 3 days.
.
While you were here, you were found to be anemic with low blood
count. This should be evaluated further by your primary care
physician.
.
We made the following changes to your medicines:
1. Take clopidogrel ([**Last Name (STitle) **]) 2 doses on [**10-23**], then one pill
every day thereafter. Take with 325 mg of aspirin to prevent the
stent from clotting off again.
2. Decrease metoprolol to 50 mg daily to lower your heart rate
3. Increase furosemide to 20 mg daily to get rid of extra fluid
4. STOP taking omeprazole, start famotidine twice daily instead
to treat your heartburn.
5. START neutrophos for 3 doses to treat your low phosphate
level
6. STOP taking simvastatin, take Atorvastatin instead to lower
your cholesterol.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: TUESDAY [**2190-11-2**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10604**], MD [**Telephone/Fax (1) 3329**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 72614**], MD
Specialty: Cardiology
Location: LOWN CARDIOVASCULAR GROUP
Address: [**Hospital1 72615**], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 34506**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] for
within 1 month of your discharge from the hospital. You will be
called at home with the appointment. If you have not heard
within 2 business days, please call the number above.
ICD9 Codes: 4280, 4019, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4932
} | Medical Text: Admission Date: [**2187-2-7**] Discharge Date: [**2187-2-27**]
Service: CARDIOTHORACIC
Allergies:
Keflex / adhesive tape
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Critical aortic stenosis
Major Surgical or Invasive Procedure:
CoreValve placement
History of Present Illness:
86 yo F with CAD s/p CABG in [**2170**] (LIMA to LAD, SVG to D2, SVG
to dRCA and SVG to OM), interstitial pulmonary fibrosis, DM,
HTN, HLD, with progressive dyspnea on exertion, admitted for
CoreValve.
.
Briefly, patient has had longstanding aortic stenosis. Cardiac
catheterizaiton at [**Hospital1 2177**] in [**2177**] which revealed a 90% distal LM
stenosis, 80% mLAD stenosis followed by T.O, 40% D1 stenosis,
90%
ostial RCA stenosis and 60% PDA stenosis. The SVG's to D2 and
SVG
to the dRCA were patent. The SVG to OM occluded at ostium, LIMA
to LAD patent, distal LAD diffusely diseased. On [**2178-1-7**], she
underwent stenting of the LM with a 3.5 x 8mm Bx velocity stent.
.
Per patient, since [**10-4**], she has been getting progressive short
of breath on exertion. She used to be able to perform all ADLs
as well as work around the house. Now, she gets very short of
breath with minimal exertion, and can only walk from her bed to
the recliner. Her symptoms are of chest tightness. The dyspnea
usually improved after sitting down for a while. She reports one
episode of syncope in [**10-4**] where she suddenly loss
consciousness. It is unclear whether that was also associated
with hypoglycemia.
.
On arrival to the floor, patient was alert and oriented, mildly
short of breath when speaking, but other comfortable. Vitals
were HR 60, BP 125/71, RR 38, O2 sat 94% RA.
.
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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: CABG in [**2170**] at NEDH with a LIMA to LAD, SVG to D2, SVG
to dRCA and SVG to OM (known occluded).
-PERCUTANEOUS CORONARY INTERVENTIONS: In [**2177**], cath showed 90%
distal LM stenosis which was stented with a 3.5 x 8mm Bx
velocity stent.
Also showed 80% mLAD stenosis followed by T.O, 40% D1 stenosis,
90%
ostial RCA stenosis and 60% PDA stenosis. The SVG's to D2 and
SVG
to the dRCA were patent. The SVG to OM occluded at ostium, LIMA
to LAD patent, distal LAD diffusely diseased.
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Fractured rib on left from last month from coughing
excessively r/t a sinus infection
- Diabetes Type II, on oral agents
- Complete hysterectomy and oopherectomy [**2176**] for ovarian CA.
No recurrence noted
- Pulmonary fibrosis - Marked restrictive ventilatory defect
on PFTs and severe fibrosis and low FVC on chest CT.
Social History:
She is a widow. She is retired currently lives with daughter.
She does not follow a diet and does not exercise regularly.
-Tobacco history: never smoked
-ETOH: none
-Illicit drugs: denied
Family History:
There is a family history of hypertension, diabetes, and heart
disease but not stroke. Her mother died at 29 of gall bladder
infection and her father died at 69 of stomach cancer. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
Physical exam on admission:
VS: T=97.3 BP=125-132/71 HR=60 RR=38 O2 sat=94% RA
GENERAL: Elderly woman, lying in bed, mildly short of breath
when speaking
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: S1, S2 obscured, Grade IV/VI crescendo-decrescendo
systolic ejection murmur radiating to the carotics
LUNGS: Mild shortness of breath. Moving air appropriately, dry
crackles diffusely
ABDOMEN: +bs, soft, multiple scars well healed. Non-tender,
non-distended.
EXTREMITIES: 1+ edema to the ankles b/l, mild edema in the
hands, r>l
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2187-2-26**] 12:58AM BLOOD WBC-8.3 RBC-3.56* Hgb-11.3* Hct-33.7*
MCV-95 MCH-31.7 MCHC-33.5 RDW-14.6 Plt Ct-342
[**2187-2-25**] 03:08AM BLOOD WBC-7.6 RBC-3.48* Hgb-10.8* Hct-32.5*
MCV-93 MCH-31.0 MCHC-33.2 RDW-14.6 Plt Ct-355
[**2187-2-26**] 12:58AM BLOOD Glucose-177* UreaN-40* Creat-0.9 Na-142
K-3.9 Cl-105 HCO3-30 AnGap-11
[**2187-2-25**] 03:08AM BLOOD Glucose-182* UreaN-45* Creat-1.0 Na-138
K-4.3 Cl-101 HCO3-32 AnGap-9
[**2187-2-11**] 03:09AM BLOOD ALT-25 AST-81* LD(LDH)-328* CK(CPK)-210*
AlkPhos-116* Amylase-22 TotBili-3.3*
[**2187-2-26**] 12:58AM BLOOD Calcium-9.9 Mg-1.7
Head CT [**2-21**]
IMPRESSION:
1. No evidence of cerebral artery occlusion.
2. Atherosclerotic disease as mentioned above.
3. Lung parenchymal opacities better appreciated on recent lung
imaging.
MR head [**2-21**]
FINDINGS: Extremely limited study. The ventricles and sulci are
prominent,
suggestive of age-related volume loss. No other findings can be
made from
this nondiagnostic study. The patient was immediately referred
to CT
angiogram.
Echo:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. There is abnormal septal motion/position. An aortic
CoreValve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. Trace aortic regurgitation and a very
small paravalvular leak are seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Well-seated, normally functioning aortic CoreValve
prosthesis with trace aortic regurgitation and a very small
paravalvular leak. Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Mild mitral regurgitation. Mild pulmonary
artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2187-2-9**],
the findings are similar. Previously, the very small aortic
paravalvular leak was not commented upon, but appears to have
been present.
Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2187-2-15**] 15:48
[**2187-2-27**] 05:30AM BLOOD WBC-9.8 RBC-3.64* Hgb-11.6* Hct-34.0*
MCV-93 MCH-31.9 MCHC-34.1 RDW-14.7 Plt Ct-367
[**2187-2-27**] 05:30AM BLOOD Glucose-142* UreaN-33* Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-29 AnGap-13
Brief Hospital Course:
Medicine Course:
86 yo F with CAD s/p CABG in [**2170**] (LIMA to LAD, SVG to D2, SVG
to dRCA and SVG to OM), interstitial pulmonary fibrosis, DM,
HTN, HLD, with progressive dyspnea on exertion, admitted for
CoreValve palcement.
.
# Aortic stenosis: Patient has critical aortic stenosis with
most recent valve area measurement of 0.7 cm2. She is currently
showing symptoms of dyspnea on minimal exertion. Patient deemed
"extreme risk" for surgical aortic valve replacement. Patient
admitted for CoreValve placement.
.
# Interstitial pulmonary fibrosis: New diagnosis for patient,
but likely long-standing. Dyspnea on exertion is at least
particially due to pulmonary disease. Recent CT chest showed
severe diffuse pulmonary fibrosis and marked restrictive
ventilatory defect on PFTs. Did not require oxygen at baseline.
Patient continued on home albuterol inhaler and Advair.
.
# Coronary artery disease: Longstanding, s/p CABG in [**2170**] (LIMA
to LAD, SVG to D2, SVG to dRCA and SVG to OM), which on recent
cardiac catheterization showed three vessel disease. Patient
currently asymptomatic.
.
# Diabetes: Patient only on glyburide at home, which was held.
Patient placed on Humalog sliding scale.
Cardiac Surgery Course:
The patient was taken to the operating room on [**2187-2-8**] where she
underwent CoreValve placement with Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for observation and recovery. Shortly following
arrival in CVICU, the patient developed cardiac arrest requiring
re-intubation and resuscitation. Echo revealed free air in the
right atrium and ventricles. She also developed rapid atrial
fibrillation and eventually converted to SR with electrical and
chemical cardioversion. Transvenous wire was placed on [**2-10**] at
the bedside by Dr. [**Last Name (STitle) **] for second degree heart block. The
patient developed a fever. Sputum cultures would grow
Pseudomonas. The patient was treated with appropriate
antibiotics.
When the patient was weaned from sedation, she was unable to
move the left upper extremity. Neurology was consulted for
evaluation and she was confirmed to have a CVA. Eventually
extubated on [**2187-2-16**]. Swallowing eval done and she had
confusion. Supportive care given while she remained in the CVICU
for monitoring.
Now alert and oriented and following commands. Aphasia resolved
and LUE remains as the only deficit. Transferred to the floor on
POD # 18. Cleared for discharge to [**Hospital 38**] Rehab Hospital in
[**Location (un) 38**] on POD #19. Follow up appts were advised.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
two
puffs inhaled 4 times daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - twoq puffs inhaled twice daily
GLYBURIDE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth twice a day
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet
-
1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth Three times daily
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth daily at hs
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth daily
CALCIUM CARBONATE - (Prescribed by Other Provider) - 600 mg
(1,500 mg) Tablet - one Tablet(s) by mouth daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 2,000 unit Capsule -
one Capsule(s) by mouth daily
GLUCOSAMINE-CHONDROIT-VIT C-MN [GLUCOSAMINE 1500 COMPLEX] -
(Prescribed by Other Provider) - 500 mg-400 mg Capsule - two
Capsule(s) by mouth daily
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider) - Tablet - one Tablet(s) by mouth daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
Critical aortic stenosis s/p CoreValve AVR
Diabetes mellitus
Coronary artery disease
CVA
Post-op respiratory failure
.
SECONDARY:
Interstitial pulmonary fibrosis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and Oriented
Activity Status: max assist- pivots briefly
LUE- moves thumb only
Discharge Instructions:
Please shower daily including washing puncture sites in groins
with mild soap, no baths or swimming for 1 week until groin
sites are healed.
Please NO lotions, cream, powder, or ointments to puncture sites
in your groins
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 one month, will be discussed at follow up
appointment
No lifting or pulling more than 10 pounds for 1 week, and then
continue to take it easy for 1 month
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call Integrated Aortic valve clinic in cardiac surgery
office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering
service will contact on call person during off hours**
Followup Instructions:
Dr.[**Name (NI) 32659**] office [**Telephone/Fax (1) 62**] (will arrange for follow up)
Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Friday [**2187-3-30**], 1:00 pm [**Hospital Ward Name **] 2A
Dr. [**Last Name (STitle) **]( neurology) Thursday [**4-12**] @ 11:30 AM [**Hospital Ward Name 23**] 8
(Neuro)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**Doctor Last Name **] [**Telephone/Fax (1) 31188**] in 3 weeks
**Please call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] with any questions or
concerns.
Completed by:[**2187-2-27**]
ICD9 Codes: 4241, 4275, 5185, 5990, 9971, 5849, 4280, 2724, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4933
} | Medical Text: Admission Date: [**2117-10-27**] Discharge Date: [**2117-11-30**]
Date of Birth: [**2080-10-11**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Sepsis, respiratory failure, pneumonia
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
electrical and chemical cardioversion
placement of left subclavian central venous HD catheter
placement of right IJ venous catheter
placement of right radial arterial line
hemodialysis
History of Present Illness:
Mr. [**Known lastname 83984**] is 37 year old man, with a history of DM, who
presented to [**Hospital6 **] on [**2117-10-21**] after a
syncopal episode. There was a question of a seizure in the field
prior to arrival. Per his family he had a upper respiratory
illness (starting [**10-12**]) with sneezing, cough for 7-10 days
with decreased PO intake and general malasie prior to
presentation. He was in shock on admission, was intubated and
started on levophed and Tamiflu, Levaquin, and Vancomycin. H1N1
was originally suspected, however Flu swab has remained
negative. He developed MSSA in the blood cultures and his
antibiotics were narrowed to naficillin. He remained on
vasopressors until [**10-24**].
His course was complicated by ARF with Cr of 1.9 worsening to
7.2 thought to be [**1-4**] ATN and requiring HD for hyperkalemia to
6. He had a HD line placed on [**10-24**]. He also had intermittant
A. fib treated with Cardizem as well as a wide complex
tachycardia. Echo showed a preserved EF without evidence of
vegitation.
On transport on [**2117-10-27**] he was paralysized and given boluses of
versed and fentanyl. HR remained tachycardic in the 140s.
Past Medical History:
DM - diet controlled
HTN
Social History:
Works as a chef. Lives in [**Location 9583**] with parents. No tobacco
or illicts. Heavy drinker.
Family History:
DMII. Father CAD. Mom RA, CVA, DM. Two brothers with CAD.
Physical Exam:
On Admission:
Vitals T 100.6 P 147 BP152/90 O2 sat. 92% on CMV
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2117-10-27**] 11:09PM WBC-12.5* RBC-4.12* HGB-12.8* HCT-37.9*
MCV-92 MCH-31.1 MCHC-33.8 RDW-14.8
[**2117-10-27**] 11:09PM NEUTS-82* BANDS-1 LYMPHS-10* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2117-10-27**] 11:09PM PLT COUNT-214
[**2117-10-27**] 11:09PM GLUCOSE-147* UREA N-39* CREAT-5.4* SODIUM-144
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-20
[**2117-10-27**] 11:09PM ALBUMIN-2.2* CALCIUM-7.5* PHOSPHATE-6.0*
MAGNESIUM-2.2
[**2117-10-27**] 11:09PM ALT(SGPT)-52* AST(SGOT)-104* LD(LDH)-437*
CK(CPK)-238* ALK PHOS-260* TOT BILI-5.2*
[**2117-10-27**] 11:09PM PT-14.4* PTT-42.1* INR(PT)-1.2*
.
Discharge labs:
[**2117-11-25**]
Glucose UreaN Creat Na K Cl HCO3 AnGap
84 13 0.8 140 3.9 104 24 16
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.9 3.58* 10.8* 33.1* 92 30.0 32.5 15.3 236
.
Imaging:
ECG Study Date of [**2117-10-27**] 10:53:18 PM
Sinus tachycardia. Incomplete right bundle-branch block.
Non-specific
ST-T wave changes. The P-R interval is 160 milliseconds.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
147 160 106 296/448 0 101 -60
.
ECG Study Date of [**2117-11-4**] 3:16:42 AM
Supraventricular tachycardia most likely representing
atrio-ventricular nodal reentrant tachycardia but cannot exclude
orthodromic atrio-ventricular reciprocating tachycardia.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
170 0 84 298/490 0 82 -95
.
CT HEAD W/O CONTRAST Study Date of [**2117-10-28**]
IMPRESSION: No acute intracranial process. Evaluation for
infection is
limited on CT. Sinus disease. Fluid within the mastoid air cells
bilaterally.
.
CT TORSO W/O CONTRAST Study Date of [**2117-10-28**]
IMPRESSION:
1. Evaluation limited due to lack of IV contrast and streak
artifact from
overlying arms. Multifocal pneumonia as seen on recent chest
x-ray.
2. Fatty liver. Otherwise, non-contrast appearance of the
abdomen and pelvis is unremarkable except for small amount of
free fluid.
.
ECHOCARDIOGRAPHY [**2117-11-1**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
.
CHEST (PORTABLE AP) Study Date of [**2117-11-16**]
FINDINGS: In comparison with study of [**11-15**], there is little
overall change in the appearance of the cardiomediastinal
silhouette with extensive right paratracheal thickening.
Extensive left lung consolidation has somewhat decreased since
the previous study. Also, the area of opacification in the right
lung has improved.
.
MR HEAD W/O CONTRAST Study Date of [**2117-11-22**]
IMPRESSION:
1. Extensive confluent T2 and FLAIR hyperintensities throughout
the centrum semiovale and peritrigonal regions without
restricted diffusion. The findings most likely represent
sequelae of a systemic metabolic/hypoxic insult with additional
considerations to include infectious or HIV-related processes
such as PML or viral encephalopathy. Given the marked
hypotension 3 weeks prior, the findings could represent evolving
watershed infarcts with pseudonormalization of the ADC map or
even osmotic demyelination in the appropriate context.
Correlation with the patient's history and followup examination
with gadolinium administration is recommended in further
evaluation.
2. Bilateral mastoid air cell effusions as well as maxillary and
sphenoid
sinus disease, which may in part be related to recent
intubation.
.
MR HEAD W/ CONTRAST Study Date of [**2117-11-22**]
IMPRESSION: Patchy foci of enhancement throughout the signal
abnormality
within the centrum semiovale with primary differential
considerations again including metabolic/hypoxic processes. The
findings could relate to subacute infarcts relating to prior
watershed event or osmotic demyelination. Correlation with CSF
sampling is recommended.
.
EMG Study Date of [**2117-11-24**]
Clinical Interpretation: Complex abnormal study. There is
electrophysiologic evidence for a mild sensorimotor neuropathy
with demyelinating and axonal features. Although this can be
seen in diabetes, the EMG reveals ongoing denervation and
chronic reinnervation in the upper and lower extremities,
suggesting a subacute process. The differential diagnosis
includes critical illness polyneuropathy and axonal variant of
[**First Name9 (NamePattern2) 7816**] [**Location (un) **] syndrome. An incidental moderate median
neuropathy at the left wrist is noted (as in carpal tunnel
syndrome).
.
MICROBIOLOGY:
[**2117-10-31**] 2:19 pm BLOOD CULTURE Source: Line-cvl.
**FINAL REPORT [**2117-11-4**]**
Blood Culture, Routine (Final [**2117-11-3**]):
KLEBSIELLA PNEUMONIAE.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species. FINAL SENSITIVITIES.
sensitivity testing performed by Microscan.
MEROPENEM = SENSITIVE ( <=1 MCG/ML ).
CEFEPIME = RESISTANT ( >=16 MCG/ML ).
UNASYN (AMPICILLIN/SULBACTAM) = RESISTANT ( >=16 MCG/ML
).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN------------ =>16 R
AMPICILLIN/SULBACTAM-- R
CEFAZOLIN------------- =>16 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>16 R
CEFTRIAXONE----------- =>32 R
CIPROFLOXACIN--------- =>2 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- 32 I
TOBRAMYCIN------------ =>64 R
TRIMETHOPRIM/SULFA---- <=2 S
Anaerobic Bottle Gram Stain (Final [**2117-11-1**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 83985**] [**Doctor Last Name 83986**] @ 0340 ON [**11-1**] - CC6D.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2117-11-1**]): GRAM NEGATIVE
ROD(S).
====
[**2117-10-31**] 2:30 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2117-11-3**]**
GRAM STAIN (Final [**2117-10-31**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2117-11-3**]):
Commensal Respiratory Flora Absent.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
286-2926K
[**2117-10-28**].
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 8 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
Brief Hospital Course:
This is a 37 y/o male with [**Hospital **] transfered from an OSH after
presenting in septic shock with Staph pneumonia / bacteremia
with a course complicated by ARF and tachycardia. He grew MSSA
in blood/sputum (at the OSH), Klebsiella in his blood and
klebsiella and pseudomonas in sputum at [**Hospital1 18**].
.
# Severe septic shock: The patient had known bacteremia,
pneumonia and sinus disease by CT scan at admission to OSH.
These findings, in addition to elevated mixed venous O2Sat of
84% and his mottled appearance suggested a septic etiology.
Cardiogenic shock was deemed unlikely, given the pt's robust BP
despite tachycardia to the 170s, high mixed venous O2sat, and
preserved LVEF on ECHO.
.
# Community Acquired Pneumonia: At presentation, the patient's
blood pressure was stable, off pressors. Culture data was
positive for MSSA in the sputum and blood early in OSH course.
CT scan showed a multi-focal pneumonia, with L > R infiltrates,
but no sign of empyema. TTE showed no vegetations. H1N1 was a
consideration, and the pt was initially treated for flu with
Tamiflu; however, after negative influenza DFA x 2 at the OSH
and another negative DFA at [**Hospital1 18**], Tamiflu was stopped. Patient
completed a 14 day course of Meropenem (inititially
nafcillin/meropenem/gentamicin narrowed to Meropenem).
.
# Ventilator-Associated Pneumonia: After intubation at the OSH,
his sputum cultures at BIDCMC grew Klebsiella pneumoniae and
pseudomonas in the sputum, and Klebsiella in the blood. Per ID
consult, patient's antiobitic regimen was changed from
nafcillin/meropenem/gent to: solely Meropenem--with a course
from [**11-5**] (the last negative blood culture) to [**11-19**], for a
total of 14 days.
.
# Klebsiella Bacteremia: Patient was treated with a 14 day
course of meropenam.
.
# Coagulase-negative Staphylococcus Bacteremia: This was felt
to be line-related. Pt was treated with 7 day course of
Vancomycin.
.
# Acute Respiratory Distress: The patient had bilateral
infiltrates on CXR and CT chest and high oxygen requirement. He
had a long course of intubation (18 days), extubated on [**11-10**]
following precedex treatment. At discharge, the patient was
satting well on room air.
.
# Acute renal failure from Acute Tubular Necrosis: Due to
hyperkalemia in the setting of ARF, the pt required HD, and
renal consult service followed him closely. Patient was
oliguric, then had post-ATN diuresis, and renal function
improved considerably, at discharge his Cr was back to baseline.
However, the patient had persistent hypomagnesemia on discharge
requiring daily supplementation, likely [**1-4**] magnesium wasting
from recovering ARF/ATN. He was discharged on magnesium po
supplementation with instructions to f/u labs in rehab.
.
# Mental depression: After extubation, pt was found to have
mental slowing with word-finding difficulties and inattention.
Both improved steadily during the hospitalization. This is most
likely a hypoxic process given the extent of ventilatory support
needed. MRI with and without contrast showed patchy foci of
enhancement throughout the signal abnormality within the centrum
semiovale with primary differential including metabolic/hypoxic
processes, subacute infarcts relating to prior watershed event,
or osmotic demyelination. Neurology suggested that this may be
a congenital defect given the symmetry on MRI; he has no prior
MRIs. LP showed no evidence of bacterial infection but was
notable for elevated protein, mildly low glucose, and only 4
WBCs. This can be c/w but less likely aseptic meningitis, CSF
cultures pending at time of discharge. Patient is scheduled for
neurology f/u as outpt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
.
# Critical illness myopathy: Patient developed myopathy during
his ICU stay. This is most likely critical illness myopathy
given greater proximal than distal muscle weakness, prolonged
failure to wean from mechanical ventilation, and initially
elevated CK. Given elevated protein in CSF and viral prodrome,
GBS is a consideration but less likely. EMG showed mild
sensorimotor neuropathy with demyelinating and axonal features
with differential diagnosis including critical
illness polyneuropathy and axonal variant of [**First Name9 (NamePattern2) 7816**] [**Location (un) **]
syndrome. Neurology felt his history was more consistent with
ICU myopathy. He was followed by physical therapy and by
discharge, his proximal muscles were 4+/5 in strength.
.
# Magnesium deficiency: Pt was noted to be persistently
hypomagnesiemia despite aggressive repletion. He had no other
electrolyte abnormalities, inc. K, Ca. Urinary Mg excretion was
extremely high at 355 mg/24 hr, likely due to postATN tubular
dysfunction. He was started on po repletion and his Mg will
needed to be followed at rehab.
.
# Tachycardia/ AFib: Although the patient's tachycardia appeared
sinus on arrival, during his course he had couple runs of
tachycardia that appeared to be regular SVT with aberrancy that
were self-limited and well-tolerated. His OSH EKG showed RBBB as
recently as [**10-26**], and there were reports of atrial fibrillation
requiring treatment with diltiazem. At one point, the patient
went into regular SVT with aberrancy during dialysis, which was
treated w/ lopressor 10, dilt 20 IV and dilt PO60 with
conversion back to sinus after 1-2 hours. Atrial irritation was
believed due to an IJ that was too deep, and was subsequently
pulled back. During another HD session, he again had aberrant
SVT, thought to be due to intracellular shifts. Finally, the
patient had another episode, during which he underwent
synchronized cardioversion and was chemically cardioverted with
amiodarone and adenosine--after this episode, adenosine was kept
at the bedside. EP was consulted, and 24 hour amiodarone was
completed. The patient had persistent tachycardia and
hypertension during his hospitalization, treated with diltiazem,
metoprolol, amlodipine, and hydralazine. Diltiazem and the
Clonidine patch were discontinued in the MICU. Lisinopril was
initiated. When he was transferred to the medical floor, he was
in NSR. The patient was eventually discharged on lisinopril,
metoprolol and amlodipine (all new medications for him).
.
# Hypertension: The patient was frequently hypertensive to the
170s and 200s SBP. This was treated with a clonidine patch due
to concern of agitation/anxiety as trigger in addition to
diltiazem, metoprolol, amlodipine, hydralazine. Diltiazem and
the Clonidine patch were discontinued in the MICU, and
Lisinopril was initiated. The patient was eventually discharged
on lisinopril, metoprolol and amlodipine.
.
# Rash on back, abdomen, thighs: Appeared to be consistent with
a drug rash, which could have been triggerred by Vanc or
Cefepime, although statistically Cefepime would be more likely.
Both drugs were discontinued on [**10-31**]; and the patient changed
to Meropenem. The rash improved clinically, became less
erythematous, and was treated with clobetasol [**Hospital1 **] 0.05% for
abdomen, and clotrimazole/hydro groin cream for rash. Vancomycin
was later added back on, without worsening of the patient's
rash--further increasing our suspicion that Cefepime was the
culprit. This rash had resolved by discharge and the
clotrimazole and hydrocortisone cream were not continued.
.
# Sacral decubitus ulcer, stage 2: This was cared for by
nursning.
.
# DM2: Patient was diet controlled prior to admission. He was
treated with glargine 50 units qHS and ISS. His insulin
requirements improved as he clinically improved. Would suggest
discharging patient on glargine and insulin sliding scale. He
will need teaching related to using insulin and using a sliding
scale. Please make sure he has close follow up with his PCP.
# Demand ischemia: During this hospitalization the patient
presented with elevated troponin and CK, but CKMB was normal
(2). This elevation was thought to be due to demand ischemia in
the setting of shock and persistent tachycardia, as well as
renal insufficiency. Cardiac enzymes were trended, and his
Troponin did not continue to rise.
.
# Mild LFT elevation: This was thought to be [**1-4**] prolonged
hypotension. His LFTs normalized over the course of his
hospitalization.
.
# Code: Full code confirmed
Medications on Admission:
Home: None
.
Medications on Transfer:
Novolog SS
Multivit
nafcilliln 2g q4h start [**10-24**]
Oseltamivir 90 mg [**Hospital1 **] started [**10-22**]
Pantoprazole 40mg IV daily
propofol gtt
acematinophen 1000mg q6h prn
ibuprofen 600mg q8h prn
morphine 2mg IV prn
NTG SL prn
Levalbuterol HFA 4 puffs q6hs
artifical tears oint q4hs
ASA 325mg Daily
Chlorhexidien 15ml q12h
plavix 75mg daily
Heparin gtt started [**10-24**]
.
previous meds in OSH:
enoxaparin 40mg daily start [**10-22**], d/c [**10-25**]
diltiazem gtt started [**10-23**], d/c [**10-25**]
levofloxacin 750mg q48h start [**10-24**], d/c [**10-25**]
digoxin 0.125 x 2 on [**10-23**]
Vancomcyin 1g IV start [**10-22**]
Discharge Medications:
1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
4. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) unit
Subcutaneous at bedtime.
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID PRN () as needed for hemorrhoid.
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Magnesium Oxide 400 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
11. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: dose based on sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] State Hospital
Discharge Diagnosis:
Primary Diagnoses:
- Community Acquired Pneumonia: Methicillin Sensitive Staph
Aureus pneumonia.
- Ventilator Associated Pneumonia: Multi-Drug-Resistant
Klebsiella and Pseudomonas.
- Bacteremia
- Septic shock
- Supra-Ventricular Tachycardia with aberrancy
- Intensive Care Unit myopathy.
- Acute Renal Failure
- Magnesium wasting
- Encephalopathy
- Extensive T2/FLAIR hyperintensities deep white matter not
otherwise specified
- Stage II sacral decubitus ulcer
Secondary:
- Diabetes mellitus type II
- Hypertension
Discharge Condition:
Afebrile, satting well on room air. Patient is alert, speaking
in short sentences and following commands/answering questions.
.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 83984**].
You were hospitalized at [**Hospital1 18**] for septic shock--low blood
pressure due to an infection. You had a severe pneumonia (a lung
infection) and blood infection, which required placement of a
breathing tube, intra-venous antibiotics and a prolonged stay in
the Medical ICU. As a result of your infection, your kidneys
gave out, and you required hemodialysis--however, with
improvement of your infection, your kidneys function improved
and returned to [**Location 213**]. At times during your hospitalization,
your heart rate became very fast and your blood pressure was
very elevated--this was treated with medications, and has since
resolved. Because of prolonged ICU stay, your muscle has become
very weak, and you need aggressive physical therapy to regain
your strength.
You also underwent brain MRI because you had some confusion
after you were extubated. The MRI had some abnormalities,
likely due to how sick you were. You then underwent a procedure
called lumbar puncture to further evaluate these changes noted
in MRIs; no active infection was found. You were also seen by
Neurology specialists.
NEW MEDICATIONS:
--Magnesium oxide
--Colace
--Multivitamin
--Linsinopril
--Pramoxine-Minreral Oil Rectal Ointment
--Clotrimazole
--Insulin Glargine
--Insulin
Followup Instructions:
You have an appointment to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
(Neurology).
Date: [**2116-12-30**]
Time: 11:00am
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg. Floor 8
Please make sure you call patient registration before coming to
the appointment([**Telephone/Fax (1) 22161**]
Please make an appointment to see your Primary Care Physician
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] [**Telephone/Fax (1) 83987**] within 1 week of discharge from
rehab. Make sure you have your blood sugar checked at this visit
as you were started on an insulin regimen for diabetes while you
were an inpatient.
ICD9 Codes: 5845, 2762, 2767, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4934
} | Medical Text: Admission Date: [**2135-12-31**] Discharge Date: [**2136-1-1**]
Service: MEDICINE
Allergies:
Fosamax / Zinacef / Penicillins / Iodine / Miacalcin /
Amiodarone / Sotalol
Attending:[**Doctor First Name 1402**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **]yo woman with h/o CAD, CHF LVEF 30%, HTN, VT s/p
dual chamber ICD [**2135-11-30**] who presented to the ED this AM after
syncopal epsode. She was in her USOH until this morning when she
woke with poor appetite. She ate a few bites of cereal and tea
and immediately became nauseated with epigastric/B lower rib
pain, had a large bowel movement, vomited and then syncopized.
her granddaughter was there and attempted to catch her fall. She
did not hit her head. She denied any palpitations, chest pain,
shortness of breath, arm or jaw pain. She awoke when the
paramedics came and she was taken the the [**Hospital1 18**] ED.
.
In ED her SBP was in the 170's, her HR in the 70's. In the
Emergency department she evidently reported chest pain "that
felt like my heart attack" asoociated with nausea, relieved by
SL NTG and morphine. She also received aspirin and plavix. On
interview in the CCU she adamantly denies any chest pain. EKG
with NSR, RBBB + [**Last Name (LF) 16990**], [**First Name3 (LF) **] deprssion in Vs-6. Bedside
ecchocardiogram showed LVEF 45%, 1+ AR, [**12-27**]+ MR, no MS, [**12-27**]+ TR,
no effusion. Pacer interrogation showed no events tachy or
brady. DDDR 50-120 ppm
.
In addition in the ED she had an abdominal CT which was
negative, CT head and neck negative, CXR showed only
cardiomegaly.
.
On the floor she feels well with the only complaint being mild
abdominal pain. she denies chest pain, SOB, nausea, vomiting. On
ROS she endorses decreased appetite x 1 week with ? 5lbs wt
loss. Denies previous abd pain; hematochezia, melena. She denies
palpitations, CP, SOB, light headedness, sensation of pacer
firing, weakness, numbness, etc. No known sick contacts or
dietary changes.
.
She had a recent hospital admit in [**11-29**] for abnormal stress
test with new lateral ischemia; cardiac cath [**2135-11-28**] showed new
occlusion of diag (comp to [**2133**]), anterolateral, apical,
posterobasilar hypokinesis. Lmain with mild dz; LAD w/ mod
diffuse dz; EF 30%; mod to severe MR; s/p ptca of occluded first
diag (unsuccessful)
Past Medical History:
CAD; "modest dz" in [**2133**]; [**2134**] cath with new diag occlusion
s/p MI in [**2118**]'s
VT since [**12-30**]; s/p amio Rx and sotalol Rx (d/c'd for side
effects); most recently on flecainide; recently d/c'd; s/p pacer
[**11-29**]
CHF with recent hospitalization [**2135-11-28**]; EF 30-40%
s/p pacer in [**11/2135**] for VT
Carotid stenosis: 40-50% L CAS; 40% R CAS
HTN
iron deficiency anemia
?osteopenia
GERD h/o esophageal ulceration and anemia
remote h/o PE
Social History:
widowed, lives in [**Location **] alone; has help with
cleaning/housework. No smoking, no EtOH, no illicit drugs.
Family History:
+ MI in mother and sister. [**Name (NI) **] h/o stroke
Physical Exam:
T 98 BP 123/30, HR 58, RR 18, 88-92% on RA
Gen: Well-appearing elderly woman in NAD; appears younger than
stated age
Neck: + R-sided carotid bruit; no LAD; approx 7cm JVD
CV: RRR grade II/VI systolic murmur heard best at RLSB; approx
7cm JVD
Pulm: CTAB
Abdomen: + BS, soft, non-distended, mild RUQ and epigastric TTP
Extremities: warm, well-perfused, no edema 2+ DP pulses B
guiaic neg in ED.
neuro: CN II-XII grossly intact; 5/5 strength all 4 extremities,
no sensory deficits.
Pertinent Results:
ruled out by cardiac enzymes x 3
.
Na 140, K 4.1, Cl 104, bicarb 28, BUN 20, Cr 0.7, gluc 112
CK 39, Trop T <0.01
LFTs all WNL; [**Doctor First Name **], lip wnl
albumin 4.0
WBC 9.6 with nl diff, hct 30.2 MCV 88, plt 216
.
CT head: No evidence of acute intracranial hemorrhage. No
fracture
identified.
.
CT neck:
1. No evidence of traumatic injury.
2. Multilevel degenerative changes in the cervical spine.
3. Extensive carotid artery calcifications.
.
Abd CT:
1. No acute abdominal pathology.
2. Extensive aortic and vascular calcifications without
aneurysmal
dilatation.
3. No free air in the abdomen.
4. Sigmoid diverticulosis without evidence of acute
diverticulitis.
.
CXR: cardiomegaly, no effusion, no pulm edema, no infiltrate
.
Eccho LVEF 45%, 1+ AR, [**12-27**]+ MR, no MS, [**12-27**]+ TR, no effusion.
Inferolat hypokinesis
.
Pacer interrogation showed no events tachy or brady.
.
EKG: sinus brady (a-paced); axis -50, ?Q in II, III, aVF. RBBB.
PR 160, QRS 150, ST depression and TWI in V4-6; similar
appearance to [**11-29**] stress test EKG
.
[**11-27**] cardiac cath: cardiac cath [**2135-11-28**] showed new occlusion of
diag (comp to [**2133**]). Lmain with mild dz; LAD w/ mod diffuse dz;
s/p ptca of occluded first diag (unsuccessful); 50% RCA lesion
at ostium; 20% L main; anterolateral, apical, posterobasilar
hypokinesis EF 30%; mod to severe MR;
Brief Hospital Course:
[**Age over 90 **] yo woman with CHF, CAD s/p MI (?IMI) and s/p recent pacemaker
for VT now presenting with syncopal episode and EKG concerning
for TWI in V4-V6.
.
# Syncope: story appears c/w situational vasovagal episode from
nausea/vomiting/defecation. She was ruled out for MI x 3 and was
chest-pain free during her admission. Arrhythmia was ruled out
by negative pacer interrogation and no telemetry events. Her
carotid stenosis is a [**Last Name 19390**] problem however there is no
h/o focal neuro symptoms. She was not hypotense. She tolerated
a regular diet and walked up the stairs w/o further syncope.
.
# Chest pain: Pt denied any chest pain, other than
lower-rib/epigastric pain to myself; however reported it to
others. This could be be [**1-27**] angina vs abdominal etiology. In
the Ddx of abdominal source is GERD, passed gall-stone,
gastritis, PUD although LFTs and abd CT were negative. She was
kept on her home-dose PPI; her stools were guiac negative. She
ruled out for MI by 3x cardiac enzymes. She may have had
ischaemia from the stress of vagally-induced hypotension. She
remained chest pain free on admission even walking up the
stairs.
.
# Cardiac:
1. Ischaemia: known CAD with 12/06 admit for new lat TWI on
stress; recent cath showing new D1 occlusion and eccho with
similar findings as today (inferolat hypokinesis/post-lat
hypokinesis). Findings on EKG likely stable from prior month.
She denies chest pain; her epigastric/rib pain and syncope could
have represented an ischaemic event vs abdominal pathology and
syncopy from vagal episode. She ruled out for MI x 3. Repeat
EKG was similar (slightly decreased STdepression/TWI). Kept on
ASA, plavix, BB, ACEI, statin. Her outpt cardiologist should
decide on the need for repeat stress test as an outpatient.
.
2. Pump: EF 45% with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **]; no current evidence of
CHF exacerbation; appeared euvolemic on exam. kept on outpt
Carvedilol 12.5 [**Hospital1 **] and quinupril/hct 10/12.5 daily.
.
3. Rhythm: h/o VT s/p dual-chamber pacer; Set to pace 50-120.
Appears to be intermittently atrially paced. No arrhythmia on
pacer interrogation.
.
# Abdominal pain/nausea/vomiting: Resolved after admission,
could have been [**1-27**] passed gallstone although LFTs wnl, PUD,
gastritis, esophagitis. She was kept on nexium and tolerated a
regular diet. She should be considered for outpt endoscopy/
other GI work-up given her iron-deficiency anemia and abdominal
pain.
.
# Anemia: labs c/w iron-deficiency. Should be f/u by
PCP/gastroenterologist.
.
# HTN: normotense on her home regimen
.
# FEN/GI: Tolerated regular diet; continued nexium
.
# PPX: was kept on SQ heparin, PPI
.
# Code: DNR/I confirmed with pt, family, and attd.
Medications on Admission:
nexium 40
coreg 6.25 QHS; 6.25 QAM
Quinapril/hct 10/12.5
ASA 81
zocor 20mg QHS
quinapril 10mg daily
ambien qhs
nifirex 150mg po bid
fosamax q week
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO daily ().
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Quinapril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1)
Tablet PO q tuesday, thursday, sat.
Discharge Disposition:
Home
Discharge Diagnosis:
primary: syncope, likely vasovagal
secondary: CHF, iron deficiency anemia, s/p IMI
Discharge Condition:
good: AFVSS, chest-pain free. able to walk up flight of steps
without chest pain or dyspnea
Discharge Instructions:
Please continue to take the same medications you were on before
coming to the hospital. You were admitted after fainting which
we think was a "vagal" reaction to your nausea/vomiting. You
did not have a heart attack, you did not have a serious
arrhythmia when we interrogated your pacemaker, your
ecchocardiogram was improved from last month, CT of your
abdomen, head and neck were normal.
.
There were some changes on your EKG that were similar to the
changes found on stress test in [**Month (only) **]. You should follow up
with your PCP and or cardiologist about this; they may suggest a
repeat stress test, but not necessarily.
.
You also have low iron levels causing anemia. You should
discuss this with your PCP and possibly [**Name Initial (PRE) **] gastroenterologist to
evalute GI causes of bleeding.
.
If you have any chest pain or pressure, shortness of breath,
light headedness, or fainting you should seek immediate medical
attention.
.
Please follow up with your PCP and cardiologist within the next
week.
Followup Instructions:
with your PCP and cardiologist in the next week
ICD9 Codes: 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4935
} | Medical Text: Admission Date: [**2135-11-15**] Discharge Date: [**2135-11-22**]
Date of Birth: [**2074-9-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atenolol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain, Dyspnea
Major Surgical or Invasive Procedure:
CABG x5 LIMA-LAD, SVG-Diag, SVG-OM1, SVG-OM2, SVG-RCA
History of Present Illness:
OUTPATIENT CARDIOLOGIST: Dr.[**Doctor Last Name 3733**]
EVENTS / HISTORY OF PRESENTING ILLNESS:
Mr. [**Known lastname 17684**] is a 61 year old male with history of IDDM, HTN,
hypercholesterolemia, 3v CAD who presents with worsening
shortness of breath over the past four days. His dyspnea on
exertion began initially in [**Month (only) **] of this year. He is a dog
walker and was walking the dogs 2 miles three times per day
without difficulty. In [**Month (only) **] he noted that he was unable to walk
two blocks without shortness of breath. He additionally had
increasing fatigue. He underwent echocardiogram which showed EF
50%, exercise MIBI showed reversible inferior wall defect. He
was admitted here [**9-8**] for elective catheterization. Cath showed
diffuse 3v disease, no intervention was done. CT surgery was
consulted for CABG planning. Repeat echo at that time showed
mild regional LV systolic dysfunction with mild hypokinesis of
distal septum and apex. Apparently CABG had been on hold pending
dental extractions. Since [**Holiday 1451**] he has had increasing
shortness of breath. He was hanging [**Holiday **] lights on [**11-12**] and
became dyspneic after 10 minutes. His shortness of breath has
worsened until today when he was unable to walk across the
street due to extreme SOB. He also report LH every morning for
the past 3 days. The lightheadedness persists for 3-4 hrs and he
feels as though he may pass out.
Past Medical History:
s/p CABGx5
PMH:DM2
Vertigo
BPH
HTN
Sciatica
Depression (suicide attempt [**2123**])
penile implant [**2133**]
Hypercholesterolemia
GERD
.
Cardiac Risk Factors:
Diabetes: Yes
Dyslipidemia: Yes
Hypertension: Yes
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse, pt reports
consumption of 2 glasses wine/weekly, although previously he
used to drink more heavily. Pt denies hx of IVDU, does have a
history of recreational drug use including cocaine and
marijuana, both last used in [**2132**]. Pt is currently sexually
active with same male partner for 5 years. Has 1 cat.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father has hx of DM, died at age 89. Mother has
hx of skin ca.
Physical Exam:
Admission
VS T 96.9, BP 138/85, HR 95, RR 18, O2sat 93% 3L, Wt 99.6, BS
119
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate. Slightly anxious.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8cm. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased breath sounds
at both bases, crackles above on right. Mild expiratory
wheezing.
Abd: Obese, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: 2+ pitting edema to above the knee. No femoral bruits.
Skin: Venous stasis changes on b/l LE.
Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge
VS 98.7 110/60 84SR 18 97% RA
Gen: NAD
Neuro: A&Ox3, non-focal exam
Pulm: CTA-bilat
CV RRR, no murmur. Sternum stable, incision CDI
Abdm: soft, NT/+BS
Ext: warm, well perfused. 1+ pedal edema
Pertinent Results:
EKG demonstrated normal sinus rhythm with rate of 90, nl axis,
nl intervals, TWF in V5-V6, I, aVF, inverted P in V1, V2..
.
2D-ECHOCARDIOGRAM performed on [**2135-8-25**] demonstrated:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the distal septum and apex. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The [**Date Range 5554**] pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2131-2-15**], the mitral regurgitation has resolved.
.
ETT performed on [**2135-9-1**] demonstrated:
IMPRESSION: 1. Moderate severity, reversible inferior wall
perfusion defect. 2. Moderate severity, partially reversible
apical perfusion defect. 3. Defects are seen at submaximal
exercise. 4. Transient ischemic dilatation. 5. Global
hypokinesis more pronounced in the inferior and apical wall. 6.
LVEF 39%.
.
CARDIAC CATH performed on [**2135-9-8**] demonstrated:
COMMENTS:
1. Selective coronary angiography demonstrated diffuse three (3)
vessel coronary artery disease. The left main demonstrated a 50%
lesion in the proximal portion of the vessel. The left anterior
descending artery was diseased throughout the vessel including a
total occlusion in the mid portion of the vessel along with a
70% lesion in the first diagonal. The left circumflex was
diffusely diseased including serial 70% lesions in the proximal
and mid portion of the vessel. The right coronary artery was a
small vessel with diffuse disease throughout the vessel.
2. Subselective arteriography of the left subclavian
demonstrated a
widely patent LIMA vessel and no obvious subclavian stenosis.
3. LV ventriculography was deferred.
4. Limited resting hemodynamics demonstrated elevated right
(RVEDP =
13mm Hg) and elevated left (mean PCWP=20mm Hg). The cardiac
index
calculated via the Fick method was preserved at 2.8.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
[**2135-11-15**] 06:48PM GLUCOSE-138* UREA N-37* CREAT-2.5* SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-17* ANION GAP-21*
[**2135-11-15**] 06:48PM CK(CPK)-414*
[**2135-11-15**] 06:48PM CK-MB-35* MB INDX-8.5* cTropnT-0.96*
[**2135-11-15**] 06:48PM WBC-6.6 RBC-4.07* HGB-12.3* HCT-34.7* MCV-85
MCH-30.2 MCHC-35.5* RDW-15.1
[**2135-11-15**] 06:48PM PLT COUNT-229
[**2135-11-15**] 06:48PM PT-13.2 PTT-24.3 INR(PT)-1.1
[**2135-11-21**] 07:10AM BLOOD WBC-10.8 RBC-3.33* Hgb-10.3* Hct-29.5*
MCV-88 MCH-31.0 MCHC-35.0 RDW-14.3 Plt Ct-237#
[**2135-11-21**] 07:10AM BLOOD Plt Ct-237#
[**2135-11-20**] 03:08AM BLOOD PT-15.6* PTT-32.9 INR(PT)-1.4*
[**2135-11-22**] 06:45AM BLOOD Glucose-104 UreaN-48* Creat-2.5* Na-138
K-4.2 Cl-106 HCO3-20* AnGap-16
[**2135-11-18**] 04:13PM BLOOD ALT-17 AST-41* LD(LDH)-255* AlkPhos-55
TotBili-0.6
RADIOLOGY Final Report
CHEST (PA & LAT) [**2135-11-21**] 3:58 PM
CHEST (PA & LAT)
Reason: assess for ptx
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p cabg and ct removal
REASON FOR THIS EXAMINATION:
assess for ptx
INDICATION: Search for pneumothorax.
COMPARISON: Comparison to [**2135-11-18**].
The endotracheal tube, the nasogastric tube, the Swan-Ganz
catheter have all been removed. No suggestion of pneumothorax.
The size of the cardiac silhouette is slightly increased; there
is a slight increase in caliber of the pulmonary vasculature. No
evidence of circumscribed opacities suggestive of pneumonia. The
lateral view shows small bilateral effusions that are limited to
the costophrenic sinuses. No other changes.
IMPRESSION: After removal of the tubes and lines, no
pneumothorax. Slight cardiomegaly with mild signs of
overhydration. Small bilateral pleural effusions.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 48984**] (Complete)
Done [**2135-11-18**] at 1:12:18 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: [**2074-9-4**]
Age (years): 61 M Hgt (in): 70
BP (mm Hg): 120/80 Wgt (lb): 220
HR (bpm): 68 BSA (m2): 2.18 m2
Indication: Coronary artery disease
ICD-9 Codes: 424.0, 786.05
Test Information
Date/Time: [**2135-11-18**] at 13:12 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild
regional LV systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The 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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
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. There is mild regional left
ventricular systolic dysfunction with moderate hypokinesis in
the apical anterior and anteroseptal segments Overall left
ventricular systolic function is mildly depressed (LVEF=45 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with mild central
mitral regurgitation. There is no pericardial effusion.
Post_Bypass:
Thoracic aortic contour is intact.
Trivial to Mild MR> Trivial TR.
Normal RV systolic function.
OVERALL LVEF 45%.
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) **] [**2135-11-18**] 15:30
Brief Hospital Course:
#. CAD: Patient with extensive history as in HPI. Has known
diffuse 3vd On admission, his cardiac biomarkers were noted to
be elevated. He was started on Nitro drip for BP control. CT
[**Doctor First Name **] was consulted and his CABG was moved forward because of his
worsening disease. It was decided to hold off on MV replacement
because he has not been able to take care of his dental disease.
Echo on admission did not show new wall motion abnormalities.
.
On [**11-18**] the patient was brought to the operating room where he
had coronary artery bypass graft x5 with LIMA-LAD, SVG-OM1,
SVG-OM2, SVG-Diag, SVG-RCA. his bypass time was 126 minutes with
a crossclamp of 108 minutes. Please see OR report for details.
He tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU. He did well in the
immediate post-operative period and was extubated the morning
after surgery. He received Vancomycin perioperatively as he was
as inpatient prior to his surgery. He was transferred from the
ICU to the step down floor on POD2. Over the next several days
his activity was advanced by the PT and nursing staff and on POD
4 it was decided he was stable and ready for discharge home with
visiting nurses
Medications on Admission:
Gabapentin 300mg TID
Losartan 25mg daily
Simvastatin 40mg daily
Loratadine
Hydrocortisone cream
NPH 67U [**Hospital1 **]
Terazosin 2mg hs
Meclizine 25mg TID
Omeprazole 20mg daily
HCTZ 25mg daily
Gemfibrazole 600mg daily
Verapamil 240mg daily
Tylenol
Burproprion 150mg [**Hospital1 **]
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
6. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: resume preop
dosing.
11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty
Seven (67) units Subcutaneous twice a day: resume preop dosing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p CABG x5 (LIMA-LAD, SVG-Diag,SVG-OM1, SVG-OM2, SVG-RCA)[**11-18**]
PMH: DM, obesity, BPH, HTN, Sciatica, depression, ^ chol, Hep B,
GERD,
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever redness or drainage from wounds.
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks
Dr [**Last Name (STitle) 48985**] in [**1-15**] weeks
Completed by:[**2135-11-22**]
ICD9 Codes: 4280, 4240, 3572, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4936
} | Medical Text: Admission Date: [**2190-5-6**] Discharge Date: [**2190-5-11**]
Date of Birth: [**2113-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2190-5-6**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
RCA, SVG to OM) and ASD Closure
History of Present Illness:
77 y/o male with chest pain and shortness of breath. Found to
have an abnormal EKG and positive stress test. Referred for
cardiac cath which revealed severe three vessel disease and 70%
left main disease. He was then referred for surgical
revascularization.
Past Medical History:
Hypertension, Diabetes Mellitus, Gastroesophageal Reflux
Disease, Peptic Ulcer Disease, Neuropathy, Benign Prostatic
Hypertrophy, s/p Appendectomy, s/p Tonsillectomy
Social History:
Quit smoking 37 years ago. Rare ETOH use. Denies recreational
drug use.
Family History:
Father died from MI at age 65
Physical Exam:
VS: 56 132/63 5'7" 170#
Gen: WD/WN male in NAD lying flat in bed
Skin: w/d -lesions
HEENT: PERRL, EOMI, anicteric, OP benign
Neck: Supple, FROM, -JVD, -bruit
Chest: CTAB -w/r/r
Heart: RRR, soft SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
Echo [**5-6**]: PRE-BYPASS: Left ventricular wall thicknesses and
cavity size are normal. Regional left ventricular wall motion is
normal. A small secundum atrial septal defect is present with a
left-to-right shunt across the interatrial septum is seen at
rest. Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
CXR [**5-10**]: The patient is status post median sternotomy, with
sternal wires and clips. Within normal limits. The pulmonary
vasculature is not engorged. There are small pleural effusions
bilaterally. The lungs are otherwise clear. The surrounding soft
tissue and osseous structures demonstrate mild degenerative
changes along the thoracic spine.
[**2190-5-10**] 10:00AM BLOOD WBC-10.0 RBC-3.74* Hgb-10.7* Hct-32.2*
MCV-86 MCH-28.7 MCHC-33.4 RDW-14.3 Plt Ct-274#
[**2190-5-10**] 10:00AM BLOOD Plt Ct-274#
[**2190-5-10**] 10:00AM BLOOD Glucose-177* UreaN-24* Creat-1.1 Na-137
K-3.7 Cl-96 HCO3-33* AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 72434**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On the day of admission
he was brought to the operating room where he underwent a
coronary artery bypass graft x 3 and an ASD closure. Please see
operative report for details. Following surgery he was
transferred to the CSRU in stable condition for invasive
monitoring. He remain intubated overnight and post-op day one he
was weaned from sedation, awoke neurologically intact and was
extubated. He was started on beta blockers and diuretics and was
gently diuresed towards his pre-op weight. Later on post-op day
one he was transferred to the telemetry floor. On post-op day
two his chest tubes were removed. On post-op day four his
epicardial pacing wires were removed. He continued to make
steady progress while working with physical therapy for strength
and mobility. On POD #4 he spiked a fever and was pancultured.
Sputum gram stain showed 4+ GPC and 3+ GNR for which he was
started on cipro. On post-op day 5 he was discharged home with
VNA services and the appropriate follow-up appointments.
Medications on Admission:
Metformin 500mg [**Hospital1 **], Aspirin 81mg qd, Zocor 20mg qd, Atenolol
50mg qd, Prilosec 20mg qd
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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID
(2 times a day) for 10 days.
Disp:*20 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Atrial Septal Defect s/p ASD Closure
PMH: Hypertension, Diabetes Mellitus, Gastroesophageal Reflux
Disease, Peptic Ulcer Disease, Neuropathy, Benign Prostatic
Hypertrophy, s/p Appendectomy, s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting greater than 10 pounds for 10 weeks. No driving for
one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 26191**] in [**3-6**] weeks
Dr. [**Last Name (STitle) **] in [**2-2**] weeks
Completed by:[**2190-5-11**]
ICD9 Codes: 4111, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4937
} | Medical Text: Admission Date: [**2123-11-4**] Discharge Date: [**2123-11-6**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Epigastric pain with nausea, left arm pain, hypertensive urgency
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 104318**] is a 43 year-old man with a history of Type 1 DM, ESRD
on HD and frequent admissions for left sided body pain and HTN
who presents with left sided body pain and hypertensive urgency
noted during HD today. He reports 1 week of stomach pain with
epigastric burning and vomiting after meals. He states that he
has left shoulder pain which has been stable for 4 months. The
pain worsens with movement of his left arm. He denies SOB,
diaphoresis, or dizziness. He states he has had severe left
sided flank pain intermittently over the past week. He denies
any local trauma. He endorses mild constipation.
.
He specifically denies any symptoms of vision changes (baseline
mild blurry vision), chest pain, difficulty breathing, shortness
of [**Known lastname 1440**], headache, or leg pain. He produces a minimal amount
of urine at baseline and denies any dysuria.
.
In the ED, his initial vital signs were 181/96 99%4L with
general abdominal tenderness and left arm pain with movement. He
received morphine 4mg, zofran 4mg, ASA 325 mg, labetalol 40mg IV
in [**4-7**] mg doses, and dilaudid 1mg. A labetalol gtt was then
started. Abdominal CT was unremarkable on preliminary read as
was EKG. Placed RIJ central line for access. Renal consult
evaluated in the ED and recommended HD in AM.
Past Medical History:
1. DM1 x 17 years
2. ESRD, on HD T,Th,Sa at [**Location (un) **] [**Location (un) **]
3. HTN, poorly controlled
4. R foot operation - bone excision
5. R foot ulcer
6. Depression with h/o SA and psych hospitalizations
7. Esophagitis on EGD [**10-22**] with negative H. Pylori
8. h/o L flank pain since [**2119**] with multiple admissions and
extensive work-up and no organic etiology for pain found
9. Diastolic CHF: LVEF >55% by echo
Social History:
His mother passed away and he now lives alone. He sees his
sister and brother on the weekends. Has four children. Former
floor tech. No smoking, EtOH, drugs. History of suicide attempt
using "lots of pills."
Family History:
Diabetes in multiple relatives on both sides.
Physical Exam:
VS - afebrile 128/78 59 99% 3L
GEN - middle aged man, falling asleep during interview
HEENT - NCAT, MM dry but [**Year (4 digits) 5235**]
CV - RRR, S1, S2, no rmg
PULM - crackles up 2/3 left lung, right basilar crackles, no
wheezes
ABD - soft, ND, +BS, tenderness to light palpation over
epigastric region otherwise nontender to palpation
EXT - wwp, 1+ pretibial edema
NEURO - CN 2-12 fxn [**Year (4 digits) 5235**], [**6-21**] MS throughout, symmetric, A*O*3
Pertinent Results:
ADMISSION LABS:
.
[**2123-11-4**] 10:15AM PT-15.6* PTT-31.0 INR(PT)-1.4*
[**2123-11-4**] 10:15AM PLT COUNT-152
[**2123-11-4**] 10:15AM NEUTS-71.4* LYMPHS-20.5 MONOS-5.3 EOS-2.2
BASOS-0.7
[**2123-11-4**] 10:15AM WBC-5.6 RBC-3.92* HGB-10.7* HCT-33.9* MCV-87
MCH-27.3 MCHC-31.6 RDW-19.1*
[**2123-11-4**] 10:15AM CALCIUM-9.4 PHOSPHATE-5.4* MAGNESIUM-1.9
[**2123-11-4**] 10:15AM CK-MB-11* MB INDX-3.8
[**2123-11-4**] 10:15AM cTropnT-0.25*
[**2123-11-4**] 10:15AM LIPASE-23
[**2123-11-4**] 10:15AM ALT(SGPT)-26 AST(SGOT)-27 CK(CPK)-286* ALK
PHOS-156* TOT BILI-0.7
[**2123-11-4**] 10:15AM estGFR-Using this
[**2123-11-4**] 10:15AM GLUCOSE-160* UREA N-36* CREAT-8.1*#
SODIUM-140 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19
PERTINENT LABS/STUDIES:
.
Hct: 33.9 -> 31.5 -> 32.0 (baseline 33-37)
Gluose: 160 -> 51 -> 135
CK: 286 -> 216
Alk Phos: 156
Troponin: 0.25 -> 0.23 (baseline elevated at 0.16 to 0.43)
EKG: sinus @86. LAE. no Q waves. trace ST depressions laterally.
CXR: The lungs are clear, without pulmonary airspace
consolidation, effusion or evidence of pulmonary edema. Cardiac
silhouette remains enlarged. Hila are within normal limits.
Osseous structures are unremarkable.
CT A/P ([**11-4**]): LUNG BASES: There is small right pleural effusion
and minimal bibasilar dependent atelectases. The lung bases are
otherwise clear. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:
Ascites and free fluid within the pelvis are not significantly
changed. The liver, pancreas, and adrenals are unremarkable.
There is small amount of pericholecystic fluid, likely related
to ascites. The spleen is mildly enlarged, measuring 13.6 cm.
The kidneys are small bilaterally, without focal abnormality
identified. The aorta is normal in caliber. Prominent nodular
soft tissue attenuation adjacent to the IVC may relate to
dilated lymphatics and is unchanged. There are no pathologically
enlarged mesenteric lymph nodes. The small bowel and colon are
normal in caliber, without evidence of wall thickening. CT OF
THE PELVIS WITH INTRAVENOUS CONTRAST: Free fluid within the
pelvis is unchanged. The rectum, sigmoid colon, prostate, and
seminal vesicles are unremarkable. There is no pelvic or
inguinal lymphadenopathy.
BONE WINDOWS: No suspicious lytic or blastic osseous lesion is
identified.
IMPRESSION: 1. Stable ascites. 2. Small right pleural effusion,
decreased in comparison to [**2123-4-16**]. No evidence of acute
intra-abdominal process.
3. Splenomegaly.
.
.
DISCHARGE LABS:
[**2123-11-6**] 06:10AM BLOOD WBC-4.0 RBC-3.57* Hgb-9.8* Hct-32.0*
MCV-90 MCH-27.6 MCHC-30.7* RDW-17.8* Plt Ct-121*
[**2123-11-6**] 06:10AM BLOOD Plt Ct-121*
[**2123-11-6**] 06:10AM BLOOD Glucose-135* UreaN-24* Creat-7.0*# Na-138
K-4.7 Cl-99 HCO3-27 AnGap-17
[**2123-11-6**] 06:10AM BLOOD Calcium-8.9 Phos-5.2*# Mg-1.9
Brief Hospital Course:
Patient is 44 yo man with history of Type 1 Diabetes and ESRD
who presented with flank pain and hypertensive urgency in the
setting of prolonged N/V/D.
#. Hypertensive urgency - Patient presented with hypertensive
urgency while at [**Month/Day/Year 2286**]. In the ED, his BP was 181/76. He
was transferred to the MICU, where a central line was placed,
and he was started on a Labetalol drip. He was weaned off the
Labetalol during his first night in the MICU, after which he was
able to tolerate his PO medications. It appears that this
hypertensive episode was secondary to medication non-compliance
amd fluid overload in the setting of N/V/D. The patient was
dialyzed twice while in the hospital, and his BP returned to his
baseline when PO medications were restarted. He was discharged
with close outpatient follow-up.
.
# Flank pain: The patient has left-sided flank pain, which has
been present since [**2119**]. Despite previous workup of CT, MRI,
and U/S, no clear etiology has been found. It is thought that
this may be secondary to thoracic neuropathy. Despite multiple
pain regimens and pain service consultation, his pain has flared
in this manner several times over the last 6 months requiring
hospitalization for IV narcotics and BP control. The patient
was ruled out for a MI, and he was restarted on his home doses
of Tylenol, Lidocaine patch, Duloxetine, and Neurontin. He was
also given Morphine prn for pain. Patient tolerated these
medications well and stated that his pain was somewhat improved
on discharge.
#. Stage 5 CKD: Patient has a history of stage 5 CKD. He
received [**Year (4 digits) 2286**] twice during this hospital stay. He was
continued on his home regimen of B Complex-Vitamin C-Folic Acid
1 mg daily and PhosLo 667 TID, as soon as he was able to take
oral medications. He did not have any acute events during this
hospital stay.
.
#. Diabetes: Patient has a history of Type 1 Diabetes. He was
continued on his home regimen of 70/30 home regimen of 15 units
in the morning and 20 units with dinner. He tolerated this well
and did not have any acute events during this hospital stay.
.
Medications on Admission:
1.Aspirin 81 mg daily.
2.Lisinopril 20 mg daily
3.Metoprolol Succinate 200 mg daily
4.Nifedipine 60 mg SR [**Hospital1 **]
5.Glycopyrrolate 1 mg TID PRN
6.Zolpidem 5 mg QHS PRN
7.B Complex-Vitamin C-Folic Acid 1 mg daily
8.Calcium Acetate 667 mg TID
9.Hydromorphone 2 mg Q6H PRN
10.Gabapentin 250 mg/5 mL
11.Valsartan 80 mg [**Hospital1 **]
12.Sevelamer 800 mg TID
14.Insulin (70-30) 15 units in the morning and 20 units at night
15.Colace 100 mg daily
16.Omeprazole 40 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
5. Glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed.
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: as directed Units Subcutaneous twice a day: Please use 15
Units in the morning and 20 Units at night.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypertension
Type 1 Diabetes Mellitus
Left flank pain
Secondary:
Chronic Kidney Disease, Stage 5
Discharge Condition:
Good. Patient is able to tolerate his oral medications, and his
blood pressure is currently stable.
Discharge Instructions:
You were admitted to the hospital because you had nausea and
vomiting and your blood pressure was extremely elevated. You
were admitted to the MICU, where you were started on a Labetolol
drip. Your nausea gradually improved, and you were able to
start your oral medications. You were dialyzed twice during
this admission, and your blood pressure returned to your
baseline.
While you were here, we made the following changes to your
current medications:
1. We started you on Famotidine for your acid reflux.
Please take all medications as prescribed.
Please keep all previously [**Hospital1 1988**] [**Hospital1 4314**]
Please return to the ED or your healthcare provider immediately
if you experience shortness of [**Hospital1 1440**], confusion, chest pain,
problems with your vision, headaches, fevers, chills, or any
other concerning symptoms. Please weigh yourself every morning,
and call your doctor if you gain more than 3 lbs. Please adhere
to a low sodium (2 gm/day)diet.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2123-12-6**] 12:15
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **]
Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2124-1-10**] 10:30
Completed by:[**2123-11-7**]
ICD9 Codes: 4280, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4938
} | Medical Text: Admission Date: [**2158-8-15**] Discharge Date: [**2158-8-18**]
Date of Birth: [**2125-11-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
32M with hx of etoh abuse, varices, depression seen at [**Location (un) 7453**] ED for report of vomiting blood. There was no blood in
vomit at OSH or with EMS. By report has been on an eight-day
binge; also has known varices per family. His alcohol level at
that emergency room was 266, Hct 43. He got protonix and
octreotide. His stool was reportedly guaiac positive.
.
He also arrives on a section 12 for a SI; told staff at OSH ED
that he would "drink myself to death". Received Haldol by EMS.
.
On exam in the ED he is extremely somnolent with VS 98.2, 84,
147/76, 16, 95/RA. He is not answering any questions.
.
Labs significant for:
CBC with WBC 8.5, nl differential, Hct 41.9, platelets 316. INR
1.1, PTT 21.8. Creatinine 0.9. LFTs nl with alb 4.6 and bili
0.6, etoh 193, and other tox negative. UA with ketones.
.
GI consulted with plan to admit to ICU and scope in am unless
hemodynamically unstable overnight.
He was started on an octreotide drip - 50mcg bolus, 50mcg/hour.
Did not start PPI drip. Did not do NGT lavage given concern of
varices. Has two 18 G IVs.
VS on transfer: 87, 148/81, 19, 100/RA.
.
On the floor, with use of phone interpreter and in person
patient denies past or current SI/SA but that he was drinking
tequila with his friends and came to the hospital because he
needed help. He does not remember vomiting blood or how much
blood he vomitted. He denies abdominal pain, fevers, or history
of liver problems. [**Name (NI) **] had endoscopy 1 month ago in [**Hospital 86**]
Hospital, unknown result. Does gets alcohol withdrawal, but no
history no seizures. Started to cry.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-etoh abuse, ?varices per family
-depression
Social History:
Works in landscaping.
- Tobacco: denied
- Alcohol: yes, 13 years, can't quantify how much
- Illicits: denies
Family History:
non contributory
Physical Exam:
Admission Physical exam
Vitals: 127/74, 88, 95/RA
General: Alert, oriented to person and hospital, NAD, tearful
when discussing alcohol withdrawal
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Skin: no palmar erythema or spider angiomata
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge physical exam
Physical Exam:
Vitals: T:97.9 BP:150/92 P:93 R:21 18 O2:98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
Admission labs:
[**2158-8-15**] 07:55PM PT-13.1 PTT-21.8* INR(PT)-1.1
[**2158-8-15**] 07:55PM PLT COUNT-316
[**2158-8-15**] 07:55PM NEUTS-62.0 LYMPHS-33.8 MONOS-3.4 EOS-0.3
BASOS-0.6
[**2158-8-15**] 07:55PM WBC-8.5 RBC-5.13 HGB-15.1 HCT-41.9 MCV-82
MCH-29.4 MCHC-36.0* RDW-14.5
[**2158-8-15**] 07:55PM ASA-NEG ETHANOL-193* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-8-15**] 07:55PM ALBUMIN-4.6
[**2158-8-15**] 07:55PM LIPASE-34
[**2158-8-15**] 07:55PM ALT(SGPT)-27 AST(SGOT)-31 ALK PHOS-66 TOT
BILI-0.6
[**2158-8-15**] 07:55PM GLUCOSE-153* UREA N-9 CREAT-0.9 SODIUM-142
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-20
[**2158-8-15**] 09:30PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2158-8-15**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Discharge labs:
[**2158-8-18**] 07:20AM BLOOD WBC-7.1 RBC-4.62 Hgb-13.8* Hct-37.9*
MCV-82 MCH-30.0 MCHC-36.5* RDW-14.3 Plt Ct-267
[**2158-8-18**] 07:20AM BLOOD Plt Ct-267
[**2158-8-18**] 07:20AM BLOOD Glucose-92 UreaN-15 Creat-0.9 Na-141
K-4.2 Cl-104 HCO3-29 AnGap-12
[**2158-8-18**] 07:20AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3
Endoscopy ([**2158-8-16**]): Grade B-C esophagitis in the lower third
of the esophagus compatible with moderate to severe esophagitis.
Friability, erythema and congestion in the whole stomach
compatible with chemical gastritis, cannot rule out portal
gastropathy. There were no esophagel varices. Otherwise normal
EGD to third part of the duodenum.
Brief Hospital Course:
Hospital summary: 32 yo M with hx of etoh abuse, varices per
family, presents with 1 episode of hematemesis at home.
Transferred to MICU given varices history. EGD performed with no
varices identified. Patient transferred to medicine and
discharged. No withdrawal symptoms present at discharge.
.
Active Issues:
.
# Hematemesis: Likely secondary to gastritis/esophagitis. No
varices identified on endoscopy. Patient denies history of
varices in the setting of sobriety. Vitals were stable
throughout admission. Patient started on IV PPI and sucralafate
with resolution in his symptoms. His hematocrit was stable
during admission. At discharge he was continued on oral PPI and
sucralafate for two week course.
.
# Etoh abuse: Patient reports months with no alcohol intake
followed by binges with up to 2 bottle of tequilla consumed per
day. Patient was monitored on diazepam CIWA scale, however no
diazepam was administered. Patient says he wants to enter rehab.
Numbers for alcohol rehab's willing to take patient's without
health insurance were provided.
.
Inactive issues:
.
#Suicidality: Patient was admitted to the OSH on a section 12
after telling staff he was trying to drink himself to death.
Patient received banana bag and thiamine/folate/mvi
supplementation. Given the suicidal ideation expressed at the
OSH ED, psychiatry was consulted and recommended social work
evaluation and provision of resources for EtOH self referral
programs. He contracted for safety and did not express suicidal
feelings.
.
Transitional issues:
[**Hospital **] rehab: There are two residential treatment programs that
could potentially take the patient when they have an opening.
Patient needs to call them everyday to see if they can take him:
1. [**Location (un) 22870**] [**Hospital1 1474**]: [**Telephone/Fax (1) 70459**]
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 70454**]
Medications on Admission:
None
Discharge Medications:
1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day for 14 days.
Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastritis
Esophagitis
EtoH Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your last admission
to [**Hospital1 18**]. You presented complaining of blood in your vomit
following a four day drinking binge. We repleted your
electrolytes and performed an endoscopy to determine if you had
any veins in your esophagus at risk for bleeding. You did not.
We did find some evidence of inflammation in your esophagus and
stomach (esophagitis and gastritis) which was secondary to your
binge drinking.
Please stop drinking alcohol. Alcohol will cause damage to your
liver in the future and could cause death secondary to
intoxication or bleeding.
There are two residential treatment programs that could
potentially take you when they have an opening. You need to
call them everyday to see if they can take you:
[**Location (un) 22870**] [**Hospital1 1474**]: [**Telephone/Fax (1) 70459**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 70454**]
You were started on a new medication:
- START omeprazole 40mg twice daily for two weeks
- Sucralafate 1 gram four times daily, if you are unable to
afford this medication you can also use Maalox or Tums.
- You should also consider starting a multivitamin everyday
Followup Instructions:
There are two residential treatment programs that could
potentially take you when they have an opening. You need to
call them everyday to see if they can take you:
1. [**Location (un) 22870**] [**Hospital1 1474**]: [**Telephone/Fax (1) 70459**]
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 70454**]
Also, contact [**Hospital6 **] ([**Telephone/Fax (1) 90849**] and see
if they can help you establish care with a primary care
physician. [**Name10 (NameIs) **] discuss follow up in the future with
gastroenterology.
ICD9 Codes: 2851, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4939
} | Medical Text: Unit No: [**Numeric Identifier 61802**]
Admission Date: [**2192-4-11**]
Discharge Date: [**2192-5-6**]
Date of Birth: [**2192-4-11**]
Sex: F
Service: NB
ID: Baby Girl ([**Name2 (NI) 61803**]) [**Known lastname 16651**] is a 25 day old former 33 wk
premature infant who is being discharged from the [**Hospital1 18**] NICU.
HISTORY: Baby girl [**Known lastname 16651**] was born at 33 weeks gestation
to a 28-year-old Gravida 2, para 0 mother with prenatal labs
A+, antibody screen negative, hepatitis B surface antigen
negative, RPR nonreactive, rubella immune, and GBS unknown.
Pregnancy was notable for an abnormal triple screen butwith a
normal fetal survey and a normal
amniocentesis.
Mother presented 1 day prior to delivery with spontaneous
rupture of membranes. She was treated with antibiotics and
two doses of betamethasone, and labor was then induced.
Infant was born via vaginal delivery with Apgar scores 7 and
8.
Her admission physical examination was remarkable for a pink
infant with normal vital signs. Temperature 98.2, respiratory
rate 60, heart rate 170. She had mild hypertelorism, soft
anterior fontanel, moderate molding, an intact palate, mild
subcostal retraction, clear breath sounds, no murmur. Present
femoral pulses, flat, soft, nontender abdomen. Normal
external female genitalia, stable hips, normal perfusion,
tone and activity.
Her admission weight was 1810 grams.
HOSPITAL COURSE:
Respiratory. She was stable on room air throughout her stay.
Mild apnea and bradycardia spells were noted, with last
episode see on [**5-1**]. By the time of discharge, infant had
been without
any apnea or bradycardic episodes for 5 days.
Cardiovascular. She has been cardiovascularly stable with
normal blood pressures and perfusion throughout her stay.
Fluids, Electrolytes and Nutrition. She was initially
hypoglycemic with glucoses of 43 and 37 requiring two D10-W
boluses and an increase in intravenous fluid rate over the
first day of her life. Her glucoses stabilized with
peripheral intravenous glucose and were normal thereafter.
Enteral feedings were initiated on day of life 2 and slowly
advanced until she reached full feedings by day of life 5.
Her calories were increased to a maximum of 26 K cals per
ounce of Similac special care or breast milk. At the time of
discharge, she is feeding all PO ad lib breast milk or similac
24
calories per ounce with adequate intake and weight gain.
Weight at discharge is 2650gm.
GI. She had a bilirubin on day of life 3 that was 8.0. She
was started on phototherapy. Her bilirubin peaked at 10.8 on
day of life five. Her phototherapy was discontinued for a
bilirubin of 9.0 on the following day and her rebound was
6.0/0.3.
Hematology. Her admission hematocrit was 61%; this was followe
d
up over the next two days of her life and was found to be 66%
and
then 63% on day of life three. Hematocrit prior to discharge
on [**5-5**] was 39.4%.
Infectious Disease. She was started on ampicillin and
gentamicin shortly after birth. She completed a 48 hour
course with these antibiotics which were discontinued when
blood culture was negative at 48 hours. Her initial complete
blood count had a white blood cells count of 10.1 with 54%
polys and 0 bands. She has had no infectious issues
throughout the remainder of the interim summary.
Neurology. She does not meet criteria for screening head
ultrasound.
Screening. Audiology hearing screening was performed and pass
ed
bilaterally on [**2192-4-24**].
Routine health care maintenance. Hepatitis B vaccine was give
n
on [**2192-4-29**]. Car seat safety screening was passed [**2192-4-27**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To home.
DISCHARGE DIET: Breast milk or similac supplemented to 24
cals/oz with similac powder.
DISCHARGE MEDICATIONS: None.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 38832**], [**Doctor Last Name 61804**]Health Center
DISCHARGE DIAGNOSIS:
1. Prematurity at 33 weeks.
2. Presumed sepsis ruled out.
3. Hyperbilirubinemia.
4. Hypoglycemia resolved.
5. Apnea of prematurity, resolved.
[**Last Name (LF) 1877**], [**First Name3 (LF) **] M.D [**MD Number(1) 37238**]
MEDQUIST36
D: [**2192-5-1**] 15:05:49
T: [**2192-5-1**] 16:16:45
Job#: [**Job Number 61805**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4940
} | Medical Text: Admission Date: [**2102-4-23**] Discharge Date:
Date of Birth: [**2046-4-26**] Sex: M
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 55 year old Haitian
man with a history of hepatitis C cirrhosis diagnosed in [**2090**]
on physical examination. The patient presented in late
[**Month (only) 956**] to the Liver Clinic with a worsening shortness of
breath, ascites and increased lower extremity edema. The
patient received the majority of his care at [**Hospital6 14430**] and has been managed well there since [**2090**]. At that
time, the patient had a work-up for a liver transplant
initiated and in [**2102-3-19**] he was noted to be Child's
Class C with a score of 10 and found to have a large
mediastinal lymphadenopathy that was concerning for lymphoma.
A biopsy of the lymphadenopathy was obtained and was found to
be nonspecific.
On [**4-23**], the patient presented to the Emergency
Department with worsening lower extremity pain. He was given
morphine and Ativan and found to have an elevated white blood
cell count with 14% bands. The patient subsequently
developed hypotension with a blood pressure in the 70s over
20, at which time he was started on the sepsis protocol in
the Emergency Department. He received three liters of
intravenous fluids and transiently given phenylephrine. His
blood pressure soon stabilized and he was transferred to the
Surgical Intensive Care Unit for further care.
In the Surgical Intensive Care Unit his diuretics were held,
his pressors were stopped immediately and the patient
improved. There was initially concern for infection. The
patient had no ascites, therefore, no SBP and no evidence of
pneumonia. The patient was given antibiotic treatment for a
presumed pneumonia that could not be visualized and white
blood cell count improved but lower extremity pain persisted.
PAST MEDICAL HISTORY:
1. Hepatitis C cirrhosis diagnosed in [**2090**].
2. Upper gastrointestinal bleed with Grade 1 varices in [**2101-6-16**].
3. Diabetes mellitus, diet controlled.
4. Hypertension.
5. Benign prostatic hypertrophy.
6. Anemia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION FROM HOME:
1. Lasix 80 mg a day.
2. Glipizide XL 5 mg q. day.
3. Tamsulosin 0.4 mg a day.
4. Neurontin 300 mg three times a day.
5. Protonix 40 mg q. day.
6. Nadolol 10 mg q. day.
7. Aldactone 50 mg three times a day.
8. Fentanyl patch 25 micrograms applied on the day of
admission.
PHYSICAL EXAMINATION: On admission to the Emergency
Department, the patient was afebrile with a temperature of
98.2 F.; heart rate of 100; blood pressure of 86/78 that
decreased to 74/34; respiratory rate of 20 and he was 97% on
room air. In general, he was somnolent. He had icteric
sclerae. Pupils were equal and reactive and constricted.
Extraocular muscles are intact bilaterally. Mucous membranes
were dry and oropharynx was clear. He had a supple neck with
no jugular venous distention. He had occasional bibasilar
rhonchi with good air movement. His heart had a regular rate
with no murmurs, rubs or gallops. His abdomen was obese,
soft, nontender, distended, without overt fluid wave present.
There was no shifting dullness and no palpable masses.
Extremities were warm and dry and with three plus pitting
edema to the mid tibia bilaterally. No clubbing or cyanosis
and one plus pedal pulses bilaterally. Skin had a Fentanyl
patch in place. No rashes. Neurological: The patient was
somnolent and arousable to voice, positive asterixis.
Follows commands. Cranial nerves II through XII were intact.
The patient had no focal deficits.
IMPRESSION: The impression at admission was for hypotension
concerning for sepsis and encephalopathy and possible
fentanyl overdose.
LABORATORY: Pertinent labs on admission were a white blood
cell count of 21.7, 14% bands. Platelets of 187. T-bili of
3.4, albumin of 2.1. INR of 2.2, AST of 118, ALT of 70,
alkaline phosphatase of 123.
Arterial blood gases on room air are 7.47, 26, 140, 98%
saturation; potassium of 63 and a lactate of 62.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit and blood pressure stabilized and after
ruling out infection, white count normalized with fluids and
it was felt that the patient had dehydration encephalopathy
and hypotension induced by Fentanyl patch placement.
The patient was stable on transfer to the floor, was
monitored carefully and focus became that which was necessary
for his lower extremity pain which was quite severe. The
patient could not ambulate more than five steps with Physical
Therapy. With Pain Service consultation, the patient
received 25 micrograms Fentanyl patch which did not alleviate
his pain. This was increased to 50 micrograms which did not
help his pain, which was then increased to 75 micrograms
which did not change his pain management at all.
Concomitantly, the patient received Oxycodone of 10 to 20 mg
q. four hours p.r.n. The patient did not request this more
than two to three times per day for breakthrough pain, but
overall the concern was that the patient's pain was described
as going throughout his legs, burning in nature in his lower
extremities always at a level of six out of ten going up to
ten out of ten with shooting burning pain on his lateral
thighs bilaterally that occurred with movement.
Subsequent physical examinations revealed a numbness and lack
of sensation in the lateral thigh regions of the superficial
femoral nerve, in the region of the lateral femoral cutaneous
nerve. The sensation was intact throughout the rest of the
extremities, upper and lower.
The patient was given gentle diuresis for edema of the
ankles, but room air saturations remained normal and the
patient had no evidence for ascites. The patient was
maintained on fluid restriction at 1500 cc and Lasix 40 mg a
day was given by mouth. The patient's creatinine was at 0.8
to 0.9 and increased to 1.9 and the patient was found to be
in acute renal failure. This was presumed to be due to
prerenal state given a physical examination consistent with
dehydration.
The patient received normal saline with subsequent correction
of creatinine.
BRIEF SUMMARY OF HOSPITAL ISSUES:
1. HYPOTENSION ON ADMISSION: Medication induced was the
presumed diagnosis. The patient had no further hypotensive
episodes throughout admission.
2. LOWER EXTREMITY PAIN: This seemed to be neuropathic by
history and examination with component of meralgia
paresthetica from his abdominal distention that was present.
There was no evidence for B12, folate or syphilis as an
etiology. An MRI of the spinal cord weeks prior had revealed
no nerve compression or evidence of abscess or meningeal
enhancement. Subsequent MRI of the entire spine revealed no
lesions throughout.
The patient's primary care physician was [**Name (NI) 653**] to discuss
if the patient ever had a history of this pain in the past.
Per the patient's primary care physician at [**Hospital1 346**], he noted that the patient had pain
that was noted to worsen whenever patient had edema. This
frequently occurred in the setting of cryoglobulinemia and
vasculitis that was biopsy proven per him. No records from
[**Hospital6 **] were obtainable.
The patient was noted on past admission to have an elevated
ESR greater than 100 and a CRP that was elevated
significantly. There was concern that he was having a
current exacerbation of his vasculitis and cryoglobulinemia
at this time causing lower extremity pain. Cryoglobulins
were checked multiple times and found to be negative.
Neurology was consulted and EMG was done and was found to be
nonspecific and did not reveal diffuse slowing. The
Neurology consultation felt that the pain was most likely due
to meralgia paresthetica and diabetic neuropathy, despite the
fact that the patient had a hemoglobin A1C less than six.
There was also concern that it was a perineoplastic syndrome
affecting the femoral nerve bilaterally given the patient's
history of lung nodules seen on past CT scan. A repeat CT
scan was done and revealed resolution of the right upper lobe
lung nodule and stable lymphadenopathy in the mediastinum
region.
The pain was managed daily and ambulation was encouraged.
Physical Therapy was given and on subsequent days the patient
reported that his pain seemed to be symptomatically better
despite decreasing fentanyl patch dosages down to 50
micrograms q. day and decreasing breakthrough pain
medications of Oxycodone down to 10 mg up to three doses per
day.
Once the pain was managed, the patient was discharged home
with services and was advised to follow-up with his primary
care physician at [**Hospital6 **] at which time he
could be set up with Neurology follow-up or to call [**Hospital1 1444**] for follow-up in [**Hospital 878**]
Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 53243**]. This was deferred initially on
discharge given that no appointments were available until the
end of [**2102-6-17**], and it was felt that patient may need to see
Neurology prior to that.
Due to the consideration that the pain was due to meralgia
paresthetica complicated by diabetic neuropathy complicated
by exacerbation of L5-S1 radiculopathy, the patient was
instructed to continue Physical Therapy and have home
Physical Therapy and continue pain management. If pain was
not noted to improve with Physical Therapy and ambulation,
the patient should follow-up to have nerve biopsies to rule
out vasculitis or some other nerve pathology.
2. HEPATITIS C, CIRRHOSIS, HEPATIC ENCEPHALOPATHY: The
patient was maintained on spironolactone and Lasix diuresis.
The patient periodically became encephalopathic and lactulose
was increased at these times with the goal of three to five
bowel movements per day which resulted in normalization of
mental status.
3. HYPONATREMIA: The patient's baseline was in the low 30s
and periodically went down to 125. This was monitored
carefully and presumed to be due to excessive ADH in the
setting of hepatitis C and cirrhosis.
4. INFECTIOUS DISEASE: For infectious disease issues, the
patient did receive Levofloxacin, Flagyl and Vancomycin for
three days while in the Intensive Care Unit. Those were then
discontinued once it was determined that the patient was not
likely to have had any infection. During admission, the
patient had one fever spike up to 100.5 F. and this was
isolated. Studies for infection at that time revealed no
abnormalities. The patient was followed clinically and was
noted to have no fevers and no evidence for infection.
White blood cell count was noted to increase up to 32 during
admission. This was also in the setting of
the patient having acute renal failure and a creatinine of
1.9. There were no focal signs or symptoms to suggest an
acute bacterial process. An abdominal CT failed to
demonstrate significant ascites to suggest risk of
peritonitis. well. Clostridium difficile
studies were sent and were pending at the time of discharge.
The patient appeared clinically non-toxic and did not receive
empiric antibiotic therapy.
5. HEMATURIA: This was noted once on admission. This was
thought to be due to trauma and Foley. This was rechecked
and there was no evidence for red blood cells or protein
which ruled out concern for cryoglobulinemia or vasculitis
involving kidneys.
The mediastinal right upper lung mass and lymphadenopathy
noted on previous CT scan and the noncontributory FNA that
had been done, it was interesting that the right upper lung
mass had resolved in three weeks and this decreased the
likelihood that it was due to malignancy. The patient was
instructed to have CT scans followed and to have additional
biopsies as an outpatient to be arranged by [**Hospital6 14430**].
The patient was also noted to have an elevated TSH during
admission as well as postural tremor of low amplitude in his
right hand. It was not clear if this was new given the fact
that the patient was hospitalized and had other issues. At
the time, it was felt that this should be followed and
rechecked as an outpatient and that there was no clear
benefit of working up hypothyroidism in the setting of
hospitalization and concurrent illnesses that could possibly
elevate hormone levels.
6. THROMBOCYTOPENIA: This was noted to worsen throughout
admission. Heparin was given subcutaneously initially and
was held. HIT antibody was sent and was found to be
negative. Thrombocytopenia was presumed secondary to liver
disease.
7. DIABETES MELLITUS TYPE 2: For diabetes mellitus type 2,
the patient was maintained on glyburide 2.5 mg q. day. This
is decreased from his home dose due to hypoglycemic episodes
occurring in patient.
DISPOSITION: Place of discharge is presumably home with
Visiting Nurses Association services and Physical Therapy.
DISCHARGE MEDICATIONS:
1. protonix 40 mg q. day.
2. Lasix 20 mg p.o. q. day.
3. Glipizide 2.5 mg q. day.
4. Spironolactone 50 mg p.o. twice a day.
5. Lidocaine patches to bilateral thighs for 12 hours q.
day.
6. Tamsulosin 0.4 mg q. 24 hours.
7. Lactulose to be taken five times daily in order to have
two to three bowel movements daily.
8. Oxycodone p.r.n. three times a day.
9. Gabapentin 1000 mg p.o. three times a day.
10. Nadolol 10 mg q. day.
11. Fentanyl patch 50 micrograms per hour q. 72 hours.
DISCHARGE INSTRUCTIONS:
1. The patient was discharged home with Physical Therapy and
follow-up appointments as noted above.
The remainder of dictation or changes to be done by the next
intern.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 6374**]
MEDQUIST36
D: [**2102-5-5**] 20:14
T: [**2102-5-5**] 21:55
JOB#: [**Job Number 53244**]
cclist)
ICD9 Codes: 5715, 5849, 2767, 2765, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4941
} | Medical Text: Admission Date: [**2189-6-16**] Discharge Date: [**2189-6-24**]
Date of Birth: [**2107-4-16**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transfer from OSH for Pre pontine hemmorhage work up and
evaluation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an 82 year-old woman with a PMH of prior colon CA,
mild dementia and chronic pain. She was transferred from an OSH
therefore this history is almost entirely from the OSH transfer
records.
She was reportedly in her USOH yesterday. This morning around
1am
she fell and struck her head. She reportedly did not have LOC
but
it is not clear why she fell. She was taken to an OSH where she
was evaluated and noted to have difficulty walking and was
"incapacitated with back pain". She was however awake and not
noted to be severely confused. She may have had a HA. A head CT
was obtained which showed SAH around the brainstem. She was then
sent for MRI and MRA. This should a large mass of blood around
the brainstem but no clear vessel abnormality. She was then
transferred here by [**Location (un) **]. Per verbal report she was given 1
gm of Cerebryx prior to transfer.
Per the reports she has a history of a fall and was noted to be
too unsteady to walk. It seems that she was "incapacities with
back pain". Per [**Location (un) **] she developed hypertension shortly
prior to arrival and then on route to the ED here she became
rapidly obtunded. In the ED she was noted to be unresponsive and
stiff with jerking movements. She was then intubated for airway
protection. Her ED course was otherwise remarkable for very
labile BP's with alternating SBP's in the 60-190's
ROS: UA
Past Medical History:
Hypertension
Colon CA
Dementia
Social History:
Married. Lives w/ husband who also has mild dementia is HCP. [**Name (NI) **]
5 children.
Family History:
Noncontributory
Physical Exam:
Vitals: T: 98.6 PR P: 90's R: 16 BP: 60-190/ 30-110's SaO2: 96%
on ET
General: intubated, sedated
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: no carotid bruits appreciated. severe nuchal rigidity
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: 1+ edema
Neurologic:
-Mental Status: unresponsive to verbal/nox stim prior to
intubation with symmetric jerking movements of all extremities,
no gaze deviation
CN
I: not tested
II,III: unable to visualize discs
III,IV,V: no dolls, EOMI, no ptosis. No nystagmus
V: + corneals bilaterally, nasal tickle on the R
VII: face symmetric
VIII: UA
IX,X: no gag
[**Doctor First Name 81**]: UA
XII: UA
Motor: Normal bulk, increased tone throughout. No myoclonus.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0--------------- mute
R 0--------------- mute
-Sensory: No withdrawal to nox stim
-Coordination: UA
-Gait: UA
On discharge:
Pertinent Results:
[**2189-6-16**] 08:34PM GLU-315* UREA N-29* CREAT-1.5* SODIUM-139
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-17* ANION GAP-18
CK-MB-23* MB INDX-1.4 cTropnT-0.17*, CK(CPK)-1680*, ALT(SGPT)-16
AST(SGOT)-41* LD(LDH)-285* CK(CPK)-1365* ALK PHOS-52 TOT
BILI-0.6, LIPASE-14, ALBUMIN-3.2* CALCIUM-7.2* PHOSPHATE-4.3
MAGNESIUM-1.9, TSH-1.6, PHENYTOIN-8.7*, WBC-19.1* RBC-2.85*
HGB-9.1* HCT-27.1* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.9,
NEUTS-87.0* LYMPHS-10.6* MONOS-2.2 EOS-0.1 BASOS-0.1, PLT
COUNT-142* LPLT-1+, PT-13.2 PTT-28.0 INR(PT)-1.1
[**6-16**] Head CT: 1. Large amount of subarachnoid hemorrhage
surrounding the brainstem tracking
both superiorly and inferiorly as described above with
significant mass effect
on the brainstem. Trace amount of intraventricular hemorrhage.
The exact
etiology/source of bleeding is unclear although either a
posterior circulation
aneurysm/vascular malformation or hemorrhage from spinal
vascular lesion is
most likely. When feasible, a dedicated CTA or conventional
angiogram would be
recommended. An urgent neurosurgical consultation is also
recommended given
the degree of mass effect on the brainstem.
2. Calcified right frontal meningioma with noncalcified right
posterior
parietal lesion which depicted uniform enhancement on outside
MRI. This may represent a non-calcified meningioma (although
somewhat atypical for patient age) with additional lesions such
as lymphoma or metastases also within the differential.
Continued followup is recommended.
Findings were marked as urgent, and posted to the ED dashboard
immediately
after the exam was completed. Findings were also discussed in
person with the
consulting neurology resident, Dr. [**Last Name (STitle) **] shortly after
image
acquisition.
[**6-16**] CTA: No obvious aneurysm in the ehad on the source images;
however, final read is pending review of 3D reformations. Close
follow up wit CT head to assess stability of inracranial
hemorrhage. Conventional angio if necessary
CT c-spine: 1. No acute fracture or malalignment is seen in the
cervical spine.
2. Right occipital bone fracture with overlying soft tissue
swelling,
nondisplaced, nondepressed.
3. Large amount of blood again seen surrounding the brainstem
and extending
inferiorly into the upper spinal canal causing mass effect on
the brainstem
and upper thecal sac. In the mid cervical spine, there is
narrowing of the
canal due to posterior osteophyte formation at multiple levels,
with
indentation of the thecal sac anteriorly. If there is concern
for cord injury
or compression, MRI would be recommended for more sensitive
evaluation.
NOTE ON ATTENDING REVIEW:
While I agree with most of the prelim read give above and soft
tissue swelling
in the right occipital region, the thin lucency noted in the rt.
occipital
bone can represent part of the sutureverssu non-displaced
fracture, more
likely the former. Pl.see the details on CTA report.
Extent of mass effect on the cervical cord is difficult to
assess on the
present study and can be better evaluate dwith MR.
The source of hemorrhage is not clear and work up to find the
cause in the
head/ spine is to be considered.
[**6-17**] CT abd: Distraction fracture of L1 vertebral body involving
the anterior and
middle columns with retroperitoneal hematoma extending into the
right
retroperitoneal space. In addition, hyperdense material is seen
anterior to
the spinal cord from T12 through L1 which may represent an
extra-axial bleed,
which is causing posterior displacement of the cord. Evaluation
is limited by
artifact from vertebral body fixation hardware, which appears
grossly intact.
Evaluation of the solid intra-abdominal organs is limited by
lack of IV
contrast; however, the kidneys, liver, and remaining solid
intra-abdominal
organs appear intact. Moderate amount of fluid in the abdomen
and pelvis,
likely simple however, cannot exclude small intra-abdominal
bleed from
unidentified source. NG tube is not in the stomach. Blood in the
distal
esophagus. Excreted contrast seen in bilateral proximal ureters
indicative of
renal dysfunction.
[**6-17**] MRI spine: Known oblique transverse type fracture involving
the L1 vertebral body
with sparing of the superior endplate, which transverses both
the anterior and posterior margins and is associated with a
large epidural hematoma with anterior and posterior elements
which pretty much tracts throughout the lumbar and upper sacral
spine. There is a mass effect noted on the exiting cauda equina
with the nerve roots centrally clumped. This is most marked at
the fracture site spanning from T12-L1 where there is little
visualized CSF and less marked mass effect more posteriorly
where a rim of CSF is again noted and likely relates to the
patient's underlying laminectomy which allows some
decompression. Additional regions of scattered subdural and
epidural hematoma are noted within the cervical and thoracic
spine without any significant cord compression. No cord edema is
identified. The known peribrainstem hemorrhage is unchanged and
the degree of retroperitoneal hematoma and small bilateral
pleural effusions is also stable.
[**6-18**] CT abd: No evidence of liver laceration. Stable amount of
fluid in abdomen and pelvis. Stable size of retroperitoneal
hematoma from L1 fracture. No evidence of renal involvement.
Probable stable extra-axial hematoma from T12 to L1 around
spinal cord, but again difficult to assess due to large amount
of streak artifact.
[**6-18**] Angio abd: Aortogram demonstrating pseudoaneurysm of a
right L1 lumber artery which was successfully embolized
selectively with Gelfoam slurry and coils.
[**6-22**] CT Head: Stable w/ expected evolution of the infarct
Brief Hospital Course:
Admitted from Outside hospital after sustaining a fall, striking
her head and undergoing CT imaging which showed a pre pontine
hemorrage with a positive traponin leak. She was airlifted to
[**Hospital1 18**] for further neurosurgical treatment and evaluation.
Neuro ICU course:
Neuro:
Cervicomedullary junction bleed and SAH: Pt was continued on
dilantin for possible seizure. EEG was done but was limited by
artifact. No epileptiform activity was seen. Dilantin was
discontinued and she had no clinical events suspicious for
seizure. She was sedated but off sedation when off sedation she
moves all extremities and opened her eyes intermittently. She
was not following commands. Her exam remained stable and her
prepontine hemorrage was considered stable. No aneurysm was
found on CTA. Angio was deferred due to ARF and it was not felt
to be likely to change management.
L1 fx, epidural bleeding, and cord displacement: Spine consulted
and recommended fixation. She was kept of log roll precautions.
MRI confirmed these findings.
CV: Remained stable. Bedside echo confirmed nl LV fxn.
Resp: She remained stably intubated on the vent. Extubated [**6-22**]
after the family decided to transition to comfort measures.
FEN/GI:
Retroperitoneal hemorrhage: On CT abdomen she was found to have
retroperitoneal heamorrage without any liver lac or other
identified source. Angio was done to identify the source and
found aortic L1 branch pseudoaneurysm which was successfully
embolized w/ coil and gel foam.
Heme: Her hematocrit continued to drop, requiring multiple
transfusions due to the intraabdominal bleeding until the
coiling procedure. Her hematocrit stabilized. Last transfusion
was [**6-18**].
ID: She was treated with ceftriaxone for LLL pnuemonia.
Antibiotics were broadened to vanc/cipro/zosyn on [**6-18**].
Renal: Her Cr rose as high as 1.6 due to ARF. Contrast loads
were minimized and she was treated with mucomyst. By [**6-22**] her
Cr had trended back down to 0.7.
Endo: she was treated with insulin sliding scale.
Code status: Although she was intubated on arrival she was DNR.
Social: Family meeting was held [**6-18**] and then repeat family
meeting was held on [**6-22**] when bleeding and ARF were stable but
her neurologic status was not improving. The family decided to
transition her care to comfort measures and she was extubated on
[**6-22**] pm.
Medications on Admission:
pain medications per report
Discharge Disposition:
Expired
Discharge Diagnosis:
Pre Pontine Cerebral Hemorrhage
Discharge Condition:
Patient passed away
Discharge Instructions:
Patient comfort measures only
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 5849, 5070, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4942
} | Medical Text: Admission Date: [**2116-10-22**] Discharge Date: [**2116-11-4**]
Date of Birth: [**2036-4-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea/Chest Pain
Major Surgical or Invasive Procedure:
[**2116-10-27**] - Coronary Artery Bypass Graft x 3 (Lima to LAD, SVG to
Diag, SVG to PDA)
History of Present Illness:
80 y/o female transferred from [**Hospital3 **] center for
pre-op evaluation regarding CABG. Initially presented with
SOB/CP at outside hospital. Cardiac cath revealed 3VD (LAD 70%,
LCX 50%, RCA 905).
Past Medical History:
Hypertension
Hypercholesterolemia
"Renal Tumor" s/p Left Nephrectomy
Hearing Impaired
Urinary Tract Infection
Social History:
Denies ETOH ot tobacco abuse.
Family History:
Father died of MI at 83. Brother MI at 42 and died of MI at 68.
Another brother had MI at 48. 2 Brothers had sudden death from
aneurysms at ages 55, 65.
Physical Exam:
VS: 70 140/70 16 99% on 2L
General: WD/WN, age appropriate WF in NAD
Head: NC/AT
Neck: Without masses or Bruits
Lungs: CTAB, decreased bs at bases bilat.
Heart: +S1S2, -c/r/m/g
Abd: Soft, NT/ND +BS, Left flank incision well-healed
Ext: Bilat. Varicosities, 1+ edema (R>L)
Neuro: Grossly non-focal, A&O x 3
Pertinent Results:
Carotid U/S [**10-23**]: <40% stenosis [**Country **], No significant stenosis
of [**Doctor First Name 3098**]
Echo [**10-23**]: EF>55%, -AS/AI, Trivial MR, preserved biventricular
systolic function
[**2116-10-22**] 07:15PM BLOOD WBC-7.0 RBC-4.39 Hgb-13.6 Hct-38.5 MCV-88
MCH-31.0 MCHC-35.2* RDW-12.9 Plt Ct-256
[**2116-10-31**] 06:35AM BLOOD WBC-9.6 RBC-4.33 Hgb-13.5 Hct-38.1 MCV-88
MCH-31.1 MCHC-35.3* RDW-14.2 Plt Ct-121*
[**2116-10-22**] 07:15PM BLOOD PT-12.8 PTT-44.4* INR(PT)-1.1
[**2116-10-30**] 02:18AM BLOOD PT-12.5 PTT-29.7 INR(PT)-1.0
[**2116-10-22**] 07:15PM BLOOD Glucose-148* UreaN-22* Creat-1.1 Na-133
K-3.8 Cl-96 HCO3-26 AnGap-15
[**2116-11-1**] 01:20PM BLOOD Glucose-135* UreaN-25* Creat-1.1 Na-134
K-4.3 Cl-99 HCO3-23 AnGap-16
[**2116-10-22**] 06:07PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2116-10-22**] 06:07PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2116-10-23**] Carotid Duplex Ultrasound
1. Mediastinal and bilateral hilar lymphadenopathy. Further
evaluation with a contrast- enhanced chest CT is recommended.
2. No evidence of pneumonia or overt CHF.
[**2116-10-23**] ECHO
The left atrium is normal in size. 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
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
[**2116-10-24**] CXR
Lungs are mildly hyperinflated. Heart is at the upper limits of
normal or slightly enlarged. The aorta is calcified and
unfolded. Mild prominence of the right paratracheal soft tissues
likely reflects vascular ectasia in someone of this age. No CHF,
infiltrate, or effusion is identified. Subsegmental atelectasis
or scarring is present at both bases. Minimal blunting of both
costophrenic angles is noted.
[**2116-10-29**] CXR
Lung volumes are decreased slightly following extubation. There
is more atelectasis at the base of the left lung, but no change
in tiny left pleural effusion or any indication of pneumothorax
following removal of the left pleural drain. Cardiomediastinal
silhouette has enlarged minimally, but still normal caliber.
Right lung grossly clear. A Swan-Ganz catheter tip projects over
the main pulmonary artery.
[**2116-11-3**] Head CT
1. No evidence for acute intracranial hemorrhage. Small low
attenuation is seen involving the periventricular white matter,
nonspecific probably related to chronic microvascular ischemic
changes. Hyperostosis frontalis. If there is clinical suspicion
for an acute ischemic event, correlation with MRI would be
helpful if clinically indicated.
[**2116-11-3**] EEG
Official results pending
By report it was completely normal.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] via transfer from [**Hospital1 62664**] center on [**2116-10-22**] for surgical management of her
coronary artery disease. She underwent routine pre-operative
work-up which included a carotid u/s and echocardiogram. Please
see pertinent results. Ms. [**Known lastname **] also had renal and cardiology
consults pre-operatively. Ciprofloxacin was started for a
urinary tract infection. Ms. [**Known lastname **] was stable on medical
management and her surgery was delayed secondary to bed
availability. On [**2116-10-27**], Ms. [**Known lastname **] was taken to the operating
room where she underwent Coronary Artery Bypass Grafting to
three vessels. She tolerated the procedure well.
Postoperatively, she was transferred to the cardiac surgical
intensive care unit in stable condition. Pt. remained intubated
through operative day one secondary to mild metabolic acidosis.
She was weaned from mechanical ventilation and was extubated by
postoperative day two. Ms. [**Known lastname **] developed several runs of
ventricular tachycardia and Amiodarone was started. She also had
elevated blood pressure which required nitroglycerin which was
ultimately weaned off without difficulty. Her chest tubes and
pacing wires were removed per protocol. On postoperative day
three to the telemetry floor on POD #3. She was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with her postoperative strength and
mobility. Beta blockade was titrated for optimal heart rate and
blood pressure support. On postoperative day seven, Ms. [**Known lastname **]
became acutely confused. A neurology consult was obtained and a
head CT scan was performed. This revealed several areas of old
lacuna infarcts but no new acute infarcts or hemorrhages. An
EEG was performed which was reported as normal. Her zantac was
discontinued. Her mental status cleared. Ms. [**Known lastname **] continued to
make steady progress and was discharged home on postoperative
day eight. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist
and her primary care physician as an outpatient.
Medications on Admission:
1. Toprol XL 50mg qd
2. Heparin gtt
3. HCTZ 12.5mg qd
4. Levaquin 250mg qd
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
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:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10
days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 805**] [**Last Name (NamePattern1) **] Care
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Hypercholesterolemia
"Renal Tumor" s/p Left Nephrectomy
Acute postoperative confusion
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with warm water and gentle soap.
Gently pat dry. Do not apply lotions, creams, ointments, or
powders to incisions.
Do not lift more than 10 pounds for 2 months.
Do not drive for 1 month.
If you notice any drainage from incisions, redness or fever
greater than 101, please call office immediately.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks (Call [**Doctor First Name **] at
[**Telephone/Fax (1) 62665**] to schedule appointment in [**Location (un) 37361**], RI)
Follow-up with Dr. [**Last Name (STitle) 62666**] in [**1-30**] weeks
Follow-up with Dr. [**Last Name (STitle) **] in [**12-29**] weeks
Completed by:[**2116-11-4**]
ICD9 Codes: 4271, 4111, 5990, 2762, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4943
} | Medical Text: Admission Date: [**2200-9-2**] Discharge Date: [**2200-9-11**]
Date of Birth: [**2159-4-2**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
hypoxia, hemodynamic instability
Major Surgical or Invasive Procedure:
1. Ultrasound-guided puncture of left common femoral
artery.
2. Ipsilateral second-order catheterization of left
external iliac artery.
3. Pelvic arteriogram.
4. Stent placement in common iliac artery.
5. Perclose closure of the left common femoral arteriotomy.
History of Present Illness:
41 yo M with h/o L4 burst fracture s/p L3-L5 fusion, complicated
by psoas abscess and formation of chronic sinus tract,
presenting with bleeding from sinus tract, fever, and hypoxia.
The patient had an L4 burst fracture in [**2195**], fused with cage in
[**State 108**]. He later developed a fluid collection in that area, and
has a drain put in [**2200-8-25**]. 1 month later, the drain was
pulled, and the patient developed a draining sinus tract. The
patient was taken to the OR for debridement in 12/[**2197**]. This was
complicated by ureter injury. Since then, the patient had
persistent yellow/green drainage from the sinus tract.
On Sunday, the patient developed profuse bleeding from sinus
tract, which resolved before he reached [**Hospital3 417**] Medical
Center. At [**Hospital3 417**], the patient had a abd/pelvis CT
showing post-surgical changes in the left psoas muscle extending
into the left lateral abdominal wall, with no discrete fluid
collection or hematoma. Labs were notable for WBC 14.9, 51%
bands. The [**Hospital 228**] hospital course was complicated by fever
to as high as 103, hypotension to 89/43 which was
fluid-responsive, and further bleeding from the sinus tract in
the setting of fever and vomiting. Surgery consulted at the [**Hospital 6451**] hospital, who packed the sinus tract but did not
pursue more aggressive debridement. Pt was directly transferred
to the internal medicine
team at the [**Hospital1 18**] for further management of sinus tract
infection.
Upon arrival to the floor, patient was noted to have active,
profuse bleeding of bright red blood from the sinus tract. He
was hypotensive to low 100's/60's, with HR in low 100's. He was
bolused 3L NS, and transfusion of 2 units of PRBCs and FFP was
begun. He was given Vanc + Zosyn for broad coverage, and
admitted
to the ICU. His hemodynamics stabilized with BP's 120s/60's, and
HR 80's. The pressure dressing was removed, and sinus tract
examined, which did not appear to be actively bleeding any
longer. A CTA of abdomen/pelvis demonstrated active
extravasation of blood from a lumbar artery to L psoas muscle.
Vascular surgery
was consulted for further management.
Review of systems:
-Constitutional: +fevers, chills. Lost 10 pounds in past year.
-Resp: No cough. No shortness of breath.
-CV: No chest pain. No dizziness or lightheadedness.
-GI: No abdominal pain. +non-bloody emesis on Sunday. Chronic
diarrhea/BRBPR. No melena. No bowel or bladder incontinence.
-GU: No difficulty urinating or pain with urination.
-Neuro: No focal weakness, tingling, or numbness.
Past Medical History:
ulcerative colitis
L4 burst fracture s/p L3-L5 fusion [**2196**]
chronic sinus tract, as above
IVC filter placed via right groin
previous ureteric stent, now removed
PAST SURGICAL HISTORY:
s/p L ankle ORIF with hardware placement
s/p lumbar fusion with hardware placement
s/p OR washout/debridement [**12/2198**]
Social History:
Works as [**Doctor Last Name 3456**]. Married. Lives with wife.
-Tob: [**1-26**] cig/month
-EtOH: none
-Drugs: none
Family History:
hyperlipidemia
Physical Exam:
ADMISSION
T 98.9, HR 93, BP 115/64, RR 19, O2 Sat 96%/6L NC (was on NRB on
transfer to MICU)
Gen: No acute distress.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. Mild basilar rales.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding.
Back: Sinus tract in left flank with wick in place and large
amount of blood on dressing but no active bleeding.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. Face symmetric. Strength 5/5 throughout upper and
lower extremities.
DISHCARGE
T 99.7 HR 72 BP 132/78 RR 16 97%RA
Gen: No acute distress.
Neuro: A+Ox3.
Resp: Normal respiratory effort. No resp distress.
CV: RRR. Normal s1 and s2.
Abd: +BS. Soft. NT/ND.
Ext: Warm and well-perfused.
Pulses: Radial pulses palp bilaterally. DP/PT palp bilat
Pertinent Results:
CTA Abd/Pelvis
1. Psoas phlegmonous changes are again visualized with a chronic
sinus tract. However, the left psoas appears enlarged with
hyperdense foci consistent with intramuscular hemorrhage with
evidence of foci of active arterial extravasation. Evaluation of
the left psoas is somewhat obscured by streak artifact from
adjacent metallic structures. However, multiple dilated tortuous
structures are visualized and may represent mycotic aneurysms
involving the iliolumbar artery versus foci of hemorrhage.
2. Relatively stable appearance of mild left hydronephrosis
tapering to the level of the left psoas collection.
3. Mild wall thickening and hyperemia involving the descending
colon, sigmoid colon, and rectum. Although these findings may
represent proctocolitis, evaluation is somewhat limited due to
lack of distention of the bowel. Correlation with symptoms is
recommended.
4. New mild ascites as well as new bilateral small pleural
effusions with
adjacent airspace atelectasis.
5. Right fat-containing inguinal hernia descending into the
scrotal sac with a right hydrocele.
6. IVC filter in place.
7. L4 burst fracture with L3-L5 cage.
.
MRA Abd w and w/o Contrast
Pseudoaneurysm from the left common iliac artery arising
adjacent to lumbar orthopedic hardware within the left psoas
muscle. This arises roughly 2 cm from the origin of the left
common iliac artery and 1 cm proximal to the origin of the left
internal iliac artery. Large multilobulated pseudoaneurysm
occupying the left psoas muscle with large surrounding thrombus
and hemorrhage. Report was urgently communicated to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at 5:57 p.m. on [**2200-9-5**], and with the
interventional radiology fellow on call at pager [**Numeric Identifier 5603**] at the
time of scan.
Blood cultures negative.
[**2200-9-10**] 07:40PM BLOOD Hct-31.5*
[**2200-9-10**] 03:51AM BLOOD WBC-9.8 RBC-3.49* Hgb-9.9* Hct-28.3*
MCV-81* MCH-28.4 MCHC-35.0 RDW-16.0* Plt Ct-631*
Brief Hospital Course:
HOSPITAL COURSE
41 yo M with h/o L4 burst fracture s/p L3-L5 fusion complicated
chronic sinus tract, presenting with active bleeding from sinus
tract, fever, hypoxia and hemodynamic instability, found to have
pseudoaneurysm of left common iliac artery communicating w sinus
tract, now s/p endovascular stenting. Patient admitted to MICU.
Course in MICU [**Date range (1) 40895**]:
#Pseudoaneurysm of left common iliac artery: Patient initially
presented to [**Hospital1 18**] in setting of profuse bleeding from sinus
tract. Patient received 6 units pRBCs, 2 units FFP, 1 bag
platelets. CTA abd/pelvis demonstrated intramuscular hemorrhage
at area of ileopsoas with a mycotic psuedoaneurysm w evidence
active arterial extravasation. IR attempted embolization of the
psuedoaneurysm, but were unable to locate the artery feeding it.
Subsequent MRA demonstrated pseudoaneurysm from the left common
iliac artery with large surrounding thrombus and hemorrhage.
Patient was transferred to Vascular Service and underwent
endovascular stenting.
.
#Hypoxemia: Following transfer, patient w worsening oxygen
requirement, fluffy infilatrate on CXR. Initial concern was for
CHF vs ARDS [**2-26**] unknown infectious process. Timeline not
consistent w TRALI. TTE demonstrated low-normal systolic
ejection function w possible hypokinesis of basal inferoseptal
segment. Patient received 10mg IV lasix w good effect, although
patient remained w 2L O2 requirement at time of transfer.
#Fever: Patient initially w fever and bandemia at OSH w/o
localizing symptoms or culture data. Patient has a long history
of signs of infection w/o positive culture data. Patient
remained w intermittent fevers through the ICU stay. Likely
source of infection is known sinus tract. Patient treated w
vanco/zosyn. No culture data at time of transfer.
.
#Ulcerative colitis - No known flare. Held lialda given ongoing
other issues.
Patient was transferred to VICU on [**2200-9-6**]. He underwent angio
and endovascular stent placement x2 in the common iliac artery
on the left with perclosure of left common femoral artery on
[**9-6**]. Bleeding continued and patient was transfused 2 units of
blood and patient underwent repeat angio with another stent
placed on [**9-8**]. Crit was still low so additional 2 units of
blood were given. Patient did well postoperatively. Crits were
closely followed and stable. Pt was switch from vanco/zosyn to
bactrim. Patient was tolerating a regular diet, pain well
managed and ambulating on his own. Discussed operation to remove
hardware in a few weeks, patient seems amenable. Discussed
operation with Dr. [**Last Name (STitle) 1391**] and Dr. [**Last Name (STitle) 363**]. Patient will go home
on Bactrim. On discharge, pt was ambulating, tolerating regular
diet, pain controlled, hematocrit stable.
Medications on Admission:
Lialda 1.2 grams, 2 tabs daily
Discharge Medications:
1. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): Take until you come back to
hospital for reoperation.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left common iliac pseudoaneurysm.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? 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 to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-30**] weeks for
post procedure check and CTA
Followup Instructions:
If you have questions call Dr.[**Name (NI) 1392**] office [**Telephone/Fax (1) 1393**].
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4944
} | Medical Text: Admission Date: [**2155-11-21**] Discharge Date: [**2155-12-1**]
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Unstable angina status post myocardial
infarction
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 46993**] is an 86-year-old
female with a past medical history significant for type II
diabetes mellitus, coronary artery disease status post
myocardial infarction and peptic ulcer disease who began
experiencing substernal chest pain upon exertion at the
beginning of [**2155-10-26**]. She was admitted to the [**Hospital6 1760**] on [**2155-10-30**] at which
time she ruled in for myocardial infarction by CK/MB cardiac
enzyme which was 12.3 She was also found to have an
electrocardiogram notable for ST depressions and flipped
T-waves. During the aforementioned admission, the patient
underwent cardiac catheterization which showed significant
two vessel disease with a LAD which had a long 70% mid vessel
stenosis.
PAST MEDICAL HISTORY:
1. Type II diabetes mellitus which is diet controlled.
2. Peptic ulcer disease
3. Hiatal hernia
4. Coronary artery disease
PAST SURGICAL HISTORY:
1. Repair of hiatal hernia
2. Hysterectomy
3. Partial gastrectomy
ADMISSION MEDICATIONS:
1. Lopressor 25 mg by mouth twice per day
2. Enteric coated aspirin 325 mg by mouth once per day
3. Lansoprazole
4. Calcium tablets 500 mg by mouth 3x per day
5. Nitroglycerin ointment as needed for chest pain
6. Multivitamin
ALLERGIES: THE PATIENT REPORTS AN ALLERGY TO CODEINE.
SOCIAL HISTORY: The patient lives alone with home services.
She denies any prior use of tobacco, alcohol or illicit
drugs.
FAMILY HISTORY: Mrs.[**Known lastname 46994**] family history is significant of
her mother and a brother who died of myocardial infarctions,
both in their 70s.
PHYSICAL EXAMINATION: On initial physical examination, Mrs.
[**Known lastname 46993**] was found to have a heart rate of 80 beats per minute in
sinus rhythm with a blood pressure of 155/66. Her height was
4 feet 10 inches and her weight was 102 pounds.
GENERAL: She was a pleasant and elderly woman in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Her pupils were equal,
round and reactive to light and accommodation. Her
extraocular muscles were intact.
NECK: Supple with trachea in the midline and no visible
jugular venous distention. Her carotid arteries were 2+
palpable with no audible bruits. There was no
lymphadenopathy.
CARDIAC: She had a regular rate and rhythm with normal S1
and S2 heart sounds. There were no murmurs, rubs or gallops
LUNGS: Clear to auscultation bilaterally with good air entry
and movement.
ABDOMEN: Soft, nontender, nondistended, with no
hepatosplenomegaly or other palpable masses.
EXTREMITIES: Warm and dry with no peripheral edema.
NEUROLOGIC: She was alert and oriented to person, place and
time and her motor and sensory systems were grossly intact.
LABORATORY DATA available from her prior admission in early
[**Month (only) 1096**] was significant for a hematocrit of 33.7, an INR of
1.3 and electrolytes. Chem-7 showing a sodium of 140,
potassium of 4.5, chloride of 107, bicarbonate of 23, BUN of
14, creatinine of 0.8 with a blood glucose of 111.
RADIOLOGIC STUDIES: Mrs. [**Known lastname 46993**] underwent a preoperative chest
x-ray which showed no apparent abnormalities. She also had
undergone cardiac catheterization in early [**Month (only) 1096**] which
showed two vessel disease as previously mentioned in the
History of Present Illness.
HOSPITAL COURSE: Mrs. [**Known lastname 46993**] was admitted to the Operating
Room on [**2155-11-21**] where she underwent a coronary
artery bypass graft x2. Please see the dictated operative
note for details of this procedure, but in summary the
patient underwent a bypass graft x2 with the left internal
mammary artery anastomosed to the left anterior descending
and a saphenous vein graft of the coronary artery. She also
underwent pericardial patch repair of the right atrium with
Bio-glue. She was subsequently transferred to the Cardiac
Surgery Recovery Unit in stable condition, with a mean
arterial pressure of 95, A-paced, and on a propofol drip at
20 mcg per kg per minute. On the night of her surgery, she
developed acute onset of a sinus tachycardia with a heart
rate in the 130s, which was refractory to adenosine and
intravenous metoprolol. Pacing was also unable to decrease
her heart rate.
At this time, an electrophysiology consult was obtained, and
her heart rate was controlled using E and V pacing as well as
increase in her dosage of beta blocker, and antiinflammatory
medication for a pericardial rub which could be heard at this
time. The laboratory results on postoperative day #1 were
significant for a hematocrit of 32 and a white blood cell
count of 8.6. At this time, her electrolytes were
significant for a sodium of 146, potassium of 4.5, chloride
of 112, bicarbonate of 23, BUN 18, creatinine of 0.7. Her
magnesium at the time was 2.4 and her INR was 1.0. She also
had an arterial blood gas which showed a pH of 7.38, PCO2 46,
and a PO2 of 172.
Her blood pressure was held in control using a Neo-Synephrine
drip to combat the blood pressure lowing effects of her
increasing doses of beta blocker. She was, at this time,
also started on esmolol, as the previously given Lopressor
had not been fully effective. Her heart rhythm during this
time was at times sinus, but also at times atrial
fibrillation. On postoperative day #3, she continued to be
tachycardic and in atrial fibrillation from time to time.
She was at this time on Lasix, Lopressor and aspirin. Her
esmolol was weaned and she was started on oral amiodarone.
Her Lopressor was further increased on postoperative day #4
and she was started on captopril. She continued to oscillate
between atrial fibrillation and sinus rhythm. She was awake
and alert and doing well from the standpoint of her surgery.
Her episodes of tachycardia became shorter in duration, and
she spent more time in sinus rhythm.
At this time, a speech and swallowing evaluation was also
obtained as the patient was noted to have trouble swallowing
her pills. She did not have any difficulty with any of the
diet attempts that were made including .................
puree and jello. She was not found to aspirate, and her diet
was to be advanced as tolerated. She was at this time also
on a diltiazem drip in order to help with rate control. This
was stopped on postoperative day #5. The patient was able to
maintain a sustained period of sinus rhythm. By
postoperative day #6, she had been in normal sinus rhythm for
a full 24 hour period. Her amiodarone was decreased now due
to bradycardia to 400 mg by mouth twice per day. Her heart
rate at this time was 63 beats per minute and in sinus
rhythm. She was subsequently transferred to the floor on
postoperative day #6 where she did quite well. She continued
to improve from the standpoint of her diet and mobility. Her
incision was healing well and she had good sternal stability.
She continued to slowly diurese and continues to have minimal
lower extremity edema. On approximately postoperative day
#8, she began having multiple loose stools per day and was
empirically started on 500 mg of Flagyl by mouth 3x per day
and a stool sample was sent for Clostridium difficile toxin.
Her Lopressor and captopril were titrated according to her
heart rate and blood pressure to fully meet her heart rate
and blood pressure control needs. Due to her age and living
situation, it was thought prudent that she spend a brief time
in a skilled care nursing facility, where she could be more
closely monitored. She was screened and deemed ready for
discharge on postoperative day #10.
PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE:
VITAL SIGNS: Notable for a temperature of 96?????? Fahrenheit,
heart rate of 86 and sinus rhythm, blood pressure of 123/50,
with an oxygen saturation of 100% on room air.
GENERAL: She was sitting in a chair, alert and oriented to
person, place and time.
HEART: Regular rate and rhythm with normal S1, S2 and no
murmurs.
LUNGS: Clear to auscultation bilaterally with good air entry
and movement.
CHEST: Her sternal incision was healing quite nicely with
good sternal stability.
ABDOMEN: Soft, nontender and nondistended. Her incisions
were open to the air, clean and dry.
EXTREMITIES: Warm and well perfuse with no evidence of pedal
edema.
DISCHARGE LABORATORIES: A complete blood count with a white
blood cell count of 8.2, hematocrit of 31.1 and a platelet
count of 187,000. Her Chem-7 showed a sodium of 137,
potassium of 5.2, chloride of 105, bicarbonate of 28, BUN of
21, creatinine of 0.9 with a blood glucose of 117. Her
magnesium at the time is 1.5 for which she will be repleted
prior to discharge.
DISCHARGE MEDICATIONS:
1. Lopressor 37.5 mg by mouth twice per day to be held for a
systolic blood pressure less than 100 or a heart rate less
than 60
2. Captopril 6.25 mg by mouth 3x per day to be held for a
systolic blood pressure below 110
3. Flagyl 500 mg by mouth 3x per day
4. Amiodarone 400 mg by mouth once per day
5. Protonix 40 mg by mouth once per day
6. Enteric coated aspirin 325 mg by mouth once per day
7. Colace 100 mg by mouth twice per day
8. Lasix 20 mg by mouth once per day
9. Dulcolax suppository 10 mg per rectum once per day as
needed for constipation
10. Benadryl 25 mg by mouth each night at the hour of sleep
as needed for sleep.
11. Milk of Magnesia 30 ml by mouth each night as needed for
constipation
12. Tylenol 650 mg by mouth 4x every four hours as needed for
pain
DIET: Her diet should be a cardiac heart healthy diet.
ACTIVITY: Her activity should be as tolerated, though she
would probably benefit from some further physical therapy in
order to increase her strength and mobility.
DISPOSITION: Skilled nursing facility
FOLLOW UP: Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in four weeks time.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name (STitle) 46995**]
MEDQUIST36
D: [**2155-12-1**] 09:55
T: [**2155-12-1**] 11:01
JOB#: [**Job Number 46996**]
ICD9 Codes: 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4945
} | Medical Text: Admission Date: [**2182-9-16**] Discharge Date: [**2182-9-20**]
Date of Birth: [**2107-2-27**] Sex: M
Service:
NOTE - An addendum will be dictated when the patient is
discharged.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
male with a past medical history significant for coronary
artery disease, diabetes and chronic renal insufficiency,
admitted to Coronary Care Unit following cardiac
catheterization for ventilatory support and Intensive Care
Unit monitoring. The patient originally presented to an
outside hospital the morning of admission complaining of
chest pain and symptoms of congestive heart failure. An
electrocardiogram showed a new left bundle branch block. He
was then transferred to [**Hospital6 256**]
for emergent cardiac catheterization. The patient went
immediately to the Catheterization Laboratory upon arrival.
Catheterization showed three vessel coronary artery disease,
patent graft, left internal mammary artery to the left
anterior descending, patent saphenous vein graft to the
posterior descending artery and patent saphenous vein graft
to obtuse marginal 1. It was significant for increased right
and left filling pressures. Angioplasty was then performed
on the aortoiliac bypass graft, left circumflex coronary
artery with failed angioplasty of obtuse marginal 1. The
patient developed significant respiratory distress following
catheterization and was ventilated for ventilatory support
with transfer to the Coronary Care Unit on a ventilator.
PAST MEDICAL HISTORY: Coronary artery disease status post
coronary artery bypass graft redo, three vessels in [**2159**],
four vessels in [**2170**], diabetes mellitus times 13 years,
chronic renal insufficiency with baseline creatinine 2.3,
prostate cancer diagnosed in [**2171**] refractory to hormone
therapy followed by Dr. [**Last Name (STitle) **], gout, depression, anemia,
congestive heart failure with unknown ejection fraction.
SOCIAL HISTORY: History of tobacco use, 30 pack years, quit
in [**2158**], occasional alcohol.
HOME MEDICATIONS:
1. Calcitriol .25 mcg q. day
2. Calcium acetate 657 mg t.i.d.
3. Docusate 100 mg b.i.d.
4. Epogen 10,000 units subcutaneous q. Thursday
5. Felodipine 5 mg q. day
6. Iron 325 mg t.i.d.
7. Fluoxetine 20 mg q. day
8. Glipizide 5 mg q. AM
9. Hydralazine 40 mg b.i.d.
10. Hydroxyzine 25 mg b.i.d.
11. Metoprolol 25 mg t.i.d.
12. Omeprazole 40 mg q. day
13. Senna two tablets b.i.d.
14. Simvastatin 20 mg q. day
15. Allopurinol 50 mg q. day
16. Isosorbide mononitrate 60 mg q. day
17. Lasix 60 mg b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs, temperature
96, heartrate 60, blood pressure 179/57, oxygen saturation
100% on 30% FIO2, weight 108 kg. General: Elderly male in
no acute distress. Head, eyes, ears, nose and throat, pupils
equal, round and reactive to light and accommodation.
Oropharynx clear. Neck supple. No lymphadenopathy. Chest
clear to auscultation anteriorly, no wheezes. Heart, regular
rhythm, II/VI systolic murmur at the lower left sternal
border with no radiation. Abdomen, soft, nontender,
nondistended, positive bowel sounds. Extremities, 1+ edema.
Pulses dopplerable bilaterally. Venous stasis changes
bilaterally. Neurological, intubated, sedated. Moves
extremities times four.
LABORATORY DATA: White blood count 15.8, hematocrit 29.8,
platelets 228. Sodium 142, potassium 4.7, chloride 111,
bicarbonate 18, BUN 86, creatinine 5.0, glucose 138. Calcium
8.7, magnesium 1.7, phosphorus 4.6. Chest x-ray:
Cardiomegaly, mild congestive heart failure.
Electrocardiogram, sinus rate at 80, left bundle branch
without ST changes.
HOSPITAL COURSE: Cardiovascular - Ischemia, the patient with
a history of coronary artery disease, transferred from an
outside hospital for emergent cardiac catheterization
following new left bundle branch block at an outside
hospital. During catheterization, the patient underwent
percutaneous transluminal coronary angioplasty to the left
circumflex with serial percutaneous transluminal coronary
angioplasty of obtuse marginal 1. Following catheterization
he was maintained on a statin, Plavix, and Aspirin. He was
initially on a nitroglycerin drip which was then converted
over to p.o. He was also started on Hydralazine and titrated
up on a beta blocker. This was subsequently converted to
Carvedilol. The patient did not have any further episodes of
chest pain or ischemia during the hospitalization.
Pump, the patient with congestive heart failure Class 4. The
patient underwent echocardiogram following cardiac
catheterization which showed an ejection fraction of 30 to
40% and severe hypokinesis inferiorly and posteriorly along
with 1+ mitral regurgitation and impaired ventricular
relaxation. Immediately following catheterization the
patient was diuresed on a Natrecor drip. He was quickly
weaned off of this and titrated over to daily intravenous
Lasix. He was initially started on beta blocker and later
converted over to Carvedilol which he tolerated well. He was
also started on Hydralazine and put back on his
nitroglycerin. He continued to receive prn Lasix for
symptoms of fluid overload.
Rhythm, the patient remained in sinus rhythm and was
monitored on Telemetry throughout his hospital course.
Pulmonary - The patient was intubated following cardiac
catheterization for respiratory distress following minimal
diuresis with Natrecor drip. The patient was quickly weaned
off of the ventilator and successfully extubated without any
complications. He did not require any additional oxygen
requirements throughout the hospitalization and had no
symptoms of respiratory distress.
Infectious disease - The patient developed leukocytosis and
diarrhea during hospitalization and a stool sample was
positive for Clostridium difficile toxin. He was started on
Vancomycin therapy for treatment of Clostridium difficile
colitis. His symptoms of diarrhea improved following
initiation of antibiotic therapy.
Renal - The patient with chronic renal insufficiency with
baseline creatinine of 2.3. At admission, his creatinine was
acutely elevated up to 5.0, thought to be due to dye load
during catheterization. He was aggressively hydrated and his
creatinine trended down. He briefly bumped his creatinine
due to hypovolemia during his diarrhea but this resolved with
hydration. He was eventually put back on his daily Lasix
dose for maintenance.
Fluids, electrolytes and nutrition - The patient's volume
status and electrolytes were followed throughout admission.
He received multiple electrolyte repletions.
Heme - Anemia, the patient with baseline anemia believed due
to chronic renal insufficiency. He was continued on iron and
Epogen per his home regimen. He required transfusion of 2
units of packed red blood cells during the hospitalization.
His acute drop was thought to be following his
catheterization procedure. He responded appropriately to the
transfusions and remained hemodynamically stable.
Endocrine - Patient with diabetes mellitus. His Glipizide
was held initially and he was placed on sliding scale
insulin. Following resumption of the regular diet he was
converted back to home medicines.
Prophylaxis - The patient was maintained on subcutaneous
heparin and proton pump inhibitor throughout his
hospitalization.
Code status - The patient was a full code throughout the
hospitalization.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSIS:
1. Myocardial infarction with cardiac catheterization
2. Congestive heart failure
3. Acute and chronic renal failure
DISCHARGE MEDICATIONS/FOLLOW UP INSTRUCTIONS: Will be
dictated in an addendum to this discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2182-9-20**] 15:06
T: [**2182-9-20**] 16:22
JOB#: [**Job Number 5213**]
ICD9 Codes: 4280, 5849, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4946
} | Medical Text: Admission Date: [**2186-11-30**] Discharge Date: [**2186-12-13**]
Date of Birth: [**2135-4-10**] Sex: M
Service: SURGERY
Allergies:
Remicade / Lipitor
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Crohn's disease with colon-splenic fistula.
Major Surgical or Invasive Procedure:
Exploratory laparotomy, total abdominal colectomy, and
splenectomy
History of Present Illness:
67-year-old male with longstanding Crohn's disease that
fistulized to the spleen, progressively worsened with
conservative management. He presented to clinical service for
evaluation and management.
Past Medical History:
1)Crohn's disease: diagnosed in [**2166**], followed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1940**], involving colon primarily, no bowel surgery, intolerant
of 6-MP and remicade, failed Humira
2)Hypertension
3)Hyperlipidemia
4)h/o DVT
5)Reactive arthritis
6)Sleep Apnea, improved w/wt loss
7)Obesity
8)Substance Abuse
9)Depression
10)Chronic Back Pain
11)Allergic rhinitis
12) s/p open cholecystectomy
[**89**]) Intraabdominal abscess s/p surgical drainage and antibiotics
[**5-13**]
Social History:
Currently on disability for Crohn's, previously worked as
painter, denies alcohol use. 45 pack-year smoker 1 pack per day.
Family History:
Positive for colitis and diabetes. Negative for
colon cancer.
Physical Exam:
97.5, 84,140/82,20, 94 % room air
General:alert and oriented x 3
Cardiac:regular,rate,rhythm,
Pulmonary:clear
Abdomen: soft nontender, nondistended
Incision:abdominal staples intact no erythema, no edema
Extremities:+2 dorsalis pedis, +2 bilateral lower extremity
edema
Pertinent Results:
[**2186-11-29**] 10:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2186-11-29**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2186-11-29**] 04:18PM LACTATE-0.8
[**2186-11-29**] 04:15PM GLUCOSE-109* UREA N-13 CREAT-1.1 SODIUM-128*
POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-27 ANION GAP-13
[**2186-11-29**] 04:15PM estGFR-Using this
[**2186-11-29**] 04:15PM ALT(SGPT)-8 AST(SGOT)-14 ALK PHOS-86 TOT
BILI-0.6
[**2186-11-29**] 04:15PM WBC-11.1*# RBC-3.10* HGB-9.8* HCT-28.9*
MCV-93 MCH-31.5 MCHC-33.7 RDW-13.8
[**2186-11-29**] 04:15PM NEUTS-75.2* LYMPHS-17.9* MONOS-4.7 EOS-1.7
BASOS-0.5
[**2186-11-29**] 04:15PM PLT COUNT-437
[**2186-12-13**] 06:35AM BLOOD WBC-8.8 RBC-3.19* Hgb-9.6* Hct-29.9*
MCV-94 MCH-30.0 MCHC-32.0 RDW-14.2 Plt Ct-986*
[**2186-12-12**] 06:25AM BLOOD WBC-10.8 RBC-3.02* Hgb-9.2* Hct-28.6*
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.6 Plt Ct-860*
[**2186-12-11**] 09:30AM BLOOD WBC-8.4 RBC-3.03* Hgb-9.3* Hct-29.7*
MCV-98 MCH-30.8 MCHC-31.4 RDW-13.9 Plt Ct-910*
[**2186-12-10**] 07:25AM BLOOD WBC-10.3 RBC-2.94* Hgb-9.2* Hct-28.0*
MCV-95 MCH-31.3 MCHC-32.8 RDW-14.1 Plt Ct-829*
[**2186-12-9**] 10:30AM BLOOD WBC-12.9* RBC-2.89* Hgb-9.3* Hct-27.9*
MCV-96 MCH-32.0 MCHC-33.2 RDW-14.0 Plt Ct-782*
[**2186-12-8**] 06:40AM BLOOD WBC-13.7* RBC-2.91* Hgb-9.1* Hct-27.7*
MCV-95 MCH-31.3 MCHC-33.0 RDW-14.5 Plt Ct-561*
[**2186-12-7**] 07:15AM BLOOD WBC-17.9* RBC-3.01* Hgb-9.4* Hct-28.6*
MCV-95 MCH-31.3 MCHC-32.9 RDW-14.6 Plt Ct-517*
[**2186-12-6**] 02:47AM BLOOD WBC-16.0*# RBC-3.58* Hgb-11.3* Hct-33.6*
MCV-94 MCH-31.6 MCHC-33.7 RDW-14.9 Plt Ct-436
[**2186-12-5**] 08:05PM BLOOD WBC-9.8# RBC-3.78* Hgb-11.5* Hct-34.9*
MCV-92 MCH-30.4 MCHC-32.9 RDW-14.2 Plt Ct-423
[**2186-12-5**] 03:30PM BLOOD WBC-5.3 RBC-3.08* Hgb-9.3* Hct-28.8*
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.0 Plt Ct-420
[**2186-12-4**] 06:30AM BLOOD WBC-5.8 RBC-3.03* Hgb-9.3* Hct-28.6*
MCV-95 MCH-30.7 MCHC-32.5 RDW-12.9 Plt Ct-408
[**2186-12-3**] 05:50AM BLOOD WBC-5.1 RBC-2.84* Hgb-9.0* Hct-26.7*
MCV-94 MCH-31.7 MCHC-33.8 RDW-13.5 Plt Ct-404
[**2186-12-1**] 06:10AM BLOOD WBC-8.6 RBC-2.93* Hgb-8.9* Hct-27.6*
MCV-94 MCH-30.4 MCHC-32.3 RDW-13.1 Plt Ct-405
[**2186-11-29**] 04:15PM BLOOD WBC-11.1*# RBC-3.10* Hgb-9.8* Hct-28.9*
MCV-93 MCH-31.5 MCHC-33.7 RDW-13.8 Plt Ct-437
[**2186-12-13**] 06:35AM BLOOD Glucose-102* UreaN-2* Creat-0.7 Na-137
K-3.9 Cl-100 HCO3-31 AnGap-10
[**2186-12-12**] 06:25AM BLOOD Glucose-114* UreaN-2* Creat-0.8 Na-140
K-3.9 Cl-101 HCO3-30 AnGap-13
[**2186-12-11**] 09:30AM BLOOD Glucose-124* UreaN-3* Creat-0.8 Na-141
K-4.0 Cl-104 HCO3-32 AnGap-9
[**2186-12-10**] 07:25AM BLOOD Glucose-114* UreaN-4* Creat-0.7 Na-144
K-4.3 Cl-106 HCO3-32 AnGap-10
[**2186-12-9**] 04:45PM BLOOD UreaN-4* Creat-0.8 Na-145 K-4.0 Cl-106
HCO3-31 AnGap-12
[**2186-12-9**] 02:00PM BLOOD Glucose-106* UreaN-4* Creat-0.9 Na-148*
K-4.1 Cl-106 HCO3-32 AnGap-14
[**2186-12-7**] 07:15AM BLOOD Glucose-97 UreaN-4* Creat-0.9 Na-141
K-4.4 Cl-106 HCO3-28 AnGap-11
[**2186-12-6**] 04:59PM BLOOD UreaN-3* Creat-0.8 Na-138 K-4.4 Cl-104
HCO3-26 AnGap-12
[**2186-12-6**] 02:47AM BLOOD Glucose-176* UreaN-2* Creat-0.7 Na-137
K-4.7 Cl-104 HCO3-25 AnGap-13
[**2186-12-5**] 08:05PM BLOOD Glucose-171* UreaN-2* Creat-0.8 Na-139
K-4.3 Cl-106 HCO3-26 AnGap-11
[**2186-12-7**] 07:15AM BLOOD ALT-5 AST-9 LD(LDH)-160 AlkPhos-54
TotBili-0.2
[**2186-12-6**] 02:47AM BLOOD ALT-10 AST-11 AlkPhos-51 TotBili-0.4
[**2186-12-4**] 11:25AM BLOOD ALT-9 AST-8 LD(LDH)-108 AlkPhos-66
TotBili-0.1
[**2186-11-29**] 04:15PM BLOOD ALT-8 AST-14 AlkPhos-86 TotBili-0.6
[**2186-12-12**] 06:25AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.6
[**2186-12-11**] 09:30AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8
[**2186-12-10**] 07:25AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8
[**2186-12-9**] 02:00PM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9
[**2186-12-7**] 07:15AM BLOOD Calcium-8.2* Phos-4.9* Mg-2.1
[**2186-12-6**] 04:59PM BLOOD Phos-4.9* Mg-1.6
[**2186-12-6**] 08:46AM BLOOD Type-ART Temp-36.6 Rates-/16 PEEP-5
FiO2-40 pO2-80* pCO2-39 pH-7.43 calTCO2-27 Base XS-1
Intubat-INTUBATED Vent-SPONTANEOU
[**2186-12-6**] 06:15AM BLOOD Type-ART Temp-35.9 pO2-82* pCO2-36
pH-7.45 calTCO2-26 Base XS-1 Intubat-INTUBATED Vent-SPONTANEOU
[**2186-12-6**] 03:02AM BLOOD Type-ART Temp-35.9 pO2-83* pCO2-37
pH-7.43 calTCO2-25 Base XS-0 Intubat-INTUBATED
[**2186-12-5**] 10:15PM BLOOD Type-ART Temp-35.9 pO2-136* pCO2-39
pH-7.41 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED
[**2186-12-5**] 08:05PM BLOOD Type-ART Temp-36.4 Rates-16/5 Tidal V-600
PEEP-5 FiO2-50 pO2-83* pCO2-45 pH-7.37 calTCO2-27 Base XS-0
Intubat-INTUBATED
Brief Hospital Course:
51 year old with history of Crohn's disease who presented with
recurrent fevers and abdominal pain consistent with a Crohn's
flare. Patient was recently admitted to medical service with
similar presentation and was managed with Cipro and Flagyl.
After completing his antibiotic course as an outpatient setting
he developed fevers to 102 F that persisted over 10 days. He
subsequently returned to the emergency room with left upper
quadrant pain and fevers on [**2186-11-29**]. A Cat Scan was performed
revealing a colosplenic fistula and intrasplenic abscess. The
patient was admitted to the East Surgical Service on [**2186-11-30**]
and started on Cipro/Flagyl intravenous empirically. Patient
continued to spike fevers and was taken to the operating room on
[**2186-12-5**] where he underwent exploratory laparoscopic, total
abdominal colectomy and splenectomy.
Patient received a total of 3 units red blood cell, 4.5 Liter
lactated ringers and 500 ml Albumin 5% throughout the procedure
in response to estimated blood loss of 1500 cc during
splenectomy. Patient required phenylephrine briefly during the
operation but was easily weaned off at closing. Due to
difficulty oxygenation on PEEP of 5, patient was kept intubated
and was transferred to the intensive care unit for mechanical
ventilation and monitoring overnight. He was successfully
extubated on [**2186-12-6**] on 40% aerosol cool and sats in the mid
90's.
He had a nasogastric in place and complained of difficulty
swallowing most likely due to intubation. The abdominal midline
incision with dry sterile dressing with saturated scant serous
drainage. He also had bilateral JP drains which were eventually
discontinued. Postoperatively he was weaned off the patient
care analgesia and was transitioned to oral analgesia.The
nasogastric tube was discontinued on postoperative day 5. On
[**2186-12-8**], the patient was noted to have an oxygenation saturation
of 85% on 3L NC O2, lungs sounds were diminished but the patient
appeared stable. He responded appropriately to an albuterol
nebulizer however, after the therapy was completed, he promptly
dropped his O2 sat back to the 80's. A chest PA/LA film was
ordered which showed left lower lobe and possibly lingular
collapse with volume loss and left mediastinal shift as well as
moderate pleural effusion. The patient was taken to radiology
for drainage of this pleural effusion. Dur ring the attempted
drainage, only a few milliliters of fluid was removed and there
was a concern for hemothorax. A chest CT scan was ordered which
showed Left lower lobe atelectasis, small left pleural
effusion, hounsfield units suggestive of simple fluid and trace
pericardial effusion. Because of concerns for pneumonia, the
patient was started on a coarse ceftriaxone intravenously until
eventually being changed to Augmentin by mouth. Chest PT,
nebulizing treatments, and incentive spirometry continued and
the patient improved to sating 96% on room air.
He tolerated clear sips and the diet was advanced to regular
on postoperative day 6. In the afternoon had approximately 30ml
of bilious emesis. A KUB was ordered which showed multiple
dilated loops of bowel, likely due to post-op ileus. The patient
was kept in house and diet was backed down to NPO, however the
patient was progressed to clear liquids and regular diet on
[**2186-11-12**], the patient was discharged home tolerating a regular
diet.
The Foley catheter was discontinued and he is voiding without
any difficulty. Of note he was noted to have +2 lower extremity
edema and was restarted on home dose Hydrochlorothiazide. The
abdominal incision staples clean, dry intact with no erythema or
edema. The patient was discharged home with the appropriate
medical surgical follow-up.
Medications on Admission:
Simvastatin 20', Risperidone 1 QHS, Duloxetine 60', Iron
300', Percocet prn, Albuterol INH, HCTZ 12.5', Fluticasone 50
daily
Discharge Medications:
1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-4**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 8 days: take 1 tablet every
eight hours for 8 days. Please take the full antibiotic
prescription.
Disp:*24 Tablet(s)* Refills:*0*
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): please apply only one nicotine patch
at a time, please refrain from smoking while wearing the
nicotine parch.
Disp:*30 Patch 24 hr(s)* Refills:*0*
8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Please do not drink alcohol or drive
a car while taking this medication.
Disp:*30 Tablet(s)* Refills:*0*
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
Crohn's disease with colonic-splenic fistula.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the General Surgery Inpatient Unit and had
a total abdominal colectomy and splenectomy. After your surgery
you developed a small post-operative illeus which is common
after bowel surgery and anesthesia which caused you to vomit. We
advanced your diet slowly and monitored your hydration status,
you are now tolerating a regular diet and passing flatus and you
are ready to be discharged home. Monitor your abdominal incision
for signs of infection which include redness, swelling,
drainage, or fever. Your abdominal staples will be removed at
your follow-up appointment. It is important that you monitor
your bowel function. If you develop any of the following
abdominal symptoms please call the office or go to the emergency
room if they are severe: nausea, vomiting, increased abdominal
pain, increased abdominal distension, or inability to tolerate
food or liquids. You may continue a regular diet however it is
important that you take things slow. A bland diet is ideal for
the next 2 days until you feel that your bowels are functioning
properly. You have passed gas and stool prior to your discharge
however, it is still possible for you to have a small slowing of
your gastrointestinal system. Continue to walk several times a
day. Please seek immediate attention if you develop shortness of
breath, chest pain. We have verified with your primary care
doctor that you take hydrochlorothiazide 15mg daily. Please take
all of your home medications. You have some swelling in your
legs, please continue to elevate them as tolerated. You have
been restarted on your
Hydrochlorothiazide, medication to help remove the extra fluid,
take 25 mg once a day. Your spleen has been removed, it is
important to arrange a follow-up appointment with your primary
care provider for your immunizations and monitoring of the
swelling in your legs. Please resume taking your home
medications. You will be given a prescription for hydromorphone
for pain, take 2mg every four hours as needed for pain. Please
do not drink alcohol while taking narcotic pain medication. You
may take over the counter stool softener colace while taking
narcotic pain medications. You may also take acetaminophen
(Tylenol) as written, do take more than 4000mg acetaminophen in
a 24 hour period.
After your surgery you had fluid in your lung which was
concerning for pneumonia. We have been treating you with the
antibiotic augmenting for this pneumonia. You will be given a
prescription for Augmentin (Amoxicillin-Clavulanic Acid) take
500 mg every 8 hours for 8 more days. Please take all
antibiotics as,prescribed. Please call and schedule an
appointment to be seen in clinic in [**2-4**] weeks [**Telephone/Fax (1) 33502**].
Please also call your primary care doctor to make an appointment
to have three vaccinations: Haemophilus B (HIB), Meningococcal
vaccine, Pneumococcal vaccine. Please also get a flu shot from
your doctor if you have not already. We called your physician to
let him know you needed these. We have made an appointment for
your with Dr. [**Last Name (STitle) **] for [**2186-12-25**] at 1100 am.
You may shower, please [**Month/Day/Year **] the incision dry do not rub. No heavy
lifting for 6 weeks after surgery.
Please continue your smoking cessation. You should use one
nicotine patch daily and do not smoke if wearing the patch.
Followup Instructions:
Schedule an appointment to be seen by Dr. [**Last Name (STitle) **] in clinic in
[**2-4**] weeks [**Telephone/Fax (1) 160**].
Call your PCP to update them about your care and recieve the
vaccines listed above.
[**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital1 **] HEALTH CARE [**Location (un) 2352**] - ADULT
MEDICINE
Address: 1000 [**Last Name (LF) **], [**First Name3 (LF) 2352**],[**Numeric Identifier 13951**]
Phone: [**Telephone/Fax (1) 1144**]
Fax: [**Telephone/Fax (1) 6443**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2186-12-25**] 11:00
Provider: [**Name10 (NameIs) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2187-2-6**]
3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2187-3-12**] 8:30
Completed by:[**2186-12-13**]
ICD9 Codes: 486, 5119, 5180, 4019, 3051, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4947
} | Medical Text: Admission Date: [**2118-2-10**] Discharge Date: [**2118-2-14**]
Date of Birth: [**2061-3-20**] Sex: F
Service: SURGERY
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Worsening rash, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 56F with a history of hypertension, hyperlipidemia, and
depression who has had a complicated past 4-5 months history
notable for post-ERCP pancreatitis with ARDS/pneumonia requiring
extensive ICU stay, is readmitted following ERCP yesterday and
development of rash, fever, hypotension, and tachycardia at
rehab
today.
.
In [**Month (only) **] this unilingual spanish speaking patient
was admitted to [**Hospital6 3105**] w/ choledocholithiasis
and bile duct dilatation on U/S. ERCP on [**10-20**] showed a 1cm stone
that could not be removed. A bile duct stent was placed. After
ERCP, she developed pancreatitis c/b ARDS requiring ICU
admission
and mechanical ventilation. Because the
patient continued to saturate at 87% on RA, she was discharged
to rehabilitation on [**2117-11-2**] w/ 2L supplemental O2 by NC and a
steroid taper.
.
She they re-presented to [**Hospital6 3105**] w/ RUQ pain 3
days after discharge w/ worsening right upper quadrant pain. She
was transferred to [**Hospital1 18**] after CT abdomen showed a large
multilobulated pancreatic pseudocyst possibly compressing the
CBD. ERCP revealed an obstructed stent in the major papilla.
This
stent was successfully replaced and a 5mm stone removed.
Post-procedure, the patient became tachycardic with SBP in the
80s and poor O2 sats, requiring phenylephrine and NRB in the
ERCP
suite. She was admitted to the ICU where she required intubation
for hypoxic resiratory failure. The patient's shock was
initially
thought to be secondary to biliary sepsis, and she was treated
with broad spectrum antibiotics, including vanc and zosyn, for
strep anginosus and strep mileri in blood cultures.
.
The patient's liver enzymes and bilirubin trended down
indicating
that the restenting of the biliary system had succesfully
decompressed the obstruction. Repeat abdominal CT that showed
the
pancreatic pseudocyst had shrunk, but there was an increased
amount of intra-peritoneal fluid, particularly in the left
gutter. A drain was inserted into the paracolic gutter, which
showed an amylase level of [**Numeric Identifier 61575**], suggesting that the patient's
pseudocyst had ruptured, either before the patient's ERCP or at
some point in her hospital course. After draining the fluid
collection, the patient's hemodynamic status improved.
.
She remained in the ICU for over a month with persistent
hypotension and intermittent fevers. After developing a diffuse
rash, Derm consulted and thought it was possibly related to
zosyn
drug reaction, and she was treated with a course of steroids.
She
ultimately was discharged to rehab with a tracheostomy.
.
This morning, following ERCP yesterday, she spiked fevers to
102,
became hypotensive to 80s systolic and HR to 150s. She was taken
to [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] and transferred here for further care. Patient
denies pain, nausea, vomiting, diarrhea, cough, shortness of
breath. Of note, she recieved cipro and flagyl peri-procedure
the day prior to admission
Past Medical History:
Hypertension
Hyperlipidemia
Depression
Choledocholithiasis
Pancreatitis
ARDS
Elbow surgery
Tubal ligation
Social History:
Currently living at [**Hospital3 **].
- Tobacco: 2-3 per day for many years
- Alcohol: occasional
- Illicits: denies
Family History:
sister s/p cholecystectomy
Physical Exam:
On Discharge:
V/S: T 97.8 P 96 BP 100/60 RR 18 O2 96%
GEN: NAD, AAx3
CV: RRR, no m/g/r
Lungs: CTAB
ABD: Soft, NT/ND
Pertinent Results:
[**2118-2-10**] 05:08PM BLOOD WBC-25.2*# RBC-3.56* Hgb-10.5* Hct-31.6*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.2 Plt Ct-266
[**2118-2-14**] 05:45AM BLOOD WBC-9.7 RBC-3.52* Hgb-10.4* Hct-31.9*
MCV-91 MCH-29.6 MCHC-32.7 RDW-13.8 Plt Ct-261
[**2118-2-10**] 05:08PM BLOOD Neuts-97.9* Lymphs-0.7* Monos-0.6*
Eos-0.7 Baso-0.1
[**2118-2-13**] 01:48AM BLOOD Neuts-59.8 Lymphs-14.5* Monos-2.5
Eos-22.0* Baso-1.1
[**2118-2-10**] 05:08PM BLOOD Glucose-140* UreaN-16 Creat-0.8 Na-136
K-4.8 Cl-107 HCO3-22 AnGap-12
[**2118-2-14**] 05:45AM BLOOD Glucose-121* UreaN-12 Creat-0.5 Na-137
K-4.0 Cl-103 HCO3-27 AnGap-11
[**2118-2-11**] 02:21AM BLOOD TSH-0.36
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment on [**2118-2-10**]. The patient was initially
managed in the ICU, and then transferred to the floor on [**2118-2-13**]
once stable.
Neuro: The patient did not complain of pain during her stay. No
pain medications were needed. She remained alert and oriented x3
during her entire hospital stay.
CV: The patient was initially hypotensive upon admission with
SBP in the 80s. A CVL was placed and she was started on
levo/phenylephrine drip to keep SBP > 100. The patient was also
given agressive fluid resuscitation and albumin to improve BP.
The phenylephrine was weaned as patient's BP tolerated, and by
HD3 it was stopped. The patient then remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially NPO upon admission, but
diet was advanced as tolerated without any problems. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Initially, the
patient's WBC was elevated with a peak of 34 on HD2, but this
came down rapidly and was normal upon discharge. The patient was
initially started on empiric vancomycin. ID was consulted and
recommended amikacin, aztreonam, daptomycin, and clindamycin,
which the patient was started on HD 2. Dermatology was also
consulted as well and felt that this was likely a drug induced
reaction. After 48hrs of negative cultures all atbx were
stopped. Triamcinolone cream was applied to the rash, and it
improved throughout the remainder of her stay. At time of
discharge, patient appeared less red and the rash had improved
substantially.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
Ultimately, it was felt that the patient's condition was due to
a drug reaction, likely from the cipro/flagyl that she received
after the ERCP. The patient should be avoid these medications in
the future and other healthcare providers should be aware of
this severe drug reaction. Furthermore, caution should also be
taken when giving IV contrast to this patient. It is possible
that her reaction was exacerbated by the contrast given for her
prior study.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
-Mag oxide
-Prevacid 30 daily
-lovenox 40 daily
-pravastatn 40 daily
-vitamin C, MVI
-colace
Discharge Medications:
1. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for itchy rash.
Disp:*2 bottles* Refills:*0*
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care Agency
Discharge Diagnosis:
Rash, Hypotension
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 if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-31**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Please monitor your rash and please notify your surgeon and PCP
if rash is getting worse or if it becomes painful or more
swollen.
Followup Instructions:
You have an appointment on [**2118-3-25**] @ 10:15 with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
You will have a CT scan performed on the day of your visit. Dr. [**Name (NI) 76749**] office will contact you with details regarding your CT
scan.
Please call [**Telephone/Fax (1) 274**] with any questions.
Completed by:[**2118-2-14**]
ICD9 Codes: 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4948
} | Medical Text: Admission Date: [**2157-2-28**] Discharge Date: [**2157-3-10**]
Date of Birth: [**2109-5-26**] Sex: M
Service: MEDICINE
Allergies:
Iron / lisinopril
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Peritonitis
Major Surgical or Invasive Procedure:
right femoral tunnelled 12 French 20-cm hemodialysis catheter
placement
Removal of peritoneal dialysis catheter
History of Present Illness:
History of Present Illness: 47 YOM with history of ESRD on PD,
H/O endocarditis s/p St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] and MVR here at [**Hospital1 18**] in
[**8-/2156**] transferred from OSH for peritonitis refractory to
systemic antibiotics.
.
Patient was initially admitted to [**Location (un) 16843**] Hoispital with
Upper GI bleed secondary to esophageal ulcer that required no
intervention. His [**Location (un) **] was held and following observation
and stability of his HCT his heparin gtt was restarted. Unclear
when he was exactly diagnosed with peritonitis bc be have no
formal documentation of infected fluid but likely around 1.24.
He was started on systemic Per his transfer summary cultures
grew out klebsiella that is sensitive to amikacin, ampicillin
and sulbactam, cefoxiti, ciprofloxacin, uimipenam and bactrim
but resistent to tobramycin, gentimycin, ceftriaxone, cefepime
and cephazolin and ampicillin. His antibiotic course to date is
unclear as there are references to vancomycin, gentamycin,
tygacil and levofloxacin. Most recently he was on levofloxacin
and tygacil and recently switched to ertapenam.
.
.
On arrival to the MICU, he is drowsy but arousable with heparin
gtt running and one PIV. Poor peripheral stick. ABG attempted
for labs. Right femoral line placed under ultrasound guidance.
.
Past Medical History:
ESRD on PD
HTN
h/o multiple line infections
restless leg syndrome
asthma
h/o VRE
h/o endocarditis s/p [**Location (un) 1291**] and MVR
h/o MRSA
Social History:
Social hx: pt currently in jail, has been there since [**2152**]; was
previously imprisoned [**2137**]-[**2138**]. He denies any history of etoh,
ex smoker quit 20 y/a, [**1-31**] PPD x 10 years, cocaine use,
marijuana use, denies history IVDU
Family History:
family hx: mother with HTN
Physical Exam:
On Admission to MICU:
Vitals: 88 125/89 O2 SAt 100% on RA
General: Drowsy but arousable. Mild distress.
HEENT: Dry mucous membranes
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, mechanical S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, TTP diffusely, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: Bilateral grafts with evidence of multiple vascular
procedures.
On Discharge:
Vitals: 98.6 100-111/68-78 95 18 95% on RA
General: NAD, AxOx3
HEENT: Dry mucous membranes
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, mechanical S1 + S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mildly TTP diffusely, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: Bilateral grafts with evidence of multiple vascular
procedures.
ACCESS: HD tunnel catheter placed on R femoral. double lumen L
femoral catheter.
Pertinent Results:
On Admission:
[**2157-2-28**] 10:35PM BLOOD WBC-8.0# RBC-3.28* Hgb-9.4* Hct-29.5*
MCV-90 MCH-28.6 MCHC-31.7 RDW-17.5* Plt Ct-239
[**2157-2-28**] 10:35PM BLOOD Neuts-80* Bands-0 Lymphs-8* Monos-9 Eos-0
Baso-1 Atyps-0 Metas-1* Myelos-1*
[**2157-2-28**] 10:35PM BLOOD PT-14.3* PTT-35.1 INR(PT)-1.3*
[**2157-3-1**] 10:28AM BLOOD ESR-85*
[**2157-2-28**] 10:35PM BLOOD Glucose-98 UreaN-130* Creat-14.4*#
Na-132* K-4.9 Cl-89* HCO3-27 AnGap-21*
[**2157-2-28**] 10:35PM BLOOD Calcium-8.7 Phos-13.5*# Mg-2.5
[**2157-2-28**] 10:35PM BLOOD CRP-249.7*
[**2157-3-6**] CT Abdomen
FINDINGS:
LUNG BASES: There are bilateral pleural effusions left larger
than right.
Adjacent linear opacities are seen in the lung bases
representing atelectasis. Patient is status post sternotomy and
mitral valve repair.
ABDOMEN AND PELVIS: Within segment V/VI of the liver there is a
small focal hypoattenuation which is too small to characterize
but probably represents a simple hepatic cyst. There are no
other focal hepatic lesions. There is no intra- or extra-hepatic
biliary ductal dilatation. Gallbladder is collapsed. The
spleen, pancreas, adrenal glands appear within normal limits.
The patient is status post bilateral renal resections.
Evaluation of bowel demonstrates regions of diffuse thickening
of the small bowel (2, 53) and colon (2,46) . There is
enhancement of the peritoneal layers consistent with the
provided history of peritonitis. There are regions of free
intraperitoneal gas (2, 30). There is an additional region of
extraluminal gas seen in the right upper quadrant of the abdomen
(2, 34). The etiology is not entirely elucidated and could be
related to residual gas which was also seen on the previous
study. There is no evidence of extravasated oral contrast [**Doctor Last Name 360**]
to suggest an enteric perforation. The peritoneal dialysis
catheter has been removed.
There is no mesenteric or retroperitoneal lymphadenopathy.
Atherosclerotic
vascular calcification of the abdominal aorta is noted. The
abdominal aorta is normal in caliber.
Since previous study the right femoral line has been replaced
and a new
tunneled dialysis catheter has been placed with its tip
terminating in the
right atrium. Note is also made of another left femoral IV line
the tip of
which terminates in the right atrium.
Findings within the skeleton most consistent with renal
osteodystrophy.
There is generalized anasarca.
IMPRESSION:
1. Continued pneumoperitoneum, which could relate to the prior
presence and subsequent removal of the peritoneal dialysis
catheter. No evidence of oral contrast extravasation to suggest
an enteric perforation. Enhancing peritoneal layers consistent
with provided history of peritonitis.
2. Thickening of [**Known lastname **] of the small bowel and colon suggestive of
ileocolitis, possibly secondary.
3. Interval removal of peritoneal dialysis catheter and
placement of right
femoral vein access tunnelled catheter and left femoral access
PICC line, the tips of which terminate in the right atrium.
4. Bilateral pleural effusions with adjacent atelectasis.
Discharge Labs:
[**2157-3-10**] 06:08AM BLOOD WBC-7.6 RBC-2.59* Hgb-7.9* Hct-24.5*
MCV-95 MCH-30.3 MCHC-32.0 RDW-17.0* Plt Ct-226
[**2157-3-10**] 06:08AM BLOOD PT-29.4* PTT-98.3* INR(PT)-2.8*
[**2157-3-10**] 06:08AM BLOOD Glucose-111* UreaN-19 Creat-5.8*# Na-138
K-3.9 Cl-99 HCO3-33* AnGap-10
[**2157-3-10**] 06:08AM BLOOD Calcium-8.7 Phos-4.0# Mg-2.0
[**2157-3-9**] 06:18AM BLOOD calTIBC-109 Ferritn-[**2163**]* TRF-84*
[**2157-3-7**] 09:31AM BLOOD PTH-239*
[**2157-3-1**] 10:28AM BLOOD CRP-258.2*
Brief Hospital Course:
Assessment and Plan: 47 YOM with ESRD on PD, [**Month/Day/Year 1291**] AND MCR [**3-3**] to
endocarditis, difficult vascular access trasnmitted to [**Hospital1 18**]
MICU for mangement of ESBL klebsiella peritonitis.
.
# ESBL Klebsiella and GNR peritonitis: Patient remained
hemodynamically stable throughout his MICU course. Culture data
from the OSH shows Klebsiella oxytoca resistant to ceftaz and
ampicillin. Patient was started on IV meropenem and vancomycin
in addition to intraperitoneal vancomycin and meropenem.
Transplant surgery removed the PD catheter on HD#2 ([**2157-3-2**])
and patient was intubated for the procedure though quickly
extubated on return. Fluid from the PD catheter grew
enterobacter cloacae complex senstive to meropenem. Per ID,
vancomycin was discontinued and meropenmen was continued IV.
Patient felt subjectively improved after removal of PD catheter
on [**2157-3-2**] and he was maintained on dilaudid for pain control.
A right femoral tunneled HD catheter was placed on [**2157-3-2**].
The line clotted during the initial attempted run of HD on [**3-3**].
On [**3-4**] the line was replaced on [**3-4**]. On [**3-5**], the patient spike a
fever to 101 and vancomycin was restarted. Blood cultures were
obtained, and after 3 days of no growth and the patient
remaining afebrile, vancomycin was discontinued. Meropenem was
discontinued on the day of discharge and the patient was
discharge on 5-more days of ertapenem 500mg IV daily to complete
a 14 day course of abx since removed of the PD catheter.
.
# ESRD: Initially on PD due to poor 'end-stage' vascular access
issues in the past. Temporary femoral HD line was placed by IR
on hospital day #2 and PD catheter was removed that same day.
Hemodialysis was attempted on HD#3 but the dialysis line did not
work. After a tunnel HD line was placed on HD#4 and The patient
then successfully underwent HD on HD#4 and HD#5 and was started
on MWF HD. He will need to comtinue 3 times weekly HD. Iron
and Epo were held given active infection. These will need to be
restarted per renal after discharge.
.
# [**Month/Day (4) 1291**]/MVR: History of St. [**Male First Name (un) 1525**] valves. Kept on heparin gtt
given multiple interventions during this hospitalization. The
patient was restarted on [**Male First Name (un) **] on [**2157-3-4**] and became
therapeutic to 2.8 (target 2.5-3.5) on [**2157-3-10**] and heparin was
discontinued. The patient was discharged on warfarin 8mg PO
daily and should continue to have INR monitoring and dosing
adjustment.
.
#.conjunctivitis- The patient developed conjunctivitis on [**2157-3-9**]
and was started on Erythromycin 0.5% Ophth Oint 0.5 in both eyes
TID. He was discharge to complete 5 additional days of
treatment.
.
# HTN: Normotensive throughout hospital course. Not on
medications
.
# GERD: The patient was started on famotadine on admission. He
complained of acid reflux on the daily prior to discharge while
on famotadine and was switched to omeprazole.
Transition Issues:
- INR monitor with a target INR of 2.5-3.5
Medications on Admission:
amiodarone 200mg
amitryptiline
phoslo 2 tabs tid
renagel 3 tabs tid
asa 325mg qday
levodopa/carbidopa 25/250
benadryl
colace 100mg daily
senna
metoprolol 50 [**Hospital1 **]
simethicone
nepro
darbopoietin 60 mcg q week
.
Medications on transfer:
heparin gtt
dilaudid 1 mg IV q4h prn pain
Insulin sliding scale
duonebs
tylenol 650 q4h prn pain/fever
zofran 4mg IV q6hours prn
Ertapenam 0.5g IV q24.
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
2. warfarin 2 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4
PM: adjust for goal INR 2.5-3.5.
3. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. ertapenem 1 gram Recon Soln Sig: One (1) 500mg Intravenous
once a day for 5 days.
6. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic TID (3 times a day).
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
12. darbepoetin alfa in polysorbat 60 mcg/0.3 mL Syringe Sig:
One (1) Injection once a week.
13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Peritonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were transferred to [**Hospital1 69**] for
an abdominal infection. You were treated with antibiotics and
the peritoneal dialysis catheter was removed. A new
hemodialysis dialysis catheter was placed in your groin. You
will need to continue to undergo hemodialysis on Mondays,
Wednesdays and Fridays. You will need to complete 5 more days
of antibiotics.
Medication Changes:
START taking omeprazole 20mg by mouth daily
START Ertapenam 500mg intravenously daily for 5 more days
START Calcium Acetate [**2146**] mg by mouth with three times a day
with meals.
START taking Warfarin 8 mg by mouth daily, please have this
medication adjusted by your doctor
START taking sevelamer CARBONATE 2400 mg three times day with
meals
START Erythromycin 0.5% Ointment in both both eyes three times
daily for 5 additional days
START camphor-menthol 0.5-0.5% lotion
START docusate sodium 100 mg by mouth twice daily as needed for
constipation
START simethicone 80 mg by mouth up to four time daily as needed
for gas
START acetaminophen 325 mg 1-2 tablets as need for pain/fever up
to 4 times daily
STOP any other medications
Followup Instructions:
Please keep the following appointments:
Department: TRANSPLANT CENTER
When: THURSDAY [**2157-3-24**] at 1:15 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2157-4-12**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT
When: TUESDAY [**2157-4-12**] at 10:00 AM
With: TRANSPLANT ID [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4949
} | Medical Text: Admission Date: [**2118-5-2**] Discharge Date: [**2118-5-5**]
Date of Birth: [**2087-3-8**] Sex: M
Service: NEUROLOGY
Allergies:
Dilantin Kapseal / Tegretol / Phenobarbital / [**Year (4 digits) 51350**] / Lamictal
/ Augmentin / Ativan / Trileptal / Banzel / Clindamycin /
Silkskin Bath / Benadryl
Attending:[**First Name3 (LF) 11291**]
Chief Complaint:
Increased seizure frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
31RHM with global developmental delay and intractable epilepsy
with complex partial and secondary generalised seizures
secondary to bilateral nodular periventricular heterotopias on 4
AEDs at baseline presents with seizure clusters in the setting
of a likely URI possibly viral similar to his previous admission
in 10/[**2116**].
Patient has a somewhat similar presentation to his recent
admission in [**9-1**]-7/[**2116**]. At that point, his last cluster had
not been for over 1 year and had one additional admission to
[**Hospital3 **] in setting of PNA and flu and was admitted to [**Hospital1 18**] for
seizures in [**2112**]. Since then there has been He has never been
in status epilepticus or admitted to ICU/intubated for seizures.
Patient had been unwell with nasal congestion and a cough for
the past 1 week. He had a CXR which was apparently negative and
received Flonase which improved symptoms and has a mild residual
cough. This seems to be a common precipitant for seizures. He
also had "low grade fevers" to low 99s per mother and apparently
small increases in temperature from his baseline of 97.5F can
also lower seizure threshold. His mother also noticed at times
that he was sweating.
His seizures started on Friday having had no seizures for
perhaps over 1 month. He had two brief typical seizures on going
to bed on Friday [**4-29**] and then had two more brief (up to 30s)
seizures on Saturday morning. Then by 14:30 on [**4-30**] he started
having a cluster and was having seizures every 5-10 minutes. He
would also have breaks when he would not seize for an hour or
two then go
back to seizing. For his seizures, his mother gave him 6mg
diazepam x1 on [**4-30**]. He also had a seizure while in a chair when
he fell and hit his head sustaining a small bruise around his
left eye. He slept through the night seizure free until [**5-1**] at
0300 when he started having a further cluster of seizures every
5-10 minutes and lasting up to 30-45s each. He was given 10mg po
diazepam then there was a gap of [**1-30**] hours when it appeared that
his seizures had stopped but then recurred at 7-7:30pm when he
had a further persistent cluster of similar duration and hit his
chin against a wastebasket falling out of bed around this time.
After a further 5mg po diazepam at home, EMS were called and he
was taken to [**Hospital3 **] Hospital.
At [**Hospital3 **] Hospital, he was noted to have seizures every [**4-7**]
minutes and was loaded with IV valproate 500mg and given a
further 10mg diazepam (5mg IV and 5mg po). Vitals were stable at
OSH and BP on transfer was 96/53. Had a CT head scan there was
reported as normal.
On transfer to [**Hospital1 18**], he was noted to be seizing every [**1-31**]
minutes brief 10-20s episodes of his typical seizures involving
rolling from left to right and moving legs and writhing arms,
neck will extend and will occasionally grunt and slightly foam
at the mouth. On resolution of his seizure, he will return back
to
baseline. He was also hypotensive to SBP 80 after 2mg IV
midazolam and 200mg IV vimpat. This was treated with IVF and
eventually recovered to the 90s with lowest recorded SBP 70s
although on repeat this was 80. He was never symptomatic with
his hypotension. Given persistence of seizures he was due to
receive a further 200mg IV vimpat in the ED but as this was not
ready from pharmacy had to be given in the ICU. Due to concerns
regarding possible infection he was treated with IV ceftriaxone
2g empirically.
Typical semiology is described below and involves often starting
with a warning gutteral noise and then proceeding to flailing of
the legs and arms some times with head turn to the right, back
can arch and neck extends, his pupils dilate and extends his
neck stares and looks up and eyes roll and latterly can make
further grunting noises and then after a duration of currently
up to 30-45s (at most up to 90s and only once had a prolonged 10
minute episode at the time of seizure diagnosis of 10 minutes).
Please see below for prior semiologies. With me, he was having
seizures as described every 3-5 minutes and lasting [**9-17**]
seconds with return of consciousness in between which is
typical. His last
seizure was more than 1 month ago but he can have sporadic
seizures, generally at least once per month in the setting of
any intercurrent illness. Post-ictally he is briefly tired and
his speech can be slurred or has difficulty getting the words
out although this is transient and only lasts maximum 23 minutes
until he is back to baseline.
He walks, talks in simple sentences and needs partial assistance
with dressing and assistance toileting and bathing and can feed
himself. Full details under social history.
Currently, patient is drowsy appropriately and patient was noted
to be coughing slightly not productive and with nasal
congestion. He was not sweaty but was pale. Now with complex
partial seizures every 3-5 minutes lasting currently 10-20s.
On neuro [**Last Name (LF) **], [**First Name3 (LF) **] mother, the pt denied headache, loss of
vision,
blurred vision, diplopia, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies new difficulties
producing
or comprehending speech. Denied focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies new difficulty with gait.
On general review of systems, per mother the pt denied chills.
No
night sweats but motehr did note sweating no recent weight loss
or gain. Denied shortness of breath. Denied chest pain. Denied
nausea, vomiting, constipation or abdominal pain. Per motehr had
one episode of loose stools and Rx with immodium. No recent
change in bladder habits. No dysuria. Denied arthralgias or
myalgias. Denies rash.
Past Medical History:
Recent epilepsy history:
At his last admission, this presentation was similar with a
likely URI prodrome of cough and congestion without fevers or
chills leading to clusters of typical seizures with return to
his
mental status baseline in between events. At that point had
received significant diazepam (20mg) as has significant
paradoxcal behavioural problems with lorazepam. As below, at
that
time, he was started on standing diazepam 5 mg q6hr, Banzel dose
increased to 400 mg [**Hospital1 **]. He did not have too much benefit from
these changes and continued to seizure approximately 3-5 times
per hour. Due to his extensive history of allergic reactions to
antiepileptics, he was loaded with Vimpat as he was naive to
this
medication. His seizures were significantly more controlled on
this medication within just 3 days. He was discharged on a
diazepam taper and off vimpat.
Previous semiologies:
1) Drop attacks - where he will sudenly drop withouut warning to
the floor
2) Complex partial - rolling and staring with eyes rolling
upwards and per documentation at last admission also involved
head turning to the right which is usual and also with back
arching, tonic flexion of arms with kicking movements of legs.
3) GTC - more vigorous form of above with violent clonic shaking
of all 4 limbs
4) Staring spells which can last perhaps only 2 seconds
PMH:
- epilepsy: diagnosed age 18 though was likely having
undiagnosed seizures since childhood [**12-30**] bilateral nodular
periventricular heterotopias (thus Phase I evaluation at CHB was
aborted)
- Past anticonvulsants tried include Dilantin, tried about 8
years ago, which led to retained fluids and a high fever.
Tegretol was apparently never used because it was said that he
should not be on Tegretol due to a Dilantin cross reaction.
Phenobarbital and lorazepam have both led to "crazy behavior" in
the past, according to the mother. [**Name (NI) 51350**] led to cognitive
deterioration.
Lamictal caused rash.
In [**2112**], ZNG was started and later he was admitted for LTM and
Trileptal added and VPA tapered. Trileptal caused hyponatremia
and a rash and was stopped. Lyrica added. He did not tolerate
attempts to wean Valium because of increased seizure frequency.
[**2114**] started Banzel and stopped Lyrica.
He then had a Valium taper to 3 mg qHS until admission in
[**8-/2117**]
when he was started on standing diazepam 5 mg q6hr, Banzel dose
increased to 400 mg [**Hospital1 **]. He did not have too much benefit from
these changes and continued to seizure approximately 3-5 times
per hour. Due to his extensive history of allergic reactions to
antiepileptics, he was loaded with Vimpat as he was naive to
this
medication. His seizures were significantly more controlled on
this medication within just 3 days. He was discharged on a
diazepam taper and off vimpat.
Never been on felbamate per previous documentation.
- global developmental delay
Social History:
The patient lives with mother on [**Hospital3 **] - parents are
separated.
Baseline has global developmental delay can partially dress
himself and needs assiatance with toileting and bathing due to
hand coordination. He can feed himself and can in some manner
make himself a [**Location (un) 6002**]. Can verbalise well in siomple sentances
and make himself understood.
Mobility: He walks unaided.
Smoking: No
Alcohol: No
Illicits: No
Family History:
Mother - hypothyroidism, migraines
- maternal uncle with mental retardation and seizure disorder (?
prompted by eating bananas. Seizures stopped after he stopped
eating bananas)
Maternal grandmother - CHF, maternal grandfather - IHD and died
of MI
Father - prostate issues - little more information as separated
Paternal grandfather ? Alzheimer's and paternal grandmother ?
Alzheimer's
Sibs - 1 sister with asthma and depression and now stating has
CHF although per mother ? untrue claim for attention-seeking
means
1 other sister well
There is no history of strokes less than 50, neuromuscular
disorders, or movement disorders.
Physical Exam:
Physical Exam on Admission:
Vitals: T:97.6 P:80 regular R:16 BP:89/67 dropped to 70s
rechecked manually 80 after IV midazolam and latterly was SBP 92
SaO2:97% RA dropped to lowest 90% during seizures but latterly
99% on RA
General: Drowsy but could verbalise and was alert in between
seizures at baseline. At times irritated and occasionally
combative during examination. Patient is pale.
HEENT: NC/AT, no scleral icterus noted, MM dry, no lesions noted
in oropharynx on limited view due to patent compliance.
Conjunctivae somewhat pale.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
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 C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Extremities somewhat cold. Calves SNT bilaterally.
Skin: no rashes or lesions noted. Bandaid on chin and slight
bruising above left eye.
Neurological examination:
- Mental Status:
In between seizures could verbalise at baseline saying "no", go
away "leave me alone" and latterly full sentences to his mother
asking for water etc with slightly slurred speech.
Intermittently agitated and refusing examination and
occasionally combative. Follows commands when wants to.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk when not seizing, when seizing
pupils 6.5mm bilaterally. Blinks to threat bilaterally.
Funduscopic exam not possible due to patient incooperation.
III, IV, VI: Left esotropia and difficult assessment but could
almost fully abduct on right gaze and otherwise intact without
nystagmus grossly.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, facial musculature symmetric. Speech
slightly dysarthric.
VIII: Hearing intact to voice bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: Unable to fully assess.
XII: Tongue protrudes in midline otherwise unable to fuly
assess.
- Motor: Normal bulk, tone throughout.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Strength is full throughout in UE and LE bilaterally.
- Sensory: No deficits to light touch or cold sensation and
patient could not tolerate furtehr testing.
- DTRs:
BJ SJ TJ KJ AJ
L 2 2 2 2 1
R 2 2 2 2 1
There was no evidence of clonus.
[**Last Name (un) 1842**] negative.
Plantar response was flexor bilaterally.
- Coordination: Reaches well bilaterally to target.
- Gait: Unable to assess.
Physical Exam on Discharge:
Normal general physical physical exam.
Neurologic exam reveals a developmentally delayed young man who
is resistant to any exam. His cranial nerves are grossly intact
and motor exam is notable for symmetric antigravity and against
resistance in all extremities.
Pertinent Results:
[**2118-5-2**] 02:06PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2118-5-2**] 02:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2118-5-2**] 05:15AM GLUCOSE-91 NA+-136 K+-3.9 CL--106 TCO2-20*
[**2118-5-2**] 05:15AM HGB-15.1 calcHCT-45
[**2118-5-2**] 05:10AM WBC-7.7# RBC-4.17* HGB-14.4 HCT-42.5 MCV-102*
MCH-34.4* MCHC-33.8 RDW-12.4
[**2118-5-2**] 05:10AM NEUTS-64.4 LYMPHS-28.7 MONOS-4.8 EOS-1.4
BASOS-0.6
[**2118-5-2**] 05:10AM PLT COUNT-169
[**2118-5-3**] 04:09AM BLOOD Valproa-75
CXR [**2118-5-3**]: IMPRESSION: Left lung nodular and ground-glass
opacity concerning for aspiration or pneumonia.
Preliminary EEG from the ICU: IMPRESSION: This is an abnormal
continuous ICU monitoring study because of the presence of a
diffuse encephalopathy with admixed paroxysmal interictal
epileptiform activity mainly over the right parasagittal central
regions.
Brief Hospital Course:
ICU and Hospital course:
31 RHM with global developmental delay and intractable epilepsy
with complex partial and secondary generalized seizures
secondary to bilateral nodular periventricular heterotopias on 4
AEDs at baseline presents with seizure clusters in the setting
of URI symptoms similar to his previous admission in 10/[**2116**].
On admission he was having complex partial seizures lasting
30-45s every 3-5 minutes with return to baseline in between. He
was treated with 10mg PO diazepam and 500mg IV valproate at an
outside hospital and subsequently transferred to [**Hospital1 18**]. He
received 2 doses of IV vimpat 200mg as well as 2mg IV midazolam
upon presentation here and was admitted to the ICU for further
management. He initially became somewhat hypotensive to 80's
systolic following vimpat load and midazolam in the ED.
Hypotension improved with IVF.
He continued to have frequent seizures and was started on
standing diazepam 5mg PO Q6hrs as well as Vimpat IV 200mg [**Hospital1 **].
His home medications were continued at their current doses. He
had one additional cluster of 4 seizures within 30 minutes in
the afternoon of [**5-2**] and subsequently became seizure free. EEG
showed diffuse encephalopathy with admixed paroxysmal interictal
epileptiform activity mainly over the right parasagittal central
regions. CXR showed a LLL opacity concerning for pneumonia. He
was started on ceftriaxone empirically.
[**Known firstname **] was transferred to the floor on the Epilepsy service. He
was weaned off diazepam bridge and continued on vimpat. Mom felt
strongly that he we would not need the vimpat standing as an
outpatient, however we felt that it was important to continue
him on it for the next few weeks untill his PNA had resolved. He
has multiple medication allergies that his antibiotic choice. He
was switched to Azithromycin to complete a course for community
acquired PNA.
The patient did generally well on the floor with some episodes
of agitation that were felt to be related to the diazepam as he
has had these in the past. He was discharged in good condition
on his regular home medications with the addition of Vimpat.
Medications on Admission:
Depakote 750 at 7am/500 at 3pm/750 at 10pm
Keppra [**2105**] at 7a,/1500 at 3pm/[**2105**] at 7pm
Banzel 400mg [**Hospital1 **] (7am and 7pm)
Zonegran 500mg HS at 10pm
All brand name meds
Vitamin B6 200mg qd
MVI
MgO 400mg qd
Vitamin D 1000units qd
Vitamin C 500mg qd
Diazepam PRN seizures - has both 2mg and 5mg tablets and if more
intense or frequent seizures gives 5mg
Discharge Medications:
1. rufinamide 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. pyridoxine 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
7. lacosamide 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. zonisamide 100 mg Capsule Sig: Five (5) Capsule PO DAILY
(Daily).
9. levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
12. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
14. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for seizures.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Seizures, 2. Pneumonia
Discharge Condition:
Mental Status: Clear and coherent with intellectual disability
Level of Consciousness: Alert and interactive with persistent
agitation.
Activity Status: Ambulatory - depneds on caregiver [**First Name (Titles) **] [**Last Name (Titles) **].
Neuro Exam: Agitation requires significant redirection.
Otherwise non-focal neurologic exam.
Discharge Instructions:
Mr. [**Known lastname **] was admitted with status epilepticus in the
setting of a pneumonia. He was originally admitted to the ICU
where he was bridged with medications - including diazepam and
vimpat. He was transferred to the floor and did well. He is
being discharged on the Vimpat to continue until discussed
further with his epileptologist, Dr. [**First Name (STitle) 437**]. He will also
continue on a course of Azithromycin for community acquired
penumonia. He had no other medication changes to his
antiepileptic medications made.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2118-5-27**] 9:30
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4950
} | Medical Text: Admission Date: [**2169-4-2**] Discharge Date: [**2169-4-8**]
Date of Birth: [**2091-3-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Iodine / Shellfish Derived
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p unwittnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 year old woman who takes Plavix and Aspirin daily and fell
[**4-2**] at her daughter's home. The patient is intubated and non
communicative at the time of initial exam. Her daughter and
health care proxy is able to relay the events from the time of
the patients fall at 430 pm [**4-2**]. Her daughter reports that she
was in another room when her mother fell. The daughter heard
her mother fall and went immediately to her side. The patient
tripped on the last stair of her home. There was no observed
loss of consciousness and the patient stated at the time of the
fall that she lost her footing on the steps. At baseline, the
patient has difficulty with her knees that caused her
unsteadiness. The patient had a left eyebrow laceration from
the fall, but was completely neurologically intact per the
daughter. The daughter took the patient to [**Name (NI) 620**] [**Name (NI) **] . At 7pm
the pt became aphasic and lethargic and had a Head CT which
showed a large left intraparenchymal bleed. The patient was
electively intubated and transferred to [**Hospital1 18**] ED for definitive
care.
Past Medical History:
diabetes, HTN, CABG X 2 vessels-[**2160**], CVA following CABG
[**2160**], cataract surgery [**2167**].
Social History:
husband has advanced [**Name (NI) 2481**] and 2 daughters are the
designated Health Care Proxy for the patient. One of the
daughters lives in [**Name (NI) 26692**]
Family History:
non-contributory
Physical Exam:
On Admission:
Gen: intubated no eye opening to voice or stimulus.
HEENT: left eyebrow laceration, ecchymosis around left eye
Pupils: 3 to 2.5 mm EOM pt not cooperative
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS-6
Orientation: not oriented
Recall:
Language: intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
mm 2.5 bilaterally.
III, IV, VI,V, VII,VIII,IX, X,[**Doctor First Name 81**],XII: face appears symmetric-pt
unable to perform cranial nerve exam due to poor mental status
Motor: purposeful Left upper extremity, lifting off bed reaching
for ET tube, flexes and withdraws bilateral lower extremities to
painful stimulation, minimal movement of right upper extremity
to
noxious stimuli. No abnormal movements/tremors. Pronator
drift-pt
unable to perform
Pertinent Results:
Labs on Admission:
[**2169-4-2**] 09:45PM BLOOD WBC-13.4* RBC-4.38 Hgb-12.3 Hct-37.9
MCV-87 MCH-28.2 MCHC-32.6 RDW-12.8 Plt Ct-312
[**2169-4-2**] 09:45PM BLOOD Neuts-85.7* Lymphs-9.3* Monos-4.4 Eos-0.3
Baso-0.3
[**2169-4-2**] 09:45PM BLOOD PT-13.3 PTT-25.6 INR(PT)-1.1
[**2169-4-2**] 09:45PM BLOOD Glucose-158* UreaN-21* Creat-0.8 Na-141
K-4.1 Cl-107 HCO3-22 AnGap-16
[**2169-4-2**] 09:45PM BLOOD CK-MB-11*
[**2169-4-2**] 09:45PM BLOOD cTropnT-<0.01
[**2169-4-3**] 02:19AM BLOOD Phenyto-13.8
Imaging:
Head CT [**4-2**]:
NON-CONTRAST HEAD CT: Compared to two hours prior, there has
been slight
interval increase in the large left frontal intraparenchymal
hemorrhage, which now measures 7.5 x 3.8 cm in greatest
dimension, previously 6.7 x 3.8 cm. The hemorrhage has now
dissected into the left lateral ventricle with a small amount of
blood also layering within the right lateral ventricle. There is
mass effect on the ventricles, however no evidence of
hydrocephalus. 7 mm of rightward midline shift and subfalcine
herniation are unchanged. Moderately extensive right
parietotemporal subarachnoid hemorrhage is stable. The basal
cisterns are preserved with no evidence of uncal herniation. The
left lens is absent. There is no soft tissue hematoma or skull
fracture.
IMPRESSION:
1. Slight interval increase in extent of large left frontal
intraparenchymal hemorrhage, now with extension into the left
lateral ventricle. No evidence of hydrocephalus.
2. Unchanged 7-mm of rightward midline shift.
3. Stable moderate right parietotemporal subarachnoid
hemorrhage.
Head CT [**4-3**]:
IMPRESSION: No significant change compared to eight hours prior
except for
slight redistribution of intraventricular blood products.
Unchanged large
left frontal intraparenchymal hemorrhage and moderate right
subarachnoid
hemorrhage.
Head CT [**4-4**]:
NON-CONTRAST HEAD CT: There has been no significant interval
change in
multiple intracranial hemorrhages. The left frontal
intraparenchymal
hemorrhage measures 7.6 x 4.4 cm, grossly unchanged when
accounting for head position. The moderate right parietotemporal
subarachnoid hemorrhage is also unchanged. Small amount of blood
layering within the ventricles is unchanged. There is no new
hydrocephalus. Subfalcine herniation and 5 mm of rightward
midline shift are stable. Left lens is absent. The calvarium and
soft tissues are normal.
IMPRESSION: No significant interval change in large left frontal
IPH and
moderate right parietotemporal subarachnoid hemorrhage. No
change in mass
effect or intraventricular extension of blood. No hydrocephalus.
EKG [**4-3**]:
Sinus rhythm with borderline resting sinus tachycardia. Left
ventricular
hypertrophy by voltage. Inferolateral ST-T wave changes with ST
segment
depressions may be due to ischemia, etc. Compared to the
previous tracing
of [**2169-4-2**] precordial voltage is more prominent. ST-T wave
changes are
more apparent. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 134 82 [**Telephone/Fax (2) 82209**] 162
EKG [**4-5**]:
There is arm lead reversal. Sinus rhythm. Left atrial
abnormality. Probable left ventricular hypertrophy with
secondary repolarization abnormalities. Compared to the previous
tracing of [**2169-4-3**] no diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 112 84 344/415 110 123 -51
CXR [**4-5**]:
FINDINGS: As compared to the previous examination, the
pre-existing left
lower lung opacity has slightly increased in density and evolves
towards a
retrocardiac consolidation. The pre-existing left lower lobe
opacity is of
similar density but slightly more extensive, the changes could
be consistent with bilateral evolving aspiration pneumonia. The
size of the cardiac silhouette is slightly increased. There is
no evidence of fluid overload. The monitoring and support
devices are unchanged. No evidence of larger pleural effusions.
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] after transfer from OSH with
significantly sized intracranial hemorrhage while on
anticoagulation therapy from previous cardiac surgery. Upon
admission; she was administered platelets and admitted to the
intensive care unit for continuous monitoring. On [**4-3**], repeat
head CT was performed and determined to be stable, and not
indicitative of ongoing hemorrhage. She was subsequently
extubated. On [**4-4**], she was observed to have difficulty managing
her secretions, and an arterial blood gas was performed and
revealed a PaO2 in the 50s, and was reintubated. Head CT was
again performed to evaluate whether the ICH had evolved to
attribute to the poor respiratory effort, but was stable. On
[**4-5**], a bedside mini bronchoscopy was done to evaluate if she
had aspirated any secretions during her period of poor
respiratory effort. A lung consolidation was identified, and
antibiotics were started. On [**4-5**] her exam was stable and social
work was consulted for family regarding the possibility for
trach/peg & DNR/I status. On [**4-6**] her sodium was 153, mannitol
was stopped, free H2O was increased to 150cc QID, and her exam
was stable. On [**4-7**] she had a troponin leak 1.19 and a family
meeting w/ palliative care where the conclusion was to make her
CMO and she was eventually extubated and started on morphine for
comfort. On [**4-8**] she passed away.
Medications on Admission:
janumet 50mg/500mg, Plavix 75 mg, diltiazem 300 mg, cilostazol
50 mg, Cymbalta 30 mg, aspirin 81 mg, Zetia 10 mg, simvastatin
80 mg, cilostazol 50 mg
Discharge Disposition:
Expired
Discharge Diagnosis:
Left intraparenchymal hemorrhage, intraventricular hemorrhage,
and right subarachnoid hemorrhage.
Aspiration Pneumonia
NSTEMI(+troponin 1.19)
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
ICD9 Codes: 5070, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4951
} | Medical Text: Admission Date: [**2166-5-20**] Discharge Date: [**2166-5-26**]
Date of Birth: [**2126-1-20**] Sex: M
Service: CSU
SERVICE: Cardiothoracic Surgery.
HISTORY OF PRESENT ILLNESS: This is a 40-year-old male with
2-3 month history of chest pain and dyspnea on exertion. He
had a positive stress test and underwent a cardiac
catheterization which revealed three-vessel coronary artery
disease with an ejection fraction of approximately 35
percent. He was referred to Dr. [**Last Name (STitle) 70**] for evaluation of
coronary artery bypass graft.
PAST MEDICAL HISTORY: Diabetes mellitus, status post
cadaveric renal transplant, hypertension, high cholesterol,
hepatitis C.
SOCIAL HISTORY: Positive for smoking and positive alcohol
abuse.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Captopril 50 mg p.o. b.i.d.
2. Imdur 60 mg p.o. q d.
3. Aspirin 81 mg p.o. q d.
4. Zantac 150 mg p.o. q d.
5. Prograf 2 mg p.o. b.i.d.
6. Folate 1 mg p.o. q d.
7. CellCept 1,000 mg p.o. b.i.d.
8. Lipitor 10 mg p.o. q d.
9. Atenolol 100 mg p.o. q a.m. and 50 mg p.o. q p.m.
10. Protonix 40 mg p.o. q d.
11. Humalog insulin sliding scale.
12. Bactrim one tablet p.o. Monday, Wednesday and
Friday.
13. Prednisone 5 mg p.o. q d.
14. Lantus insulin.
PHYSICAL EXAMINATION: He was afebrile with stable vital
signs. His lungs were clear. Heart was regular. Abdomen was
soft, nontender, nondistended with bowel sounds present. He
had a well healed renal transplant scar.
LABORATORY DATA: His labs are all within normal limits.
HOSPITAL COURSE: The patient was seen in consultation and it
was decided that the patient would undergo a coronary artery
bypass graft. The patient was taken to the Operating Room on
[**2166-5-21**] for a coronary artery bypass graft times three.
Please see the Operative Report for further details. The
patient was transferred to the Cardiac Surgery Recovery Unit
postoperatively and was slowly weaned from his ventilator and
extubated. He was put on multiple agents to enhance his blood
pressure. These were slowly weaned over the next couple of
days. The Transplant Renal service was consulted for
management of his renal transplant medications and they
followed him throughout his hospital course. The patient was
weaned from the ventilator and weaned from his cardiac
medications over the next couple of days. He had chest tubes
placed intraoperatively and those were ultimately removed
prior to discharge.
Also, the [**Hospital6 30927**] was consulted for
management of his insulin during this hospital stay. They
followed him throughout and managed his insulin accordingly.
The patient continued to do well. His blood pressure
medications were slowly titrated up as he was able to be
weaned from his pressors. His chest tubes were removed.
Psychiatry was consulted on [**2166-5-23**] because the patient
was combative and there was a question of whether or not he
was withdrawing. They felt that this patient was delirious
likely due to postoperative and postanesthesia effects, as
well as nicotine and questionable alcohol withdrawal. His
delirium slowly resolved and the patient was normal without
any signs of agitation prior to discharge. The patient
continued to do well and Physical Therapy was consulted. He
was ambulating significantly on his own and continued to
improve. He was able to do stairs and actually ultimately was
going outside on his own to smoke and was active. The patient
was discharged to home on [**2166-5-26**] and he was doing well.
The patient was discharged to home in stable condition on
[**2166-5-26**].
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft times three.
2. Diabetes mellitus.
3. Renal insufficiency, status post cadaveric renal
transplant.
4. Hypertension.
5. High cholesterol.
6. Hepatitis C.
7. Positive for smoking.
8. Positive for alcohol use.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q d.
2. Percocet 1-2 tablets p.o. q four hours p.r.n.
3. Atenolol 100 mg p.o. q a.m. and 50 mg p.o q p.m.
4. Imdur 60 mg p.o. q d.
5. Plavix 75 mg p.o. q d.
6. CellCept 1,000 mg p.o. b.i.d.
7. Prednisone 5 mg p.o. q d.
8. Lipitor 10 mg p.o. q d.
9. Folic acid 1 mg p.o. q d.
10. Protonix 40 mg p.o. q d.
11. Prograf 2 mg p.o. b.i.d.
12. Lantus.
13. Bactrim one tablet p.o. Monday, Wednesday and
Friday.
14. Reglan 10 mg p.o. q.i.d. with meals.
15. Vitamin C 500 mg p.o. b.i.d.
16. Captopril 50 mg p.o. t.i.d.
CONDITION ON DISCHARGE: Stable condition.
FOLLOW UP: The patient is to follow-up with his primary care
physician [**Last Name (NamePattern4) **] [**1-10**] weeks and with his renal doctor as well, as
well as with his cardiologist and follow-up with Dr.
[**Last Name (STitle) 70**] in [**4-15**] weeks.
DISPOSITION: The patient is discharged to home in stable
condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], MD 2358
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2166-5-26**] 14:21:40
T: [**2166-5-26**] 15:00:30
Job#: [**Job Number 18897**]
ICD9 Codes: 4019, 2720, 3051, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4952
} | Medical Text: Admission Date: [**2134-8-22**] Discharge Date: [**2134-8-30**]
Date of Birth: [**2062-7-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
72 y/o M with hx of stage 4 squamous cell esophageal CA who has
been on palliative chemo with xeloda and s/p recent radiation
therapy who presents from home with respiratory distress.
.
Per the ED and the family, he had been home about a week with
plans to transition to home hospice and eventually recover
enough to make it home to [**Country 3587**] when he started having more
[**Last Name (LF) 83413**], [**First Name3 (LF) **] increasing morphine requirement for pain in his
whole body and then the last two days, respiratory distress.
They deny that he was coughing or choking, saying that he just
doesn't swallow at all anymore. He had no other focal
complaints. When his breathing reached a point they could not
control anymore, EMS was called and he was brought to the ED
with the family following close behind.
.
In the ED, initial vitals were significant for tachypneia,
hypoxia and an SBP in the 80s. After a brief discussion with the
family, he was intubated. He received IVF boluses with a
response in his BPs. He was given vanco/flagyl in the ED and
ordered for levofloxacin but did not receive it due to timing
and access. Over his ED course, he was noted to get more
hypotensive with SBPs in the 80s. He was no longer responding to
IVF boluses, so L femoral CVL was placed and levophed was
started.
.
On arrival to the floor, he was intubated and sedated and not
withdrawing to pain or moving on his own.
Past Medical History:
1. History of squamous cell esophageal cancer
2. History of hypertension for the last two years.
3. History of mild depression under control.
4. History of mild benign prostate hypertrophy.
5. History of mild elevated cholesterol levels and glucose
levels.
6. The patient is status post significant burn with skin
grafting in [**2098**]. He had major surgical procedures at that time
.
# stage IVb esophageal cancer of squamous cell histology:
Patient presented in with a three-month history of dysphagia to
our clinic in [**2133-9-12**]. Further workup disclosed a
circumferential lesion in the mid third of the esophagus. A
biopsy of the lesion disclosed a squamous cell carcinoma of the
esophagus. Additional findings included lymphadenopathy in the
periesophageal area corresponding to a locally advanced cancer
as well as additional lymphadenopathy in his right
supraclavicular and cervical area. His PET CT scan demonstrated
FDG uptake in all enlarged lymph node areas and biopsy of the
supraclavicular node confirmed carcinoma.
Social History:
40-pack-year history of smoking. The patient also had a prior
alcohol intake history of approximately seven drinks a week;
however, quit completely over two years ago. The patient is
originally from [**Country 3587**] and lives in the city Boa
Vista. His daughters live in the city of [**Name (NI) 32775**] in
[**State 350**]. The patient currently has insurance through Mass
Health.
Family History:
Noncontributory
Physical Exam:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL, Pupils dilated
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
No(t) Clear : , Rhonchorous: R > L)
Abdominal: Soft, Non-tender, Bowel sounds present, GT in place
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, cool extremities
Musculoskeletal: Muscle wasting
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
Pertinent Results:
[**2134-8-22**] 9:10 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2134-8-26**]**
URINE CULTURE (Final [**2134-8-26**]):
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
.
.
.
.
[**2134-8-22**] 9:10 pm BLOOD CULTURE
**FINAL REPORT [**2134-8-30**]**
Blood Culture, Routine (Final [**2134-8-29**]):
STREPTOCOCCUS ANGINOSUS. ISOLATED FROM ONE SET ONLY.
Susceptibility testing requested by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 83414**]
#[**Numeric Identifier **] [**2134-8-26**].
CLINDAMYCIN IS SENSITIVE AT 0.12MCG/ML.
Sensitivity testing performed by Sensititre. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
.
.
[**2134-8-23**] 06:02AM BLOOD Glucose-151* UreaN-54* Creat-0.7 Na-140
K-4.5 Cl-114* HCO3-22 AnGap-9
[**2134-8-24**] 03:21AM BLOOD Glucose-127* UreaN-33* Creat-0.6 Na-142
K-4.4 Cl-112* HCO3-20* AnGap-14
[**2134-8-25**] 03:55AM BLOOD Glucose-121* UreaN-30* Creat-0.5 Na-143
K-4.1 Cl-114* HCO3-22 AnGap-11
[**2134-8-26**] 03:39AM BLOOD Glucose-111* UreaN-28* Creat-0.5 Na-146*
K-3.7 Cl-116* HCO3-23 AnGap-11
[**2134-8-27**] 02:34AM BLOOD Glucose-133* UreaN-20 Creat-0.5 Na-139
K-3.6 Cl-103 HCO3-28 AnGap-12
.
.
[**2134-8-22**] 09:10PM BLOOD WBC-4.9 RBC-2.56* Hgb-8.4* Hct-25.0*
MCV-98 MCH-32.9* MCHC-33.7 RDW-16.4* Plt Ct-138*
[**2134-8-24**] 04:22PM BLOOD WBC-9.0 RBC-2.73* Hgb-9.1* Hct-25.0*
MCV-92 MCH-33.2* MCHC-36.2* RDW-16.9* Plt Ct-104*
[**2134-8-27**] 02:34AM BLOOD WBC-5.8 RBC-3.59* Hgb-11.4* Hct-32.8*
MCV-91 MCH-31.7 MCHC-34.8 RDW-16.8* Plt Ct-69*
Brief Hospital Course:
Mr. [**Known lastname **] was a 72 yo man with a hx of stage 4 squamous cell
esophageal CA who presented with acute respiratory distress and
hypotension, worrisome for aspiration pneumonia and septic
shock. This was a week after he had been discharged home on home
hospice, but in the ED his code status was reversed to Full
Code. Apparently the goal of his home hospice was to stabilize
him enough to send him home to [**Country 3587**] to die there.
# Hypoxic Respiratory Distress: Given his recent hospitalization
for dysphagia and increased cancer pain at home, most likely
cause was aspiration pneumonia. He was started on an 8 day
course of vanco/cefepime/flagyl for HAP and aspiration coverage
on [**8-23**]. Sputum GS showed 4+ GNR, 3+ GPC in pairs/chains, 2+ GP
rods. Pt continued to spike fevers until overnight on [**8-24**]. He
was kept on contact precautions for presumed MRSA. Repeat chest
X rays showed no significant change. Initially, he was
ventilated on Assist Control, but overbreathing on this setting
and high autoPEEP prompted switching him to PS with increased
sedation. He required 2-limb restraints to prevent
self-extubation throughout his MICU course. Pt was kept on
bronchodilators and sedated to comfort on Versed and Fentanyl
drips with intermittent boluses for agitation. Attempts to wean
him off the ventilator were unsuccessful. Pt was too agitated
and weak to breathe adequately off the vent. He remained
unresponsive. On [**8-29**], it was decided to remove ventilatory
support, and the patient expired a day later. Pt was kept NPO
for entire MICU course.
# SEPSIS WITHOUT ORGAN DYSFUNCTION: Pt had positive blood
cultures from [**8-22**] of Strep anginosus, but the validity and
source of this bacteremia is not clear: the Strep grew in only 1
out of 4 tubes, and the sputum culture from [**8-22**] grew GNR. Other
than the lungs, other sources of infection include the urine, GI
tract, and skin. Urine culture on [**8-22**] showed <[**Numeric Identifier 4856**]
Enterococci, and U/A was negative. Follow-up urine cx was
negative. Follow-up blood cultures have grown nothing to date.
No sign of skin breakage or other potential skin source of
infection on physical exam. Pt did not have diarrhea in the
unit, so bowel infection unlikely. The pt continued to spike on
broad-spectrum antibiotics that should have covered all
bacterial infections. Furthermore, lactate was trending down.
Despite finishing an 8-day course of broad-spectrum antibiotics
for aspiration PNA/sepsis and improving in terms of infectious
signs (pressures, wbc, lactate), pt's overall condition did not
improve.
# Hypotension: Most of this was probably due to his sepsis, but
bleeding as evidenced by his continually dropping hct may also
have been contributing. Initially adrenal insufficiency was also
in the differential: this became unlikely since stress-dose
steroids in-house did not improve his pressures. Pressures
dropped as pressors were weaned, but urine output remained good,
albeit decreased overall, with a stable Cr of 0.5. Pt received a
considerable amount of fluids (+8.5L TBB) and was diuresed with
Lasix once off pressors and with stable sbp>100.
# Acute Anemia: hct dropped from 40 to 25 in the week before
admission; no evidence of frank bleed, guaiac positive in the
ED. He was started on IV PPI at admission. Pt??????s hct continued to
drop: he received 2 units blood for a hct of 21 on [**8-23**] with
recovery to 27 and again on [**8-25**] for a hct of 22. Pt seemed to
be bleeding, likely [**3-16**] indolent GIB from esophageal cancer, but
other factors also contributing: hemodilution, anemia of acute
illness. [**Month (only) 116**] also have had underlying pancytopenia due to bone
marrow infiltration of his cancer or suppression from extended
course of palliative chemo. Retics were inappropriately low.
Hemolysis was very unlikely given t bili of 0.4 at admission and
lack of jaundice; this was confirmed by hemolysis labs that were
negative.
#Thrombocytopenia: Pt initially thought to have pancytopenia at
admission, but leucopenia normalized after the first day of
hospitalization ?????? likely due to acute infection ?????? and hct
decreased steadily while thrombocytopenia remained stable. Thus
3 lines probably had different reasons for being down, and BM
infiltration from cancer seemed to be less likely after the
first 2 days of his MICU stay. The pt's new thrombocytopenia
(138 at admission) was initially relatively stable and most
likely due to sepsis. There was an acute drop in plt count to 69
mid-course that may have been drug-related. DIC was unlikely
given wnl and then elevated fibrinogen. D-dimer at admission was
elevated, but that could also have been [**3-16**] cancer or septic
shock.
#CANCER (MALIGNANT NEOPLASM), ESOPHAGEAL: terminal, pt had been
on home hospice with the plan of returning to [**Country 3587**] to die.
On 14 d on, 14 d off of palliative chemo (Xeloda) since [**Month (only) 404**]
in [**Country 3587**], d/c??????ed at last admission ([**8-3**]), no longer on
chemo/radiation since then. Pt was made DNR at a family meeting
on [**8-23**]. Dr. [**Last Name (STitle) 174**] communicated important information on [**8-24**],
that pt's goals of care were not hospice per se but
stabilization before returning to [**Country 3587**] on commercial
flight. Pt's family seemed ready to keep him at intubated on a
vent and sedated for an indefinite period. Palliative Care was
consulted on [**8-24**]. Pt was made CMO on [**8-29**].
.
# ARF: had new ARF at admission, but Cr returned to [**Location 213**] after
receiving fluids and remained stably normal. Likely pre-renal
from septic shock with poor perfusion. Creatinine and urine
output were monitored during his hospitalization.
.
# Hypothyroidism: no hx of hypothyroidism. TSH 0.23, follow up
fT4 0.66 -> central hypothyroidism. Could be [**3-16**] sick euthyroid
vs pituitary hypoperfusion from septic shock or (unlikely)
metastasis. No role for Synthroid initiation at that point.
# Depression: unclear baseline. On a TCA and Librium at home,
which we held in the unit.
.
# Hyperlipidemia: simvastatin held in the unit.
Medications on Admission:
Isosource 1.5 cal, 5.5 cans daily with 1L flushes
Timolol 0.5% gtts [**Hospital1 **]
Fluticasone nasal spray [**Hospital1 **]
Dexamethasone 4 mg [**Hospital1 **]
Clomipramine 25 mg daily (TCA)
Chlordiazepoxide 10 mg [**Hospital1 **] (librium)
Famotidine 40 mg/5ml 2.5 ml [**Hospital1 **]
Morphine 10mg/5ml 5 ml q6hrs PRN
Zofran 4mg/5ml 5 ml daily
Allopurinol 300 mg daily
Simvastatin 20 mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2134-9-2**]
ICD9 Codes: 5990, 2851, 4019, 2720, 2875, 2449, 2724, 311, 5849, 5070, 2760, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4953
} | Medical Text: Admission Date: [**2141-6-29**] Discharge Date: [**2141-7-14**]
Date of Birth: [**2067-10-17**] Sex: F
Service: Vascular Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
female, transfer from [**Hospital 1474**] Hospital on [**2141-6-29**] where she
presented on [**2141-6-26**] with nausea and vomiting, abdominal
pain, and bloody diarrhea. CT scan at [**Hospital 1474**] Hospital
revealed a probable superior mesenteric artery occlusion at
which time the patient was transferred acutely to [**Hospital1 346**] for assessment and treatment by the
vascular surgery team. The patient began experiencing
symptoms on [**2141-6-24**], first starting off with lower abdominal
pain, copious diarrhea and nausea and vomiting. The patient
was admitted to [**Hospital 1474**] Hospital on [**2141-6-26**] after diarrhea
became bloody in nature. At [**Hospital 1474**] Hospital the patient's
abdominal pain and abdominal physical examination worsened.
CT examination on [**2141-6-29**] revealed superior mesenteric
artery occlusion at which time the patient was transferred to
[**Hospital1 69**]. At [**Hospital 1474**] Hospital
the patient was also noted to have developed a new-onset
atrial fibrillation, which was thought to be the source of a
potential embolus to the superior mesenteric artery.
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia. 3. Borderline diabetes mellitus. 4.
Status post appendectomy. 5. Status post exploratory
laparotomy for trauma in the past.
PHYSICAL EXAMINATION: Upon admission to [**Hospital1 346**] the patient was noted to have
regular rate and rhythm, clear to auscultation bilaterally.
Abdominal examination was remarkable for a very tender
abdomen with positive guarding, positive rigidity and
positive rebound tenderness. Rectal examination was guaiac
positive. Extremity examination was dorsalis pedis and
posterior tibial pulses palpable bilaterally. Femoral pulse
was palpable bilaterally. There were no carotid bruits
noted.
LABORATORY DATA: On admission the patient was noted to have
a white count of 22, hematocrit 41.1, platelet count 273,
sodium 140, potassium 3.5, chloride 108, bicarbonate 26, BUN
16, creatinine 0.7, glucose 224, calcium 9.3, magnesium 2.1,
phosphorous 1.1.
Emergency angiogram was ordered and obtained which revealed
an occlusion of the superior mesenteric artery.
HOSPITAL COURSE: After the angiogram results were received
the patient was taken emergently to the operating room for
superior mesenteric artery thromboembolectomy. The patient
was noted to have no dead or necrotic bowel at the time of
exploratory laparotomy. An occlusion was noted 1-2 cm distal
to the origin of the superior mesenteric artery. Clot was
evacuated with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] catheter and Dacron patch was
applied for closure. The patient was closed primarily with
no plans for a second look operation due to strong palpable
and dopplerable pulses post thromboembolectomy and a
significant pinking up and reperfusion of the bowel with no
areas of transmural infarction noted.
The patient was discharged to the intensive care unit at this
time. Intensive care unit course was remarkable for
continued abdominal tenderness as well as episodes of
diarrhea. Postoperative angiogram on [**2141-7-5**] showed wide
patency of the superior mesenteric artery. Repeat CT scan
also showed widely patent mesenteric vessels with portions of
bowel wall edema. At this time the patient's symptoms and
radiologic findings were attributed to a reperfusion type
injury.
The patient's postoperative course was also significant for
episodes of agitation in the intensive care unit. As the
patient's abdominal symptoms and diarrhea resolved, the
patient was transferred to the floor on [**2141-7-9**]. The
patient's postoperative course on the floor was unremarkable.
The patient was weaned off of TPN, started on clears, and
eventually advanced to a general diet which she tolerated
well. The patient is currently on a post-gastrectomy type
diet of small portions of food, many meals per day.
The patient was also seen by physical therapy to be evaluated
for home safety. The patient was also made therapeutic on
Coumadin for new-onset atrial fibrillation. The patient's IV
heparin was discontinued on [**2141-7-13**]. Cardiology follow up
recommended echocardiogram in one month's time prior to
cardioversion attempt. Until that time the patient is to
remain on Coumadin with a therapeutic INR between 2 and 3.
The patient is currently stable, tolerating p.o.
DISCHARGE STATUS: To rehabilitation facility or to home with
help from her two daughters who are nurses.
DISCHARGE DIAGNOSES: Superior mesenteric artery occlusion.
DISCHARGE MEDICATIONS:
1. Pepcid 20 mg p.o. b.i.d.
2. Coumadin 2.5 mg p.o. q.h.s.
3. Premarin 0.625 mg p.o. q.d.
4. Atorvastatin 20 mg p.o. q.d.
5. Nystatin oral suspension 5 mL p.o. q.i.d. p.r.n.
6. Metoprolol 25 mg p.o. b.i.d.
7. Captopril 12.5 mg p.o. t.i.d.
8. Miconazole powder 2% one application topically q.i.d.
p.r.n.
9. Clonidine TTS one patch q. week.
10. Albuterol inhaler 1-2 puffs q. 6 hours p.r.n.
11. Tylenol 325 to 650 mg p.o. q. 4-6 hours p.r.n.
12. Dilaudid 2 mg p.o. q. 2 hours p.r.n. for pain.
FOLLOW-UP PLANS: The patient is to follow up with Dr.
[**Last Name (STitle) **] in one week.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2141-7-14**] 10:45
T: [**2141-7-14**] 11:33
JOB#: [**Job Number 51588**]
ICD9 Codes: 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4954
} | Medical Text: Admission Date: [**2123-12-4**] Discharge Date: [**2123-12-5**]
Date of Birth: [**2054-10-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
respiratory distress, fevers, sepsis
Major Surgical or Invasive Procedure:
[**12-4**]
-intubation
-placement of left internal jugular central venous line
-placement of right radial arterial line
[**12-5**]
-placement of right femoral line
History of Present Illness:
Mr. [**Known lastname 64263**] is a 69 year old gentleman with CLL x10 years s/p 2
blast crises this year. He was previously treated with Rituximab
and Fludarabine several years ago but did not repeat this
regimen due to anemia/thrombocytopenia. Baseline WBC has been in
130s. He was most recently treated with Treeandra(?) 3 wks prior
to admission, and prednisone 60mg that was initiated 4-5 days
ago. He reports he was in his usual state of health until about
3 days ago when he developed sore throat, fever and malaise. He
has had increased difficulty breathing, nasal congestion and
cough. He reports decreased PO intake over the past few days. He
felt nauseous and had at least one episode of coffee-ground
emesis and non-bloody diarrhea that began the night prior to
admission. He reports [**4-7**] profusely watery bowel movements the
day of admission, but no bright red blood per rectum or melena.
He denies sick contacts and recent travel.
In the ED, initial VS were T 100.3 BP 96/53 HR 109 RR 16 SaO2
93% RA
He became tachycardic in the ED, with T max 102.6. He was given
2L IVF, vanc/levofloxacin and oseltamivir. CXR showed
multifocal PNA, and EKG was benign. 90-91 NC, 98-99 NRB. Vitals
prior to ICU admission were: HR 111 BP 97/53 RR 39 SaO2 94% NRB.
Past Medical History:
1. CLL dx 10 yrs ago w/ 2 blast crises- previously treated with
Rituximab and Fludarabine, most recently treated with
2. Obstructive sleep apnea, on C-PAP
3. Hyperlipidemia
Social History:
Lives alone in [**Location 34697**]. Has girlfriend, [**Name (NI) **] nearby who has
been healthy. Daughter [**Name (NI) 553**] is HCP and very involved in care
Family History:
nc
Physical Exam:
T=104.1 BP=97/55 HR=150s RR= 28
Admission exam:
GENERAL: pleasant, cooperative ill-appearing male in moderate
respiratory distress
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. mucous membranes dry.
CV: tachycardic, irregular rhythm. No murmurs appreciated, no
JVD.
LUNGS: rhonchorous breath sounds B/L, poor air movement in b/l
bases
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. 4+/5 strength B/L LE, [**6-8**] grip
strength B/L. [**2-5**]+ reflexes patella and ankle B/L
Pertinent Results:
[**2123-12-4**] 10:47PM TYPE-ART TEMP-37.0 RATES-30/ TIDAL VOL-500
PEEP-18 O2-100 PO2-82* PCO2-42 PH-7.19* TOTAL CO2-17* BASE
XS--11 AADO2-589 REQ O2-97 INTUBATED-INTUBATED VENT-CONTROLLED
[**2123-12-4**] 10:47PM LACTATE-1.9 K+-4.5
[**2123-12-4**] 08:52PM TYPE-ART TEMP-35.9 RATES-30/ TIDAL VOL-550
PEEP-15 O2-100 PO2-60* PCO2-33* PH-7.26* TOTAL CO2-15* BASE
XS--11 AADO2-620 REQ O2-100 INTUBATED-INTUBATED VENT-CONTROLLED
[**2123-12-4**] 07:07PM WBC-310.8* RBC-2.34* HGB-7.4* HCT-23.8*
MCV-102* MCH-31.6 MCHC-31.1 RDW-22.8*
CXR [**12-4**]- Bilateral prominence of the hila and interstitial
markings with
left pleural effusion most compatible with congestive heart
failure. Left
retrocardiac opacity, may be from effusion and atelectasis
though underlying pneumonia cannot be excluded.
[**2123-12-5**]:
11.5
462.6>---------< 46 95% lymphs
34.6
ABG: 7.13/ 45.7/ 64/ 16/ -14
Brief Hospital Course:
69 y/o gentleman with Chronic Lymphocytic Leukemia s/p
chemotherapy and recent use of prednisone, was admitted to [**Hospital Unit Name 153**]
with fevers of 104, sepsis and respiratory distress.
Given patient's immunocompromised state due to advanced cancer
and prednisone use, infectious etiologies of fever are most
likely. Due to presentation of respiratory difficulty, cough and
high fever, pulmonary infectious processes such as bacterial
pneumonia, (especially w/ encapsulated organisms like strep
pneumo) PCP pneumonia or influenza are highly likely, or his
pulmonary infiltrates seen on CXR could be due to inflammatory
vascular leak causing an ARDS type picture. Legionella is
another possibility given PNA like symptoms in conjunction w/
diarrhea or diarrhea itself could be caused by C. diff colitis
or bacterial or viral etiologies. CVA tenderness and fever
could point to pyelonephritis as a potential source of
infection. Another possibility is aggressive transformation of
his malignancy such as [**Doctor Last Name 6261**] transformation which would be
characterized by high fever, elevated LDH and association with
previous fludarabine use.
[**Hospital Unit Name 13533**]:
Mr. [**Known lastname 64264**] fevers and hypotension were likely due to sepsis,
complicated by underlying malignancy and immunosuppression. On
day of admission [**12-4**], patient was febrile to 104, had WBC of
310, with HR in 150s-160s. He was diaphoretic, tachycardic and
tachypneic and was having difficulty speaking in complete
sentences due to respiratory distress. He was given a cooling
blanket and broad-spectrum antibiotics (vancomycin, levofloxacin
and zosyn) were initiated. Patient was pan-cultured, and given
IVF for hydration with 1 L NS boluses. He developed increased
work of breathing and went into atrial fibrillation with heart
rate in the 160s, refractory to low-dose diltiazem, so
amiodarone drip was started. Patient eventually went into sinus
rhythm on amiodarone drip, but due to oxygen desaturations and
increased work of breathing, decision was made to intubate.
Patient's daughter [**Name (NI) 553**] notified of intubation. Anesthesia
arrived to intubate patient at assist/cmv at Vt 500 x 30 RR,
PEEP 15, 100% FiO2. He was given fentanyl and midazolam for
sedation. A left internal jugular central line and right radial
arterial line were placed emergently due to hypotension.
Infectious Disease and Oncology were consulted who evaluated the
patient while intubated. Patient's blood pressures continued to
drop with systolic pressures in the 70s and 80s, so levophed was
initiated, and titrated til it was at maximum dose. Serial
arterial blood gasses were measured and patient was profoundly
acidotic, with mixed respiratory and metabolic acidosis having
pH of 7.19. Vasopressin was initiated as a second pressor, but
only had minimal effect on blood pressure. Mr. [**Known lastname 64263**] was
thought to be maximally vasodilated form septic shock and he did
not possess enough neutrophils to fight the infection. His
repeat WBC count trended upward to 462. Repeat ABGs showed no
improvement. Dopamine was initiated as a 3rd pressor due to
systolic pressures in the 60s-70s. Patient was given multiple
fluid boluses over night with very little effect on blood
pressure and urine output. Patient's urine output continued to
worsen, and by the morning of [**12-5**], his fluid balance was 13
liters positive. Blood cultures returned positive for gram
positive cocci in pairs and clusters, and patient's vancomycin
was changed to linezolid as per ID recommendations, for better
VRE coverage. His zosyn was changed to meropenem for broad
coverage and clindamycin was added due to its inhibitory effects
on bacterial protein synthesis and therefore, action against
endotoxins. Patient continued to do poorly, and emergent femoral
line was placed due to concern of inaccurate readings from right
radial arterial line. ABG on [**12-5**] 7.13/ 45/ 64/ 16/ -14 and
lactate was 5.1 . Mini BAL was conducted on [**12-5**] and results
later showed positivity for pneumocystis. Blood cultures were
later shown to grow staph aureus. The patient expired on
[**2123-12-5**] with family at his bedside.
He was pronounced by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 50153**] and family agreed to
autopsy.
Medications on Admission:
1. lipitor 10mg daily
2. prednisone 60mg daily
3. valtrex (prophylaxis)
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
n/a
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2123-12-15**]
ICD9 Codes: 0389, 5849, 2762, 2875, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4955
} | Medical Text: Admission Date: [**2105-3-31**] Discharge Date: [**2105-4-6**]
Date of Birth: Sex: F
Service: [**Hospital Unit Name 153**]
HISTORY OF PRESENT ILLNESS: This is an 87 year old woman
with a history of Methicillin resistant Staphylococcus aureus
urinary tract infection, history of aspiration, status post
coronary artery bypass graft, who is a nursing home patient
with a recent admission for presumed urosepsis roughly one
and one half weeks ago. The patient was admitted under the
sepsis protocol and treated with Vancomycin once culture data
from her nursing home grew Methicillin resistant
Staphylococcus aureus in her urine. The patient defervesced
and was discharged home on Levofloxacin. Two days after her
discharge, the patient started to develop nausea and vomiting
and abdominal pains. The patient also noted a productive
cough of white sputum. At her nursing home, the patient was
found to have desaturated to 82% in room air and was
transferred to the Emergency Department at [**Hospital1 346**]. On arrival, the patient was
normotensive, in atrial fibrillation with a ventricular rate
of 150 and temperature of 103.8. The patient later became
hypotensive, systolic blood pressure in the 70s, requiring
fluid resuscitation. The patient was given 1.5 liters of
normal saline, one gram of Vancomycin, 500 mg of Levofloxacin
and 500 mg Metronidazole in the Emergency Department. The
patient was initially started on Levophed and Dobutamine
drips for hypotension. The patient was subsequently
transferred to the [**Hospital Unit Name 153**].
PAST MEDICAL HISTORY:
1. History of falls thought to multifactorial.
2. Hypertension.
3. Cerebrovascular accident in [**2092**], small cerebrovascular
accident or transient ischemic attack in [**2105-2-1**].
4. Left hemianopsia.
5. Coronary artery bypass graft with a porcine aortic valve
replacement in [**2092**], and the patient is currently on
Coumadin.
6. Degenerative joint disease.
7. Total hip replacement [**2100**].
8. Cataract surgery.
9. Congestive heart failure with questionable diastolic
heart failure, echocardiogram in [**2105**], showing an ejection
fraction greater than 65% with a 2.0 centimeter atrial
myxoma, symmetric left ventricular hypertrophy, mild dilation
of the left atrium.
10. History of paroxysmal atrial fibrillation.
11. Methicillin resistant Staphylococcus aureus urinary tract
infection in [**2105-2-1**].
12. Questionable aspiration pneumonia in the past.
13. Total abdominal hysterectomy.
14. Appendectomy.
15. Hemorrhoidectomy.
16. Colonic polypectomy.
ALLERGIES: Sulfa.
MEDICATIONS ON ADMISSION:
1. Artificial tears.
2. Detrol 1 mg twice a day.
3. Coumadin 2 mg q.h.s.
4. Levofloxacin 250 mg once daily.
5. Protonix 40 mg p.o. once daily.
6. Zoloft 75 mg p.o. once daily.
7. Aspirin 81 mg p.o. once daily.
8, Multivitamin.
9. Lopressor 25 mg twice a day.
10. Fluticasone.
11. Colace 100 mg once daily.
12. Fosamax 70 mg q.Friday.
13. Albuterol and Atrovent nebulizer every six hours.
14. Lipitor 10 mg once daily.
15. Calcium 500 mg twice a day.
16. Senna twice a day.
17. Iron Sulfate 325 mg once daily.
SOCIAL HISTORY: The patient is a resident at [**Hospital3 14109**] Home. She is DNR/DNI but pressors are OK.
PHYSICAL EXAMINATION: On admission, temperature was 99.4,
pulse 117, blood pressure 98/45, currently on Levophed,
respiratory rate 24, oxygen saturation 96% on two liters of
nasal cannula. Her CVP is 10. On general examination, she
is in no acute distress, awake, alert and oriented and
responsive. The pupils are equal, round, and reactive to
light and accommodation. Mucous membranes are dry. On lung
examination, she has crackles one third up bilaterally
without any evidence of wheezing. Heart examination is
irregularly irregular, tachycardic. Abdominal examination is
soft, nontender, nondistended. Extremities show no pedal
edema and no cyanosis with occasional ecchymosis. Neurologic
examination - The patient is alert and oriented times three,
grossly intact.
LABORATORY DATA: On admission, urinalysis was negative for
evidence of infection, less than one bacteria, no leukocyte
esterase, negative white blood cells. White blood cell count
on admission was 16.2, with 17 bands.
Chest x-ray showed no evidence of infiltrates but bilateral
basilar atelectasis. Electrocardiogram showed atrial
fibrillation at a rate of roughly 120s.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit under the sepsis protocol. The patient was given
aggressive fluid resuscitation and required Levophed pressor
for her hypotension. The Dobutamine drip initially was
weaned off as the patient was tachycardic.
The patient was initially febrile. The source was unclear
but thought to be partially treated Methicillin resistant
Staphylococcus aureus urinary tract infection and the
possibility of tracheobronchitis/pneumonia. The patient was
initially placed on Vancomycin and Imipenem for broad
spectrum coverage given that her blood pressure was low and
appeared to be septic. The patient was pancultured. Blood
cultures grew coagulase negative Staphylococcus aureus in two
out of four bottles. Urine culture was negative. Sputum
cultures were inconclusive. The patient was later switched
to , Tazobactam and Vancomycin
antibiotics for coverage. The patient had defervesced soon
after antibiotic administration. Echocardiogram was
performed to visualize evidence of vegetation and signs of
endocarditis. The transthoracic echocardiogram did not show
evidence of vegetations.
The patient was tachycardic during hospital course with heart
rates into the 120s with evidence of heart failure. Based on
prior echocardiograms, the patient had diastolic heart
dysfunction. Controlling the rate was difficult as the
patient was hypotensive. She was started on Digoxin. She
was loaded and given daily doses of Digoxin with better rate
control. The patient was also diuresed slightly with Lasix
given that she had mild oxygen requirement and evidence of
pulmonary edema. For the patient's atrial fibrillation, she
was continued on Coumadin and her coagulation was monitored
daily.
Once tachycardia was improved, blood pressure became normal
and the patient was weaned off Levophed pressor. The patient
maintained good urine output and mentation during her
hospital course.
At the time of dictation, the patient was being transferred
to a medical floor. Please see discharge addendum for
further details of hospital course.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Name8 (MD) 10402**]
MEDQUIST36
D: [**2105-4-6**] 16:57
T: [**2105-4-6**] 18:18
JOB#: [**Job Number 14113**]
ICD9 Codes: 5070, 4280, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4956
} | Medical Text: Admission Date: [**2175-7-18**] Discharge Date: [**2175-7-30**]
Date of Birth: [**2175-7-18**] Sex: F
Service: NB
HISTORY: This infant was born at 36 and 6/7 weeks gestation
via Cesarean section to a 34 year-old, G2, P1 now 2 mother
with prenatal labs that were unremarkable. Blood type AB
positive, antibody negative, HBSAG negative, RPR nonreactive,
Rubella immune, GBS negative. The [**Last Name (un) **] was [**2175-8-9**]. There
were no risk factors for infection. Mother was afebrile.
Artificial rupture of membranes was at delivery. There were
no antepartum antibiotics administered. This pregnancy was
notable for borderline IUGR with an estimated fetal weight of
less than 10th percentile, low-lying placenta, three episodes
of vaginal bleeding for which the patient was given
betamethasone on [**2175-6-9**].
Infant emerged vigorous with Apgars of 9 and 9. Baby
developed grunting in the delivery room and shortly after
birth had increased work of breathing and came to the NICU
approximately 2 hours after birth for perioral cyanosis.
Physical examination on admission showed a birth weight of
2650 grams which is 25th to 50th percentile. Length of 45 cm
which is 25th percentile. Head circumference of 32.5 cm
which is 25 to 50th percentile.
Physical examination at discharge: active, alert infant
comfortable in an open crib. HEENT showed anterior fontanel
soft and flat. No molding. Palate intact. CV: Normal rate
and rhythm, no murmur. Pulmonary: Clear lungs fields. No
grunting, flaring, or retractions. Abdomen soft, nontender,
nondistended. Positive bowel sounds. Three vessel cord.
Genitourinary: Normal female genitalia. Extremities:
Normal. Neuro: Normal. Normal reflexes, suck, and general
tone.
Growth measurements at discharge: Weight = 2445 grams, HC =
32.5 cm, Length = 46.0 cm.
HOSPITAL COURSE BY SYSTEMS:
Respiratory: The infant was briefly given an oxygen [**Doctor Last Name **] and
quickly progressed to nasal prong CPAP. Chest x-ray showed
mild hyaline membrane disease. The infant showed worsen ing
respiratory distress and after approximately 24 hours of age,
the infant had clinical decompensation with increased work of
breathing and increased FI02 requirements, requiring
intubation, at which time she was given Surfactant. Shortly af
ter the Surfactant administration and intubation, the infant
had a chest x-ray which showed a right pneumothorax. The
pneumothorax was not needled or treated and was just
monitored over time which resolved within 24 hours after its
onset. The infant self- extubated 24 hours after being
intubated and has remained in room air since that time. The
infant has had no issues with apnea or bradycardiac episodes
after extubation.
Cardiovascular: The infant has maintained a normal
cardiovascular status with no signs of murmur and is well
perfused.
Fluids, electrolytes and nutrition: The infant was made
n.p.o. on admission to the NICU and a peripheral IV was
inserted for IV fluids. Enteral feedings were initiated on
[**2175-7-22**], day of life 4 after the infant self-extubated. The
infant has been p.o. ad lib since that time, feeding E24 with
iron. Most recent weight is 2.445 kg.
Gastrointestinal: The infant developed hyperbilirubinemia
with a peak bilirubin level of 15.2 over 0.4 on [**2175-7-23**] at
which time phototherapy was started early in the a.m. A
repeat bilirubin level was done approximately 24 hours later
which was 10.8 over 0.4. Phototherapy was discontinued and a
rebound bilirubin level on [**2175-7-25**] (Day 7) was 10.5/0.3.
Hematology: CBC and blood culture were screened on admission
due to the increased work of breathing to rule out sepsis.
The hematocrit was 42. Platelet count of 375,000.
Infectious disease: CBC and blood culture were screened on
admission due to rule out sepsis from respiratory distress.
CBC was benign. The infant was started on ampicillin and
gentamicin which were subsequently discontinued at 48 hours
of age when the blood cultures remained negative and the
clinical status improved.
Neurology: The infant has maintained a normal neurologic
examination for gestational age.
Sensory:
Audiology: Hearing screen prior to discharge was obtained and
the infant passed in both ears.
Psychosocial: [**Hospital1 18**] social worker has been in contact with
the family. There are no active social concerns at this time
but, if there are any concerns, the social worker can be
reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 7019**] [**Last Name (NamePattern1) **], MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **],
telephone number [**Telephone/Fax (1) 37259**].
CARE RECOMMENDATIONS:
FEEDINGS: Ad lib p.o. feeds of Enfamil 24 with iron.
MEDICATIONS: None.
Iron supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All infants
fed predominantly breast milk should receive Vitamin D
supplementation at 200 i.u. (may be provided as a multi-
vitamin preparation) daily until 12 months corrected age.
Car seat position screening: Passed.
State newborn screen was sent on [**2175-7-21**] and [**2175-7-30**]. No
abnormal results have been reported.
IMMUNIZATIONS RECEIVED: Hepatitis B Vaccine on [**2175-7-25**].
IMMUNIZATIONS RECOMMENDED:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received the Rotavirus vaccine. The
American Academy of Pediatrics recommends initial vaccination
of preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
FOLLOWUP: Follow-up appointment is recommended with the
pediatrician on within 2 days of discharge.
DISCHARGE DIAGNOSES:
1. Late preterm infant.
2. Respiratory distress syndrome, resolved.
2. Right pneumothorax resolved.
3. Hyperbilirubinemia, resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2175-7-24**] 04:01:27
T: [**2175-7-24**] 06:02:54
Job#: [**Job Number 73428**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4957
} | Medical Text: Admission Date: [**2188-11-20**] Discharge Date: [**2188-12-18**]
Date of Birth: [**2164-7-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Tylenol Overdose
Major Surgical or Invasive Procedure:
[**2188-11-21**] Right IJ HD Catheter insertion, Left IJ triple lumen
catheter insertion
Hemodialysis
History of Present Illness:
Ms. [**Known lastname **] is a 24yF who is transferred from OSH with tylenol,
motrin, aleve and advil OD. On [**11-18**] the patient reports that
her boyfriend broke up with her and at 8:30pm she took ~80
extrastrength tylenol, ~20 aleve, ~20 advil, ~20 motrin. She
vomited shortly after taking the pills and vomitted ~10 tylenol
pills. She was driving at the time of the OD. She had severe
nausea and had multiple bouts of emesis. She denies hematemesis
but does report severe abdominal pain in the RUQ. The following
day at 3:30pm, she told her co-worker what she had done and was
taken to OSH by ambulance. At 6:30pm mucomyst and protonix gtt.
She remained hemodynamically stable with an intact mental
status. Lab values at OSH were significant for a tylenol level
of 153 and salicylate 21 at 22 hours after the OD. Alt 1209, Ast
1149, AO 69, Tb 4.7. The patient was transferred to [**Hospital1 18**] for
further managment.
Of note the patient did have a similar overdose when she was 11
years old--she either overdosed on her mother's "heart pills" or
tylenol. When asked if this was a suicide attempt, she insists
that she has never attempted suicide and that these two attempts
were to get attention.
Past Medical History:
PMH: OD at 11yrs--treated with NG lavage
PSH: none
HPV s/p LEEP
IUD placement
Social History:
Employed in cleaning houses. 12pack smoking year history, social
ETOH use. Marijuana in past but has not smoked in many years.
Denies hx IVDU.
Family History:
Mild MR in mother and sister. 3 sisters with asthma. "heart
disease" in mother
Physical Exam:
On Admission:
VS T 97.7 HR 74 BP 122/68 RR 96% SAT RA
Gen: A and O x 3. Flat affect. Minimal insight
Card: RRR midsystolic click. no m/r/g
Pulm: end expiratory wheeze
Abd: exquisitely TTP in RUQ. No rebound. Voluntary gaurding
Ext: No edema
PHYSICAL EXAMINATION: on admission to Liver service [**2188-11-27**]
VS (in SICU) 98.3 (tm 99.4 at 0400) BP 122/75 Hr 70 RR 18
O298/RA
GENERAL - young well nourished anxious appearing young caucasian
female, sitting in bed at bedside, flat affect, AOx3
HEENT - PERRL, b/l scleral hemorrhage w clear conjunctival
discharge, EOMI, unable to assess if sclerae icteric, MMM, OP
clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT, mild tenderness, no rebound/guarding
EXTREMITIES - diffuse nonpitting edema in UE/LE, no c/c, 2+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-28**] throughout, sensation grossly intact throughout
Pertinent Results:
[**2188-11-20**] 03:23AM PT-58.5* PTT-40.1* INR(PT)-6.6*
[**2188-11-20**] 03:23AM WBC-31.1* RBC-4.52 HGB-14.3 HCT-41.9 MCV-93
MCH-31.6 MCHC-34.1 RDW-13.6
[**2188-11-20**] 03:23AM ASA-13.8 ETHANOL-NEG ACETMNPHN-72*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-11-20**] 03:23AM HCG-<5
[**2188-11-20**] 03:23AM ALBUMIN-3.8 CALCIUM-8.1* PHOSPHATE-3.9
MAGNESIUM-1.8
[**2188-11-20**] 03:23AM LIPASE-45
[**2188-11-20**] 03:23AM ALT(SGPT)-7485* AST(SGOT)-8310* LD(LDH)-6180*
CK(CPK)-107 ALK PHOS-50 AMYLASE-39 TOT BILI-3.1*
[**2188-11-20**] 03:23AM FIBRINOGE-144*
[**2188-11-20**] 03:23AM GLUCOSE-117* UREA N-11 CREAT-1.1 SODIUM-138
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-13* ANION GAP-19
[**2188-11-20**] 05:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-TR KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM
[**2188-11-20**] 05:52AM HCV Ab-NEGATIVE
[**2188-11-20**] 05:52AM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**11-21**] CXR: FINDINGS: In comparison with study of [**11-20**], there
has been placement of a right IJ catheter that extends to the
upper portion of the SVC and a left IJ catheter that extends
slightly more distally. No evidence of pneumothorax. There is
some increased prominence of the transverse diameter of the
heart with ill-defined pulmonary vessels suggesting elevated
pulmonary venous pressure. Hazy opacification in the right
hemithorax could represent layering effusion. Mild atelectatic
changes are seen at the bases.
[**11-26**] CXR: IMPRESSION:
1. New retrocardiac consolidation without evidence of volume
loss, likely pneumonia, but may represent atelectasis.
2. Small left pleural effusion with interval decrease in the
small right-sided effusion.
3. Stable position of right IJ line with slight advancement of
the left IJ line into the mid-to-lower SVC.
RUQ u/s [**2188-11-28**]
IMPRESSION: No hydronephrosis. No cyst or stone or solid mass
seen
bilaterally. Increased echogenicity of the kidneys bilaterally
is consistent
with diffuse parenchymal disease.
Liver u/s
MPRESSION:
1. Echogenic liver consistent with fatty infiltration; other
forms of more
severe hepatic fibrosis/cirrhosis cannot be ruled out.
2. Small bilateral pleural effusions.
3. Thickened gallbladder wall likely reactive given underlying
liver
disease/toxicity.
CT abd [**2188-12-2**]
IMPRESSION:
1. Left pleural effusion with associated passive atelectasis.
2. Diffuse subcutaneous anasarca as well as edema throughout the
mesentery, likely representing aggressive hydration.
3. No evidence of retroperitoneal bleed.
[**2188-12-15**] 06:00AM BLOOD HCV Ab-NEGATIVE
[**2188-11-20**] 05:52AM BLOOD HCV Ab-NEGATIVE
[**2188-12-16**] 4:35 am IMMUNOLOGY CHM S# [**Serial Number 88173**]H.
**FINAL REPORT [**2188-12-17**]**
HCV VIRAL LOAD (Final [**2188-12-17**]):
HCV RNA detected, less than 43 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
[**2188-12-12**] 4:20 am IMMUNOLOGY
CHM S# [**Serial Number **]H QUANTITATION BEYOND 850,000 IU/ML ADDED
[**12-12**].
**FINAL REPORT [**2188-12-15**]**
HCV VIRAL LOAD (Final [**2188-12-15**]):
HCV RNA detected, less than 43 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
[**2188-12-15**] 2:08 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2188-12-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2188-12-16**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2188-11-20**] 5:52 am SEROLOGY/BLOOD Source: Venipuncture.
**FINAL REPORT [**2188-11-21**]**
RAPID PLASMA REAGIN TEST (Final [**2188-11-21**]):
NONREACTIVE.
Reference Range: Non-Reactive.
COPPER
Test Result Reference
Range/Units
COPPER, 24 HOUR URINE 66 H 15-60 mcg/24 h
24 HR URINE VOLUME 1350 mL/24 h
REPORT COMMENT: PH:5
THIS TEST WAS PERFORMED AT:
[**Company **]/CHANTILLY
[**Numeric Identifier 14272**]
CHANTILLY, [**Numeric Identifier 14273**]
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 14274**], MD
Comment: Source: CVS
EGD [**2188-12-4**]
Findings: Esophagus: Normal esophagus.
Stomach:
Other Unable to visualize stomach due to large food bolus
Duodenum: Normal duodenum.
Impression: Unable to visualize stomach due to large food bolus
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Ms. [**Known lastname **] is a 24 year old female who was initially admitted to
the SICU [**11-20**] two days after intentional overdose of tylenol,
motrin, aleve, and advil resulting in fulminant hepatic failure
and acute renal failure requiring dialysis. In regards to her
liver failure, her tylenol level upon transfer was noted to be
153. She was maintained on a mucomyst drip which was initially
started immediately upon admission to the OSH approximately 22
hours after consumption of medications. This was continued
throughout her ICU course. Upon [**Hospital **] transfer to [**Hospital1 18**], her
bilirubin was elevated to 3.1, INR was 6.6, and transaminases
were in the 7000s. Her INR continued to rise as high as 10 on
HD#2 when this was reversed with FFP and vitamin K for CVL and
dialysis line placement. At the time of transfer her bilirubin
was Her transaminases continued to rise and peaked on at [**Numeric Identifier 2249**]
and [**Numeric Identifier 7206**] and are now trending down. They were 1166 and 57 at
the time of transfer out of the SICU. Her total bilirubin was
12.3 at the time of transfer. During her ICU course she was
noted to have worsening hepatic encephalopathy, however was
always arousable and oriented, and never required intubation or
placement of cerebral bolt. After several days however, her
lethargy began improving and at the time of transfer she was
alert, awake, oriented x 3, and following commands without
difficulty. Upon admission to the SICU she was evaluated by
social work and psychiatry because of the overdose and was
diagnosed with adjustment disorder vs. MDD, and was felt to
require psychiatric admission once medically cleared. She was
maintained on 1:1 during her entire SICU course.
#Tylenol overdose: Taken 80tabs at home prior to admission to
OSH after breakup with her boyfriend. She was transferred to
[**Hospital1 18**] for further care and consideration for liver transplant.
Pt has been on SICU followed by transplant surgery, hepatology,
toxicology, psychiatry and nephrology. Pt was listed as status 1
however did not require a transplant. Likely will not transplant
now unless she decompensates.
Labs on admisison: ([**11-20**]) INR 6.6, peaked later that day to
9.5. Creat (pk) 6.8, peak transaminases ALT [**Numeric Identifier 88174**], AST [**Numeric Identifier 7206**].
Admission bilirubin 3.1, and increased to peak 20.2 in setting
of concomitant infections: HAP, UTI, and Cdiff. Bilirubin and
WBc trended down after initiation of flagyl for ciff and
continuation of vanco and zosyn for HAP. She was started on NAC
@ 6.25mg/kg/hr on admission per toxicology recommendations and
was discontinued on [**2188-12-3**]. Synthetic function and glucose
levels improving and pt did not require insulin coverage after
transfer to general wards on [**2188-11-27**]. Postprandial nausea
eventually resolved.
She was transfused 1u pRBC on [**12-2**] and [**12-13**] for slowly
downtrending Hct. EGD negative for varices, gastropathy or other
findings. She was continued on PPI until dx'd w cdiff then
swtiched to H2 blocker. Most likely explanation for anemia is
gastritis [**2-26**] ICU stay and noncompliance w PPI during initial
days in transfer to general liver wards.
She was also started on pantoprazole until dx'd w Cdiff and then
changed to ranitidine. Pt was followed by psychiatry during her
stay. She was continued w 1:1 sitter while in-house with plan to
transfer to inpt psych unit when medically cleared. Sec. 12
signed, in chart.
She was taken for liver biopsy on [**12-16**] (transjugular) for
unresolving LFTs, low ceruloplasmin, and workup of possible
Wilson's D. Liver biopsy showed resolving inflammation [**2-26**]
tylenol overdose. Expect LFTs to resolve over time. Urine copper
slightly elevated. Possible KF rings on bedside ophthalmology
exam. She will follow up at ophthalmology clinic for slit lamp
exam - appt in DC plan. Liver copper level pending - Will be
followed up by Dr. [**Last Name (STitle) **] at liver clinic follow up in [**Month (only) 1096**].
Rest of liver workup to be completed as an outpatient. Medically
cleared from hepatic standpoint.
Plan for weekly labs drawn: cbc, chem10, coags, and lfts. To be
followed by the liver clinic.
# ARF: Course has been complicated by anuria on hospital day 2
and metabolic acidosis. She was seen and followed by nephrology.
Her UA was significant for muddy brown casts consistent with
ATN from tylenol and NSAID induced toxicity. Her Cr on
admission was initially 1.1, however this began to quickly rise
and she began having worsening oliguria. She was also noted to
have a gap and nongap metabolic acidosis. This was initially
treated with sodium bicarbonate. However, she ultimately
required dialysis. She is currently dialyzed on a Monday,
Wednesday, and Friday schedule.
Had first HD last Friday [**11-21**] via R-IJ, and was last dialyzed
on Wednesday [**12-3**]. Renal U/s obtained for prognostic value.
Tunneled line was deferred for improving renal function. HD was
discontinued on [**12-3**] after pt exhibited multiple days of
increasing urine output >1L daily and spontaneously decreasing
serum creatinine [**12-5**]. HD line was removed on [**12-3**]. Pt cont to
put out >2L urine daily, and serum creatinine resolving towards
normal. Renal team signed off given resolving kidney injury.
Would continue to avoid NSAIDs.
# HAP: HD# 7 her WBC count was noted to rise from 8.8 to 18.6.
Urine and blood cultures were sent and remain negative. A
portable chest xray was concerning for a retrocardiac opacity
that may represent a pneumonia. She was started on empiric
vancomycin and zosyn for HAP and questionable chest xray
findings on portable study. She continued to exhibit low grade
temps however was never hypoxic, and did not have cough, sputum
production, pleurisy, SOB or chest pain. She completed an 8 day
course of ABX. On [**12-11**] she complained of SOB and noted to have
fever to 102. Chest xray suggestive of pneumonia likely [**2-26**]
aspiration event from vomiting episode one day before. She was
started on Vancomycin, IV flagyl, and cefepime for broad
coverage given underlying liver disease and prior ICU stay. She
completed 8 day course on [**12-17**] w/o difficulty and has been
afebrile since initiation. Negative blood cultures. PICC removed
on [**12-18**].
# Cdiff: Pt continued to have abd pain and low grade temps on
the floor. Normal stool output. Cdiff positive on repeat toxin
assay and pt was started flagyl 500mg Q8 on [**12-1**] with plan to
continue coverage until [**12-15**]. WBC downtrended and low grade
temps abated after initiation of flagyl. Plan to continue PO
flagyl therapy for 2 weeks to prevent relapse given recent broad
spectrum antibiotic therapy.
# UTI: Urine cx growing coag neg staph that was obtained in ICU.
Foley cath dc'd and culture susceptibility to vancomycin - pt
completed 8 day course w concomitant coverage for HAP.
# Psych: Pt denies SI/HI/AH/VH however it is clear that she
intentionally overdosed. Pt is unable to signout AMA. Social
work and psychiatry following. Pt has no HCP, estranged from
mother/sisters, ex-boyfriend does not want to be involved, 5yo
daughter in full custody of grandparents.
Has been texting w ex boyfriend over last few days prior to
transfer to psych. Unwilling to discuss w team.
Describes abd discomfort likely [**2-26**] capsular irritation from
tylenol injury. Will cont to feel this sensation pending liver
healing up to 3-6months possible. Alleviated anxiety and
sensation w 0.25mg PO lorazepam QHS.
Insomnia managed with trazodone 25mg qhs w good effect.
Medications on Admission:
None
Discharge Medications:
1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-26**]
Drops Ophthalmic PRN (as needed) as needed for discomfort.
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 13 days: continue for 13 day course to prevent
relapse given recent broadspectrum abx.
Discharge Disposition:
Extended Care
Facility:
deaconness 4
Discharge Diagnosis:
Tylenol overdose
Hospital acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after an overdose on a number
of over the counter medications including tylenol. While you
were here, these medications caused your liver and kidneys to
fail. You required dialysis to filter your blood since your
kidneys could not do so. At the time of discharge, you are no
longer requiring dialysis as your kidneys have recovered. Also,
you were treated here for a pneumonia and a UTI. You were found
to have an infection in your colon which requires antibiotic
treatment. Your follow up test for this infection was negative
however you need to continue this antibiotic to prevent
recurrence for another 2 weeks.
.
The following changes were made to your medications:
STARTED Flagyl for 14 days
STARTED Ranitidine to prevent GI pain and formation of ulcers
.
Please follow up with your doctors as stated below.
Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2188-12-22**] at 1:45 PM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 54295**] will contact you with appt information regarding time.
Department: LIVER CENTER
When: THURSDAY [**2189-1-8**]
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5845, 5070, 5990, 2762, 2859, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4958
} | Medical Text: Admission Date: [**2184-10-5**] Discharge Date: [**2184-10-10**]
Date of Birth: [**2126-5-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2184-10-6**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
OM, SVG to Diag, SVG to PDA)
History of Present Illness:
58 y/o male with 2 week h/o chest "burning". Had a +ETT and then
referred for cardiac cath. Cath revealed 3 vessel disease. He
was then transferred from OSH to [**Hospital1 18**] for surgical management.
Past Medical History:
Hypertension
Hypercholesterolemia
Benign Prostatic Hypertrophy
Arthitis
Herniated Disc s/p surgery x 2
Social History:
Lives with wife. Contractor. -[**Name2 (NI) **] x 10yrs. 1 ETOH/wk.
Family History:
+FH: Father died of MI at age 56. Brother died of MI at age 59.
Physical Exam:
Admission
NAD
HEENT: EOMI, PERRL, OP benign
Lungs: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft NT/ND +BS
Ext: Warm, 2+pulses throuhgout, trace edema
Neuro: A&O x 3, MAE, non-focal
Discharge
Temp 98.6, HR 72, B/P 117/67, RA Sat 94% Wt: 105.9kg (preop
104.5kg)
Lungs: Clear to ausculation bilaterally
Heart: Regular, S1, S2
Abdomen: Soft, nontender, nondistended
Ext: Warm, trace edema
Neuro: alert and oriented x3
Incision: sternal midline and left leg - no drainage, no
erythema
Pertinent Results:
Echo [**10-6**]: Pre-CPB: Left ventricular wall thicknesses and cavity
size are normal. Resting regional wall motion abnormalities
include mild apical hypokinesis.. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic [**Month/Year (2) 5236**]. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Post CPB: Preserved biventricular systolic
fxn. No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Other parameters as pre-bypass.
[**2184-10-5**] 04:10PM BLOOD WBC-6.3 RBC-4.25* Hgb-13.2* Hct-36.3*
MCV-85 MCH-31.2 MCHC-36.5* RDW-13.4 Plt Ct-215
[**2184-10-5**] 04:10PM BLOOD PT-12.3 PTT-26.6 INR(PT)-1.1
[**2184-10-5**] 04:10PM BLOOD Glucose-88 UreaN-15 Creat-1.0 Na-144
K-5.0 Cl-105 HCO3-30 AnGap-14
[**2184-10-5**] 05:43PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2184-10-9**] 05:30AM BLOOD WBC-10.1 RBC-3.14* Hgb-9.9* Hct-27.0*
MCV-86 MCH-31.6 MCHC-36.7* RDW-13.4 Plt Ct-170
[**2184-10-9**] 05:30AM BLOOD Plt Ct-170
[**2184-10-9**] 05:30AM BLOOD Glucose-108* UreaN-22* Creat-0.9 Na-138
K-4.4 Cl-100 HCO3-31 AnGap-11
CHEST (PORTABLE AP) [**2184-10-8**] 11:34 AM
CHEST (PORTABLE AP)
Reason: s/p CT d/c, eval ptx
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with s/p CABG
REASON FOR THIS EXAMINATION:
s/p CT d/c, eval ptx
INDICATION: Status post CABG. Evaluate for pneumothorax.
PORTABLE AP CHEST.
COMPARISON: [**2184-10-6**].
A right IJ catheter tip overlies the distal SVC. There is
moderate cardiomegaly. The patient is status post CABG with
normal alignment of the sternal sutures. There has been interval
removal of the ET tube and the NG tube, chest tubes and
mediastinal drain. There is no pneumothorax, no CHF. The left
retrocardiac opacity obliterating the diaphragmatic silhouette
is consistent with atelectasis.
IMPRESSION:
1. No pneumothorax.
2. Left lower lobe atelectasis.
DR. [**First Name (STitle) 29814**] [**Name (STitle) 65954**] [**Doctor Last Name **]
Approved: FRI [**2184-10-8**] 11:41 PM
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 18252**] was transferred from the OSH
after cath revealed severe 3 vessel coronary artery disease. He
underwent usual pre-operative testing and on [**10-6**] he was brought
to the operating room where he underwent a coronary artery
bypass graft x 4. Please see operative report for surgical
details. He tolerated the procedure well and was transferred to
the CSRU for invasive monitoring in stable condition. Later on
this day he was weaned from sedation, awoke neurologically
[**Month/Year (2) 5235**] and was extubated. On post op day one his chest tubes
were removed. He was also started on Beta blockers and diuretics
and was transferred to the floor. He was gently diuresis, and
physical activity increased. On POD 4 he was discharged home
with services.
Medications on Admission:
Toprol XL 25 qd, Lisinopril 10 qd, Lipitor 10 qd, Aspirin 325
qd, NTG prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Hypertension, Hypercholesterolemia, Benign Prostatic
Hypertrophy, Arthitis, Herniated Disc s/p surgery x 2
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower over incisions and pat dry.
No lotions, creams, or powders on incisions.
No driving for one month.
No lifting greater than 10 pounds for 10 weeks.
Call for fever greater than 100, redness or drainage from
incisions.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 3659**] in [**2-13**] weeks
Dr. [**Last Name (STitle) 59121**] in [**1-12**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2184-10-11**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4959
} | Medical Text: Admission Date: [**2199-8-12**] Discharge Date: [**2199-8-20**]
Date of Birth: [**2143-10-8**] Sex: F
Service: GREEN SURGERY
HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old female
with a history of multiple ventral hernia repairs, the latest
being on [**2199-6-15**], who presents to the Emergency Room
today with diaphoresis, nausea, vomiting, and fever. Her
abdominal wound was opened secondary to intermittent
serous drainage and mild scattered erythema. She was put on
Keflex followed by levaquin and the erythema resolved. At
present, she has no complaints of chest or abdominal pain.
Patient has also had some loose stoo since last night.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Goiter.
3. Obesity.
4. Asthma.
5. Fibromyalgia.
PAST SURGICAL HISTORY:
1. Multiple mesh ventral hernia repairs, last one being [**2199-6-15**], with prior panniculectomy.
2. Cesarean section x2.
3. Right salpingo-oophorectomy.
4. Liver hemangioma resection.
5. Left breast biopsy.
MEDICATIONS:
1. Synthroid.
2. Diovan.
3. Calcium.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs: Temperature is 99.8,
blood pressure is 85/52, pulse is 96, respiratory rate is 14.
Her heart examination is regular, rate, and rhythm with no
murmurs, rubs, or gallops. Her lungs are clear to
auscultation bilaterally. Abdomen is soft with mild to moderate
right upper quadrant tenderness distinct from her incisional
wound on the right mid abdomen. She is obese. Positive bowel
sounds in all four quadrants. Rectal examination is guaiac
negative. Extremities are without clubbing, cyanosis, or edema.
LABORATORIES: White blood cell count was 23.5, hematocrit
33.9, platelets 268. Sodium 137, potassium 3.6, chloride
100, bicarbonate 23, BUN 21, creatinine 1.0, glucose of 138.
After Dr [**Last Name (STitle) 519**] noted her to be icteric, LFTs were obtained
(below) and found elevated.
Chest x-ray was negative.
CT scan of the abdomen and pelvis showed a stable appearance
of a fatty infiltrated liver with no abscesses in either the
peritoneal cavity or the abdominal wall. It also showed some
stranding and soft tissue thickening adjacent to the skin
defect in the right anterior abdominal wall without any
associated abscess. There is some evidence of diverticulosis
and inguinal hernia on the right that was nonobstructive.
HOSPITAL COURSE: Patient was admitted to the floor for apparent
sepsis without any localizing source. She was given empiric
levofloxacin and Flagyl antibiotics. She was kept NPO and
was aggressively rehydrated.
On hospital day one, [**2199-8-13**], patient was admitted to the
SICU with hypotension of 70s-80s systolic blood pressure.
On hospital day one, the patient was transferred from the
floor to SICU with hypotension. Patient has had chronic
right upper quadrant abdominal wound for multiple hernia
repairs. She denied any chest pain, shortness of breath,
cough, congestion, or any blood in her bowel movements. She
also denies any stiff neck, photophobia, rash, numbness,
weakness, or tingling. She also denies any dysuria,
hematuria, or frequency.
On admission to the SICU, the patient was hypotension with
minimal response with fluids. She is on levofloxacin and
Flagyl. Vancomycin was added on the day of admission to the
SICU. Her laboratories prior to admission to the SICU was
white blood cell count of 23.5, hematocrit of 33.9, platelets
268. Chem-7 was normal. Urinalysis was preliminarily
negative. AST 86, ALT 89, LDH 229, alkaline phosphatase 76,
total bilirubin 3.8, amylase 47, ESR of 75 with a C-reactive
protein of 29.
While in the SICU, patient received an arterial line. Also
received a left subclavian central venous line. Infectious
Disease was consulted and requested hepatitis serology as
well as blood and stool cultures which were sent. While in
the SICU, a PA catheter was inserted. The patient was
treated with Levophed with good response. Patient's levo was
weaned off with approximately 12 hours. Patient continued to
be treated with Levaquin, Flagyl, and Vancomycin. An
echocardiogram was negative for any vegetations. Patient was
ruled out for myocardial infarction by electrocardiogram and
cardiac enzymes. She had a liver and a gallbladder
ultrasound done on [**8-14**] that was negative.
She had intermittent episodes of atrial fibrillation and
flutter that was self limiting. She was treated with
Lopressor and transfused 1 unit of packed red blood cells.
Electrolytes were repleted. Patient was transferred to the
floor on hospital day three.
Upon transfer to the floor, patient's LFTs were AST 108, ALT
139, alkaline phosphatase 124, total bilirubin of 4.1 with a
direct bilirubin of 2.7. GI was consulted. They suggested that
the LFT pattern was suggestive of sepsis of unknown etiology.
The surgical service felt that an episode of self-limiting
cholangitis, given the RUQ pain, unclear source of sepsis, and
previous major liver resection, was equally plausible.
Hepatitis panels were drawn and were all negative. In
addition, an MRI cholangiogram was normal. Stool cultures were
all negative.
While on the floor, the patient was advanced from NPO to a
regular diet as tolerated. The patient was able to tolerate
regular food without difficulty. The patient was out of bed
and ambulating. She had no complaints of pain and was
afebrile. She had no other episodes of hypotension. Her
LFTs and white blood cell count continued to trend downward.
White blood cell count on the day of discharge was down to
10.7. Her last Chem-7 on the day prior to discharge was a
sodium of 143 potassium 4.1, chloride 108, bicarb of 29, BUN
of 8, creatinine of 0.5, and a glucose of 110. LFTs showed
an ALT of 36, and AST of 23, alkaline phosphatase of 78,
amylase 42, and total bilirubin of 0.8.
Patient's abdominal wound continued to be changed twice a day
on the floor with Dakin solution. On the day of discharge,
the wound is clean, dry, and intact without any evidence of
erythema. The patient was discharged home on a seven day
course of Flagyl and levofloxacin.
CONDITION ON DISCHARGE: Good/stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Bacteremia/sepsis (fever, nausea, vomiting, diarrhea, and
hypotension) of unknown origin, possibly biliary.
2. Hypertension.
3. Goiter.
4. Asthma.
DISCHARGE MEDICATIONS:
1. Dakin solution sodium hypochloride 0.5% liquid to be
applied on wet-to-dry dressings [**Hospital1 **].
2. Flagyl 500 mg tablets one tablet po tid for seven days.
3. Levaquin 500 mg tablets one tablet po q day for seven
days.
4. The patient is also instructed to go back on her home
medications.
FOLLOW-UP PLANS: The patient is to followup with Dr. [**Last Name (STitle) 519**]
next [**Last Name (LF) 2974**], [**2199-8-30**]. She is instructed to call his
secretary to schedule an appointment, and telephone number is
provided.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 28130**]
MEDQUIST36
D: [**2199-8-20**] 11:35
T: [**2199-8-28**] 08:23
JOB#: [**Job Number 103555**]
ICD9 Codes: 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4960
} | Medical Text: Admission Date: [**2140-3-1**] Discharge Date: [**2140-3-18**]
Date of Birth: [**2075-9-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
[**2140-3-2**] Rigid bronchoscopy with airway biopsies
[**2140-3-8**] Bronchoscopy, Esophagoscopy, Cervical mediastinoscopy,
Laparotomy with harvesting of omental flap and repair of
umbilical hernia, Right thoracotomy with intrapericardial
pneumonectomy,
radical mediastinal lymphadenectomy and omental flap
bronchoplasty.
History of Present Illness:
64M with recently diagnosed squamous cell ca of RLL presents
from a referring institution with hemoptysis, BRBPR, generalized
weakness and fatigue. He is s/p neoadjuvant chemotherapy and
radiation recently ending mid-[**Month (only) **]. He was transferred to
[**Hospital1 18**] for intervention.
Past Medical History:
h/o knee injury s/p surgical repair
childhood rheumatic fever
Social History:
1 ppd as adult, lives alone in [**Location (un) 5503**].
Physical Exam:
NAD, mildly tachypnic at rest
Bilateral rhonchi (R>L), + bilateral wheezes
RRR
soft, NT, ND
no edema
Pertinent Results:
[**2140-3-14**] 04:30AM BLOOD WBC-4.8 RBC-3.22* Hgb-9.8* Hct-28.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-15.0 Plt Ct-229
[**2140-3-14**] 04:30AM BLOOD Plt Ct-229
[**2140-3-14**] 04:30AM BLOOD Glucose-107* UreaN-38* Creat-3.6* Na-142
K-3.5 Cl-106 HCO3-27 AnGap-13
[**2140-3-10**] 04:59PM BLOOD ALT-40 AST-55* LD(LDH)-329* AlkPhos-66
TotBili-0.9
[**2140-3-14**] 04:30AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.4
[**2140-3-2**] Bronch Pathology:
Main carina, Trachea, and Right mainstem biopsies:
1. Fragments of fibrinopurulent exudate, acute and chronic
inflammation.
2. Scant fragments of granulation tissue with changes
consistent with history of radiation therapy.
3. Respiratory epithelium with squamous metaplasia and florid
regenerative change.
[**2140-3-3**] ECHO: LVEF 60%, nl LA, nl LV thickness, nl LV filling
pressure, no masses/thrombi in LV, no VSD, RV chamber size and
wall motion nl, mildly dilated ascending aorta, no Ao regurg,
trivial MR, no pericardial effusion.
[**2140-3-3**] Lung Scan: Matched decreased ventilation and perfusion in
the right lower lobe corresponding to the patients known lung
mass. The right lower lobe contributes little to current
pulmonary function.
[**2140-3-4**] UGI: No evidence of obstruction or stricture. Tiny 2 mm
left-sided
esophageal diverticulum seen approximately at C6 level.
[**2140-3-7**] PFTs:
SPIROMETRY 11:15A Pre drug Post drug
Actual Pred %Pred Actual %Pred
%chg
FVC 2.52 3.49 72 2.81 81
+11
FEV1 1.84 2.48 74 2.09 84
+13
MMF 1.28 2.59 49 1.60 62
+25
FEV1/FVC 73 71 103 75 105
+2
LUNG VOLUMES 11:15A Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 4.40 5.45 81
FRC 2.22 3.03 73
RV 1.81 1.96 92
VC 2.63 3.49 75
IC 2.18 2.42 90
ERV 0.40 1.07 38
RV/TLC 41 36 115
He Mix Time 3.63
DLCO 11:15A
Actual Pred %Pred
DSB 9.38 24.35 39
VA(sb) 3.82 5.45 70
HB 8.30
DSB(HB) 12.31 24.35 51
DL/VA 3.22 4.47 72
[**2140-3-11**] Renal US: Normal [**Doctor Last Name 352**]-scale and Doppler renal
ultrasound.
Brief Hospital Course:
64M with a large, cavitary RLL squamous cell ca transferred with
hemoptysis, weakness and fatigue. On arrival he had fever of
103.3 and was started empirically on vanc and zosyn for
presumptive post-obstructive pneumonia. On HD2 pt underwent
rigid bronchoscopy with airway biopsies which showed no evidence
of tumor (only inflammation) at the hilum. He was subsequently
worked up for possible resection of R lung. Despite vanc and
zosyn for pneumonia, pt continued to spike fevers, but all
cultures were negative. He had no episodes of hemoptysis during
his hospital stay. PFT's and quantitative V/Q scan suggest 75%
of function remains in left lung, which implies adequate reserve
to tolerate resection and pneumonectomy. ECHO was negative for
mitral or aortic valve vegetations. Pt was also complaining of
dysphagia. UGI showed a 2mm left-sided esophageal diverticulum
seen approximately at C6 level, but
no obstruction or stricture. He was explained the risks,
benefits, and alternatives to surgery (particularly, his
increased risk of death given recent chemotx/radiation/active
infection), and it was decided to proceed with the operation.
On [**2140-3-8**], pt underwent laparotomy with harvesting of omental
flap and repair of umbilical hernia, right thoracotomy with
intrapericardial pneumonectomy,
radical mediastinal lymphadenectomy and omental flap
bronchoplasty (see operative report for details). Pt was
extubated in the operating room and transferred to the CSRU for
ICU monitoring.
[**Name (NI) **], pt was requiring neo for hypotension. His
pain was controlled with epidural and PCA. His intake (IV and
PO) was initally limited to 1L/day given his reduced lung
volume. As expected, his Cr rose secondary to acute pre-renal
failure. Nephrology was consulted to assist in management of
his ARF. Vanc levels were checked daily and dosed as needed.
Renal US was negative for hydronephrosis. His urine output
continued to be adequate. On POD1, the chest tube was removed
and post-pull CXR was negative for PTX. On POD3 pt was doing
well and transferred to the floor. The remainder of his
hospital course was uneventful. His diet was advanced to
regular pureed, although he was having difficulties taking in
POs secondary to his dysphagia. PT and OT evaluated and cleared
him for discharge home. His epidural and foley were removed and
pain controlled with PO analgesia. His antibiotics were
continued 10d post-op and were completed [**2140-3-18**].
Disposition planning initiated and coordinated w/ case
management, social work, thoracic surgery/team NP, physical
therapy.
By POD 10 pt was stable and discharged home in stable condition
with VNA services, evaluation of home services, specifically
physical therapy. Pt has some local supports in addition to VNA
services.
Medications on Admission:
protonix 40mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*240 ML(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
7. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed.
Discharge Disposition:
Home With Service
Facility:
Community VNA of [**Location (un) 6981**]
Discharge Diagnosis:
PAST MEDICAL HISTORY:
1) Squamous cell lung cancer: Diagnosed in [**2138**]. Status post
chemotherapy and radiation, last in mid-[**1-28**]) Knee injury status post surgical repair
3) Childhood rheumatic fever
4) Esophageal diverticulum
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office/Thoracic Surgery office ([**Telephone/Fax (1) 170**])
for: fever, shortness of breath, chest pain, excessive foul
smelling drainage from incision sites, fever, or chills or
difficulty swallowing.
Take medications as directed
Take pain medication as directed and as needed. You may take
tylenol of narcotic medication too strong and makes you too
drowsy.
No driving if taking narcotic medication.
You may shower when you return home. NO tub baths, hot tubs, or
swimming for 3-4 weeks.
You will be followed by Dr. [**Last Name (STitle) **] for surgical issues.
By Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 55855**] for other health issues/ primary care issues
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on [**3-31**] at 11am in
the [**Hospital Ward Name 23**] clinical center [**Location (un) **]. Arrive 45 minutes prior
to your appointment and report to the [**Hospital Ward Name 23**] clinical center
[**Location (un) **] radiology for a routine chest XRAY.
You have a follow up appointment with the nephrologist Dr. [**Last Name (STitle) 1860**]
[**2140-3-25**] at 3:30pm [**Hospital Ward Name 23**] [**Location (un) 436**] Medical Specialties
([**Telephone/Fax (1) 60**])
Completed by:[**2140-3-22**]
ICD9 Codes: 5845, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4961
} | Medical Text: Admission Date: [**2196-8-24**] Discharge Date: [**2196-10-3**]
Date of Birth: [**2144-8-3**] Sex: F
Service: MEDICINE
Allergies:
Lactose / Heparin Agents / Bactrim / meropenem / Zosyn /
Levofloxacin / pantoprazole
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Desquamative skin rash
Major Surgical or Invasive Procedure:
Extubation [**2196-8-26**]
Lumbar puncture
History of Present Illness:
Ms. [**Known lastname 53536**] is a 52 year old female well know to this service
with a complicated history as detailed in multiple previous
notes. In brief she has a history of HIV (last CD4 782 and VL
undetectable) and adult still's disease (on chronic steroids)
and she presented originally on [**8-12**] with L shoulder and L ankle
pain but had a complicated MICU course with hypotension and
multi-organ failure thought to be due to still's
flare/macrophage activation syndrome. She ultimately required
transfer to the burn unit at [**Hospital1 112**] on [**2196-8-22**] for concern of SJS
vs TEN given evolving desquamating skin lesions. After a 3 day
hospitalization, she is being transferred back to the MICU at
[**Hospital1 18**].
The patient's recent troubles began when she was seen in clinic
on [**8-12**] with left shoulder and ankle pain. She underwent an
arthrocentesis which showed very high neutrophil count and
therefore she was admitted with concern for septic arthritis. On
[**8-13**], the patient was taken to the OR for I&D of her L ankle and
L shoulder. Soon after the surgery, the patient rapidly
deteriorated and became unstable with fever, hypotension,
tachycardia, and lactic acidosis. She was then transferred to
the MICU for hypoxemia and hypotension. She required intubation,
pressors, and CVVH for oliguric renal failure. Her course was
further complicated by pancytopenia, DIC, and transaminitis. She
was treated empirically with broad spectrum antibiotics
including doxycycline, Piperacillin-Tazobactam, vancomycin, and
meropenem which were discontinued as a bacterial source was
thought to be unlikely.
The source of her acute illness appears to be a flare of still's
disease. She was treated with high dose steroids and anakinra
with some improvement. [**Month/Day (4) **] cultures from [**8-19**] grew [**First Name5 (NamePattern1) 564**]
[**Last Name (NamePattern1) 53550**] and she was started on micafungin. Then on [**8-22**] she
developed skin sloughing concerning for SJS/TEN and she was
transferred to a burn unit for further management.
In the [**Hospital1 112**] burn unit she was seen by dermatology who performed
biopsy which was inconclusive and thought consistent with
cytotoxic drug erruption versus TEN. Throughrout course at
[**Hospital1 756**], skin lesions remained stable and did not progress,
dermatology did not think clinical picture was consistent with
SJS or TEN and though they agree that this was a severe drug
rash. She was seen by GYN who did not note any internal
involvment but did note labial involvment. Opthalmology
recommended continuation of erythromycin eye drops for possible
bacterial conjunctivitis and did not think there was any
opthalmic involvment related to the drug rash. She began to make
increasing amounts of urine and did not receive any further
CVVH. She was transfused 1 unit PRBC for HCT 19 with improvment
to 22.
Ventilator setting were weaned to prssure support [**5-14**] and on the
day of transfer, she tolerated pressure support 0/0 for 45
minutes and appeared comfortable.
Given clinical improvment, she was transferred back to [**Hospital1 18**] for
further management. Vitals on transfer: HR 78 135/65
(110-130/50-60) pressure support [**5-14**] tital volume 380 and rr 20
40%Fio2 SaO2100% Since 12AM IN:520 OUT:1200
On arrival to the [**Hospital1 18**] MICU [**8-24**], vitals were T: 98.5 HR 81 BP
139/*77 Breathing 26 on [**10-14**] pulling tidal volumes 350-400
satting 100% on FIO2 40%. She appeared anxious and denied pain.
further review of systems was unable to be obtained.
Past Medical History:
1. HIV/AIDS Diagnosed in [**2174**], nadir CD4 count= 3, most recent
CD4 784 on HAART, VL undetectable
2. Positive HBVc antibody, consider suppressed by the HAART.
3. Positive PPD, status post INH 12/[**2189**].
4. Hypothyroidism. s/p iodine ablation in [**10/2188**], on
replacement.
5. Chronic anemia.
6. Herpes zoster [**2188-2-10**].
7. [**Doctor Last Name 1193**]-Chiari type 1 malformation.
8. Hypophosphatemia and hypopotassemia. Secondary to RTA.
9. Proximal renal tubular acidosis. Secondary to Tenofovir.
10. Adult onset Still's Disease
11. Osteopenia
Detailed Rheumatologic History:
-- [**7-17**] Dx Adult Onset Stills Disease (fever, polyarthritis,
rash, ferritin 32K). Pred
60 to 7.5 in [**10-17**] -> joint flare. Pred 20, MTX 7.5/wk.
-- [**11-17**] ICU for flare (fever, neck LAD, hypotension, ferritin
82K) and ?viral diarrhea. H.d. steroids, then pred 40 x 2 mo,
down to 20 in [**2-18**]. Joint flare x3 in 4 months. Pred 40, MTX up
to 25/wk in [**6-18**].
-- [**7-18**] Infliximab 3 mg/kg q8wks added.
-- [**12-18**] ICU for flare on pred 10 mg (fever, neck LAD,
hypotension, ferritin 22K). H.d. steroids, then pred 40.
-- [**5-19**] Joint flares. Infliximab up to 5.6 mg/kg q6wks, in [**11-19**]
to 7 mg/kg q6wks.
-- [**12-19**] ICU with flare (fever, hypotension, neck LAD, rash,
ferritin 67K). Intub for pulm edema. IVP steroids x3 days, then
60 mg QD. Anakinra 100 QD started. MTX/Infliximab d/c'd.
-- [**1-20**] Stable. Pred at 20 mg. Anakinra continued.
-- [**3-20**] Anakinra held one dose for WBC of 2.8, ICU admission for
systemic flare, pressors x2d, early signs of MAS but no HSM,
transient diarrhea. Pred 60 mg, anakinra QD continued. Bactrim
switched to Mepron.
-- [**5-20**] Systemic flare on pred 30. ICU admission (intubation,
pressors x2d), IVP solumedrol x3d, anakinra QD continued. New
hemolytic anemia/thrombocytopenia. IVIG 2g/kg x1. RTA, bicarb
wasting, later diarrhea again. Discharge on pred 60 mg.
-- [**6-20**] Anakinra d/c'd, monthly tocilizumab 8 mg/kg infusions
started at [**Hospital1 112**]. Monthly pred taper to 40 mg in [**7-20**], to 25 mg in
[**12-20**], to 10 mg in [**3-21**].
-- [**3-21**] no manifestations of active Still's disease, and was
advised to taper the prednisone to 7 mg.
-- [**5-21**] seen by Dr. [**Last Name (STitle) **] and prednisone reduced to 5mg
-- admitted [**2196-7-27**] with exacerbation of Still's disease with
polyarthritis and septic shock [**2-11**] C.diff colitis while being on
Tocilicumab (Ferritin 17.000) -> treated with Prednisone 60 mg
daily and antibiotics D/C [**2196-8-5**]
-- seen by Dr. [**Last Name (STitle) **] in his office for follow up on [**2196-8-11**] -> L
ankle pain and swelling appreciated -> Dr. [**Last Name (STitle) **] tapped her
ankle: Joint fluid: 78.000 WBC -> admitted for concern for
septic joint
Social History:
From [**Country 4574**] and emigrated to U.S. in [**2174**]. She has 2 daughters
and 2 sons.
[**Name (NI) 1139**]: Denies
EtOH: Denies
Illicits: Denies
Family History:
Daughter with possible rheumatoid arthritis
Physical Exam:
On Admission [**2196-8-24**]:
VS: T: 98.5 HR 81 BP 139/*77 Breathing 26 on [**10-14**] pulling tidal
volumes 350-400 satting 100% on FIO2 40%.
General: intubated eyes open, appearing anxious, following
commands.
HEENT: right > Left conjunctival injection, Sclera anicteric
b/l,
slightly dry,
Neck: supple, no lymphadenopathy appreciated,
Lungs: Clear to auscultation bilaterally in the anterior fields
CV: Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, BS+.
GU: foley in place
Rectal: rectal tube is in place
Ext- warm, well perfused, 2 + pitting edema in lower
extremities
Neuro- equal pupils 4mm, moving all extremities, unable to raise
feet off bed
Skin:
-- Face Violaceous maculae overlying cheeks bilateraly with
sparing of nasolabial folds
-- Back, medial/posterior thighs abdomen with superficial
desquamation
-- Right midneck Left breast and left groin fold with small
scattered ulcerations
- No bullae noted, negative nicholeski sign.
Discharge exam:
Tmax 98.3 102-119/72-81 102-111 18 100%/RA
Gen: NAD, flat affect
Lungs: CTAB
CV: RRR, S1S2+, no m/r/g
Abdomen: Soft, NT, ND, BS+
Ext: trace edema b/l LE. No swelling or erythema of joints.
strength 4/5
Neuro: A and O x 3
Pertinent Results:
ADMISSION LABS:
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] WBC-7.6# RBC-2.74* Hgb-7.6* Hct-22.5*
MCV-82 MCH-27.7 MCHC-33.8 RDW-19.7* Plt Ct-46*
[**2196-8-26**] 04:30AM [**Month/Day/Year 3143**] Neuts-46.6* Lymphs-49.1* Monos-2.8
Eos-1.0 Baso-0.5
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] PT-11.1 PTT-30.8 INR(PT)-1.0
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] Fibrino-157*#
[**2196-9-3**] 04:06AM [**Month/Day/Year 3143**] Gran Ct-1256*
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] Glucose-118* UreaN-90* Creat-2.9*#
Na-148* K-4.6 Cl-113* HCO3-21* AnGap-19
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] ALT-43* AST-111* AlkPhos-468*
TotBili-2.1*
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] Albumin-2.8* Calcium-6.6* Phos-4.4#
Mg-2.2
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] Ferritn-[**Numeric Identifier 53551**]*
[**2196-8-25**] 12:03AM [**Month/Day/Year 3143**] CRP-33.6*
Discharge labs:
[**2196-10-2**] 07:41AM [**Month/Day/Year 3143**] WBC-5.2 RBC-2.77* Hgb-8.7* Hct-26.3*
MCV-95 MCH-31.4 MCHC-33.0 RDW-18.6* Plt Ct-235
[**2196-10-3**] 05:20AM [**Month/Day/Year 3143**] Glucose-131* UreaN-21* Creat-0.6 Na-139
K-4.1 Cl-109* HCO3-24 AnGap-10
[**2196-9-28**] 05:39AM [**Month/Day/Year 3143**] ALT-30 AST-24 AlkPhos-79 TotBili-0.3
[**2196-10-3**] 05:20AM [**Month/Day/Year 3143**] Calcium-8.6 Phos-4.4 Mg-1.6
[**2196-10-2**] 07:41AM [**Month/Day/Year 3143**] Ferritn-2871*
[**2196-10-2**] 07:41AM [**Month/Day/Year 3143**] CRP-0.5
Imaging:
MRI HEAD [**9-8**]:
FINDINGS: There are innumerable lesions with increased T2/FLAIR
signal,
several of which show contrast enhancement as well as rapid
diffusion. The lesions are randomly distributed, involving
mostly the subcortical white matter, but several also involve
the deep sulcal [**Doctor Last Name 352**] matter (7:13). There are lesions within
the cerebellum as well as the brainstem. There is no intra- or
extra-axial hemorrhage, shift of normally midline structures, or
edema. The ventricles and basal cisterns are normal in size and
configuration. The principal intracranial vascular flow voids,
including those of the dural venous sinuses, are preserved.
There is fluid opacification of the right mastoid air cells.
Otherwise, the visualized paranasal sinuses, left mastoid air
cells, and middle ear cavities are clear. Orbital and
extracranial soft tissues are unremarkable.
IMPRESSION: Given the patient's suspected diagnosis of
hemophagocytic
lymphohistiocytosis (HLH), the imaging findings are classic for
this disease entity. Other entities can appear similarly by MRI
but are much less likely, including lymphoma, granulomatous
disease, or sarcoidosis.
BONE MARROW PATHOLOGY [**9-1**]:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
-CELLULAR MYELOID DOMINANT MARROW WITH MATURING TRILINEAGE
HEMATOPOIESIS
-FOCAL CLUSTERS OF HEMOPHAGOCYTIC HISTIOCYTE SEEN.
Note: The finding of increased macrophages and macrophages with
ingestion of cells and debris, with concurrent marked elevated
ferritin level in this patient who is also pancytopenic, raises
the possibility of macrophage activation syndrome. The
histiocytic collection is multi-focal, but does not over-run the
marrow hematopoiesis at this stage (~20-30%); this decrease may
be related to the therapy the patient received prior to the bone
marrow studies. Please correlate with clinical (e.g. fever,
splenomegaly) and other laboratory findings (e.g. triglyceride
and fibrinogen levels).
By immunohistochemistry CD68 stains an increase number of
histiocytes estimated to be 30% of bone marrow cellularity forms
scatter clusters, and some contain intracellular debris. CD3
highlights T-cells which are scattered throughout the marrow and
form a major subset of lymphocyte in comparison to the
CD20-positive B-cells.
MICROSCOPIC DESCRIPTION
Peripheral [**Month/Year (2) **] Smear:
The smear is adequate for evaluation. Erythrocytes are
decreased and normochromic with marked anisopoikilocytosis
including spherocytes, schistocytes, and dacrocytes. Nucleated
red cells are present. The white [**Month/Year (2) **] cell count is markedly
decreased. Neutrophils exhibit reactive changes, including
toxic granulation and vacuolization. Rare forms with nuclear
hypolobation and pelgeroid nuclei are seen. The platelet count
appears markedly decreased.
A manual differential shows: 83% neutrophils, 9% lymphocytes, 4%
monocytes, 1% eosinophils, 1% metamyelocytes.
Aspirate Smear:
The aspirate material is inadequate for evaluation due to lack
of spicules and hemodilution. Erythroid precursors are
proportionately decreased in number and exhibit dyspoietic
maturation, including cells with irregular nuclear contours and
asymmetric nuclear budding. Occasional megaloblastoid
pronormoblasts are seen. Myeloid precursors are proportionately
decreased in number and show normal maturation. Megakaryocytes
are not seen. Rare histiocytes and intracytoplasmic debris are
noted.
A 200 cell manual differential shows: 1% Promyelocytes, 4%
Myelocytes, 1% Metamyelocytes, 23% Bands/Neutrophils, 57%
Erythroids, 14% Lymphocytes.
Clot Section and Biopsy Slides:
The core biopsy material is adequate for evaluation. It
consists of two fragments, each up to 1 cm of core biopsy of
trabecular marrow, cortical bone, and periosteum with a
cellularity of 60-70%. The M:E ratio estimate is increased.
Erythroid precursors are relatively decreased in number and have
dyspoietic maturation, including forms with asymmetric nuclear
budding. Myeloid precursors are proportionately increased in
number. Megakaryocytes are decreased in number with focal loose
clustering, and include occasional small hypolobated forms.
There are multiple small interstitial lymphoid aggregates
composed of small mature lymphocytes occupying 5% of marrow
cellularity. Focal increase of eosinophils is also seen.
Occasional foci with macrophages have ingested cellular material
and amorphous eosinophilic debris, suggestive of macrophage
activation syndrome. These areas occupy approximately 10% of
the marrow cellularity.
ABDOMINAL U/S [**8-14**]:
IMPRESSION:
1. Thickened, edematous gallbladder wall without GB distension-
likely
secondary to hepatitis.
2. Cholelithiasis.
3. Partially imaged right pleural effusion.
LIVER U/S [**8-19**]:
IMPRESSION:
1. No bile duct dilatation and normal liver, without focal or
diffuse abnormalities.
2. Bilateral pleural effusions and ascites.
ECHO [**8-22**]:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. The main pulmonary artery is
dilated. There is a trivial/physiologic pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal regional and global biventricular systolic function. Mild
mitral regurgitation.
MRI [**2196-9-20**]
FINDINGS: There is near complete resolution of the T2/FLAIR
signal
hyperintensities in the white matter and complete resolution of
the abnormal enhancement. There is no abnormal enhancement.
There is no abnormaldiffusion. No new lesions are identified,
and there is no space-occupyinglesion or mass, mass effect, or
shift of normal midline structures.
Intracranial vascular flow voids are preserved. Fluid is again
noted withinthe mastoid air cells. Otherwise, the visualized
paranasal sinuses, orbits, and soft tissues are unremarkable.
IMPRESSION: Near complete resolution of the T2/FLAIR signal
hyperintensities in the white matter and complete resolution of
the abnormal enhancement. As the patient has been treated with
steroids, the dramatic interval improvement in the findings over
a short time course suggests lymphoma as the underlying
diagnosis.
Microbiology:
-CMV viral load:[**2196-8-25**]
CMV Viral Load (Final [**2196-8-26**]):
2,060 copies/ml.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
-CMV viral load: [**2196-8-31**] (Final [**2196-9-3**]):
11,700 copies/ml.
-CMV viral load [**2196-9-7**] (Final [**2196-9-11**]):
CMV DNA detected, less than 600 copies/mL.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
Urine culture [**2196-8-31**]
[**2196-8-31**] 2:16 am URINE Source: Catheter.
**FINAL REPORT [**2196-9-2**]**
URINE CULTURE (Final [**2196-9-2**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 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-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VIRAL CULTURE [**9-1**]:
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2196-9-7**]):
DR [**Last Name (STitle) 53552**] DAS REQUESTED CULTURE TO BE PERFORMED AND SENT
OUT FOR
SENSITIVITY TESTING [**2196-9-2**].
HERPES SIMPLEX VIRUS TYPE 2.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Antiviral Susceptibility, Acyclovir
Organism Herpes Simplex Type 2
Acyclovir 1.6 S
The median inhibitory dose or
concentration
(MID or MIC) is expressed in
mcg/mL.
S = Susceptible R =
Resistant
Comment: SKIN SCRAPINGS
[**2196-9-1**] 5:27 pm Direct Antigen Test for Herpes Simplex Virus
Types 1 & 2: HERPES SIMPLEX VIRUS TYPE 2.
Viral antigen identified by immunofluorescence.
[**2196-8-31**] 8:07 pm IMMUNOLOGY Source: Line-PICC.
**FINAL REPORT [**2196-9-5**]**
HBV Viral Load (Final [**2196-9-5**]):
HBV DNA not detected.
[**2196-9-9**] 12:15 pm [**Month/Day/Year **] (Toxo) CHEM S# 15S.
TOXOPLASMA IgG ANTIBODY (Final [**2196-9-13**]):
POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
11.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
A positive IgG result generally indicates past exposure.
Infection with Toxoplasma once contracted remains latent
and may
reactivate when immunity is compromised.
[**2196-9-13**] 2:55 pm CSF;SPINAL FLUID Source: LP.
**FINAL REPORT [**2196-9-13**]**
CRYPTOCOCCAL ANTIGEN (Final [**2196-9-13**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
[**2196-9-13**] 2:55 pm CSF;SPINAL FLUID Source: LP #3.
UNABLE TO
PERFORM SMEAR AS A MATTER OF PROTOCOL [**2196-9-13**].
GRAM STAIN (Final [**2196-9-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white [**Month/Day/Year **] cell count..
FLUID CULTURE (Final [**2196-9-16**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
ACID FAST SMEAR (Final [**2196-9-14**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
CMV PCR (CSF) [**2196-9-13**]: Not detected
Toxoplasma Gondii PCR (CSF) [**2196-9-13**]: not detected
[**Male First Name (un) 2326**] virus PCR [**2196-9-13**]: negative
HHV6 DNA [**2196-9-13**]: not detected
[**Doctor Last Name 3271**] [**Doctor Last Name **] Virus DNA, Qualitative Real-Time PCR [**2196-9-13**]
EBV DNA, QL PCR DETECTED
Source: CSF
Brief Hospital Course:
Ms. [**Known lastname 53536**] is is a 52 year old female with history of HIV and
adult-onset Still's disease on chronic steroids who had a
complicated hospital course including shock and ARDS with
multiorgan failure after wash-out of left shoulder and left
knee, cytotoxic drug eruption with admission to [**Hospital1 112**] burn unit,
subsequent neutropenia and SIRS, CMV viremia, diagnosis of
secondary HLH.
BRIEF HOSPITAL COURSE:
She initially presented to [**Hospital1 18**] [**2196-8-12**] with L shoulder and L
ankle pain. Taken to the OR on [**8-13**] for I&D of her L ankle and L
shoulder. Shortly after the patient rapidly deteriorated and
became unstable with fever, hypotension, tachycardia, and lactic
acidosis. She was then transferred to the MICU for hypoxemia and
hypotension. She required intubation, pressors, and CVVH for
oliguric renal failure. Her course was further complicated by
pancytopenia, DIC, and transaminitis. She was treated
empirically with broad spectrum antibiotics including
doxycycline, Piperacillin-Tazobactam, vancomycin, and meropenem
which were discontinued as a bacterial source was thought
unlikely. Her course was further complicated by fungemia and a
cytotoxic drug eruption necessitating transfer to the [**Hospital1 756**]
burn unit on [**2196-8-22**]. She returned to [**Hospital1 18**] on [**2196-8-24**]. No
specific [**Doctor Last Name 360**] was identified but her Anikinra was stopped.
Shortly after return she was successfully extubated on [**8-26**]. She
was briefly called out to the floor on [**8-30**] and had a bone
marrow biopsy [**8-31**]. Later that day she became febrile to 102 and
tachycardic with a WBC count of 0.8 and was transferred back to
the ICU with neutropenic fever where she was started on
cefepime, flagyl and stress dose steroids with significant
clinical improvement. She developed new genital lesions on [**9-1**]
which were seen by derm and felt consistent with HSV for which
she was started on acyclovir. Patient was deemed clinically
stable for transfer from ICU. Given bone marrow findings
suggestive for HLH, patient was transferred to BMT for potential
chemotherapy treatment. Clinical picture, however, suggested
patient was not deteriorating as rapidly as would be expected
with HLH, so chemotherapy was held after case reviewed at
multidisciplinary pathology conference. Patient was initiated on
gancyclovir for CMV viremia; acyclovir was discontinued given
coverage with gancyclovir. Patient's presumed Stills Flare was
treated with steroids, in close collaboration with rheumatology.
Kineret (anakinra) re-initiation was discussed, and
allergy/immunology was consulted given risk that Kineret may
have triggered the drug eruption. This was felt to be very
unlikely, and plan was for patient to reinitiate Kineret after a
10% test dose. Given decision not to pursue chemotherapy at this
time, patient was transferred to general medicine with hem/onc
consult followup for further management. On the medicine
service, patient was restarted on anakinra with good results.
She was treated with Neupogen for neutropenia, which resolved
slowly. See below for further details:
*****************
**ACTIVE ISSUES**
*****************
1. Adult Stills Flare: Initial presentation with multiorgan
failure and hypotension was felt related to flare of adult
Stills disease and/or MAS. She was treated with Anakinra and
high dose steroids with significant improvement. Her Anakinra
was subsequently stopped due to concern for it causing her
neutropenia. Given concern for continuing Stills Flare,
rheumatology and allergy/immunology were involved. Rheumatology
recommended restarting anakinra. Allergy/immunology was
consulted because of patient's drug eruption while on anakinra
(and many other medications), reaction judged most likely due to
antibiotics (meropenem, zosyn, bactrim as likely culprits).
Patient restarted on anakinra [**9-13**] with good results, and
methylprednisolone began to be tapered. Ferritin and CRP
downtrending. Patient was also found to have hyperglycemia
likely secondary to steroids, and this was managed with an
insulin sliding scale with night-time glargine.
2. HLH/MAS: Bone marrow biopsy [**8-31**] showing evidence of HLH,
most likely secondary to Stills flare. The patient was
transferred to BMT for initiation of chemotherapy. However,
given patient's overall clinical improvement on high dose
steroids and the fact that fibrinogen and platelets hit a
plateau, the decision was made not to pursue chemotherapy.
3. Neutropenia: Progressive neutropenia across second admission
most likely due to MAS/HLH, although CMV or medications may also
have played a role. Anakinra was stopped as there are rare cases
of it causing neutropenia. Patient received GCSF from [**9-1**] to
[**9-4**] with a significant increase in her white count. While on
the BMT service, her white count began dropping again in the
absence of anakinra. Neupogen was restarted [**9-10**] and discontinued
[**9-18**] after granulocyte count normalized. She was re-started on
Anakinra [**9-13**] without significant impact on her counts.
4. ? DIC/[**Doctor First Name **]: In setting of acute illness during last admission
patient had hemolytic anemia, thrombocytopenia, low fibrinogen,
initially prolonged PTT, and schistocytes on smear. This was
initially thought to be DIC associated with the Still's flare
and not a separate thrombotic microangiopathic process.
Haptoglobin remained low at <5 and there were some schistocytes
on smear. However, patient's coags remained normal and
fibrinogen/platelets reached plateau (albeit low). Exact
etiology was not elucidated upon transfer from BMT, however
coags remained normal through remainder of hospitalization and
platelets improved.
5. Anemia: Patient received transfusions early in the course of
her hospitalization but had a relatively stable hematocrit over
the two weeks prior to transfer to BMT. She again required
transfusion after transfer to the medicine service, but then her
hematocrit was relatively stable. She was noted to be guiaic
positive early in the admission. Patient was found to have a
Coombs+ test of uncertain clinical significance (has been
Coombs+ in the past), and also had an inappropriately low
reticulocyte count. Consideration was paid to immunologic
process overlayed on anemia of chronic disease.
6. Thrombocytopenia: Felt most likely due to underlying HLH.
Platelets hit nadir of 13 during prior admission and a nadir of
35 during the current admission (on [**9-5**]). Not actively
bleeding. SQ Heparin held (also with heparin allergy). With
treatment of Still's, platelets normalized in the week prior to
discharge.
INFECTIOUS:
1. Altered mental status with newly identified abnormal head MRI
findings: Patient noted to be altered from baseline by family
members; noted to be hypo and hyperactive delirium by nursing
staff, with frequent hallucinations. Patient found to have CMV
viremia, for which she was started on gancyclovir. Head MRI was
performed, which was abnormal and consistent with HLH as well as
a broad differential diagnosis including lymphoma, sarcoid,
others. It was not felt that the MRI was consistent with a
Stills Flare or CMV encephalitis. Given appearance on MRI,
infectious etiologies were considered. LP was offered, but
patient initially refused. Further discussion with radiology re.
appearance on MRI raised potential for fungal vs. lymphoma vs.
rickettsia, although not classic appearance for any of these
(vs. HLH, for which this is classic). Radiology did not feel
this was bacterial or other parasitic or CMV encephalitis or
EEQ. Rickettsia and serum toxoplasma were negative. LP on [**9-13**]
showed was negative for toxoplasma, CMV, HHV6. No acid fast
bacilli on smear, no growth on CSF culture to date. CSF did have
detectable EBV, significance of this is unclear. Concern for
lymphoma, so MRI of head was repeated, which showed near
resolution of previously evident hyperintensities and
enhancement in the context of patient having been on high dose
steroids. Heme/onc service was consulted regarding these
findings, felt that lesions were not typical for lymphoma and
most likely were due to HLH/Still's flare. Patient will need a
repeat MRI of head in future to evaluate for interval change,
but this does not need to be done in the near term.
2. CMV viremia: Patient was found to have low grade viremia
ranging from ~800 to ~[**2184**]. There are case reports of CMV
associated with Stills disease flares but causality is
uncertain. Patient was started on gancyclovir. Acyclovir was
held in context of initiating gancyclovir. CMV viral load
improved significantly with therapy. Patient switched to
valgancyclovir and will continue on this indefinitely as an
outpatient.
3. HSV: Patient had worsening excoriations on her gentalia and
peri-anal area with increasing pain. Evaluated by derm and felt
most consistent with HSV. DFA returned positive for HSV 2. She
was started on acyclovir and then subsequently transitioned to
gancyclovir (which was started primarily for CMV viremia).
Although her lesions persisted after a seven day course of
acyclovir, pain decreased. Dermatology assessed and noted that
the lesions had improved. Possibility of proceeding to foscarnet
treatment was discussed among the BMT team, ID, and dermatology,
but was not pursued given lack of clinical gravity in light of
broader picture. Acyclovir sensitivities were sent and were
normal. Patient discharged on valgancyclovir.
4. HIV: On HAART as an outpatient with last CD4 of 782 and viral
load undetectable. Her HAART regimen was held initially given
her acute illness (and concern for potential drug interaction)
but was restarted on [**8-26**].
5. Fungemia: [**Month/Year (2) **] cultures from [**8-19**] isolated Candidia [**Month/Year (2) 53550**]
which is sometimes found in cheeses and known to cause
nosocomial bloodstream infections. Catheter tip grew the same
organism and is likely the source of the fungemia. All lines
were pulled on [**8-21**]. Treated with 12 day course of Fluconazole
200mg PO daily (initially intended 14 day course) which ran from
[**8-22**] through [**9-3**].
6. Abdominal pain & C. Diff Colitis: Patient had recently been
treated for C. Diff colitis with oral vancomycin (Day 1 = [**7-28**]).
The plan is to continue PO Vanc 125mg Q6H PO until 2 weeks after
resolution of diarrhea so she should continue this until [**10-7**].
7. Hepatitis B: She has a history of hepatitis B which has
previously felt to have been suppressed by her HAART therapy.
There was initially concern that some of her current symptoms
were due to reactivation of her Hep B. A viral load was checked,
however, and was undetectable.
8. UTI: E Coli UTI [**8-31**]. Foley changed. Treated with Cefepime in
setting of neutropenia.
OTHER ACTIVE ISSUES:
1. Cytotoxic drug eruption: During the last admission on [**8-21**]
dermatology was consulted for an evolving rash. On [**8-22**] the rash
had worsened with desquamation of the skin and positive nicolsky
sign. There were also oral lesions and diffuse ulcerations of
the tracheobronchial epithelium seen during bronchoscopy. She
was transferred to the [**Hospital1 112**] burn unit from [**Date range (1) 51030**]. The rash at
its peak involved 3% of the body surface area and has since been
improving. Biopsy results were felt consistent with a drug
eruption and not consistent with SJS/TEN. As she was on multiple
antibiotics prior to developing the rash (doxycycline,
piperacillin-tazobactam, vancomycin, meropenem, and bactrim) as
well as pantoprazole and Anakinra, it was impossible to
determine what caused the reaction. The eruption has primarily
resolved and is now healing. Allergy/immunology was consulted,
who believed that eruption was likely [**2-11**] antibiotics, in
decreasing likelihood, meropenem, zosyn, and bactrim. Kineret
was not felt likely to have contributed. They did not think a
skin test would be useful because these are for IgE reactions,
not Type IV hypersensitivity. Patch tests also would not be
useful with a biologic [**Doctor Last Name 360**] because of inability to interpret
results. Allergy/immunology and dermatology did not feel testing
antibiotics was advisable given history of drug eruption.
2. Non-anion gap metabolic acidosis with +UAG: Renal consulted.
Thought to be chronic issue with normalization of laboratories
while on CVVH. Uncertain etiology, likely distal RTA picture.
Sodium bicarb repletion continued.
3. Transaminitis: Most likely related to shock liver from
profound hypotension when she first presented on [**7-20**]. A
right upper quadrant U/S was unrevealing. Her LFTs continued to
improve and had normalized by time of discharge.
CHRONIC ISSUES
1. Hypothyroidism: Stable on her home dose of Levothyroxine
Sodium 150 mcg PO/NG DAILY.
TRANSITIONAL ISSUES:
-Taper steroid dose: Solumedrol 50mg TID [**Date range (1) 4215**], Solumedrol
40mg TID [**Date range (1) 17341**], Solumedrol 30mg TID [**Date range (1) 17342**], Solumedrol
20mg TID [**Date range (1) 17343**], prednisone 60mg daily starting [**10-14**]
-trend CRP, ferritin, CBC, Chem 10, LFTs every other day and fax
results (along with current steroid dose) to Dr. [**Last Name (STitle) **] and Dr.
[**First Name (STitle) **], rheumatology [**Telephone/Fax (1) 44524**]
-please check fingersticks QACHS while on high dose steroids and
receiving insulin, adjust glargine as needed
-patient will need follow-up MRI following steroid taper and
return to normal steroid dose to ensure continued
improvement/resolution of brain lesions
-monitor hematocrit, consider further work-up of guaiac positive
stool in future
-follow up final AFB culture from CSF (may take 3-8 weeks to be
final) and final viral culture from CSF (both still preliminary
negative on discharge)
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Efavirenz 600 mg PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Oxybutynin 10 mg PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Raltegravir 400 mg PO BID
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Vancomycin Oral Liquid 125 mg PO Q6H
Day 1 [**7-28**]
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Calcium Carbonate 500 mg PO BID
12. Vitamin D [**2184**] UNIT PO DAILY
13. Sodium Bicarbonate 650 mg PO TID
14. Ibuprofen 800 mg PO Q8H:PRN joint pain
15. Phos-NaK *NF* (potassium & sodium phosphates) 280-160-250 mg
Oral [**Hospital1 **]
16. Emtricitabine 200 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Calcium Carbonate 500 mg PO TID
3. Efavirenz 600 mg PO DAILY
4. Emtricitabine 200 mg PO Q24H
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Raltegravir 400 mg PO BID
7. Sodium Bicarbonate 650 mg PO TID
8. Vancomycin Oral Liquid 125 mg PO Q6H
last day [**2196-10-7**]
9. Vitamin D [**2184**] UNIT PO DAILY
10. anakinra *NF* 100 mg SC DAILY Reason for Ordering: per
rheumatology recs, pt has Still's disease, on high dose
steroids, previously on anakinra + steroids at home.
11. Atovaquone Suspension 1500 mg PO DAILY
12. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN topical pain
14. Magnesium Oxide 400 mg PO BID
with food
15. MethylPREDNISolone Sodium Succ 50 mg IV Q8H
please conduct slow taper per page 1 and discharge summary
inistructions
Tapered dose - DOWN
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Ranitidine 150 mg PO BID
18. Senna 1 TAB PO BID:PRN Constipation
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
20. ValGANCIclovir 900 mg PO Q24H
21. Phos-NaK *NF* (potassium & sodium phosphates) 280 mg ORAL
[**Hospital1 **]
22. Oxybutynin 10 mg PO DAILY
23. Ibuprofen 800 mg PO Q8H:PRN joint pain
24. Alendronate Sodium 70 mg PO QMON
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] [**Hospital1 **]
Discharge Diagnosis:
Still's disease
Secondary HLH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 53536**],
You were hospitalized at [**Hospital1 69**]
with a flare of your Still's disease, which caused lung, liver
and kidney problems, as well as anemia, low platelets and low
white [**Hospital1 **] cell count. You also developed a severe skin
reaction to one of the medications (likely an antibiotic) that
you were given during the hospitalization. You had diarrhea and
were treated for c. difficile.
Changes to your home medications include:
-START anakinra 100mg
-STOP Bactrim SS 1 tab daily and START atovaquone 1500mg daily
in its place
-START insulin glargine 12 units at bedtime and insulin sliding
scale
-START magnesium oxide 400mg [**Hospital1 **]
-STOP prednisone 5mg and START steroid taper as dictated by
rheumatology (and as written in discharge instructions)
-STOP omeprazole and START rantidine 150mg twice daily in its
place
-START valgancyclovir 900mg daily
It was a pleasure taking care of you during your hospitalization
and we wish you a speedy recovery and all the best going
forward.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2196-10-12**] at 9:00 AM [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RHEUMATOLOGY
When: WEDNESDAY [**2196-10-19**] at 2:30 PM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2196-10-3**]
ICD9 Codes: 5845, 2762, 5990, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4962
} | Medical Text: Admission Date: [**2167-5-4**] Discharge Date: [**2167-5-22**]
Service: BLUE SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 82 year-old male
who was emergently transferred from the [**Hospital 4068**] Hospital with
ascending cholangitis. He presented with abdominal pain and
dehydration. His laboratories upon admission were white
count of 11,600. His total bilirubin was 3.3, his ALT was
131, AST 697, amylase 48, PTT 22.2. His INR was 1.1. His CT
scan was consistent with a common bile duct stone.
PAST MEDICAL HISTORY: Significant for emphysema,
hypertension, chronic renal failure, renal insufficiency,
Parkinson's, history of pneumonia, deep venous thrombosis,
status post left nephrectomy, status post splenectomy. He
has an allergy to penicillin.
MEDICATIONS ON ADMISSION: Synthroid, Lasix, Verapamil,
Sinemet, cimetidine and he had been started on Vancomycin,
Levaquin and Flagyl at the [**Hospital 4068**] Hospital.
PHYSICAL EXAMINATION: Upon admission was significant for a
temperature of 98.4, heart rate 115, 104/59, 22, 94 percent.
On examination his neck was supple. He was tachycardic. He
was clear to auscultation bilaterally. His abdomen was
slightly distended, tender to palpation in the right upper
quadrant with guarding. He had deceased bowel sounds. He
was guaiac negative and no masses on rectal examination.
Laboratories were as mentioned.
He was admitted to the Intensive Care Unit for an emergent
endoscopic retrograde cholangiopancreatography. He was
n.p.o. on strict antibiotics. As mentioned he was admitted
to the Intensive Care Unit. The endoscopic retrograde
cholangiopancreatography completed on [**2167-4-29**] at 11 P.M.
revealed a dilated irregular common bile duct with multiple
large filling defects. Additional images showed a wire which
transversed the dilated extrahepatic biliary system. Final
image showed a pig-tail catheter in place traversing the
common duct. The actual description of the ERCP is as
follows: The biliary duct was cannulated at and a
sphincterotomy was performed. Copious purulent discharge was
returned from the common bile duct consistent with ascending
cholangitis. Diffuse dilation was seen of the common bile
duct with the common bile duct measuring 15 mm. Irregular
stones ranging in size from 5 to 10 mm that were causing the
partial obstruction were seen at the common bile duct. There
was post obstructive dilatation. A solitary stone was
extracted from this vessel using a sphincterotome. A 5 cm x
#10 French double pig-tail biliary stent was placed
successfully in the common bile duct using a standard
introducer kit. The impression at that time was
periampullary diverticulum, suppurative cholangitis,
choledocholithiasis, biliary dilatation and a successful
biliary sphincterotomy along with partial clearance of the
common bile duct stone with successful placement of a double
pig-tail stent in the common bile duct. The patient was
readmitted to the Intensive Care Unit where he remained
stabilized on levofloxacin, Flagyl and Vancomycin. He was on
Neo-Synephrine drip at .25 and a dopamine drip at 5. He was
afebrile with stable vital signs at that time. His drips
were weaned off on [**2167-5-7**]. He received fluid hydration
overnight for hypovolemia. Patient continued to do well. A
right radial line was placed on [**2167-5-7**] without complication.
On [**2167-5-8**], hospital day number five, the patient required
intubation for respiratory distress. He was started on
propofol and dopamine. He was diuresed with some success.
At that time he was on assist control. He was assessed by
nutrition at that time who recommended total parenteral
nutrition repletion of electrolytes and a feeding tube. He
was successfully extubated on [**2167-5-8**] and was continued on
TPN and tube feeds. He was still on Vancomycin, Levaquin and
Flagyl at this time. His temperature maximum was 100.5. On
[**2167-5-13**] a chest x-ray revealed nasogastric tube tip in the
distal esophagus which was repositioned. A right IJ central
venous catheter was in the distal superior vena cava. There
was small bilateral pleural effusion with a tortuous aorta.
There were bilateral [**Location (un) 931**] rods and a spinal stimulator
were in place as well.
Physical Therapy evaluated the patient on [**2167-5-11**] and
recommended bed motility, transfer and hemodynamic stability
prior to increased activity. He continued to be stabilized
and was screened for rehabilitation over the next few days of
his hospitalization. His Dopamine drip was weaned off and he
remained afebrile on broad spectrum antibiotics. He had a
video swallow examination for dysphagia which revealed no
evidence of frank aspiration. At this time honey thick and
nectar thickened liquids and soft diet were recommended. It
was also recommended that he eat foods that had the same
consistency, i.e. no milk and cereal. He was seen by
cardiology on [**2167-5-14**] for his continued hypotension. He was
continued in the Intensive Care Unit through [**2167-5-17**] at which
point he was transferred to the floor. His temperature was
97.2 and his blood pressure was 116/53 on no drips. His
white count was 5.7. His creatinine was 1.6 and he was
making adequate urine.
He continued to do well and his antibiotics were discontinued
on [**2167-5-19**]. At this time he remained afebrile. He was seen
by Physical Therapy and they approved him for rehabilitation
screening. He was seen by nutrition and he was tolerating
adequate p.o. and did not need a Dobbhoff tube. He was much
more alert and oriented and was deemed stable from this
vantage point as well. Chest x-ray obtained on [**2167-5-19**]
revealed improved congestive heart failure with improving
bilateral pleural effusion. It showed improvement in his
lung volumes with a decrease in the bibasilar atelectasis.
He had culture data, blood cultures from [**5-5**] which had
no growth. He had sputum culture also from the 20th which
was also negative for any organism.
DISCHARGE CONDITION: Good.
DISPOSITION: To rehabilitation facility.
FOLLOW UP: Should be with Dr. [**First Name (STitle) 2819**] in two weeks.
FINAL DISCHARGE DIAGNOSIS:
1. Acute ascending cholangitis.
2. Chronic renal insufficiency.
3. Hypertension.
4. Lymphedema.
5. Parkinson's disease.
6. Prostate cancer.
7. Hypothyroidism.
8. History of deep venous thrombosis.
9. History of small bowel obstruction and exploratory
laparotomy.
10. Cataract surgery.
11. Duodenal periampullary diverticulum.
12. Suppurative cholangitis.
13. Choledocholithiasis.
14. Biliary dilatation.
15. Sphincterotomy during endoscopic retrograde
cholangiopancreatography.
16. Partial clearance of common bile duct stone during
sphincterotomy.
17. Placement of a stent in the common bile duct during
endoscopic retrograde cholangiopancreatography.
18. Respiratory failure.
19. Pneumonia.
20. Hypotension.
21. Hypovolemia.
22. Extended pressor requirement.
23. Failure to thrive with requirement of Dobbhoff feeding
tube.
24. Requirement for physical therapy given prolonged
immobility.
25. Requirement for tube feedings given inability to
tolerate p.o.
26. Requirement for total parenteral nutrition during
hospitalization.
DISCHARGE MEDICATIONS:
1. Heparin 5,000 units subcutaneously q 12 hours.
2. Albuterol 1 to 2 puffs q 4 hours p.r.n.
3. Carbidopa/levodopa 25/100 tablets, 1 tablet p.o. t.i.d.
4. Pergolide mesylate 1 mg tablet [**1-16**] tablet p.o. t.i.d.
5. Entacapone 200 mg 1 tablet p.o. t.i.d.
6. Albuterol 1 nebulizer 1 q 4 hours p.r.n.
7. Synthroid 25 mcg 1 tablet p.o. q.d.
8. Digoxin 125 mcg .5 tablets p.o. q.d.
9. Pepcid 20 mg p.o., b.i.d.
10. Miconazole t.i.d. p.r.n.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Last Name (NamePattern1) 54759**]
MEDQUIST36
D: [**2167-5-22**] 11:09
T: [**2167-5-22**] 11:10
JOB#: [**Job Number 54760**]
ICD9 Codes: 0389, 2765, 4280, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4963
} | Medical Text: Admission Date: [**2116-6-23**] Discharge Date: [**2116-7-1**]
Date of Birth: [**2074-8-7**] Sex: M
Service: Cardiothoracic
CHIEF COMPLAINT: The patient is a 41-year-old male with
newly discovered aortic insufficiency referred by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 16072**] to [**Hospital6 256**] for cardiac
catheterization to further evaluate his aortic valve and
determine his need for surgery.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an active
otherwise healthy police officer who developed a cough about
a year ago. The cough occurs only in the morning when he
first wakes up and is productive for yellow and sometimes
blood tinged secretions. Since [**Month (only) 116**], he has been experiencing
profound shortness of breath. He has also been getting up in
the middle of the night due to shortness of breath and
sleeping in an elevated position on the couch. He denies
lightheadedness or orthopnea. An echocardiogram done on [**6-23**] showed moderate left ventricular hypertrophy with an
ejection fraction of 50% and 4+ aortic insufficiency. Aortic
valve was not coapting properly. There was flow reversal in
the descending aorta, tricuspid regurgitation, normal PA
pressures with a mildly dilated LV outflow tract. Also noted
were a dilated sinus of Valsalva and dilated ascending aorta.
PAST MEDICAL HISTORY:
1. Hypertension
2. Remote tobacco use, quit 14 years ago
ALLERGIES: He has no known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Atenolol 25 mg qd
2. Captopril 25 mg [**Hospital1 **]
Height is 5 feet 10 inches. Weight is 194 pounds.
LAB DATA: White count 4.9, hematocrit 46.3, platelets 192.
Sodium 140, potassium 5.2, chloride 107, CO2 28, BUN 26,
creatinine 1.8, INR 1.1.
SOCIAL HISTORY: Married police officer in [**Location (un) **].
HOSPITAL COURSE: On the day of admission, the patient was
brought to the catheter lab where he underwent cardiac
catheterization. Please see the catheter report for full
details. In summary, the catheter showed 1+ mitral
regurgitation with 3+ to 4+ aortic insufficiency, normal
coronary arteries without lesions and ejection fraction of
45%. Following his cardiac catheterization, Cardiothoracic
Surgery was consulted. The patient was consented and agreed
to surgery. On [**6-25**], he was brought to the Operating
Room. Please see the Operating Room for full details. In
summary, the patient had an aortic valve replacement with a
29 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. He tolerated the
operation well and was transferred from the Operating Room to
the Cardiothoracic Intensive Care Unit. The patient did well
in the immediate postoperative period. His anesthesia was
reversed. Initial attempts at weaning him from the
ventilator were unsuccessful due to a relative hypoxia
requiring high [**Name (NI) 42684**] and 7.5 to 10 of PEEP.
On the morning of postoperative day #1, the patient's PEEP
was weaned to 5. His FIO2 was also weaned and he was
successfully extubated. During that period, the patient
remained hemodynamically stable and later in the day of
postoperative day #1, he was transferred from the Intensive
Care Unit to [**Hospital Ward Name 121**] Six for continuing postoperative care and
cardiac rehabilitation.
On postoperative day #2, the patient's Foley and chest tubes
were discontinued. His activity level was increased with the
assistance of the nursing staff and physical therapy. Over
the next several days, the patient was noted to have a low
grade temperature with a maximum temperature of 101.9??????. He
was pan cultured at that time. Sputum and blood cultures
returned negative. His urine culture came back positive with
an Escherichia coli urinary tract infection for which he was
treated with Levaquin 500 mg qd x14 days. Additionally, the
patient had chest x-ray and echocardiogram, both of which
were negative for a fever source. The patient continued to
progress in the postoperative period and on postoperative day
#7, it was deemed that he was stable and ready to be
discharged to home.
At the time of discharge, the patient's physical exam is as
follows:
VITAL SIGNS: Temperature 99.3??????, heart rate 84 sinus rhythm,
blood pressure 137/86, respiratory rate 18, O2 saturation 94%
on room air. Weight preoperatively is 85.5 kg, at discharge
it is 82 kg.
LAB DATA: White count 4.5, hematocrit 27.4, platelets 220.
Sodium 138, potassium 4.5, chloride 99, CO2 25, BUN 34,
creatinine 1.9, glucose 92.
PHYSICAL EXAM:
VERTICAL
GENERAL: Alert and oriented x3, moves all extremities,
conversant.
RESPIRATORY: Clear to auscultation bilaterally.
HEART: Heart sounds regular rate and rhythm with no murmur.
STERNUM: Stable. Incision with Steri-Strips open to air,
clean and dry.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: Warm and well perfuse with no cyanosis,
clubbing or edema.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg qd
2. Colace 100 mg [**Hospital1 **]
3. Metoprolol 25 mg [**Hospital1 **]
4. Captopril 25 mg tid
5. Levaquin 500 mg qd x12 days
6. Dilaudid 2 to 4 mg q 4 to 6 hours prn
DISCHARGE DIAGNOSES:
1. Aortic insufficiency, status post aortic valve
replacement with a #29 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve
2. Hypertension
DISCHARGE STATUS: The patient is to be discharged home.
DISCHARGE CONDITION: Stable
FOLLOW UP: He is to have follow up with Dr. [**Last Name (STitle) 16072**] in four
weeks and follow up with Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2116-7-1**] 10:12
T: [**2116-7-1**] 10:24
JOB#: [**Job Number 42685**]
ICD9 Codes: 4241, 4280, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4964
} | Medical Text: Admission Date: [**2168-1-4**] Discharge Date: [**2168-1-7**]
Date of Birth: [**2114-5-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 53 year old female with history of HCV/HCC
cirrhosis s/p OLT on [**2167-11-9**], t2DM, presenting with new onset
hyperkalemia. She had labs drawn per routine today and K+ was
noted to be elevated. Kidney function was at baseline and her
diabetes has been poorly controlled as of late. She has been
making good urine and stooling normally. She only complains of
feeling slightly unwell with mild chills and near-baseline
abdominal pain, but no cough, fever, nausea/vomiting, dysuria,
chest pain, or shortness of breath.
Of note, the patient has had 2 prior hospitalization at [**Hospital1 18**]
over the past 2 months. She had an orthotopic liver transplant
and ventral hernia repair performed on [**2167-11-9**] and was then
re-admitted on [**2167-12-10**] with abdominal pain and fevers. On this
next admission, she was found to have a high-grade small-bowel
obstruction with transition point at the site an inferior
midline ventral hernia, suspicious for strangulation. Reduction
and repair of umbilical and incisional hernia was performed with
Prolene mesh and she was sent home on [**2167-12-16**].
.
In the ED, initial VS were: 98.1, 75, 147/81, 18 and 100% RA.
She complained only of diaphoresis and mild chills. Potassium
noted to be elevated at 8.2 (re-checked and not hemolyzed), so
she was medicated with 30gm kayexalate po, calc gluc 2gm IV, 1
amp d50, and 10 units insulin with some improvement in the
hyperacute T waves on EKG (otherwise normal) and K+ of 8.4 then
5 units insulin and another amp of D50 and calcium gluconate 2gm
IV x1. Renal was notified for possible urgent dialysis and
dialysis cathether placement at some point this evening. She
was given Dilaudid 4mg PO for abdominal pain. She was
transferred to the MICU for frequent K+ monitoring and potential
initiation of dialysis. On transfer, vitals were: 98.0, 90,
150s/85, 20 and 96% RA.
Past Medical History:
- HCV: Dx [**2166**]; she is infected with G3A genotype. She has no
history of UGIB or varicies. She has no history of IDU or
transfusions. now s/p liver transplant [**2167-11-9**]
- DM-2
- Asthma: never required hospitalization or intubation
- Migraine headaches
- history of Gallstones
- ? peripheral vascular disease
- Cirrhosis
- Diuretic refractory ascites s/p TIPS [**2167-3-25**]
- HCC s/p RFA ablation
Social History:
She has 2 children and 2 grandchildren ages 15 and 18. They have
no pets, she does not garden or keep indoor plants. She has
worked in a local store as a stockperson. Not working. From
[**Male First Name (un) **] and moved here 40 yrs ago.
.
She was born in [**Male First Name (un) 1056**]. While there, she worked in assembly
lines, stores, and other manual labor jobs; She left [**Male First Name (un) 1056**]
over 40 years ago, and lived first in [**Location (un) 7349**] then NJ with her
present husband. They moved to [**State 87856**] over 1 year
ago.
Family History:
There is no known family history of liver disease or liver
cancer. She has 6 brothers and 5 sisters; her father died when
she was 17 (ETOH abuse) and her mother is alive and living in
[**Name (NI) 108**] now.
Physical Exam:
Vitals: T: 97.0, BP: 144/77, P: 84 R: 16 and O2: 98% on RA
General: Alert, oriented, no acute distress, pleasant middle
aged female laying in bed comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear,
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: well healing surgical incisions, midline and
diagonally, with some skin peeling around the umbilicus, no
active drainage, diffuse abdominal tenderness, +BS, nondistended
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2168-1-5**] 04:54AM BLOOD WBC-4.0 RBC-3.35* Hgb-10.1* Hct-31.8*
MCV-95 MCH-30.2 MCHC-31.8 RDW-16.3* Plt Ct-142*
[**2168-1-4**] 05:30PM BLOOD WBC-5.7 RBC-3.57* Hgb-11.0* Hct-34.0*
MCV-95 MCH-30.6 MCHC-32.2 RDW-16.1* Plt Ct-153
[**2168-1-5**] 04:54AM BLOOD Glucose-70 UreaN-16 Creat-0.9 Na-143
K-5.7* Cl-108 HCO3-30 AnGap-11
[**2168-1-4**] 05:30PM BLOOD Glucose-130* UreaN-17 Creat-1.0 Na-136
K-8.4* Cl-107 HCO3-24 AnGap-13
[**2168-1-4**] 05:10PM BLOOD Glucose-126* UreaN-16 Creat-0.9 Na-140
K-6.2* Cl-109* HCO3-26 AnGap-11
[**2168-1-4**] 04:50PM BLOOD Glucose-147* UreaN-17 Creat-0.9 Na-133
K-8.2* Cl-107 HCO3-19* AnGap-15
[**2168-1-5**] 04:54AM BLOOD Calcium-9.5 Phos-4.9* Mg-1.5*
Pertinent Labs:
[**2168-1-7**] 06:05AM BLOOD ALT-31 AST-42* AlkPhos-100 TotBili-0.4
[**2168-1-7**] 06:05AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.6
[**2168-1-5**] 04:54AM BLOOD tacroFK-7.0
[**2168-1-6**] 06:10AM BLOOD tacroFK-9.7
[**2168-1-7**] 06:05AM BLOOD tacroFK-14.1
Microbiology:
MRSA SCREEN (Final [**2168-1-7**]): No MRSA isolated
[**2168-1-5**] 11:44AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
Brief Hospital Course:
53 year old female with history of HCV/HCC cirrhosis now s/p
orthotopic liver transplant on [**2167-11-9**] presenting with
hyperkalemia refractory to medical management.
# Hyperkalemia: She initially presented with hyperkalemia in the
setting of feeling unwell over the past week. K+ elevated at
routine outside lab check, and refractory to initial attempts at
K+-uresis and membrane stabilization. Only mild EKG changes
were noted. She was transferred to the MICU for further
observation. Insulin with glucose and Kayexalate were given,
Bactrim was stopped and fludrocortisone was started on a three
times per week regimen. Tacrolimus and mycophenolate were kept
at the same doses. Her potassium trended down to a normal range.
.
# Liver transplantation: She is 2 months out of her OLT, with
only complication of a questionable strangulation in a ventral
hernia 1 month s/p transplant. Her post-op course has been
otherwise unremarkable and she is followed closely by the
[**Hospital 1326**] clinic ([**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **]), who sent her to [**Hospital1 18**] for
evaluation for hyperkalemia. Tacrolimus and mycophenolate were
continued and doses were not changed. Valganciclovir and
Fluconazole were continued for prophylaxis. Bactrim was stopped
and inhaled pentamidine was started for PCP [**Name Initial (PRE) 1102**].
.
# Abdominal pain: Patient reports that abdominal pain is close
to her baseline pain, for which she uses hydromorphone at home.
We continued her home regimen for pain control.
.
# Type 2 diabetes mellitus: Patients says that her glucose has
been uncontrolled as of late. Last A1c was 5.4 in [**2167-3-24**].
She was discharged on 75/25 insulin at 20 units qAM and 10 units
qPM. We decreased her pm dose of insulin due to an episode of
hypoglycemia in the morning during this hospitalization. It was
quickly corrected with [**Location (un) 2452**] juice and snacks.
.
#Transitional- She has follow up appointments with [**Last Name (un) **], her
PCP and the liver transplant clinic. She was instructed to have
lab work drawn and the results will be faxed to Dr. [**Last Name (STitle) **]. She
was also given a blood sugar log for her to use at home.
Medications on Admission:
1. mycophenolate mofetil 1000 mg [**Hospital1 **]
2. prednisone 15 mg daily (on a taper from transplant clinic)
3. valganciclovir 900 mg daily
4. fluconazole 400 mg daily
5. sulfamethoxazole-trimethoprim 400-80 mg daily
6. docusate sodium 100 mg [**Hospital1 **]
7. pantoprazole 40 mg daily
8. insulin lispro protam & lispro 100 unit/mL (75-25) Insulin
Pen Sig: per home scale dosing Subcutaneous twice a day: 40
units q AM and 25 units q PM.
9. tacrolimus 1.5 mg [**Hospital1 **]
10. hydromorphone 2-4 mg q4h PRN
11. albuterol sulfate 90 mcg/Actuation HFA 1 puff [**Hospital1 **]
12. ergocalciferol (vitamin D2) 50,000 unit qweek
13. sodium polystyrene sulfonate 15 grams PR per transplant
clinic
Discharge Medications:
1. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
taper per transplant clinic.
3. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
4. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Insulin protam & lispro 100 unit/mL (75-25) Insulin
Subcutaneous twice a day: 20 units qAM and 25 units qPM.
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for abdominal pain.
Disp:*24 Tablet(s)* Refills:*0*
9. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation twice a day as needed for shortness of
breath.
11. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO Three
Times Weekly (Mon, Wed, Fri).
Disp:*12 Tablet(s)* Refills:*2*
12. pentamidine 300 mg Recon Soln Sig: One (1) Recon Soln
Inhalation QMONTH (): To be scheduled by the Liver Transplant
center in the future. .
13. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
14. sodium polystyrene sulfonate
15 Grams PR per transplant clinic
15. Outpatient Lab Work
Please have lab work obtain on Monday [**1-11**]. Please draw BMP and
fax results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 697**].
Discharge Disposition:
Home With Service
Facility:
VNA of Greater RI
Discharge Diagnosis:
Primary:
-- Hyperkalemia
-- Hypoglycemia
-- Hepatitis C, status post liver transplant
-- Diabetes Type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure caring for you while you were admitted with
high blood potassium levels. The elevated potassium level was
felt to be secondary to your medications. Changes were made to
your medications and your potassium level improved. These
changes are listed below.
.
On the day of discharge you had an episode of hypoglycemia (low
blood sugar) which resolved with [**Location (un) 2452**] juice. If you feel that
your blood sugar is low in the future please check your blood
sugar and drink juice or eat something sweet. We have reduced
your insulin dosing and gave you a log to monitor your blood
sugars after discharge. You should keep you follow up
appointment with [**Last Name (un) **] Diabetes center in the future.
.
The following changes were made to your medications:
-- STOP Bactrim, you were given inhaled pentamidine in its place
-- START Florinef (fludrocortisone) 0.1mg on Monday, Wednesday,
Friday
-- CHANGE Insulin Dosing to (75/25 Insulin) 20 units in the
morning and 10 units at night.
Please keep all follow up appointments:
Followup Instructions:
Please keep your follow up appointment with the [**Last Name (un) **] Diabetes
Center on Monday [**1-11**]. Bring the log of your blood
sugars to this follow up visit.
Name: [**Month (only) **],SAPNA
Specialty: INTERNAL MEDICINE
Location: [**Hospital 87857**] HEALTH CENTER
Address: [**Hospital1 87858**], [**Location (un) **],[**Numeric Identifier 87859**]
Phone: [**Telephone/Fax (1) 78064**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 78063**]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office or have questions, please
call the number above.
Department: TRANSPLANT
When: TUESDAY [**2168-1-19**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
ICD9 Codes: 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4965
} | Medical Text: Admission Date: [**2107-5-4**] Discharge Date: [**2107-5-9**]
Date of Birth: [**2056-5-8**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
female with a history of hypertension, ulcerative colitis who
over the past six months has had a complaint of chest pain,
shortness of breath, dyspnea on exertion. She had an
echocardiogram done in [**Month (only) 404**] which was significant for 3+
mitral regurgitation, 2+ aortic regurgitation and mild aortic
stenosis. The mitral valve area was 1.7 cm square. A
cardiac catheterization was performed which was normal and
was significant for an ejection fraction of 50%. She
presents to [**Hospital6 256**] for mitral
valve replacement surgery.
PAST MEDICAL HISTORY:
1. Ulcerative colitis
2. Hypertension
3. Asthma
4. Anemia
5. Hypercholesterolemia
PAST SURGICAL HISTORY:
1. Status post hysterectomy
2. Status post appendectomy
3. Status post dilatation and curettage
ADMISSION MEDICATIONS:
1. Proventil 2 puffs prn
2. Serevent 2 puffs [**Hospital1 **]
3. Flovent 2 puffs [**Hospital1 **]
4. Asacol 3 tablets po tid
5. Captopril 25 mg po bid
6. Uniphyl 1 qd
7. Claritin 10 mg po qd
ALLERGIES: PREDNISONE LEADS TO HEADACHE, NAUSEA AND VOMITING
AND FLOXIN HAS A SKIN SENSITIVITY.
PHYSICAL EXAM:
GENERAL: On admission, the patient is a middle aged woman,
obese, who is in no acute distress.
VITAL SIGNS: Temperature 99??????, heart rate 84, blood pressure
128/77, respiratory rate 14, O2 saturation 97.
LUNGS: Clear to percussion and auscultation.
CARDIAC: Normal S1, but increased S2. No gallop was
audible. A [**3-16**] near holosystolic murmur at the apex and
lower left sternal border. A faint 1/6 systolic ejection
murmur at the base, no diastolic murmur, no rub.
ABDOMEN: Soft, nontender without organomegaly. Bowel sounds
were normal.
EXTREMITIES: No edema of the extremities. No cyanosis.
NEUROLOGIC: She is alert and oriented x3.
IMAGING: Electrocardiogram showed normal sinus rhythm within
normal limits.
HOSPITAL COURSE: On the day of admission, the patient went
to the Operating Room and underwent mitral valve replacement
with a 31 mm Carbomedics valve. She tolerated the procedure
well, went to the PACU. Overnight, she remained
hemodynamically stable. She had an AAI in place at a rate of
60. Her nitroglycerin was weaned with blood pressures of 90
to 110/50s to 60s. The patient, early on postoperative day
#1, had a complaint of nausea related to Percocet. It was
changed to Dilaudid with good effect. She was found stable
and was transferred to the floor on postoperative day #1 of
the remainder of recovery. She remained afebrile and
hemodynamically stable. On postoperative day #2, the Foley
was discontinued and the pacing wires were discontinued. She
was out of bed and ambulating. She was evaluated by physical
therapy and she is currently at a level 5 activity. On
postoperative day #3, the chest tube was discontinued without
any incidents. During her postoperative course, she was
started on her Coumadin anticoagulation. Her INRs responded
appropriately and on discharge is at 2.6. The patient was
ambulating without assistance, has been tolerating a regular
diet. Wound has remained clean, dry and intact. The patient
is now ready for discharge to home. She will follow up with
Dr. [**Last Name (STitle) **] in the office in approximately one month.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg po qd x2 days
2. [**Doctor First Name **] 60 mg po bid
3. Uniphyl 600 mg po qd
4. Protonix 40 mg po qd
5. Flovent metered dose inhaler 110 mcg 2 puffs q 12 hours
6. Serevent metered dose inhaler 2 puffs q 12 hours
7. Albuterol metered dose inhaler 2 puffs q4h prn
8. Lopressor 25 mg po bid
9. Dilaudid 2 mg po q4h prn
10. Colace 100 mg po bid
DISCHARGE CONDITION: Stable. The patient will go home with
VNA for wound checks qd and PT/PTT trial starting on
Wednesday [**2107-5-11**]. The results will be sent to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 54268**] for dressing and cleaning appropriately.
The patient will follow up with Dr. [**Last Name (STitle) **] in approximately
four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2107-5-9**] 13:15
T: [**2107-5-10**] 09:23
JOB#: [**Job Number **]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4966
} | Medical Text: Admission Date: [**2168-2-23**] Discharge Date: [**2168-5-17**]
Date of Birth: [**2113-2-2**] Sex: M
Service: MEDICINE
Allergies:
Ipratropium And Derivatives / Peanut Containing Products /
Acyclovir
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Febrile neutropenia
Major Surgical or Invasive Procedure:
Central line placement
bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 54-year-old man with a history of plasma cell
leukemia/myeloma with IgG paraprotein complicated in the past by
DVT/PE, who is day 11 s/p DPACE. The patient presented to clinic
today with fever to 100.8 and a WBC count of 0.1 (ANC pending).
He was admitted for DPACE on [**2168-2-12**] due to rapid progression of
disease (markedly elevated IgG level) s/p Cytoxan on [**2-1**]. He
tolerated DPACE well, only experiencing some fatigue and water
retention, and was discharged to home with 10days of neupogen
injections. He experienced progressive fatigue upon discharge
home, however had no fevers or localizing signs at home. He has
had no appetite since discharge. He has a rash on his scalp and
face consistent with folliculitis which has been present since
discharge. Accompanying the above weakness, he has been
experiencing some associated shortness of breath. He was getting
dressed to come in to clinic and felt as though he could not
catch his breath. This was alleviated with rest. He has also
developed some oral lesions. He denied any nasal congestion,
sore throat, headache, chest pain, dysuria, hesitancy or urinary
frequency. He does report decreased bowel movements which he
attributes to decreased PO intake. He does report some mild
epigastric "pressure" which is relieved with belching.
.
He presented to clinic and on arrival noted a non-productive
cough and fever. He had no cough prior to this afternoon.
.
Review of systems: No chest pain, palpitations. No nausea,
vomiting, diarrhea or constipation, or back pain. No numbness or
tingling of his extremities. No headaches, dizziness, blurred
vision. He denies any bleeding or increased bruising, hematuria,
hematochezia, epistaxis or gum bleeding. All other systems
reviewed in detail and negative except for what has been
mentioned above.
Past Medical History:
Past Oncologic History:
1. Diagnosed on [**12/2164**] with plasma cell leukemia/myeloma when
he presented with sepsis.
2. Status post hyper-CVAD x2 cycles in [**1-/2165**] and 01/[**2165**].
3. Status post Cytoxan 750 mg/m2 for 2 days with Decadron pulses
followed by thalidomide at 200 mg daily in 2/[**2165**]. This
treatment was complicated by a left leg DVT for which he was
started on coumadin.
4. Status post autologous stem cell transplant in 05/[**2165**].
5. Noted for recurrent disease and treated on the
Revlimid/Velcade study, number 04-130 with excellent response to
treatment from [**7-/2166**] until [**1-/2167**], however discontinued on
protocol due to pulmonary embolism in 01/[**2167**].
6. Started maintenance Velcade in [**8-/2167**] with three and half
cycles of therapy given his first cycle was given without
Decadron, Decadron added for the subsequent cycles.
7. Initiated treatment with Revlimid alone on [**2167-12-16**] with
increasing doses for 21-day cycle with therapeutic Lovenox to
100 mg b.i.d. due to history of PE.
8. Given cytoxan therapy on [**2-1**], tolerated well.
9. Treated with DPACE on [**2171-2-12**], tolerated well.
.
Other Past Medical History:
1. Hx of DVT [**2165**], hx of PE [**2-/2167**]
2. Renal insufficiency
3. Hx of Zoster
Social History:
Denies any current smoking, quit smoking 15 years ago, denies
any alcohol use or history of alcohol abuse, denies any IVDU.
Currently lives in [**Hospital1 1474**] with his wife and child. Works as a
computer programmer. Has one child, currently alive and well.
Family History:
He has a maternal uncle with lung cancer and a paternal uncle
with [**Name2 (NI) 500**] cancer. He has 1 brother, 1 sister and 1 half brother.
His sister has MS, and his half brother died from diabetes. His
mother died from a stroke, and his father is still alive and
well.
Physical Exam:
VS: T:100.8 HR: BP: RR: Sat: %RA
Gen: Fatigued appearing male, in no distress, sitting up on
hospital bed.
HEENT: NCAT, PERRL, sclera anicteric, oropharynx with some
aphthous ulcers on buccal mucosa, tongue, throat erythematous,
no exudates, no thrush
LN: no cervical, axillary lymphadenopathy
CV: RRR, normal S1/S2, no m/r/g, no tenderness to palpation of
precordium
Lungs: Clear to auscultation bilaterally, No w/r/rh
Abdomen: Soft, nondistended, normoactive bowel sounds, no
hepatosplenomegaly. Mild tenderness to deep palpation of
epigastric region.
Ext: Trace edema bilaterally. No clubbing, cyanosis, or calf
pain, DP pulses are 2+ bilaterally
Neuro: A + O x 3, CN II-XII grossly intact, Motor [**6-11**] both upper
and lower extremities, Sensation grossly intact to light touch
Skin: pink, warm, rash noted at hair follicle over scalp, nose,
chest. POC - dressed, clean, dry, intact.
Pertinent Results:
Admission Labs:
[**2168-2-23**] 02:40PM BLOOD WBC-.1* RBC-3.07* Hgb-11.2* Hct-30.1*
MCV-98 MCH-36.6* MCHC-37.3* RDW-14.5 Plt Ct-41*
[**2168-2-23**] 02:40PM BLOOD Plt Smr-VERY LOW Plt Ct-41*
[**2168-2-23**] 02:40PM BLOOD Gran Ct-20*
[**2168-2-24**] 12:15AM BLOOD SerVisc-2.0*
[**2168-2-23**] 02:40PM BLOOD Glucose-165* UreaN-22* Creat-1.6* Na-129*
K-4.5 Cl-100 HCO3-24 AnGap-10
[**2168-2-23**] 02:40PM BLOOD ALT-32 AST-25 LD(LDH)-117 AlkPhos-56
TotBili-0.7
[**2168-2-23**] 02:40PM BLOOD TotProt-12.1* Albumin-3.0* Globuln-9.1*
Calcium-9.7 Phos-4.8* Mg-1.5*
[**2168-2-23**] 02:40PM BLOOD PEP-ABNORMAL B IgG-8079* IgA-8* IgM-8*
Discharge Labs:
Reports:
[**2-23**] CXR:
IMPRESSION: No acute pulmonary process. As noted previously, the
3 mm nodule seen on CT is not evident on the radiographs.
.
[**2-24**] Skin biopsy:
Skin, right face (A):
Skin with central dilated follicle and mild perifollicular
chronic inflammation.
Note: No leukemic infiltrate is seen in the sections examined
and inflammation is minimal (there is a focal mild
perifollicular lymphohistiocytic infiltrate). While there is a
central dilated follicle, no Demodex is seen within the
follicle. The findings are non-specific and clinical correlation
is needed. Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 54131**] is notified of the diagnosis on
[**2168-2-25**].
.
[**3-1**] ECHO: MPRESSION: Very small, mobile echodensity as
described above on the aortic valve annulus/sinus. The location
is very atypical for a vegetation and no aortic regurgitation is
seen. Compared with the prior study of [**2168-2-12**], the findings are
similar (the mobile echodensity is less well defined, but
suggested on clip #[**Clip Number (Radiology) **]). If clinically indicated, a TEE might be
better able to define the aortic annular echodensity.
[**3-27**] Abd MRI
1. Right lower lobe airspace disease, which may be infection or
atelectasis.
2. Evidence of hemosiderosis.
3. L3 compression fracture deformity appears chronic.
4. Gallbladder wall thickening.
5. No abnormal lesions within the liver or spleen, however,
evaluation for hepatosplenic candidiasis is limited due to the
lack of post-contrast imaging. If clinically warranted, patient
should return for post-contrast images.
[**4-2**] CXR
1. Support lines in place.
2. Right basilar atelectasis and small left-sided pleural
effusion.
ECHO:
Conclusions:
The left ventricular cavity size is normal. LV systolic function
appears
depressed. There is probably inferior hypokinesis but views are
technically suboptimal. LV ejection fraction difficult to
estimated (?45%). Right ventricular chamber size is normal.
Right ventricular systolic function is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2168-4-20**],
left ventricular function now appears similar in suboptimal
views. Heart rate is now slightly lower.
...
CT Chest:
IMPRESSION:
1. Rapidly enlarging right hilar mass, obstructing the right
middle lobe bronchi and markedly narrowing bronchus intermedius
and right lower lobe bronchi. Findings are most consistent with
a neoplastic process, and bronchoscopy would have a high yield
for diagnosis. In an immune-suppressed patient, granulomatous
infection may sometimes mimic a neoplastic process.
2. New small right pleural effusion.
3. Diffuse skeletal lucencies consistent with myeloma.
....
Discharge labs
Brief Hospital Course:
Mr. [**Known lastname **] is a 54-year-old man w/ history of plasma cell
leukemia/multiple myeloma who has hx of PE during treatment with
Revlimid, s/p recent DPACE treatment here with febrile
neutropenia.
.
# Plasma cell leukemia/myeloma: The patient recently received
DPACE and was persistently neutropenic. Originally presented
with non-productive cough since this afternoon, oral lesions and
papular rash noted on scalp and face. He was originally started
on Cefepime monotherapy for febrile neutropenia and Bactrim and
Valacyclovir were continued for PCP and HSV prophylaxis
respectively. Blood and urine cultures were taken in clinic. CXR
was done which was negative for an infiltrate. His counts on
presentation were low and he was continued on daily neupogen
injections. On [**2-24**], Cefepime was switched to [**Last Name (un) **]/Vanco as his
blood cultures grew out Coagulase negative staph and strep
viridans. In addition, on [**2-24**], as his IgG came back at 8000, he
was instructed to start to take his own Revlimid (15mg daily).
Given his slow to respond white count, the revlimid was tapered
to 5mg daily and stopped temporarily. The revlimid was restarted
with decadron on [**3-1**] for four days. He received 4 days of
decadron, completed on [**3-4**]. He continued to take the Revlimid
at 15mg. He was also started on lovenox for DVT prophylaxis
given his history of PE while on Revlimid. While on lovenox,
his platelets were checked twice daily and kept >50. Bm Bx done
on [**3-9**] showed 50% plasma cells. Patient was started on
pentostatin/TBI mini-allo SCT. Revlimid and lovenox were stopped
prior to transplant. Patient was given pentostatin and TBI with
Day 0 was [**4-5**] he tolerated the transplant well but had muscle
pain. He then received received MTX day +1, +3, +5. His counts
were slow to recover but now ANC >[**2161**]. Antibiotics have been
slowly taken off and the patient remains AF. However, there were
signs that disease is worsening (IgG increased to ?9000). As
well the right middle low mass that was thought to be a
plasmacytoma showed increasing size on repeat CT. Therefore he
was started thalidomide [**4-28**] for treatment of myeloma as his
disease was previously responsive to this. Given that he
previously had a DVT/PE on this regimen, he was started on
heparin gtt with a goal of 50-70 and give platelets with goal
of >50
.
# Dyspnea: Respiratory distress several times week of [**4-18**] and
eventually needed [**Hospital Unit Name 153**] stay with 1 night of BiPAP after
bronchoscopy thought to be due to pulmonary edema but with only
mild improvement with lasix. Also with concern for engraftment
syndrome or DAH, but with little improvement with steroids or
evidence on bronchoscopy. Sputum cultures show aspergillus. Will
continue posaconazole at treatment dosage. No signs of fluid
overload and improvement without diuresis making aspergillus
infection likely.
.
# Muscle pain- Likely secondary to marrow edema or fungal infx.
Gradually improving. Initially required a fentanyl PCA that was
converted to a fentanyl patch that was removed o n [**4-29**].
.
# Hypertension/tachycardia- Occurred after transplant. Was
started on metoprolol and eventually achieved control at
metoprolol 75 mg.
.
# Bacteremia: On cultures drawn on admission, he grew 2 bottles
of coagulase negative staph and 1 bottle of strep viridans. The
suspected sources of the bacteremia were the rash of the scalp
as a source of the coagulase negative staph and his aphthous
ulcers as the source of his strep viridans. He was initially
placed on Cefepime and Vancomycin, however after his cultures
grew out he was changed to Meropenem and Vancomycin. His fever
curve trended back to normal. Because of the culture positive
for Strep viridans and question of possible endocarditis, an
echocardiogram was done which showed a small fluttering
echodensity on the aortic annulus which was stable from an
echocardiogram three weeks earlier. Multiple blood cultures were
negative and cefepime and vancomycin were stopped after he was
afebrile for 2 weeks. As patient began to spike fevers again
with no clear source these were restarted 1 wk prior to
transplant.
.
# ? Transfusion reaction: A blood transfusion was stopped on
[**2-24**], as the patient was febrile during the transfusion. An
investigation was done and the conclusion was that the fever was
likely due to the patient's bacteremia and was unrelated to the
transfusion. He went on to receive blood transfusions for the
remainder of the hospitalization.
.
# Rash: The patient presented with a papular rash on scalp,
face. He was seen by dermatology who did a biopsy on [**2-24**]. The
results showed no leukemic infiltrate in the sections examined
and inflammation is minimal (there is a focal mild
perifollicular lymphohistiocytic infiltrate). While there is a
central dilated follicle, no Demodex was seen within the
follicle. He developed a second rash on [**2-25**] which seemed
related in timing to the initiation of Meropenem and Vancomycin.
As this was deemed the most appropriate antibiotic regimen, he
was started on atarax 4x/day with good response in the rash. The
rash resolved within 2 days and the atarax was stopped without
recurrence of symptoms.
.
# Renal insufficiency: The patient presented with creatinine of
1.6.
Per OMR, creatinine is often elevated with worsening of disease.
His creatinine continued to improve with hydration but again
worsened when being diuresed for concern of volume overload.
Remains persistently high despite no diuresis. Urine studies
show likely secondary to myeloma.
.
# Transaminitis- patient has underlying fatty liver seen on RUQ
US and MRI and then voriconazole was started which caused a rise
in his LFTs. Vorinconazole was stopped after 2 days and LFTs
continued to rise for days and then trended down. He was treated
with ursodiol as well. LFTs remained normal after transplant
and stayed normal while being treated on posaconazole.
Medications on Admission:
Valtrex 1000 mg daily
Bactrim DS 1 tab [**Hospital1 **] MWF
Neupogen SC daily
Discharge Medications:
NA
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Plasma Cell Leukemia
Multiple Myeloma
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2168-6-22**]
ICD9 Codes: 431, 5845, 4280, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4967
} | Medical Text: Admission Date: [**2110-4-23**] Discharge Date: [**2110-4-28**]
Date of Birth: [**2082-8-15**] Sex: M
Service: Medicine, [**Doctor Last Name **] Firm
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old
male with recurrent pneumonias complicated by empyema and
intubation who presented to the Emergency Department on the
day of admission complaining of several days of fever and
cough.
A chest x-ray obtained at that time was consistent with right
lower lobe and retrocardiac pneumonia. He was discharged on
oral azithromycin; however, on returning home he was unable
to sleep, had difficulty breathing, and a persistent cough
(producing a thick yellow sputum) that prompted his return to
the Emergency Department.
On the second evaluation, the patient's oxygen saturation was
found to be 88% on 100% nonrebreather, and he was tachypneic
(with a respiratory rate of 40 to 50). He was also producing
copious amounts of sputum and was agitated. He was intubated
emergently and received 3 liters of saline resuscitation and
was started empirically on metronidazole and ampicillin and
was admitted to the Medical Intensive Care Unit for further
evaluation.
PAST MEDICAL HISTORY:
1. Bipolar disorder.
2. Schizoaffective disorder.
3. Hypertension.
4. Recurrent pneumoniae.
5. History of rheumatic heart disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Clozapine 175 mg p.o. twice per day.
2. Valproate 125 mg p.o. four times per day.
3. Atenolol 50 mg p.o. once per day.
4. Azithromycin 500 mg (the patient one dose prior to
returning to the Emergency Department).
SOCIAL HISTORY: The patient lives with his father and
brother in [**Name (NI) 577**]. He does not smoke cigarettes or drink
alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 104.8, heart rate was 120s,
respiratory rate was 22, the patient was intubated. Blood
gas was as follows: 7.3/60/93. Head, eyes, ears, nose, and
throat examination revealed the patient had pinpoint pupils
and sclerae were anicteric. The neck was supple without
lymphadenopathy or jugular venous distention. Heart was
tachycardic with a regular rate and rhythm. Normal first
heart sounds and second heart sounds. There were no extra
sounds. The lungs revealed diffuse rhonchi bilaterally with
wheezing on inspiration and expiration. The abdomen was
slightly obese, soft, nontender, and nondistended. No scars.
Normal bowel sounds. No organs were palpable. Extremity
examination revealed there were no rashes, clubbing,
cyanosis, or edema. Vascular examination was intact; radial,
carotid, dorsalis pedis, and posterior tibialis pulses.
Neurologic examination revealed the patient was sedated.
PERTINENT LABORATORY VALUES ON PRESENTATION: On return to
the Emergency Department, his white blood cell count was 13,
hematocrit was 40, and platelets were 160. INR was 1.2. The
chemistry panel was normal. Urinalysis was normal. Serum
toxicology screen was unremarkable. Urine toxicology screen
detected benzodiazepines.
An electrocardiogram revealed sinus tachycardia with a new
right bundle-branch block (note, the right bundle-branch
block did not persist once the patient was fluid resuscitated
and afebrile).
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit, was ventilated using the acute respiratory
distress syndrome protocol and was successfully extubated 36
hours after admission and was transferred to the Medicine
Service.
His workup in the Intensive Care Unit included serologic
tests for influenza A and B virus, human immunodeficiency
virus 1; and all tests were negative. He had one positive
blood cultures on [**4-22**] which grew coagulase-negative
staphylococcal species.
His medications on transfer to the medicine floor were as
follows: Levofloxacin 500 mg p.o. once per day, ceftriaxone
1 g q.24h., valproic acid 125 mg q.4h., atenolol 50 mg p.o.
once per day, clonazepam 0.5 mg q.8h., and heparin
subcutaneously.
At that time, his examination was as follows: Vital signs
revealed temperature was 99.2, heart rate was 62 to 85, blood
pressure was 150 to 160/82 to 89, and oxygen saturation was
95% on 3 liters nasal cannula. Examination was significant
for decreased breath sounds without fremitus or egophony over
the lower halves of both lung fields.
The patient's oxygen requirement decreased on hospital day
five, and he was successfully weaned off of oxygen. He was
evaluated by the Physical Therapy Service who did not
recommend further treatment upon discharge.
On hospital day six, the patient complained of pain on
urination attributed to his Foley catheter. A repeat
urinalysis was normal except for the presence of a small
amount of blood. The pain resolved upon discharge.
DISCHARGE DIAGNOSES:
1. Multilobar pneumonia.
2. Bipolar disorder.
3. Schizoaffective disorder.
4. Hypertension.
5. Recurrent pneumoniae.
6. History of rheumatic heart disease.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. every 24 hours (to complete a
14-day course).
2. Prozapine 175 mg p.o. twice per day.
3. Clonazepam 0.5 mg p.o. every 8 hours.
4. Atenolol 50 mg p.o. once per day.
5. Valproic 125 mg p.o. four times per day.
DISCHARGE STATUS: The patient was discharged to home.
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2110-4-28**] 08:41
T: [**2110-4-28**] 08:49
JOB#: [**Job Number 94027**]
ICD9 Codes: 486, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4968
} | Medical Text: Admission Date: [**2103-3-17**] Discharge Date: [**2103-3-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
status post cardiac arrest
Major Surgical or Invasive Procedure:
Chest tube
Arterial line
Central line
History of Present Illness:
[**Age over 90 **] year old female with a history of atrial fibrillation, CAD
s/p MI, PVD, CVA who presents s/p cardiac arrest. Pt was found
down at a rehab facility. EMT was called when she was found
down in the nursing home. She was intubated in the field and
was noted to be in PEA arrest. CPR was performed and she was
given epinephrine and atropine x 3. CPR performed by EMTs and
3Xepi plus 3X atropine. In our ED CPR continued for 2-3 mins
and then regained pulse. Noted to have crepitis likely from CPR
on left so got a left sided chest tube. ETT pulled back because
in right main stem. CXR good placement ETT after pulling back.
EKG afib with wide QRS but cards thought from acidemia. Pupils
fixed. Right CVL Fem line placed (initially had IO line). VBG
6.76/58/76/9. Got an amp bicarb and on a bicarb drip at 150ml an
hour. 2 units ffp ordered as well as two units prbcs. Had CT
head negative for bleed. Hypotensive in Ed (70/40) so started
levophed drip. VS prior to transfer: 101/62 levo on
1.2mc/kg/min. Temp rectally 96.6. HR 106 101/62 vented 450X18.
.
Past Medical History:
CHF with EF of 75% from echo
Atrial Fib on coumadin
s/p PCM
CAD s/p MI in 79
DM II (diet controlled )
Multiple CVA
PVD s/p femoral embolectomy
Social History:
Pt lives in [**Location **] and is independant of ADLs. Communication:
Patient via russian interpreter. Grand Niece & HCP-- [**Name (NI) 83407**]
[**Telephone/Fax (1) 83408**] cell [**Telephone/Fax (1) 83409**]
[**Female First Name (un) 83410**] Daughter & 2nd HCP-- [**Telephone/Fax (1) 83411**]
NH-->[**Telephone/Fax (1) **]
Family History:
NC
Physical Exam:
General: Intubated, sedated
HEENT: Pupils fixed, non-reactive, MM dry
Neck: No LAD
Lungs: Diffuse rhonchi
CV: Tachy, heart sounds obscured by diffuse rhonchi
Abdomen: Firm, distended, hypoactive bowel sounds
Ext: Cool, no edema
Pertinent Results:
[**2103-3-17**] 01:24PM TYPE-ART PH-7.21*
[**2103-3-17**] 01:24PM freeCa-1.02*
[**2103-3-17**] 12:10PM TYPE-ART PO2-174* PCO2-37 PH-7.18* TOTAL
CO2-15* BASE XS--13
[**2103-3-17**] 12:10PM TYPE-ART PO2-174* PCO2-37 PH-7.18* TOTAL
CO2-15* BASE XS--13
[**2103-3-17**] 12:10PM LACTATE-13.1*
[**2103-3-17**] 12:10PM freeCa-0.63*
[**2103-3-17**] 11:56AM TYPE-ART PO2-48* PCO2-62* PH-7.03* TOTAL
CO2-18* BASE XS--16
[**2103-3-17**] 11:56AM LACTATE-13.9*
[**2103-3-17**] 11:56AM freeCa-0.88*
[**2103-3-17**] 11:14AM LACTATE-14.2*
[**2103-3-17**] 11:14AM LACTATE-14.2*
[**2103-3-17**] 11:14AM freeCa-0.89*
[**2103-3-17**] 11:13AM GLUCOSE-124* UREA N-45* CREAT-1.9*
SODIUM-151* POTASSIUM-5.8* CHLORIDE-114* TOTAL CO2-13* ANION
GAP-30*
[**2103-3-17**] 11:13AM GLUCOSE-299* UREA N-39* CREAT-1.7*
SODIUM-149* POTASSIUM-5.7* CHLORIDE-111* TOTAL CO2-11* ANION
GAP-33*
[**2103-3-17**] 11:13AM ALT(SGPT)-414* AST(SGOT)-942* LD(LDH)-2219*
CK(CPK)-284* ALK PHOS-76 TOT BILI-1.2
[**2103-3-17**] 11:13AM ALT(SGPT)-399* AST(SGOT)-947* LD(LDH)-1891*
CK(CPK)-386* ALK PHOS-53 TOT BILI-1.1
[**2103-3-17**] 11:13AM CK-MB-26* MB INDX-9.2* cTropnT-0.50*
[**2103-3-17**] 11:13AM CK-MB-35* MB INDX-9.1 cTropnT-0.66*
[**2103-3-17**] 11:13AM WBC-7.0 RBC-3.14* HGB-9.0* HCT-30.3* MCV-97
MCH-28.8 MCHC-29.8* RDW-19.0*
[**2103-3-17**] 11:13AM WBC-5.4 RBC-1.90*# HGB-5.6*# HCT-18.4*#
MCV-97 MCH-29.3 MCHC-30.4* RDW-18.4*
[**2103-3-17**] 11:13AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ BURR-OCCASIONAL
STIPPLED-OCCASIONAL PAPPENHEI-OCCASIONAL
[**2103-3-17**] 11:13AM NEUTS-75* BANDS-1 LYMPHS-16* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-5* MYELOS-0 NUC RBCS-4*
[**2103-3-17**] 11:13AM PT-30.8* PTT-150* INR(PT)-3.1*
[**2103-3-17**] 11:13AM PT-24.2* PTT-150* INR(PT)-2.3*
Brief Hospital Course:
On arrival to MICU, she was noted to be persistently hypotensive
despite max levophed. Started on vasopressin followed by
escalating neosynephrine. With severe metabolic acidosis
6.76/58/76 with lacate peak at 14.2, given 2 amps bicarb
followed by bicarb drip. Also given FFP given severe
coagulopathy and concern for bleed (hct down to 18.4 from
baseline ~30s). In setting of blood products with worsening
oxygenation with desaturations to 85% on FiO2 100%, PEEP 15. The
patient was continued on three pressors for blood pressure
support and her BP still remained low.
The health care proxy was called to bedside. The patient was s/p
cardiac arrest and in DIC, unable to be cooled. She remained
hypotensive despite maximal pressors. After discussions with the
housestaff and attending physician, [**Name10 (NameIs) **] health care proxy did
not wish to further escalate care and made the patient DNR. The
patient died of PEA cardiac arrest with her HCP at her side.
The case was referred to the medical examiner, however, the
medical examiner declined the case. The family did not want an
autopsy.
Medications on Admission:
Unknown
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
-Sepsis, multisystem organ failure
-status post cardiac arrest
-disseminated intravascular cogulation
Discharge Condition:
Expired, not applicable
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 2762, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4969
} | Medical Text: Admission Date: [**2200-5-21**] Discharge Date: [**2200-5-26**]
Date of Birth: [**2131-4-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
This is a 69 year old man with PMH of colostomy 20 years ago who
presents with bleeding per rectum. He reports being in his
normal state of health until 4 days ago, when he noticed slight
stomach ache, then had maroon bowel movements, [**4-13**] daily. He
reports that this continued until the morning of presentation,
when he had a syncopal episode and went to the ER on [**Location (un) 7453**] by EMS. He was found to have a HCT of 19, and was given
3 units prbc. An abdominal CT was performed with showed possible
gastric mass but was limited by lack of contrast. He was
transferred to [**Hospital1 18**] by [**Location (un) **].
.
At [**Hospital1 18**], his initial hct was 26. He was tachycardic to 117 but
blood pressure was 137/56. He had a bowel movement reported to
be "maroon" with some black parts, but denies black bowel
movments otherwise. He was admitted to the ICU for further
management and endoscopy.
.
ROS: He denies abdominal pain, nausea, vomiting, hematemesis,
fever, chills, lightheadedness, chest pain, shortness of breath,
or other concerns.
Past Medical History:
diverting colostomy [**2182**] for 12 months, then reversed, for
"stomach leak"
Social History:
Lives at home. Drinks 2-3 drinks per night. Smokes 1 ppd.
Family History:
no bowel problems
Physical Exam:
V: Tc 97.6 P108 BP 109/59 R20 100% RA
Gen: slightly disheveled, no distress
HEENT: right pupil with cataract, left none. Reactive to light.
OP clear. MM dry
Resp: CTA bilaterally
CV: tachycardic, nl s1s2 no mGR
Abd: soft NTND +BS
Ext: no edema
Pertinent Results:
EKG: sinus tachy at 118 no Q waves no ST/t wave changes.
.
Imaging: CXR: AP bedside chest shows normal heart and aorta
without vascular congestion, consolidations, or effusions.
Lungs are well inflated with relative prominence central
pulmonary vessels suggesting possible emphysema/cor pulmonale.
No comparison exams on PACS.
.
CT Chest:
1. No duodenal or pancreatic mass identified. Inflammatory
changes between the pancreatic head and duodenum as well as
enhancement and dilatation of the common bile duct are likely
secondary inflammatory changes related to recently seen duodenal
bulb ulcer (see Careweb for EGD findings from [**2200-5-22**]).
2. Four-mm nodule in the right upper lobe abutting the major
fissure. Conservative followup in one year is recommended to
ensure stability.
3. Multiple bilateral renal hypodensities are too small to
characterize, but likely cysts.
4. Tiny bilateral pleural effusions with adjacent atelectasis.
.
[**2200-5-21**] 03:00PM PT-13.8* PTT-23.4 INR(PT)-1.2*
[**2200-5-21**] 03:00PM GLUCOSE-133* UREA N-57* CREAT-1.3* SODIUM-135
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-19* ANION GAP-14
[**2200-5-21**] 04:35PM PLT COUNT-188
[**2200-5-21**] 04:35PM WBC-13.3* RBC-2.79* HGB-9.1* HCT-26.3* MCV-95
MCH-32.6* MCHC-34.5 RDW-14.6
[**2200-5-21**] 04:35PM NEUTS-76.3* LYMPHS-18.3 MONOS-5.1 EOS-0.1
BASOS-0.3
[**2200-5-21**] 06:50PM ALBUMIN-2.5* CALCIUM-7.5* PHOSPHATE-2.9
MAGNESIUM-1.3*
[**2200-5-21**] 06:50PM LIPASE-35
[**2200-5-21**] 06:50PM ALT(SGPT)-27 AST(SGOT)-25 ALK PHOS-46
AMYLASE-54 TOT BILI-1.1
Brief Hospital Course:
69M with remote history of colectomy, reversed, presented with
syncope and GI bleed
.
1) GI bleed - Still unclear whether upper or lower. although
suspect upper source. Intially, he was NPO with serial HCTs. He
also received a PPI [**Hospital1 **]. Endoscopy revealed small hiatal hernia,
erosion in the antrum compatible with non-steroidal induced
gastritis, ulcer in the posterior bulb (given thermal therapy).
Otherwise normal EGD to second part of the duodenum. He was
transfused 3 units PRBCs and remained hemodynamically stable. H
pylori sent and pending at time of discharge; patient started on
empiric therapy that can be discontinued if serology returns
negative. Counseled to stop alcohol as well.
.
2) Syncope - most likley syncope in setting of GI bleed. 1 set
CE's negative. EKG - sinus tach. Tele x 24 hours showed no
events.
.
3) Smoking - Given nicotine patch while in hospital. Counseled
on need to stop smoking. Lung nodule incidentally seen on CT
scan chest; should get repeat CT scan in next 6 months-year to
follow for stability.
Medications on Admission:
ibuprofen 2 tabs 3-4 times weekly for "cold prevention"
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day for 14 days.
Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. Tetracycline 250 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours).
Disp:*240 Capsule(s)* Refills:*2*
3. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: Two (2)
Tablet PO QID (4 times a day) for 14 days.
Disp:*112 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Blood Loss Anemia
Gastric Hemorage
Duodenitis with hemorage
Duodenal Ulcer
Discharge Condition:
Good
Discharge Instructions:
Please note: you have a 4 mm nodule that was noted on your chest
CT. This needs to be followed up in 6 months to 1 year. Please
discuss with your primary care doctor, as this could represent
cancer. You need to stop smoking completely.
.
Your stool will likely turn black on the anti-biotics you will
be on. This is normal, however, if it becomes truly black or
tarry, or have blood in the stool, you should immediately go to
the hospital. You are recommended to get a repeat endoscopy in
a month.
Followup Instructions:
Please make a follow up appointment with a primary care doctor
in the next week to get follow up blood counts and overall care.
.
CT chest in 6 months to 1 year
.
You will need to follow up with our gastroenterology service for
a repeat endoscopy in [**5-16**] weeks, as well as follow up on your
biopsies.
ICD9 Codes: 2851, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4970
} | Medical Text: Admission Date: [**2198-2-23**] Discharge Date: [**2198-2-28**]
Date of Birth: [**2134-7-19**] Sex: M
Service: CARDIOTHOR
CHIEF COMPLAINT: The patient is a 63 year-old patient with
silent ischemia. He was referred for an outpatient cardiac
catheterization.
HISTORY OF PRESENT ILLNESS: Hypertension, diabetes,
peripheral vascular disease. The patient reports a remote
history of chest discomfort dating back to [**2183**]. He
described a brief episode of chest and epigastric discomfort
and was told this was angina. Since that time he has been
free of any chest pain.
In [**2197-2-16**] the patient was admitted to [**Hospital3 3834**]
[**Hospital3 **] for symptoms of right eye blindness, weakness and a
right sided headache. He was diagnosed with CVA. Follow up
studies revealed carotid disease. He was subsequently had a
right CVA in [**2197-3-19**].
Stress test completed prior to his surgery revealed a fixed,
inferior defect and a small anterior defect. He did not have
chest pain but did have diffuse ST-T wave changes at a low
work load. The echo at that time revealed inferior
hypokinesis extending to the inferior base. The ejection
fraction was 35 to 40%.
He came in on [**2198-2-22**] and had another routine exercise
tolerance test which reportedly had multiple areas of
reversibility. The EKG had [**Street Address(2) 2051**] depressions after two
minutes and positive associated shortness of breath. On
[**2198-2-23**] the patient was taken to the cardiac catheterization
lab. Please see report for full results.
In brief in summary he had an ejection fraction of 40%, fixed
inferior [**Doctor First Name **] akinesis, 90% left vein, 60% occlusion of LAD,
80% occlusion of left circumflex, 90% of proximal right
coronary artery occlusion. He also had trace MR.
PAST MEDICAL HISTORY:
1. Prior silent MI.
2. Diabetes.
3. CVA in [**2197-2-16**].
4. Right sided hernia.
5. Constipation.
PAST SURGICAL HISTORY: He had a right carotid endarterectomy
on [**2197-3-19**].
ALLERGIES: He has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 325 milligrams q day.
2. Glucophage 1,000 milligrams [**Hospital1 **].
3. Zestril 5 milligrams q day.
4. Pravachol 20 milligrams q day.
5. Lopressor 50 milligrams [**Hospital1 **].
6. Imdur 30 milligrams q day.
7. Regular insulin 6 units q A.M. and NPH 18 units at hour
of sleep.
SOCIAL HISTORY: The patient is from [**Country 11150**]. He speaks
English. He is married and lives with his family.
PHYSICAL EXAMINATION: ON admission he had no complaints of
chest pain or shortness of breath at that time. His blood
pressure was 200/108. Heart rate 84, normal S1, S2 heart
sounds. No murmurs, rubs, or gallops. Lungs are clear. He
was 100% saturated on room air. His pulses femoral 2+
bilaterally, also had positive bruits bilaterally. Dorsalis
pedis 1+ bilaterally, posterior tibialis 2+ on the right and
1+ on the left. Extremities were warm, no edema. His
fasting blood sugar was 142.
HOSPITAL COURSE: On [**2198-2-23**] the patient underwent
coronary artery bypass surgery times four, LIMA to the
posterior LAD, the saphenous vein graft to the anterior LAD,
saphenous vein graft to the obtuse marginal and a saphenous
vein graft to the right coronary artery. During surgery he
was unsuccessful coming off the coronary bypass pump on first
attempt. An intra-aortic balloon pump was placed and he was
successfully weaned off the pump on second attempt. After
surgery he was transferred to the CSRU on Levophed,
Neo-Synephrine and Milrinone as well as Propofol drips.
Immediate postoperative course was complicated by excessive
bleeding from the chest tubes. He was re-explored at 3 A.M.
on [**2198-2-24**] and found to have an arterial bleed for which
he underwent cauterization. He was weaned off the
intra-aortic balloon pump that was discontinued on
[**2198-2-24**]. He also was weaned off the Milrinone at that time
and was weaned off the ventilator and extubated.
Once extubated and awake he was also weaned off his
Neo-Synephrine and Levophed drips.
On postoperative day two he became hypertensive and was
started on nitroglycerin drip and also given Hydralazine and
was started on Lopressor.
On postoperative day three the patient was transferred to 4 6
and continued to improve.
On postoperative day five the patient was discharged.
DISCHARGE MEDICATIONS:
1. Lasix 20 milligrams po q day times 14 days.
2. Potassium Chloride 20 milliequivalents po bid times seven
days.
3. Colace 100 milligrams po bid.
4. Zantac 150 milligrams po bid.
5. Enteric coated aspirin EC-ASA 325 milligrams po q day.
6. Glucophage 1,000 milligrams po bid.
7. Zestril 5 milligrams po q day.
8. Pravachol 20 milligrams po q while asleep.
9. NPH insulin 9 units subcutaneous while asleep.
10. Regular sliding scale insulin 151 to 200 3 units, 201 to
250 6 units, 251 to 300 9 units, greater than 300 12 units.
11. Amiodarone 400 milligrams po tid times six days. Then
Amiodarone 400 milligrams po bid times seven days. Then
Amiodarone 400 milligrams po q day times seven days.
12. Lopressor 50 milligrams po bid.
13. Percocet one to two tablets po q four to six hours prn
for pain.
PHYSICAL EXAMINATION ON DISCHARGE: Neuro - pupils equal and
reactive. Equal strength bilaterally. Cardiovascular -
regular rate and rhythm at a rate of 63 beats per minute.
Lungs - left subcutaneous emphysema, breath sounds clear
anteriorly. Peripheral vascular - feet warm, pulses
palpable, 2+ pedal edema. Sternum is stable with no
drainage. Right leg incision with a small pinpoint open area
with serous drainage.
DISCHARGE CONDITION: The patient's condition at discharge is
stable.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post CABG times four.
2. Postoperative atrial fibrillation.
3. Diabetes.
4. CVA.
5. Hernia.
DI[**Last Name (STitle) 408**]E PLAN: Follow up with Dr. [**Last Name (Prefixes) **] in one month
and follow up with primary care physician in one month.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 33063**]
MEDQUIST36
D: [**2198-2-28**] 12:37
T: [**2198-2-28**] 12:23
JOB#: [**Job Number 33064**]
ICD9 Codes: 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4971
} | Medical Text: Admission Date: [**2174-5-27**] Discharge Date: [**2174-6-7**]
Date of Birth: [**2100-2-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
. Urgent coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery,
saphenous vein graft to posterior left ventricular
branch and saphenous vein sequential graft to obtuse
marginal 1 and 2 on [**2174-6-1**]
History of Present Illness:
Mr. [**Known lastname 53743**] is a 74 yo M with ILD, COPD, CAD, dCHF, DMII and CKD
who presented with intermittent chest pain over the course of
the last 3 days associated with shortness of breath. Pain is
non-radiating. It is made worse with swallowing. Patient
eventually decided to come in after talking to a friend with a
cardiac history.
In the ED, Initial VS were 98.3 73 116/67 16 98% RA. Troponin
was noted to be elevated at 0.18. EKG showed PRWP and <1mm ST
depressions in V4,V5. He received Aspirin and was admitted to
the cardiology service for further management.
Cardiac cath was done and Cardiac surgery was consulted for
coronary revascularization.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
# Interstitial Lung disease
# CAD
# CKD, baseline creat 1.7
# Diabetes Mellitus Type 2 with ophthalmic complications
# Hypercholesterolemia
# Hypertension
# Esophageal Reflux
# Osteoarthritis
# Spinal Stenosis s/p Laminectomy
# Thyroid Nodule
# Colonic Polyp
# BPH
# Cataracts
# Glaucoma
# Hiatal hernia
# Obesity
# Erectile dysfunction
# Cataract
# Retinal vascular occlusion
# Hearing loss
# Glaucoma, primary open angle
# Osteoarthritis
# BPH
# Anemia, iron deficiency
Social History:
# Home: Able to climb stairs at home. Ambulates with a walker.
# Work: Retired since [**2160**]. Has worked as karate instructor in
the past.
# Tobacco: hx tobacco use, 20 pack-years (quit in [**2145**])
# Alcohol: Rare
# Drugs: Denies
Family History:
Denies family history of early malignancy or SCD.
Physical Exam:
INITIAL:PHYSICAL EXAMINATION:
VS- 98.0 136/83 62 20 100% RA
GENERAL- WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK- Supple without JVD.
CARDIAC- PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis or ulcers
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2174-6-7**] 05:26AM BLOOD WBC-12.7* RBC-2.68* Hgb-7.0* Hct-21.7*
MCV-81* MCH-26.0* MCHC-32.2 RDW-17.3* Plt Ct-330
[**2174-5-27**] 12:15PM BLOOD WBC-8.2 RBC-4.87 Hgb-12.1* Hct-38.8*
MCV-80* MCH-24.8* MCHC-31.1 RDW-15.8* Plt Ct-242
[**2174-6-7**] 06:24AM BLOOD Hct-22.7*
[**2174-6-7**] 05:26AM BLOOD UreaN-12 Creat-1.4* Na-134 K-4.0 Cl-98
HCO3-32 AnGap-8
[**2174-5-27**] 12:15PM BLOOD Glucose-346* UreaN-21* Creat-1.9* Na-135
K-3.8 Cl-92* HCO3-35* AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86412**] (Complete)
Done [**2174-6-1**] at 3:30:18 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-2-13**]
Age (years): 74 M Hgt (in): 76
BP (mm Hg): 120/70 Wgt (lb): 244
HR (bpm): 70 BSA (m2): 2.41 m2
Indication: Coronary artery disease; hypertensive heart disease
ICD-9 Codes: 402.90, 786.51
Test Information
Date/Time: [**2174-6-1**] at 15:30 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2012AW02-: Machine: u/S6
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 13 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *1.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Normal aortic arch diameter.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient appears to be in sinus rhythm. Results were
Conclusions for post-bypass data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
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. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with focalities in the mid and
apical inferior. inferoseptal and inferolateral walls.. Overall
left ventricular systolic function is mildly depressed (LVEF= 45
%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened. The left coronary cusp is non mobile.
A 0.3 x 0.3 cm calcium deposit seenon the right coronary cusp.
There is mild aortic valve stenosis (valve area 1.6cm2). No
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results before surgical
incision.
POST-BYPASS:
Intact thoracic aorta.
LVEF 50%.
There is a mild improvement of wall motions in the inferior,
inferoseptal and inferolateral segments.
No new valvular findings. Aortic valve findings remains the same
as prebypass.
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) **] [**2174-6-1**] 16:49
?????? [**2164**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2174-6-1**] Mr. [**Known lastname 53743**] was taken to the operating room and
underwent Urgent coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery, saphenous
vein graft to posterior left ventricular branch and saphenous
vein sequential graft to obtuse marginal 1 and 2 with Dr.[**First Name (STitle) **].
Please see operative note for further surgical details.
Cardiopulmonary Bypass time=75 minutes. Cross clamp time =67
minutes.He tolerated the procedure well and was transferred to
the CVICU intubated and sedated for invasive monitoring. He
awoke neurologically intact and was extubated. He weaned off
pressor support, was transiently requiring Nitroglycerine for
postop hypertension and Beta-blocker/Statin/ASA and diuresis was
initiated. Chest tubes and Pacing wires were discontinued per
protocol. Postoperatively he went into atrial fibrillation.
Amiodarone was given and he converted to normal sinus rhythm.
POD#2 he transferrred to the step downunit for further
monitoring. Physical Therapy was consulted for strength and
mobility. He was transfused packed blood cells for chronic
anemia which was worsened by volume resucitation postop. Postop
hypoglycemia resolved with decrease in lantus dosing. He slowly
progressed and was cleared by Dr.[**First Name (STitle) **] for discharge to [**Hospital **]
rehabilitation on POD# 6. All follow up appointments were
advised.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from AtriuswebOMR.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
2. Gabapentin 100 mg PO BID
3. Meclizine 25 mg PO DAILY
4. Clonazepam 0.25 mg PO DAILY
5. Atenolol 50 mg PO DAILY
hold for SBP <90
6. Verapamil SR 240 mg PO BID
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
8. Simvastatin 20 mg PO QHS
9. insulin aspart *NF* 100 unit/mL Subcutaneous QACHS
per sliding scale
10. insulin glargine *NF* 100 unit/mL Subcutaneous [**Hospital1 **]
38u AM 38u PM
11. Torsemide 100 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 30 mg PO TID
13. Oxycodone SR (OxyconTIN) 20 mg PO Q8H
hold for sedation or RR < 12
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
15. Omeprazole 40 mg PO BID
16. Aspirin 81 mg PO DAILY
17. Fluoxetine 30 mg PO DAILY
18. Metolazone 1.25 mg PO 1X/WEEK (MO)
19. Calcitriol 0.25 mcg PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR)
20. Vitamin D 50,000 UNIT PO QMONTH
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *Ecotrin Low Strength 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
RX *brimonidine 0.15 % 1 drop [**Hospital1 **] twice a day Disp #*1 Vial
Refills:*0
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
RX *dorzolamide-timolol 2 %-0.5 % 1 drop [**Hospital1 **] twice a day Disp
#*1 Vial Refills:*0
4. Fluoxetine 30 mg PO DAILY
RX *fluoxetine 20 mg 1.5 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
RX *latanoprost 0.005 % 1 drop opth HS Disp #*1 Vial Refills:*0
6. Metolazone 1.25 mg PO 1X/WEEK (MO)
RX *metolazone 2.5 mg 0.5 (One half) tablet(s) by mouth once
weekly Disp #*20 Tablet Refills:*0
7. Oxycodone SR (OxyconTIN) 20 mg PO Q8H
hold for sedation or RR < 12
RX *OxyContin 20 mg 1 tablet(s) by mouth q 8h Disp #*60 Tablet
Refills:*0
8. Simvastatin 20 mg PO QHS
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Furosemide 80 mg IV BID
RX *furosemide 10 mg/mL 80 mg Iv twice daily twice a day Disp
#*1 Vial Refills:*0
11. Glargine 30 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
RX *Lantus 100 unit/mL as directed 30 Units before BKFT; 30
Units before BED; Disp #*1 Vial Refills:*0
RX *Humulin R 100 unit/mL Up to 8 Units per sliding scale ACHS
Disp #*1 Vial Refills:*0
12. Lactulose 30 mL PO DAILY
RX *lactulose 10 gram/15 mL (15 mL) 3 ml by mouth daily Disp #*1
Tablet Refills:*0
13. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1.5 tablet(s) by mouth three times
a day Disp #*60 Tablet Refills:*0
14. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q @4h Disp #*30
Tablet Refills:*0
15. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 tab by mouth q 12H Disp #*60
Tablet Refills:*0
16. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
17. Meclizine 25 mg PO DAILY
RX *meclizine 25 mg 1 tablet(s) by mouth daily prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**] @ [**Location (un) **]// [**Hospital 1263**] hospital
Discharge Diagnosis:
-coronary artery disease
-s/p Urgent coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery,
saphenous vein graft to posterior left ventricular
branch and saphenous vein sequential graft to obtuse
marginal 1 and 2.
Secondary:
Past Medical History:
?Interstitial Lung disease
CAD
Diastolic CHF
CKD, baseline creat 1.8-2
Diabetes Mellitus Type 2 with ophthalmic complications
Hypercholesterolemia
Hypertension
Esophageal Reflux
Osteoarthritis
Spinal Stenosis
Thyroid Nodule
Colonic Polyp
BPH
Cataracts
Glaucoma
Hiatal hernia
Obesity
Erectile dysfunction
Retinal vascular occlusion
Hearing loss
Anemia, iron deficiency
Past Surgical History:
s/p Laminectomy
bialteral cataract surgery
Left ear tumor removed
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**First Name (STitle) **] #[**Telephone/Fax (1) 170**] on
Cardiologist:
Please call to schedule appointments with your
Primary Care Dr.[**First Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 11962**] in [**11-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-6-7**]
ICD9 Codes: 4280, 496, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4972
} | Medical Text: Admission Date: [**2200-2-21**] Discharge Date: [**2200-3-11**]
Date of Birth: [**2200-2-21**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby boy, [**Known lastname **] [**Known lastname 52416**],
triplet No. 2, is a 2035 gram baby boy [**Name2 (NI) **] at 32-1/7 weeks
gestational age to a 35-year-old G6, P1-4 mother with
prenatal screens A positive, antibody negative, hepatitis B
surface antigen negative, RPR nonreactive, cystofibrosis
negative, Rubella immune, GBS unknown. Chorionic sampling
for this triplet was a normal 46 XY cardiotype. This
pregnancy was conceived with the assistance of Clomid and was
uncomplicated until the day prior to admission when the mother
presented with spontaneous rupture of membranes and onset of
labor. She was admitted to [**Hospital3 **], treated with
betamethasone, magnesium sulfate, bed rest and transferred to
the [**Hospital1 69**] Neonatal Intensive
Care Unit for further care.
Delivery was by cesarean section. Baby emerged with
decreased respiratory effort and tone. He responded well to
bulb suctioning, stimulation and brief positive pressure bag
and mask ventilation with four breaths. Apgars were 7 at one
minute and 8 at five minutes. Baby was noted to have mild
retractions and grunting in the Delivery Room and persisted
in the Neonatal Intensive Care Unit so he was placed on CPAP
with good improvement.
PHYSICAL EXAMINATION: Ruddy, pink, large 32-week-old
gestational age male triplet. Weight was 2035 grams (80th
percentile), length 45 cm (75th percentile) and head
circumference 31.5 cm (80th percentile). Anterior fontanelle
was soft and flat with sutures mobile, mild bruising on
head, palate intact, short frenulum. Breath sounds were
clear and equal with decreased retractions on CPAP with good
air entry and mild intermittent grunting. Normal heart
sounds with no murmur. Abdomen was soft with no organomegaly
with a three vessel cord. Genitalia were appropriate for
gestational age with testes palpable bilaterally. Good tone
throughout with symmetrical examination.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: [**Known lastname **] was intubated in the Neonatal
Intensive Care Unit and given a dose of surfactant. He
self-extubated and was placed on CPAP but weaned by day of
life three to a nasal cannula. He remained on nasal cannula
until he was six days old at which time he was transitioned
to room air. He has been comfortable on room air, generally
saturating greater than 94% since then.
On [**3-6**] he had an increased number of
de-saturations. A sepsis evaluation was initiated and he was
started on caffeine, which he continues to date. The last
two days, however, have not shown any spells of apnea of
prematurity.
2. Fluids, Electrolytes and Nutrition: [**Known lastname **] was
initially NPO and received peripheral parenteral nutrition.
He has been advanced on enteral feeds and is currently taking
150 cc/kg/day of Premature Enfamil supplemented to 26
calories per ounce and with ProMod. He has been tolerating
these feeds well without any problems. The weight at time of
transfer was 2305 grams.
On [**3-7**] through 16th, there have been Hemoccult
positive stools with possible red streaking in the stools.
Because there is a sibling at home who suffers from milk
protein allergy, the patient was started on [**3-10**] on
Nutramigen supplemented to 24 calories per ounce. However,
evaluation of the stool on the day of discharge revealed
Hemoccult negative stools and no fecal leukocytes. It is
unclear whether this has actually been formula intolerance.
3. Gastrointestinal: Phototherapy was initiated on [**1-24**] for a bilirubin of 12.7 and discontinued on [**2-26**]
for a bilirubin of 5.4. Follow-up bilirubin on [**2-28**]
was 4.3. Baby's blood type is not known.
4. Hematology/Infectious Disease: [**Known lastname **] was started on a
sepsis evaluation on admission. His initial CBC showed a
white blood cell count of 10.7, hematocrit 52, platelet count
266,000, with a differential of 31% polys, 0% bands, 67%
lymphocytes. Antibiotics were discontinued after blood
cultures had been no growth for 48 hours.
Because of increased episodes of de-saturations, a sepsis
evaluation was repeated on [**3-6**]. At that time,
white blood cell count was 23 with 63% polys, 1% bands,
hematocrit 36, platelet count 357,000. A blood culture was
also sent. Antibiotics were not started at that time because
of the reassuring differential. However, that blood culture
grew out methicillin-resistant Staphylococcus aureus the
following day. Prior to initiating antibiotics, a repeat
blood culture was drawn and then [**Known lastname **] was started on
vancomycin and gentamicin. The second blood culture has been
negative and the vancomycin and gentamicin was discontinued
after three days. A lumbar puncture was done the day after
antibiotics were started on [**3-9**] and showed four
white blood cells, eight red blood cells, negative Gram
stain, glucose 45, protein of 81. The cerebrospinal fluid
culture has remained negative. Because [**Known lastname **] clinically
was improving with fewer desaturations even before starting
antibiotics and because the second blood culture did not
confirm MRSA prior to starting vancomycin and gentamicin, we
suspect that the initial blood culture was a contaminant. He
has now been off antibiotics for two days and continues to do
well clinically.
5. Neurology: A head ultrasound was performed on [**3-7**] and was normal.
6. Sensory: Hearing screening was performed with automated
auditory brain stem responses with normal results on [**3-6**]. An ophthalmology examination was performed on [**3-10**] which showed immature retinal vasculature, zone three,
bilaterally.
CONDITION AT TRANSFER: Stable.
DISCHARGE DISPOSITION: [**Hospital3 **] Special Care
Nursery.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Hospital 36653**] Pediatrics.
CARE/RECOMMENDATIONS: Feeds at discharge were Nutramigen
supplemented to 24 KCal/ounce, all by gavage feeding.
DISCHARGE MEDICATIONS: Caffeine Citrate 16 mg po qday.
STATE NEWBORN SCREEN: Sent on [**3-6**] with results
pending.
IMMUNIZATIONS: Hepatitis B immunization No. 1 was given on
[**3-6**].
Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: (1) [**Month (only) **] at less than 32 weeks; (2) [**Month (only) **] at 32 to
35 weeks and plan for day care during RSV season, with smoker
in the household, neuromuscular disease, airway abnormalities
or with preschool sibs or (3) With chronic lung disease.
DISHARGE DIAGNOSES:
1. Prematurity
2. Respiratory distress syndrome
3. Apnea of prematurity
4. Hyperbilirubinemia
5. Sepsis evaluation (x2)
6. Rule- out milk protein allergy
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Name8 (MD) 50790**]
MEDQUIST36
D: [**2200-3-11**] 12:43
T: [**2200-3-11**] 12:45
JOB#: [**Job Number 52418**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4973
} | Medical Text: Admission Date: [**2156-5-12**] Discharge Date: [**2156-5-19**]
Date of Birth: [**2156-5-12**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**First Name9 (NamePattern2) 55885**] [**Known lastname 1004**] is the former
2.86 kg product of a 37-2/7 weeks gestation pregnancy born to
a 23-year-old G1, P0 woman. Prenatal screens: Blood type O
positive, antibody negative, hepatitis B surface antigen
negative, RPR nonreactive, rubella immune, group B Strep
negative. This pregnancy was complicated by increasing
maternal hypertension. She underwent Pitocin induction on
the day of delivery. The infant was born by spontaneous
vaginal delivery. A nuchal cord tightly wrapped was noted at
delivery. Apgars were 6 at one minute and 8 at five minutes.
The mother had epidural and spinal anesthesia, and also
received [**Known lastname **] at approximately two hours prior to delivery.
Initially, the infant went to the Newborn Nursery, where he
is noticed to have shallow respirations and apnea with
associated cyanosis requiring positive pressure ventilation
and blow-by O2. The Neonatal Intensive Care Unit was
notified and the infant was transferred for further
evaluation and care.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 2.86 kg (25th to 50th percentile). Length 47
cm (25th to 50th percentile). Head circumference 33 cm (50th
percentile). General: Nondysmorphic infant with periodic
breathing and intermittent apnea. Head, eyes, ears, nose,
and throat: Anterior fontanel is soft and flat. Symmetric
facial features. Palate intact. Chest: Shallow
respirations, essentially clear breath sounds.
Cardiovascular: Regular, rate, and rhythm, no murmur.
Femoral pulses: plus 2. Abdomen is soft, nontender, no
masses, three-vessel cord. GU: Normal male genitalia.
Testes descended. Spine: Straight. Hips stable.
Neurologic: Somewhat hypotonic and listless. Otherwise,
nonfocal.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
Respiratory: Chest x-ray obtained upon admission showed
normal lung expansion with clear lung fields and a normal
cardiothymic silhouette. Oxygen saturations were greater
than 95 percent on room air. The infant was given Narcan x 1
(mother received [**Name (NI) **]). His spontaneous apnea and
desaturations resolved. However, he did have desaturations
with feeds over the first three days of life. A change in
nipple type to the NUK nipple was made and the infant did
very well with this with resolution of desaturations with
feedings. His mother has been in frequently feeding the baby
and does very well with pacing him and [**Location (un) 1131**] his cues.
Cardiovascular: [**Location (un) 55885**] maintained normal heart rates and
blood pressures during admission. On discharge a soft
systolic murmur was auscultated on the left sternal border
with some radiation to axilla. This may be consistent with
flow or PPS. Another consideration is a small VSD. The infant
has been hemodynamically stable and no further evaluation was
done at this time.
Fluid, electrolytes, and nutrition: Enteral feeds were
started within hours after delivery. As noted, there were
some episodes of desaturations. He has been breast feeding
plus feeding expressed mother's milk and Enfamil 20 taking
180 cc/kg/day. Weight on the day of discharge is 2.92 kg
with a length of 48 cm and a head circumference of 33 cm.
Infectious disease: A blood count and blood culture were
obtained upon admission to the Neonatal Intensive Care Unit.
The white blood cell count was 19,000 with a differential of
60 percent polys, 0 percent bands. The blood culture was no
growth. The baby was not treated with antibiotics.
Gastrointestinal: Peak serum bilirubin occurred on day of
life six, a total of 11.1/0.2 mg/dl with an indirect of 10.9
mg/dl. No phototherapy was given.
Hematology: Hematocrit at birth was 42 percent. [**Location (un) 55885**]
did not receive any transfusion of blood products.
Neurology: Narcan was administered upon admission to the
Neonatal Intensive Care Unit. The apnea and lethargy
resolved quikly after receipt. [**Location (un) 55885**] has maintained a
normal neurological exam, and there are no neurological
concerns at the time of discharge.
Sensory: Audiology. Hearing screening was performed with
automated auditory brain stem responses. [**Location (un) 55885**] passed in
both ears.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **], [**Location (un) 55886**], [**Street Address(2) 14531**], [**Hospital1 1474**], [**Numeric Identifier **], phone number
[**Telephone/Fax (1) 3183**]
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Adlib breast feeding or bottle feeding Enfamil 20.
2. No medications.
3. Car seat position screening was performed. [**Telephone/Fax (1) 55885**] was
observed for 90 minutes in his car seat without any episodes
of oxygen desaturation or bradycardia.
4. State newborn screen was sent on [**2156-5-15**] with no
notification of abnormal results to date.
Immunizations received: Hepatitis B vaccine was administered
on [**2156-5-15**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the three criteria: 1. Born at less than 32 weeks, 2.
Born between 32 and 35 weeks with two of three of the
following: daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW-UP APPOINTMENTS SCHEDULED OR RECOMMENDED: Appointment
with Dr. [**Last Name (STitle) **] within three days of discharge.
DISCHARGE DIAGNOSES:
1. Apnea post maternal [**Last Name (STitle) **], resolved with Narcan.
2. Feeding immaturity.
3. Suspicion for sepsis ruled out.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2156-5-19**] 07:10:11
T: [**2156-5-19**] 07:49:33
Job#: [**Job Number 55887**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4974
} | Medical Text: Unit No: [**Numeric Identifier 60657**]
Admission Date: [**2152-2-26**]
Discharge Date: [**2152-3-11**]
Date of Birth: [**2152-2-26**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 449**] [**Known lastname 60653**] is a former 1.37
kilogram product of a 28 week twin gestation pregnancy born
to a 37 year old G-5, P-1 now 3 woman. Prenatal screens -
Blood type O negative, antibody negative, Rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
Strep status unknown. The pregnancy was complicated by twin-
to-twin transfusion syndrome. There were multiple
amniocenteses performed and a laser ablation procedure
performed at 24 weeks gestation at Women and [**Hospital 60658**]
Hospital in [**Doctor Last Name **]. Twin A was the recipient twin and
was noted on prenatal ultrasounds to have a cardiac
dysfunction. This twin B was the donor twin. The mother
underwent elective cesarean section at 28 weeks gestation.
Twin B emerged vigorous and crying. Apgars were 7 at one
minute and 8 at five minutes. He required oxygen, drying and
suctioning only in the delivery room. He was admitted to the
Neonatal Intensive Care Unit for treatment of prematurity.
PHYSICAL EXAMINATION ON ADMISSION TO THE NEONATAL INTENSIVE
CARE UNIT: Weight 1.37 kilograms - 75th percentile, length
37 cm - 50th percentile, head circumference 28.5 cm - 75th
percentile. General - Nondysmorphic male in respiratory
distress. HEENT - Anterior fontanelle open and flat, normal
facies, palate intact. Chest - Coarse breath sounds with fair
aeration. Cardiovascular - Regular rate and rhythm without
murmur. Normal femoral pulses. Abdomen - Soft, non-tender, non-
distended, no masses. Patent anus. GU- Normal premature male,
testes undescended. Spine - Straight, normal sacrum. Extremities
- Moving all, hips stable. Neurologic - Tone and reflexes
appropriate for gestational age.
HOSPITAL COURSE:
1. Respiratory. [**Known lastname 449**] was intubated shortly after admission
to the Neonatal Intensive Care Unit and treated with
surfactant for his respiratory distress. He was continued
on assisted ventilation through day of life number seven
when he was extubated to continuous positive airway
pressure. On day of life number nine he transitioned to
nasal cannula O2. At the time of discharge he is on nasal
cannula O2 13 ml per minute. His respirations are easy.
Breath sounds are clear. Baseline respiratory rate is 30-
50 breaths per minute. [**Known lastname 449**] was also treated for apnea
of prematurity with caffeine. He has up to three episodes
of spontaneous apnea noted per day.
2. Cardiovascular. On day of life number two a cardiac
echocardiogram was obtained and showed a large PDA and
patent foramen ovale. He was treated with a course of
indomethacin. Repeat echocardiogram on [**2152-3-1**] showed a
very small patent ductus arteriosus. At the time of
discharge, his heart rate is 140-160 beats per minute with
a recent blood pressure of 73/46 with a mean of 54. No
murmurs have been noted.
3. Fluids, electrolytes and nutrition. [**Known lastname 449**] was initially
NPO and maintained on intravenous fluids. He had a
percutaneously inserted central catheter placed on day of
life number five. Enteral feeds were started on day of
life number six and gradually advanced to full volume.
The percutaneously inserted central catheter was removed
on [**2152-3-10**]. At the time of discharge he was taking 150
ml/kg/day of breast milk fortified to 22 calories per
ounce with human milk fortifier. The most recent set of
serum electrolytes were on [**2152-3-6**] with a serum sodium of
137, a potassium of 5.4, chloride of 103 and a total
carbon dioxide of 23. Weight on the day of discharge was
1.26 kilograms.
4. Infectious disease. Due to his prematurity and
respiratory distress, [**Known lastname 449**] was evaluated for sepsis at
the time of admission to the neonatal intensive care unit.
A white blood cell count was within normal limits. A
blood culture was obtained prior to starting intravenous
ampicillin and gentamicin. The blood culture was no
growth at 48 hours and the antibiotics were discontinued.
5. Hematological. [**Known lastname 449**] is blood type O negative, Coombs
negative. Hematocrit at birth was 44.7 percent. He did
not received any transfusions or blood products during
admission.
6. Gastrointestinal. [**Known lastname 449**] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life two with a total
of 9.1, 0.6 mg/dl direct. He received phototherapy for
approximately six days. Repeat bilirubin on day of life
number seven was a total of 3.2, 0.4 mg/dl direct.
7. Neurological. [**Known lastname 449**] maintained a normal neurological exam
during admission and there were no neurological concerns
at the time of discharge. A head ultrasound was performed
on [**2152-2-29**] and was within normal limits.
8. Sensory. Hearing screening has not yet been performed.
9. Ophthalmology. [**Known lastname 449**] will require screening eye exam for
retinopathy of prematurity. The first exam is recommended
at four to five weeks of life.
10.Psychosocial. The parents have been very involved
with both of their sons' clinical courses. [**Known lastname 60659**]
brother, [**Name (NI) **], was gravely ill with refractory hypotension
and renal failure. He expired on [**2152-3-9**].
CONDITION ON DISCHARGE: Good.
DISPOSITION: Transfer to [**Hospital3 **] for continuing
level II care. The primary pediatrician is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3450**], M.D.,
[**Hospital 28678**] Medical Associates, [**Location (un) 60660**], [**Location (un) **], [**Numeric Identifier 60661**], phone number [**Telephone/Fax (1) 36247**].
CARE AND RECOMMENDATIONS:
1. Feeding. Breast milk 22 calories per ounce at 150
cc/kg/day.
2. Medication. Caffeine citrate 10 mg PG once daily.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screen was sent on [**2152-2-29**] with all results
within normal limits. A repeat screen was sent on
[**2152-3-11**].
5. No immunizations administered thus far.
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following three criteria: Born at less
than 32 weeks; born between 32-35 weeks with two of the
following - Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; or with chronic lung disease.
Influenza immunization is recommended annually in the
fall for all infants once they reach six months of age.
Before this age and for the first 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out-of-home care-givers.
DISCHARGE DIAGNOSES:
1. Prematurity at 28 weeks' gestation.
2. Twin B of twin gestation.
3. Twin-to-twin transfusion syndrome, donor twin.
4. Respiratory distress syndrome.
5. Apnea of prematurity.
6. Suspicion for sepsis ruled out.
7. Patent ductus arteriosus.
8. Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 60662**]
Dictated By:[**Last Name (NamePattern1) 60663**]
MEDQUIST36
D: [**2152-3-11**] 05:50:27
T: [**2152-3-11**] 06:56:56
Job#: [**Job Number 60664**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4975
} | Medical Text: Admission Date: [**2158-4-27**] Discharge Date: [**2158-6-1**]
Date of Birth: [**2103-6-1**] Sex: F
Service: SURGERY
Allergies:
Dilaudid / Codeine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
percutaneous tracheostomy
Extended left hemicolectomy with
takedown of splenic flexure and ileostomy
History of Present Illness:
Ms. [**Known lastname **] is a 54-year female with a history of diabetes,
coronary artery disease, hypertension, renal transplant and
significant peripheral [**Known lastname 1106**] disease who presented with a
several day history of abdominal discomfort and worsened over
the past 24 hours. She was seen in the emergency room and was
found to be in relative extremis condition. Although
hemodynamically stable, she had extensive peritonitis. She
underwent a CTA of the abdomen which demonstrated what appeared
to be a thrombosis of the SMA and thickening of the left and
right colon. She was taken to the operating room urgently for
exploration.
Past Medical History:
MI x2, CABG x2, DM1 with retinopathy/neuropathy/nephropathy. CRT
'[**43**] (Dr. [**Last Name (STitle) 15473**], PVD, LBKA [**6-/2147**], fem-[**Doctor Last Name **] '[**48**] w/ [**Doctor Last Name **]-DP bypass,
^chol, L eye prosth, b/l breast ca, chr anemia, CRI (baseline Cr
2.0)
Physical Exam:
on discharge:
Afebrile, BP 11/79-166/65, 74, 14, 100% Trach Mask
AOx3
CTA B/L
Trache in position
Abd soft, NT, ND
Resolving erythema over R knee
- edema
Pertinent Results:
[**2158-4-27**] 05:30AM BLOOD WBC-5.7 RBC-4.01*# Hgb-13.8# Hct-40.1#
MCV-100* MCH-34.5* MCHC-34.5 RDW-18.5* Plt Ct-240
[**2158-4-30**] 02:54AM BLOOD WBC-18.1* RBC-3.18* Hgb-10.6* Hct-32.1*
MCV-101* MCH-33.4* MCHC-33.0 RDW-19.1* Plt Ct-178
[**2158-5-5**] 03:00AM BLOOD WBC-20.9* RBC-2.45* Hgb-8.2* Hct-24.2*
MCV-99* MCH-33.4* MCHC-33.8 RDW-19.3* Plt Ct-235
[**2158-5-8**] 03:13AM BLOOD WBC-8.7 RBC-2.46* Hgb-8.2* Hct-24.1*
MCV-98 MCH-33.1* MCHC-33.8 RDW-19.3* Plt Ct-162
[**2158-5-16**] 01:47AM BLOOD WBC-7.1 RBC-2.28* Hgb-7.4* Hct-21.9*
MCV-96 MCH-32.7* MCHC-34.1 RDW-18.6* Plt Ct-196
[**2158-5-20**] 03:20AM BLOOD WBC-7.3 RBC-3.10* Hgb-9.8* Hct-29.1*
MCV-94 MCH-31.7 MCHC-33.8 RDW-17.2* Plt Ct-262
[**2158-5-31**] 03:09AM BLOOD WBC-7.4 RBC-3.13* Hgb-10.0* Hct-29.3*
MCV-94 MCH-32.0 MCHC-34.2 RDW-16.9* Plt Ct-261
[**2158-5-26**] 04:08AM BLOOD PT-12.6 PTT-25.6 INR(PT)-1.1
[**2158-4-28**] 02:48AM BLOOD PT-17.9* PTT-34.7 INR(PT)-1.7*
[**2158-5-31**] 03:09AM BLOOD Glucose-205* UreaN-72* Creat-1.4* Na-140
K-4.1 Cl-112* HCO3-20* AnGap-12
[**2158-5-24**] 03:01AM BLOOD Glucose-117* UreaN-93* Creat-1.8* Na-146*
K-3.9 Cl-109* HCO3-27 AnGap-14
[**2158-5-19**] 02:25AM BLOOD Glucose-76 UreaN-94* Creat-1.9* Na-139
K-3.7 Cl-100 HCO3-27 AnGap-16
[**2158-5-12**] 05:11AM BLOOD Glucose-125* UreaN-90* Creat-2.0* Na-140
K-3.9 Cl-104 HCO3-23 AnGap-17
[**2158-5-4**] 05:09PM BLOOD Glucose-195* UreaN-86* Creat-2.6*# Na-135
K-3.8 Cl-105 HCO3-19* AnGap-15
[**2158-4-27**] 05:25PM BLOOD Glucose-219* UreaN-88* Creat-3.0* Na-143
K-3.6 Cl-110* HCO3-16* AnGap-21*
[**2158-5-29**] 02:34AM BLOOD ALT-32 AST-37 AlkPhos-214* Amylase-37
TotBili-0.8
[**2158-5-13**] 12:09PM BLOOD ALT-54* AST-50* CK(CPK)-25* AlkPhos-179*
Amylase-64 TotBili-0.5
[**2158-5-3**] 03:02AM BLOOD ALT-16 AST-26 LD(LDH)-348* AlkPhos-78
Amylase-148* TotBili-0.2
[**2158-5-3**] 05:43PM BLOOD Lipase-102*
[**2158-4-27**] 01:35PM BLOOD Lipase-113*
[**2158-5-31**] 03:09AM BLOOD Calcium-11.4* Phos-3.0 Mg-1.8
[**2158-5-28**] 02:27AM BLOOD Calcium-12.5* Phos-2.8 Mg-2.1
[**2158-5-25**] 03:00PM BLOOD Calcium-11.7* Phos-3.6 Mg-2.2
[**2158-5-18**] 02:34AM BLOOD Albumin-2.4* Calcium-9.2 Phos-4.2 Mg-1.9
[**2158-5-29**] 02:34AM BLOOD calTIBC-168* TRF-129*
[**2158-5-30**] 03:17AM BLOOD Ferritn-880*
[**2158-4-29**] 02:41AM BLOOD Triglyc-156* HDL-15 CHOL/HD-6.7
LDLcalc-55
[**2158-5-3**] 05:43PM BLOOD TSH-1.9
[**2158-5-28**] 02:27AM BLOOD PTH-21
[**2158-5-5**] 12:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2158-5-30**] 06:49AM BLOOD FK506-6.3
[**2158-5-29**] 06:54AM BLOOD FK506-5.9
[**2158-4-27**] 01:59PM BLOOD Glucose-459* Lactate-4.7*
[**2158-4-27**] 03:20PM BLOOD Glucose-352* Lactate-5.6* Na-140 K-3.7
Cl-108
[**2158-4-27**] 05:42PM BLOOD Glucose-203* Lactate-6.3*
[**2158-4-28**] 01:06PM BLOOD Glucose-147*
[**2158-4-28**] 06:37PM BLOOD Glucose-133* Lactate-1.2
[**2158-5-28**] 09:08AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2158-5-28**] 09:08AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2158-5-28**] 09:08AM URINE RBC-0-2 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-<1
[**2158-5-23**] 11:08AM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-OCC
Epi-0 TransE-0-2
[**2158-5-23**] 11:08AM URINE CastHy-[**11-13**]*
[**2158-5-8**] 11:45 am URINE
**FINAL REPORT [**2158-5-9**]**
URINE CULTURE (Final [**2158-5-9**]):
YEAST. >100,000 ORGANISMS/ML..
[**2158-5-28**] 9:08 am URINE
**FINAL REPORT [**2158-5-30**]**
URINE CULTURE (Final [**2158-5-30**]):
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
CTA PELVIS W&W/O C & RECONS [**2158-4-27**] 8:01 AM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
Reason: NO IV CONTRAST, eval for divertic, aortic dz, mesenteric
isc
Contrast: VISAPAQUE
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with severe ab pain
REASON FOR THIS EXAMINATION:
NO IV CONTRAST, eval for divertic, aortic dz, mesenteric
ischemia
CONTRAINDICATIONS for IV CONTRAST: Cr 3.3 today, renal
transplant pt
HISTORY: 54-year-old woman with severe abdominal pain. The
patient has history of end-stage renal disease, status post
renal transplant.
TECHNIQUE: Multidetector axial images of the abdomen and pelvis
were obtained without contrast. A mesenteric CTA was then
performed with 80 cc of Visipaque followed by delayed venous
sequence.
CT ABDOMEN: There is bibasilar atelectasis. The liver,
gallbladder, spleen, and adrenal glands are unremarkable. The
pancreas and native kidneys are atrophic. Stomach and small
bowel loops are unremarkable. There appears to be inflammatory
stranding and slight wall thickening of the transverse colon and
hepatic flexure. A small amount of free fluid is identified
tracking around the liver. There is no free air. No mesenteric
or retroperitoneal lymphadenopathy is identified. The ventral
hernia is noted in the epigastrium.
CT PELVIS: Foley catheter is noted in the bladder. The uterus,
adnexa, sigmoid colon, and rectum are unremarkable. There is a
small amount of pelvic free fluid. Moderate hydronephrosis is
again identified in the transplant kidney. This is not
significantly changed from the most recent renal ultrasound of
[**2156-11-27**]. A small cyst is noted in the transplant kidney
as well. There are no suspicious lytic or sclerotic osseous
lesions.
CTA IMAGES: There is severe atherosclerotic disease. Bilateral
iliac stents are noted. The mesenteric vessels are highly
calcified and there is significant amount of plaque within the
superior mesenteric artery. However, the mesenteric vessels
appear patent, and no [**Year (4 digits) 1106**] occlusion is identified. The 3D
reformats demonstrate patency and flow to the segments of
abnormal- appearing colon.
IMPRESSION:
1. Severe atherosclerotic disease especially involving the
superior mesenteric artery, but patent mesenteric vasculature.
2. Inflammatory stranding and slight wall thickening of the
transverse colon and splenic flexure consistent with colitis,
most likely infectious or related to a low flow state.
3. Small amount of free fluid in the abdomen and pelvis.
4. Moderate hydronephrosis in the transplant kidney which is not
significantly changed compared to [**2156-11-27**].
RENAL TRANSPLANT U.S. [**2158-5-2**] 10:07 AM
RENAL TRANSPLANT U.S.
Reason: assess cadaveric renal transplant for clot/occlusion
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with h/o cadaveric renal transplant, now
admitted w/ SMA occlusion s/p OR w/ R colectomy, now worsening
renal function
REASON FOR THIS EXAMINATION:
assess cadaveric renal transplant for clot/occlusion
INDICATION: History of cadaveric renal transplant, admitted with
SMA occlusion, status post colectomy, now with worsening renal
function. Please assess for clot or occlusion.
COMPARISON: [**2156-11-27**].
TECHNIQUE: Renal transplant ultrasound.
FINDINGS: A transplant kidney is again identified within the
left lower quadrant, measuring 11.6 cm in length. Moderate
hydronephrosis of the transplant kidney appears approximately
unchanged in degree since [**2156-11-27**]. There is ascites
throughout the abdomen, including within the left lower quadrant
adjacent to the transplant. Doppler examination of the
transplant kidney demonstrates visibly less venous flow in the
periphery of the renal cortex in comparison with the previous
examination. The diastolic flow on pulse Doppler waveforms
appears diminished. Resistive indices range from 0.63 to an
estimated upper value of 0.8. The main renal vein appears patent
and demonstrates a normal waveform. There is no echogenic
thrombus within the main renal artery or vein.
IMPRESSION:
1. Stable hydronephrosis of the transplant kidney.
2. Continued slight increase in resistive indices and visual
decrease in venous flow within the transplant kidney. No
evidence of thrombosis of the main renal artery or vein.
Conclusions:
1. The left atrium is moderately dilated.
2.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 low normal (LVEF
50-55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
5.The estimated pulmonary artery systolic pressure is normal.
6. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review)
of [**2156-5-13**], the EF is slightly more vigorous then.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2158-5-5**]
17:14.
[**Location (un) **] PHYSICIAN:
[**Known lastname **],[**Known firstname 21022**] [**2103-6-1**] 54 Female [**Numeric Identifier 21023**]
[**Numeric Identifier 21024**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 21025**]/dif
SPECIMEN SUBMITTED: COLON (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2158-4-27**] [**2158-4-27**] [**2158-5-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies: [**Numeric Identifier 21026**] COMMON FEM ART. PLAQUE (RT.)
[**Numeric Identifier 21027**] EMC/jh/mf.
[**Numeric Identifier 21028**] SENTINEL, RT BREAST RE-EXC./bb.
[**Numeric Identifier 21029**] RT BREAST MICROCALCS/lb.
(and more)
DIAGNOSIS
Colon (A-Q):
1. Colon with transmural infarction with ulceration and
serositis.
2. Mucosal infarction present at distal resection margin.
3. Proximal resection margin viable.
4. Mesenteric vessels with mild focal medial calcification.
5. Ileum, cecum, ileocecal valve, and appendix, no diagnostic
abnormalities recognized..
7. One lymph node, no malignancy identified.
Brief Hospital Course:
From the ED patient was taken to the SICU fairly quickly,
intubated, and then taken to the OR for a R extended colectomy &
ileostomy/[**Doctor Last Name **] for gangrenous R colon due to SMA thrombus.
#Neuro/Psych: when the patient was tolearting PO medications,
her home antidepressants were restarted. Ativan PRN was used to
tx her anxiety. Morphine was given for tracheostomy site pain.
#Pulm: Patient was intubated fairly immediately after being
admitted to the SICU from the ED and remained so after the OR.
She failed extubation multiple times. She was oringinally
extubated POD2 and remained extubated for over a week. She was
reintubated on [**5-14**] with NGT and swanz-ganz catheter placement
after being brought to unit the day before for shortness of
breath and a negative V/Q scan. Extubation was attempted a few
days later and she failed within minutes. Thoracic surgery
performed a fiberoptic bronchoscopy which did not show any
abnormalities. She continued to have a good cuff leak and stayed
on low ventilatory support. Extubation was again attempted on
[**5-23**] and the second time she failed within hours. A percutaneous
trachesotomy was eventually performed on [**5-26**] at the bedside, and
she has done well weaning to a trach mask since that time. It is
still unknown why patient continued to fail extubation.
#CV: cardiology was involved. Patient was in fluid overload with
pulmonary edema and cardiomegaly, underwent diuresis and
altering of blood pressure medications as her pressures were
running on the high end for a significant period of time. ECHO
showed mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **],LVEF 40-50%,3+MR,2+TR, mod PA HTN and on [**5-11**]
was WORSE vs [**5-5**]. She is discharged with stable BP controlled
on oral agents.
#GI: patient's ostomy has functioned well since the surgery
without any problems. She has been followed by the osteomy
nurses. Patient had multiple instances of repeat abdominal pain
with elevated white counts in the setting of immunosuppression
so KUBs and a few CTs were performed to rule out any
obstruciton, abscesses, or acute surgical complications. Diet
was advanced from sips to clears on POD4. She then went back and
forth from from cleras to NPO for the next week during
intermittent episodes of abdominal pain. Was eventually on a
regular diet for a few days before having to be reintubated gain
for respiratory failure. Elemental tube feeds were started slow
only [**5-27**], they were advanced on [**6-1**] when she had no abdominal
pain. On [**6-1**] her feeding tube became dislodged during a coughing
spell. It was replaced by interventional radiology.
#Renal/Electrolytes: Patient had post-op ATN in the setting of a
previous kidney transplant. A renal consult was obtained. Had
renal US which showed stable hydronephrosis of the transplant
kidney. Continued slight increase in resistive indices and
visual decrease in venous flow within the transplant kidney. No
evidence of thrombosis of the main renal artery or veinHad HD at
one point. Later developed hyponatremia and hypercalcemia. Was
started on calcitonin [**Hospital1 **] and diuresed and hydrated with some
normal saline. Her sodium normalized, though her calcium
remained elevated.On [**6-1**] the calcitonin was discontinued and
pamidronate was given (30mg IV x 1); it may be repeated in [**1-27**]
weeks. Patient continues on her immunosuppression for her
transplant.
#Endo: was followd by [**Last Name (un) 387**] for her DM-I. required an insulin
drip intermittently. Is discharged with stable blood glucose,
controlled with insulin.
#heme: Throughout her admission, patient received a total of 8
units of red cells for falling hematocrits.
#ID: was given a few doses of vancomycin peri- and post-op as
well as zosyn for 2 weeks post-op. She also received a course of
levo toward the end of her stay for E Coli in her urine which
will complete on [**2158-6-3**].
#Nutrition: Patient was maintained on TPN throughout her stay
and later was started on trophic TF via a dobhoff. Tube feeds
should be advanced and TPN decreased over time.
#Rheum: Early [**Month (only) **] patient complained of R knee pain - had a
gout flair with suprapatellar bursitis. Was started on cochicine
taper and calcitonin [**Hospital1 **].
Medications on Admission:
Allopurinol 100', ASA 81', Ativan 0.5 q8prn, CaCO3cVIT D
600-200", CATAPRES-TTS 2 0.2MG/24HR 2 patches qwk, Doxazosin 2',
Lisinopril 2.5', Fluoxetine 30', Lasix 40", Lantus 26hs, Novolog
SS, Imuran 25', Isosorbide mono 90qAM/30qPM, Lipitor 10',
Lopressor 75", Nifedipine 90', NTG 0.4' SL prn, Prednisone 7,
Prograf [**1-26**], Procrit 6000 qSu/W, Ranitidine 150"
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
9. Lisinopril 20 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. Isosorbide Dinitrate 20 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
12. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
14. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
15. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheeze/sob.
19. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Pantoprazole 40 mg IV Q24H
21. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q6H
(every 6 hours) as needed for anxiety.
22. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q2H (every
2 hours) as needed for tracheostomy pain .
23. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
24. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q4-6H (every 4 to 6 hours) as needed: for sbp>150.
25. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
26. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous ASDIR (AS DIRECTED): per provided sliding
scale.
27. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
28. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred
Fifty (250) mg Intravenous Q24H (every 24 hours): through doses
on [**6-3**].
29. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
30. Tacrolimus 1 mg Capsule Sig: as directed Capsule PO twice a
31. Alendronate 5 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
1. mesenteric ischemia
2. pancreatitis
3. respiratory failure
4. acute renal failure
5. R prepatellar bursitis
6. HTN
7. DM-I
8. anemia of chronic renal disease and chronic disease
9. hypercalcemia
10. hypernatremia
Discharge Condition:
Good
Discharge Instructions:
please seek medical attention if you experience fever > 101.5,
severe nausea, vomitting, pain, shortness of breath
please take medications as directed
Followup Instructions:
1. Please call the transplant clinic [**Telephone/Fax (1) 673**] to schedule
appointments with both Dr. [**Last Name (STitle) **] and with one of the
transplant surgeons
2. Follow up with your Cardiologist within one month to have
your Lisinopril restarted.
3. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-6-6**]
11:00
[**Month/Day/Year **] NON-INVAS [**Month/Day/Year 3628**] [**Month/Day/Year **] [**Month/Day/Year 3628**] (NHB) Date/Time:[**2158-7-10**]
10:00Provider: [**Month/Day/Year **] NON-INVAS [**Month/Day/Year 3628**] [**Month/Day/Year **] [**Month/Day/Year 3628**] (NHB)
Date/Time:[**2158-7-10**] 10:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB)
Date/Time:[**2158-7-10**] 10:30
Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2158-7-10**] 11:00
ICD9 Codes: 2749, 9971, 486, 4280, 2760, 5990, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4976
} | Medical Text: Admission Date: [**2124-3-6**] Discharge Date: [**2124-3-6**]
Date of Birth: [**2043-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Mental status change; hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 80 year-old woman with a history of CAD and
neurogenic bladder requiring suprapubic catheter who presents
with change in mental status and hypotension. In speaking with
nurse [**First Name (Titles) **] [**Last Name (Titles) **], patient was in her usual state of health
yesterdy though constipated requiring a suppository (reportedly
with good effect). On the morning of admission, noted by staff
to be altered, "throwing her arms all over" and saying "help,
help, help" with some complaints of back/abdominal pain. The
[**Name8 (MD) 11582**] MD was notified and the patient was sent to the ED for
evaluation. EMS vitals included RR of 28 with SBP>110.
.
In the ED, initial T 98.1, BP 153/129, HR 100, RR 24, unable to
get O2 sat. BP trended down to as low as 85/43 with HR in the
90s. T as high as 100.6. RR increased to 30s with O2 sat in
90s on NRB. Was given ~5 liters. Also given vanco 1g IV, zosyn
4.5mg IV and was started on levofed.
.
Of note, suprabupic catheter was last changed on [**2124-2-7**]. Was
supposed to be changed on [**2-28**] but didn't go because of weather.
Past Medical History:
1. Coronary artery disease
- s/p inferior MI in [**2117-10-29**] with PCI with BMS to RCA
- s/p PCI ([**10-4**]) for instent restosis
2. Multiple Sclerosis
- wheelchair bound
- neurogenic bladder with suprapubic catheter - changed qmonth
3. Diastolic dysfunction
4. Peripheral vascular disease with history of RLE ulcers
5. Osteoporosis
6. Depression
7. History of left tib/fib fracture s/p external fixation
([**6-1**])
8. History of right hip fracture, status post open reduction and
internal fixation ([**5-/2113**])
9. History of multiple falls
10. History of sacral decub ulcer, complicated by osteomyelitis
in [**2121-4-28**]
Social History:
Previously smoked 2ppd tobacco x several years; quit >15 years
ago. History of alcohol abuse, but no alcohol for > 50 years.
Currently lives at [**Hospital1 599**] of [**Location (un) 55**].
Family History:
Non contributory
Physical Exam:
VITALS: T 95.6, BP 91/25, HR 97, O2 98% on NRB
GEN: Lying on left side, in mild distress complaining of back
pain. Bear-hugger on.
HEENT: Pupils 4mm->3mm and sluggish.
CV: Borderline tachycardic; no obvious murmur.
PULM: Diffiult to hear breath sounds though no obvious crackles.
ABD: Distended and tympanic; mildly TTP
EXT: Warm in UE and cool in LE. No edema.
BACK: No spinal tenderness or CVA; sacrum skin intact.
NEURO: Alert but not oriented (won't answer when asked her
name). Moving upper extremeties but no lower.
Pertinent Results:
[**2124-3-6**] 11:00AM WBC-40.2*# RBC-3.77* HGB-10.7* HCT-35.2*
MCV-94 MCH-28.4 MCHC-30.4* RDW-15.6*
[**2124-3-6**] 11:00AM NEUTS-71* BANDS-8* LYMPHS-7* MONOS-12* EOS-0
BASOS-1 ATYPS-0 METAS-1* MYELOS-0
[**2124-3-6**] 11:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-3-6**] 11:00AM cTropnT-0.04*
[**2124-3-6**] 11:00AM LIPASE-25
[**2124-3-6**] 11:00AM ALT(SGPT)-12 AST(SGOT)-31 CK(CPK)-40 ALK
PHOS-77 AMYLASE-276* TOT BILI-1.3
[**2124-3-6**] 11:00AM GLUCOSE-144* UREA N-60* CREAT-1.7*#
SODIUM-138 POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-13* ANION
GAP-25*
[**2124-3-6**] 11:06AM LACTATE-8.0*
[**2124-3-6**] 04:32PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-9.0* LEUK-MOD
[**2124-3-6**] 04:32PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-[**3-2**]
[**2124-3-6**] 08:12PM LACTATE-8.9*
[**2124-3-6**] 08:12PM TYPE-CENTRAL VE TEMP-38.9 PO2-49* PCO2-39
PH-6.98* TOTAL CO2-10* BASE XS--24 INTUBATED-NOT INTUBA
COMMENTS-100.1 AXIL
[**2124-3-6**] 11:00PM LACTATE-10.6*
[**2124-3-6**] 11:00PM TYPE-CENTRAL VE PO2-37* PCO2-66* PH-6.87*
TOTAL CO2-13* BASE XS--25
Brief Hospital Course:
Medical ICU Course:
The patient was admitted with septic shock, likely due to
urosepsis or perforated abdominal viscus. She received
early-goal directed therapy with 6L IVF and was placed on
pressors for a few hours. Abdominal CT showed significant fecal
overload, and manual disimpaction was attempted. Initially her
lactate responded well to IVF, however she became increasingly
acidotic with hypotension and bradycardia. Per her advanced
directive, she was not intubated, and she expired.
Medications on Admission:
1. FUROSEMIDE - 20 mg three times weekly
2. LISINOPRIL - 5 mg daily
3. NITROGLYCERIN - 0.3 mg SL PRN
4. SIMVASTATIN - 80 mg daily
5. BACLOFEN - 15 MG QID
6. MIRTAZAPINE - 30 mg QHS
7. QUETIAPINE - 50 mg QHS
8. RISEDRONATE - 35 mg weekly
9. TRAMADOL - 25 mg Q6H PRN
10. ZOLPIDEM - 5 mg QHS
11. OMEPRAZOLE - 20 mg [**Hospital1 **]
12. ACETAMINOPHEN - PRN
13. ASCORBIC ACID
14. CALCIUM CARBONATE-VITAMIN D3 - 600 mg (1,500 mg)-200 unit
[**Hospital1 **]
15. DOCUSATE - 100 mg [**Hospital1 **]
16. MILK OF MAGNESIA PRN
17. JUVEN - 1 Packet daily
18. SENNOSIDES - 8.6 mg QHS
19. FLEET ENEMA - weekly
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock secondary to probable perforated viscus complicated
by severe constipation
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
Noen
Completed by:[**2124-3-15**]
ICD9 Codes: 0389, 5849, 2762, 5990, 311, 4439, 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4977
} | Medical Text: Admission Date: [**2180-12-16**] Discharge Date: [**2180-12-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right frontal hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 84 y/o female with HTN, chronic hyponatremia (of
unclear etiology), who presented s/p fall 1 week ago and MS
changes. History obtained from patient's daughter: patient
sustained a fall at home approximately 1 week ago and was found
on the floor at home by her son, who came in to check on her.
She was conscious but altered - patient was unable to specify
how the fall occured. She was able to ambulate easily after the
fall and was taken to the [**Hospital1 392**] ER that day. Per report, CT
head demonstrated bilateral subdural hygromas and generalized
cerebral atrophy. A CXR showed a possible PNA and urine
reportedly was dirty. She was admitted for MS changes and had
intermittent worsening periods of confusion during her hospital
course. She is normally AO x 3 and interactive at baseline, but
after the fall has been AO x [**1-18**] with lucid periods
intermittently. She was treated with both ciprofloxacin for a
presumed UTI and azithromycin for possible bronchitis at the
OSH. Her daughter noted that 1-2 days into her hospital course,
she had a small bruise on the back of her head. The patient
improved slightly on her own and was discharged to a [**Hospital1 1501**] on
Thursday night. However, she continued to be confused at the [**Hospital1 1501**]
and it was noted that the occipital bruise had increased in
size, so she was sent to the [**Hospital1 392**] ER on Saturday for
re-evaluation. Repeat head CT was read as a right front epidural
hematoma and she was transferred to [**Hospital1 18**] for further managment.
.
In the ED, initial VS were T 97, BP 144/58, HR 65, RR 20, SaO2
98%/RA. A repeat head CT was done and she was seen by
neurosurgery - CT showed a small right extraaxial bleed (no
intraventricular or intraparenchymal bleed, no mass effect). She
received 2 L NS for her low Na of 121. She also received 10 mg
IV labetolol x 1 and 1" NTP for a BP of 170/60, with improvement
to the 140's systolic.
.
Currently the patient denies any concerns or complaints. She is
comfortable.
Past Medical History:
HTN
PMR - on prednisone
Hypothyroidism
Hyponatremia - baseline Na low 120s (unclear etiology)
Left eye macular degeneration
Right eye s/p corneal transplant - 1 month ago
Baseline leukocytosis (14.2 on [**2180-10-16**] per routine labs with
PCP)
Social History:
Lives alone, normally performs ADLs, interactive. Most recently
at [**Hospital1 1501**] since last Thursday. No tobacco, EtOH. Daughter and son
involved in care and check on patient frequently.
Family History:
Non contributory
Physical Exam:
Tc 98.1, BP 136/68, HR 85, RR 16, SaO2 98%/RA
General: pleasant, elderly female in NAD, AO x 1 (to self), hard
of hearing
HEENT: NC/AT, +corneal opacity in right eye. Left pupil
3mm->2mm. MMM, OP clear
Neck: supple, no LAD or TMG
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS
Ext: no c/c/e, wwp
Neuro: AO x 1, speech fluent but nonsensical at times. CN II-XII
intact, MS [**5-20**] throughout, sensation to light touch intact
grossly. Normal FTN.
Pertinent Results:
[**2180-12-16**] CXR -
Two views with no comparisons. There is borderline LV
enlargement,
but no pulmonary vascular congestion, significant pleural
effusion, or other evidence of CHF. No focal consolidation is
seen. There is atherosclerosis involving the thoracic aorta,
and dense calcification of the mitral annulus. Incidentally
noted is evidence of chronic left rotator cuff disease.
.
[**2180-12-16**] CT head - Bilateral small extraxial fluid follections
and small acute right extraxial hematoma, measuring 4 mm from
the inner table. Negligible mass effect.
.
[**2180-12-16**] EKG - NSR at 65 bpm with nl axis. PR prolongation at 200
ms. [**Name13 (STitle) **] acute ST or T wave changes. No prior available for
comparison.
.
Repeat Ct head [**12-17**]: A small 4-mm extra-axial hematoma is
unchanged in size and appearance compared to one day prior. Left
greater than right bilateral low-density extra-axial collections
are also unchanged. There is no new hemorrhage, and no evidence
of infarction. Osseous structures and soft tissues are
unremarkable. Air- fluid levels are again noted within the
sphenoid sinus.
IMPRESSION:
1. Unchanged small right extra-axial hematoma.
2. Unchanged bilateral extra-axial fluid collections, which may
represent chronic subdural hematomas.
These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 10:00 p.m.
on [**2180-12-17**].
.
ECHO [**12-18**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
CT head [**12-20**]:
FINDINGS: Comparison is made to [**2174-12-18**] and [**2180-12-16**].
Again seen are hypodense bilateral subdural collections over the
frontal
convexities which appear minimally decreased in size compared to
the prior
study. Again seen is a hyperdense component over the right
frontal lobe
measuring approximately 1.9 by approximately 0.4 cm, which is
not
significantly changed in size. This may represent a more acute
subdural
hematoma component or alternatively an incidental meningioma.
There are no intracranial hemorrhages. The [**Doctor Last Name 352**]/white matter
differentiation is maintained. The ventricles and extraaxial
CSF spaces are marginally prominent as before. There is a
moderate degree of white matter hypodensities consistent with
chronic microangiopathic changes.
The visualized orbits are normal. Vascular calcifications are
seen. There is a mucous retention cyst within the left sphenoid
air cell.
Not significantly changed since the prior studies is a
nondisplaced fracture of the left occipital bone with no
underlying intracranial hemorrhage or swelling of the overlying
scalp.
IMPRESSION:
Minimal decrease in size of hypodense collections over the
frontal lobes
bilaterally.
No significant change in size of the hyperdense component over
the right
frontal lobe which may represent an acute subdural hematoma
versus a
meningioma.
Nondisplaced left occipital bone fracture.
[**2180-12-22**]
Sodium 130
Brief Hospital Course:
84 y/o female with HTN, chronic hyponatremia, s/p recent fall,
p/w extraaxial bleed and MS changes.
.
# Right frontl hematoma/Bilateral frontal fluid collections
Small in size, no evidence of mass effect. Unclear if was blood
or fluid collection. Thought secondary to recent fall and
trauma. On review of records from outside hospital, patient had
a CT of the head which showed no evidence of extra-axial
collections on [**12-11**]. These collections were first noted on a
CT head from the outside hospital on [**12-16**]. Neurosurgery was
consulted upon arrival to [**Hospital1 18**] and felt that there was minimal
contribution of fluid collection to current clinical situation.
A CT head was repeated the following day which showed stability
in extraaxial bleed. Neuro checks remained stable and nonfocal
throughout. In the setting of persistent disorientation in the
MICU, a CT head was again repeated 3 days later which showed
slight improvement in L sided fluid collection and otherwise
unchanged head CT. A non-displaced L Occipital bone fracture
was noted for the first time on this head CT but was then
retrospectively seen on prior head CTs and was reportedly
unchanged. There was no underlying bleeding or other
intracranial abnormality. Neurosugery recommended repeat CT head
in 4 weeks to reassess extra-axial collections.
.
# Syncope
Patient was found down at home, unclear cause,unwitnessed.
Syncope considered as a possible cause. She had no events on
telemetry during her hospital course to suggest arrhythmia. She
had an echo performed which showed mild LVH and diastolic
dysfunction but no significant valvular abnormalities. She had a
CTA of her head on [**2180-12-12**] at the outside hospital which showed
atherosclerotic calcified plaques of the internal carotid
arteries but no evidence of hemodynamically significant stenosis
or other vascular abnormalities. No further workup indicated at
this time.
.
# MS changes
Per patients family, she was different from normal baseline.
However, MS had been worse since her previous admission to the
outside hospital. Her subdural fluid collections were possibly
contributing given the temporal correlation of her fall, the
development of the fluid collections, and the onset of her
delerium. However, the collections were small and improved over
time so it was also considered that the patient was delerius
from prolonged hospitalization including prolonged MICU course.
Patient remained pleasant throughout MICU course with only mild
sundowning responsive to reorientation. She required soft wrist
restraints once to prevent her from getting out of bed and
responded to 5 mg of zyprexa. Her hyponatremia was a chronic
problem and was not thought to be contributing. She had a
thorough infectious work up as well which was unremarkable,
Zyprexa was discontinued prior to discharge due to questionable
effectiveness. Her mental status continues to wax and wane.
.
# Hyponatremia
Patient with long-standing history of hyponatremia in the low
120's at baseline of unclear etiology. Received 2 L NS in the
ED, Na 121->128 over 8 hours. Response to fluid suggested some
evidence of hypovolemic hyponatremia. However, after
stabilization, serum osms were low, urine osms were high, and
urine sodium was elevated suggesting SIADH. Patient was managed
with fluid restriction throughout her course with stable Na
throughout. At discharge fluid restriction will not be
mantained. Reasoning is that her baseline sodium is in the low
120s and she has not been on any prior fluid restriction. Given
her age the decision was made to opt for quality of life and not
restrict her fluid intake unnecessarily.
.
# Leukocytosis
WBC 14 with left shift with 90% PMN's. Baseline WBC was 14.2 on
routine blood work per her PCP's office, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 93632**].
Thought secondary to chronic prednisone therapy. Recently on
treatment for UTI and bronchitis. While here infectious work up
was unremarkable. She developed a thrombocytosis during her
MICU stay which was also suggestive of infection. However,
repeat infectious work up continued to be unremarkable. Baseline
hematocrit 34 and platelets 430 on last lab slip on [**2180-10-16**] at
PCP's office.
.
# HTN
Continued on atenolol, lisinopril, cardizem.
.
# PMR
Continued on prednisone 8mg daily.
.
# F/E/N
Regular diet. Fluid restriction of 1000cc.
.
# PPx
Heparin SQ
.
# Communcation - with daughter, HCP, [**Name (NI) **] [**Name (NI) 10113**]
(c)[**Telephone/Fax (1) 93633**], (h)[**Telephone/Fax (1) 93634**], (w) [**Telephone/Fax (1) 93635**]
.
# Code - Full Code (confirmed with HCP)
Medications on Admission:
1. ASA 81 mg daily
2. Atenolol 100 mg daily
3. Diltiazem CR 240 mg daily
4. Cipro 250 mg daily - recently started
5. Colace 100 mg daily
6. Calcium carbonate 1000 mg daily
7. Prednisone 8 mg daily
8. Lisinopril 40 mg daily
9. Levothyroxine 50 mcg daily
10. Prednisolone eye gtt
11. Erythromycin eye gtt
12. Azithromycin 250 mg daily - recently started
13. Vitamin D 800 units daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
8. PredniSONE 5 mg/5 mL Solution Sig: Eight (8) ml PO DAILY
(Daily).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic TID (3 times a day).
12. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic TID (3
times a day).
13. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Intracranial extra-axial bleed
2. Traumatic nondisplaced occipital bone fracture
3. Delirium
4. Syncope NOS
Secondary:
1. Hypertension
2. Hypothyroidism
3. Polymyalgia rheumatica
4. Chronic SIADH
Discharge Condition:
Stable, mental status waxes and wanes
Discharge Instructions:
You were admitted for concern of a bleed in your head after the
fall you experienced. You were seen by neurosurgery who did not
believe any surgical intrvention was indicated. You had repeat
CT scan of your head which showed minimal resolution of the
pocket of fluid. You will have a repeat scan of your head in
[**Month (only) 404**] which will be reviewed by neurosurgery. Your sodium
level was low, this has been a chronic issue and is not overly
concerning, there is no need to restrict your fluid intake given
this has been a chronic issue and you have not been on fluid
restriction prior to admission.
Please continue to take all medications as prescribed.
Please continue to follow a 1.5 L fluid restriction.
Please have a head CT without contrast repeated on [**2180-1-24**] to
assess for resolution of the fluid collections under your skull.
This will be on the same day you follow up with Dr. [**Last Name (STitle) **] of
Neurosurgery.
Please follow up with your PCP as below.
Please call your doctor or return to the hospital for feversm,
chills, chest pain, shortness of breath, lightheadedness,
confusion, numbness, weakness, or any other concerns.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] of Neurosurgery on [**2180-1-24**] 1:45
pm. You should have a CT of your head repeated before your
appointment. Phone: ([**Telephone/Fax (1) 11314**]
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-19**] weeks. Dr. [**Name (NI) 93636**] office will call to schedule a follow up appointment.
Phone: ([**Telephone/Fax (1) 93637**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4978
} | Medical Text: Admission Date: [**2108-4-5**] Discharge Date: [**2108-4-10**]
Date of Birth: [**2025-1-23**] Sex: F
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Ambien
/ Penicillins
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 83F with hx of COPD on 2L home O2,
pulm HTN, and [**Hospital **] transferred from BIDN and admitted to the MICU
for hypotension and SOB concerning for cardiogenic shock. Pt
presented to BIDN ED with dehydration and, per report, has been
having poor PO intake over the last few weeks due to low
appetite and was found to be hypotensive to as low as the 70's
systolically with [**Last Name (un) **] (Cr of 1.4 from prior baseline of 0.9).
She was otherwise asymptomatic and this was assessed as severe
dehydration and was given 5L of fluid without response to blood
pressure. Patient was started on dopamine became tachycardic to
130s without much improvement in blood pressure, he was switched
to phenylephrine and patient was transferred for further workup.
Arrived to our ED without central access. Of note, patient has
noticed dark stools for the last 2 days but denies bright red
blood per rectum and was guaiac positive at OSH ED with crit of
25.9 down from prior baseline of high 30's. UA negative, UCx and
BCx sent. She also describes some nausea and a 10 pound
unintentional weight loss in the last month. She otherwise
denies fevers, chills, chest pain, abdominal pain, vomiting,
diarrhea, urinary symptoms, or localized numbness, weakness, or
tingling.
.
ED Course:
In the ED, initial vitals were: T 98.8, HR 83, BP 90/48, RR 16,
SvO2 93% 10L NRB.
-BP's in the 70-80's systolically on neosyneprhine
-CVL RIJ placed
-Started on norepinephrine with good response
-Given stress dose hydrocort
-CXR with b/l pleural effusions and fluid overload
-BNP 3800
-CVP 12
-EKG with new q-waves
-Trop of 0.11 (0.139 @ OSH)
-WBC 15.9, PLT 618, INR 1.4, Cr 1.2
-Lactete 3.2 -> 1.8
-Bedside echo with good squeeze per report
-Cardiology consulted and saw patient in ED, discovered that [**12-26**]
weeks ago she had moderate chest pressure that woke her from
sleep 2 nights in a row for which she did not seek medical care.
Reviewed her EKG which demonstrated NSR @ 97, NA, NI, new
inferior Q waves, late transition with anterior Q waves, and
anterolateral ST and T changes consistent with old MI. Recs for
plavix load, high dose atorva, serial enzymes, urgent bedside
TTE, and intervention as soon as possible or in case of
mechanical complication.
.
On arrival to the MICU, patient's VS: Afebrile, 96, 91/53, 18,
94% 10L NRB. Patient feels comfortable and is pleasant but SOB.
She confirms the above history.
Past Medical History:
COPD on 2L NC baseline
Hypothyroidism
Asthma
HTN
Pulmonary Hypertension c/b LE edema
h/o SVT
Social History:
Social History: Retired anesthesiologist. She lives in [**Hospital 4382**] with a roommate. She is independent in her ADLs/IADLs.
She is a remote smoker who quit 25 years ago. She drinks
alcohol, [**2-26**] drinks daily. She has no history of drug abuse.
Family History:
Family History: Non-contributory
Physical Exam:
Afebrile, 96, 91/53, 18, 94% 10L NRB.
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, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
On Admission:
[**2108-4-5**] 09:30PM BLOOD WBC-15.9* RBC-2.52* Hgb-8.1* Hct-27.4*
MCV-109* MCH-32.1* MCHC-29.6* RDW-15.2 Plt Ct-618*
[**2108-4-6**] 03:31AM BLOOD WBC-19.1* RBC-2.40* Hgb-7.9* Hct-26.6*
MCV-111* MCH-32.8* MCHC-29.6* RDW-15.8* Plt Ct-602*
[**2108-4-5**] 09:30PM BLOOD Neuts-88* Bands-0 Lymphs-6* Monos-5 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2108-4-6**] 03:31AM BLOOD Neuts-97.4* Lymphs-1.5* Monos-0.9*
Eos-0.1 Baso-0.1
[**2108-4-5**] 09:30PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Target-OCCASIONAL
Stipple-OCCASIONAL
[**2108-4-6**] 03:31AM BLOOD Plt Ct-602*
[**2108-4-6**] 03:31AM BLOOD PT-16.4* PTT-34.6 INR(PT)-1.5*
[**2108-4-5**] 09:30PM BLOOD Plt Smr-HIGH Plt Ct-618*
[**2108-4-5**] 09:30PM BLOOD PT-15.1* PTT-29.4 INR(PT)-1.4*
[**2108-4-6**] 03:31AM BLOOD Glucose-142* UreaN-15 Creat-1.2* Na-137
K-3.8 Cl-107 HCO3-21* AnGap-13
[**2108-4-5**] 09:30PM BLOOD Glucose-125* UreaN-14 Creat-1.2* Na-138
K-3.8 Cl-104 HCO3-23 AnGap-15
[**2108-4-6**] 03:31AM BLOOD ALT-53* AST-280* LD(LDH)-274* CK(CPK)-131
AlkPhos-126* TotBili-2.1*
[**2108-4-5**] 09:30PM BLOOD ALT-33 AST-164* AlkPhos-136* TotBili-1.9*
[**2108-4-5**] 09:30PM BLOOD Lipase-13
[**2108-4-6**] 03:31AM BLOOD CK-MB-9 cTropnT-0.09*
[**2108-4-5**] 09:30PM BLOOD cTropnT-0.11*
[**2108-4-5**] 09:30PM BLOOD proBNP-3816*
[**2108-4-6**] 03:31AM BLOOD Albumin-2.4* Calcium-7.1* Phos-3.6
Mg-1.2*
[**2108-4-5**] 09:30PM BLOOD Albumin-2.4* Calcium-7.2* Phos-3.7
Mg-1.3*
[**2108-4-6**] 03:45AM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-47* pH-7.24*
calTCO2-21 Base XS--7
[**2108-4-5**] 11:36PM BLOOD Type-CENTRAL VE pO2-91 pCO2-48* pH-7.23*
calTCO2-21 Base XS--7 Intubat-NOT INTUBA
[**2108-4-6**] 03:45AM BLOOD Lactate-1.5
[**2108-4-5**] 11:36PM BLOOD Lactate-1.8
[**2108-4-5**] 09:43PM BLOOD Lactate-3.2*
[**2108-4-6**] 2:17 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
CHEST (PORTABLE AP) Study Date of [**2108-4-5**] 9:24 PM
IMPRESSION: Opacification of the lower lungs, greater on the
right than left, probably reflecting pleural effusions and
associated atelectasis, although an infectious process is hard
to exclude. Regular lung markings and architecture suggesting
there may be emphysema.
Portable TTE (Focused views) Done [**2108-4-6**] at 1:00:00 AM
FINAL
Conclusions
Poor image quality. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is probably preserved (LVEF>50%).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. RV with normal free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
EKG: NSR @ 97, NA, NI, Q waves in II, III, TWI's in I, V5, V6,
poor r-wave progression
Brief Hospital Course:
Assessment and Plan: 83F with hx of COPD, HTN, Pulm HTN, and
remote smoking hx admitted to the MICU with GIB, evidence of
recent inferior MI, pneumonia and hypotension/septic shock
requiring pressor support.
.
# Pneumonia/septic shock/Hypoxia: Patient presented with hypoxia
and left lower lobe consolidation. She was started on broad
spectrum antibiotics and pressors for blood pressure support.
Sputum cultures grew Staph Aureus which had been appropriately
covered by vancomycin. However, she continued to require
pressors and continued to clinically deteriorate. Multiple
discussion were held regarding goals of care. Initially the goal
was to wean her off pressors so that she could go home with
hospice. However she was not able to be weaned off. SHe was then
made CMO and her pressors and antibiotics were stopped. She was
started on morphine drip for comfort and she passed away shortly
after.
.
# Recent Inferior MI c/b Cardiogenic Shock: She had evidence of
a new inferior MI
on her EKG. Because of her hypotension it was initially thought
that she had a component of cardiogenic shock. An echo was
performed which showed preserved LVEF, in conjunction with low
central venous pressure makes cardiogenic shock highly unlikely.
.
# Concern for UGIB: Patient's hematocrit on admission was lower
than previous baseline. She was trasnfused two units PRBC in the
setting of hypotension and concern for active GIB. However her
HCT remained stable. GI was consulted who felt that she was not
having GI bleeding and that further intervention was not
waranted.
Medications on Admission:
Medications: Pt unsure of her meds, per recent outpatient note:
Symbicort 1 puff twice a day
thyroxine 75 mcg daily
atenolol 25 mg daily
Detrol 4 mg daily
tramadol 50 mg daily
Ativan 0.5 mg prn sleep
furosemide 20 mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2108-4-10**]
ICD9 Codes: 0389, 2851, 5849, 4168, 4019, 2449, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4979
} | Medical Text: Admission Date: [**2111-4-8**] Discharge Date: [**2111-4-21**]
Service: VSU
CHIEF COMPLAINT: Left lower extremity ischemic pain for 3
days.
HISTORY OF PRESENT ILLNESS: This is an 81-year-old African
American female with known coronary artery disease,
congestive heart failure, with an ejection fraction of [**11-15**]
percent, previous CVA and peripheral vascular disease who
underwent a right axillary bifemoral bypass in [**2108-3-3**]
who presents with 3-4 days of increasing left foot pain and
discoloration. Also noted to have mental status changes,
i.e., hallucinations. Head CT in the emergency room was
negative. The patient now is admitted for left lower
extremity acute ischemia. The patient describes pain at rest
minimally with ambulation. No fevers, chills, nausea,
vomiting, shortness of breath, chest pain. No dysuria.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin 325 mg daily.
2. Atenolol 50 mg daily.
3. Captopril 12.5 mg t.i.d.
4. Digoxin 0.25 mg daily.
5. Diltiazem 120 mg daily.
6. Colace 100 mg b.i.d.
7. Lasix 20 mg a day.
8. Gemfibrozil 600 mg b.i.d.
9. Coumadin 3 mg daily.
10. NPH insulin 25 units q.a.m., 7 units at dinner with a
regular sliding scale.
PAST MEDICAL HISTORY:
1. Coronary artery disease, three vessel disease by cardiac
catheterization with a history of myocardial infarction
in [**2093**].
2. History of congestive heart failure with an ejection
fraction of [**11-15**] percent.
3. History of CVA.
4. History of hypertension.
5. History of hypercholesterolemia.
6. History of type 2 diabetes.
7. History of nephrolithiasis.
PAST SURGICAL HISTORY:
1. Cholecystectomy, remote.
2. Right ureteral stenting in [**2109**].
3. Appendectomy, remote.
4. Bilateral cataract surgeries, remote.
5. Right axillary bifemoral bypass on [**2108-3-27**].
SOCIAL HISTORY: The patient lives in [**Hospital3 **] with
her family. She denies tobacco or alcohol use.
PHYSICAL EXAMINATION: General: No acute distress. Oriented
x2. No JVD or carotid bruits. Heart is irregular/irregular
rhythm. Lungs are clear to auscultation bilaterally.
Abdominal exam is remarkable for a ventral hernia reducible.
Extremities are no edema. Rectal exam is Guaiac negative.
Pulse exam shows Dopplerable right axillofem graft. Femoral
pulses are Dopplerable, monophasic bilaterally, popliteal on
the right is monophasic Dopplerable signal on the left
absent. The DP on the right is triphasic, Dopplerable and the
PT is absent. On the left the DP and PT are absent
bilaterally. The left leg is mottled with sensory intact and
diminished motor function. The patient is admitted to the
vascular service now for further evaluation and treatment.
HOSPITAL COURSE: The patient was initially evaluated in the
emergency room and admitted to the vascular service. She was
begun on vanco, levofloxacin for antibiotic care. Her
preoperative medications were continued. She did have some
EKG changes with ST depressions in V4-V5, questionable
myocardial infarction. The patient's admitting CKs were 387
and over the next 48 hours CK was 209. CK MBs were 3 and 4.
Troponin levels were 0.2. Cardiology was requested to see the
patient for preoperative assessment for evaluation.
Recommendations-she was a high surgical candidate with known
severe ischemic cardiomyopathy with a semi-compensated left
ventricular function. They felt that no further cardiac
workup was indicated at this time. The patient should be
restarted on her Lasix, spironolactone should be added to her
regimen and increase from 12.5 to 25 mg daily with monitoring
of K. Diltiazem should be discontinued secondary to
myocardial suppression, a beta blockade, Toprol, should be
advanced to 150 mg a day. Digoxin should be changed to 0.125
mg per day and gemfibrozil should be changed to fenofibrate.
The patient's Coumadin was held and she was placed on IV
heparin for anticoagulation for a chronic atrial
fibrillation. Long discussions with the family to determine
plan of action, arteriogram to see if we can reconstruct or
just undergo amputation. The patient's family was undecided.
The [**First Name4 (NamePattern1) 3208**] [**Last Name (NamePattern1) 4869**] was consulted for diabetic management. The
patient was preopped on [**2111-4-15**] for anticipated left
AKA and underwent a left AKA without complication on [**2111-4-15**]. She was transferred to the PACU in stable
condition. Postoperatively, she remained hemodynamically
stable. Her postoperative crit was 31.1, BUN 15, creatinine
0.7. The patient remained intubated overnight and was
transferred to the SICU for continued monitoring and care.
She was weaned overnight and extubated. She remained
hemodynamically stable. Her physical examination was
unremarkable. Her dressing was clean, dry, and intact. She
was transferred to the VICU for continued care. She required
readjustment in her regular insulin dose for her
hyperglycemia with slow improvement.
On postoperative day #1 the patient was converted to p.o.
medications. Ambulation to the chair was begun. Heparin was
restarted and Warfarin was reinstituted. Her antibiotics were
discontinued on postoperative day #2. Her Swan line was
converted to CVL on postoperative day #2. She continued to
require Lasix for diuresis. The A-line was discontinued.
Hematocrit was 28.7, BUN 11, creatinine 0.7. She continued to
be followed by the vascular service and her primary care
physician.
Physical therapy evaluated the patient on postoperative day
#3. The recommendations were that the patient could be
discharged to home with home physical therapy and 24-hour
care. The family is aware of this and this was their
decision. A repeat echocardiogram will be obtained prior to
the patient's discharge to determine her left ventricular
function.
On postoperative day #5 she continued to do well, was
afebrile. Her left flap was warm, pink, without erythema. The
right DP and PT were Dopplerable signals only. The IV heparin
was continued until her INR was greater than 2.0. The patient
will continue with diuresis. She is at baseline. Will be
planning discharge to home with services in the next 24
hours.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg t.i.d.
2. Acetaminophen 325 mg tablets 2 q.6 h.
3. Isosorbide dinitrate 10 mg t.i.d.
4. Digoxin 125 mcg daily.
5. Captopril 12.5 mg t.i.d.
6. Protonix 40 mg daily.
7. Colace 100 mg b.i.d.
8. Senna 8.6 mg tablets 1 b.i.d. as needed.
9. Warfarin 3 mg a day.
10. Lasix, dosing 40 mg a day.
11. Potassium 20 mg a day.
12. Aspirin 325 mg daily.
13. Crestor 10 mg at [**Year (4 digits) 21013**].
14. Insulin sliding scale as follows: NPH 40 units q.a.m., 20
units at [**Year (4 digits) 21013**], Humalog sliding scale before meals and
at [**Year (4 digits) 21013**], before meal sliding scale, glucose less than
100 no insulin; 101-150 at 6 units; 151-200 at 10 units;
201-250 at 12 units; 251-300 at 16 units; 301-350 at 18
units; 351-400 at 20 units; greater than 400 notify
physician. [**Name10 (NameIs) **] sliding scale glucoses less than 150
no insulin; 151-200 at 7 units; 201-250 at 9 units; 251-
300 at 11 units; 301-350 at 13 units; 351-400 at 15
units; greater than 400 notify physician.
DISCHARGE INSTRUCTIONS: INR should be monitored as required.
The patient should follow-up with the primary care physician.
[**Name10 (NameIs) 18303**] INR 2.0 to 3.0. There should be no stump shrinkage due
to the amputated site. If the patient develops a fever of
greater than 101.5 she should notify Dr.[**Name (NI) 1392**] office.
If the wound becomes red, there is swelling or drainage, the
patient should call Dr.[**Name (NI) 1392**] office. The right heel
should be protected with a multi_____ splint at all times.
DISCHARGE DIAGNOSIS:
1. Left foot ischemia with rest pain.
2. History of peripheral vascular disease, status post right
axillobifemoral bypass graft [**2108-3-3**], failed.
3. Coronary artery disease with history of myocardial
infarction in [**2093**].
4. History of congestive heart failure with ejection
fraction of 10 percent.
5. History of hypertension.
6. History of hypercholesterolemia.
7. History of cerebrovascular accident.
8. History of type 2 diabetes, insulin-dependent,
uncontrolled.
9. History of atrial fibrillation, anticoagulated.
MAJOR SURGICAL PROCEDURES: Left above knee amputation [**2111-4-15**].
FOLLOW UP: The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in
[**3-6**] weeks for an office appointment at [**Telephone/Fax (1) 1393**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2111-4-20**] 10:12:28
T: [**2111-4-20**] 12:00:10
Job#: [**Job Number 92917**]
ICD9 Codes: 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4980
} | Medical Text: Admission Date: [**2195-9-11**] Discharge Date: [**2195-9-21**]
Date of Birth: [**2124-1-28**] Sex: F
Service: NEUROSURGERY
Allergies:
morphine / pollen / cats / Oxycodone
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Anterior kyphosis due to tumor T7 and T8.
Major Surgical or Invasive Procedure:
1. Open reduction of compression fracture T7 and T8.
2. Arthrodesis from T1 to T11segmental.
3. Instrumentation T1 to T11.
History of Present Illness:
Dr. [**Last Name (STitle) 739**] saw Ms. [**Known lastname 41033**] as a neurosurgical evaluation
follow-up
after her visit in the hospital and hospitalization. She has a
large lytic lesion on the vertebral body of T7 and minimal on T8
on one side. She was placed on TLSO brace while she was getting
radiation treatment in hopes of
improving her symptoms and not needing surgery. However, she
still has significant back pain and point tenderness.
Her strength was full in both lower extremities. No
hyperreflexia, no
myelopathy. CT imaging showed a lytic lesion at T7 seems to
have increased in size and also there is anterior wedge collapse
of the T7 vertebral body.
Relatively stable T8 lesion.
Dr. [**Last Name (STitle) 739**] recommended a thoracic fusion and she agreed
to proceed.
Past Medical History:
PMH:
-T3 N0 large cell lung carcinoma with neuroendocrine features,
s/p lobectomy and chemotherapy
-Asthma
-GERD
-Hypercholesterolemia
PSH:
-Open appendectomy
-B breast lumpectomy
-Left meniscus repair
-Right cataract
-Carpal tunnel
Social History:
Lives with family. Tobacco 50 pack-year quit [**2163**]. ETOH
occasional
Family History:
non-contributory
Physical Exam:
Motor exam: full strength in upper and lower extremities
bilaterally
Sensory: intact to light touch in all groups
incision is with slight staple irritation redness along incision
extr: no c/c/e
Pertinent Results:
[**2195-9-10**] MRI T-Spine: Soft tissue mass replacing the majority of
the T7 vertebral body with interval pathologic compression
fracture of the T7 vertebral body. Soft tissue mass extends
into the T6 and T8 vertebral bodies as described above; findings
are again compatible with metastatic disease.
[**2195-9-12**] T-spine Xray AP and Lateral: T1-11 fusion, adequate
hardware placement and [**Last Name (un) 2043**] alignment
[**2195-9-14**] KUB:Diffuse mildly dilated loops of small and large
bowel are compatible with ileus.
[**9-16**] LENIs - No evidence of deep vein thrombosis either right or
left lower extremity.
Brief Hospital Course:
The patient was admitted to the Neurologic Surgery Service for
management of a anterior kyphosis due to tumor T7 and T8. The
patient was taken to the OR and underwent an uncomplicated T1-11
instrumented fusion. The patient tolerated the procedure
without complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with intravenous medication with
a transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
advancement with diet and ambulation. On the evening of POD 2
she developed worsening back pain and required an increase in IV
pain medication for breakthrough pain.
In the morning of POD3 however the patient developed an episode
of delerium that cleared over 20-30 minutes, likely related to
pain medication and muscle relaxants and exhaustion. UA and
culture were sent. Geriatrics team was consulted for
recommendations on pain medications to limit delerium. She
developed abdomninal pain and distension and KUB demonstrated
Ileus. Soap [**Last Name (un) **] enema was administered for presence of larege
amounts of stool on KUB. She was passing flatus and was somewhat
more confortable on [**9-15**]. She was mobilized with PT and OT. Her
Foley was discontinued. Per Geriatrics, trazodone replaced
benadryl for her sleep aide and tylenol was made ATC.
[**9-16**] patient was having some loose stools, but was having
difficulty urinating. She was straight cathed several times and
eventually the foley catheter was replaced. Lower extremity
Dopplers were performed for complaint of calf tenderness and
there was o DVT. Follow up KUB showed minimal improvment in
ileus and no SBO. She was OOB more on [**9-17**] and continued to have
significant flatus. she had less pain.
On [**9-18**], patient continued to have mild nausea. As a result,
patient was started on reglan to increase gastric motility. In
addition, her foley was d/c'd in routine fasion.
She continued to improve in terms of her constipation. She
continued to pass [**Last Name (un) **]. Belly pain improved. Now DOD, patient
is afebrile, VSS, and neurologically stable. Patient's pain is
well-controlled and the patient is tolerating a good oral diet.
Pt's incision is clean, dry and intact without evidence of
infection. Patient is ambulating without issues. Patient's
brace was fitted and patient received instructions on care and
appropriate use. She is set for discharge home in stable
condition and will follow-up accordingly.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - albuterol
sulfate HFA 90 mcg/actuation Aerosol Inhaler
1 to 2 puffs inhaled every 4-6 hours as needed
ESTERTEST - (Prescribed by Other Provider) -
GABAPENTIN - gabapentin 100 mg capsule
1 capsule(s) by mouth three times a day
HYDROMORPHONE - hydromorphone 2 mg tablet
[**1-5**] tablet(s) by mouth every 3-4 hours as needed for pain
LACTULOSE - (Prescribed by Other Provider) - lactulose 20
gram/30 mL Oral Soln
30 ml by mouth twice a day
MEDROXYPROGESTERONE - (Prescribed by Other Provider) -
medroxyprogesterone 2.5 mg tablet
Tablet(s) by mouth
OMEPRAZOLE - (Prescribed by Other Provider) - omeprazole 20 mg
capsule,delayed release
2 (Two) capsule(s) by mouth DAILY
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - Diovan
160
mg tablet
1 (One) tablet(s) by mouth once a day
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
cholecalciferol (vitamin D3) 1,000 unit capsule
1 Capsule(s) by mouth DAILY
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) -
Colace 100 mg capsule
1 capsule(s) by mouth twice a day
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider; OTC)
-
polyethylene glycol 3350 17 gram/dose Oral Powder
17 g by mouth twice a day
SENNOSIDES [SENNA] - (Prescribed by Other Provider; OTC) -
senna
8.6 mg tablet
1 tablet(s) by mouth twice a day
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
max 4g/day
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Administered by Respiratory
3. Bisacodyl 10 mg PO/PR DAILY
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO BID
6. Gabapentin 200 mg PO TID
7. Heparin 5000 UNIT SC TID DVT prophylaxisi
8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
9. Lactulose 30 mL PO Q 8H
10. Lidocaine 5% Patch 2 PTCH TD DAILY
to paraspinal muscles on each side of incision, DO NOT place
over incision. 12 hrs on, 12 hours off
11. Metoclopramide 10 mg PO TID
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Ondansetron 8 mg IV Q6H:PRN N/V
14. Polyethylene Glycol 17 g PO DAILY no BM
15. Senna 2 TAB PO QHS
16. Simethicone 40-80 mg PO QID:PRN GAS
17. Valsartan 80 mg PO DAILY
Hold for SBP < 100
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Anterior kyphosis due to tumor T7 and T8.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? You should wear your brace when out of bed or when your head
of bed is above 30 degrees.
?????? You may put the brace on at the edge of your bed.
?????? You may use a shower chair to bathe without the brace on.
?????? No tub baths or pool swimming for two weeks from your date of
surgery.
?????? Do not smoke.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
??????Please return to the office in [**7-14**] days (from date of surgery)
for removal of your staples. This appointment can be made with
the Physician Assistant or [**Name9 (PRE) **] Practitioner. Please make this
appointment by calling [**Telephone/Fax (1) 1272**]. If you live quite a
distance from our office, please make arrangements for the same,
with your PCP.
??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 4 weeks. You will need AP and
Lateral Thoracic Spine X-rays prior to your appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2195-9-21**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4981
} | Medical Text: Admission Date: [**2184-9-20**] Discharge Date: [**2184-9-27**]
Date of Birth: [**2119-12-26**] Sex: M
Service: SURGERY
Allergies:
Keflex
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
renal transplant
Major Surgical or Invasive Procedure:
Renal transplant right iliac fossa.
History of Present Illness:
64M with DM and HTN with ESRD and on dialysis for
approximately 1 year presents for renal transplantation.
Overall
feels well, denies fevers, chills, nausea, vomiting, diarrhea,
recent illness, travel or sick contacts.
Past Medical History:
PMH: ESRD (most likely secondary to DM nephropathy, T/Th/Sat
HD),
DM, HTN, now resolved SDH after fall, actinic keratosis
PSH: RUE AV fistula creation
Social History:
married, lives with wife, no smoking or alcohol use
Family History:
HTN
Physical Exam:
Discharge physical
NAD
no murmurs
ctab
abd protubertant, incision c/d/i, closed with staples, some
surrounding ecchymosis, no rebound or guarding
no LE edema
Pertinent Results:
On Admission: [**2184-9-20**]
WBC-4.4 RBC-3.41* Hgb-11.7* Hct-37.0* MCV-108*# MCH-34.3*#
MCHC-31.7 RDW-16.2* Plt Ct-160
PT-12.5 PTT-25.5 INR(PT)-1.1
UreaN-54* Creat-4.9*# Na-140 K-4.3 Cl-97 HCO3-29 AnGap-18
ALT-12 AST-27
Albumin-4.4 Calcium-9.3 Phos-4.5 Mg-2.4
At Discharge [**2184-9-27**]
WBC-7.7 RBC-2.79* Hgb-9.3* Hct-28.9* MCV-104* MCH-33.3*
MCHC-32.1 RDW-15.6* Plt Ct-175
Glucose-112* UreaN-62* Creat-3.7* Na-136 K-3.4 Cl-98 HCO3-29
AnGap-12
ALT-13 AST-27 AlkPhos-54 TotBili-0.6
Albumin-3.0* Calcium-8.4 Phos-3.3 Mg-2.3
tacroFK-9.0
Brief Hospital Course:
This is a 64 yo M w/ ESRD likely secondary to diabetes who was
admitted to the hospital for a renal transplantation. He was
taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and underwent transplant
without complications.
On the night of POD#0, the patient had acute change in mental
status. Was given Narcan 1.6 mg, will little change. NC Head CT
did not show acute changes, and he was transferred to SICU, and
returned to baseline without further intervention. Transferred
back to floor on POD#1 with no further events.
#RENAL
Was dialyzed as needed, he was not dialyzed day of discharge as
his creatinine was slightly decreased and renal was recommending
watching for now. Received ATG doses x 4 and received intra-op
solumedrol with routine taper, cellcept per protocol as well as
starting prograf on the evening of POD 0. Levels have been
monitored daily with dosing adjusted per level.
On day of discharge pt and staff felt safe to discharge pt to
rehab with close follow up.
Medications on Admission:
erythropoietin on HD, felodipine 5', nortriptyline 75',
furosemide 40'', neurontin 300''', toprol XL 50'(non-HD days),
actos 45', allopurinol 100', calcium acetate 2 pills with meals,
simvastatin 20', tricor 145', fish oil
Discharge Medications:
1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection every six (6) hours.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for Pain.
10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
13. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours): Total dose 3.5 mg [**Hospital1 **].
17. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day: Total dose 3.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 8**]
Discharge Diagnosis:
ESRD now s/p kidney transplant
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 the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, incisional
redness, drainage or bleeding, increased pain over the graft
site, inability to tolerate food, fluids or medications,
decreased urine output.
Labs to be drawn daily initially, and send results to the
transplant clinic, fax # [**Telephone/Fax (1) 697**], as nephrologists will
determine need for further hemodialysis. Once stable, the labs
may be drawn every Monday and Thursday.
Please do not adjust medications without consultation with the
transplant clinic
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2184-9-30**] 3:20, [**Hospital **] clinic, [**Street Address(2) **],
[**Hospital Unit Name **], [**Location (un) **], [**Location (un) 86**], MA
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2184-10-12**] 9:50
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2184-10-12**] 11:00
Completed by:[**2184-9-27**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4982
} | Medical Text: Unit No: [**Numeric Identifier 63770**]
Admission Date: [**2198-5-12**]
Discharge Date: [**2198-5-22**]
Date of Birth: [**2198-5-12**]
Sex: M
Service: NBB
HISTORY: [**Doctor Last Name **] is a 33-week gestation male delivered at
[**Hospital3 **] due to premature rupture of membranes and
preterm labor. He was transferred to [**Hospital1 18**] NICU due to lack
of available beds at [**Hospital3 1810**].
PRE/PERINATAL HISTORY: Mother is a 29 year old para [**12-28**] mother
who presented to [**Hospital3 **] with limited prenatal care and
limited known history. This was an unexpected pregnancy, and she
initially presented for TAB at which time ultrasound
estimated gestational age of 21 weeks. She then presented to
[**Hospital3 **] with premature rupture of membranes, preterm
labor, and footling-breech presentation at what would be 33-
weeks gestation based on 21-week gestation ultrasound, and was
taken for c-section.
Mother did admit to cocaine use during pregnancy, but denied
other substance abuse. Maternal toxicology screen was positive
for cocaine. Prenatal labs obtained after delivery included BT
O+/Ab-, RPR NR, RI, and HBsAg-.
Infant was delivered by C-section. Infant required PPV in
the OR with Apgars of 3 and 7, and was transferred to the
special care nursery and put on 30% oxygen [**Doctor Last Name **] with
saturations greater than 95%. An IV was started at 100 cc per
kilogram and normal saline was given to maintain adequate
blood pressures. CBC and blood culture were sent, and
ampicillin and gentamicin were administered. Erythromycin eye
ointment and vitamin K were given. The transport team arrived
at 1 hour of age, and proceded to intubation for respiratory
distress.
The transport team gave a total of 5 micrograms per kilogram
of fentanyl as well as succinylcholine for intubation, and then
started the infant on SIMV settings of 18/5 at a rate of 25. The
infant was given an additional 10 cc per kilogram of normal
saline for mean blood pressure of 29 and a single dose of Pavulon
prior to transport due to continued high activity level of the
[**Known firstname **] despite fentanyl. [**Known firstname 37958**] was transported without incident to
[**Hospital3 **].
ADMISSION PHYSICAL EXAM: Weight 1555 grams, birth weight
from [**Hospital3 **] was 1480 grams, which is 25th percentile
for 33 weeks, 50th percentile for 31 weeks. Length 44.5 cm,
15% for 33 weeks. Head circumference 28.5 cm, 15% of 29
weeks. Nondysmorphic with overall appearance consistent with
33-weeks gestation by physical exam. Anterior fontanel is
soft, open, and flat. Orally intubated with ET tube placed at
7.5 cm. Minimal intercostal retractions. Breath sounds clear,
slightly louder on right than left. Breath sounds even with
tension on a tube. Normal rate and regular rhythm without a
murmur. Two-plus peripheral pulses including femorals. Benign
abdomen without hepatosplenomegaly. No masses. Normal male
with testes high in scrotum bilaterally. Normal back and
extremities with hips deferred. Skin: Pink and well perfused,
hypotonic without spontaneous movement, status post Pavulon.
Initial chest x-ray showed lung fields quite clear. Normal
cardiothymic silhouette and normal bowel gas pattern.
HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Doctor Last Name **] remained
intubated during his 1st day of life, requiring increased SIMV
settings due to significant respiratory acidosis, attributed
primarily to sedation. He received two doses of surfactant, and
was extubated to room air on day of life two, with gases with
PCO2s in the 30s. He had no apneic events during his hospital
course and he remained on room air through the rest of his
admission.
Cardiovascular: After his initial saline boluses, he required
no further blood pressure resuscitation. UAC and UVC had been
placed on admission. UAC was removed after 24 hours. UVC was
removed on day of life 6.
Fluid, electrolytes, and nutrition: [**Doctor Last Name **] was started on 80
cc per kilogram of 10% dextrose fluid and was increased to a
total volume of 150 cc per kilogram per day by day of life 6.
He was started on enteral feeds by day of life 2 with
Premature Enfamil formula at 20 calories per ounce. He
reached full-volume feeds by day of life 7. He was advanced
on calories to 24 calorie feeds by day of life 9. Weight on
discharge was 1540 grams, and he was being fed 150 cc/kg/day of
PE 24, primarily by gavage.
GI: Phototherapy was initiated at a bilirubin level of 8.8 on
day of life 2. Peak bilirubin level was 9.0 with a direct
component of 0.3. Phototherapy was discontinued on day of
life 6 with a rebound bilirubin level of 5.6 with a direct
component of 0.3.
Hematology: Initial hematocrit was 39.9. Infant was begun on
iron supplementation.
Infectious disease: Infant was given ampicillin and gentamicin
for 48 hours after birth pending blood cultures and clinical
course. Initial CBC was unremarkable, and blood cx were
negative.
Neurology: Exam remained within normal limits. No head
ultrasounds were required given gestational age and infant's
well appearance.
Audiology: Hearing screen has not been performed at this
time. It will be done closer to discharge.
Psychosocial: [**Hospital1 18**] social work was involved with this
family. Urine toxicology screen on the infant was positive
for cocaine at [**Hospital3 **], and a 51A was filed. DSS was
involved, and has been updated throughout hospitalization.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Infant is being transferred to [**Hospital 1474**]
Hospital.
NAME OF PEDIATRICIAN: Is unknown at this time as has not
been named by the family or DSS.
FEEDS AT DISCHARGE: Premature Enfamil 24 calories per ounce
at a volume of 150 cc per kilogram per day currently. [**Doctor Last Name **]
is able to take only some of his feeds by mouth. The rest are
gavage fed. Newborn screens at this time have been normal.
DIAGNOSES ON DISCHARGE: Prematurity, hyperbilirubinemia
resolved, feeding immaturity.
Of note, the [**Known firstname **] received hepatitis B vaccine and hepatitis
B immunoglobulin immediately after birth given unknown status
of mother.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) 61635**]
MEDQUIST36
D: [**2198-5-22**] 08:12:33
T: [**2198-5-22**] 08:51:59
Job#: [**Job Number 969**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4983
} | Medical Text: Admission Date: [**2165-2-20**] Discharge Date: [**2165-3-18**]
Service: MEDICINE
Allergies:
Tramadol / Advil / Nsaids / Hydrocodone
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Colonoscopy with electrocautery of polypectomy site.
History of Present Illness:
86yo man with PMH significant for duodenal ulcer bleed, s/p
polypectomy 2 wks ago, s/p R hip arthroplasty [**11-17**], presented
with blood clots per rectum, maroon stools. He had a recent
admission in [**11-17**] for hematemesis, at which time he was found
to have a duodenal ulcer bleed, initially resolving with
embolization, but recurrent bleeding with resolution after
exploratory laparotomy, duodenotomy, oversewn ulcer, and J-tube
placement. At the time, he also had a biopsy of a liver mass and
an IVC filter placed for peripheral venous clots. In [**1-18**] he had
a colonoscopy which showed cecal polyps, Grade 1 internal
hemorrhoids, and diverticulosis of the sigmoid colon.
.
In the ED, NG lavage was negative. He denied abdominal pain.
Past Medical History:
1. Hypertension
2. Chronic obstructive pulmonary disease
3. Osteoarthritis
4. Osteopenia
5. Dementia
6. Depression
7. Status post bilateral inguinal hernia repair
8. Status post bilateral cataract surgery
9. Status post right total hip replacement
Social History:
lives in [**Hospital3 **] facility (came from [**Hospital **] rehab);
never smoked; no alcohol or IVDU; has 2 sons.
Family History:
noncontributory
Physical Exam:
T 97.6 P 109, BP 140/55, RR 18, 100% on 3L
Gen: pale elderly man lying flat in bed
HEENT: anicteric, R surgical pupil 4mm and nonresponsive, L
pupil 2mm, nonresponsive; OP clear w/ MMM, no JVD
CV: [**2-18**] holosystolic murmer at LLSB
Pulm: CTA anteriorly, no crackles or wheezes
Abd: obese, +BS, soft, NT, ND
Ext: warm, faint DP B, no edema
Neuro: able to answer most questions but mildly confused
Pertinent Results:
Admission labs:
CBC: WBC-11.2* RBC-4.01*# Hgb-10.1* Hct-30.6* MCV-76*#
MCH-25.2*# MCHC-33.0 RDW-17.4* Plt Ct-373
Diff: Neuts-78.1* Lymphs-15.4* Monos-4.9 Eos-1.5 Baso-0.1
Coags: PT-12.8 PTT-22.7 INR(PT)-1.1
Chem 10: Glucose-110* UreaN-17 Creat-0.6 Na-139 K-4.3 Cl-104
HCO3-24
Calcium-8.8 Phos-3.4 Mg-1.9
LFTs: ALT-18 AST-17 AlkPhos-128* Amylase-42 TotBili-0.1
.
More recent labs:
CBC: WBC-7.7 RBC-4.14* Hgb-11.1* Hct-33.0* MCV-80* MCH-26.7*
MCHC-33.5 RDW-17.2* Plt Ct-323
Coags: PT-13.3* PTT-22.8 INR(PT)-1.2*
Chem 10: Glucose-107* UreaN-6 Creat-0.5 Na-142 K-3.0* Cl-108
HCO3-24
Calcium-8.0* Phos-2.9 Mg-1.7
.
Imaging:
GIB study: Technically inadequate exam due to poor labeling.
This study could be repeated if necessary in 24 hours.
[**Last Name (un) **]: Diverticulosis of the sigmoid colon and distal descending
colon. Polyp in the cecum. Grade 1 internal hemorrhoids.
Brief Hospital Course:
Assessment: 86yo man with past medical history significant for
recent duodenal bleed s/p exploratory laparotomy with
duodenectomy and oversewn ulcer, s/p polypectomy 2 weeks ago,
presented with lower GI bleed thought secondary to polypectomy,
now s/p cauterization with stable hematocrit.
.
Hospital course is reviewed below by problem:
.
1. Gastrointestinal bleed: He was admitted to the MICU, where he
was thought to have a lower GI bleed. He was transfused two
units PRBCs. A GIB study was technically inadequate. He had a
colonoscopy, which showed diverticulosis of the sigmoid and
distal descending colon, a cecal polyp, and grade 1 internal
hemorrhoids. The cecal polyp was cauterized. He remained
hemodynamically stable and his hematocrits remained stable after
the procedure. He was treated with [**Hospital1 **] protonix.
.
2. Clostridium difficile infection - On [**2-25**], he was noted to
have green diarrhea. This was positive for c. diff. He was
started on a 14 day course of flagyl. By day 10, he was still
having diarrhea and began to spike fevers again. Vancomycin po
was started on [**3-6**]. He was discharged with instructions to
complete a course of PO vancomycin and Flagyl ending on [**2165-3-20**].
.
3. Hypertension - Lopressor was held secondary to GI bleed, then
restarted once he was stable with good blood pressure control,
and converted to Toprol XL prior to discharge.
.
4. Chronic obstructive pulmonary disease - The patient was
maintained on albuterol prn.
.
5. Depression - Seroquel was changed to Celexa during
hospitalization.
.
6. Nutrition - He had a speech and swallow evaluation, and was
continued on aspiration precautions. He needed observation for
meals. Medications were crushed in applesauce. He had a kosher
ground diet, with nectar thickened liquids. Tube feeds at the
time of discharge were Promote w/ fiber Full strength. He was
also started on ascorbic acid and zinc sulfate supplements to be
taken for 2 weeks, per nutrition recs.
.
7. Left thumb swelling - During the hospitalization, he was
noted to have left thumb swelling. He had no evidence of trauma,
and had no clear history of thumb swelling previously. He was
treated with a short course of colchicine, rest, elevation.
NSAIDs were not given due to his GI bleed. The rheumatology
service was consulted, who felt that he had no clear indication
of any inflammatory crystal disease, and that the thumb was not
amenable to tap. An x-ray showed no evidence of fracture. It may
have been secondary to unwitnessed minor trauma. It resolved
with conservative management during hospitalization.
.
8. Code status - full
Medications on Admission:
1. flomax 0.4mg po daily
2. dulcolax prn
3. ferrous sulfate 300mg
4. Folvite 1mg
5. colace
6. lactulose prn constipation
7. tylenol
8. Lopressor 12.5 [**Hospital1 **]
10. Seroquel 12.5mg 2pm and 8pm and prn
11. zinc ointment
12. Bacitracin
13. Beconase nasal spray [**Hospital1 **]
14. Ocean nose spray
15. MVI
16. Prevacid 30mg [**Hospital1 **]
17. thiamine
18. Albuterol nebs prn
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO BID (2 times a day).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO
BID (2 times a day) for 10 days.
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 10 days.
16. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. heparin Sig: 5000 (5000) units Subcutaneous twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
1. Lower gastrointestinal bleed
2. Coronary artery disease
3. Hypertension
4. Clostridium difficile infection
Discharge Condition:
Good; the patient is hemodynamically stable with stable serial
hematocrits.
Discharge Instructions:
Take all medications as prescribed below.
.
Please follow up with Dr. [**Last Name (STitle) 1603**] in the next week.
.
Call your doctor or go to the emergency room if you have any
lightheadedness, dizziness, large black bowel movements, red
blood in your bowel movements, loss of consciousness, nausea,
vomiting, abdominal pain, chest pain, shortness of breath, or
any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 1603**] at [**Telephone/Fax (1) 719**] to make a follow up
appointment.
Completed by:[**2165-3-18**]
ICD9 Codes: 496, 311, 4019, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4984
} | Medical Text: Admission Date: [**2156-9-23**] Discharge Date: [**2156-10-8**]
Date of Birth: [**2093-3-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2156-9-24**] right and left heart catheterization, coronary
angiogram,left ventriculogram
[**2156-9-30**] Aortic valve replacement(21 St. [**Male First Name (un) 923**] Regent mechanical
valve),Ascending aortic aneurysm resection and interposition
tube graft(28 Gelweave graft),Coronary artery bypass graft
x1(saphenous vein graft to posterior descending artery).
History of Present Illness:
This 63 year old male presented to an outside ED on [**2156-9-23**] for
4 weeks of gradually worsening dyspnea and chest discomfort and
was noted to be in heart failure. He was given ASA, sl
nitroglycerin, Bumex and Avalox. He was transferred to [**Hospital1 18**] for
futher treatment after his dyspnea improved.He underwent right
and left cardiac catheterization. He was noted to be in flutter
after DCCV. [**9-29**]. Echocardiography showed severe aortic
stenosis ([**Location (un) 109**] 0.7 cm2, mean gradient 27 mmHg, peak gradient 42
mmHg).
On catheterization he was noted to have 100% distal RCA
occlusion with left to right collaterals to distal vessel, LAD
30% proximal stenosis, otherwise diffuse disease distally with
probable distal occlusion of apical LAD. 30% stenosis of OM1.
Aortic valve with peak aortic gradient of 40 mmHg, area 0.6 cm2.
Right heart cath with PASP 51 mmHg, PCWP 23 mmHg, RVEDP 21 mmHg.
Consultation for evaluation of coronary bypass and aortic valve
replacement was obtained.
Past Medical History:
None known
no medical care in "years"
Social History:
Unemployed, lives alone in a rooming house.
-Tobacco history: none
-ETOH: ~10 drinks/wk
-Illicit drugs: none
Family History:
Brother died of CHF age 62, mother had PPM.
estranged from son
Physical Exam:
VS: T=97.4 BP=122/94 HR=127 RR=22 O2 sat=100,2L Wt: 86kg
GENERAL: WDWN male in NAD. Mood, affect appropriate.
HEENT: MMM.
NECK: Supple with JVP of [**10-12**] cm.
CARDIAC: Rapid regular rhythm, 2/6 systolic murmur at RUSB. No
S3 or S4 appreciated.
LUNGS: Appears mildly dyspneic. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. +BS.
EXTREMITIES: 2+ edema to knees, trace to mid thighs. 2+ radial
pulses.
Pertinent Results:
[**2156-9-30**] Echo Pre CPB: Mild spontaneous echo contrast is seen in
the body of the left atrium. No mass/thrombus is seen in the
left atrium or left atrial appendage. Mild spontaneous echo
contrast is seen in the body of the right atrium. No atrial
septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 15
%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. The ascending aorta is
moderately dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve is bicuspid. There is critical
aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There are bilateral pleural effusions.
The cardiac output is 2.0L/min. Dr. [**Last Name (STitle) **] was notified
in person of the results. Post CPB: The cardiac output is
4.0L/min. The patient is on an epinephrine infusion. There is a
well seated mechanical valve in the aortic position. There is a
tube graft in the ascending aorta. The visible contours of the
thoracic aorta are intact. The aortic valve has a mean gradient
of 7mmHg and no insufficiency. There is trace/mild MR, which
appears slightly improved.
The left ventricular ejection fraction is improved at 25-30%.
[**2156-10-6**] 08:30AM BLOOD WBC-7.4 RBC-3.05* Hgb-10.1* Hct-29.7*
MCV-97 MCH-33.0* MCHC-33.9 RDW-14.5 Plt Ct-252
[**2156-9-30**] 12:15PM BLOOD WBC-10.2 RBC-3.23* Hgb-11.1* Hct-31.2*
MCV-97 MCH-34.3* MCHC-35.6* RDW-14.1 Plt Ct-198
[**2156-9-23**] 01:15AM BLOOD WBC-7.9 RBC-4.32* Hgb-15.0 Hct-43.5
MCV-101* MCH-34.6* MCHC-34.4 RDW-13.7 Plt Ct-361
[**2156-10-6**] 08:30AM BLOOD PT-48.9* PTT-43.8* INR(PT)-5.3*
[**2156-10-5**] 05:24AM BLOOD PT-34.5* PTT-37.1* INR(PT)-3.5*
[**2156-10-4**] 04:24AM BLOOD PT-22.5* PTT-56.5* INR(PT)-2.1*
[**2156-10-3**] 08:27PM BLOOD PT-20.6* PTT-47.7* INR(PT)-1.9*
[**2156-10-3**] 11:42AM BLOOD PT-20.3* PTT-91.4* INR(PT)-1.9*
[**2156-10-3**] 01:30AM BLOOD PT-17.9* PTT-33.1 INR(PT)-1.6*
[**2156-10-6**] 08:30AM BLOOD Glucose-82 UreaN-23* Creat-1.0 Na-133
K-4.1 Cl-96 HCO3-29 AnGap-12
[**2156-9-23**] 01:15AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-139
K-4.3 Cl-101 HCO3-24 AnGap-18
Brief Hospital Course:
He underwent right and left cardiac catheterizations for
evaluation of his disease. He was noted to be in atrial flutter.
Echocardiography showed severe aortic stenosis ([**Location (un) 109**] 0.7 cm2,
mean gradient 27 mmHg, peak gradient 42 mmHg. Catheterization
noted 100% distal RCA occlusion with left to right collaterals
to distal vessel, LAD 30% proximal stenosis, otherwise diffuse
disease distally with probable distal occlusion of apical
LAD,30% stenosis of OM1. Aortic valve with peak aortic gradient
of 40 mmHg, area 0.6 cm2. Right heart cath with PASP 51 mmHg,
PCWP 23 mmHg, RVEDP 21 mmHg. He was referred for surgical
evaluation.
After preoperative workup, he was taken to the Operating Room
where surgery as noted was performed. See operative note for
details. He weaned from bypass on Neo-Synephrine and Propofol.
He weaned from these and was extubated on POD 1. He became very
agitated and confused, pulling out his mediastinal and right
chest tubes resulting in a pneumothorax. A right tube was
replaced due to a pneumothorax. Valium was administered for
alcohol withdrawal treatment and he his agitation subsided.
Sedation was decreased, he remained stable and CTs were removed
on [**10-5**]. Sedation was stopped on [**10-6**].
Diuresis was institued and beta blockers were resumed.
Metoprolol was changed to Carvedilol due to his low ejection
fraction. Anticoagulation with coumadin was started for
mechcanical AVR. He also experienced post-operative atrial
fibrillation and was treated with amiodarone.
As he lives alone in a rooming house and has no social support,
is anticoagulated for mechcanical AVR and recovering from
surgery, a stay at rehabilitation was deemed appropriate. He
will need an INR of 2.5-3.5 as a target. His wounds were clean
and healing well at discharge.
[**2156-10-8**] INR 2.7- needs to 2mg coumadin today.
NEXT INR draw [**2156-10-9**]
Medications on Admission:
None
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, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks: then decrease to 200mg daily.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
9. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Outpatient Lab Work
daily INR/PT until stable, then as needed
11. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Coumadin 1 mg Tablet Sig: as directed for mech AVR Tablet PO
once a day: Goal INR for mech AVR 2.5-3.5. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Acute Heart Failure
Atrial Flutter
Severe aortic stenosis
s/p Aortic valve replacement
Ascending aortic aneurysm
s/p resection of ascending aorta
Coronary artery disease
s/p Coronary artery bypass graft
alcohol abuse
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema:trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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. [**First Name (STitle) **] on [**11-1**] at 1:15 PM ([**Telephone/Fax (1) 170**])
Cardiologist: Dr. [**Last Name (STitle) **] on [**10-25**] at 9:20 AM
**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 MECH AVR/AFib
Goal INR 2.5-3.5
First draw [**2156-10-9**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2156-10-8**]
ICD9 Codes: 5849, 5119, 4254, 4280, 412, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4985
} | Medical Text: Admission Date: [**2136-4-27**] Discharge Date: [**2136-5-2**]
Date of Birth: [**2111-12-5**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
TCA overdose
Major Surgical or Invasive Procedure:
Arterial line placement
Subclavian line placement
History of Present Illness:
23 [**Last Name (un) 9232**] with history of OSA, substance abuse and 4 past SI
attempts in the past transferred from OSH for management of TCA
overdose. Per report patient ingested 3.2g of desipramine. On
arrival to OSH ED patient's EKG showed a widened QRS (130's).
She was intubated and hyperventilated and a Sodium bicarb drip
was started as well as a lipid infusion. Per report patient had
several tonic movements that were felt to represent seizure
activity. She received 16mg of ativan, and was paralyzed for
transfer with 2 mg of vecuronium. She is transferred on a
midazolam drip. Tox screen at OSH was reportedly negative. QRS
at time of transfer 116.
.
On arrival to [**Hospital1 18**] she is intubated and sedated.
Review of systems:
Not obtained as patient intubated and sedated.
Past Medical History:
Sleep apnea
Daytime fatigue
Substance abuse
Previous SI
Social History:
Report of multiple suicide attempts
- Tobacco: unknown
- Alcohol: Unknown
- Illicits: history of opiate use. Tox screen negative
Family History:
Not available
Physical Exam:
ADMISSION:
Vitals: BP:108/63 P:90 R:18 O2:98%
General: Intubated and sedated
HEENT: Sclera anicteric, ETT in place
Neuro: Pupils 3mm and reactive bilaterally OTW sedate and unable
to cooperate with exam.
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds absent,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2136-4-27**] 08:30PM BLOOD WBC-10.9 RBC-3.29* Hgb-10.9* Hct-32.0*
MCV-88 MCH-32.9* MCHC-37.6* RDW-13.1 Plt Ct-229
[**2136-4-27**] 08:30PM BLOOD PT-13.3 PTT-27.6 INR(PT)-1.1
[**2136-4-27**] 08:30PM BLOOD Glucose-108* UreaN-10 Creat-0.1* Na-138
K-4.1 Cl-102 HCO3-24 AnGap-16
[**2136-4-27**] 08:30PM BLOOD ALT-48* AST-63* LD(LDH)-565* AlkPhos-31*
TotBili-0.7
[**2136-4-27**] 08:30PM BLOOD Albumin-3.5 Calcium-7.5* Phos-3.4 Mg-2.1
[**2136-4-27**] 08:24PM BLOOD Type-ART Temp-37.2 pO2-201* pCO2-40
pH-7.45 calTCO2-29 Base XS-4
.
DISCHARGE LABS:
[**2136-4-30**] 03:13AM BLOOD WBC-5.1 RBC-3.36* Hgb-10.8* Hct-29.8*
MCV-89 MCH-32.2* MCHC-36.3* RDW-12.8 Plt Ct-140*
[**2136-5-1**] 06:20AM BLOOD WBC-4.5 RBC-3.73* Hgb-11.9* Hct-32.9*
MCV-88 MCH-31.7 MCHC-36.1* RDW-12.8 Plt Ct-183
[**2136-5-2**] 06:15AM BLOOD WBC-5.2 RBC-4.37 Hgb-13.6 Hct-38.8 MCV-89
MCH-31.1 MCHC-35.0 RDW-12.8 Plt Ct-231
[**2136-4-30**] 03:13AM BLOOD Glucose-121* UreaN-6 Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-27 AnGap-13
[**2136-4-30**] 08:21AM BLOOD Glucose-131* UreaN-8 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-26 AnGap-14
[**2136-4-30**] 08:40PM BLOOD Glucose-103* UreaN-15 Creat-0.8 Na-139
K-4.6 Cl-101 HCO3-29 AnGap-14
[**2136-5-1**] 06:20AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-135
K-4.4 Cl-101 HCO3-27 AnGap-11
[**2136-5-2**] 06:15AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-140
K-4.3 Cl-102 HCO3-30 AnGap-12
.
STUDIES:
CXR [**4-27**]:
REASON FOR EXAMINATION: Evaluation of tubes and lines position.
Portable AP chest radiograph was reviewed with no prior studies
available for comparison.
The ET tube tip is 7 cm above the carina, slightly higher than
expected, above the level of the clavicular head. The left
central venous line tip is at the level of upper SVC. The NG
tube tip is in the stomach.
Heart size and mediastinal contours are unremarkable for this
supine portable radiograph. Lungs are clear with no appreciable
pleural effusion or pneumothorax.
.
CXR [**4-28**]:
The ET tube tip is 6 cm above the carina. The NG tube tip is in
the stomach.
The right subclavian line tip is at the level of mid SVC.
Cardiomediastinal silhouette is stable. Lungs are essentially
clear. No appreciable pleural effusion or pneumothorax is seen.
.
EKG [**5-1**]
Sinus rhythm with atrio-ventricular conduction delay. Early R
wave transition. Non-diagnostic Q waves inferiorly. Compared to
the previous tracing of [**2136-5-1**] atrio-ventricular conduction
delay is now evident.
TRACING #2
Read by: FISH,[**Doctor First Name **] E.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 204 84 [**Telephone/Fax (2) 60085**] 70
Brief Hospital Course:
HOSPITAL COURSE:
Pt is a 24 YO with history of [**Hospital **] transferred from OSH for
management of TCA toxicity. She was intubated for airway
protection, and toxicology was consulted. Serial ECGs were done
with ABG's and frequent lytes. She was treated with sodium
bicarb and aggressive lyte repletion. Her QRS was prolonged, and
decreased with sodium bicarb to 106.
.
# TCA overdose: Patient was intubated and sedatied on admission
with a QRS >100 on admission to the MICU. No seizure activity
was witnessed. She was intubated for airway protection, and
toxicology was consulted. Serial ECGs were done with ABG's and
frequent lytes. She was treated with sodium bicarb and
aggressive lyte repletion. Her QRS was prolonged, and decreased
with sodium bicarb to 106. Patient was called out to the
medicine floor for further management prior to transfer to
psychiatry. On the floor she was monitored w serial EKGs and [**Hospital1 **]
lytes. She was stable on the floor and did not require
aggressive repletion of lytes. Her QRS was <100ms for >36hours
prior to discharge.
.
# Suicide Attempt: Patient has a history of depression and
previous psychiatric admission. Psychiatry consulted and
recommended restarting home dose of lamictal and trilafon.
Following medical clearance patient will be admitted to
psychiatry.
.
# Normocytic Anemia: Hematocrit on admission was 32, prior
baseline 37. All cell lines had decreased and anemia was thought
to be likely dilutional. Probable also iron deficiency anemia
given young female, however, not microcytic. Pt also with large
phlebotomizing during this admission. Fe studies suggestive of
Fe deficiency anemia. Currently 29.8 and stable. PO iron
supplementation was started in the ICU and dc'd on the floor for
constipation.
.
# Tooth pain: s/p chip in L molar after eating apple. Pt has not
had recent dental care as she lost her insurance. She complains
of mild/moderate discomfort but tolerated po intake and solid
food. Tylenol was continued for pain control and benzocaine
spray or anbesol could be applied if needed. Pt would benefit
from a dental evaluation during her psych stay if possible as
she does not have dental insurance.
.
# Tachycardia: noted on telemetry this AM. In conjunction w pt
c/o thirst and "dryness", would attribute to dehydration. Low
suspicion for PE given lack of hypoxia, pleurisy and normal
EKGs. Could also be related to ICU deconditioning however she
was intubated for only 1 day and is healthy otherwise. Pt
reports concentrated urine which supports theory of dehydration.
EKGs have been sinus rhythm. Recent TSH wnl.She was given 2L NS
boluses and observed to have appropriate oral intake of fluids.
Tachycardia resolved. Orthostatics were check and wnl - she was
ambulated and not symptomatic.
.
# substance abuse: hx of EtOH abuse (stopped [**11/2135**]) and opioid
dependence in past. Would avoid narcotics and benzos if
possible.
.
# Depression: Outpt psych Dr. [**Last Name (STitle) 174**] at [**Hospital1 11485**] Mental Health.
Recently restarted lamictal per psych recs which pt states is
helpful. Has had multiple suicidal attempts in past most
recently 1mo ago, discharged from [**Hospital1 **] 3 days prior to
admission. She was continued on home lamictal and trilafon
doses w plans to defer initiation of antidepressants until psych
facility placement. She was monitored w 1:1 sitter and section
12 in chart.
.
# Transaminitis: AST/ALT were mildly elevated on admission. The
etiology was unclear thought possibly med effect vs. viral vs.
decreased perfusion. Unclear if BP transiently low in setting of
OD. Patient's LFTs resolved to normal in ICU.
Medications on Admission:
Desipramine 100-150mg QHS
Lamictal 100mg PO daily
Trilafon 4mg PO QHS
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. perphenazine 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
3. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day as needed for constipation.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every [**6-6**]
hours as needed for anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]
Discharge Diagnosis:
TCA overdose
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a medication overdose. You
required ICU level care and needed life support until the
medication was weaned. You were transferred to the general
medicine wards for observation and additional care prior to
transfer to psychiatry.
.
Psychiatry was consulted during your stay. It was felt that you
required inpatient psychiatric treatment for your mental health
issues. Per psychiatry recommendations, the inpatient psych
facility will manage your medications and initiate
antidepressant therapy upon transfer.
.
Regarding your chipped tooth (L upper molar) you should be
evaluated by a dentist upon discharge from the psychiatric
facility or in house if possible. Since you are able to tolerate
food and drink, your tooth does not require urgent evaluation.
.
The following changes were made to your medications:
STARTED Lorazepam 0.5mg for anxiety
STARTED Miralax for constipation
STARTED nicotine patch 21mg daily
Continued Perphenazine 4mg at nighttime
Continued Lamotrigine 100mg daily
You do not need to continue the iron supplements.
.
Followup Instructions:
Please follow up with your primary care and psychiatric
physicians after discharge.
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4986
} | Medical Text: Admission Date: [**2121-4-23**] Discharge Date: [**2121-5-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
SOB, abdominal pain. In the [**Name (NI) **] Pt. was found to be in
A.flutter, cardioverted, became hypotensive/SOB. Transferred to
the CCU for further monitoring and eval for further treatment of
A.flutter.
Major Surgical or Invasive Procedure:
temporary pacer
intubation
central venous line
arterial line
History of Present Illness:
85 yo M w/ hx. of hyperlipidemia and HTN presented to his PCP
with [**Name Initial (PRE) **]/o abd pain and DOE and SOB x 2-3 days. Found to
tachycardic (140's) with RA 02 sats were 93%. Pt. reports
flu-like symptoms 2-3 weeks prior, but has otherwise been
healthy. He does not report any change in his excercise
tolerance. He can walk up to a quarter mile which has not
changed. He does report intermittent DOE over the past several
years. He also noticed his abdomen has distended and
uncomfortable since Sunday.
ROS: denies HA, chest pain, N/V. He reports constipation (small
BM this AM) and diffuse abdominal pain since Sunday. All other
ROS as above.
.
In the ED: initial VS 98.8 HR 140 BP 162/88 RR 18 02 92% RA to
96% on 4L NC
Presented with a rapid rate. Given adenosine 6mg x2, flutter
waves noted on EKG, given Dilt 20 x ?2, lopressor 10 iv, esmolol
60mg. ASA 81mg, lasix, NTG SL, NTG ointment, he was cardioverted
(DCC synchronized 50J w/fentanyl 50mcg&propofol 30mcg) with
conversion to NSR following a long pause. However, following
cardioversion he became bradycardic to the 50's and hypotensive
80/50 given 1L NS and placed on a NRB and given 1 amp of calcium
gluconate. He became hypotensive and SOB, a CXR showed failure
and he was given 120 IV lasix. In the ED his intial ABG was
7.39/23/103 with a lactate of 4.3. of He was started on a
heparin GTT and transferred to the CCU.
.
In the CCU he progressively became SOB and complained of
worsening abdominal pain, diaphoretic, appeared to go into
respiratory arrest then went into asystolic arrest, CPR was
initiated. He was given Epi x3, bicarb x2, atropine x2, he was
intubated and resuscitated after approximately 7 min of CPR.
When his pulse returned, his rhythm with a.fib/RVR of 140 with
SBP of 200's. He was given 5 IV lopressor and a temporary pacing
wire was placed by cardiology.
.
REVIEW OF SYSTEMS:
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.
Denies recent fevers, chills or rigors. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
He did report dyspnea on exertion as discussed above.
Past Medical History:
History of bladder cancer
S/P Prostatectomy
Prostatic stone
SPINAL STENOSIS
HIATAL HERNIA, W/ REFLUX
PSORIASIS
BASAL CELL CANCER
HYPERCHOLESTEROLEMIA
S/P CARPAL TUNNEL SURGERY- RIGHT.
HYPERTENSION, BENIGN ESSENTIAL
COLON ADENOMAS
Social History:
lives alone
works part time
drives independently
Family History:
Noncontributory.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 92.9 (oral) 98.9 (rectal) BP 103/70 HR 78 RR 28 O2 99RA
Gen: Elderly gentleman. Oriented x3. Mild distress from diffuse
abdominal discomfort. Can complete full sentances.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVP detected
CV: Distant heart sounds, RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
Slightly barrel chested. intermitently tachypneic, no accessory
muscle use. decreased breath sounds at the bases.
Abd: diffusely tender to palpation and distended. Hyperactive
BS. could not assess HSM. Abd aorta not enlarged by palpation.
No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
CXR: (portable [**4-23**]) IMPRESSION: Interstitial edema with small
bilateral pleural effusions consistent with CHF/volume overload.
More dense opacity within the right infrahilar region likely
represents alveolar edema; however, consolidation cannot be
excluded
and repeat radiographs are recommended.
.
LABORATORY DATA:
CK 153
Troponin 0.07
CK-MB 9
Anion GAP 15
CBC with 2 bands
Bicarb 20, crt. 1.6
Initial ABG 7.39/23/103
.
Abdominal/Pelvic CT:
1. Bilateral pleural effusions, right greater than left and
compression atelectasis.
2. Left exophytic heterogeneous renal cyst concerning for renal
cell carcinoma. MRI is recommended for further characterization.
Right intracortical hypodensity not fully characterized, could
also be evaluated with MRI.
4. Foley catheter with its balloon inflated in the prostatic
urethra. Repositioning is recommended.
5. Bilateral minimally displaced acute rib fractures.
6. Cholelithiasis without evidence of cholecystitis.
7. L3 lytic lesion just inferior to the superior endplate, could
be degenerative in nature, however, cannot rule out metastatic
disease.
8. Atherosclerotic changes.
.
TTE [**2121-4-24**]:
The left atrium is elongated. The estimated right atrial
pressure is
11-15mmHg. There is mild symmetric left ventricular hypertrophy.
The left
ventricular cavity size is normal. There is moderate to severe
global left ventricular hypokinesis (ejection fraction 30
percent) with some regional
variation (apex appears somewhat more hypocontractile than base,
and posterior wall appears somewhat more hypocontractile than
the rest of the ventricle). Right ventricular chamber size is
normal. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
MRI abdomen/pelvis [**2121-4-28**]:
1. Bilateral simple renal cyst. Exophytic left renal lesion seen
on CT scan of [**2121-4-24**] corresponds to a simple renal cyst.
2. Bilateral pleural effusions with atelectasis/consolidation.
3. Aortoiliac atherosclerosis.
Brief Hospital Course:
Hospital course: this patient is a 85M with a history of HTN and
hyperlipidemia who presents with SOB and abd pain x 3 days,
found to be in new onset A.flutter. In the ED s/p cardioversion
(50 J), pt. became hypotensive and hypoxic with a lactic
acidiosis. Soon after transfer to the CCU, he had a asystolic
arrest, he was resucitated and intubated he was extubated on
[**4-26**]. Incidentally, a CT scan of the abdomen shows a left renal
mass c/w RCC.
.
1. Respiratory/cardiac arrest: It was unclear why this occured,
possible secondary to respiratory failure and lactic acidosis.
Initially there was suspicion of sepsis due to an elevated WBC
and complaints of abdominal pain. However, abdominal workup did
not reveal a source of infection and cultures have remained
negative. The patient was in asystolic arrest for approximately
9 minutes. ACLS was initiated immediately, spontaneous rhythm
was re-established after epinephrine/atropine/bicarb were
administered. HE was intubated and a temporary pacing wire
placed. A follow up head CT did not show any evidence of
ischemic injury. The patient pulled out his temporary pacer. He
was extubated and his respiratory status was stable throughout
his stay.
.
2. Metabolic acidosis: the patient initial ABG 7.39/24/103 with
a lactic acid of 4.3. The etiology of his lactic acidosis is
unclear although it could be secondary to hypoperfusion, as the
patinet was hypotensive in the ED. Other possibilities
entertained were ischemic bowel, given the patients complaints
of abdominal pain also sepsis as discussed above. He was given
bicarb, and ventilator adjustments were made as needed. his
lactic acidosis resolved.
.
3. Presumed sepsis: Patient presented with an elevated WBC
count, was tachycardia and hypotension on admission. He was
started on empiric vanco/zosyn. However, no source was
identified, cultures remained negative and abx. were stopped.
.
4. abdominal pain: Mr. [**Known lastname 14**] c/o of [**2-23**] days of abd. pain
prior to admission. He also reports distension and constipation.
Obstruction or perforation were ruled out and a surgical
evaluation was negative for an acute abdominal process.
.
5. Left renal mass: CT shows a L renal exophytic mass with
characteristics of a RCC. However, a renal MRI for further eval
on [**2121-4-28**] showed b/l simple renal cysts.
.
6. Pump: No prior TTE on record. After his cardiac arrest, a TTE
showed left ventricle hypokinesis. his prior cardiac function is
unknown. He was started on heparin for prophylaxis against
thrombus formation and for his atrial flutter. He was
transitioned to coumadin on discharge.
.
7. CHF: pt has no known history of CHF, in the ED a CXR showed
signs consistent with failure. It is unclear if this is of acute
onset or has been undiagnosed. The pt. has an unclear hx. of
intermittent DOE. A echo showed an EF of 30%, however, this was
also in the setting of asystolic arrest. He was discharged on
standing lasix, which should be stopped by his primary care
physician as appropriate.
.
8. Rhythm: New onset atrial flutter, s/p cardioversion in the ED
at which time he converted to NSR but became hypotensive and
bradycardic. A temporary pacer was accidentally
self-discontinued by the patient. However, the patient did not
have any significant pauses since then. He was started on a
heparin drip with transition to coumadin. His INR was 2.4 on
discharge. EP was following the patient throughout the hospital
stay, they did not feel a pacemaker was indicated.
.
9. Hypertension: At home the patient was on HCTZ. As pt. was
initially hypotensive, antihypertensives were held. While
intubated, pt. became hypertensive and was started on
hydralizine iv which was transitioned to po. In addition,
lopressor was added after extubation. On discharge, his blood
pressure was well controlled with toprol xl and hydralazine. His
hydralazine should be transitioned to an ace inhibitor once his
renal failure resolves.
.
10. ARF- baseline Cr = 1.2, presented with a creatinine of [**12-28**].
Possible pre-renal [**1-24**] to poor perfusion due to hypotension.
After the cardiac arrest his creatinine rose to 4.1 due to ATN.
He continued to produce urine. His creatinine stabalized at 4.
and began to trend down, on discharge his creatinine was 3.2.
.
11. Anemia- baseline Hct of 35. Remained stable without
requirement for transfusion.
.
12. FEN: cardiac diet.
.
15. Code: Full
Medications on Admission:
VITAMIN B-12 TAB 1000 TR 1 QD
ASPIRIN TAB 81MG qday
PRILOSEC CAP 20MG CR 1 po qday
HCTZ 12.5 mg qday
TIZANIDINE HCL 4 MG TABS 1 tab po qd
CLOBETASOL PROPIONATE 0.05 % CREAM
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain for 2 weeks.
5. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
1. atypical atrial tachycardia
2. congestive heart failure, EF 30%
3. spinal stenosis
4. rib fractures
Secondary diagnosis:
History of bladder cancer
S/P Prostatectomy
Prostatic stone
SPINAL STENOSIS
HIATAL HERNIA, W/ REFLUX
PSORIASIS
BASAL CELL CANCER
HYPERCHOLESTEROLEMIA
S/P CARPAL TUNNEL SURGERY- RIGHT.
HYPERTENSION, BENIGN ESSENTIAL
COLON ADENOMAS
Discharge Condition:
stable. ambulating.
Discharge Instructions:
You presented with an abnormal heart rhythm for which you
underwent electrical cardioversion. Your hospital course was
complicated by a cardiac arrest and intubation.
- Important: on your abdominal CT, a left renal mass was noted.
Further workup of this mass showed this to be a simple cyst.
However, your primary care physician should be made aware of
this finding.
- please continue to take your medications as prescribed.
your new medications are: toprol XL, coumadin, hydralazine,
lasix
- your hydrochlorothiazide was stopped, discuss with your
primary care physician prior to restarting.
- once your kidney function normalizes your hydralazine should
be stopped and you should be started on an ACE-inhibitor to be
decided by your primary care physician
- if you again have symptoms of shortness of breath or chest
pain or other worrisome symptoms, please seek medical attention.
- please follow up with your appointments as below
Followup Instructions:
follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-24**] weeks.
[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**]
Completed by:[**2121-5-1**]
ICD9 Codes: 4280, 4275, 2762, 5849, 5119, 5180, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4987
} | Medical Text: Admission Date: [**2117-12-1**] Discharge Date: [**2117-12-7**]
Date of Birth: [**2047-12-11**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26207**] is a 69 year-old
male with a past medical history of insulin dependent
diabetes times forty five years with triopathy including a
cerebrovascular accident in the past as well as chronic
bladder infections, hypertension, hypercholesterolemia who
presented to outside hospital in [**Hospital1 1474**] on [**2117-11-30**]
with complaints of chest pain and heaviness.
Electrocardiogram changes at the [**Hospital1 1474**] Emergency Room
showed ST depressions in V5 and V6, ultimately ruled in by
enzymes. He was treated with nitropaste, Lopressor and
heparin as well as glycoprotein 2B3A inhibitors. He was
ultimately transferred on the fifth to the [**Hospital1 346**] to the Cardiac Critical Care Unit
where he was without pain.
ADMISSION LABORATORY: His admission laboratories were
significant for a white count of 9000, hematocrit 38,
platelet count 251, BUN and creatinine of 19 and .9. The
enzymes from the outside hospital for his myocardial
infarction were not available at the time of this dictation.
MEDICATIONS IN TRANSIT: Lopressor 25 mg po b.i.d., insulin
13 units NPH and 15 units in the morning and NPH 15 units in
the morning. Serax 15 to 30 mg po q.h.s. prn. Nitropaste
one inch to the chest wall q 6, Lipitor 40 mg po q.d.
Aspirin 325 mg po q day. Captopril 12.5 mg po t.i.d. and
Colace 100 mg po b.i.d.
He was ultimately brought to the Operating Room on [**2117-12-2**]
for a three vessel coronary artery bypass graft. His
preoperative catheterization on [**2117-12-1**] had showed a mild
increase to the left ventricular and diastolic pressures and
an EF of 50%, 1+ MR, right heart dominant system. The left
main coronary artery had 60% osteal stenosis. The left
anterior descending coronary artery was diffusely diseased
with a 70% proximal disease and 60% mid disease in the left
anterior descending coronary artery. The left circumflex has
a 60% proximal stenosis at the level of the obtuse marginal
one. The right coronary artery had a mid 70% lesion as well
as a distal 40% just after the posterior descending artery.
On [**2117-12-2**] he went to the Operating Room with Dr. [**Last Name (STitle) 70**]
where he underwent a three vessel coronary artery bypass
graft including a left internal mammary coronary artery to
the left anterior descending coronary artery, saphenous vein
graft to the obtuse marginal one and a saphenous vein graft
to the posterior descending coronary artery. The patient was
transported to the Post Cardiac Critical Care Unit.
Postoperatively, he was extubated on the night of surgery.
Hemodynamically he remained stable. On the morning after
surgery his laboratories were noted for a hematocrit of 28.
His BUN and creatinine was 16 and .8. He was neurologically
intact, cardiovascularly stable. His chest tubes were
removed. He was started on Lasix, Lopressor and aspirin and
transferred to the floor. By postoperative day number two he
was ambulating at a level three approximately 250 to 300
feet.
He did have issues of some low grade postoperative delirium
felt to be secondary to his narcotics and the baseline issue
of possible dementia, hypoxia, hypovolemia, bleeding,
electrolyte abnormalities and so on were ruled out
accordingly. The patient continued to work with respiratory
therapy as well as with physical therapy aggressively. He
was ambulating at a level four by the date of discharge. The
patient may be more appropriate to go to rehab and was
therefore set up for this as such.
His white count on [**2117-12-5**] was significant for 14,000
elevated from 11, hematocrit 28 and 230 for platelets.
Potassium 4.8, BUN and creatinine 23 and 1.0. His calcium,
magnesium and phosphorous were 1.08, 1.9 and 4.0, which were
repleted as needed. He had a chest x-ray, urinalysis as well
as aggressive pulmonary toilet to try to figure out the
etiology of his elevated white count on postoperative day
number three. Additionally he began to have a low grade
fever of 100.8. Subsequently the patient was placed on
Levaquin as it was felt he may have a possible urinary tract
infection and he typically was treated with Bactrim for any
evidence of a urinary tract infection. He ultimately never
spiked higher then 100.8. Cultures never grew anything.
Urine cultures were still pending at the time of discharge
and he is on Levaquin at present for a seven day course. He
was afebrile times 24 hours. On the day of discharge his
temperature was 97.7, 93 pulse and regular, blood pressure
148/70, 24 respiratory rate and sating 93% on 2 liters.
Finger sticks were mildly elevated, however, the [**Last Name (un) **]
Consult Service was working with the patient accordingly.
DISCHARGE MEDICATIONS: Lopressor 150 mg po q.a.m. as well as
100 mg po q.p.m. His h.s. NPH 16 units subQ as well as a
Humalog sliding scale with meals and 26 units of NPH in the
morning, 4 units subQ at supper. Additional medications for
this patient includes Lasix 20 mg po q.a.m., K-Dur 20
milliequivalents po q day, Captopril 12.5 mg po t.i.d.,
Percocet as needed. Colace 100 mg po b.i.d., Ranitidine 150
mg po b.i.d., aspirin 325 mg po q day, Lipitor 40 mg po q
day.
FOLLOW UP: His follow up will include a follow up
appointment with Dr. [**Last Name (STitle) 70**] one month from the time of
this dictation and discharge as well as to have a wound check
from one week from the time of discharge. He is to follow up
with his cardiologist in two to four weeks for medication
titration and overall systems review.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSES:
Status post three vessel coronary artery bypass grafting for
three vessel coronary artery disease.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2117-12-7**] 09:17
T: [**2117-12-7**] 09:16
JOB#: [**Job Number 26208**]
ICD9 Codes: 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4988
} | Medical Text: Admission Date: [**2152-12-28**] Discharge Date: [**2153-2-3**]
Date of Birth: [**2152-12-28**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Name2 (NI) 70113**] #2 is the 1605
gram product of a 31 and [**5-14**] week twin gestation pregnancy to
a 32 year-old, Gravida 1, Para 0 to 2 Mother whose prenatal
labs included blood type A positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B surface antigen
negative and GBS unknown. Pregnancy was notable for
spontaneous monochorionic, diamniotic twins with no
discordant growth noted. Pregnancy was reported uncomplicated
until yesterday when mother presented with right lower
quadrant pain. Evaluation was notable for bilateral
hydronephrosis and leukocytosis with diagnosis thought to be
nephrolithiasis but no definitively. Mother was treated with
Ampicillin and Gentamycin and Dilaudid for pain control.
Fetal status was reassuring with BBB 8 over 8 x2. The day
before delivery, in the afternoon, mother experienced PPROM
followed by preterm contractions. She was given a dose of
betamethasone at 4:30 p.m. and was started on magnesium. On
the morning of delivery, she was found to have advanced
cervical dilation with pelvic pain and was taken for elective
Cesarean section. No maternal fever was noted. At delivery,
twin #2 emerged with good tone and respiratory effort,
receiving only brief blow-by oxygen in DR. [**Last Name (STitle) **] were 8 and
9 and infant was brought to the NICU.
PHYSICAL EXAMINATION: Weight 1605 grams, 50th percentile.
Head circumference 30 cm, 50 to 75th percentile. Length 42.5
cm, 50th percentile. Vital signs: Temperature 96.5; heart
rate 150s; respiratory rate 50 to 60; blood pressure 50/75
with a map of 33. Oxygen saturation 89 to 90% in room air to
98% with blow-by oxygen. General: Well developed premature
infant, in moderate respiratory distress at rest. Active
with exam. Thin, warm, pink, no rashes. HEENT: Fontanel
soft and flat. Ears flush, nares normal. Palate intact. Neck
supple, no lesions. Chest: Poorly aerated, coarse mild to
moderate retractions. Cardiac: Regular rate and rhythm. No
murmur, femoral pulses 2+. Abdomen soft, no
hepatosplenomegaly. No masses. Three vessel cord, quiet
bowel sounds. Genitourinary: Normal premature male. Testes
descended. Anus patent. Extremities, hip, back normal.
Neuro: Normal tone and activity. Intact moro and grasp.
HOSPITAL COURSE:
1. Respiratory: On the day of birth, baby was placed on
nasal [**Name (NI) **] which he stayed on until day of life 3 when
he was transitioned to room air. He has been stable on
room air since that time. He had some apnea of
prematurity that was treated with caffeine until day of
life 18.
2. Cardiovascular: Baby has had stable blood pressures, has
never needed pressors or boluses since birth and has been
noted to have a soft intermittent murmur that has not
been heard for the past couple of days prior to
discharge.
3. Fluids, electrolytes and nutrition: Baby was started
n.p.o. on IV fluids and started on feeds on day of life 2
and was advanced as tolerated. He is currently on ad lib
feeds of breast milk 24 with NeoSure added or NeoSure 24
formula. He has been growing well. His weight on day of
discharge was 2520g.
4. Gastrointestinal: Baby had a maximum bilirubin of 7.8 on
day of life 3 and was on phototherapy for 4 to 6 days and
has had no bilirubin issues since that time.
5. Hematology: At birth, baby's hematocrit was 44.5 with
normal platelets at 329. He was started on iron on day
of life 16 and continues on that currently. He was also
started on a multi-vitamins on day of life 26 which has
since been discontinued. His most recent hematocrit was
on [**1-22**]. It was 30.3 with a retic count of 1.8.
6. Infectious disease: At birth, baby was placed on
Ampicillin and Gentamycin for rule out sepsis which was
discontinued after 48 hours. On day of life 4, there was
a rule out sepsis as well with a question of nec with a
bilious spit and he was placed on Vancomycin and
Gentamycin for 48 hours at that time. Everything was
negative. His brother contracted RSV virus
in the unit here. This baby has been tested negative for RSV
twice. The last negative was on
[**1-29**]. He has no nose drainage, wheezing or
retractions, and has has mild nasal congestion.
7. Neurology: The baby has never had any neurologic issues.
HUS on [**1-5**] and [**1-23**] were both within normal.
8. Sensory:
Audiology: Hearing screen passed both ears.
Ophthalmology: Eyes examined most recently on [**1-15**]
revealing immaturity of the retinal vessels but no ROP as of
yet. A follow-up examination should be scheduled 3 weeks from
previous exam on [**1-15**] with Dr. [**Last Name (STitle) **].
CONDITION ON DISCHARGE: Excellent.
DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: [**Hospital **] Pediatrics in
[**Location (un) **].
CARE RECOMMENDATIONS:
1. Feeds at discharge: We recommend continuing NeoSure 24
or breast milk 24 for optimal growth.
2. Medications: Baby continues on iron 2 mg/kg per day and
multi-vitamins.
3. Car seat position screening: Baby was tested in a car
seat position test and passed that on [**2-1**].
4. State newborn screening: The baby had state newborn
screens that were normal.
5. Immunizations received:
Baby received [**Name2 (NI) 38801**] vaccination on [**1-26**] and hep-B
vaccination on [**2-1**].
1. Immunizations recommended:
(a) [**Month (only) 38801**] RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria: (1) Born at less than 32 weeks;
(2) Born between 32 weeks and 35 weeks with two of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease.
(b) Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: Scheduled/recommended:
1. Baby will follow-up with PCP [**Last Name (NamePattern4) **] 2 days.
2. EI has been consulted and VNA will come to the home.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31759**], [**MD Number(1) 56662**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2153-2-2**] 14:32:16
T: [**2153-2-2**] 15:14:56
Job#: [**Job Number 70114**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4989
} | Medical Text: Admission Date: [**2163-10-20**] Discharge Date: [**2163-10-25**]
Date of Birth: [**2100-3-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI (upon transfer from ICU to floor): Mr. [**Known lastname **] is a 63 year
old Male with Type 2 DM w/ complications, hypertension,
hyperlipidemia, CKD stage 3, hypothyroidism, recently admitted
for mild hyperosmolar non-ketotic state who p/w N/V,
light-headedness, and malaise. Patient states that he had
non-bilious, non-bloody emesis that lasted less than 24 hours
and resolved prior to his presentation to ED. States that he did
not feel right and decided to come to ED. Denies sick contacts,
recent illness, diarrhea, chest pain, SOB, fevers, chills, or
abdominal pain. States that he misses a dose of Insulin
approximately once per week but is otherwise good about taking
his meds on daily basis as prescribed. However, PCP notes
indicate that non-adherence is more long-standing, and they are
concerned for early onset dementia.
Initial vital signs in ED: 98.3 85 135/68 16 100%. Labs notable
for: Na 115, Cr 3.0, AG 20, serum acetone negative. Urine: Na
15, trace ketone, LE/nit/WBC neg. CXR negative. Started on an
Insulin gtt for presumed DKA and admitted to the ICU. Quickly
weaned off Insulin drip overnight and now on Humalog 75-25 20U
[**Hospital1 **]. Na improved to 131 with normal saline. Feels much better.
No complaints at this time.
Past Medical History:
Type 2 DM for >20 years- Insulin dependent. Last HbA1c is 8.5%
in [**2163-8-10**].
Benign Hypertension
Hypercholesterolemia.
CKD Stage 3/diabetic nephropathy.
Hypothyroidism
Social History:
retired cab driver, lives alone and is independent in his ADLs,
has children that live in [**Location (un) 86**], denies tobacco/EtOH/illicits
Family History:
father died of lung CA, denies known DM or CAD
Physical Exam:
On Admission:
Vitals: T: BP:123/79 P:87 R: 18 O2: 100%RA
General: Alert, orientedX3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: A+0x3 with impression of mild cognitive deficit, motor
[**4-21**] throughout, preserved sensorium, normal cranial nerves.
Pertinent Results:
[**2163-10-22**] 06:45AM BLOOD WBC-7.2 RBC-4.17* Hgb-12.8* Hct-36.0*
MCV-86 MCH-30.7 MCHC-35.6* RDW-13.2 Plt Ct-279
[**2163-10-20**] 03:25PM BLOOD WBC-5.7# RBC-4.30* Hgb-13.2* Hct-36.8*
MCV-86 MCH-30.8 MCHC-36.0* RDW-12.6 Plt Ct-297
[**2163-10-23**] 06:35AM BLOOD Glucose-165* UreaN-40* Creat-3.1* Na-131*
K-4.5 Cl-102 HCO3-22 AnGap-12
[**2163-10-22**] 06:45AM BLOOD Glucose-155* UreaN-35* Creat-2.8* Na-130*
K-5.1 Cl-100 HCO3-20* AnGap-15
[**2163-10-21**] 05:17AM BLOOD Glucose-98 UreaN-29* Creat-2.8* Na-131*
K-4.4 Cl-100 HCO3-21* AnGap-14
[**2163-10-20**] 11:33PM BLOOD Glucose-174* UreaN-32* Creat-2.7* Na-122*
K-4.3 Cl-95* HCO3-18* AnGap-13
[**2163-10-20**] 08:15PM BLOOD Glucose-243* UreaN-35* Creat-2.8* Na-123*
K-4.2 Cl-93* HCO3-17* AnGap-17
[**2163-10-20**] 03:25PM BLOOD Glucose-455* UreaN-37* Creat-3.0* Na-115*
K-3.9 Cl-82* HCO3-17* AnGap-20
[**2163-10-20**] 11:33PM BLOOD ALT-11 AST-15 LD(LDH)-188 CK(CPK)-78
AlkPhos-118 TotBili-0.6
[**2163-10-21**] 05:17AM BLOOD CK-MB-3 cTropnT-0.01
[**2163-10-20**] 11:33PM BLOOD CK-MB-3 cTropnT-0.02*
[**2163-10-20**] 03:25PM BLOOD cTropnT-0.04*
[**2163-10-23**] 06:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
[**2163-10-20**] 11:33PM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.1*
Mg-1.9
[**2163-10-21**] 05:17AM BLOOD VitB12-1897* Folate-8.4
[**2163-10-20**] 03:25PM BLOOD Acetone-NEGATIVE Osmolal-271*
[**2163-10-20**] 08:15PM BLOOD TSH-5.5*
[**2163-10-21**] 05:17AM BLOOD Cortsol-19.3
[**2163-10-20**] 08:19PM BLOOD Glucose-224* Na-122* K-4.2 Cl-93*
[**2163-10-20**] 06:14PM BLOOD Lactate-2.4*
[**2163-10-20**] 06:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2163-10-20**] 06:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2163-10-20**] 06:00PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2163-10-20**] 10:42PM URINE Hours-RANDOM Glucose-839 UreaN-195
Creat-34 Na-15 K-6 Cl-13
[**2163-10-20**] 10:42PM URINE Osmolal-183
[**2163-10-20**] 11:33 pm MRSA SCREEN
**FINAL REPORT [**2163-10-23**]**
MRSA SCREEN (Final [**2163-10-23**]): No MRSA isolated.
[**2163-10-21**] 5:17 am SEROLOGY/BLOOD CHEM# [**Serial Number 24111**]V [**10-21**].
**FINAL REPORT [**2163-10-24**]**
RAPID PLASMA REAGIN TEST (Final [**2163-10-24**]):
NONREACTIVE.
Reference Range: Non-Reactive.
ECG Study Date of [**2163-10-20**] 7:57:14 PM
Sinus rhythm. Compared to the previous tracing of [**2163-9-21**] the
inferolateral ST segment changes previously recorded persist
without diagnostic interim change. Clinical correlation is
suggested.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 144 90 360/412 59 -18 -56
CHEST (PA & LAT) Study Date of [**2163-10-20**] 5:01 PM
IMPRESSION: Stable chest x-ray examination with no acute
pulmonary process
identified.
CT HEAD W/O CONTRAST Study Date of [**2163-10-21**] 10:13 AM
FINDINGS: There is no evidence of hemorrhage, edema, masses, or
mass effect. The ventricles and sulci are normal in size and
configuration. There are subcortical and periventricular white
matter hypodensities, consistent with small vessel ischemic
disease. There is evidence of old lacunar infarcts in the
bilateral basal ganglia. No fractures are identified. The
visualized portions of the paranasal sinuses and mastoid air
cells are clear. IMPRESSION: No acute intracranial process.
Brief Hospital Course:
## Type 2 Diabetes Uncontrolled with Diabetic Ketoacidosis,
Hyperosmolor state:
The patient was found to be hyperglycemic with BS of 450 and an
AG of 16 on presentation to the ED. Also with glucosuria and
trace ketonuria. Initial lactate 2.4. Was given 2L of IVF and
started on an insulin drip. The patient's BS improved and his AG
began to close. Was transferred to the MICU. On arrival to the
MICU, his AG was 13. Insulin drip was rapidly weaned off and
transitioned to half of home Insulin dose. Repeat chemistries
returned with AD < 12 and the drip was stopped. Fingersticks
were elevated, so his Insulin 75-25 mix was increased to 30U
[**Hospital1 **]. On further workup, he was noted to be very unfamilliar with
his insulin regimen, and there were serious concerns about his
ability to self manage. An OT consult and geriatrics consult
were obtained, who noted him to be quite demented with inability
to handle complex tasks. He was changed to glargine and ISS
prior to discharge, and some up titration, further titration to
be continued at the [**Hospital1 1501**].
# Hyponatremia:
The patient presented with a sodium of 115 (121 corrected).
Most likely etiology is hypovolemic hyponatremia in the setting
of dehydration from vomiting and hyperosmolar diuresis. Has had
hyponatremia previously with prior episodes of DKA/HONK which
have corrected. The patient's sodium improved to 123 (124
corrected) with IV fluids in the ED. Upon transfer to floor, Na
was already up to 131 with normal saline. This appears to be his
baseline
# Acute Renal Failure on chronic kidney disease stage 3:
- Baseline Cr ~2.5 and was 3.0 on admission. Most likely
partially pre-renal in the setting of DKA. Repeat Cr after
receiving IV fluids was 2.8, which appears to be a new baseline
for him.
# Diabetic Neuropathy
He is quite instable on his feet due to diabetic neuropathy, and
our PT service evaluated him, feeling he would benefit from
rehab. He is a fall risk.
# Abnormal ECG:
Down-sloping ST-depressions and biphasic T-waves were noted,
which are more prominent than on prior tracings. Similar changes
were noted in the past on stress testing and during illness.
MIBI was normal in [**2160**]. Had minimal troponin leak, which
trended down within 24 hours. Given his numerous risk factors
may have underlying CAD, he should be considered for outpatient
stress test.
# Multiinfarct Dementia:
Patient was suspected to have mild cognitive impairment in the
setting of his med non-adherence. Thus, a dementia work-up was
initiated in the ICU. B12, Folate were normal. TSH was slightly
elevated at 5.5 (for being on therapy). CT head showed evidence
of small-vessel ischemic disease but was otherwise unremarkable.
Further work-up was initiated by the OT and geriatrics teams;
his MOCA score was 14/30 demonstrating marked dementia; further
OT questions such as "what would you do in case of a kitchen
fire" demonstrated lack of home safety ("talk with a friend",
and with prompting would call "999"). He should also not be
driving.
# Hypothyroidism:
TSH was found to be 5.5, but there was a question as to whether
or not he takes his medication daily, even though patient claims
to do so. Therefore, he was continued on his home dose of
Levothyroxine.
# Benign Hypertension:
Held lisinopril in the setting of [**Last Name (un) **] and was later restarted.
Atenolol was switched to Metoprolol given that Atenolol has
decreased excretion in CKD since it is water-soluble.
# Hyperlipidemia:
Continued home statin.
Full Code
Family Contact/Health Care Proxy: Duaghter Miata [**Known lastname **]: Phone:
[**Telephone/Fax (1) 24112**] Other Phone: [**Telephone/Fax (1) 24113**]
Medications on Admission:
Synthroid 75mcg daily
Omeprazole 20mg daily
Atenolol 37.5mg daily
ASA 81mg daily
Lisinopril 10mg daily
Lovastatin 40mg QHS
Gabapentin 300mg [**Hospital1 **]
Testosterone 50 mg/5 gram (1 %) Gel TD daily
Miralax [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Senna 8.6mg [**Hospital1 **]
Bisacodyl 5mg daily PRN
Humalog Mix 75-25 45U [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
5. lovastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*45 Tablet(s)* Refills:*0*
8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous once a day.
10. insulin lispro 100 unit/mL Cartridge Sig: Sliding Scale
Humalog Subcutaneous QACHS: See Attached.
11. testosterone 1 %(50 mg/5 gram) Gel in Packet Sig: One (1)
packet Transdermal once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location **] center [**Location (un) **]
Discharge Diagnosis:
Hyponatremia
Acute renal failure
CKD Stage 3/Diabetic Nephropathy
Type 2 Diabetes Uncontrolled with Hyperosmolar State
Diabetic Ketoacidosis
Dementia - Multiinfarct
Hypothyroidism
Hyperlipidemia
Benign Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to treat high blood sugar and low sodium. The
high blood sugar was treated with an Insulin drip in the
Intensive Care Unit (ICU). After this was stopped, you were
restarted on the Insulin you take at home.
You were evaluated by our occupational therapy and geriatrics
services, who feel you are not safe to manage your medications
at home, and will be going to a facility.
Followup Instructions:
You should make an appointment with your primary care [**First Name8 (NamePattern2) **]
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 798**]
You should also make an appointment with Dr. [**Last Name (STitle) **] at [**Last Name (un) **]
[**Telephone/Fax (1) 3402**]
ICD9 Codes: 5849, 2761, 3572, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4990
} | Medical Text: Admission Date: [**2192-5-7**] Discharge Date: [**2192-5-10**]
Date of Birth: [**2137-7-15**] Sex: M
Service: MEDICINE
Allergies:
Crestor
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Carotid stenosis
Major Surgical or Invasive Procedure:
L and R heart catheterization
R carotid catheterization and stenting
History of Present Illness:
This 54 year old man with a history of hypertension,
hyperlipidemia and diabetes who is was admitted for scheduled
cardiac catheterization and stenting of 99% occluded right ICA,
which was noted during pre-op eval for aortic stenosis repair.
Recent relevant history includes dx of severe AS (valve area of
0.7cm2 and mean gradient 60) in [**9-21**], after auscultation of
aortic murmur. Other than fatigue, he has had no symptoms
suggestive of aortic stenosis. Subsequent noninvasive testing
in [**1-21**] showed critical right internal carotid stenosis, and
moderate left internal carotid stenosis. Pt admitted to [**Hospital1 1516**]
team for cardiac cath & stenting of carotid.
Past Medical History:
1. HTN: treated, range 150s/90s
2. Type 2 IDDM: dx'd [**2185**], insulin added to oral agents 2 months
ago
3. Metabolic Syndrome: Obese (5'7" and weighs 235 lbs with
mostly abdominal obesity), dyslipidemia
4. Remote history of depression and anxiety.
5. Surgical repair of torn L meniscus
6. Poor dentition: scheduled for tooth extraction
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
Social History:
Social history is significant for no current tobacco use; chewed
tobacco for 23 years and quit 6 months year ago. He consumes
about 4 drinks a week. No h/o illicit drugs. He walks as a
form of exercise averaging 4 hours a week. He works as a train
mechanic for the [**Company 2318**]. He is married with 2 children.
Family History:
His son was diagnosed with HTN at 28. His daughter has type I
DM. Mother with h/o diabetes and COPD. Father committed
suicide. H/o of CAD and CVA on both sides.
Physical Exam:
On admission
VS - T 98.4, BP 124/79, P 76, R 18, O2 sat 96% RA
Gen: Middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, + carotid bruit b/l L>R
CV: RRR, 3/6 systolic ejection murmur loudest at RUSB.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: BS normoactive. Soft, NTND. No HSM palpated.
Ext: R cath site clean with no hematoma visible, no femoral
bruit.
Skin: No stasis dermatitis, no ulcers.
Pulses: Right: Femoral 2+, DP 2+; Left: Femoral 2+, DP 2+.
Pertinent Results:
[**2192-5-8**] 07:44AM
WBC-7.2 RBC-4.52* Hgb-14.4 Hct-40.0 MCV-89 MCH-31.9 MCHC-36.0*
RDW-12.9 Plt Ct-136*
Glucose-158* UreaN-25* Creat-1.1 Na-136 K-4.2 Cl-97 HCO3-28
AnGap-15
EKG performed on [**2192-5-7**] demonstrated: SR at 70 bpm with nl
axis/intervals, LVH.
Cardiac Cath performed on [**2192-5-8**] demonstrated:
1. Coronary arteries are normal.
2. Severe aortic stenosis by echo ([**Location (un) 109**] 0.75 cm2).
3. Severe stenosis involving the right internal carotid artery
(string
sign). The left internal carotid demonstrated a 50% stenosis
with brisk
flow that cross filled the right hemisphere.
Brief Hospital Course:
Pt is a 54 yo male with a PMH of HTN, dyslipidemia, DM, severe
AS & R carotid stenosis who presented for cardiac catherization
and stenting.
Carotid stenosis: Cardiac cath did not show any flow limiting
coronary lesions, but the R internal carotid was deemed 99%
occluded and the left, 50%. There was a robust cross filling to
the right hemisphere by left-sided collaterals. Cardiology,
Behavior Neurology, and Vascular Surgery discussed management of
R carotid stenosis with patient. A decision was made to pursue
R carotid stenting on [**2192-5-8**] by Vascular Surgery with
Cardiology. Post-procedure, antihypertensives were held in light
of pt's low-normal BP. Pt was given a Plavix load. The right ICA
was successfully stented and pt was admitted to Cardiac Care
Unit for observation. Pt was started on home meds of ASA (325
mg), plavix, and Dopamine drip post-op. Statins were not given
due to a h/o drug reaction (myositis). Pt continued to remain
asymptomatic, and he was successfully weaned off of Dopamine on
[**2192-5-9**]. Heparin drip was also discontinued on [**5-9**].
Aortic stenosis: The cath once again showed severe aortic
stenosis (0.75 cm2). The patient was scheduled for outpatient
appointment with CT surgery to schedule AV replacement. He will
need dental clearance for dental procedure scheduled before the
surgery.
Hypertension: The patient's outpatient antihypertensives (HCTZ,
Carvedilol, Lisinopril) were held before the stenting procedure
on [**5-8**] due to low-normal BP as above. They were held on
discharge as well.
DM: Oral hypoglycemics were held. Pt was continued on his
outpatient Glargine dose with Humulog sliding scale.
Medications on Admission:
Aspirin 81 mg po daily
Plavix 75 mg po daily (started [**5-4**])
HCTZ - dose uncertain
Lisinopril 40 mg po daily
Carvedilol 3.125 mg po qAM, 6.25 mg po qHS
Metformin 1000 mg po bid, 500 mg po with lunch
Glipizide 20 mg [**Hospital1 **]
Glargine 16 U qHS
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
UNTIL [**2192-6-8**] only.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours as needed for constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain: not to exceed more than 4
grams a day. .
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Plus 500 mg at lunch time. Take as you were before admission to
hospital.
7. Glipizide 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
8. Insulin Glargine 100 unit/mL Solution Sig: One (1) 18 units
Subcutaneous once a day: Return to home insulin regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Right carotid stenosis [stenting on [**2192-5-9**]]
2. Critical aortic stenosis
Secondary:
1. Diabetes
2. Hypertension
3. Metabolic syndrome
4. Sleep apnea
5. Poor dentition
Discharge Condition:
Asymptomatic, afebrile, and hemodynamically stable.
Discharge Instructions:
You came to [**Hospital1 69**] for a scheduled
cardiac catheterization and right carotid stenting. The
arteries supplying your heart were normal. A stent was placed
in your right carotid artery.
Your aortic valve area was confirmed to be critically tight on
cardiac cath. You will require aortic valve surgery as
discussed with Cardiothoracic Surgery.
It is important that you continue to take Aspirin and Plavix
after your stenting. Please do not stop these medications
unless Dr. [**Last Name (STitle) 911**] or your heart surgeon tell you to do so.
Stopping these medications, particularly Plavix may lead to
blockage of your stent.
Please do not take your blood pressure medications
(hydrochlorothiazide, lisinopril, carvedilol), until you are
instructed to restart them.
Please keep all of the follow up appointments.
If you develop chest pain, shortness of breath or any other
concerning symptoms, please call your primary care doctor or go
to the nearest Emergency Department.
Followup Instructions:
Follow-up Instructions:
You are scheduled for an outpatient appointment with
Cardiothoracic Surgery in order to discuss and schedule your
aortic valve repair surgery. You will also need dental
clearance before your dental procedure. The appointment is
scheduled for [**2192-5-17**] at 1:15 with
[**Name6 (MD) **] [**Name8 (MD) 6144**], MD. Phone:[**Telephone/Fax (1) 170**]
You have an appointment at the VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2192-6-6**] 8:00. You are to see [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD after
the vascular lab appointment. Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2192-6-6**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2192-5-11**]
ICD9 Codes: 4241, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4991
} | Medical Text: Admission Date: [**2154-10-26**] Discharge Date: [**2154-10-30**]
Date of Birth: [**2078-4-11**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
1. chest tube
2. ventilator
History of Present Illness:
76 yo m hx of COPD and asthma, and prior spontaneous
pneumothorax was transferred from [**Location (un) 620**] ER. Pt seen there with
SOB and resp distress. He was treated with Solu-Medrol 150ml IV
x 1 and nebs. Then CXR showed a right pneumothorax. Pt was
intubated with a 7.5 tube and a 24-chest tube was placed. He was
transferred from OSH due to need for chest tube care. There was
no hx of trauma. He was placed on a propofol gtt for sedation.
.
Per his son, pt has been stressed and he is concerned about him
being depressed. He talked to him on the phone yesterday
afternoon. The pt had a cough and increased congestion which he
thought was allergies, but the son was concerned that he was
down playing his respiratory symptoms.
.
In the ER, he had initial VS of 82, 115/76, 16, 100% on FIO2 of
100%. He had a CXR showing ET tube and chest tube placement. He
has access with PIV 18 x 2. VS on transfer to floor were HR 82
BP 112/68 RR 16 100% fio2 of 100% temp 98.8. Propofol was at
30mcg/min.
.
On the floor, pt was able to follow commands. Had no pain.
Unable to complete ROS.
Past Medical History:
-Hx of Left sided pneumothorax, failed chest tube tx, and
required VATS left upper lobe and left lower lobe bleb and
bullectomy followed by parietal pleurectomy and chemical
(doxycycline) pleurodesis in [**2152-10-24**]
-Afib
-HTN
-COPD, 29% FEV1, Diffusion capacity 71%, severe obstruction
-Asthma
-Right inguinal hernia repair [**2148**]
-Left incarcerated indirect inguinal hernia repair with mesh and
plug [**2153**]
Social History:
Lives alone. Was a pipe/cigar smoker x 53 years, quit many years
ago per son. [**Name (NI) **] ETOH.
Family History:
non-contributory
Physical Exam:
On admission
Vitals- T: 96.1 BP: 123/69 P: 81 R: 23 O2: 100%
Gen- Intubated, NAD, able to follow commands
HEENT-OP unable to visualize due to ET tube
NECK-supple, no LAD
CHEST-some tenderness at chest tube site, CTA in anterior
fields, a soft rub sound at chest tube site
CV-rrr, no murmur, 2+ radial pulses
ABD-soft, NT, ND, +BS, no HSM
EXT-1+ pitting edema 1/3 up calves, warm ext
NEURO-Able to responded to commands, moves all extremities,
opens eyes
SKIN-no rashes visible
On discharge
Vitals- T: 96.1 BP: 123/69 P: 81 R: 24 O2: 97 2LNC, amb sat 91%
RA
Gen- AOx3, NAD
HEENT-OP w/o pharyngeal erythema
NECK-supple, no LAD
CHEST-bandaged CT site. b/l symmetric BS with end-exp wheezes
throughout
CV-rrr, no murmur, 2+ radial pulses
ABD-soft, NT, ND, +BS, no HSM
EXT-1+ pitting edema 1/3 up calves, warm ext
NEURO-Able to responded to commands, moves all extremities,
opens eyes
SKIN-no rashes visible
Pertinent Results:
On admission:
Lactate:1.8
UA with Pro 100, Ket 15, Nit negative, bld lrg, micro pending
ABG- 7.27/49/323
Trop-T: 0.10
146 111 19
-------------< 137
3.9 25 0.9
CK: 985 MB: 39 MBI: 4.0
WBC 17.1
plts 216
hct 43.7
N:94.0 L:2.3 M:3.2 E:0.1 Bas:0.4
PT: 11.9 PTT: 21.7 INR: 1.0
.
Micro:
blood and urine cx pending
.
Images:
CXR
right chest tube in place, ET tube in place, pneumothorax
resolved
.
EKG:
NSR at rate of 74, R prime in V2, Q wave in lead III only, wide
P wave indicating likely some left atrial enlargement
On discharge:
[**2154-10-30**] 07:05AM BLOOD WBC-8.6 RBC-4.39* Hgb-13.4* Hct-38.3*
MCV-87 MCH-30.6 MCHC-35.1* RDW-14.3 Plt Ct-242
[**2154-10-29**] 06:53AM BLOOD Neuts-75.0* Lymphs-16.5* Monos-6.4
Eos-1.7 Baso-0.4
[**2154-10-30**] 07:05AM BLOOD Glucose-100 UreaN-16 Creat-0.7 Na-143
K-3.5 Cl-107 HCO3-28 AnGap-12
Brief Hospital Course:
76 y.o. M with hx of COPD and prior left pneumothorax, now
presenting at OSH with respiratory distress and found to have
right pneumothorax, s/p intubation and chest tube.
1. Respiratory Distress/Pneumothorax: Pt has long hx of severe
COPD and prior hx of pneumothorax, placing pt at risk for
spontaneous pneumo. Also there is some concern for recent
exacerbation and increased coughing, which may have caused his
pneumo. Chest tube is in place and on suction with resolved
pneumothorax on recent CXR. The patient was extubated on [**10-27**]
without complications. IP was consulted for management of chest
tube. Chest tube placed to wall suction. Serial XRays followed.
Pt was transferred to the medicine service on [**10-28**]. The Chest
tube was to water seal without air leak for 24 hours and then
pulled after chest xray confirmation of no PTX. Post Chest tube
films immediatedly and 12hrs after d/c of chest tube again
showed resolution of pneumothorax. Antibiotics were restarted
2. COPD/asthma hx: Pt has hx decreased lung function with
obstructive disease. Per report of son pt had increased cough
and SOB at home, this is concerning for a COPD exacerbation.
Possible infection, since WBC is elevated to 17. However no
clear fevers. Had Solu-Medrol 125mg at OSH today. Initially,
started azithromycin but stopped this after no s/s of infection.
Placed on albuterol and ipratropium nebs standing. Started pt's
Symbicort.
3. Demand Ischemia: Mildly elevated troponin and elevated CK.
EKG without concerning changes for ACS. Patient likely had
demand ischemia from respiratory distress. Ruled out MI with CE
x 3.
4. Afib: EKG today in sinus. Restarted diltiazem.
5. Hypertension: Confirmed medication and restarted diltiazem.
6. Possible UTI: UA mildly positive. F/u urine culture. Held off
on abx treatment.
Code: confirmed full, per HCP
Communication: [**Name2 (NI) **]
[**Name (NI) 3508**] [**Name (NI) **] [**Name (NI) 51305**] [**Telephone/Fax (1) 51306**]
Medications on Admission:
Combivent 2puffs QID
Diltiazem ER 300 mg daily
albuterol 2 puffs QID
Lorazepam 0.5 mg po BID prn
Furosemide 20 mg po daily
Symbicort 160/4.5
theophylline ER 400 mg po BID
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Theophylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Pneumothorax
Secondary diagnosis:
1. COPD/Asthma
2. Atrial fibrillation
Discharge Condition:
He was back at baseline breathing status on room air at time of
discharge with no PTX on chest x-ray.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Location (un) 620**] after you were
intubated and found to have a collapsed lung on your right side.
the collapsed lung was thought to be a rupture of a bleb after
coughing, which you have had on your right side in the past. A
chest tube was placed in [**Location (un) 620**] to re-expand the lung. With us
your breathing was monitored closely and you were place on your
home breathign medications. You also had labwork that showed no
infection in your urine but did show some probably chronic
infection in your lungs, related to your COPD. When your chest
tube slowed in the amount it was draining and it showed no leak
in your lungs for 24 hours you had it removed and chest x-ray
was done to confirm that your lung was appropriately expanded.
Medication Changes:
None
Please see your PCP or go to your local emergency department if
you experience shortness of breath, increase in cough or sputum,
fevers, chest pain, or any other symptoms that concern you.
Followup Instructions:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22882**]
Specialty: PCP
Date and time: Tuesday, [**11-5**] at 1:00pm
Location: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3862**]
Phone number: [**Telephone/Fax (1) 28634**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4992
} | Medical Text: Admission Date: [**2187-10-1**] Discharge Date: [**2187-10-6**]
Date of Birth: [**2119-4-19**] Sex: M
Service: CSURG
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain on exertion
Major Surgical or Invasive Procedure:
CABG X 3
History of Present Illness:
68 y/o male w/angina for 5 years prior to admission, recent
increase in symptoms, with decreased exercise tolerance. Had +
ETT, followed by cardiac catheterization which revealed 40% LM,
60-70% LAD, 70 % Cx, and diffuse, mild RCA disease, LVEF 59%.
He was admitted on [**2187-10-1**] for CABG.
Past Medical History:
Type 2 DM
sleep apnea
prostate cancer (s/p prostatectomy)
hypercholesterolemia
s/p penile implant
s/p appy
s/p bilat hernia repairs
Social History:
retired engineer
married, lives with wife
[**Name (NI) **]. ETOH (few per week)
remote smoker (quit 40 years ago)
Family History:
non-contributory
Physical Exam:
pulse 63, bp 176/104 (pre-op), physical exam entirely WNL on
admission
pre-op labs unremarkable.
Pertinent Results:
[**2187-10-6**] 09:15AM BLOOD WBC-8.4 RBC-3.48* Hgb-10.8* Hct-31.4*
MCV-90 MCH-31.0 MCHC-34.3 RDW-12.5 Plt Ct-321
[**2187-10-6**] 09:15AM BLOOD PT-13.0 PTT-24.0 INR(PT)-1.1
[**2187-10-3**] 06:58AM BLOOD PT-12.7 INR(PT)-1.0
[**2187-10-6**] 09:15AM BLOOD Glucose-157* UreaN-13 Creat-0.8 Na-140
K-4.2 Cl-101 HCO3-28 AnGap-15
Brief Hospital Course:
To OR on day of admission ([**10-1**]), underwent CABG X 3 (LIMA >
LAD, SVG > OM, SVG > Diag) by Dr. [**Last Name (STitle) **]. Extubated day of
surgery.
Transferred from ICU on POD # 1, went into rapid AFib on POD #1
(v. rate 120's), treated with IV amiodarone, transitioned to PO
amiodarone, lopressor increased, converted back to NSR the
following day, but went back into AF (110-120's) again on POD
#3. Coumadin started. Pt. has since converted back to NSR
(70's).
Pt. has progressed well from a PT standpoint, ambulating
independently. BP has been a bit more elevated with increased
activity. He received captopril 50mg once this morning,
lisinopril 20 mg this afternoon, and should start lisinopril 40
mg po QD in the am.
PE:
neuro: intact
pulm: lungs CTA bilat
cor: RRR
abd: benign
sternal incision clean, steris intact
trace peripheral edema
Medications on Admission:
ASA 325 mg QD
Metformin 1000 mg [**Hospital1 **]
lisinopril 60 mg PO QD
Norvasc 10 mg po QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): for 1 week, then 400 mg (2 tabs) QD for 1 week,
then 200 mg (1 tab) poQD until D/c'd by Dr. [**Last Name (STitle) **].
Disp:*120 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin EC 81 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*
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: 5mg today ([**10-6**]) and tomorrow ([**10-7**]), then INR
draw, and check with Dr. [**Last Name (STitle) **] for continued dosing.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
post-op AFib
DM
HTN
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or ointments to incisions
no lifting > 10 # or driving for 1 month
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**1-30**] weeks
with Dr. [**Last Name (STitle) **] next week (pt. has appt)
with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2187-10-6**]
ICD9 Codes: 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4993
} | Medical Text: Admission Date: [**2123-12-25**] Discharge Date: [**2124-1-7**]
Date of Birth: Sex: F
Service: [**Hospital1 139**]
CHIEF COMPLAINT: The patient is a 77-year-old woman with
unresectable pancreatic cancer with pulmonary embolism and
small-bowel obstruction.
HISTORY OF PRESENT ILLNESS: The patient presented to an
outside hospital on [**12-24**] after her daughter noticed
increased somnolence and vomiting.
She was taken to [**Hospital3 15174**] and was found to
be unresponsive. She was intubated for airway protection. A
computed tomography scan showed a small-bowel obstruction.
BRIEF SUMMARY OF HOSPITAL COURSE: She was transferred to
[**Hospital1 69**] Intensive Care Unit.
Upon arrival a repeat abdominal computed tomography showed
ascites and partial small-bowel obstruction and enlargement
of the pancreatic head. The patient was evaluated by Surgery
who felt that the mass was unresectable. The small-bowel
obstruction was managed medically. The patient was
extubated.
Her course was then complicated by development of a
non-ST-elevation myocardial infarction.
The patient was transferred to the medical floor on [**2123-12-28**] where she desaturated to 85% on 4 liters. It was
thought that the patient had vomited and aspirated. A
computed tomography angiogram was performed which showed
bilateral pulmonary emboli. Lower extremity Doppler studies
also revealed bilateral deep venous thrombi. The patient was
started on heparin intravenously and an inferior vena cava
filter was placed. The patient subsequently developed
heparin-induced thrombocytopenia syndrome. Her platelets
dropped from 150 to 98. Heparin was stopped.
At that point, the patient realized her diagnosis and
prognosis. The patient stated that she was not interested in
radiation or chemotherapy. Code discussions were held with
the patient and her family. She was made comfort measures
only.
The patient was transferred to the medical floor. The
hospital course the following day, on transfer to the medical
floor, the patient passed away while on a morphine drip. The
family were notified and declined autopsy.
CONDITION AT DISCHARGE: Expired.
DISCHARGE STATUS: Not applicable.
DISCHARGE DIAGNOSES:
1. Pulmonary embolism.
2. Deep venous thromboses.
3. Pancreatic cancer.
4. Small-bowel obstruction.
5. Aspiration pneumonia.
6. Heparin-induced thrombocytopenia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**]
Dictated By:[**Name8 (MD) 53260**]
MEDQUIST36
D: [**2124-2-26**] 10:20
T: [**2124-2-26**] 10:38
JOB#: [**Job Number 53261**]
ICD9 Codes: 5070, 2765, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4994
} | Medical Text: Admission Date: [**2177-8-11**] Discharge Date: [**2177-8-18**]
Date of Birth: [**2125-8-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Paxil
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain, DOE
Major Surgical or Invasive Procedure:
[**2177-8-14**] CABG x 3 (LIMA->LAD, SVG->OM, SVG->PDA)
History of Present Illness:
52 yo Female with PVD, DM presented with chest pain and dyspnea,
cardiac cath showed LM and RCA disease.
Past Medical History:
Left femoral-DP bypass with in-situ greater saphenous vein
CVA X 2 on coumadin
Asthma
RAS
HTN
myofascial pain syndrome
Social History:
35 pack year smoking history, lives with boyfriend
Family History:
n/c
Physical Exam:
NAD, flat after cath
lungs CTAB ant/lat
RRR
Abdomen benign, obese
Extem warm, no edema, healed LLE incision
Pertinent Results:
[**2177-8-18**] 04:34AM BLOOD Hct-32.1*
[**2177-8-16**] 02:30PM BLOOD WBC-14.4* RBC-3.49* Hgb-10.4* Hct-30.8*
MCV-88 MCH-29.8 MCHC-33.8 RDW-15.2 Plt Ct-219
[**2177-8-18**] 04:34AM BLOOD PT-26.4* INR(PT)-2.7*
[**2177-8-17**] 10:15AM BLOOD PT-21.3* INR(PT)-2.1*
[**2177-8-16**] 07:00AM BLOOD PT-14.2* PTT-29.3 INR(PT)-1.3*
[**2177-8-18**] 04:34AM BLOOD UreaN-11 Creat-0.6 K-3.9
[**2177-8-16**] 02:30PM BLOOD Glucose-168* UreaN-11 Creat-0.8 Na-134
K-4.4 Cl-100 HCO3-24 AnGap-14
Brief Hospital Course:
She was seen by neurology preoperatively to assess stroke risk.
She awaited several days off of plavix prior to be taken to the
operating room on [**2177-8-14**] where she underwent a CABG x 3. She
was transferred to the ICU in critical but stable condition on
neosynephrine, propofol and insulin. She was extubated later
that same day. She was transferred to the floor on POD #1. On
POD #2, she vomited, KUB showed no obstruction and LFTs were
normal. Her vomiting rosolved with IV protonix. She did well
postoperatively and was ready for discharge home on POD #4.
Medications on Admission:
lovastatin, plavix, hydroxyzine, actos, metoprolol, coumadin,
lisinopril, theophylline, glipizide, clonidine, flexeril,
albiuterol, percocet, nitro
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
8. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
CAD
HTN
lipids
CVA x 2
PVD s/p L SFA stent & L fem-dp bypass c/b infection& dehiscence
renal srtery stenosis s/p stent
asthma
lung nodule
migraines
fatty liver
right hand tendonitis
myofascial pain syndrome
s/p left hand tendon surgery
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 lifting more than 10 pounds or driving until follow up with
sutgeon or while taking narcotic pain medicine.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**First Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] (thoracic surgery). Please call to arrange
follow up for lung nodules.
Already Scheduled appointments:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2177-8-20**]
11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2177-8-20**] 11:45
Completed by:[**2177-8-18**]
ICD9 Codes: 4019, 4439, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4995
} | Medical Text: Admission Date: [**2119-7-19**] Discharge Date: [**2119-8-3**]
Date of Birth: [**2042-10-29**] Sex: M
Service: SURGERY
Allergies:
Demerol / Morphine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic Cancer
Major Surgical or Invasive Procedure:
Exploratory Laparoscopy
ERCP with Metal Stent
EUS with Celiac Plexus Block
History of Present Illness:
This is a 76M s/p multiple recent admissions for pancreatitis at
an OSH. Work-up at the OSH included CT demonstrating a
pancreatic head mass and EUS with biopsy demonstrating
pancreatic adenocarcinoma. He presented to Dr.[**Name (NI) 9886**] clinic
on [**2119-6-19**] for further management. On presentation, he
complained of severe epigastric pain radiating to the back, and
was actively retching/vomiting. He was recently discharged
[**2119-6-29**] on TPN to rehab. He is now a transfer from rehab for
pre-op work-up in preparation for Whipple procedure.
Review of systems: denies chest pain, denies shortness of
breath,
denies headaches, all other systems WNL
Past Medical History:
Pancreatic Cancer
CAD s/p NSTEMI, s/p R circumflex stent [**12-27**], TIA, HTN,
hypercholesterolemia, COPD, DM (diet controlled), hemorrhoids,
recurrent UTIs, nephrolithiasis, arthritis, bladder ca s/p
radical cystectomy & urostomy, s/p parastomal hernia repair, s/p
L hip ORIF, s/p L CEA [**1-27**]
Social History:
Former truck driver. Married and divorced 3x, no children.
150+ pack-year smoking history. No EtOH.
Family History:
Father: cancer. Mother: cerebral hemorrhage after fall, ?stroke.
1 sister with CAD s/p triple bypass, 2 sisters s/p MI, 1 sister
still living. Brother: leukemia.
Physical Exam:
Vitals- T 97.9, HR 87, BP 118/56, RR 18, O2sat 96% RA
Gen- NAD, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- RLQ ileal conduit with hernia, moderate epigastric pain, no
peritoneal signs
Rectal- deferred
Ext- warm, well-perfused, no edema
Pertinent Results:
[**2119-7-19**] 05:45PM BLOOD WBC-7.4 RBC-3.24* Hgb-9.3* Hct-28.3*
MCV-87# MCH-28.8 MCHC-33.0 RDW-17.0* Plt Ct-333
[**2119-7-23**] 06:30AM BLOOD WBC-11.9* RBC-3.24* Hgb-9.2* Hct-28.2*
MCV-87 MCH-28.5 MCHC-32.7 RDW-18.2* Plt Ct-556*
[**2119-7-24**] 03:56AM BLOOD WBC-10.8 RBC-3.50* Hgb-10.0* Hct-30.6*
MCV-87 MCH-28.6 MCHC-32.7 RDW-18.3* Plt Ct-533*
[**2119-7-24**] 03:56AM BLOOD Glucose-125* UreaN-25* Creat-0.8 Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
[**2119-7-21**] 05:04AM BLOOD ALT-508* AST-203* AlkPhos-980* Amylase-25
TotBili-10.7*
[**2119-7-24**] 03:56AM BLOOD ALT-218* AST-42* AlkPhos-627* Amylase-25
TotBili-2.6*
[**2119-7-24**] 03:56AM BLOOD Lipase-10
[**2119-7-23**] 06:30AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.1 Mg-2.0
.
Radiology Report CTA PANCREAS W/ CTCP Study Date of [**2119-7-19**]
10:35 PM
Preliminary Report !! PFI !!
Comparison to CT [**2119-6-19**]. An Ill-defined low attenuation mass
within the head
of the pancreas measures 1.8 x 1.6 cm. There is new moderately
severe intra
and extrahepatic biliary dilatation as well as pancreatic
dilatation. The
pancreatic duct measures 9 mm near the level of the mass. There
is
peripancreatic stranding centered around the head. There is a
para-aortic
lymph node with a necrotic appearing center measuring 15x7mm
(3b:173). New
hazy soft tissue density encases the SMA as it courses near the
pancreatic
head (3b:164-168). The normal contour of the SMV is maintained
as it courses
anterior to the pancreas. New low attenuation areas including:
segment VI 8
mm (3b:177), 7mm IVB (3b:175), 7 mm and 6 mm in [**Doctor First Name **] are
suspicious for
metastasis but are too small to definitely characterize. A
ventral hernia
contains a loop of small bowel and a abdominal defect in the RLQ
contains a
loop of colon and several loops of small bowel. There is no
obstruction.
.
ERCP
Procedures: A small sphincterotomy was performed in the 12
o'clock position using a sphincterotome over an existing
guidewire.
A 6cm covered wall stent biliary stent was placed successfully
(Ref: 6971 / LOT [**Numeric Identifier 78701**]). Good drainage of white bile was
noted.
Impression: The major papilla was buldging and distorted.
Tight 3 cm malignant looking distal biliary stricture
Small sphincterotomy performed.
A 6 cm covered wallstent was placed successfully in bile duct.
.
EUS
EUS
findings: Celiac Plexus Neurolysis:
EUS was performed using a linear echoendoscope at 7.5 Mhz
frequency and Celiac Plexus Neurolysis was performed: The
take-off of the celiac artery was identified.
A 22 gauge needle was primed with saline and advanced adjacent
to the Aorta, just superior to the celiac artery take-off. This
was aspirated to assess for vascular injection. No blood was
noted. Buipuvacaine 0.25% X 10 cc was injected. Dehydrated 98%
alcohol X 10 cc was injected. Saline 3 cc was injected. The
needle was then withdrawn.
Mass: A > 1.5 cm ill-defined mass was noted in the head of the
pancreas. The mass was hypoechoic and heterogenous in
echotexture. The borders of the mass were irregular and poorly
defined.
Impression: EUS guided Celiac Plexus Neurolysis was performed.
Ill-defined mass in the head of the pancreas.
Brief Hospital Course:
This is a 76 year old male with pancreatic cancer who was
recently discharged to rehab on TPN and tolerating sips. He
returned to go to the OR.
A CT pancreas protocol was obtained and showed New low
attenuation areas including: segment VI 8 mm (3b:177), 7mm IVB
(3b:175), 7 mm and 6 mm in [**Doctor First Name **] are suspicious for
metastasis but are too small to definitely characterize. On
[**7-20**], he went to the OR for Exploratory Laparoscopy, aborted
Whipple due to liver mets.
Pain: He still complained of lots of abdominal pain. A Chronic
pain consult was obtained and helped manage his medications. He
then went EUS for celiac plexus block on [**2119-7-25**]. His pain was
improved.
Obstructive Jaundice: Due to the mass effect, his Tbili was 10.
He then went for ERCP with placement of 6cm covered stent. His
Tbili trended down and his jaundice improved.
FEN: He continued on TPN. He was then started on a diet and his
diet can be advanced as tolerated.
UTI: He had a positive UA and was on Cipro/Flagyl.
Oncology: He was seen by Oncology and will follow-up as
outpatient.
Medications on Admission:
Metamucil, Senna, gabapentin 300', Plavix 75', loratadine 10',
Cartia XT 180', folic acid ?, ASA 325', Tylenol, MVI,
simvastatin 40', temazepam 15 qhs, Advair 500/50", Combivent"",
Prilosec 20'
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a
day.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Hydromorphone 4 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed.
10. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection four times a day.
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Discharge Disposition:
Extended Care
Facility:
Life Care Center, [**Location (un) 2199**]
Discharge Diagnosis:
Pancreatic Cancer - Metastatic
Acute on Chronic Pain
UTI
Obstructive Jaundice
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue to take a
stool softener.
* Continue to ambulate several times per day.
* No heavy lifting (>[**10-4**] lbs) until your follow up
appointment.
* Continue with TPN as ordered. You may also eat and advance
your diet as tolerated. Once taking in adequate POs, the TPN cn
stop. sted daily.
Followup Instructions:
Please follow-up with Oncology Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2119-7-31**] 3:00
Completed by:[**2119-7-28**]
ICD9 Codes: 0389, 486, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4996
} | Medical Text: Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-9**]
Date of Birth: [**2131-1-2**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 56 year old man who has been seen in the Ed on
multiple occasions for frequent falls while intoxicated. He fell
from standing the night of admission and this was witnessed by
friends. [**Name (NI) **] was transferred to [**Hospital1 18**] for evaluation. CT head
showed bilateral SDH. He received Dilantin 1gm IV x1.
Neurosurgery was consulted.
Past Medical History:
1. Alcoholism, prior MICU admission for airway protection during
acute intoxication (w/ valium overdose).
2. Hepatitis C.
3. Seizure disorder.
4. Status post depressed skull fracture in [**2162**].
5. Status post right craniotomy.
6. Status post C4 fracture in [**2173**].
7. Status post delirium tremens.
8. H/o Aspiration pneumonia.
9. Hypertension.
10. Right ankle fracture.
11. Right arm thrombophlebitis.
Social History:
He is homeless and currently staying with friends. [**Name (NI) **] reports
to parole services. He is not currently working. He has a 43
year smoking history, currently smokes <[**12-10**] PPD. He drinks up to
3 quarts of vodka daily. He has a history of occasional
marijauna use. No documentation of cocaine or heroin use, but
patient has h/o IVDU is his teens. His sister managed his
finances.
Family History:
Mother has h/o alcoholism, HTN.
Physical Exam:
On Admission:
O: T: 97.6 BP: 165/106 HR: 55 R 14 O2Sats 100%
Neuro:
Mental status: Intoxicated
Orientation: Oriented to person, place, and date.
Language: Speech thick/slurred
Given patient's intoxication, neuro exam is limited. Pt opens
eyes to voice, oriented x3, follows commands w/prompting, pupils
2mm reactive bilaterally, BUE antigravity- full motor assessment
limited from lack of effort/intoxication; BLE slightly
antigravity but briskly withdraws to noxious. Face appears
symmetric and tongue midline.
At Discharge:
Patient left AMA
Pertinent Results:
[**2187-8-7**] 02:20AM PT-12.1 PTT-31.2 INR(PT)-1.0
[**2187-8-7**] 02:20AM PLT COUNT-133*
[**2187-8-7**] 02:20AM NEUTS-46.5* LYMPHS-46.3* MONOS-5.2 EOS-1.4
BASOS-0.6
[**2187-8-7**] 02:20AM WBC-3.2* RBC-3.94* HGB-13.6* HCT-38.9*
MCV-99* MCH-34.6* MCHC-35.0 RDW-14.4
[**2187-8-7**] 02:20AM ASA-NEG ETHANOL-295* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2187-8-7**] 02:20AM PHENYTOIN-LESS THAN
[**2187-8-7**] 02:20AM estGFR-Using this
[**2187-8-7**] 02:20AM GLUCOSE-85 UREA N-10 CREAT-0.9 SODIUM-148*
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-31 ANION GAP-14
[**2187-8-7**] 02:27AM GLUCOSE-78
[**2187-8-7**] 02:27AM COMMENTS-GREEN TOP
[**2187-8-7**] 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0
LEUK-NEG
[**2187-8-7**] 02:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2187-8-7**] 02:40AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2187-8-7**] 02:40AM URINE HOURS-RANDOM
CT head [**2187-8-7**]
1. Acute small bifrontal subdural hematomas with small amounts
of adjacent
subarachnoid blood.
2. Non-displaced left superior frontal fracture extending to the
sagittal
suture at the vertex, with overlying subgaleal hematoma.
3. This patient had 32 prior head CTs since [**2184-1-13**], and 9
additional prior
head CTs between [**2175-4-27**] and [**2179-12-11**].
CT C-spine [**2187-8-7**]
1. No acute fracture or subluxation.
2. Unchanged chronic dens fracture and posterior fusion of
C1-C3, without
evidence of hardware related complications.
3. This patient had 19 prior cervical spine CTs since [**2184-2-2**].
CT head [**2187-8-7**]
1. Stable appearance of right frontal hemorrhagic contusion
which exerts mass effect on the frontal [**Doctor Last Name 534**] of the right
lateral ventricle. Adjacent
subarachnoid hemorrhage shows mild increase.
2. Nondisplaced left superior frontal bone fracture, better
demonstrated on prior bone algorithm-reconstructed images.
Brief Hospital Course:
//Mr. [**Known lastname 5126**] was admitted to [**Hospital1 18**] on [**8-7**] for bilateral SDH's.
He was in a cervical /collar for CT finding of stable C2
fracture and posterior cervical fusion. Repeat CT findings
showed a large increase in right SDH. He remained neurologically
unchnaged with LUE weakness and drift.
Patient left on [**2187-8-9**] against medical advice.
Medications on Admission:
Unknown, patient has not been compliant in the past.
Discharge Medications:
Patient left AMA
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Bilateral SDH
Cervical Fracture
Discharge Condition:
Patient Left AMA
Discharge Instructions:
Patient left AMA
Followup Instructions:
Patient Left AMA
Completed by:[**2187-10-11**]
ICD9 Codes: 2760, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4997
} | Medical Text: Admission Date: [**2192-11-26**] Discharge Date: [**2192-12-13**]
Date of Birth: [**2107-11-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Decompensated CHF
Major Surgical or Invasive Procedure:
Intubation, central line, arterial line, EGD
History of Present Illness:
85 yoM with AF on coumadin s/p pacemaker [**2-/2192**] admitted for
decompensated CHF and transferred to the CCU s/p PEA arrest.
See [**Hospital1 1516**] note for more details, but in summary, pt admitted for
worsening DOE and LE swelling over several days. His outpatient
cardiologist did a TTE which he read as normal. Pt admitted to
the [**Hospital1 1516**] service where a TTE was repeated, showing mild apical
hypokinesis but preserved EF. Given the focal area of
involvement, an ischemic etiology was considered although per
Dr.[**Doctor Last Name 3733**], this may have been related to dyssynchrony. The
patient was diuresed and coumadin held while awaiting cardiac
catheterization tomorrow. In the interim, he did have a
witnessed fall yesterday - reported by roommate to have
collapsed; no event on telemetry, and CT head unremarkable. His
mental status seemed to have waned somewhat today, so CT head
was repeated, which again was unremarkable.
.
This evening around 5pm, the pt developed chest pain. His EKG
showed new lateral TWI. Pt was then noticed to become cyanotic;
O2 sat 60% on pleth but tracing poor. He subsequently became
pulseless, and a code blue called. Compressions were initiated,
and pt received epinephrine x1. Rhythm strips showed narrow
complex waveforms. A right femoral line was placed, and IV
fluids were hung with improvement in his BP. During intubation,
large food particles were aspirated. There was return to
spontaneous rhythm within 10 minutes. A bedside echo during
code reportedly showed preserved LV function. Pt was
transferrred to the CCU for further management.
.
He also underwent speech & swallow evaluation which showed
evidence of aspiration. Per his wife, he is usually monitored
while eating but did have a hamburger today without supervision.
He reported to her not feeling well with neck pain, chest pain,
coughing and emesis after that meal. On further suctioning in
the ICU, he was found to have multiple pieces of hamburger in
his ET tube.
.
Unable to obtain ROS as pt intubated and sedated.
Past Medical History:
1. CARDIAC RISK FACTORS: Diet-controlled diabetes, -
Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: AF with slow ventricular response s/p ppm 3/[**2191**].
3. OTHER PAST MEDICAL HISTORY:
Cardiac Risk Factors: (-)Diabetes (diet controlled),
(-)Dyslipidemia, (+)Hypertension, (+) Smoking, (-) FH early MI
or sudden cardiac death
.
Cardiac History:
AF with slow ventricular response, s/p pacemaker [**2192-3-17**]
.
OTHER PAST MEDICAL HISTORY:
-Dementia
-Thoracic Aortic Aneurysm [**3-/2192**] 5.2 cm < 5.5 threshold for
surgery
-Anxiety
-Depression
-S/p surgery on his left outer ear for removal of a skin cancer
-Blind left eye
Social History:
-Smoking/Tobacco: 120 PY (2 x 60y), quit 10 years ago
-EtOH: None
-Illicits: None
-Lives at/with: Wife at home, who cares for him. Veteran of WWII
Navy), retired [**Location 27256**] Sugar Refinery worker.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission to MICU
VS: T=96.8 BP=134/73 HR=75 RR=15 O2 sat=98% on FiO2 of 100%
GENERAL: Chronically ill-appearing elderly Caucasian male
intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 13 cm.
CARDIAC: Very distant heart sounds. IIR, normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: CTAB ant/lat with no audible rales.
ABDOMEN: Soft, ND. No HSM. Abd aorta not enlarged by palpation.
No abdominal bruits.
EXTREMITIES: 1+ pitting edema b/l to mid calf. R 3rd and 4th
toes cyanotic. R femoral CVL in place.
PULSES:
Right: Carotid 2+ Femoral 2+ DP dopp PT dopp
Left: Carotid 2+ Femoral 2+ DP dopp PT dopp
Pertinent Results:
On admission:
[**2192-11-26**] 04:50PM BLOOD WBC-6.9 RBC-5.24 Hgb-11.2* Hct-36.8*
MCV-70* MCH-21.3* MCHC-30.4* RDW-17.8* Plt Ct-184
[**2192-11-26**] 04:50PM BLOOD Neuts-79.9* Lymphs-14.0* Monos-5.1
Eos-0.5 Baso-0.5
[**2192-11-26**] 04:50PM BLOOD PT-30.8* PTT-30.8 INR(PT)-3.1*
[**2192-11-26**] 04:50PM BLOOD Glucose-109* UreaN-25* Creat-1.1 Na-143
K-4.6 Cl-99 HCO3-37* AnGap-12
[**2192-11-26**] 04:50PM BLOOD calTIBC-273 VitB12-215* Ferritn-180
TRF-210
.
On Admission to MICU
[**2192-11-30**] 01:18AM BLOOD WBC-3.1*# RBC-5.05 Hgb-10.8* Hct-35.1*
MCV-69* MCH-21.4* MCHC-30.9* RDW-17.4* Plt Ct-126*
[**2192-11-30**] 01:18AM BLOOD Neuts-68 Bands-25* Lymphs-3* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2192-11-30**] 01:18AM BLOOD PT-21.7* PTT-27.2 INR(PT)-2.0*
[**2192-11-30**] 01:18AM BLOOD Glucose-157* UreaN-28* Creat-1.0 Na-142
K-3.8 Cl-102 HCO3-34* AnGap-10
[**2192-11-30**] 01:18AM BLOOD ALT-30 AST-29 CK(CPK)-232 AlkPhos-38*
TotBili-1.1
[**2192-11-30**] 01:18AM BLOOD CK-MB-7 cTropnT-0.02*
[**2192-11-30**] 01:18AM BLOOD Calcium-7.4* Phos-4.1 Mg-1.6
[**2192-11-30**] 12:15PM BLOOD Type-ART pO2-72* pCO2-56* pH-7.35
calTCO2-32* Base XS-3
[**2192-11-30**] 12:15PM BLOOD Type-ART pO2-72* pCO2-56* pH-7.35
calTCO2-32* Base XS-3
[**2192-11-30**] 07:07AM BLOOD freeCa-1.11*
=======================STUDIES==================
[**2192-11-26**] (admission): V-paced with underlying afib.
[**2192-11-29**] (chest pain): Afib with TWI in II, III, aVF, TWI/F in
V3-V6.
[**2192-11-29**] (CCU): V-paced with udnerlying afib with same TWI/F as
above.
.
2D-ECHOCARDIOGRAM:[**2192-11-27**] The left atrium is moderately
dilated. The right atrium is markedly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild left ventricular systolic
dysfunction with apical hypokinesis (see cell 55). The right
ventricular cavity is dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened (?#). There are filamentous
strands on the aortic leaflets consistent with Lambl's
excresences (normal variant). There is no aortic valve stenosis.
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 with moderate
tricuspid regurgitation (in the region of the pacer lead). There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
85yo M w/ AF s/p pacer in [**3-/2192**], dementia, HTN who presented
with BLE swelling, being diuresed with plan for cardiac cath
[**11-30**] who is now s/p PEA arrest with ROSC, likely related to
aspiration event with evolving sepsis and [**Last Name (un) **].
.
# s/p PEA arrest/Aspiration event: Pt was intubated during
arrest without difficulty and intially hemodynamically stable
with right femoral CVL in place, without pressor requirement.
Arrest most likely related to aspiration event earlier in day
given history of eating hamburger without supervision by wife,
difficulty breathing and general sense of not being well and
findings on ETT suction with large piece of hamburger in upper
airway and smaller pieces in lower airways. He was started on
Levofloxacin empirically for CAP given CXR findings prior to
aspiration. He was started on pressure support but became
tachypneic and ABG showed respiratory acidosis with pCO2>100. He
was changed to CMV with larger tidal volumes and acidosis
improved. FiO2 requirement fluctated between 60 and 100% and
secretions became darker and thicker. He was changed to
Meropenem (PCN allergy)/Vanco/Flagyl when patient began to rigor
and was hypothermic and hypotensive with SBPs down to the 50s.
Sedation was changed from propofol to fentanyl/versed and he was
bolused with a total of 5L normal saline for presumed evolving
sepsis. Levophed was also added and requirement increased to
0.16 at time of transfer to MICU service. Sputum and blood
cultures were sent. At the MICU he had a bronchoscopy done which
showed some thick mucuous in the left lung. His pressures and
UOP improved with IVF and his levophed was weaned down. He was
diuresed with Lasix as it was thought his respiratory issues are
related to an aspiration pna and pulmonary edema as he got over
7L during rescusitation. Given how much fluid he was given and
his chest xray showing pulmonary edema, attempts were made to
diurese the patient even while still on Levophed. Discussions of
a trach and PEG were discussed with the family however on [**12-9**]
the patient was able to be extubated. His meropenem was d/c'd on
[**12-9**] and his Vanc was d/c'd on [**12-11**] as his sputum cx grew only
respiratory flora. He was on a face tent satting at 96% at an
Fi)2 of 50-100% for the remainder of his hospitalization.
.
# ACUTE KIDNEY INJURY: Foley was placed. Pt's urine output
decreased steadily after periods of hypotension overnight
following arrest, possibly [**1-17**] ATN. He was given a total of 5L
NS and yet urine output was minimal. Creatinine increased from
baseline of 0.9 to a high of 1.6 on [**12-1**]. With continued IVF,
the patient's creatinine trended down to 1.3 and his UOP
increased. His creatinine stayed at 1.4 for the remainder of his
admission.
.
# CORONARIES: No known CAD, but regional wall motion abnormality
on TTE. Plan was for patient to go to cath [**11-29**], though after
consideration of ability to cooperate during cath, now plan is
to be medically managed. Arrest unlikely to have been related to
ischemia, no changes on ECG, PEA not usually an ischemic rhythm.
Cardiac enzymes were cycled and were flat. Metoprolol was
continued while in the MICU except when hypotensive.
.
# PUMP: Pt's LVEF 50% on TTE, was being diuresed on floor prior
to transfer to CCU service. Appeared overloaded on exam with
elevated JVP, pedal edema, and CXR findings prior to aspiration
event. Further diuresis was held given ongoing hypotension,
however this was restarted in the MICU. ACEI was also held and
metoprolol was continued but not given based on holding
parameters. Echo was performed on [**12-5**] to evaluate cardiac
function which showed very mild anterior and septal apical
hypokinesis with preserved ejection fraction. The patient was
continued on a lasix gtt intermittently as his pressures
tolerated it. He was also on pressors as it was felt that fluid
needed to be diuresed in order to improve his respiratory
status. The patient came off pressors on [**12-9**] on the day he was
extubated and was able to maintain his blood pressures for the
remainder of his hospitalization.
.
# RHYTHM: Intermittently in Afib with rescue ventricular pacing
and bradycardia on transfer to the CCU. Electrolytes repleted
closely. In the MICU he continued to have this rhythm.
.
# Dementia: Pt is known to be a chronic aspirator, secondary to
dementia. Memantine and donepizil were continued. Prior to
hospitalization, the patient was able to bathe and clothe
himself but required assistance with many tasks from his wife.
[**Name (NI) **] is not oriented to place or time at baseline. Once extubated,
there was concern about feeding him given his lack of cough and
hx of chronic aspirations. His wife felt she would want to try
feeding him a little for comfort.
.
# Anxiety/Depression: Patient was sedated initially with
propofol and then transitioned to fentanyl/midazolam so diazepam
was held and escitalopram was continued. Escitalopram was
continued for the rest of his admission and the patient was
given Seroquel for agitation.
.
# Goals of Care: On [**12-10**] the patient was made DNR/DNI per wife.
On [**12-12**] palliative care came to speak to the patient and her
family. The family was not interested in hospice at this time.
They wanted pt to be comfortable and would prefer restraining pt
rather than over medicating him to sedate him as they feel he
gets happiness from grabbing at the rail and picking at things.
.
CODE STATUS: [**Name (NI) **] wife [**Name (NI) 1743**] (HCP): [**Telephone/Fax (1) 106251**] (Home).
[**Name (NI) **] wife was told that he is at risk for chronic
aspiration given dementia and this is likely to happen again. He
became DNR/DNI on [**12-11**] per patients wife.
.
.
.
[**12-13**] UPDATE:
I was called to evaluate the patient for unresponsiveness and
lack of spontaneous breathing. On exam, the patient had no
breath sounds, no peripheral pulses, and his pupils were fixed
and dilated. In brief, he is an 85 year old male who was
initially admitted to [**Hospital1 18**] for a heart failure exacerbation and
had a hospital course complicated by an aspiration event which
led to PEA arrest requiring resuscitation and intubation. He
then developed aspiration PNA and became septic. He was
successfully extubated, but had persistent thick secretions
which
he was unable to clear. The patient's family did not want to
pursue reintubation which would likely require a trach and PEG
to
be placed. He was therefore made DNR/DNI with comfort goals but
not absolutely CMO. Unfortunately, he developed mucous plugging
of his right lung that could not be cleared with suctioning and
his respiratory status declined. He was pronounced at 10:20 AM
and the attending critical care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **],
was
notified. We attempted to contact his wife, [**Name (NI) 1743**], several
times as it became evident that his respiratory status was
progressively declining. Unfortunately, she was not able to be
reached either before or after his death at the point this note
was written.
Medications on Admission:
Lisinopril 20 [**Hospital1 **]
Amlodipine 5
Coumadin 5,5,7,5,7,5 (6 day cycle)
Diazepam 2.5 AM, 5 PM
Namenda 10 [**Hospital1 **]
Aricept 10 QHS
Celexa 20 QHS
Vit E 400 daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Completed by:[**2192-12-13**]
ICD9 Codes: 0389, 5070, 5845, 4280, 4019, 4168, 4275, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4998
} | Medical Text: Admission Date: [**2192-8-29**] Discharge Date: [**2192-9-5**]
Date of Birth: [**2134-5-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
[**2192-8-31**]
1. Urgent coronary artery bypass graft x5; left internal
mammary artery to left anterior descending artery and
saphenous vein sequential grafting to posterior
descending artery and posterior left ventricular branch
and saphenous vein grafts to diagonal and distal
circumflex.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
Mr. [**Known lastname 38430**] is a 58 year old man with a
history of tobacco abuse and coronary artery disease who was
found unresponsive by his wife. His family performed CPR, EMS
arrived and administered amio and epinepherine and shocks. He
was
brought to [**Hospital6 3105**] emergency department where
he went into PEA arrest and CPR/hypothermia were administered.
He was intubated and admitted. After two days he was extubated,
but then experienced acute renal failure, acidemia, and anuria.
Past Medical History:
CAD with stent placement in [**2183**]
Hyperlipidemia
Tobacco Abuse
L subpectoral hematoma s/p CPR, now with penrose drain
bilateral rib fractures s/p CPR
Past Surgical History
kidney stone removal
abdominal surgery after gunshot
Cardiac Procedures
CAD with stent placement in [**2186**]
Social History:
Lives with:wife and children
Contact:[**Last Name (NamePattern4) 38433**] (wife) Phone #([**Telephone/Fax (1) 38434**]
Occupation:fork-lift operator
Cigarettes: Smoked no [] yes [x] last cigarette Current smoker,
smoked 2 packs per every 3 days for many years
ETOH: < 1 drink/week [x] [**12-27**] drinks/week [] >8 drinks/week []
Illicit drug use (none)
Family History:
No coronary artery disease
Physical Exam:
Pulse: 49 Resp: 16 O2 sat: 96%RA
B/P 105/67
Height:68 inches Weight:170 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [x] 1+
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 1+ Left:1+
Carotid Bruit Right:- Left:-
Pertinent Results:
Intra-op TEE [**2192-8-31**]
Conclusions
Pre-Bypass:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. A small patent foramen ovale is present by
color flow doppler.
Left ventricular wall thickness, cavity size and global systolic
function are normal (LVEF >55%). Doppler parameters are most
consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter with simple atheroma. The diameters of aorta
at the sinus, ascending and arch levels are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
Moderate [2+] tricuspid regurgitation is seen.
Post-bypass:
The patient is A-paced on a phenylephrine infusion.
The left ventricular function is preserved with an estimated
ERF-55%. No apparent wall motion abnormalities.
TR remains 2+.
There is no echocardiographic evidence of an aortic dissection
s/p decannulation.
The remainder of the exam is unchanged.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2192-9-3**] 15:47
?????? [**2182**] CareGroup IS. All rights reserved.
.
[**2192-9-5**] 07:25AM BLOOD WBC-9.6 RBC-3.29* Hgb-8.8* Hct-27.3*
MCV-83 MCH-26.9* MCHC-32.4 RDW-15.9* Plt Ct-360
[**2192-9-4**] 07:25AM BLOOD WBC-13.5* RBC-3.18* Hgb-8.7* Hct-26.4*
MCV-83 MCH-27.3 MCHC-32.8 RDW-15.6* Plt Ct-298
[**2192-9-3**] 03:20AM BLOOD WBC-11.7* RBC-3.11* Hgb-8.4* Hct-25.8*
MCV-83 MCH-27.1 MCHC-32.7 RDW-15.6* Plt Ct-311
[**2192-9-5**] 07:25AM BLOOD Glucose-121* UreaN-22* Creat-1.2 Na-137
K-3.7 Cl-96 HCO3-31 AnGap-14
[**2192-9-4**] 07:25AM BLOOD Glucose-107* UreaN-24* Creat-1.3* Na-133
K-3.7 Cl-94* HCO3-29 AnGap-14
[**2192-9-3**] 05:09PM BLOOD Glucose-110* Na-134 K-3.9 Cl-92*
Brief Hospital Course:
The patient was brought to the Operating Room on [**2192-8-31**] where
the patient underwent CABG x 5 with Dr. [**First Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. He did develop bradycardia on POD 1,
requiring Atrial pacing. He was hyperkalemic with Potassium
6.7. This was treated with insulin and D50 and resolved. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient
developed acute kidney injury with a peak creatinine of 2.6. It
would trend down to baseline prior to discharge. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD 5
the patient was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged home with VNA in good condition with appropriate
follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. Naproxen 375 mg PO Q12H
Discharge Medications:
1. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. HYDROmorphone (Dilaudid) 2-6 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg [**11-21**] tablet(s) by mouth q3h
Disp #*60 Tablet Refills:*0
4. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
5. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl [Acid Control] 150 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
7. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
8. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*7 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
CAD with stent placement in [**2183**]
Hyperlipidemia
Tobacco Abuse
L subpectoral hematoma s/p CPR, now with penrose drain
bilateral rib fractures s/p CPR
Past Surgical History
kidney stone removal
abdominal surgery after gunshot
Cardiac Procedures
CAD with stent placement in [**2186**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace 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**], [**2192-9-11**]
11:45
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2192-10-9**] 2:00, [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) 4922**], [**2192-9-25**] at 1:45pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 29068**] in [**2-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2192-9-5**]
ICD9 Codes: 5845, 2768, 2724, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 4999
} | Medical Text: Admission Date: [**2191-10-5**] Discharge Date: [**2191-10-12**]
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old
male with a known history of aortic stenosis. He originally
had an echocardiogram in [**2191-3-28**] which showed left
ventricular hypertrophy with preserved left ventricular
function. Peak aortic gradient at the time was noted to be
at 80, mean of 40, with a valve area of 0.8 sq.cm. There was
mild aortic insufficiency, mild to moderate mitral
regurgitation, and [**Hospital1 **]-atrial enlargement. However, the
patient reports that since the end of [**Month (only) **], he has had
noticeable lightheadedness when exerting himself. In fact,
during one such episode, he was pushing a wheelbarrow when he
felt weakness. He also, at that time, complained of pounding
heart, and a mild heaviness in his chest as well as
lightheadedness and some shortness of breath. The patient
also complains of increasing fatigue. The patient denied any
claudication, orthopnea, edema, or paroxysmal nocturnal
dyspnea.
Given the history of aortic stenosis and symptoms of
exertional dyspnea and congestive heart failure, a cardiac
catheterization was performed on [**2191-10-5**]. The cardiac
catheterization revealed mild to moderate left main coronary
artery disease, severe calcific aortic stenosis, moderate
mitral regurgitation with mitral annular calcification, as
well as mild biventricular diastolic dysfunction. The
estimated left ventricular ejection fraction was
approximately 70%.
PAST MEDICAL HISTORY:
1. Atrial fibrillation
2. History of bradycardia status post pacemaker implantation
3. Aortic stenosis
4. Arthritis
5. History of alcohol abuse
6. Hearing impairment
PAST SURGICAL HISTORY:
1. Tonsillectomy
2. Bilateral cataract surgery
ALLERGIES: Neosporin causes swelling.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.25 mg every other day, 0.375 mg every other day
2. Celebrex 200 mg by mouth once daily
3. Coumadin 1 mg every day except Wednesday, when the
patient takes 2 mg
4. Vitamin C 500 mg by mouth once daily
5. Vitamin E 400 mg once daily
LABORATORY DATA: On admission, hematocrit 36.6, white blood
cell count 8.1, platelet count 166. PT 14.9, PTT 50.7, INR
1.5. Glucose 96, BUN 14, creatinine 1.0, sodium 137,
potassium 3.8.
SOCIAL HISTORY: History of alcohol use. Lives with his son.
PHYSICAL EXAMINATION: Temperature 97.1, heart rate 71, blood
pressure 164/63, respiratory rate 20, oxygen saturation 95%
on room air. Cardiac examination showed an irregular rhythm,
III/VI systolic murmur best heard at the base. Respiratory
examination showed lungs clear to auscultation bilaterally.
Head, eyes, ears, nose and throat examination within normal
limits. General examination: The patient is an elderly
male, in no apparent distress. Extremities: No edema
bilaterally. Pulses present.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on [**2191-10-5**], as stated previously. His LMCA
was calcified, with an ostial 30% and a distal 50% stenosis.
The left anterior descending was calcified with a mid-vessel
40% stenosis involving a diagonal branch. The left
circumflex artery had mild diffuse disease, including at its
origin. The right coronary artery had mild diffuse disease
proximally. The estimated ejection fraction was 70%. At
that time, it was thought that surgery would be appropriate,
given the patient's symptoms and examination findings.
On [**2191-10-6**], given the history of coronary artery disease,
aortic stenosis and aortic insufficiency, the patient
underwent coronary artery bypass grafting x 2 (left internal
mammary artery to left anterior descending, saphenous vein
graft to diagonal). In addition, the patient underwent
aortic valve replacement with a #21 [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial valve. The procedure was without complications.
The patient tolerated the procedure well. Please see the
full operative note for details.
The patient was transferred to the Intensive Care Unit in
good condition. The patient was maintaining good blood
pressure. He was making adequate urine. He remained
afebrile. His incisions remained clean, dry and intact. The
patient was extubated on the night of his surgery. His
hematocrit remained stable. He was diuresed aggressively.
An aggressive pulmonary toilet was used. His chest tube was
removed on postoperative day one.
On postoperative day two, while still in the Intensive Care
Unit, the patient continued to do well. His Digoxin was
restarted. His Coumadin was restarted as well. The pacing
wires were removed, as was the Foley catheter. His
electrolytes were repleted as needed. Physical Therapy was
consulted, which followed the patient throughout his
hospitalization. The patient continued to be in atrial
fibrillation, which was no change from his preoperative
status.
The patient had some difficulty raising his oral secretions.
The patient consistently had signs of upper airway
congestion. He was bringing up thick brown sputum. The
patient was started on Levaquin prophylactically. Culture of
the sputum showed no significant growth. His blood cultures
showed no significant growth.
The patient was consequently transferred to the regular floor
in stable condition. He continued to do well, and maintained
adequate blood pressure. He was noted to have some
difficulty swallowing, which was thought to be due to his
oral secretions. A speech and swallow test was performed by
his bedside that was inconclusive. A video-assisted speech
and swallow test was then performed, which showed the patient
to be low risk for aspiration. It was suggested that he
crush his pills, otherwise he was cleared to eat a regular
diet.
The patient was continued on Coumadin, with his dose adjusted
to a goal INR of 2.0 to 2.5. He had one episode of urinary
retention, and a Foley catheter was inserted briefly and then
discontinued.
The patient was discharged to a rehabilitation center in
stable condition.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting x 2
2. Aortic stenosis and aortic insufficiency status post
aortic valve replacement
3. Atrial fibrillation
4. Hypertension
5. Arthritis
DISCHARGE MEDICATIONS:
1. Coumadin, dose to be adjusted to goal INR of 2.0 to 2.5
2. Digoxin 0.25 mg by mouth every other day and 0.375 mg by
mouth every other day
3. Levofloxacin 500 mg by mouth once daily for three days,
for a complete course of one week
4. Celebrex 200 mg by mouth once daily
5. Vitamin C 500 mg by mouth once daily
6. Vitamin E 400 units
7. Lasix 40 mg by mouth twice a day for ten days
8. Potassium chloride 20 mEq by mouth twice a day for ten
days
9. Ibuprofen 400 mg by mouth every eight hours as needed for
pain
10. Ipratropium bromide two puffs inhalers four times a day
11. Albuterol one to two puffs inhaler every six hours as
needed
12. Captopril 25 mg by mouth three times a day
13. Lopressor 50 mg by mouth twice a day
14. Milk of magnesia 30 ml by mouth daily at bedtime as
needed for constipation
15. Colace 100 mg by mouth twice a day as needed
16. Ranitidine 150 mg by mouth twice a day
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with his surgeon, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] in approximately four weeks.
2. The patient is to follow up with his cardiologist in
approximately three to four weeks.
3. The patient is to follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27542**], in approximately one to two
weeks.
4. The patient is to follow up in the [**Hospital 197**] Clinic to
have his Coumadin levels adjusted to the goal INR of 2.0 to
2.5 for his atrial fibrillation.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 10097**]
MEDQUIST36
D: [**2191-10-11**] 22:12
T: [**2191-10-12**] 00:36
JOB#: [**Job Number 21305**]
ICD9 Codes: 4019 |
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