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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5000 }	Medical Text: Admission Date: [2142-11-1] Discharge Date: [2142-11-10] Date of Birth: [2081-4-9] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: palpitations and chest pain Major Surgical or Invasive Procedure: [2142-11-5] Coronary Artery Bypass Graft x3 (left internal mammary -> left anterior descending, saphenous vein graft -> diagonal, saphenous vein graft -> posterior descending artery) MAZE procedure, Removal of mass from pulmonic valve History of Present Illness: 61 year old man presented to [First Name9 (NamePattern2) 65581] [Location (un) ] with palpitations and chest pain left sided, non-radiating, described as sharp in nature. He has history of this pain for years, always associated w/ exertion--shoveling, walking up inclines. On day of presentation to OSH, he developed pain on a 2 mile walk with wife. [Name (NI) 1194] resolved w/ rest. Recurred later in day, after eating & having BM. The pain escalated, worst ever. He noted his "heart racing." No SOB, diaphoresis, N/V, or pre-syncope. Went to [Location (un) ] ED, where pain relieved w/ 2SL nitroglycerin. Pt found to be in AF w/ RVR, rate in the 140??????s. EKG anterolateral ST depression (per records). Transferred for cardiac catherization Past Medical History: Hypertension Hypercholesterolemia Paraxsymal Atrial Fibrillation Prostate cancer s/p prostatectomy & radiation Hx of fibroblastoma of pulmonic valve Varicose veins Social History: Married, lives with spouse, retired police officer (works some part-time); Remote h/o smoking, stopped over 25yrs ago, smoked 2-3cigs per day for ~20yrs; 2-3glasses of wine per night Family History: mother had CAD after age 65; father died at age 53 of AAA rupture Physical Exam: Admission VS--96.9, 106/70, (106-112/70-81), 92 (92-100), 18 Gen: well-nourished, well-appearing man, NAD Integumentary: no rashes, no cyanosis HEENT: PERRL, EOMI, MMM, OP clear, no LAD, no carotid bruits CV: RRR, Nml s1s2, no M/R/G Pulm: CTAB Abd: +BS, soft, NTND, No HSM Back: no CVA tenderness Ext: no edema, 2+ DP pulses; no femoral bruits, no groin hematoma Neuro: a&o3, no focal neuro deficts Discharge Vitals 98.1, 89 SR, 116/68, 20, RA sat 96% weight 86.6 Neuro: alert and oriented x3, MAE R=L strength Pulmonary: clear to ausculation bilaterally - decreased left base Cardiac: RRR, no murmur/rub/gallop Abdomen: soft, nontender, nondistended, + bowel sounds Extremeties warm +1 edema pulses +2 Incisions: Sternal midline healing no drainage, no erythema, sternum stable Left leg endovascular harvest steristrips, no drainage no erythema Pertinent Results: [2142-11-8] 06:20AM BLOOD WBC-9.3 RBC-3.25* Hgb-10.0* Hct-28.4* MCV-87 MCH-30.6 MCHC-35.1* RDW-14.9 Plt Ct-150 [2142-11-1] 10:15AM BLOOD WBC-5.1 RBC-5.07 Hgb-15.1 Hct-43.7 MCV-86 MCH-29.8 MCHC-34.5 RDW-13.3 Plt Ct-179 [2142-11-9] 06:10AM BLOOD PT-12.4 PTT-27.2 INR(PT)-1.1 [2142-11-8] 06:20AM BLOOD Plt Ct-150 [2142-11-1] 08:49AM BLOOD PT-12.4 INR(PT)-1.1 [2142-11-1] 10:15AM BLOOD Plt Ct-179 [2142-11-8] 06:20AM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-136 K-4.6 Cl-102 HCO3-27 AnGap-12 [2142-11-1] 10:15AM BLOOD Glucose-269* UreaN-16 Creat-0.9 Na-135 K-3.7 Cl-106 HCO3-20* AnGap-13 [2142-11-1] 10:15AM BLOOD ALT-22 AST-18 CK(CPK)-60 AlkPhos-57 Amylase-47 TotBili-1.2 [2142-11-2] 07:37AM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE CHEST (PA & LAT) [2142-11-9] 8:55 AM CHEST (PA & LAT) Reason: pleural effusion/pneumothorax [Hospital 93] MEDICAL CONDITION: 61 year old man s/p CABG MAZE REASON FOR THIS EXAMINATION: pleural effusion/pneumothorax INDICATIONS: 61-year-old man status post CABG and maze. CHEST, PA AND LATERAL: Comparison is made to [2142-11-7]. The patient is status post coronary artery bypass graft surgery. The heart is mildly enlarged. Cardiac and mediastinal contours are unremarkable. There is a tiny right apical pneumothorax, and a probable tiny left apical pneumothorax, perhaps not discernable previously because of differences in technique. There is persistent volume loss at the left base with small effusions. Otherwise the lungs are clear. IMPRESSION: 1. Stable right apical pneumothorax. 2. Probable tiny left apical pneumothorax. 3. Stable volume loss at the left base. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1507] DR. [First Name11 (Name Pattern1) 3347] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 5034] Sinus rhythm. Early precordial QRS transition is non-specific. ST-T wave configuration suggests early repolarization pattern but clinical correlation is suggested. Since the previous tracing of [2142-11-5] sinus tachycardia and low T wave amplitude are now absent. TRACING #2 Read by: [Last Name (LF) ],[Known firstname 177] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 79 118 70 362/396.42 52 10 29 GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions: PRE-BYPASS: The left atrium is normal in size. 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. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. A homogenous echodensity of 1.5cm X 1cm is seen on the pulmonic valve c/w probable vegetation or mass is seen on the pulmonic valve. There is no pericardial effusion. POST_BYPASS: Preserved biventricular systolic function. Overall LVEF 60%. Trivial MR. The pulmonic valve is not visualized anymore after removal of the same by the surgeon. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD on [2142-11-5] 16:26. [Location (un) ] PHYSICIAN: Brief Hospital Course: Transferred from outside hospital and underwent cardiac catherization that revealed 3 vessel coronary artery disease. He was evaluated for cardiac surgery and underwent preoperative work up. On [2142-11-5] he was transferred to the operating room for coronary artery bypass graft surgery, MAZE procedure, and removal of mass from pulmonic valve. Please see operative report for further details. He was then transferred to the cardiac surgery recovery unit. In the first 24 hours he woke up neurologically intact and was extubated without difficulty. He was weaned from all vasoactive medications and was transferred to [Hospital Ward Name ] 2 on post operative day 2. He continued to progress. He remains in normal sinus rhythm on beta blockers and amiodarone, and coumadin was started. Activity was increased and he continued to progress. On post operative day 5 he was ready for discharge home with VNA services. Plan for INR to be checked [11-12] with results to Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 8430] with goal INR 2-2.5. Medications on Admission: Meds at home: Lipitor 40mg Zetia 10mg Ecotrin Atenolol 25mg Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease Paraxysmal Atrial Fibrillation Hypertension Hyperlipidemia Prostate cancer s/p resection and chemotherapy Discharge Condition: good Discharge Instructions: [Month (only) 116] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [First Name (STitle) ] [Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 5543] in [2-17] weeks please call for appointment Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 8430] in 1 week ([Telephone/Fax (1) 8431]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3633]) PT/INR to be checked [11-12] with result to Dr [Last Name (STitle) 8430] for further dosing Completed by:[2142-11-10] ICD9 Codes: 4111, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5001 }	Medical Text: Admission Date: [2114-11-13] Discharge Date: [2114-11-22] Date of Birth: [2039-8-6] Sex: F Service: MEDICINE Allergies: Aspirin / Hydralazine / Ace Inhibitors / Diovan / Heparin Agents Attending:[First Name3 (LF) 826] Chief Complaint: hypoxia/tachypnea, fever Major Surgical or Invasive Procedure: Left subclavain line History of Present Illness: Ms. [Known lastname 349] is a 75yo woman with h/o ESRD on HD, DM2, CHF, afib and CAD who presented to the ER today from her NH with complaint of fever to 103.8, chills, diaphoresis and confusion. On arrival to the ER she was found to have temp 101.0, HR 126, bp 180/86, and to be satting 82% on RA which improved to mid-90s on 4LNC. Chest XR showed continued and possibly increased R pleural effusion. She complained of midl abdominal pain, and CT abd/pelvis was unremarkable except for known enlarged gallbladder. She was given 1LNS, vanco and levo and was sent to HD where they were able to remove 1.2L. While at HD, the patient spontaneously desaturated to the 80s on 4LNC and required 50% face mask to regain sats of the mid-90s. ABG at that time showed 7.36/58/271. Stat CXR showed R pleural effusion but no clear pna. She received nebs and zosyn and was transferred to the MICU for further care. . In the MICU the patient had a bedside ultrasound to evaluate her effusion which showed no safe area for diagnostic tap. After a few hours in the MICU she dropped her pressures to as low as sbp78. She was given 1500cc total of NS. Central line was placed in a sterile fashion (LIJ) and she was started on levophed. Her blood cultures returned 4/4 bottles GPC in clusters. Past Medical History: - R pleural effusion tapped in [7-29] neg for malignant cells or infection (attempted tap x 3 without success, on fourth attempt were able to remove 200cc only) - CAD: cath [11-26] with 3VD, s/p cypher [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 to RCA. - atrial fibrillation - pulmonary HTN - hypertension - hyperlipidemia - DM2 - Severe lumbar spondylosis and spinal stenosis s/p laminectomy in [2110] - basal cell carcinoma - CHF: echo [1-28] shows 55% EF - hyperkalemia - ESRD on HD since [2111] after IV contrast for cath - Osteomyelitis T5-T6 on suppressive vancomycin for 3 months ([2113-4-13] was day 1) - MRSA bacteremia from HD line infection - mild-to-moderate cord compression [Date range (1) 3046]/05 and evaluated by neurosurgery felt mild and did not put patient at risk for cauda equina syndrome. - urosepsis - several HD line changes Social History: Lives at [Hospital ] [Hospital ] Nursing Home since [2111] and has been bedridden since that time [1-25] spinal stenosis. Past tobacco (quit [2111] 10py). Has three children - daughter nad son both in [Name (NI) 86] area and split her HCP. Widowed in [2108]. Retired - worked in retail clothing. Family History: Father died of CVA at 64yo. Mother died of MI at 86yo. Brother had CAD. Grandmother had T2DM Physical [Year (4 digits) ]: 102.0, 92, 150/40, 100% on 50% face mask, 28 gen: responds appropriately to questions, increased work of breathing, quite tachypneic, diaphoretic, severe kyphosis heent: PERRL (constricted), NCAT neck: unable to estimate jvp given pt inability to turn head cor: rrr, s1s2, no r/g/m pulm: scattered wheezes, decreased BS at right base abd: soft, ntnd, +bs, no hsm ext: no c/c/e, w/w/p Pertinent Results: [2114-11-13] 10:30PM LACTATE-2.1* [2114-11-13] 10:20PM GLUCOSE-142* UREA N-22* CREAT-1.9* SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-31 ANION GAP-10 [2114-11-13] 10:20PM CALCIUM-7.0* PHOSPHATE-2.1* MAGNESIUM-1.4* [2114-11-13] 10:20PM VANCO-7.6* [2114-11-13] 10:20PM WBC-9.5 RBC-3.43* HGB-11.3# HCT-32.3# MCV-94 MCH-32.8* MCHC-34.9 RDW-14.4 [2114-11-13] 10:20PM PLT COUNT-83* [2114-11-13] 10:20PM PT-16.6* PTT-27.6 INR(PT)-1.5* [2114-11-13] 10:20PM FDP-10-40 [2114-11-13] 06:41PM GLUCOSE-194* UREA N-21* CREAT-2.0* SODIUM-140 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-36* ANION GAP-13 [2114-11-13] 06:41PM CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-1.6 [2114-11-13] 06:41PM CORTISOL-43.6* [2114-11-13] 06:41PM WBC-12.5* RBC-4.47 HGB-14.4 HCT-42.6 MCV-95 MCH-32.1* MCHC-33.7 RDW-14.5 [2114-11-13] 06:41PM PLT COUNT-92* [2114-11-13] 06:41PM PT-14.6* PTT-25.8 INR(PT)-1.3* [2114-11-13] 06:41PM FIBRINOGE-654* D-DIMER-4952* [2114-11-13] 05:40PM TYPE-ART PO2-271* PCO2-58* PH-7.36 TOTAL CO2-34* BASE XS-5 [2114-11-13] 05:40PM LACTATE-2.2* K+-4.5 [2114-11-13] 05:40PM HGB-15.2 calcHCT-46 [2114-11-13] 10:11AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 [2114-11-13] 10:11AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM [2114-11-13] 10:11AM URINE RBC-[2-25]* WBC-[2-25] BACTERIA-NONE YEAST-NONE EPI-0-2 [2114-11-13] 10:00AM GLUCOSE-168* UREA N-35* CREAT-2.8* SODIUM-137 POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-29 ANION GAP-16 [2114-11-13] 10:00AM estGFR-Using this [2114-11-13] 10:00AM ALT(SGPT)-25 AST(SGOT)-32 LD(LDH)-244 CK(CPK)-20* ALK PHOS-205* AMYLASE-45 TOT BILI-0.4 [2114-11-13] 10:00AM CK(CPK)-22* [2114-11-13] 10:00AM LIPASE-20 [2114-11-13] 10:00AM CK-MB-2 cTropnT-0.07* [2114-11-13] 10:00AM CK-MB-NotDone cTropnT-0.08* [2114-11-13] 10:00AM ALBUMIN-3.5 [2114-11-13] 10:00AM CALCIUM-9.1 PHOSPHATE-3.2 MAGNESIUM-1.7 [2114-11-13] 09:45AM LACTATE-1.3 [2114-11-13] 09:35AM WBC-12.0* RBC-4.48# HGB-14.4# HCT-42.5# MCV-95 MCH-32.2* MCHC-33.9 RDW-14.4 [2114-11-13] 09:35AM NEUTS-85* BANDS-10* LYMPHS-0 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2114-11-13] 09:35AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2114-11-13] 09:35AM PLT COUNT-89* . . ECHO: [2114-11-14] Conclusions: 1. The left atrium is mildly dilated. The left atrium is elongated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6.There is mild pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Impression: No echocardiographic evidence of endocarditis seen. . CXXR [2114-11-14] IMPRESSION: No change is demonstrated in large right pleural effusion and atelectasis of the right lower lobe. An infectious process cannot be excluded. The left lung is unremarkable. The left subclavian line tip terminates in the left brachiocephalic vein. . . Discharge Labs: Hct 31 WBC 7.6 Plt 180; Na 137 K 4.3 BUN 15 Crt 2.6 Brief Hospital Course: #MRSA sepsis: Pt was admitted to the MICU and started on vancomycin and zosyn for antibiotic coverage. Once sensitivities returned as MRSA, the zosyn was discontinued. Her blood pressures were low on initial presentation so the patient was given bolus IV fluids and levophed. Her CVP was maintained above 8. She was eventually weaned off of the levophed. An extensive workup for the source of infection was limited by patient's wishes. She had a TTE which was negative but refused an MRI of the spine. The patient was afebrile during the ICU course. Surveillance cultures were negative after [2114-11-14]. She will receive long duration therapy with 6wks of Vancomycin to cover for osteomyelitis, as she has had this in the past. Her most recent vanco level was pending at time of discharge. . #Heparin Induced Thrombocytopenia: The patients platlet count continued to fall during her ICU stay. Heparin products were held and sent off HIT Ab labs which eventually came back positive. Her central line was also discontinued which was pre-treated with heparin. . #ESRD: The patient has ESRD and received dialysis through her fistula while in the MICU. No complications. Last dialysis was on [2114-11-22]. Pt required extra sessions of dialysis because of HD-related hypotension, which limited the extent of dialysis that could be done in one session. She was started on EPO 4000units with dialysis for CKD-related anemia. . #CAD: continue pt's BB and plavix. allergy to asa and ace. . #Chronic back pain w/ spinal stenosis: continue outpt morphine SR 30 qMon-Wed-Fri, and IR 15 q6h prn, as well as lidoderm patch. pt appears to be at her baseline back pain, however we wanted to do an MRI to rule out osteomyletis or epidural abscess but the patient refused. #[Female First Name (un) 564] UTI: Ms [Known lastname 349] had [Female First Name (un) ] in her urine and was started on a 7d course of fluconazole 200mg daily. This will completed on [2114-11-22]. She does not have a foley catheter and makes 20-30cc urine/day. . #DM: pt was continued on humalog sliding scale. Her glucose was well controlled with this. . #H/o Afib: pt was in sinus rhythm throughout her hospital stay. . #CAD: no evidence of ischemia during hospital stay. Pt continued on outpatient CAD regimen. Medications on Admission: metoprolol 12.5mg po bid prilosec 20mg po qday folic acid 1mg po qday plavix 75mg po qday lidoderm patch on 8am off 8pm vitamin C 500mg po bid ms contin 30mg po qMWF calcium carbonate 500mg po tid calcitriol 0.5mg qmwf celexa 20mg po qday klonopin 0.5mg po bid duonebs prn morphine IR 15mg po q4 prn Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q8AM-8PM (). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous QHD (each hemodialysis): Continue until [12-26], [2114]. 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QMOWEFR (Monday -Wednesday-Friday). 10. Morphine 15 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 11. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 19. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml Injection ASDIR (AS DIRECTED): TO BE GIVEN WITH DIALYSIS (4000units QHD). 20. Insulin Lispro (Human) 100 unit/mL Solution Sig: 2-10 units Subcutaneous ASDIR (AS DIRECTED): sliding scale 151-200 give 2u, 201-250 give 4u, 251-300 give 6u, 301-350 give 8u, 351-400 give 10u,. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Primary MRSA Sepsis End stage renal disease on Hemodialysis Heparin Induced thrombocytopenia . Secondary: Diabetes mellitus type II Spinal stenosis Congestive heart failure Hypertension Discharge Condition: Stable Discharge Instructions: Please continue to take all medications as prescribed. You will need to have a long course of vancomycin (an antibiotic) for your blood infection, this will likely be for 6 weeks. . If you have chest pain/pressure, fevers/chills, shortness of breath, nausea/vomiting, or any other concerning symptoms please call your PCP or come to the ED. . 1. Take medications as directed. 2. Attend all follow up appointments. . Your last Hemodialysis was on Thursday [2114-11-22] . Please AVOID HEPARIN PRODUCTS you had a reaction to it that caused your platelet count to drop. Followup Instructions: Please follow up with your PCP/NH physician--[Name10 (NameIs) 2113],[First Name3 (LF) 2114] R. [Telephone/Fax (1) 608] ICD9 Codes: 5119, 5856, 4280, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5002 }	Medical Text: Admission Date: [2161-12-22] Discharge Date: [2161-12-31] Date of Birth: [2119-9-15] Sex: F Service: SURGERY Allergies: Vasotec / Metformin / Lactose Attending:[First Name3 (LF) 1390] Chief Complaint: MVC Major Surgical or Invasive Procedure: [2161-12-23] - L1 through L3 spinal fusion, closed reduction nasal fracture, primary closure of right alar base laceration History of Present Illness: 42 yo F s/p MVC, unrestrained driver. Veered off road into [Doctor Last Name 6641]. +LOC, +airbag deployment. Unclear cause of crash; pt thinks she may have fallen asleep. Seen at OSH, found to have unstable L2 burst fracture, as well as L1 and L3 transverse process fractures. Imaging of CT torso, head, cspine otherwise negative on preliminary read. Transferred to [Hospital1 18] for further management. Pt also noted to have significant left facial swelling; transferred to TSICU for airway monitoring. INJURIES: - L2 unstable burst fracture - L1 bilateral transverse process fractures - L3 right transverse process fracture - mildly displaced nasal bone fracture Past Medical History: PMH: - DM2 - HTN - obesity - MRSA - chronic pain PSH: - lap RnY gastric bypass ([Doctor Last Name ] [2159]) c/b intraperitoneal bleed requiring emergent exlap ([Doctor Last Name ] [2159]) - lap cholecystectomy [2152] Social History: Patient lives at home with her parents, husband, and two children. Patient is a house wife, and her husband is a waitor at a chinese restaurant. Patient denies tobacco, alcohol or drug use. Family History: Family history of diabetes: father, paternal grandmother and grandfather. Maternal grandmother with [Name2 (NI) 499] cancer. Physical Exam: 96.4, 87, 108/60, 20, 98 % on room air alert and oriented, no acute distress facial edema, improved scleral hemorrhages bilaterally, periorbital ecchymoses bilaterally, EOMI, PERRL bruising along anterior neck, full ROM CTA B/L RRR soft, obese abdomen, nondistended, mild tenderness in epigastrium Pertinent Results: [2161-12-22] 07:55PM WBC-10.1# RBC-4.27 HGB-12.6 HCT-37.3 MCV-88 MCH-29.6 MCHC-33.8 RDW-12.7 [12-22] CT torso (2nd read): L2 burst fracture with moderate bony retropulsion into the spinal canal with small perivertebral hematoma. Transverse process fractures of L1, L2 and L3. Otherwise no acute injury in the chest, abdomen, or pelvis. [12-22] CT head (2nd read): No acute intracranial hemorrhage [12-22] CT cspine (2nd read): No acute fracture or malalignment of the cervical spine [12-22] CT face: Mildly displaced right nasal bone fracture. Significant soft tissue swelling and hematoma over the left face [12-22] CXR: no acute process [12-22] MRI L spine: Burst fracture of L2 with tear of the anterior and posterior longitudinal ligaments, but no obvious involvement of the interspinous ligaments. Significant retropulsion of fracture fragments into the spinal canal with posterior displacement and compression of the cauda equina. The conus terminates at the L1 level. [12-24] CXR: Tip of endotracheal tube is above the level of the clavicles, terminating about 7 cm above the carina. This could be advanced several centimeters for standard positioning. New nasogastric tube is coiled within the proximal stomach. Cardiomediastinal contours are within normal limits, and lungs are clear. No pleural effusion or pneumothorax. [2161-12-25] CT Torso: There is mild bilateral atelectasis. The airways are patent to the subsegmental level. There are no pulmonary nodules. No pulmonary effusion or pneumothorax. A central venous catheter is seen with the tip in the superior vena cava. The heart, pericardium, and great vessels are normal. No axillary or mediastinal lymphadenopathy is seen. The esophagus is normal and there is no hiatal hernia. Lack of contrast enhancement limits the examination of the intraabdominal viscera. Within the limitation, the liver, spleen, adrenals, pancreas, and kidneys are unremarkable. There is a small exophytic, hypodense lesion in the superior pole of the right kidney, that is too small to characterize. The patient is post-cholecystectomy and post Roux-en-Y gastric bypass. The gastrojejunal and jejunojejunal anastomoses are intact. The [Month/Day/Year 499] is within normal limits. The intraabdominal vasculature is unremarkable. There is no free fluid or free air. There is no abdominal wall hernia. There is no mesenteric or retroperitoneal lymphadenopathy. No evidence of intraabdominal bleed. The bladder is normal, there is a Foley catheter seen in the bladder. The terminal ureters, rectum, uterus, and adnexa are unremarkable. There is no free fluid in the pelvis. There is no pelvic wall or inguinal lymphadenopathy. The patient is post L1-L3 fusion. Some small foci of air are seen in the posterior subcutaneous tissues consistent with postoperative changes. There is a defect in the left iliac crest from prior bone graft donor site. No hematomas are seen. Brief Hospital Course: Ms. [Known lastname ] was admitted to the TSICU for intensive care and management following her MVC. On [2161-12-23] she went to the operating room with orthopedic surgery for L1-L3 spinal fusion and closed reduction of nasal bone fracture by plastic surgery. Post-operatively she was febrile to 103.2 and cultures were sent. She was extubated the following day but pain control posed a challenge so the chronic pain team was consulted. Lopressor was administered given tachycardia and hypertension but she subsequently was hypotensive to the 70's, which partially responded to a 1L bolus and neo was started. Her hematocrit trended down and she was transfused 2u pRBCs for hct 19. She subsequently stabilized off pressors and was transferred to the floor. Pain control continued to be an issue on the floor. Her regimen was altered multiple times including the use of lidocaine patch, gabapentin, standing tylenol, long acting PO narcotics, and short acting PO narcotics. Ms. [Known lastname ] was fitted for a TLSO brace and received that on [12-28]. She began working with PT and OT who recommended a course of inpatient rehab, feeling that she is a fall risk, needing more time to adjust to the brace, and that she will benefit from an aggressive PT/OT program to assist her in regaining her strength and prior activity level. She did have a mild TBI screen and OT felt that she had normal processing and would not require a cognitive [Month/Year (2) ] follow up after discharge. The patient remained very resistant to being discharged to a rehabilitation facility and preferred to stay in the hospital and work with PT/OT until they cleared her for home with services. She did work with PT daily and both her family were educated in the use of the TLSO brace and in coordinating ADLs with the use of the brace, rolling walker, and commode. On [12-31], Ms. [Known lastname ] was discharged to home with home PT and follow up appointments with her primary care provider, [Name10 (NameIs) ] chronic pain physician, [Name10 (NameIs) ] plastic surgeon, her orthopedic spine surgeon, and her bariatric surgeon and nutritionist. She is also being asked to make a routine ophthalmology appointment to have a dilated fundoscopic exam in the near future. She was discharged with prescriptions for a 10 day supply of her pain medication regimen in order to provide her with enough medication until her follow up visit with her chronic pain physician [Last Name (NamePattern4) ] [2162-1-7]. She was given prescriptions for all of the pain medications other than the liquid oxycodone. It was difficult to find a local pharmacy that carried a supply of oxycodone in the liquid form. This prescription was filled by [Hospital1 18] pharmacy and the patient was given a 7 day supply of the medication at the time of discharge. Medications on Admission: - dilaudid 8mg liquid q3-4 - Lantus 20-40 units intermittently - Vitamin B-12' - Cozaar 150' Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. docusate sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. gabapentin 300 mg Capsule [Hospital1 ]: One (1) Capsule PO TID (3 times a day). Disp:30 Capsule(s) Refills:0 5. acetaminophen 500 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q8 (). Disp:60 Tablet(s) Refills:0 6. morphine 45 mg Cap, ER Multiphase 24 hr [Hospital1 ]: One (1) Cap, ER Multiphase 24 hr PO Q8H (every 8 hours). Disp:30 Cap, ER Multiphase 24 hr(s) Refills:0 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Hospital1 ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:10 Adhesive Patch, Medicated(s) Refills:0 8. famotidine 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Cozaar 50 mg Tablet [Hospital1 ]: Three (3) Tablet PO once a day. Disp:90 Tablet(s) Refills:2 10. multivitamin Tablet [Hospital1 ]: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 11. thiamine HCl 100 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Calcium Citrate + 315-200 mg-unit Tablet [Hospital1 ]: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 13. oxycodone 5 mg/5 mL Solution [Hospital1 ]: [11-14] mL PO q3. Disp:900 mL Refills:0 14. Lantus 100 unit/mL Solution [Month/Year (2) ]: Twenty (20) units Subcutaneous at bedtime. Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Polytrauma L2 unstable burst fracture L1 bilateral transverse process fractures L3 right transverse process fracture mildly displaced nasal bone fracture Discharge Condition: You must wear the TLSO brace at all times when you are out of bed and walking around. Discharge Instructions: You have been treated for multiple injuries that you endured as a result of a car accident. You had multiple specialty teams participating in your care and it is very important that you follow up with each of them. We have made appointments for you listed below. If you need to change the date or time for these appointments, please contact their offices. You will need to see your primary care provider, [Name10 (NameIs) ] chronic pain physician, [Name10 (NameIs) ] spine surgeon, and the plastic surgeon. Your bariatric surgeon would also like to follow up with you. We also advise you to make a routine appointment to be evaluated by an ophthalmologist to have a dilated eye examination. You will be working with home physical therapists as well and it is important that you keep your brace on at all times when you are out of bed and follow their recommendations closely as they work with you moving forward. You should not drive while taking narcotic pain medications. It is very important that you follow this restriction. You cannot safely drive on your current medication regimen. You should take the bowel regimen prescribed to you to prevent constipation while taking your current pain medication regimen. You should take the vitamins prescribed to you as directed by your bariatric surgeon. You should plan to take 20 units of lantus each night, every night. Check your sugars at home. Follow up with your primary care doctor about your diabetes regimen. It is important that you take your medicine everyday, it is long-acting, and helps to keep your sugars under control throughout the day. Followup Instructions: [2162-6-15] 11:15a [Last Name (LF) ],[First Name3 (LF) ] H (LIVER CTR.) LM [Hospital Unit Name ], [Location (un) ] LIVER CENTER (SB) [2162-2-17] 10:30a [Location (un) ],GASTRIC SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] BARIATRIC SURGERY [2162-2-17] 10:15a [Doctor Last Name ],GASTRIC SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] GASTRIC BYPASS PRIVATE (NHB) [2162-1-12] 01:00p MANDYAM,VASUDEV C. (Primary Care) SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] [Hospital 191] MEDICAL UNIT (SB) [2162-1-12] 09:40a [Last Name (LF) 4983],[First Name8 (NamePattern2) 1141] [Last Name (NamePattern1) 95] (Ortho-Spine) SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] SPINE CENTER (SB) [2162-1-7] 08:40a [Doctor Last Name 8380] FLUORO 6 (Chronic Pain) ONE [Location (un) ] PLACE ([Location (un) ], MA), [Location (un) ] PAIN MANAGEMENT CENTER (SB) [2162-1-4] 02:00p [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]-CC3 [Doctor First Name 147] SPEC (Plastic Surgery) SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] SURGICAL SPECIALTIES CC-3 (NHB) Completed by:[2161-12-31] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5003 }	Medical Text: Admission Date: [2154-6-15] Discharge Date: [2154-7-1] Date of Birth: [2087-2-16] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Increased lethargy/Nausea Major Surgical or Invasive Procedure: [2064-6-18] closed left thoracostomy [2154-6-20] pericardial window History of Present Illness: This 67 year old black female is well known to the cardiac surgery service as she is s/p mitral valve repair(26mm Ring), coronary artery bypass x2(LIMA-LAD,SVG-OM1)on [2154-5-25] with Dr.[Last Name (STitle) 914]. She presents to the ED today from [Hospital1 ] in [Hospital1 8] with increasing lethargy and nausea. Upon ED workup she was found to have a supratherapeutic INR of 10.6. The CXR revealed a large left effusion, she had acute renal insufficiency with a creatinine of 4.2(baseline of 1.4) and electrolyte disturbance including hyperkalemia. She was admitted to the intensive care unit. Past Medical History: s/p mitral valve repair(26mm Ring),coronary artery bypass x2(LIMA-LAD,SVG-OM1)on [2154-5-25] insulin dependent diabetes mellitus hypertension depression hypercholesterolemia chronic osteomyelitis of feet coronary artery disease mitral regurgitation s/p multiple foot operations/resections diabetic retinopathy diabetic neuropathy Social History: Lives at home. No alcohol, tobacco, illicit drugs Family History: noncontributory Physical Exam: admission: Pulse: 53 Resp: 19 O2 sat: 97% B/P Right: 122/75 Left: Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [] Chest: (R)crackles/(L)very diminished sternal incision: Open pin hole mid sternotomy. Scant amount of serous drainage. Stable. No [Doctor Last Name ]/click Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [11-24]+pitting LE edema Neuro: Grossly intact Pulses: DP 2+ Femoral Right: Left: DP Right: Left: PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit Right: Left: Pertinent Results: [2154-6-16] ECHO Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are moderately thickened. There is a moderate sized pericardial effusion, which is likely cirumferrential although subcostal images are markedly suboptimal. There are no echocardiographic signs of tamponade. IMPRESSION: Probably normal biventricular function with moderate pericardial effusion (? circumferrential) and no echocardiographic signs of tamponade. [2154-6-16] Abdominal Ultrasound 1. Left pleural effusion. 2. Pulsatile flow within the portal vein, which is patent with hepatopetal flow. This may represent hepatic congestion due to congestive heart failure. Correlate clinically. 3. No evidence of hydronephrosis or renal calculi to explain renal failure. [2154-6-15] 02:30PM BLOOD WBC-9.1 RBC-3.19* Hgb-8.8* Hct-27.4* MCV-86 MCH-27.6 MCHC-32.0 RDW-19.0* Plt Ct-215 [2154-7-1] 05:04AM BLOOD WBC-9.3 RBC-3.25* Hgb-8.7* Hct-27.8* MCV-86 MCH-26.8* MCHC-31.3 RDW-19.3* Plt Ct-330# [2154-7-1] 05:04AM BLOOD PT-21.8* INR(PT)-2.0* [2154-6-30] 06:15AM BLOOD PT-23.0* INR(PT)-2.2* [2154-6-29] 04:30AM BLOOD PT-23.1* INR(PT)-2.2* [2154-6-27] 05:09AM BLOOD PT-20.8* PTT-40.5* INR(PT)-1.9* [2154-6-26] 04:51AM BLOOD PT-20.1* INR(PT)-1.9* [2154-6-25] 05:26AM BLOOD PT-19.2* PTT-38.6* INR(PT)-1.8* [2154-7-1] 05:04AM BLOOD Glucose-105* UreaN-37* Creat-1.3* Na-129* K-5.0 Cl-95* HCO3-27 AnGap-12 [2154-6-27] 05:09AM BLOOD Glucose-115* UreaN-37* Creat-1.1 Na-135 K-4.6 Cl-99 HCO3-29 AnGap-12 [2154-6-15] 02:30PM BLOOD Glucose-138* UreaN-92* Creat-4.2# Na-127 K-6.0* Cl-93* HCO3-18* AnGap-22* Brief Hospital Course: Mrs. [Known lastname 85671] was admitted to the [Hospital1 18] on [2154-6-15] for further management of her supratherapeutic INR, acute renal insufficency and pleural effusion. Her hyperkalemia was treated with dextrose, insulin and Kayexalate. FFP and Vitamin K were given for her elevated INR. An echocardiogram was performed which showed normal biventricular function with a moderate pericardial effusion with no clear echocardiographic signs of tamponade. The renal service was consulted for assistance with her renal failure. Dopamine was started for renal perfusion. She was pancultured for fever. A chest tube was attempted however failed given her habitus. Thoracentesis was thus performed which drained 1500cc of fluid. the effusion quickly recurred and a left chest tube was ultimately placed on [6-19]. The PICC line present on admission was removed and cultured and a new central line placed. Vancomycin was started and will continue until [6-22]. On [6-20], given the total clinical setting it was decided to proceed with pericardial drainage in the Operating Room. 500cc of fluid was removed with a prompt improvment of cardiac output measured via the PA catheter in place. The drains were removed when appropriate and anticoagulation was resumed for her chronic atrial fibrillation. She was continued on antibiotics for her osteomyelitis at the direction of the Infectious Disease service. She developed c. difficile colitis and was teeated with oral Flagyl and vancomycin. She remained afebrile and was ready for return to rehabilitation. The Infectious Disease service will follow her for the osteomyelitis and labs have been ordered to be sent to them. She still requires revascularization of ther lower extremeties. STOP [7-1] Medications on Admission: Paroxetine 20(1),Senna 8.6 (2 prn) Docusate Sodium 100 (2),Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)hours,Simvastatin 20(1)Calcium Acetate 667(3),Acetaminophen 325 (4 prn), Aspirin 81(1), Ranitidine HCl 150(2),13. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day),Metoprolol Tartrate 25 (3) Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush,Coumadin 2.5 mg Tablet Sig: as ordered Tablet PO once a day: INR goal 2-2.5,Amiodarone 200 mg Tablet Sig: as below Tablet PO twice a day: two tablets (400mg) [Hospital1 ] for 2 weeks, then one (200mg)twice daily for two weeks, then one daily,Furosemide 20(2)glargine 86 units SQ q am. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp\. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Five (5) ML Injection PRN (as needed) as needed for line flush. 13. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: as directed ac/hs Subcutaneous ac &hs: 120-160:2units SQ 161-200:4units SQ 201-260:6units SQ 261-300:8units SQ. 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 17. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours). 18. Cefepime 2 gram Recon Soln Sig: Two (2) gm Injection Q8H (every 8 hours). 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day. 20. Outpatient Lab Work CBC w/diff,LFTs,BUN,creatinine,trough vanco level weekly and fax to [Hospital 18] [Hospital ] Clinic ([Telephone/Fax (1) 1419]) Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: s/p mitral valve repair(26mm Ring), coronary artery bypass x2(LIMA-LAD,SVG-OM1)on [2154-5-25] insulin dependent diabetes mellitus pericardial effusion acute renal failure hypertension depression hypercholesterolemia chronic feet infections coronary artery disease mitral regurgitation s/p multiple foot operations/resections bilat foot ulcers diabetic retinopathy diabetic neuropathy peripheral vascular disease Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral medications Incisions: Sternal - healing well, no erythema or drainage Feet-wet to dry dressings daily to open sites. Edema 1+ [Name Prefix (Prefixes) ]-[Last Name (Prefixes) ] Discharge Instructions: 1) 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 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month until follow up with surgeon 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] 09/07/10/ at 1:15 ([Telephone/Fax (1) 170]) Please call to schedule appointments with your: Primary Care Dr. [First Name (STitle) ] L.[First Name (STitle) 18376] in [11-24] weeks ([Telephone/Fax (1) 3530]) Cardiologist Dr. [Last Name (STitle) ] in [11-24] weeks Vascular surgery as previously scheduled Infectious Disease-Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 457]) on [7-26] at 10am Weekly labs(CBCw/diff,BUN,creatinine,LFTs,trough Vanco level) and Fax results to [Hospital ] Clinic at [Telephone/Fax (1) 1419]. Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2-2.5 First draw m-W-Fr for two weeks then as directed. Results to rehab MD Completed by:[2154-7-1] ICD9 Codes: 5849, 5119, 2767, 3572, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5004 }	Medical Text: Admission Date: [2108-4-9] Discharge Date: [2108-4-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ]yo male with history of congestive heart failure, chronic kidney disease, gout, GERD, anemia, and possible MDS was admitted from the ED with weakness. . He initially presented to geriatrics clinic with 2-3 weeks of diarrhea and vomiting. Additional review of systems was notable for the following: poor intake, decreased appetite. He denied fevers, shaking chills, chest pain, shortness of breath, palpitations, abdominal pain, bright red blood per rectum, muscle aches, and pain. . Upon arrival in the ED, temp 98.3, HR 70, BP 75/45, and pulse ox 97%. His exam was notable for dry mucous membranes, irregular heart rate, and decreased skin turgor. His abdominal and pulmonary exams were unremarkable. He received levofloxacin 750 mg IV x 1, metronidazole 500mg IV x 1, potassium chloride 20mEq IV x 1, and 1L NS IVF. RUQ US demonstrated unchanged cholelithiasis and CXR was unremarkable. He was admitted to the [Hospital Unit Name 153] for further management of his hypotension and weakness. Upon arrival to the [Hospital Unit Name 153] he reports feeling much improved with improved strength. Past Medical History: 1. Congestive Heart Failure - [8-21] EF 20-30%, dilated RV, [12-16]+ MR, 1+ TR, dilated and hypokinetic RV - follows with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and Dr. [First Name8 (NamePattern2) 401] [Last Name (NamePattern1) 437] 2. Atrial Fibrillation - follows with Dr. [Last Name (STitle) ] - s/p BiV ICD - NSR on amiodarone therapy 3. Chronic Kidney Disease - Baseline Creatinine 2.3-2.8 - followed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4883] 4. Gout 5. GERD 6. Osteoarthritis 7. Myelodysplastic Syndrome - followed with Drs. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 410] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4135] - baseline hematocrit 32 / baseline platelets 100-120 / baseline WBC [3-18] 8. BPH 9. Hypertension 10. s/p Appendectomy Social History: - Home: lives in an [Hospital3 ] facility in [Location (un) 583]; supportive family with 1 daughter in CT, 1 daughter in [Name2 (NI) ], and 1 son in [Name2 (NI) ]; - Occupation:high school graduate and retired heating engineer - EtOH: Denies - Drugs: Denies - Tobacco: Quit smoking 20 years ago. Family History: Noncontributory Physical Exam: VS: T95, BP 104/46, HR 70, RR 23, O2sat 100% RA Gen: Elderly male, fatigued, no acute distress, resting comfortably in bed HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, JVP elevated to 8cm CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, mild rales at bases b/l, no wheezes or rhonchi ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant . On transfer: VS: T96.2, BP 89/62, HR 68, O2sat 97%RA Brief Hospital Course: [Age over 90 ] yo male with multiple medical problems including congestive heart failure, atrial fibrillation on coumadin, chronic kidney disease, and myelodysplastic syndrome was admitted to the [Hospital Unit Name 153] with hypotension in the setting of two weeks of diarrhea, treated with intravenous fluids. His course was notable for progressive renal failure and anuria. The patient and his family elected to focus on comfort; he was seen by the palliative consult team. His family spent the day with him on [4-18]; he died on [2108-4-19]. Medications on Admission: 1. Allopurinol 100mg PO qod 2. Amiodarone 200mg PO daily 3. Betamethasone cream daily 4. Calcitriol .25mcg PO q MWF 5. Colchicine .6mg PO qod 6. Aranesp 7. Furosemide 120mg PO tid 8. Lidocaine patch daily 9. Lisinopril 2.5mg PO daily 10. Lopressor 25mg PO bid 11. Nasonex 50mcg intranasally daily 12. Warfarin 2.5mg PO daily 13. Acetaminophen prn 14. Sarna 15. Omeprazole 20mg PO bid Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Renal failure Discharge Condition: Expired ICD9 Codes: 5849, 2762, 4254, 4280, 4240, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5005 }	Medical Text: Admission Date: [2199-4-23] Discharge Date: [2199-4-30] Service: MED HISTORY OF PRESENT ILLNESS: She is an 87-year-old woman found down by her daughter at home last seen well 24 hours prior. Patient had bilateral movement of her extremities at the scene, blood on her face. Found face down on the floor apparently moving all extremities equally at the scene, but intubated for airway protection. Was taken to [Hospital6 3426] where head CT showed a small subdural hematoma on the right. Patient was given Ativan 2 mg and then loaded with IV Dilantin. Past medical history of hypertension, asthma, ankle fracture in [2198-12-15]. On exam, her temperature was 98.9, heart rate 77, BP 131- 181/60-111. Patient was vented. She was intubated and sedated. HEENT: She had racoon eyes. Neck: She was in a C. collar. Cardiovascular: Irregular rhythm. Pulmonary: Breath sounds clear throughout. Abdomen: Soft, nontender, nondistended. Extremities: No clubbing, cyanosis, or edema. Neurologically: Sedated, not alert. Pupils: 2 mm and briskly reactive. She has positive corneals, positive gag. Face is symmetric. Minimal withdraw to noxious stimulation in all four extremities. Head CT shows right frontoparietal subdural 9 mm at its maximum thickness along the surface of the right frontal area. No midline shift and no mass effect. Patient was admitted to the ICU for close neurologic observation. Blood pressure was kept less than 140, and she was q.1h. neuro checks. INR less than 1.3. In speaking with the family on [2199-4-23], it was the family's wish that the patient become made DNR/DNI. On [4-24], the patient was extubated, and successfully and verbally following commands. Platelet count was low at 81, and she was transfused with platelets. Patient was evaluated by cardiology for her Afib. They recommended rate control, a surface echocardiogram, keeping her electrolytes within normal limits, keeping her heart rate in the 60 range. EEG was done, which just showed encephalopathy. The patient had repeat head CT which was stable. On [2199-4-25], she was transferred to the step-down unit. She remained awake, alert, following commands, and moving all extremities. On [2199-4-26], the patient had episode of nonsustained V-tach. Patient ruled out for a MI. Cardiology was notified. She continued to have some episodes of respiratory distress requiring some Lasix for CHF and also increasing heart rate with episodes of rapid Afib. Cardiology was reconsulted, and her Lopressor was increased. She was loaded with digoxin. She was seen by cardiology for possible cardioversion if rate control was not obtained. She remained neurologically opening her eyes briefly, following commands intermittently, verbalizing her name. Patient was seen by speech and swallow for possible PEG, although patient did not respond well to swallow testing. They did feel that with a couple of more days, before mental status improves, she may be able to generate a swallow without aspiration. Currently, she is at high aspiration risk and requires a feeding tube in place. Her vital signs have remained stable. She has been afebrile. She did have an induced sputum sent on [2199-4-24] that showed gram-negative rods. Although she has an allergy to penicillin, sensitivities on the sputum were performed. Currently, Bactrim sensitivity is still pending. The patient's vital signs have remained stable, and she is currently afebrile, and she was transferred to the medical service on [2199-4-29]. [Name6 (MD) ] [Name8 (MD) 739], MD [MD Number(2) 2930] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2199-4-30] 11:35:46 T: [2199-4-30] 12:01:37 Job#: [Job Number 61887] ICD9 Codes: 4280, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5006 }	Medical Text: Admission Date: [2156-1-11] Discharge Date: [2156-1-14] Date of Birth: [2090-6-6] Sex: F Service: [Company 191] HISTORY OF PRESENT ILLNESS: This is a 65 year old woman with a history of chronic obstructive pulmonary disease, bipolar disorder, status post abdominal aortic aneurysm, who was transferred from outside hospital, intubated secondary to no available Intensive Care Unit beds at outside hospital. Apparently, the patient presented from home with increased shortness of breath, fever of uncertain duration. She had no vomiting, diarrhea, chest pain or palpitations. Per outside hospital, other systems reviewed and negative. On presentation to the outside hospital, she was saturating 84% on four liters nasal cannula with an arterial blood gas of 7.17/77/44/27/67% on BiPAP 15/6 with 15 liters oxygen. She was then intubated after failing BiPAP. Further history is not available as the patient is currently intubated and sedated. PAST MEDICAL HISTORY: 1. Recent diagnosis of chronic obstructive pulmonary disease without pulmonary function tests. 2. Bipolar disorder. 3. Anxiety. 4. Narcotic dependence. 5. Status post right total knee replacement. 6. Status post abdominal aortic aneurysm repair. ALLERGIES: Prednisone and Bactrim. PHYSICAL EXAMINATION: Vital signs revealed a temperature of 101.2, pulse 74, blood pressure 120/60 on assist control 700/16. In general, intubated and sedated but arousable. Head, eyes, ears, nose and throat anicteric. Neck supple with no lymphadenopathy or jugular venous distention. Lungs - rhonchorous bilaterally. No decreased breath sounds. LABORATORY DATA: White blood cell count was 9.7, hematocrit 53.8, platelet count 198,000, neutrophils 85, lymphocytes 10%. Sodium 141, potassium 4.6, chloride 102, bicarbonate 33, blood urea nitrogen 32, creatinine 1.6, glucose 185. Chest x-ray showed mild upper zone redistribution with borderline cardiomegaly, no infiltrate. Electrocardiogram showed normal sinus rhythm, left atrial dilatation, T wave inversions in III and V1 without comparison. HOSPITAL COURSE: 1. Respiratory failure - This was felt secondary to chronic obstructive pulmonary disease causing hypercapnia and congestive heart failure causing hypoxia. A transthoracic echocardiogram was obtained which demonstrated left atrial mild dilatation and elongation, right atrial dilatation, mild symmetric left ventricular hypertrophy and hyperdynamic systolic dysfunction with an ejection fraction of 75% without wall motion abnormalities. This was felt to represent diastolic dysfunction as the patient with evidence of congestive heart failure on examination and chest x-ray. She was diuresed with intravenous Lasix and started on Diltiazem for rate control. The patient was treated with Aspirin and her cardiac enzymes cycled which were negative for myocardial infarction. The patient was felt also to be in exacerbation of her chronic obstructive pulmonary disease given significant wheezing on examination. She was not treated with p.o. steroids secondary to history of bipolar disorder exacerbated by steroid use. She was treated with inhaled steroids and inhaled bronchodilators. She was started on Ceftriaxone and Azithromycin for questionable community acquired pneumonia versus bronchitis exacerbating her chronic obstructive pulmonary disease. Repeat chest x-ray demonstrated persistent left lower lobe consolidation. The patient did well with this treatment and was extubated in 24 hours. She continued diuresis and treatment for chronic obstructive pulmonary disease. The patient was then transferred to the floor. The patient did well until [2156-1-16], when she was found to be rather somnolent in bed. Arterial blood gas demonstrated a pH of 7.33, pCO2 81, and pO2 of 54, bicarbonate of 45. This arterial blood gas was felt to be representing a chronic respiratory acidosis and metabolic compensation. Given her multiple psychiatric medications and pain medications, we discontinued her Neurontin, discontinued her Gabapentin and Flexeril, decreased her Fentanyl patch to 25 and decreased her Trazodone dose. The patient has since done well and her breathing is approaching her baseline although she remains oxygen dependent which she was not on at home. Plan is to continue diuresis, bronchodilators and inhaled steroids. She will be followed as an outpatient after rehabilitation with pulmonary function tests and a sleep study by her primary care physician, [Name10 (NameIs) 1023] was [Name (NI) 653] during her hospitalization. 2. Acute renal failure - The patient was admitted with a creatinine of 1.6 of unclear etiology. Repeat twelve hours later was 1.0 and the patient remained in the 0.7 to 0.9 range for the remainder of the hospital course. It is unclear the etiology of her elevated creatinine. 3. Bipolar disorder - We avoided the use of oral Prednisone secondary to risk of her psychiatric exacerbation. She was continued on her psychiatric medications but we were unable to get in contact with her psychiatrist to confirm each of these. 4. Chronic back pain - The patient was continued on her Fentanyl patch and Gabapentin and Flexeril. As noted above, her Fentanyl patch was decreased to 25. Her Gabapentin was discontinued and her Flexeril was discontinued as well secondary to sedation. This may be reevaluated at a further date. Until then, she was treated with p.r.n. Percocet. 5. Polycythemia - It was felt this is likely secondary to the patient's chronic respiratory acidosis. TSH was checked and is normal. Liver function tests, B12 and folate are pending at the time of this dictation. These may be followed up as an outpatient basis. The patient does deny significant alcohol use. 6. Deconditioning - The patient complains of chronic weakness at home. Her neurologic examination was unrevealing. TSH and electrolytes were normal. She was continued with physical therapy and will need further physical therapy on a rehabilitation basis. 7. Tobacco abuse - The patient was extensively counseled on the need for her to quit smoking. She was started on a Nicotine patch. She reports an allergy to Wellbutrin which was therefore not started. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To [Hospital ] Rehabilitation. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Chronic obstructive pulmonary disease. 3. Diastolic heart failure. 4. Bipolar disorder. 5. Acute renal failure. FOLLOW-UP PLANS: The patient will follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 311] after discharge from rehabilitation and with her psychiatrist, Dr. [Last Name (STitle) ] [Name (STitle) 12696], at [Telephone/Fax (1) 93017]. MEDICATIONS ON DISCHARGE: 1. Levofloxacin 500 mg p.o. once daily times four days. 2. Senna one tablet p.o. twice a day p.r.n. 3. Lactulose 30ml p.o. three times a day p.r.n. 4. Docusate 100 mg p.o. twice a day. 5. Nicotine patch 14 mg q24hours times five weeks. 6. Trazodone 100 mg one to two tablets p.o. q.h.s. 7. Citalopram 20 mg p.o. once daily. 8. Zonisamide 100 mg p.o. once daily. 9. Aspirin 325 mg p.o. once daily. 10. Clonazepam 1 mg p.o. three times a day. 11. Olanzapine 40 mg p.o. q.p.m. 12. Acetaminophen 325 mg two tablets q6hours. 13. Enoxaparin 40 mg q24hours while the patient immobile. 14. Guaifenesin 100 mg p.o. q6hours p.r.n. 15. Ibuprofen 400 mg two tablets p.o. q8hours. 16. Pantoprazole 40 mg p.o. once daily. 17. Fentanyl patch 25 mcg one patch q24hours. 18. Bumetanide 1 mg p.o. once daily. 19. Albuterol inhaler two puffs q4hours. 20. Ipratropium inhaler two puffs q6hours. 21. Fluticasone inhaler two puffs twice a day. 22. Albuterol nebulizer q4hours p.r.n. 23. Ipratropium nebulizer q6hours p.r.n. [Name6 (MD) ] [Last Name (NamePattern4) 5837], M.D. [MD Number(1) 8285] Dictated By:[Name8 (MD) 11246] MEDQUIST36 D: [2156-1-17] 10:56 T: [2156-1-17] 11:50 JOB#: [Job Number 93018] ICD9 Codes: 486, 2762, 5849, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5007 }	Medical Text: Admission Date: [2166-11-29] Discharge Date: Date of Birth: [2096-7-26] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 70 year old male with a history of bilateral lung cancer, status post resection and chemotherapy and radiation who experienced shortness of breath and diaphoresis the morning of his admission. He called his family and they found him to be short of breath, diaphoretic and they called Emergency Medical Services. The patient then had a PEA witnessed arrest, cardiopulmonary resuscitation was initiated. The patient was intubated in the field. He was given Epinephrine via his endotracheal tube, Atropine and his pulse and blood pressure were covered in the ambulance. The patient was taken to [Hospital 882] Hospital. At [Hospital 882] Hospital he again arrested (PEA arrest), cardiopulmonary resuscitation was initiated again and he was resuscitated with 2 mg of Epinephrine, 1 mg of bicarbonate and his first arterial blood gas was 6.90 pH, pCO2 of 111 and pAO2 of 123. He was started on a Dopamine drip. A left subclavian central line was placed and the patient was started on a Versed drip. He was transferred to [Hospital6 256] for further management as he received his care here. PAST MEDICAL HISTORY: 1. Right upper lung cancer, right upper lobe biopsy in [2166-4-26] consistent with adenocarcinoma, status post wedge resection, left upper lobe bronchial washings with poorly differentiated large cell cancer, status post lobectomy. The patient underwent chemotherapy with Carboplatin and Taxol and radiation there which he finished the week prior to his admission. 2. Hypertension. 3. Hypercholesterolemia. 4. Peptic ulcer disease. 5. Chronic sinusitis. SOCIAL HISTORY: Positive tobacco use with a 50 pack year history until [2165]. He had a history of occupational exposure to asbestos. FAMILY HISTORY: Positive for skin cancer, question melanoma, grandfather with carcinoma of the lip. MEDICATIONS ON ADMISSION: Amiodarone 200 mg p.o. q. day, Atenolol 25 mg p.o. q. day, Hydrochlorothiazide 25 mg p.o. q. day, Lipitor 10 mg p.o. q. day, Colace and Percocet prn, Trazodone 50 mg p.o. q.h.s., Tylenol, Flovent, Atrovent, Nasocort, Levaquin 500 q. day times seven days, Compazine prn, Metamucil, Robitussin, Oxycodone prn, Oxacillin prn. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Physical examination on admission revealed temperature 93.3, blood pressure 75/54, heartrate 129. Ventilator settings, assist control 800 by 16 with a rate of 16, 100% FIO2 and 5 positive end-expiratory pressure. In general he was intubated and not responsive to painful stimuli. Head, eyes, ears, nose and throat, pupils dilated, not responsive to light. Neck, unable to assess jugulovenous pressure. Cardiovascular, tachycardiac, regular rate, no murmurs. Lungs, coarse breathsounds bilaterally anterior with question of slightly diminished breathsounds at the left base. Abdomen, decreased bowel sounds, soft, nondistended. Rectal deferred. Obstetrics negative at outside hospital. Extremities, cool, mottled, positive dorsalis pedis pulses bilaterally. No edema and no urine was noted in his Foley catheter bag. LABORATORY DATA: On admission white count was 4.3, hematocrit 33.1, platelets 161, INR 1.4, PTT 38.5, ALT 314, AST 325, ALV 922, alkaline phosphatase 133, amylase 148, calcium 1.1, free calcium 1.17, lactate 6.9, sodium 142, potassium 3.3, chloride 101, bicarbonate 20, BUN 23, creatinine 1.1, anion gap of 20. Phosphorus 7.8, albumin 3.0. His electrocardiogram showed sinus tachycardia with right bundle branch block, T wave inversions in V1 and V2, T wave inversion in V3. Lower extremity ultrasound showed bilateral common femoral deep vein thrombosis and left superior clot. Chest x-ray showed right upper lobe infiltrate. HOSPITAL COURSE: 1. Pulmonary - The patient underwent a computed tomographic angiography which showed multiple pulmonary embolisms. He underwent thrombectomy with directed total parenteral alimentation. An inferior vena cava filter was placed by Interventional Radiology. He was started on heparin. He experienced hypoxemia and ventilatory failure secondary to pulmonary embolism but he also has a history of underlying lung disease including wedge resections, radiation, likely chronic obstructive pulmonary disease. During his hospital course the patient was treated for his pulmonary emboli and he was able to be slowly weaned from the ventilator. On [2166-12-5], the patient had a self-extubation which failed. He was reintubated and experienced likely intubation-associated pneumonia. His sputum grew out Methicillin-resistant Staphylococcus aureus. He was started on Vancomycin. He had a bedside tracheostomy performed and has since that time been slowly able to be weaned from the ventilator. He, at this time, is able to be weaned to tracheostomy mask for three to four hours per day. 2. Infectious disease - The patient had 2 out of 2 positive blood cultures from a left subclavian line that was discontinued and he was started on Vancomycin. His peripheral cultures remained no growth deep. He had Methicillin-resistant Staphylococcus aureus pneumonia and has been treated with Vancomycin to complete a two week course. 3. Heme - The patient received one unit of blood. His hematocrit remained stable. His platelets initially decreased but later recovered and have since then been normal. It was felt that he had likely consumption from his large clot burden as well as poor production given his recent chemotherapy. He was therapeutic on heparin and Coumadin was started prior to discharge. 4. Renal - Initially the patient had his creatinine bumped to 2.5, likely secondary to acute tubular necrosis from his arrest and also in the setting of large diload for computed tomographic angiography and angiogram. His creatinine trended down. He had good urine output and his kidney function was normal at the time of discharge. 5. Gastrointestinal - He initially had elevated liver function tests which recovered over his initial hospital stay. It was felt this was secondary to shock liver. He also had coffee ground emesis through his nasogastric tube after his total parenteral alimentation. He was started on Protonix and he had no further bleeding. At the time of discharge he was having normal bowel movements that were guaiac negative. 6. Nutrition - The patient was started on tube feeds via his percutaneous endoscopic gastrostomy that was placed at the bedside by Gastroenterology. He was tolerating them well. 7. Cardiovascular - The patient remained off of his antihypertensive medications during his hospital stay. These can be restarted as needed after discharge. 8. Access - The patient will be evaluated for a PICC line to be placed prior to discharge to complete his course of antibiotics. He has a tracheostomy and percutaneous endoscopic gastrostomy tube. The remaining discharge summary will be dictated as an addendum with discharge medications. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern1) 9422] MEDQUIST36 D: [2166-12-14] 10:50 T: [2166-12-14] 10:56 JOB#: [Job Number 43212] ICD9 Codes: 4275, 5845, 2875, 2762, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5008 }	Medical Text: Admission Date: [2136-5-3] Discharge Date: [2136-5-12] Date of Birth: [2101-1-25] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: thoracic tumor Major Surgical or Invasive Procedure: T8-12 Lami for tumor and Fusion T8-L2 History of Present Illness: Pt is a pleasant 35-year-old gentleman who had developed lower back pain. An MRI was obtained, which demonstrated a spinal and paraspinal mass. This is worked up with a biopsy, which was diagnostic for a low-grade spindle cell tumor. He continues to be asymptomatic,in particular, he denies any difficulty with bowel, bladder, or gait. His back pain is mild. Past Medical History: His past medical history is significant for asthma and cluster headaches. Social History: He does not smoke. He continues to work. Family History: NC Physical Exam: On examination, his motor strength is [3-31] in the upper and lower extremities. His sensory examination was intact with respect to the modality of light touch. His reflexes were normal and symmetric. There was no point tenderness in the thoracolumbar spine. There was no clonus and toes were downgoing bilaterally. Pertinent Results: An MRI of the thoracic spine obtained on [2135-12-26] was available for review. It demonstrates a left-sided paraspinal mass that proceeds from roughly T8-L1. It seems to originate from paraspinal location and expands to neuroforamina at T9-10, T10-11, T11-12, and T12-L1. There is significant extension within the spinal canal, which displaces the spinal cord from left to right. The majority of the mass is in the paraspinal region. The bone appears to be scalloped rather than invaded. Brief Hospital Course: Pt was admitted electively to the hospital and brought to the OR where under general anesthesia a thoracic laminectomy, excision of paraspinal mass, thoracic instrumented fusion and iliac crest bone graft was performed. He tolerated this procedure well and post-op was transferred intubabted to the SICU. His motor and sensation post op were intact. Pt developed anemia post-operatively and was transfused 2 units of autologus blood. Post transfusion hct remained at 26. he was extubated on first post op morning. He was begun on PCA. Drainage from 2 drains placed intra-op was monitored. His activity and diet were advanced. he was transferred to the floor. While on the floor, patient had both drains removed. A PT consult was obtained and patient began transferring and ambulating with assisstance. Pt was started on a bowel regimen and pain medications were changed to provide improved relief. On post op day #5 the pt's temperature was elevated to 102.7. CXR and UA were negative. LFT's were not elevated and he did not have any signs or symptoms of PE (no calf tenderness or cord noted on exam). Blood cultures were sent and the results no growth . His incision remains clean and dry without erythema. He has been ambulating quite frequently as well as utilizing his incentive spirometry. Chest/abdomen/pelvis CT done [2136-5-10] showed: 1. Status post thoracotomy at T8 through T10 with laminectomy extending from T9 through L1 and posterior fusion of T8 through L2. There is a collection of fluid and gas within the left paraspinal region extending from T8 through T12 as described above, which may represent post-surgical changes; however, infection cannot be excluded 2. Bilateral symmetric ill-defined low density involving the subscapularis muscles bilaterally, new since prior exam. Differentail includes muscular edema from positioning during surgery vs synovial fluid. 3. Layering left pleural effusion and adjacent compressive atelectasis. 4. Sigmoid diverticulosis without evidence of diverticulitis. IV Vancomycin 1g IV BID is started on [2136-5-11] for a 10-day course. The patient has remained afebrile for > 24 hours. His staples and drain sutures were removed [2136-5-12]. He is ambulating well, taking in food PO, and his pain is under control. Arrangements have been made for him to receive his vanco at the ER at [Hospital 71976] [Hospital 107] Hospital [Telephone/Fax (1) 71977]. Medications on Admission: albuterol, nexium, advair, zafirlukast Discharge Medications: 1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:60 Tablet(s) Refills:0 2. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed: do not drive while you are on narcotics for pain. Disp:60 Tablet(s) Refills:1 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:20 Tablet, Delayed Release (E.C.)(s) Refills:1 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily): this medication can be constipating as well as the narcotics. Make sure to compliment your diet with fluids and fiber. . Disp:120 Tablet(s) Refills:1 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO bid (). 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Bed [Hospital 485] hospital bed disp:1 10. raised toilet seat raised toilet seat with arms disp:1 11. equipment please provide a [Hospital ] hospital bed and raised toilet seat with rails 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 10 days: 10 days total, started [5-11]. Disp:18 Refills:0 13. PICC management per protocol PICC management per protocol 14. Outpatient Lab Work Please have a vancomycin trough drawn before your dose on [2136-5-14]. Please fax the results to our office [Telephone/Fax (1) 87]. 15. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tablet Sustained Release 12 hr(s) Refills:0 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home With Service Facility: Medlink Discharge Diagnosis: Thoracic Tumor fever urinary retention Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? [Month (only) 116] take daily showers. No tub baths or pools until seen in follow up. ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation - You need to have Vancomycin through your PICC line for a total of 10 days and you need a trough drawn on [2136-5-14]. Arrangements have been made at the ER at [Hospital 71976] [Hospital 107] Hospital [Telephone/Fax (1) 71977]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: Follow up with Dr [Last Name (STitle) 548] in 6 weeks with xrays. Call [Telephone/Fax (1) 2992] for appt. You should also follow up with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] [Telephone/Fax (1) 1844] from neuro-oncology on the same day as Dr [Last Name (STitle) 548] try to coordinate your appointments Completed by:[2136-5-12] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5009 }	Medical Text: Admission Date: [2150-11-25] Discharge Date: [2150-12-1] Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8587] Chief Complaint: Right femur fracture with vascular compromise Major Surgical or Invasive Procedure: [2150-11-25]: Right lower extremity angiogram, right above knee to below knee popliteal bypass graft with reversed saphenous vein, lower extremity fasciotomy. (Vascular surgery) [2150-11-25]: ORIF Left distal femur fracture with [Last Name (un) 101] plate (orthopaedics) [2150-11-27]: I&D with closure right leg wound (orthopaedics) History of Present Illness: Ms. [Known lastname ] is an 86 year old female who had a fall at home. She was taken to [Hospital3 79628] and found to have a right femur fracture and no distal pulses and a cool leg. She was then transferred to the [Hospital1 18] for further evaluation. Past Medical History: HTN osteoporosis s/p appy Right hip fracture Social History: Lives at home Family History: n/a Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended Extremities: RLE thigh with deformity, skin intact, no pulses DP/PT on doppler, toes blue/cold Pertinent Results: [2150-11-25] 05:55PM PTT-143.5* [2150-11-25] 04:23PM TYPE-ART PO2-200* PCO2-35 PH-7.35 TOTAL CO2-20* BASE XS--5 [2150-11-25] 04:23PM LACTATE-3.0* [2150-11-25] 04:05PM GLUCOSE-175* UREA N-10 CREAT-0.5 SODIUM-135 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-20* ANION GAP-11 [2150-11-25] 04:05PM CK(CPK)-402* [2150-11-25] 04:05PM CK-MB-9 [2150-11-25] 04:05PM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-3.0* [2150-11-25] 04:05PM WBC-10.8# RBC-3.68# HGB-11.0 HCT-30.8# MCV-84 MCH-30.0 MCHC-35.8 RDW-17.7* [2150-11-25] 04:05PM PLT COUNT-229 [2150-12-1] 06:15AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.9* Hct-32.3* MCV-88 MCH-29.8 MCHC-33.7 RDW-16.0* Plt Ct-266 [2150-12-1] 06:15AM BLOOD Plt Ct-266 [2150-12-1] 06:15AM BLOOD Glucose-94 UreaN-14 Creat-0.4 Na-140 K-4.6 Cl-104 HCO3-29 AnGap-12 [2150-12-1] 06:15AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.0 Brief Hospital Course: Ms. [Known lastname ] presented to the [Hospital1 18] on [2150-11-25] via transfer from [Hospital3 79628] with a right femur fracture and with no distal pulses (DP/PT). She was evaluated by the orthopaedic and vascular surgery services. She was then taken to the operating room and underwent an ORIF of her right femur fracture with orthopaedics and a right lower extremity angiogram, right above knee to below knee popliteal bypass graft with reversed saphenous vein, 2 right lower extremity fasciotomies, lateral performed by orthopaedics and medial performed by vascular surgery. She was then transferred to the Trauma ICU for further monitoring. On [2150-11-26] she was transfused with 2 units of packed red blood cells due to acute blood loss anemia. She was also started on Cipro for her urinary tract infection. On [2150-11-27] she was taken to the operating room and underwent an I&D with fasciotomy closure of her right leg. A drain was left in her medial incision. She tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. On the floor she was seen by physical therapy to improve her strength and mobility. On [2150-11-29] she was transfused with 2 units of packed red blood cells due to acute blood loss anemia. On [2150-11-30] her JP drain was removed since it had put out less than 20cc in one day. Her wound remained intact. Her lab data and vital signs were within acceptable range, her pain was well controlled, and she was tolerating a regular diet. On [2150-12-1] she was considered medically stable and was discharged to rehab in stable condition. Medications on Admission: asa 81mg daily colace 100mg [Hospital1 ] cozaar 50mg daily Toprol 25mg norvasc 10mg lexapro 5mg daily senna iron Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [Location (un) 2624] (a.k.a. [Location (un) 5481]) Discharge Diagnosis: Right femur fracture Acute blood loss anemia Right SFA disruption Urinary Tract Infection Discharge Condition: Stable/Good Discharge Instructions: Continue to be touchdown weight bearing on your right leg Continue your lovenox injections as instructed Please take all medication as prescribed Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * 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. Other: Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * Please resume all regular home medications and take any new meds as ordered. Physical Therapy: Activity: As tolerated Right lower extremity: Touchdown weight bearing Treatments Frequency: Staples/sutures out on [2150-12-11], 14 days after last surgery ([2150-11-27]), or at orthopaedic follow up visit Change dressings daily, or as needed for drainage, on right leg (dry gauze) Followup Instructions: Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP in orthopaedic clinic in 2 weeks, please call [Telephone/Fax (1) 1228] to schedule that appointment [2150-12-9] at 11:45am Please follow up with Dr [Last Name (STitle) 1391] in vascular surgery. Please call [Telephone/Fax (1) 1393] if needed to change appointment. ICD9 Codes: 2851, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5010 }	Medical Text: Admission Date: [2135-5-28] Discharge Date: [2135-5-31] Date of Birth: [2064-5-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2071] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: defibrillation cardiac catheterization [5-28] mechanical ventilation History of Present Illness: 70 yo F with no prior cardiac hx, + h/o hyperchol and htn, presented to [Hospital ] hosp ER with midsternal chest pain, nausea x 1.5 hrs. ECG showed inf STEMI. Got asa, plavix, heparin, intergrillin and was x-ferred to [Hospital1 ] for cath. here had a vf arrest in cath lab hallway, defibrillated 5 times, lido bolus and gtt; intubated for airway protection. . cath shoed TO prox rca and 80% mid rca, s/p cypher [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2; also 70 % mid lad, 60% diag (no intervention). at cath: RA 5 RV 35/7 PA 31/17/25 PCWP 17 10.2/6.33 remained hd stable; x-ferred to ccu. ste resolved post cath Past Medical History: HTN hyperchol Social History: n/c Family History: +FH of cad Physical Exam: Day of DC: 98.6 128/62 75 18 96RA 40/2200 NAD JVP flat Nl S1/S2 CTAB ant/lat soft, nd, nabs warm X 4 w/pulses X 4; cath site c/d/i Pertinent Results: Cath: PROCEDURE DATE: [2135-5-28] INDICATIONS FOR CATHETERIZATION: Ventricular fibrillation. ST segment elevation MI. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Elevated right and left sided filling pressures. 3. Acute inferior myocardial infarction, managed by acute PCI of the RCA. COMMENTS: 1. Selective coronary angiography demonstrated two vessel coronary artery disease in this right dominant circulation. The LMCA was without angiographically apparent flow limiting disease. The LAD was diffusely calcififed with a 70% mid-vessel stenosis and a 40% distal-vessel stenosis. The D1 had a 60% stenosis at the origin. The LCX had a 40% mid-vessel stenosis. The OM branches were without flow limiting disease. The RCA had a 100% proximal vessel occlusion followed by an 80% mid vessel stenosis. 2. Resting hemodynamics from right heart catetheterization demonstrated elevated right and left sided filling pressures (RVEDP=14mmHg and mean PCWP=17mmHg). Cardiac output and index were preserved at 10.2 L/min and 6.4 L/min/m2 respectively. 3. Left ventriculogram not performed to reduce contrast load. 4. Successful PCI of the proximal and mid RCA with two overlapping Cypher DES (2.5 x 13 mm and 2.5 x 28 mm), post-dilated with a 2.75 mm balloon. 5. Successful RFA arteriotomy closure with a 6 French Angioseal device. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 55 minutes. Arterial time = 50 minutes. Fluoro time = 15.9 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 150 ml Premedications: ASA 325 mg P.O. Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 1500 units IV Other medication: Atropine 0.6 mg IV Etomidate 10 mg IV Fentanyl 50 mcg IV Integrilin 5.6 cc bolus IV Integrilin 10 cc/hr IV TNG 50 mcg IC Propofol 60 mg IV bolus, then 30 mcg/kg/min Succinylcholine 40 mg IV Midazolam 2 mg IV Cardiac Cath Supplies Used: .014 CORDIS, WIZDOM SS 300 2.25 GUIDANT, VOYAGER 15 2.75 GUIDANT, HIGHSAIL, 23 2.75 [Company ], NC RANGER, 15MM 200CC MALLINCRODT, OPTIRAY 100CC 2.5 CORDIS, CYPHER RX, 28 2.5 CORDIS, CYPHER OTW, 13 ... ... TTE [2135-5-30] LVEF 50. TR 37. The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Resting regional wall motion abnormalities include basal inferoseptal and basal to mid inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. ... CXR portable [5-28]: The tip of the ETT 3.3 cm above carina - no evidence of CHF or pneumonia. ... Micro: UCx no growth ... [2135-5-28] 10:45PM TYPE-ART PO2-279* PCO2-24* PH-7.55* TOTAL CO2-22 BASE XS-1 [2135-5-28] 10:14PM GLUCOSE-108* UREA N-12 CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-21* ANION GAP-14 [2135-5-28] 10:14PM CK(CPK)-2067* TOT BILI-0.5 [2135-5-28] 10:14PM CK-MB-167* MB INDX-8.1* cTropnT-5.44* [2135-5-28] 10:14PM CALCIUM-8.2* PHOSPHATE-1.9* MAGNESIUM-1.7 [2135-5-28] 10:14PM WBC-7.7 RBC-3.66* HGB-11.2* HCT-32.7* MCV-90 MCH-30.5 MCHC-34.1 RDW-12.8 [2135-5-28] 10:14PM NEUTS-83.5* LYMPHS-12.4* MONOS-3.9 EOS-0.1 BASOS-0.1 [2135-5-28] 10:14PM PLT COUNT-186 [2135-5-28] 10:14PM PT-12.2 PTT-25.9 INR(PT)-1.0 [2135-5-28] 04:00PM TYPE-ART RATES-/21 TIDAL VOL-600 O2-100 PO2-507* PCO2-35 PH-7.23* TOTAL CO2-15* BASE XS--11 AADO2-186 REQ O2-39 INTUBATED-INTUBATED VENT-CONTROLLED [2135-5-28] 04:00PM K+-3.6 [2135-5-28] 04:00PM HGB-12.7 calcHCT-38 O2 SAT-98 Brief Hospital Course: The patient was brought to the cardiac catheterization laboratory upon arrival to [Hospital1 18]. On entry to the room, she arrested with VF. The patient was shocked at 200J and immediately cardioverted to sinus. She then began to scream and thrash before returning to VF. She was again shocked and again began to scream and thrash. This was repeated for a total of five cardioversions. Lidocaine was then administered. The patient was sedated, paralyzed and intubated and urgent cardiac catheterization was peformed. This revealed complete occlusion of the RCA which was revascularized with a cypher. There was an approximatley 60% lesion of the LAD. The plan for this lesion is outpatient stress test for consideration of future revascularization. Echocardiography was performed revealing LVEF>55% and basal inferoseptal and basal to mid inferior hypokinesis. The patient was started on ASA and plavix and we titrated up his BB and added ACE inhibition. His VF was felt [1-12] ischemia, so no further anti-arrhythmic was used. His TG was found to be 342 so gemfibrizol was initiated; the next day, on further consideration, the team decided to maximize statin with consideration of further treatment as OP. . The patient was discharged to home with recommendation of cards rehab to PCP [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 22552] in [Hospital1 ] who patient gives us permission to contact. We faxed a DC summary to him. The patient requested to see Dr. [Last Name (STitle) ] for cardiology FU; this was arranged. Medications on Admission: Lipitor Atenolol Premarin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Acute MI complicated by VFib arrest 2. HTN 3. Hypercholesterolemia Discharge Condition: stable Discharge Instructions: Please call your PCP or return to the ED if you develop chest pain/burning, shortness of breath, nausea, bloody stools, or other worrisome symptom. Please take all medications as prescribed. Followup Instructions: Cardiology: Mon, [6-20] @ 4PM w/Dr. [Last Name (STitle) ]; [Hospital Ward Name 23] building [Location (un) 436]([Hospital1 18] [Hospital Ward Name 516]); [Telephone/Fax (1) 4023] [Last Name (LF) 22552], [First Name7 (NamePattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] - [Hospital3 ] Internal Medicine on Friday, [2135-6-3] at 1PM. Please discuss with your Dr. [Last Name (STitle) 22552] arranging outpatient cardiac rehabilitation. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 2073] ICD9 Codes: 2762, 4240, 2859, 4168, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5011 }	Medical Text: Admission Date: [2123-7-2] Discharge Date: [2123-7-19] Date of Birth: [2078-7-13] Sex: F Service: INTERNAL MEDICINE CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 44 year-old woman who was brought to the Emergency Department by emergency medical services complaining of shortness of breath. The patient states that her shortness of breath has been constant, lasting all day and unrelieved by frequent use of MDIs. The EMTs noted diffuse wheezing, accessory muscle use, and oxygen saturation in the 50s. Her oxygen saturation improved to 80% on 100% face mask. On arrival to the Emergency Department the patient noted having shortness of breath progressing over several days with cough productive of yellow sputum. In the Emergency Department she was given Solu-Medrol and nebulizers. Arterial blood gases obtained in the Emergency Department demonstrated respiratory acidosis. Subsequently the patient was markedly tachypneic, and she was therefore subsequently intubated. She was also given 500 mg of Levofloxacin for empiric treatment of pneumonia. Suctioning of her airway while in the Emergency Department demonstrated yellow sputum. PAST MEDICAL HISTORY: 1. Asthma. The patient has been hospitalized twice previously in the Intensive Care Unit for asthma exacerbations, but she has never previously been intubated. 2. Legionella pneumonia in [2115]. PAST SURGICAL HISTORY: None. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Albuterol inhalers. 2. Serevent inhalers. SOCIAL HISTORY: The patient was not to believed to be actively smoking on admission to the hospital, but she does have at least a 20 pack year smoking history. She had no known history of alcohol abuse. She had no known history of prior recreational drug use, it is of note that the patient's initial urine tox screen was positive for cocaine. The patient lives alone and works in the [Location (un) 86] area. She has a very supportive family network. Her sisters were often at the bedside throughout her hospitalization. FAMILY HISTORY: Not known to be contributory. REVIEW OF SYSTEMS: Was not initially obtained secondary to the patient's respiratory distress on presentation to the Emergency Department. INITIAL PHYSICAL EXAMINATION: Temperature 97.2 degrees Fahrenheit, blood pressure of 146/80. Heart rate 100s. Oxygen saturation of 82% on 100% face mask, followed by 97% on the ventilator with 100% FIO2 and a PEEP of 10. In general, the patient was intubated and sedated. On HEENT examination her pupils were 2 mm in diameter and reactive. Her oropharynx was clear, there was no palpable lymphadenopathy and there was no jugulovenous distention. On examination of her lungs rhonchi were heard diffusely, there were no crackles. On cardiovascular examination the patient's heart was a regular rate and rhythm. There were normal S1 and S2 heart sounds and there were no murmurs, rubs or gallops. Her abdomen was soft, nonrigid and there was no guarding on examination. She had no edema of her extremities. Neurological examination was not assessed secondary to the patient's sedation. INITIAL LABORATORY EXAMINATION: Remarkable for a white blood cell count of 24.1, hematocrit 47.1, platelet count of 472. The differential on her white count included 96 neutrophils, 1 band and 3 lymphocytes. Initial coagulation studies indicated a PT of 12.4, PTT 25.9, INR of 1.1. Initial serum chemistries demonstrated a sodium of 136, potassium 5.1, chloride 97, bicarbonate 25, BUN 11, creatinine 0.6, serum glucose of 211. Initial urinalysis was contaminated. Initial arterial blood gas on 100% face mask demonstrated a pH of 7.23, PACO2 of 60 and PAO2 of 53. After intubation an initial arterial blood gas demonstrated pH of 7.09, PACO2 of 79 and PAO2 of 136. The settings were assist control with a tidal volume of 500, rate of 12 and a PEEP of 5. A second arterial blood gas obtained on assist control with a tidal volume of 500, rate of 20, and PEEP of 10 demonstrated arterial blood gas with a pH of 7.17, PACO2 of 65 and PAO2 of 85. Initial chest x-ray demonstrated an endotracheal tube 3 cm above the carinae. There was lingular and retrocardiac opacity. There was also right perihilar and upper lobe opacity. There was no evidence of pneumothorax. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. She was started on round the clock nebulizer treatments, intravenous steroids, intravenous antibiotics (Levofloxacin) and she was sedated and paralyzed given the fact that she was intubated. Her mechanical ventilation was adjusted to normalize her acid based status as well as to optimize her ventilation. On the second day of admission the patient had a brief episode of hypotension. She was briefly placed on a Dopamine drip, which was quickly weaned off as the patient's blood pressure increased appropriately. Also on the second day of admission the patient was started on Clindamycin for expanded antimicrobial coverage. In addition, her urine tox screen came back positive for cocaine on the second day of admission. This positive result raised the possibility of an aspiration pneumonia leading to an exacerbation of severe reactive airway disease as the etiology of the patient's presentation with status asthmaticus to the Emergency Department. Several days after admission the patient underwent a bronchoscopy in the Intensive Care Unit. This procedure demonstrated all airways and the endotracheal tube to be patent. Scant mucous was aspirated during the procedure. For the first several days of her hospitalization the patient required aggressive mechanical ventilatory support to maintain adequate oxygenation. She remained heavily sedated and paralyzed during the initial several days of her admission in order to minimize the stress of the mechanical ventilation. In addition, she was continued on intravenous steroids throughout the initial period of her hospitalization. On the [11-7] the patient developed mild anasarcas, she was administered intravenous Lasix and had an appropriate diuretic response. In addition, on the [11-7], the patient was taken off of Clindamycin. On the [11-8] a chest x-ray demonstrated a new left lower lobe/lingular infiltrate. Given the possibility of a new nosocomial pneumonia the patient was started on Ceftazidime as well as Vancomycin for treatment of this possible nosocomial pneumonia. On [7-10], the patient was started on Oxacillin for treatment of this possible nosocomial pneumonia and the Vancomycin was discontinued. Also on the 29th the patient had a thoracic CT scan for evaluation of the possibility of pulmonary embolism, no evidence of pulmonary emobolus were found on this scan. On the [7-10], a neurology consult was obtained for evaluation of the patient's gross motor weakness. This consulting service felt that high dose steroid myopathy was the possible etiology of the patient's diffuse weakness. They did not feel that a critical polyneuropathy was likely given the patient's preserved reflexes. In addition, they felt that a critical illness myopathy or neuropathy was also unlikely. For the next several days the patient remained difficult to wean off of the ventilator. She continued to require mechanical ventilation to maintain adequate oxygenation. On the [6-14], however, the patient was successfully extubated. She was then transferred to the General Internal Medicine Service on [2123-7-15]. On transfer to the General Internal Medicine Service, the patient was in good medical condition. She no longer had any symptoms of asthma and her asthma was being well controlled with appropriate asthma medications. She was also begun on an oral Prednisone steroid taper upon transfer to the General Internal Medicine Service. The patient remained in stable medical condition while on the Internal Medicine Service. The only significant physical finding while on this service was gross clinical evidence of a vaginal yeast infection. Given this gross clinical evidence the patient was treated empirically with Fluconazole 150 mg orally on the [7-17]. Given that the malodorous discharge did not resolve with one dose of Fluconazole the patient was again treated with 150 mg of oral Fluconazole on the [7-19]. Of note, upon extubation the patient remarks that she had been sexually assaulted prior to her admission to the hospital. A social work consult was obtained and the patient discussed this sexual assault with the social worker. The social work service offered the patient social work follow up upon discharge from the hospital. In addition, laboratory tests for syphilis, HIV, and chlamydia and gonorrhea were sent. An RPR test for syphilis was negative. At the time of discharge serum HIV test was pending. In addition, urine, chlamydia tests as well as a cervical chlamydia and gonorrhea probe were also pending. The patient continued to exhibit diffuse muscular weakness on the General Internal Medicine Service. The etiology of this weakness was believed to be secondary to prolonged administration of steroids while in the hospital. The patient was deemed by physical therapy and occupational therapy to be in excellent rehabilitation candidate. Arrangements were therefore made for the patient to be transferred to an acute rehabilitation facility upon discharge from the hospital in order for her to increase her physical and muscular strength. The patient was in good medical condition on discharge from the hospital. DISCHARGE DIAGNOSES: 1. Status asthmaticus. 2. Cocaine abuse. DISCHARGE MEDICATIONS: Salmeterol inhaler four puffs twice a day. Albuterol inhaler two to four puffs every four hours as needed. Atrovent inhaler two to four puffs every four to six hours as needed. Flovent 110 micrograms four puffs twice a day. Nystatin ointment applied topically as needed four times a day. Diphenhydramine 25 mg in the evenings as needed for sleep. The patient was sent home on a Prednisone taper. She was to take 30 mg of Prednisone once on the day following discharge followed by 20 mg once a day for three days followed by 10 mg once a day for three days followed by 5 mg once a day for seven days. That would be the end of the prednisone taper. Note an addendum will follow this dictation to note where the patient was discharged to as well as any additional information required. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[First Name (STitle) 9211] MEDQUIST36 D: [2123-7-19] 11:12 T: [2123-7-19] 11:26 JOB#: [Job Number 9212] ICD9 Codes: 5070, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5012 }	Medical Text: Admission Date: [2105-9-1] Discharge Date: [2105-9-22] Date of Birth: [2020-8-22] Sex: M Service: NEUROSURGERY Allergies: Bupropion Analogues Attending:[First Name3 (LF) 1835] Chief Complaint: FALL Major Surgical or Invasive Procedure: Left sided craniotomy for SDH evacuation [9-11] Open gastrostomy tube [9-17] History of Present Illness: This is an 85 year old man with history of dementia who lives at home with his daughter. Today he was in his driveway when he fell and struck his head. He went back into his house and called 911 for help. Upon EMS arrival he was in his usual state answering questions and oriented to himself and his family. Pt taken to OSH where he began to have mental status changes and became less responsive. He was intubated and CT of the head showed left sided SDH with midline shift and diffuse SAH with bifrontal contusions. He was transfered to [Hospital1 18] for further evaluation. He was taking ASA and plavix for a previous cardiac stenting. He did not receive any blood products prior to transfer. Past Medical History: s/p removal of duodenal adenoma dysplasia and pancreatic endocrine tumor [5-/2099] Depression Ankle fracture 3 wks ago Hypercholesterolemia Mild dementia GERD chronic constipation known urinary frequency Social History: retired pathologist, no smkg, ETOH, drugs, married, lives at home with wife Family History: father: MI in his 70s uncle: died in 60s of MI Physical Exam: On admission: PHYSICAL EXAM: BP: 151/86 HR: 74 R 18 O2Sats Gen: Intubated and sedated HEENT: Pupils: 2-1.5mm EOMs Unable to evaluate Occipital laceration noted, not currently bleeding Neck: C collar in place Extrem: Warm and well-perfused. Neuro: Mental status: Intubated and sedated. Not following commands. MAE to noxious stimuli. Sensation: Intact to noxious stimuli On Discharge: ****************** Pertinent Results: [9-1] Head CTA: IMPRESSION: 1. Extensive acute subdural hematoma along the left cerebral convexity with subdural hemorrhage along the falx and subarachnoid hemorrhage as described above. There is midline shift of approximately 6 mm. 2. Limited opacification of the distal/small branches of the intracranial internal carotid and vertebrobasilar system. The cervical and intracranial vertebral and basilar arteries appear unremarkable. The proximal branches of the intracranial internal carotid and vertebrobasilar system appear unremarkable. [9-1] Cspine CT: IMPRESSION: 1. No evidence of fracture. 2. Grade 1 anterolisthesis of C3 on 4, of indeterminant chronicity. If there is high clinical concern for a ligamentous injury, an MRI is suggested. 3. Right thyroid nodules, partially calcified. [9-3] Head CT:IMPRESSION: Overall similar appearance of extensive subdural hematoma and subarachnoid hemorrhage, with mild redistribution of blood products, making the right lateral ventricle intraventricular portion more prominent. [9-3] Head CT: IMPRESSION: No significant change in extent of the predominantly left holohemispheric subdural hematoma and subarachnoid and intraventricular hemorrhage. Stable 3-mm left to right midline shift. No new hemorrhage is identified. [2105-9-7]: CT head 1. Interval increase in the size of subdural collection with focal increased density suggestive of rebleeding. 2. Continued evolution of the previously described bilateral subarachnoid hemorrhage and bifrontal hematomas. [2105-9-7]: Video swallow Abnormal oropharyngeal swallowing videofluoroscopy with aspiration of thin liquids and nectar-thickened liquids. There was penetration of honey-thickened liquids. Patient was able to swallow puree and soft solids without aspiration or penetration. [9-11] CT HEAD Interval increase in the thickness of the left subdural fluid collection, which appears to be appropriately evolving with regard to its density. Appropriate evolution of the subarachnoid hemorrhage and bifrontal hematomas without evidence of new bleeding or infarction. [9-11] CT HEAD Post-OP Status post left subdural hematoma evacuation with improvement of midline shift and expected pneumocephalus and subcutaneous emphysema; persisting but largely unchanged subarachnoid blood. [9-21] Shoulder X-ray 3 views Calcific tendinopathy. Mild acromioclavicular and glenohumeral osteoarthritis. Brief Hospital Course: Dr. [Known lastname ] was admitted to the SICU for close neurological observation. There were discussions with his family and it was decided that he would not want extreme measures if a meaningful outcome was not expected. At that time he was made DNR/DNI. Over the first couple of hours the patients exam improved significantly therefore there were further discussions with the family. His code status was then changed to DNR only. On [9-2] he was extubated and noted to be expressively aphasic but MAE's with 4/5 strengths. On [9-3] PT and OT consults were requested for discharge planning. Speech and Swallow was also consulted to assess his risk for aspiration. He did not pass and was kept NPO at this time. He was cleared for transfer to the floor. On [9-4] & [9-5] he continued to improve neurologically. Per the patient's daughter, he had a low testosterone level at an OSH. Endocrine was consulted and did not recommend repletion at this time. On [9-6] the patient was awake, alert but continued to be aphasic. He is ambulating with nursing and complaining about being hungry and thirsty. Speech and Swallow consultation for re-evaluation was requested. On [9-7] video swallow study was done which the patient failed and thus remained NPO, the patient had a head CT which showed that there was new blood and as such Plavix was not restarted and his aspirin was discontinued. An attempt was made to place a dobhoff tube which was unsuccessful. he also pulled out his IV and the IV nurse was unable to place a new peripheral so a PICC line was requested. On [9-8] his exam remained stable and his OOB to chair. A PICC line was placed and his potassium was repleted for a level of 3.0. He also spiked a fever to 101.0 for which he was pancultured. Pt was planned for a PEG tube on [9-10] as he was deemed unsafe for PO diet by the speech and swallow team multiple times. He was scheduled for placement on [9-10]. He did have lower extremity dopplers for screening purposes given his prolonged hospital stay and bedrest. These were negative for DVT. He did have left upper extremity swelling on exam and upper extremity dopplers showed DVT within axilary vein and plan was for anticoagulation and removal of his PICC line. A routine head ct obtained prior to anticoagulation showed an increase in his left sided subdural hematoma with increase in midline shift. His exam was slightly worse on this day and was only oriented to himself. Surgery was offered to the family and they agreed to move forward with his care and he was brought to the operating room on [9-11] for burr hole drainage of his now chronic SDH. Post operatively he did well and was transported from the PACU to the floor on [9-12]. His cipro was changed from PO to IV, and his PEG was placed on hold as his daughter was [Name2 (NI) 16535] to consent for the procedure. Also on [9-12] he pulled out his PICC line. Post-operatively his exam was stable as well. He remained stable on the floor over the weekend and on [9-15] consent was obtained by IR for him to receive a PEG tube. He was taken by IR for placement of the PEG but they were unable to place it secondary to agitation and bowel positioning. On [9-16], general surgery was consulted for PEG placement under general anesthesia. On [9-17] pt taken to the OR with general surgery and underwent open PEG placement without complication. After the procedure his G tube was opened to gravity and on [9-18] medications were administered through his tube. The plan was to continue medications on this day and start tubefeeds via G tube on the morning of [9-19]. On [9-19] he was noted to have some abdominal pain and swelling and general surgery was contact[Name (NI) ] to evaluate him. After valuation they felt he was at his baseline. Also on [9-19] he was noted to have some Right shoulder pain so an orthopedics consult was called and a single view of the shoulder was ordered. the scan showed moderate AC joint arthropathy. On [9-20] he remained stable and nutrition was consulted to give recommendations for tube feeds which were obtained and implemented. His exam continued to be consistent and on [9-22] he will be discharged to rehab Medications on Admission: ASA, Plavix Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Levetiracetam 100 mg/mL Solution Sig: Ten (10) ml PO BID (2 times a day). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Effexor XR 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 14. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: LEFT SDH SUBARACHNOID HEMORRHAGE RESPIRATORY FAILURE DYSPHAGIA Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. You are being discahrged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[2105-9-30**] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5013 }	Medical Text: Admission Date: [2167-2-11] Discharge Date: [2167-2-13] Date of Birth: [2137-5-8] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[Last Name (NamePattern1) 495] Chief Complaint: Multisystem failure Major Surgical or Invasive Procedure: intubation central line placement History of Present Illness: 29 y/o M who presented to the [Hospital 1281] Hospital Emergency Room after being found unresponsive by his mother. [Name (NI) ] was spoke to his mother at 9Pm the night previously. The following morning she was unable to reach him by phone and so activated EMS. On arrival, patient was found unresponsive on the floor. He was noted to have shallow agonal breathing with BP of 100. Intubated at the site on the second attempt to to vomiting and a seizure with first attempt. . At the OSH 7.1/39/71, he was noted to be in acute liver failure with elevated tylenol level and was given activated charcoal and started on mucomyst gtt. He was then transferred to the ICU. . ICU course by system: Hypotension: IVF's given, started on levophed and vasopressin for hypotension. He was given decadron for refractory hypotension, and [Initials (NamePattern4) ] [Last Name (NamePattern4) 104] stim was performed. Zosyn empirically. BP at time of transfer was reportedly in 70's with HR 110-120. . Renal: Cr was 1.7 at time of transfer. He was given 10 amps of bicarb and started on a bicarbonate gtt 200ml per hour. . Cardiac: Bedside echo was reportedly notable for euvolemic IVC and hyperdynamic LV. . Liver: Transaminases mildly elevated with AST 87, ALT 71, INR 3, PT 13.1. He received charcoal and mucomyst as described and last tylenol level was 701. Was given low dose vitamin K for elevated INR. . Mental Status: Patient was essentially flacid w/o DTR's or corneal reflexes. His pupils were fixed and dilated. however, he was spontaneously breathing on occasion and intermittently reponsive by report from OSH. Head CT showed no evidence of acute intracranial process. CT C-spine also interpreted negative. . In Med Flight, patient was hypertensive so levophed was weaned to off, but hypotension recurred. Patient was bag ventilated and chest tube was on suction in med flight, but off suction in transport to ICU. . On arrival to the ICU, patient had a PEA arrest with return of spontaneous circulation/perfusing rhythm after 20 minutes. He received 3 amps bicarbonate and had a needle decompression of his chest performed by Dr. [Last Name (STitle) ]. Past Medical History: depression Social History: Lives alone in apartment for last 7 months. Working in a supermarket in the meat department. Father recently deceased. Was a non-smoker with occasional ETOH use. Family History: Depression Physical Exam: s/p arrest, HR low 100s, BP 106/75, RR 30, T102 Gen: Calm, non-responsive, pupils fixed and dilated (post-code) HEENT: NCAT, face puffy Chest: Symmetric breath sounds coarse Heart: irregularly irregular Abd: no bowel sounds, soft non-distended, overweight Ext: wwp, no LE edema, good LE pulses Neuro: pupils fixed and dilated, no gag, no corneal reflexes, no DTR's, agonal breathing Pertinent Results: [2167-2-11] 10:10PM BLOOD WBC-9.5 RBC-5.47 Hgb-17.7 Hct-48.3 MCV-88 MCH-32.4* MCHC-36.7* RDW-13.5 Plt Ct-266 [2167-2-12] 04:36AM BLOOD WBC-14.6# RBC-5.30 Hgb-17.0 Hct-47.6 MCV-90 MCH-32.2 MCHC-35.8* RDW-13.6 Plt Ct-235 [2167-2-12] 02:34PM BLOOD WBC-26.4# RBC-4.67 Hgb-14.9 Hct-42.7 MCV-91 MCH-31.8 MCHC-34.8 RDW-14.2 Plt Ct-168 [2167-2-12] 08:41PM BLOOD WBC-23.5 RBC-3.58* Hgb-11.5# Hct-32.5# MCV-91 MCH-32.1* MCHC-35.4* RDW-14.7 Plt Ct-131* [2167-2-13] 02:48AM BLOOD WBC-24.0* RBC-4.06* Hgb-12.8* Hct-37.3* MCV-92 MCH-31.4 MCHC-34.2 RDW-14.9 Plt Ct-103* [2167-2-11] 10:10PM BLOOD PT-37.2* PTT-45.4* INR(PT)-4.0* [2167-2-12] 04:36AM BLOOD PT-64.8* PTT-54.6* INR(PT)-7.8* [2167-2-12] 09:23AM BLOOD PT-95.9* PTT-65.8* INR(PT)-12.6* [2167-2-12] 02:34PM BLOOD PT-148.1* PTT-85.5* INR(PT)-21.5* [2167-2-12] 04:36PM BLOOD PT-34.5* PTT-76.5* INR(PT)-3.6* [2167-2-12] 08:36PM BLOOD PT-38.6* PTT-86.7* INR(PT)-4.2* [2167-2-13] 01:13AM BLOOD PT-51.0* PTT-122.8* INR(PT)-5.8* [2167-2-13] 02:48AM BLOOD PT-55.2* PTT-138.3* INR(PT)-6.4* [2167-2-11] 11:33PM BLOOD K-4.9 [2167-2-12] 04:36AM BLOOD Glucose-94 UreaN-22* Creat-2.7* Na-149* K-4.8 Cl-109* HCO3-17* AnGap-28* [2167-2-12] 09:23AM BLOOD Glucose-135* UreaN-29* Creat-3.4* Na-149* K-5.7* Cl-103 HCO3-16* AnGap-36* [2167-2-12] 02:34PM BLOOD Glucose-123* UreaN-32* Creat-4.0* Na-148* K-6.4* Cl-100 HCO3-14* AnGap-40* [2167-2-13] 02:48AM BLOOD Glucose-97 UreaN-33* Creat-4.9* Na-145 K-6.0* Cl-95* HCO3-12* AnGap-44* [2167-2-11] 10:10PM BLOOD ALT-307* AST-304* LD(LDH)-982* CK(CPK)-2474* AlkPhos-38* TotBili-1.1 [2167-2-12] 02:34PM BLOOD ALT-[Numeric Identifier 81694]* AST-9845* LD(LDH)-[Numeric Identifier 5161]* CK(CPK)-7471* AlkPhos-48 TotBili-1.6* [2167-2-13] 02:48AM BLOOD ALT-[Numeric Identifier ]* AST-[Numeric Identifier 39474]* LD(LDH)-[Numeric Identifier 41572]* CK(CPK)-7943* AlkPhos-91 TotBili-3.0* [2167-2-11] 10:10PM BLOOD CK-MB-26* MB Indx-1.1 cTropnT-0.04* [2167-2-12] 09:23AM BLOOD CK-MB-41* MB Indx-0.6 cTropnT-1.61* [2167-2-13] 02:48AM BLOOD CK-MB-38* MB Indx-0.5 cTropnT-1.77* [2167-2-12] 02:34PM BLOOD Albumin-2.1* Calcium-6.0* Phos-9.9* Mg-2.5 [2167-2-13] 02:48AM BLOOD Albumin-2.4* Calcium-7.4* Phos-10.8* Mg-2.4 [2167-2-11] 11:33PM BLOOD Acetmnp-603* [2167-2-12] 09:23AM BLOOD Acetmnp-475* [2167-2-12] 02:34PM BLOOD Acetmnp-399* [2167-2-13] 02:48AM BLOOD Acetmnp-326* [2167-2-11] 10:30PM BLOOD Type-ART pO2-60* pCO2-88* pH-6.92* calTCO2-20* Base XS--18 [2167-2-13] 03:01AM BLOOD Lactate-18.0* Brief Hospital Course: Mr [Known lastname 81695] was medflighted to [Hospital1 18] after he overdosed on tylenol and developed multisystem failure including acute hepatic failure, ARDS, and acute renal failure. He required 4 maxed out pressors to maintain a BP, but even with this his BP slowly dropped by HD#2. He remained intubated with fixed dilated pulils and no signs of cerebral function. He expired on [2-13], [2166]. Medications on Admission: Klonopin Lexapro Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: multiorgan dysfunction due to tylenol overdose Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a ICD9 Codes: 5070, 5849, 2762, 0389, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5014 }	Medical Text: Admission Date: [2187-2-26] Discharge Date: [2187-4-24] Date of Birth: [2128-11-24] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 148] Chief Complaint: pancreatic pseudocyst Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Washout and drainage of the abdomen. 3. External drainage of pancreatic pseudocyst. 4. Pancreatic necrosectomy. 5. Open cholecystectomy. 6. G tube placement. 7. J tube placement. History of Present Illness: Patient is a 56 year old gentleman who recently underwent an exploratory laparotomy and debriedment of abdominal wall abscess at [Hospital3 3583] in setting of prior subtotal gastrectomy and and partial colon resection in past. HIDA scan at [Hospital1 3325] was consistent with biliary leak. Patient complained of epigastric abdominal pain and was found to have pancreatits with amylase 1035, lipase 2280 and CT scan showing significant peripancreatic inflammatory changes consisitent with pancreatitis. He improved and was discharged home on [2187-2-21] from [Hospital3 3583] but returned on [2-24] with lower extremity edema. He was found to hava a R popliteal vein thrombosis extending to the superficial femoral vein. Repeat CT scan showed extensive perihepatic fluid collections consistent with pancreatic psuedocysts and pancreatic necrosis. Patient was subsequently transferred to the [Hospital1 18] for further management. Past Medical History: Atrial fibrilation Pancreatitis DM (recent) DVT (recent) HTN bilateral CEAs Social History: non-contributory Family History: non-contributory Physical Exam: NAD Tracheostomy capped Bibasilar crackles, good air entry abdomen soft, non-tender, healing midline open incision with overlying wound drain Pertinent Results: [2187-4-22] 8:25 pm STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2187-4-23] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2187-4-23]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [2187-4-2] 7:07 am SWAB Source: Rectal swab. FINAL REPORT [2187-4-4] R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [2187-4-4]): No VRE isolated. [2187-3-22] 09:28PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2187-3-22] 09:28PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.030 [2187-4-21] 07:25AM BLOOD WBC-9.7 RBC-2.83* Hgb-9.3* Hct-29.0* MCV-102* MCH-32.8* MCHC-32.0 RDW-24.4* Plt Ct-268 [2187-4-17] 06:00AM BLOOD WBC-6.5 RBC-2.62* Hgb-8.4* Hct-26.2* MCV-100* MCH-32.1* MCHC-32.1 RDW-22.9* Plt Ct-271 [2187-3-11] 07:05AM BLOOD Hct-23.7* [2187-3-12] 04:14AM BLOOD WBC-6.4 RBC-2.71* Hgb-8.6* Hct-25.1* MCV-93 MCH-31.7 MCHC-34.3 RDW-16.2* Plt Ct-130* Brief Hospital Course: 58-year-old gentleman admitted for treatment of a complex pancreatic pseudocyst situation secondary to gallstone pancreatitis. He had been at an outside hospital for 2 weeks prior to his transfer to us where he had evidence of a lower extremity DVT. Upon transfer to us, he had clear-cut pulmonary embolism identified and this was treated with anticoagulation. In the antrum we accessed the pancreas via CT and found it to be stable with a complex multi-loculated cystic architecture that appears to be growing slightly in size while here at [Hospital1 18]. We also recognized a bile duct stone on imaging and he had an ERCP performed prior to this procedure. He was doing well except from a respiratory standpoint where he had decompensation and evidence of an advancing pulmonary embolism. For this reason, a DVT filter was placed 3 to 4 days prior to this procedure. He continued to have respiratory distress but was doing well other than that. On the night prior to this operation, he had an acute decompensation and moved from an alkalotic state to an acidotic state. He required massive amounts of fluid resuscitation and had a progressive lactic acidosis. He had a tender tense abdomen as well.He was seen early in the morning of the [5-11] and felt that he had an acute abdominal catastrophe requiring emergent exploration. He went to the operating room on the morning of [2187-3-13] with the intent of performing exploratory laparotomy. The presumed diagnosis was ruptured pseudocyst with secondary diagnosis of dead bowel. Over the next three weeks patient remained in ICU for postop care. On [2187-4-15] patient was transfered to the floors for further care. remainder of hospital course was uneventful, he continued to be stable on TPN, tolerating regular diet. On POD 51/39 patient was cleared for discharge to rehabilitation center for further recovery. Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension [Date Range ]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 150 mg/15 mL Liquid [Date Range ]: One (1) PO BID (2 times a day). 3. Amiodarone 200 mg Tablet [Date Range ]: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet [Date Range ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Octreotide Acetate 100 mcg/mL Solution [Date Range ]: One (1) Injection Q8H (every 8 hours). 6. Albuterol 90 mcg/Actuation Aerosol [Date Range ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for dyspnea. 7. Trazodone 50 mg Tablet [Date Range ]: 0.5 Tablet PO TID (3 times a day) as needed for Agitation. 8. Warfarin 5 mg Tablet [Date Range ]: One (1) Tablet PO HS (at bedtime). 9. Oxycodone-Acetaminophen 5-325 mg Tablet [Date Range ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 12. Acetylcysteine 20 % (200 mg/mL) Solution [Last Name (STitle) ]: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed for congestion. 13. Albuterol Sulfate 0.083 % Solution [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Calcium Carbonate 500 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 15. Cephalexin 500 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO Q6H (every 6 hours). 16. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 17. Acetazolamide 250 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q12H (every 12 hours) for 5 days: d/c [4-29]. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: ruptured Pancreatic psuedocyst Discharge Condition: stable Discharge Instructions: Resume your regular medications. Take all new medications as directed. Do not drive while taking narcotics. You may shower. Allow water to run over the wound, and do not scrub. Pat the wound dry. Do not take a bath or swim until after follow-up appointment. No heavy lifting (> 10 lbs) for 6 weeks. Please call your doctor or return to the ER if you experience: -Fever (> 101.4) -Inability to eat/drink or persistant vomiting -Increased pain -Redness or discharge from your wound -Other symptoms concerning to you Followup Instructions: Please followup with Dr. [Last Name (STitle) ] in [3-24] weeks call [Numeric Identifier 66571] to schedule an appointment Completed by:[2187-4-24] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5015 }	Medical Text: Admission Date: [2119-4-6] Discharge Date: [2119-4-15] Service: MEDICINE Allergies: Bactrim Ds / Zyprexa / Lisinopril Attending:[First Name3 (LF) 552] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: CT head MRI/MRA LP Larynoscopy History of Present Illness: HPI: The patient is an 88 year old female, resident at [First Name5 (NamePattern1) 553] [Last Name (NamePattern1) 554] [Hospital3 ], with medical history pertinent for Parkinson's disease, Diabetes, and recent cornea transplant who now presents with altered mental status. Per last progress note from patient's PCP, [Name10 (NameIs) ] patient has been in her usual state of health with exception of management of a cervical vertebral fracture secondary to fall as well as plans for a repat penetrating keratoplasty (corneal transplant) s/p failed prior. The patient was at that time apparently at her baseline and cleared for surgery. The patient underwent penetrating keratoplasty on [2119-3-30] for indication of failed graft without complication. The patient was seen by her ophthalmologist on [2119-4-4] with impression that there was moderate lid edema present suggestive of hypersensitivity but no discharge to suggest infection. Polysporin was discontinued (with concern for hypersensitivty per discussion with daughter) and other meds (Pred 1% TID OS, Timolol 0.5% [Hospital1 ] OU, Xalatan QHS OS, Tobradex [Doctor Last Name ] OS QHS) continued. The patient now presents form her [Hospital3 ] with concern for altered mental status. Only limited information is available from available staff at [Hospital3 400], with report only that patient was noted tonight to be acutely confused and "not making sense". Per discussion with the patient's daughter, the patient was in her usual state of health as early as yesterday morning, looking well. Later in the day, the patient was reported to be walking up and down the hallway, refusing to go to her room. The patient was noted to be shivering and unsteady on her feet. Recommendation was made that patient be sent to hospital for further evaluation. Per discussion with daughter, the patient has had prior episodes of confusion in setting of underlying infetion, usually UTI. . ED Course: 98.4 -> 102.8 rectal, 186/84, 85, 20, 93% RA. Labs notable for WBC 8.0, lactate 1.8. Not signed out, but per nursing report and discussion a central line was attempted given poor PIV access for which the patient received Haldol. No documentation of dose is available, [Name8 (MD) ] RN to RN signout this was 5mg IV. Central line was not successfully placed and ultimately a 22 PIV in the hand was obtained. The patient had a negative UA, CXR without obvious infiltrate although limited. Ophthalmology was not contact[Name (NI) ] as [Name (NI) ] impression was that eye was not infected. LP was recommended by ED but patients' daughter declined this. The patient was given Azithromycin, Vancomycin, and Ceftriaxone empirically and is now admitted to the medical service for ongoing care. On arrival to floor patient is lethargic but wakes to voice. She answers questions although requires repeat questioning at times to wake her. Patient reports mild neck pain since having collar removed, denies headache, chest pain, dyspnea, abdominal pain or other localizing symptoms. Past Medical History: Parkinson's Disease Dementia, mild Hypertension Hyperlipidemia Hypothyroidism Type II DM, diet controlled Pernicious anemia History of breast cancer Urge incontinence s/p penetrating keratoplasty [2119-3-30] Cervical vertebral fracture Social History: She is widowed. She had a 6-year history of tobacco use but quit decades ago. Her daughter is in her 50s and is healthy. She denies alcohol use or abuse. She formerly taught English in [Country 532]; she also worked as an interpreter of [Doctor First Name 533], Japanese, and English. Family History: Non-contributory Physical Exam: On admission: Vitals: 98.3, 136/74, 76, 20, 94% RA General: elderly female. Lethargic but arousable to vocal stimuli. Only opens eyes after extensive coaching. Can answer questions but often does not respond the first time. HEENT: + mild erythema, yellow bruising, and mod edema periorbital edema surrounding left eye. PERRL Mouth: Significant tongue swelling and swollen lower lip. Barely able to visualize uvula when using a tongue depressor. No erythema of the mouth. Neck: No LAD Chest: Difficult to access given pt intermittently snoring during exam despite repeatedly waking her up. No obvious crackles. Cardiac: RRR, III/VI systolic murmur loudest at LLSB Abdomen: + bs, soft, NTND, no HSM Ext: erythema bilaterally at ankles with no skin breakdown, DP pulses and PT pulses +1, radial pulses +[12-30]. No c/c/e. Neuro: oriented to name only. States she is in her apartment. UE reflexes +2, LE reflexes difficult to access as pt not relaxing and is pulling away from babinski. Motor: Due to lethargy pt has poor participation in exam. UE strength 4-/5 except for grip [5-2] bilaterally. LE poor effort. Sensation: Intact in face, UE and LE to touch Pertinent Results: [2119-4-5] 08:25PM GLUCOSE-145* UREA N-24* CREAT-0.8 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [2119-4-5] 08:25PM ALT(SGPT)-16 AST(SGOT)-27 LD(LDH)-261* CK(CPK)-49 ALK PHOS-129* AMYLASE-35 TOT BILI-0.3 [2119-4-5] 08:25PM LIPASE-23 [2119-4-5] 08:25PM CK-MB-NotDone cTropnT-<0.01 [2119-4-5] 08:25PM ALBUMIN-4.0 [2119-4-5] 08:25PM WBC-8.0 RBC-4.42 HGB-13.1 HCT-37.5 MCV-85 MCH-29.7 MCHC-35.0 RDW-15.1 [2119-4-5] 08:25PM NEUTS-75.4* LYMPHS-17.2* MONOS-6.0 EOS-1.3 BASOS-0.2 [2119-4-5] 08:25PM PLT COUNT-152 [2119-4-5] 08:25PM PT-13.6* PTT-24.4 INR(PT)-1.2* CT head [4-5]: 1. No acute intracranial hemorrhage or acute fracture. 2. Diffuse cerebral atrophy with moderate sulcal and ventricular prominence. 3. Chronic microvascular infarcts, unchanged. 4. Paranasal sinus disease as described, likely acute in the sphenoid sinus. CT neck [4-6]: 1. Significant swelling/inflammation of the soft tissues at the base of tongue, oropharynx, with fullness in the vallecula and the piriform sinuses, overall resulting in moderate to marked narrowing of the oropharynx. The etiology of this finding is uncertain from the present study. To correlate with direct ENT examination. 2. Fullness of the hypopharynx and adjacent portions of esophagus - no adequately assessed on the present study- further evaluation recommended. 3. Increased attenuation of the fat in the carotid space, with soft tissue attenuation opacity, with heterogeneous appearance, causing indentation on the right internal jugular vein extending down along the carotid space, into the region of the thoracic inlet. This may relate to inflammation, phlegmon, and radiation-related changes if there is history of radiation in the past and less likely neoplastic. Close followup evaluation, with ultrasound can be considered to evaluate for any abscess, given the patient's symptoms of fever. CT orbits: 1. Increased attenuation of the preseptal soft tissues with some enhancement, on the left side, likely due to inflamamtion/ post-surgical changes- correlate with clinical examination. No definite abscess on the present set of images. No intraconal abnormality. F/u as clinically indicated. 2. Moderate paranasal sinus disease CT head [4-9]: 1. No acute intracranial process. 2. Persistent cerebral atrophy. 3. Chronic microvascular ischemic changes. 4. Paranasal sinus disease. MRI/MRA brain: Final Report HISTORY: Parkinson's, delirium, lethargy, right facial droop and dysarthria. Evaluate for signs of intracranial hemorrhage or acute stroke. Comparison is made to most recent head CT of [2119-4-9] TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the brain without intravenous gadolinium. 3D time-of-flight MR arteriography was also performed. Volume-rendering reconstructed images were evaluated. MRI OF THE BRAIN AND MRA OF THE BRAIN: There is no evidence of intracranial hemorrhage, masses, mass effect, or regions of restricted diffusion to suggest acute infarction. A few scattered periventricular T2/FLAIR hyperintensities are noted, which are nonspecific but likely suggest chronic small vessel ischemia. There are also adjacent prominent Virchow-[Doctor First Name ] spaces. While there is underlying global cerebral atrophy, the degree of dilatation of the ventricular system may be somewhat disproportionate to the amount of central atrophy. Small amount of fluid is noted in the mastoids bilateral. MR arteriography of the circle of [Location (un) 431] displays no aneurysmal dilatation. Mild atherosclerosis is noted in the right M1 segment. Posterior circulation is left dominant. IMPRESSION: 1. No evidence of acute infarction. Scattered changes likely related to chronic small vessel ischemic disease. 2. Question slightly disproportionate degree of ventricular dilatation in relation to the amount underlying cerebral atrophy. While this finding is nonspecific, in the appropriate clinical scenario it may reflect underlying NPH. Brief Hospital Course: This pt is a 88yo female w h/o Parkinson's disease, mild dementia and recent corneal transplant admitted to the hospital for AMS and to the ICU for airway narrowing. . # Airway narrowing: She was noted to have swelling of the tongue and lower lips on admission. A CT of the Head and Neck with IV contrast showed no clear evidence of preseptal cellulitis and ? of soft tissue infection/edema of neck and throat. Over course of day, noted to have increased audible upper airway sounds with good O2 sat of 97% on 2L which has been stable. ENT was consulted and saw extensive edema and soft tissue swelling in oropharynx with patent airway. Swelling around false cords, tonsillar edema, but true cords without edema. The team thought the swelling to be secondary to possible allergic reaction to medications. She was started on solumedrol 60IV and famotidine 20mg. She was given one dose of zosyn and then switched to unasyn to cover for possible soft tissue infection. Pt without leukocytosis, fever (was 102.8 in the ED but afebrile since), or abcess. ENT and anesthesia recommended transfer to ICU for further monitoring. She was monitored and continued on Decadron for three doses. During successive scopes by ENT, oropharyngeal edema and some secretions were seen, but airway remained patent. Unclear etiology: possible allergic reaction vs infectious process vs both given tonsils appear possibly infectious and lower airway appears more edematous and less infectious. Lisinopril was stopped, and her laryngoscopic exam visibly improved by the time she was called out to the floor. -Pt was treated for 10 days for ?soft tissue infection and switched to Augmentin for additional 5 days at dc -ENT follow up appt was set up # s/p corneal TP: lid edema on exam. Ophtho believes likely secondary to blockage of drainage and not as likely due to allergy. Ophtho felt the eye was improving and recommended decreasing doses of eye drops. -FU appt with Optho set up . #. Altered Mental Status: On admission, she was lethargic, possibly from the Haldol she received in the ED. By the time she was called out of the ICU, she was likely at her baseline mental status, pleasant and easily conversant. Shortely thereafter, however, she became agitated and combative and received 1.5mg Haldol and later the same day 5mg of Zyprexa. She remained agitated for about 36 hours before she became lethargic and barely arousable. Head CT was unchanged from before. She had not had any new fevers or new signs of infection. She had a lumbar puncture that was unremarkable. MRI/MRA was neg except for some ventriculomegaly in setting of global atrophy which was difficult to differentiate from NPH. Neurology thought it was unlikely to be NPH. EEG showed some focal acitivity concerning for sublinical seizures. Pt was started on keppra, initially continued to have periods of somnolence along with R sided facial droop (which was thought be Neurology to represent a post-ictal state with [Doctor Last Name 555] paralysis) but day before discharge had significant improvement in mental status and was alert and conversive. Due to hx of dementia and also ongoing hypoactive delirium, pt was not fully oriented but did have significant improvement in level of alertness. -Pt curently is on Keppra 1000mg [Hospital1 ] for one week and to be increased to 1500mg [Hospital1 ] later and kept at that dose. -Pt should be followed by a neurologist at [Hospital 100] Rehab -Outpt FU w neurology is already set up . #. UTI: grew Enterococcus in UCx. She was continued on Unasyn for 10 days. . #. Positive blood cultures: 1/4 bottles growing coag negative Staph. This was likely a contaminant so vancomycin was stopped. Repeat blood cultures were negative. #. Parkinson's Disease: continued Sinemet except when patient was too lethargic to safely take meds . #. Hypertension, benign: Lisinopril was stopped due to concern of angioedema. Atenolol was continued. . #. Hyperlipidemia: continued statin . #. Hypothyroidism: TSH normal on [2119-4-6] so not a picture of myxedema and cannot account for MS change. Continued levothyroxine. #. Diabetes II, diet controlled without complication: - insulin sliding scale while inpatient and bs were wnl. Pt can have [Hospital1 ] finger checks to Rehab but since not needing insulin, does not have to be on sliding scale # Deconditioning: per PT eval, pt was 2 person assist and will need significant PT therapy to get back to baseline where she was walking with a walker Medications on Admission: Tylenol 1000mg PO twice daliy Aspirin 81mg daily Atenolol 25mg daily Carbidopa/Levodopa 25/100mg three times daily Enablex 7.5mg SR daily Fish Oil 1000mg daily Levothyroxin 125mcg daily Lisinopril 20mg daily Simvastatin 10mg daily Cyanocobalamin 1000mcg daily Docusate 100mg daily Pred 1% TID OS Timolol 0.5% [Hospital1 ] OU Xalatan QHS OS Tobradex OS QHS Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)). 3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet 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). 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): for one week, then increase to 1500mg [Hospital1 ]. 14. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary: oropharyngeal swelling, delirium, urinary tract infection Secondary: Parkinson's disease, diabetes type 2, hypertension, hyperlipidemia Discharge Condition: Good Discharge Instructions: You were evaluated for confusion and found to have swelling of your tongue and throat as well as a urinary tract infection. You improved with antibiotics. You became delirious in the hospital but improved with conservative treatment. If you have fevers, chills, confusion, or any other concerning symptoms, call your doctor. Followup Instructions: 1. PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], ph: [Telephone/Fax (1) 250], please call and make appt for fu in [2-1] weeks 2. Ophtho, Dr. [Last Name (STitle) ], ph: [Telephone/Fax (1) 556], Appt is on [2119-4-28] at 11:00 AM 3. ENT, Dr. [Last Name (STitle) ], ph: [Telephone/Fax (1) 41], Appt is on [4-20], Thurs, 12:00/noon 4. Neurology, Dr. [Last Name (STitle) 557], ph: [Telephone/Fax (1) 558], Appt is on [5-9], Tuesday at 9:30 AM ICD9 Codes: 5990, 2930, 4019, 2724, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5016 }	Medical Text: Admission Date: [2122-5-29] Discharge Date: [2122-6-8] Date of Birth: [2083-10-22] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 2836] Chief Complaint: Melena, dyspnea, abdominal pain Major Surgical or Invasive Procedure: [2122-6-1] - Transduodenal mass resection and cholecystectomy History of Present Illness: Mr. [Known lastname 4186] is a 38 year-old man with a history of IBS and PUD who presents with dark stools and fatigue. He reports 2-3 months of BRBPR and clots which he had attributed to hemorrhoids. This gradually transitioned to dark stools and now tarry, black stools in the past few days. Over this time, he has had increasing fatigue and dyspnea on exertion. Today, he felt very weak and had chest pressure and heart-racing with walking less than 10 feet so came to the ED for evaluation. The patient provides a longstanding history of intermittent, sharp lower abdominal pain for which he was given the diagnosis of IBS. Multiple endoscopies over 10 years ago were unrevealing, and symptoms improved with stress and diet control. About 10 years ago, he had one episode of bright red hematemesis and recalls being diagnosed with an ulcer; he does not recall an endoscopy at that time. He was on a PPI for a short time with improvement. In the past couple months, he has noted worsening of his chronic abdominal pain after eating as well as increased nausea, heartburn, and bloating requiring frequent Tums. He denies taking NSAIDs, but his pain is especially exacerbated by coffee (3 cups/week) and alcohol (2 beers last Saturday - first in 5 years). He reports decreased po intake in this setting with about a 5 lb weight loss. . In the ED, initial vs were: T 98.7, P 134, BP 136/63, RR 18, O2sat 100%RA. Exam notable for guaiac positive black stools. He triggered for tachycardia; EKG showed sinus tachycardia with ST depressions in V3-V6. Hct 19.6 (last OMR value 44.3 in [2113]) and BUN 21, Cr 1.1; normal platelets and coags. Trop <0.01. He refused NG lavage and blood transfusions despite multiple explanations of the risks & benefits. GI recommended starting a pantoprazole bolus and gtt with plan for endoscopy in the morning. Two large-bore peripheral IVs were placed for access, and he received a total of 1L NS IVF. Of note, while in the ED, he spiked a fever to 101 for which he was given Tylenol. WBC 11.6 with 70.6 N, no bands. U/A clear, CXR unremarkable. CT abd/pelvis done en route to MICU, and pt was given flagyl 500 mg IV. On transfer, vs were: T 99, P 108, BP 113/62, RR 19, O2sat 100%RA. Past Medical History: IBS, PUD, Depression; no prior surgical history Social History: Lives alone. Divorcing from 2nd wife. [Name (NI) 1403] in Environmental Services at [Hospital1 2025]. - Tobacco: Remote h/o [1-18] ppd x 6 months. - Alcohol: Rare, as above. - Illicits: Occasional marijuana. No IVDU. Family History: Father with multiple medical problems including MI s/p CABG in his 60s. Mother with several unclear medical problems. Maternal grandfather with unknown cancer. Maternal uncle recently diagnosed with metastatic cancer, primary unclear. Sister with "abdominal pain" requiring surgery. Physical Exam: On Admission: Vitals: T 99.7, P 94, BP 125/63, RR 18, O2sat 99 RA. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, conjunctival pallor, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: WBC-11.6# RBC-2.02# Hgb-6.8# Hct-19.6# MCV-97 MCH-33.7* MCHC-34.8 RDW-15.7* Plt Ct-396# PT-13.4 PTT-22.9 INR(PT)-1.1 Glucose-120* UreaN-21* Creat-1.1 Na-135 K-3.4 Cl-101 HCO3-26 AnGap-11 ALT-17 AST-18 LD(LDH)-168 CK(CPK)-320 AlkPhos-56 TotBili-0.2 Calcium-8.8 Phos-2.3* Mg-1.9 Iron-62 Lactate-0.8 Chest X-Ray: IMPRESSION: No acute findings. The CT of the abdomen and pelvis performed several hours later excludes the presence of pleural effusions. CT Abdomen/Pelvis [2122-5-29]: IMPRESSION: Long segment gastroduodenal intussusception, with two large submucosal masses in the fourth portion of the duodenum. Brief Hospital Course: 38 year-old man with a history of IBS and PUD presenting with hematochezia and symptomatic anemia. He was admitted to the medical ICU and resuscitated for his GI bleed. He received 5 units PRBC's in the ICU, which improved his hematocrit to 29. He had a CT which was concerning for gastroduodenal intussusception. An EGD confirmed this condition, and demonstrated a 5cm mass in the duodenum. Surgery was consulted for definitive management. He was kept NPO with IV fluids and transferred to the surgical service. He was taken to the operating room on [6-1] for an exploration and resection. A transverse duodenotomy was performed, revealing a polypoid mass with a 10cm stalk connecting the mass to its origin just distal to the pylorus. The mass and stalk were excised completely. He then underwent an uncomplicated open cholecystectomy. He was brought to the floor in good condition post-operatively, with an NG tube in place. He was kept NPO with IVF and the NG tube on POD#1. Overnight into POD#2, he became achycardic to the low 110's, but was asymptomatic and otherwise hemodynamically stable. He did not have any bloody NG output or melenic stools. His tachycardia continued into the morning of POD#2, and his hematocrit was 16.5 on morning labs. At that time, he complained of some palpitations, but otherwise felt fine. He was transfused 5 units PRBC's, and his HCT improved to 29.4, where it remained stable. He never had any evidence of ongoing bleeding during this time, but was perhaps equilibrating perioperatively. Overnight into POD#3, the patient removed his own NG tube, as he felt it made him nauseated. On POD#7 the patient was advanced to clear liquid diets, his pain medication was switched from a PCA to oral pain medication without issue. The patient was advanced to a regular diet on POD#8 without issue, his nausea resolved and his hematocrit was serially checked and remained stable around 30% without further requirement for transfusion. The patient was out of bed and ambulating by POD#[3-20]. The patient's pathology demonstrated the following: I. Duodenal lesion, resection (A-K): 1. Organized collection of hyperplastic submucosal Brunner glands consistent with Brunner gland nodule with central foci of ischemic necrosis. 2. Overlying mucosa with gastric foveolar metaplasia consistent with chronic injury. 3. No dysplasia or true neoplasm identified; see note. II. Gallbladder, cholecystectomy (B): Mild chronic cholecystitis. Note: Brunner gland nodules are best considered to be hamartomatous lesions. Medications on Admission: Calcium carbonate (Tums) 1-2 tablets PO PRN Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days: For a total of 5-days. Disp:6 Tablet(s) Refills:0 3. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for bloating. Discharge Disposition: Home Discharge Diagnosis: Gastro-duodenal intussusception; GI bleeding, duodenal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to Dr.[Name (NI) 5067] surgical service for evaluation and management of your duodenal mass and GI bleeding. You are now being discharged home. Please follow these instructions to aid in your recovery. Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheeze. * 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 an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: You are scheduled to follow-up with Dr. [First Name (STitle) ] in the [Location (un) 620] office, for staple removal and wound assessment, Wednesday, [6-10], [2122]. Her office number is ([Telephone/Fax (1) 6347*]. ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5017 }	Medical Text: Admission Date: [2180-12-4] Discharge Date: [2180-12-13] Service: CARDIOTHOR CHIEF COMPLAINT: The patient is an 85-year-old woman patient of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] referred for an outpatient cardiac catheterization due to progressive dyspnea on exertion on positive ETT. HISTORY OF THE PRESENT ILLNESS: [Known firstname 33864] [Known lastname 33865] is an 85-year-old woman with no known cardiac history. She complains of several weeks of shortness of breath with a minimal amount of exertion. She states that she was recently out with her daughter doing some shopping and her daughter noticed that the patient was quite short of breath. She denied any history of chest discomfort, palpitations, or dizziness. Echocardiogram from [Month (only) 359] of this year revealed mild to moderate MI, mild TIA, moderate pulmonary artery hypertension, concentric LVH with an EF60%, sclerotic aortic valve without stenosis, Persantine exercise tolerance also done in [Month (only) ], positive for nausea and 5.5-mm inferolateral ST depression. Myoview images revealed a moderately large territory of distal anterior apical and septal ischemia. There is no history of prior infarct. The EF on myoview is 70%. The patient's height is 5 feet 7 inches. Weight 172 pounds. PAST MEDICAL HISTORY: History is significant for prior atrial fibrillation, COPD, low back pain, CVA three to four years ago with some vision loss in the right eye. PAST SURGICAL HISTORY: History is significant for appendectomy, right hip replacement six to seven years ago. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: Medications, prior to admission revealed the following: 1. Aspirin 325 mg q.d. 2. Atenolol 25 mg q.d. 3. Betapace 40 mg b.i.d. 4. Digoxin 0.125 mg q.d. 5. Lipitor 10 mg q.d. LABORATORY DATA: Data, prior to admission, revealed the white count of 10.2, hematocrit 37.0, platelet count 183,000, INR .93, glucose 108, sodium 140, potassium 4.7, chloride 104, CO2 27, BUN 23, creatinine 1.0. SOCIAL HISTORY: The patient is widowed. She lives in an [Hospital3 ] at [Location (un) 33866]. She has several supportive children. The patient underwent cardiac catheterization on [11-28]. Please see the catheterization report for full details. In summary, the catheterization showed 100% LAD after the first diagonal filling left to left collaterals, OM2 50%, RCA hazy, 90% ostial lesion, mid 50% lesion with EF of 50% and calcified mitral annulus. The patient tolerated the procedure well. The patient was to be discharged home after cardiac catheterization to return in one week for coronary artery bypass graft with Dr. [Last Name (STitle) 1537]. The patient was re-admitted to [Hospital1 69] on [12-4], at which time she was admitted to the operating room, where she underwent off pump coronary artery bypass grafting time three. Please see the operating report for full details. She tolerated the procedure well. In summary, she underwent coronary artery bypass grafting times three with a LIMA to the LAD, vein graft to OM2 and vein graft to right PDA. The patient tolerated the procedure well. She was transferred from the operating to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had an arterial and a Swan-Ganz catheter, two ventricular pacing wires, two mediastinal chest tubes, right pleural chest tube and left pleural chest tube. Mean arterial pressure was 110. CVP was 10 and she had propofol at 3 mcg/kg per minute. The patient's immediate postoperative course was complicated by brisk bleeding via her chest tubes. Later in the evening, the patient was returned to the operating room for re-exploration. Following the exploration, the patient was returned to the Cardiothoracic Intensive Care Unit. At that time she was hemodynamically stable. She did well in the Immediate Post re-exploration period. Anesthetics were reversed. She was weaned from the ventilator. On the following morning she was successfully extubated. The patient remained in stable condition throughout postoperative day #1. Hemodynamically, she was apaced at a rate of 85 with a blood pressure of 120/51 and a cardiac index of 2.3. She was breathing comfortably with oxygen saturations in the high 90s on four liters of nasal prongs. Abdomen was soft and nontender. Underlying rhythm was a junctional rhythm at a rate of 20. With her junctional rhythm the patient dropped her blood pressure. For this reason she was maintained on a dopamine drip and continued to be apaced. On postoperative day #2, the patient's epicardial pacing wires failed. Because of the failure to capture the epicardiac pacing wires, it was necessary to replace the patient's Swan-Ganz catheter with a pacing Swan-Ganz catheter. She tolerated that procedure well. She continued to be apaced with the pacing Swan. The underlying rhythm at that time was a junctional escape in the 40s with a blood pressure of 60/40 with periods of asystole. At that time electrophysiology was consulted and asked to assess the patient with no sinus rhythm or intermittent sinus rhythm following coronary artery bypass grafting. Over the next several days the patient remained hemodynamically stable. She remained in the Intensive Care Unit, where she was apaced and followed by both cardiothoracic surgery and electrophysiology to see if the patient's sinus rhythm would return to normal function. On postoperative day #7, it was decided that the likelihood of recovery of the sinus rhythm was low, and at that time she was taken to the electrophysiology laboratory where she underwent EP testing and placement of a permanent pacemaker. Following the pacemaker placement, the patient was transferred to Far 6 for continuing postoperative care and recovery from cardiothoracic surgery. On postoperative day #8, it was decided that the patient was stable and ready for transfer to rehabilitation for continuing postoperative care and physical therapy following coronary artery bypass graft and permanent pacemaker placement. At the time of transfer, the patient's condition is stable. PHYSICAL EXAMINATION: Physical examination is as follows: Temperature 98, heart rate 79, blood pressure 135/5, respiratory rate 20, oxygen saturation 95% on room air. Weight, preoperatively is 80.2 kg; on discharge 85.3 kg. LABORATORY DATA: Laboratory data revealed the following: Hematocrit 29, white blood cell count 11, sodium 136, potassium 4.5, BUN 19, creatinine 1.1, glucose 108. PHYSICAL EXAMINATION: The patient was alert, oriented times three; moves all extremities, follows commands. Respiratory: Clear to auscultation bilaterally with diminished breath sounds bilaterally at the bases. Heart sounds: Regular rate and rhythm, S1 and S2. Sternum is stable. Incision with staples, open to air, clean and dry. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities are warm and well perfused with no clubbing, cyanosis or edema. Right lower extremity incision with Steri Strips open to air, clean and dry. Left shoulder incision revealed dry sterile dressing clean and dry. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q.d. 2. Captopril 12.5 mg t.i.d. 3. Aspirin 325 mg q.d. 4. Ranitidine 150 mg q.d. 5. Colace 100 mg b.i.d. 6. Amiodarone 400 mg q.d. 7. Lopressor 25 mg b.i.d. 8. Vancomycin 1 gram q.12h. times two more doses. FOLLOW-UP CARE: The patient is to have followup with electrophysiology in the pacemaker clinic in ten days. She is also to have followup in the wound clinic in ten days and to have followup with Dr. [Last Name (STitle) 1537] in one month. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern4) ] MEDQUIST36 D: [2180-12-12] 13:25 T: [2180-12-12] 13:24 JOB#: [Job Number 33867] ICD9 Codes: 9971, 4240, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5018 }	Medical Text: Admission Date: [2100-8-6] Discharge Date: [2100-8-9] Date of Birth: [2043-1-24] Sex: M Service: CARDIOTHORACIC Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 1505] Chief Complaint: occasional chest pressure and palpitations Major Surgical or Invasive Procedure: Minimally invasive MV repair with 30mm [Doctor Last Name 405] Band [8-6] History of Present Illness: 57 yo male with chest discomfort for one year, not related to exertion, and assoc. palpitations occasionally. Has known mitral valve prolapse (MVP) for at least 10 years. Has had serial echos and cath done [7-27] showed 3+MR, nl. cors., and EF 55%. Referred to Dr. [Last Name (STitle) ] for surgical repair of MV. Had excellent exercise capacity on pre-op testing, and [6-22] TEE showed EF 60%, trace TR, flail post MV leaflet, and 3+MR with trace AI. Past Medical History: ?HTN depression/anxiety BPH MVP mild OA hands Social History: works as engineer, lives with wife, smoked remotely more than 30 years ago, 2 glasses of wine per day. Family History: non-contrib. for cardiac disease Physical Exam: HR 63, RR14, 133/77 R, 144/88 L, 6'3", 195 pounds mild rash on abdomen, NAD HEENT and neck exam unremarkable, without bruits, lungs CTA bilat. RRR, 4/6 SEM at LLSB no masses or organomegaly in abd extrems, warm, well-perfused, no edema without varicosities 2+ bilat fem, DP/PT pulses Pertinent Results: [2100-8-9] 10:38AM BLOOD WBC-9.1 RBC-3.77* Hgb-11.7* Hct-35.5* MCV-94 MCH-31.1 MCHC-33.0 RDW-12.5 Plt Ct-137* [2100-8-9] 10:38AM BLOOD Plt Ct-137* [2100-8-9] 10:38AM BLOOD Glucose-125* UreaN-21* Creat-1.1 Na-142 K-4.8 Cl-106 HCO3-28 AnGap-13 [2100-8-9] 02:44AM BLOOD Calcium-8.2* Mg-1.7 [2100-8-9] 03:04AM BLOOD freeCa-1.21 Brief Hospital Course: Admitted [8-6], underwent minimally invasive MV repair with 30 mm [Doctor Last Name 405] annuloplasty band by Dr. [Last Name (STitle) ]. Transferred to CSRU in stable condition on a phenylephrine drip. Extubated early the following morning in SR on indulin and neo drips. Weaned off neo on POD #2 and remained in unit for bed issues. CTs removed, diuresis begun, and transferred to [Hospital Ward Name 121] 2 to increase activity level. Beta blockade begun with lopressor. Patient did extremely well and was cleared for discharge late in the day [8-9]. Right thoracot. incis. unremarkable , lungs CTA bilat, RRR with no murmur, abd soft with flatus, extrems warm with 1+ edema. Discharged to home with VNA services. Medications on Admission: lisinopril 20 mg qd zoloft 75 mg qd claritin prn MVI qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 4. Zoloft 50 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:45 Tablet(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Take with food. Disp:120 Tablet(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Mitral regurgitation. Hypertension Benign prostatic hypertrophy s/p min. inv. mitral valve repair Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 6 weeks. You should shower, let water flow over wounds, pat dry with a towel. Call our office for wound drainage, temp>101.5 Do not use lotions, powders, or creams on wounds. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 2093] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Completed by:[2100-9-10] ICD9 Codes: 4240, 4019, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5019 }	Medical Text: Admission Date: [2172-7-26] Discharge Date: [2172-8-4] Date of Birth: [2112-4-1] Sex: F Service: [Last Name (un) ] SERVICE: Transplant service. CHIEF COMPLAINTS: Nausea and vomiting, abdominal pain times 2 days. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old female who presented to the ER with complaints of nausea, vomiting, and abdominal pain times 2 days, status post small- bowel obstruction on [2172-7-20], with lysis of adhesions. A past medical history of chronic renal failure, substance abuse, chronic back pain and neutropenia. She was taking anti- hypertensive medications, as well as 4 Tylenol arthritis tablets, and 4 Percocet per day for the 3 days prior to admission. She presented to the ER hypotensive, and a sepsis protocol was initiated. She was given 9 liters of IV fluids, steroids and broad spectrum antibiotics. She was treated with dopamine, vasopressin and levo-fed. Workup in the ED showed a severe anion gap, metabolic gap. The patient had been discharged 2 days prior to admission and had developed lower abdominal pain and initially crampy in nature. The patient then tried to take small amount of soup and vomited an hour later she had to three more episodes of non bloody emesis and no BMs or flatus since prior morning also complained of some 50 and occasional lightheadedness. PAST MEDICAL HISTORY: Positive for type 2 diabetes, pancreatitis, hep C type 1, hypertension. SURGICAL HISTORY: Total abdominal hysterectomy in [2155], and small bowel obstruction with resection on [2172-7-20]. ALLERGIES: No known drug allergies. MEDICATIONS: Medications at home hydralazine 25 mg p.o. q.6h., atenolol 50 mg p.o. daily, nifedipine 90 mg daily, Percocet p.r.n., lisinopril 40 mg p.o. b.i.d., NPH insulin. PHYSICAL EXAMINATION: 95.7, heart rate 90, BP 77/42, respiratory rate 30, 96% on 4 liters. She was in no acute distress initially. Dry mucous membranes. Collapsed neck veins. LUNGS: Clear. Regular rate and rhythm for heart ABDOMEN: Mildly distended. Decreased bowel sounds, firm but not tense, tender, especially right lower quadrant, with questionable guarding, and rebound. Staples in place. Clean, dry and intact. No hernias. EXTREMITIES: 2+ DP. No clubbing, cyanosis or edema. LABORATORY DATA: Hematocrit was 40 on admission, lactate was 16.5. An NG tube was placed as well as a Foley. A KUB was done initially that demonstrated small bowel obstruction, similar to [2172-7-19]. A chest x-ray on admission demonstrated bibasilar atelectasis. No pneumonia or free intra-abdominal air was identified. HOSPITAL COURSE: She was transferred to the surgical intensive care unit. A CT scan was done of her abdomen, without contrast, that demonstrated bilateral pleural effusions, ascites, mesenteric stranding, and soft tissue stranding seen, consistent with third spacing of fluid. It was noted that she was post ileal anastomosis. The anastomotic site appeared patent. Contrast passed through the small bowel and into the colon, without any definite evidence of small bowel obstruction. No free intraperitoneal air was identified. She underwent a liver and abdominal Duplex Doppler exam, that demonstrated thrombus in the left portal vein. The remaining vasculature was patent. Hepatology consult was obtained. She noted that the patient had hep C, genu type 1. Her liver enzymes were elevated in the 1000s. She also had a Tylenol level of 45. Her total bilirubin was elevated at 2.6, AST was 3214, ALT 8538, alkaline phos 171, and total bilirubin 2.6. Amylase was 34 and lipase 8. Her lactate was 16.5. This decreased to 13.4 with treatment. Her INR was 4.4. She was treated for Tylenol overdose with acetylcysteine and IV bicarb. The transplant service was consulted as well, for consideration for liver transplant, as it was noted that the patient had a positive alcohol and cocaine toxicology 2 to 3 months prior to admission. Given former hepatic failure, sedation was minimized. She was intubated. Her LFTs started to trend down. Urine culture from admission was negative. Blood cultures were negative. RPR was negative. Varicella zoster IgG serology was positive, and CMV IgG was positive. CMV IgM was negative. These labs were part of the transplant workup. Her abdomen appeared distended. Her lactate level decreased to 13.7. She continued to be n.p.o. while in the surgical intensive care unit, and pressors were weaned off. Her blood pressure was stabilized in the 148/70 range. CVP is 8. She continued on IV Vancomycin, azofloxacin and Flagyl. She gradually improved. The ventilator was weaned off. Blood pressure pressors were stopped. She continued on Protonix for prophylaxis. Her urine output was improving with autodiuresis. She continued on an insulin drip for hyperglycemia. [Initials (NamePattern4) ] [Last Name (NamePattern4) 8392] consult was obtained, to help with management of hyperglycemia. Her crit was stable, her IV fluids were adjusted. TPN was utilized well. She was n.p.o. She was extubated on [2172-7-29]. Her abdomen was mildly tender diffusely. Incision was clean, dry and intact. Neurologically she was alert most of the time, following commands, and cooperative. Her diet was gradually advanced. She tolerated this without nausea or vomiting. She was transferred out of the surgical intensive care unit on [2172-7-31]. For the remainder of her stay, her liver function tests continued to decrease. Her antibiotics were stopped. Her vital signs remained stable. Physical therapy consult was obtained, and she was cleared for home by physical therapy. Her chronic renal insufficiency was back to baseline, with a creatinine of 1.3. Her AST dropped to 112, ALT to 39, alk phos 200 and T bili of 1.4. On [2172-8-4] she was discharged home in stable condition. Vital signs were stable. She was afebrile. Abdomen was soft, nontender, nondistended. She was tolerating a regular diet. She is ambulatory. DISCHARGE MEDICATIONS: 1. Hydralazine 25 mg p.o. t.i.d. 2. Nifedipine 90 mg, sustained release, 1 tablet daily. 3. Atenolol 50 mg p.o. daily. 4. Colace 100 mg p.o. b.i.d. 5. Protonix 40 mg p.o. daily. 6. Oxycodone 5 mg, 1 to 2 tablets p.o. p.r.n. q.6h. 7. Glargine 22 units subcutaneous at bedtime. 8. Humalog insulin sliding scale p.r.n. q.i.d. DISCHARGE DIAGNOSES: 1. Chronic renal insufficiency. 2. Hepatitis C virus with elevated liver transaminase, secondary to Tylenol overuse. 3. Dehydration. 4. Diabetes type 2. 5. Metabolic acidosis. 6. Acute and chronic renal insufficiency. DISCHARGE CONDITION: Stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1286], MD [MD Number(1) 11126] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2172-8-4] 11:38:29 T: [2172-8-5] 11:58:16 Job#: [Job Number 100366] ICD9 Codes: 5849, 5990, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5020 }	Medical Text: Admission Date: [2170-5-9] Discharge Date: [2170-5-29] Date of Birth: [2170-5-9] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ] is the 1785 gram product of a 31 and [4-14] week twin gestation, born to a 35 year-old prima gravida. PRENATAL SCREENS: 0 positive, antibody negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen negative, GBS unknown. Antepartum course significant for IUI conception, otherwise benign until obstetric visit on [5-9], when hypertension was noted with proteinuria. Mother was transferred to [Hospital1 69] for delivery. Of note, family moved to [Location (un) 86] from [State 531] only 4 days prior to delivery. Mother received no Betamethasone. No fever. No intrapartum antibiotics. She had assisted rupture of membranes at delivery. Infant was delivered by Cesarean section under spinal anesthesia, had a spontaneous cry, required only blow-by oxygen and routine care in the delivery room. Apgars were 8 and 9. PHYSICAL EXAMINATION: Weight 1785 grams, 65th percentile. Length 41 cm, 35th percentile. Head circumference 30 cm, 55th percentile. Anterior fontanel soft, open and supple. Red reflex present bilaterally. Palate intact. Positive grunting, flaring and retractions. Breath sounds diminished bilaterally, symmetric with fair air entry. Regular rate and rhythm without murmur. 2+ femoral pulses including femorals. Abdomen benign, nontender, nondistended. No hepatosplenomegaly. No masses. Three vessel cord. Normal male genitalia for gestational age. Testes palpable in scrotum bilaterally. Hips deferred. Normal back and extremities. Skin pink in oxygen, well perfused, appropriate tone and strength. HOSPITAL COURSE BY SYSTEMS: Respiratory: [Known lastname 17766] started out on C-Pap with progressive respiratory distress. The infant was intubated and received 3 doses of Surfactant and was extubated by day of life number four to CPAP. He was on CPAP for 12 hours and has transitioned to room air and has been stable on room air since that date. He was started on caffeine citrate for management of apnea and bradycardia of prematurity. Caffeine citrate was discontinued on [5-22]. His last documented episode was on [5-25]. Cardiovascular: He received Indomethacin for a murmur that was demonstrated by physical examination and confirmed to be a PDA of 2 to 3 mm by echocardiogram on day of life number 2. He received a full course of Indomethacin and the murmur has not returned. Fluids, electrolytes and nutrition: His birth weight was 1785 grams. He was initially started on 80 cc/kg/day of D-10- W. Enteral feedings were initiated on day of life 6. He advanced to full enteral feedings by day of life 10. He was currently receiving 140 cc/kg/day of breast milk 26 with ProMod demonstrating good weight gain. Gastrointestinal: Peak bilirubin was on day of life number 3 of 8.9 over 0.3. He received phototherapy. His most recent bilirubin off phototherapy was on day of life number 8 ([5-17]) with 4.3 over 0.3. Hematology: Hematocrit on admission was 47.6. He did not require any blood transfusions during his hospital course. Infectious disease: CBC and blood culture were obtained on admission. CBC was benign. In light of progressive respiratory issues, Ampicillin and Gentamicin were initiated. Infant received a total of 7 day course of Ampicillin and Gentamicin for clinical course concerns. He has not received any other antibiotics at that time. Neurology: Head ultrasound performed on [5-17] was within normal limits. His physical examination has been within normal limits. Sensory: Audiology, hearing screen has not yet been performed but should be done prior to discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Level [Hospital ] hospital. NAME OF PEDIATRICIAN: Not yet identified. CARE RECOMMENDATIONS: Continue 140 cc/kg/day of breast milk 26 ProMod, wean calories as appropriate. MEDICATIONS: Continue Fer-in-[Male First Name (un) ] supplementation. State newborn screen sent most recently on [2170-5-23]. Infant has not received any immunizations. Reviewed By: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2170-5-28] 20:50:39 T: [2170-5-28] 21:22:08 Job#: [Job Number 62046] ICD9 Codes: 7742, V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5021 }	Medical Text: Admission Date: [2179-11-19] Discharge Date: [2179-11-23] Date of Birth: Sex: F Service: [Hospital Unit Name 196] HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old female with past medical history significant for congestive heart failure, moderate to severe mitral regurgitation, paroxysmal atrial fibrillation who was admitted to the CCU with bradycardia and hypotension status post cardiac catheterization. Patient initially presented to [Hospital6 2018] for an elective cardiac catheterization. She was scheduled for mitral valve replacement and required a catheterization as part of her preoperative evaluation. However, during that catheterization procedure patient decompensated with markedly elevated pulmonary capillary wedge pressure to the 50s when placed supine. Patient was then intubated and got Lasix, a nitroglycerin drip, and beta blocker. Her respiratory distress did improve at this point. However, she then became briefly bradycardiac and hypotensive. She was then started on a Dopamine drip, at which point her rate and pressure both stabilized. In addition, her wedge pressure did improve to approximately 20. Patient was then transferred to the CCU for further management. PAST MEDICAL HISTORY: 1. Congestive heart failure with diastolic dysfunction. 2. Moderate to severe mitral regurgitation. 3. Tricuspid regurgitation. 4. Aortic regurgitation. 5. Paroxysmal atrial fibrillation. 6. Hypothyroidism. 7. Non-small cell lungs cancer status post right upper lobectomy and mediastinal and lymph node dissection. 8. Rheumatic heart disease with history of rheumatic fever. HOME MEDICATIONS: 1. Lopressor. 2. Ibuprofen. 3. Darvocet. 4. Lipitor. 5. Levothyroxine. SOCIAL HISTORY: No alcohol or tobacco use. FAMILY HISTORY: Noncontributory. HOSPITAL COURSE: 1. Cardiac/Coronary: Patient admitted to the CCU following cardiac catheterization. Her catheterization showed three-vessel coronary disease. Her left main was heavily calcified with up to 30% stenosis. Her left anterior descending was heavily calcified with 50% proximal and 70% mid vessel stenoses. Her left circumflex had a moderate osteal calcification with diffuse disease to 30% proximally. Obtuse marginal 1 branch had a 70% stenosis at its origin. The right coronary artery was calcified and diffusely diseased to 50% in the mid vessel. Patient had no active ischemic symptoms on following her catheterization. She was maintained on aspirin and statin. Initially, patient was hypotensive. However, following stabilization of her blood pressure, beta blocker was added on to her medication regimen. Based on patient's three-vessel disease she was thought to be a candidate for coronary artery bypass graft. Cardiothoracic Surgery service was contact[Name (NI) ] regarding this. Initially planned to proceed directly to surgery; however, given patient's complicated medical history, instead she was discharged with plans for a readmission in the near future for a CABG. She is to follow up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] for this. 2. Pump: Patient with severe ventricular diastolic dysfunction following cardiac catheterization which did show severe diastolic dysfunction which was complicated by significant pulmonary edema. Patient did require intubation given her pulmonary edema. She also developed cardiogenic shock during the catheterization, likely a combination of her congestive heart failure decompensation and multiple medications administered. Pericatheterization, she received Lasix and beta blocker and was started on a nitroglycerin drip. Following this she was also placed on a Natrecor drip. However, she then developed hypotension and bradycardia requiring a Dopamine drip for her cardiogenic shock. A Swan-Ganz was placed for close hemodynamic monitoring. Following transfer to the unit patient was able to be weaned off the Dopamine drip and her blood pressure stabilized. There was concern for overdiuresis following her respiratory decompensation. Patient actually following discontinuation of Lasix and Natrecor continued to autodiurese several liters. She was gently rehydrated and further diuresis was avoided. Her blood pressure was closely managed to avoid any further cardiac decompensation. Following stabilization off of pressors, an angiotensin-converting enzyme inhibitor and beta blocker were added on and titrated up as tolerated. 3. Patient with history of paroxysmal atrial fibrillation on Amiodarone at time of admission: When patient was first admitted to the CCU she was in sinus rhythm. However, given her paroxysmal atrial fibrillation she was maintained on a Heparin drip with plans to eventually transition her to Coumadin. Patient did go back into atrial fibrillation. She was then restarted on her Amiodarone, and her Heparin was transitioned over to Coumadin. 4. Valve: Patient was in severe MR, AI. Patient is planned for a mitral valve replacement in the near future. However, she first underwent cardiac catheterization as detailed above for preoperative clearance. Patient was followed by the Cardiothoracic Surgery team throughout her hospital stay. [Last Name (STitle) 48164] a history of rheumatic heart disease which was thought to be the likely etiology for her valvular disease. Patient was started on the angiotensin-converting enzyme inhibitor for afterload reduction at time of discharge. She is to follow up with Dr. [Last Name (Prefixes) ] for mitral valve replacement. 5. Respiratory failure: Patient developed severe pulmonary edema during her cardiac catheterization requiring intubation. Following intubation patient was aggressively diuresed, which markedly improved her oxygen. She was subsequently weaned off the ventilator and easily extubated without any further complications. 6. Oncology: Patient with history of non-small cell lung cancer and right upper lobe lobectomy. Patient had no active oncology issues during this admission. 7. Hypothyroidism: Patient maintained on Synthroid as per her home regimen. A TSH was checked which showed her to be euthyroid at this time on an appropriate level of thyroid hormone replacement. 8. Urinary tract infection: On routine urinalysis a urine culture did grow out Enterococcus. A urinalysis showed no evidence of white cells, bacteria, or other infection. However, given the finding of Enterococcus in her urine it was decided to treat patient empirically with Cipro as per the Cardiothoracic Surgery service. Patient was given a prescription for Ciprofloxacin for a total of seven days of treatment. DISCHARGE CONDITION: Stable. DISPOSITION: To home. DIAGNOSES: 1. Coronary artery disease status post cardiac catheterization showing three-vessel disease. 2. Diastolic dysfunction. 3. Severe mitral regurgitation. 4. Aortic insufficiency. 5. Hypothyroidism. 6. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Aspirin 325 q. day. 2. Atorvastatin 20 mg q. day. 3. Levothyroxine 125 mcg q. day. 4. Pantoprazole 40 mg q. day. 5. Lisinopril 10 mg q. day. 6. Toprol XL 25 mg q. day. 7. Amiodarone 200 mg b.i.d. 8. Ciprofloxacin 500 mg b.i.d. times seven days. DI[Last Name (STitle) 408]E INSTRUCTIONS: Patient to follow up with Dr. [Last Name (Prefixes) 411] for plans of mitral valve replacement and coronary artery bypass graft. The Cardiothoracic Surgery scheduler is aware of this and will call the patient at home soon after discharge to arrange this. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4582], M.D. [MD Number(1) 4992] Dictated By:[Last Name (NamePattern1) 5212] MEDQUIST36 D: [2180-5-15] 09:54 T: [2180-5-17] 17:46 JOB#: [Job Number 48165] ICD9 Codes: 5185, 4240, 4280, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5022 }	Medical Text: Admission Date: [2157-7-21] Discharge Date: [2157-7-24] Date of Birth: [2097-12-30] Sex: M Service: General Surgery HISTORY OF PRESENT ILLNESS: Upper gastrointestinal bleed. PHYSICAL EXAMINATION: Chest was clear to auscultation bilaterally. Cardiac regular rhythm rate, no murmurs. Abdomen: Evidence of prior surgical scars, soft, nondistended, and mild left sided tenderness, no rebound signs. Extremities: No signs of edema. PERTINENT LABORATORIES: On the date of discharge, patient's hematocrit was 29.7. Chemistry was sodium 136, potassium 4.1, chloride 100, BUN 12, creatinine 0.6, and glucose 104. SUMMARY OF HOSPITAL COURSE: Mr. [Known firstname 1312] [Known lastname ] is a 59-year-old male presenting with upper GI bleed from pre-pyloric ulcer identified with esophagogastroduodenoscopy and underwent cauterization and injection with Epinephrine without residual bleed. Patient's hematocrit at the time of admission was 23, although his vital signs were stable. Patient was administered 4 units of packed red blood cells and admitted to the Intensive Care Unit for further observation. The patient's hematocrit elevated to 31 and remained stable over the past two days in the Intensive Care Unit during which time decision was made to transfer the patient to the floor. Patient was advanced to regular diet and discharged to home on hospital day #4. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home with followup with Dr. [Last Name (STitle) 468] in [8-10] days. DIAGNOSIS: Pre-pyloric ulcer, upper gastrointestinal bleed. [First Name8 (NamePattern2) 251] [Name8 (MD) ], M.D. [MD Number(1) 4984] Dictated By:[Name8 (MD) 11079] MEDQUIST36 D: [2157-10-12] 14:23 T: [2157-10-19] 07:44 JOB#: [Job Number 43384] ICD9 Codes: 2851, 2449, 4240, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5023 }	Medical Text: Admission Date: [2118-1-26] Discharge Date: [2118-1-31] Service: HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old Hispanic female with past medical history significant for diabetes, hypertension and pernicious anemia who complained of not feeling well for three days. Patient had an episode of chest heaviness, which was relieved immediately, and has been experiencing increasing shortness of breath, dyspnea on exertion, and had been described by her son as [Name2 (NI) ] and diaphoretic. On the day of admission, the patient had her usual appointment with her primary care physician, [Name10 (NameIs) ] an electrocardiogram was taken showing ischemic changes. The patient was sent to [Hospital1 ] [Hospital1 ], where an electrocardiogram was taken showing [Street Address(2) 2051] depressions in leads V2 through V4, and oxygen saturation was 79% on room air. Chest x-ray showed congestive heart failure. Patient's hematocrit was 27 and CK was 868 with MB index of 20.1, and troponin of 48.7. Patient was given aspirin, Lopressor, Lasix, intravenous nitroglycerin, after which ST segment depressions decreased from 1 to 2 mm. Patient was transferred to [Hospital6 256] for further care. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. Osteoarthritis. 4. Depression. 5. Hypercholesterolemia. 6. Pernicious anemia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Avandia, Vitamin B12 injections q. month, Cozaar dose unknown, multivitamin. SOCIAL HISTORY: The patient denies smoking or alcohol use. FAMILY HISTORY: Significant for diabetes, hypertension, no coronary artery disease. PHYSICAL EXAM ON ADMISSION: Blood pressure 95/65, heart rate 65, respiratory rate 20, oxygen saturation 100% on nonrebreather. General: Patient is an elderly female appearing comfortable in no acute distress. Head and neck exam: Pupils equal, round and reactive to light, extraocular movements intact, sclerae are anicteric, oropharynx clear, jugular venous pressure of 8 cm. Cardiac exam: Normal S1, S2, regular rate and rhythm, no S3 or S4, 2/6 systolic ejection murmur at right upper sternal border. Lungs: Rales [3-21] of the way up bilaterally. No wheezes or rhonchi. Abdomen soft, nontender, mildly distended. Good bowel sounds in all four quadrants, no masses. Extremities: Trace edema, 2+ dorsalis pedis and posterior tibial pulses bilaterally. LABORATORY EXAMINATION ON ADMISSION: White blood cell count 11.7, hematocrit 24.3, platelets 173,000. PT 14.1, PTT 144, INR 1.4, sodium 132, potassium 4.5, chloride 96, bicarbonate 22, BUN 33, creatinine 1.4, glucose 209. CK on admission 868 trending down to 649 with second set, MB 20.1 trending up 22. Troponin greater than 50. Calcium 8.7, magnesium 2, phosphate 4.4. Electrocardiogram taken at [Hospital ] [Hospital3 13049] showing normal sinus rhythm, normal axis, 3-[Street Address(2) 5366] depressions V4 to V5. Electrocardiogram at [Hospital1 ] showing normal sinus rhythm, rate of 64, [Street Address(2) 4793] depressions V2 through V4. Chest x-ray consistent with congestive heart failure. BRIEF SUMMARY OF HOSPITAL COURSE: The impression was that this is a 78-year-old female with a history of diabetes, hypertension presenting with a non ST elevation myocardial infarction with electrocardiogram consistent with likely significant coronary artery disease (left main disease versus critical three vessel disease). 1. Cardiovascular: A. Ischemia: The patient was initially adamantly refusing cardiac catheterization, so she was placed on a heparin intravenous drip, Plavix, Lopressor, and Cozaar and the goal was optimal medical management. However, the patient later agreed to go for a cardiac catheterization, which was done two days after admission, which showed 90% stenosis of proximal left circumflex, which was successfully stented, distal occlusion of right coronary artery, which was not intervened on, D1 with 40% stenosis, and left anterior descending with mild disease. Hemodynamics during cardiac catheterization revealed severely elevated left-sided filling pressures (left ventricular end-diastolic pressure of 35 mm). Left ventriculogram showed akinesis of the inferior wall, hypokinesis of the apical, anterolateral, and anterobasal walls with an ejection fraction of 33%, mild mitral regurgitation. Patient was started on Integrilin and resumed on Plavix, Lopressor, and Cozaar after cardiac catheterization, with doses of Lopressor and Cozaar being titrated as blood pressure tolerated. The patient complained of no further episodes of chest pain afterwards. B. Congestive heart failure: The patient clinically appeared to be in congestive heart failure on admission, as she was requiring 100% nonrebreather face mask and had significant rales on physical examination. The patient was given Lasix prn for a goal fluid balance of one liter negative. The patient's oxygen requirement had decreased to room air prior to cardiac catheterization. However, during a red blood cell transfusion, which the patient received after cardiac catheterization for a hematocrit of 24, the patient developed shortness of breath despite treatment with Lasix prior to transfusion and developed an increased oxygen requirement of four liters nasal cannula. Despite Lasix diuresis, the patient persistently had an increased oxygen requirement of two to four liters nasal cannula. A chest x-ray was taken revealing persistent congestive heart failure with cephalization of pulmonary vasculature and a large left-sided pleural effusion. Patient was then placed on a standing Lasix regimen of 20 mg po q.d. on the day of discharge. It was decided not to tap the effusion, as it was felt that with returning cardiac function, post myocardial infarction and with adequate daily diuresis with standing Lasix, the patient's congestive heart failure and effusions would resolve. The patient never complained of shortness of breath even with her increased oxygen requirement. 2. Renal: With the patient's history of diabetes and with an elevated creatinine to 1.4 on admission, the patient was given Mucomyst prior to cardiac catheterization for renal protection. With diuresis for congestive heart failure, the patient's BUN and creatinine were noted to rise from 33/1.4 to 57/1.6, sodium decreased from 132 to 126 (presumably secondary to diureses as well). It was decided that diuresis would have to be continued at the expense of making patient prerenal in order to treat congestive heart failure. The patient was placed on free water restriction for hyponatremia. 3. Hematology: The patient's hematocrit was 24 on admission. As her MCV was low, the patient's anemia was presumably not secondary to her pernicious anemia. Stool guaiac was negative, as were hemolysis laboratories. The patient was transfused a total of four units of packed red blood cells during hospital course, and her hematocrit was 33.5 on discharge. 4. Gastrointestinal: Patient's stools were guaiac negative on admission. The patient was placed on Protonix for gastrointestinal protection. Diet was advanced as tolerated post myocardial infarction. 5. Endocrine: The patient was resumed on Avandia for diabetes. Patient refused subcutaneous insulin sliding scale administration. Fingerstick glucose measurements remained within normal limits during hospital stay. 6. Prophylaxis: Patient was placed on Protonix for gastrointestinal protection and subcutaneous heparin. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: Patient to go to short term rehabilitation. FOLLOW-UP: Patient to follow-up with primary care physician within two weeks of discharge. MEDICATIONS ON DISCHARGE: 1. Avandia 4 mg po q.d. 2. Lopressor 50 mg po b.i.d. 3. Cozaar 75 mg po q.d. 4. Multivitamin. 5. Plavix 75 mg po q.d. 6. Aspirin 325 mg po q.d. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Name8 (MD) 2692] MEDQUIST36 D: [2118-2-14] 10:58 T: [2118-2-14] 10:58 JOB#: [Job Number 38949] ICD9 Codes: 4280, 4240, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5024 }	Medical Text: Admission Date: [2163-1-1] Discharge Date: [2163-1-8] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 13386] Chief Complaint: fever and respiratory distress Major Surgical or Invasive Procedure: Intubation PICC line removal History of Present Illness: Mr. [Known lastname 107750] is a 86M with dementia, afib, and prior strokes who presents from his nursing home with fever and respiratory distress. Per records, patient had decreased PO over last 3 days, was started on ceftriaxone and flagyl [12-31] pm for ?aspiration pna. Was febrile to 103 overnight, evaluated at [Hospital1 882]. There given 30mg diltiazem for afib with RVR, given 4L of IVF. [Hospital ] transferred to [Hospital1 18] for ICU eval. . In the ED, vitals were 99.4 149 92/48 13 92% on 50% venti mask. He was started on a diltiazem drip for rapid atrial fibrillation but BP decreased to 70's. ABG was 7.28/41/54 on ?NRB and he was subsequently intubated. He was started on neosynephrine, and was also given vancomycin 1g. Per cardiology recommendations he was bolused with amiodarone and started on an amiodarone drip; he subsequently converted to sinus rhythm. Received addl ~6L of saline in [Hospital1 ] ER. Past Medical History: afib R MCA embolic stroke [8-23] cerebellar hemorrhage s/p craniotomy [2126] alzheimers colon CA stage III s/p resection CAD HTN ASD MR LVH cervical radiculopathy/myelopathy t12 compression fracture gerd liver hemangioma CRI renal cyst bph s/p turp h/o bowel obstruction glaucoma, cataracts multiple falls h/o ETOH abuse h/o pulmonary TB [2110] Social History: Relationships: [Name (NI) ] (brother)- Cell: [Telephone/Fax (1) 107744], Home: [Telephone/Fax (1) 107745]; [Doctor First Name ] (neice, [Name (NI) 2979] daughter) - Cell: [Telephone/Fax (1) 107746]; [First Name5 (NamePattern1) 440] [Last Name (NamePattern1) 107747] (neice, and [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) ]), Cell: ([Telephone/Fax (1) 107748]; Friend [Name (NI) 751] Social: Immigrated from [Country 532] in [2134], at baseline speaks & understands limited English - translator needed. Positive h/o alcohol abuse, but per PCP note stopped drinking ~1 year ago. He does not smoke. Previously employed as a photographer. Brother states patient is a Holocaust survivor. Assistive Devices: Glasses at baseline, upper & lower dentures; no hearing aides, did not use walker or cane prior to admission. Functional Status: Was living independantly in senior housing: elevator & no steps into building. Had HHA/HM (?) for personal care & cleaning, three meals delivered to him every day. Supportive brother lives nearby & does shopping. Out-patient Neurological evaluation ([Year (4 digits) ] [2162-8-12]) notes abnormal mental status screen, h/o disinhibition and frontal dysfunction, positive visuospatial signs that may suggest Alzheimer's Disease. PCP had recently filled out forms for adult daycare. Values/Belief: [Hospital1 ] Family History: Both parents died in [2095] in the [Location (un) 25508] ghetto. Physical Exam: ON DISCHARGE: T 97.1( afebrile) BP146/68 HR 72 RR 18 O2sat 94/RA WT 61 kg BMI 26.4 incont of urine, BM x1 yesterday GENERAL: Thin elderly man in NAD, sitting up in bed HEENT: Anicteric sclerae, OP clear, poor dentition, dry tongue NECK: No LAD/TM, JVP 7,L IJ in place RESP: Decreased BS at bases, R>L; improved rhonchi CV: RRR, normal S1/S2, no m/r/g ABD: +BS, S, NT/ND, no HSM EXT: 1+ DP LLE, trace DP RLE, WWP GU: Condom catheter in place SKIN: In waffle boots, red-purple blister R heel, 3X3; fluid-filled blister L heel; stage I coccyx (the latter [Name8 (MD) ] RN notes) NEURO:progressively more alert and interactive, shaking hands ON ADMISSION Vitals 97.1 75 111/77 21 91% on AC 500x14 5 0.5 General Chronically ill appearing man, intubated and sedated HEENT Sclera anicteric, PEARL. occasional twitching of tongue. Neck IJ in place Pulm Lungs with few rales left base CV Regular S1 S2 no m/r/g Abd Flat +bowel sounds nontender Extrem No edema, toes and fingers with cyanosis, cool palpable pulses Derm No rash or peripheral stigmata of endocarditis Lines/tubes/drains Right PICC, LIJ, foley with small amount yellow urine Pertinent Results: GRAM STAIN (Final [2163-1-1]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. URINE CULTURE (Final [2163-1-3]): 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 [1-1] Renal U/S: IMPRESSION: No hydronephrosis. . [2163-1-1] 12:39 pm SPUTUM Source: Endotracheal. FINAL REPORT [2163-1-8] GRAM STAIN (Final [2163-1-1]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2163-1-6]): MODERATE GROWTH OROPHARYNGEAL FLORA. MORGANELLA MORGANII. SPARSE GROWTH. WORKUP FOR IDENTIFICATION AND SENSITIVITIES REQUESTED BY DR. [Last Name (STitle) ] (PAGER [Numeric Identifier 32140]) ON [2163-1-3]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ MORGANELLA MORGANII \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: An 86 year old (per brothers report, conflicts with [Name (NI) ]) gentleman with CAD, dementia, atrial fibrillation, and prior strokes presented with hypotension and respiratory distress from [Hospital 882] hospital. . 1. Sepsis: The patient was transferred to the MICU hypotensive and septic from a likely respiratory source based on preliminary culture data. The patient was intubated for airway protection, given fluid resuscitation started on levophed for pressor support and Vancomycin, Zosyn and Ciprofloxacin were started for hospital acquired pneumonia. The patient's blood pressures remained labile hypo- and hyper-tensive often associated with bouts of atrial fibrillation to the 120s. Prior to transfer to the medical floor the patient was stabily extubated and off pressures & fluid resuscitation. His sputum culture showed pan-sensitive Morganella. He was initieally covered with Vancomycin, Zosyn, and Ciprofloxaxin from [12-31]. Vanc was stopped on [1-4] and Zosyn stopped [1-6]. On the floor, he remained afebrile with normal white count and satting well on room air. He completed an eight day course on [1-8]. . 2. Likely aspiration event: Per speech and swallow, patient is very unlikely to safely tolerate anything PO. He previously had a G-tube which the patient pulled out. This was replaced on [2163-1-6]. - He should remain NPO per speech and swallow recommendations. He is at high risk for aspiration. - Recommend Altzheimer's clothing to prevent undressing to prevent this tube from being removed again. . 3. Acute renal failure: The patient was admitted with pre-renal acute on chronic renal failure due to significantly poor PO intake. Urine lytes were c/w ATN. He was fluid resuscitated and his creatinine and urine output improved while in the ICU. Nephrology was consulted and did not see renal replacement as indicated. ACE inhibitor held and all medications were renally dosed. UOP and creatinine have continued to improve. His baseline Cr is 1.1-1.3 and he was 1.3 on discharge. . 4. Hypernatremia: The patient was admitted with an inital Na of 170. Through free water tube feed bolus & high free water iv fluids the patient's sodium was safely and slowly lowered. On transfer to the floor, he had a free water deficit around 2 L. This resolved with aggressive free water repletion in tube feeds. Free water boluses were reduced in rate as Na improved to reduce aspiration risk. . 5. Atrial fibrillation with RVR: The patient intermittently developed atrial fibrillation with rates to 120s-130s. He was loaded with Amiodarone IV and converted to Amiodarone 200mg PO. He remained primarily in sinus rhythm once on PO medication. Metoprolol was used intermittently (when the patient was not on pressor support) but was ineffective at rate control and compromised his blood pressure. On the floor, he remained in SR. His Afib with RVR was likely provoked by catecholaminergic state of sepsis. He was continued on Amiodarone 200 mg [Hospital1 ]. He is not on anticoagulation, although this has been discussed with the patient's family. They are currently holding off given his fall risk. - can recheck TSH when over illness . 6. Coagulopathy: The patient was found to have an INR of 1.8 without clear explanation and no history of anticoagulation. His DIC work up was unrevealing and this was attributed to his nutritional state. He was treated with 2.5 mg Vitamin K on [2162-1-5] and had FFP prior to G-tube placement . 7. CAD: The patient's admission EKG indicated ST depressions with T wave inversions in the setting of a rapid rate. Troponins were mildly elevated as the patient was in renal failure, but no clear evidence of infarction was discovered. He was maintained on aspirin, except for 3 days prior to G-tube placement. No beta-blocker as above. . 8. Anemia: The patient experienced a hematocrit drop from 37 to 33 after significant fluid hydration. No evidence of bleeding was found and he was not transfused. . 9. Tongue twitching: The patient was found to have a twitching tongue on admission that was attributed to either old stroke or hypernatremia. He was loaded with Keppra but the tremor ceased. He had no further seizure activty off Keppra. . 10. Depression: His remeron was stopped in setting of altered mental status. This could be restarted as needed pending further evaluation. . 11. Glaucoma: Continued home eye drops Medications on Admission: tums 650 [Hospital1 ] vitamind 1000 daily alphagan 0.2% 1 drop ou [Hospital1 ] xalatan 0.005% 1 drop ou qhs senna [Hospital1 ], mvt daily remeron 30 qhs sorbitol 70% 30ml daily saliva substitute tid ceftriaxone 1g daily - given [12-31] at 1900 flagyl 500mg [12-31] at 2200 and at 0400 zestril 10 daily -- last dose 1/12 metoprolol 12.5 [Hospital1 ] -- last dose 1/14 prn tylenol, dulcolax, sl morphine, levsin NOT on anticoag for afib Discharge Medications: 1. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Brimonidine 0.15 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 3. Latanoprost 0.005 % Drops [Hospital1 ]: One (1) Drop Ophthalmic HS (at bedtime). 4. Calcitrate-Vitamin D 315-200 mg-unit Tablet [Hospital1 ]: One (1) Tablet PO twice a day. 5. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: Ten (10) mL PO BID (2 times a day) as needed for constipation. 7. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day: in the morning. 8. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day for 10 days: in the evening. 9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Acetaminophen 160 mg/5 mL Solution [Hospital1 ]: [10-4] mL PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: HYPOXIC RESPIRATORY FAILURE ASPIRATION PNEUMONIA ACUTE ON CHRONIC RENAL FAILURE HYPERNATREMIA ATRIAL FIBRILLAITON WITH RAPID VENTRICULA RESPONSE COAGULOPATHY CORONARY ARTERY DISEASE ANEMIA DEMENTIA POSSIBLE SEIZURE ACTIVITY DEPRESSION GLAUCOMA Discharge Condition: Stable, normal vital signs and on room air Discharge Instructions: You were admitted for an aspiration pneumonia. You had food go into your lungs that then became infected. You were inturbated, given broad-spectrum antibiotics and treated with medications to support your blood pressure. Your infection has since improved and you have completed your course of antibiotics. Followup Instructions: Please follow up with your primary care doctor. You have an appointment scheduled for [2163-7-26] at 1:40PM, but should call [Telephone/Fax (1) 250] to get this scheduled for earlier. As it is the weekend, we were unable to reschedule this for you. Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2163-4-15] 9:30 Completed by:[2163-1-10] ICD9 Codes: 5070, 5990, 5849, 5859, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5025 }	Medical Text: Admission Date: [2122-6-7] Discharge Date: [2122-6-9] Date of Birth: [2072-12-21] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5880] Chief Complaint: Pedestrian Struck Major Surgical or Invasive Procedure: None History of Present Illness: 49 yo male pedestrian struck by MV @ approx 25 mph; pt thrown approx 10 feet, + windshield damage; +ETOH, ? LOC @ scene Past Medical History: None Social History: Born in [Country 4194], lives in [Location 583]. No family in this country +ETOH +tobacco Family History: Non-contributory Physical Exam: Gen - GCS 13-14 HEENT - laceration on left forehead; PERRL Neck - Collar, trachea midline Chest - Breath sounds bilaterally; no signs injury Cor - RRR Abd - Soft, Non-tender, non-distended; FAST negative Pelvis - Stable Rectal - Nl tone, guaiac negative Back - No deformities, no tenderness Extr - 2+ DP/PT bilaterally; tender to palpation bilateral knees Pertinent Results: [2122-6-7] 08:11PM HCT-34.4* [2122-6-7] 09:14AM GLUCOSE-55* UREA N-15 CREAT-0.7 SODIUM-139 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-19* ANION GAP-17 [2122-6-7] 09:14AM WBC-11.4* HCT-37.2* [2122-6-7] 09:14AM PLT COUNT-275 [2122-6-7] 09:14AM PT-12.6 PTT-27.8 INR(PT)-1.1 [2122-6-7] 04:30AM CK(CPK)-266* [2122-6-7] 04:30AM CK-MB-5 cTropnT-<0.01 [2122-6-7] 12:10AM ASA-NEG ETHANOL-283* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2122-6-7] 12:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2122-6-7] 12:10AM FIBRINOGE-352 [2122-6-7] 12:10AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 Brief Hospital Course: 1. Cardiac - No active issues 2. Respiratory - +tobacco history; placed on Nicotine patch during hospitalization. Patient does not request desire to quit at this time. 3. Gastrointestinal - Takes Zantac 150 mg po BID 4. Genitourinary - Voiding without difficulty since foley catheter removal 5. Musculoskeletal - Evaluated by Orthopedics, recommend WBAT bilateral lower extremities; [Doctor Last Name ] knee braces on locked while ambulating; unlocked all other times. Will need MRI of both knees in 2 weeks as outpatient; an order was placed in computer for [2122-6-22]. 6. Neurologic - Takes Remeron 30 mg po QHS; did have episodes of agitation in ICU surrounding concerns over his living situation. Social work closely involved with patient and helped to diffuse situation. Medications on Admission: Remeron 30mg po qhs Zantac 150 mg po bid Discharge Medications: 1. M-Vit Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: PRN. Disp:60 Tablet(s) Refills:0 Pt reports having and taking the following meds at home: Remeron 30 mg po qhs Zantac 150mg po BID Discharge Disposition: Home with Service Discharge Diagnosis: 1. Status post pedestrian struck by MV 2. Right fibular head fx 3. Bilateral knee ligamentous injuries Discharge Condition: Stable Discharge Instructions: Weight Bearing as tolerated to both lower extremeties Bilateral [Doctor Last Name ] braces on at all times, locked while amb; unlocked at rest Followup Instructions: 1. Follow up with Orthopedics - Dr. [Last Name (STitle) 2719] [Telephone/Fax (1) 1228]; call for an appointment in the next 1-2 weeks. 2. Need MRI of both knees after discharge from hospital within next 2 weeks [Telephone/Fax (1) 13015]. Order placed in CCC for [2122-6-22]; time to be confirmed with patient. 3. D/c forehead sutures in 5 days. Primary care physician or ER can take them out, or call Trauma clinic for an appointment. [Telephone/Fax (1) 2359]. ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5026 }	Medical Text: Admission Date: [2102-5-29] Discharge Date: [2102-6-5] Date of Birth: [2055-7-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: left sided numbess Major Surgical or Invasive Procedure: None History of Present Illness: This is a 46 year old man with h/o alcohol abuse, hcv and dilated alcoholic cardiomyopathy (EF25%) who was brought into the ED by a friend after drinking large amounts of alcohol. He reports last drink about 12 hours prior to presentation. He was just discharged from [Hospital1 18] three weeks ago on [2102-5-9] for alcohol withdrawal requiring ICU monitoring and large valium taper. . He also complains of left sided numbness and tingling of his entire body from head to toe, which came on around the same time as his last drink 12 hours ago. He denies deficits in strength and sensation, and reports never having had this problem in the past. Denies trouble with speech or vision. . In the ED, his vitals were: 98.3, 102, 211/128, 16, 96%-2LNC. He got a head CT to r/o bleed and stroke. He had no EKG changes and first set of enzymes were negative. Alcohol level was 354. Tox screen was also positive for cocaine. He was given valium for alcohol withdrawal, dose unknown. He was admitted to Medicine for further care. Past Medical History: - EtOH abuse - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy - cocaine abuse - hypothyroidism - h/o head and neck cancer s/p resection and radiation in [2093] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [Female First Name (un) 564] albicans [2-/2102] - h/o C. diff colitis - h/o IVDA per OSH records (pt denies) - HCV (no serologies in OMR) Social History: Recently cut down to 5-6 cigs/day, prior to that he smoked 1 ppd x30 years. Heavy EtOH use; drinks 1 shot of Vodka every 3 hours (~1 pint per day). Sober x10 years, started drinking again 1.5 yrs ago. +Cocaine abuse. He denies IVDA although history questionable. Sexually active with his girlfriend. Reports negative HIV test 2 yrs ago. Family History: Mother - CAD. Sister - h/o CVA. Physical Exam: VITALS: 97.1, 150/102, 86, 18, 99RA GEN: A+Ox3, NAD, Calm, speech not pressured, no tremors HEENT: OP clear, MMM NECK: no LAD, no JVD CV: RRR, no m/g/r PULM: CTAB, no w/r/r ABD: Soft, NT, ND, +BS EXT: no c/e/c Pertinent Results: 145 107 6 -------------< 81 4.1 25 0.7 CK: 118 MB: 3 Trop-T: <0.01 Serum EtOH 354 Serum [Year (4 digits) 2238] Pos Serum ASA, Acetmnphn, [Year (4 digits) ], Tricyc Negative 99 6.8 > 13.4 < 288 38.2 N:42.2 L:48.5 M:4.6 E:4.0 Bas:0.6 PT: 11.9 PTT: 27.1 INR: 1.0 HEAD CT: Unremarkable head CT. CXR: 1. No acute cardiopulmonary process. 2. Emphysema and biapical pleural scarring, which is discontinuous with the pleural surface at the left apex. Followup radiographs recommended in [3-7] months to determine stability of this finding. Brief Hospital Course: Mr. [Known lastname 4223] is a 46 year old man with alchohol abuse and anxiety originally admitted to MICU for alcohol withdrawal and subsequently transferred back to the floor. . # ALCOHOL WITHDRAWAL: On original admission to the floor, the patient was requiring large doses of valium and was admitted to the ICU management of alcohol withdrawal. In the ICU, the patient was noted to be very anxious, but with few objective signs of withdrawal. There, he initially required large doses of valium and then was placed on the following taper outlined by Psychiatry: - Valium 20mg po q3h standing [6-1] - Valium 15mg po q3h standing [6-2] - Valium 10mg po q3h standing [6-3] - Valium 5mg po q3h standing [6-4] - The patient was monitored closely and did not require any PRN benzodiazepines while on the valium taper. He was discharged to home for follow up with a sobriety program. While hospitalized, he spent a significant portion of time talking with our social worker, [First Name8 (NamePattern2) 636] [Last Name (NamePattern1) 12471], to help arrange appropriate follow up for alcohol abuse treatment. - We continued the patient's thiamine, folate, and multivitamin. - He was NOT discharged with any benzodiazepines. . # Anxiety: There appeared to be a large component of anxiety prompting treatment of positive CIWA scale values while in the ICU. This did not occur on the floor. At the recommendation of Psychiatry, the patient was treated with zyprexa [Hospital1 ] prn; he was discharged home with a two-week supply of zyprexa with instructions to follow up with his primary care doctor for further management of anxiety. . # HTN: The patient has hypertension at baseline, and prior to admission, he was being treated with clonidine, lisinopril, and carvedilol. He was initially hypertensive due to withdrawal. We placed the patient on his home lisinopril as well as HCTZ. We discontinued his carvedilol given his cocaine use. - BPs were well controlled at discharge. - He was restarted on digoxin at discharge. - Of note, the patient had bottles of pills with him which were last filled in [2102-2-2]. These pill bottles (digoxin, clonidine, carvedilol) were [2-4] full. . # H/O Etoh dilated CHF: Currently stable and euvolemic. Continued digoxin as above. Discontinued carvedilol due to cocaine use. . # Hypothyroidism: We continued his levothyroxine. . # FEN: He tolerated a low sodium cardiac diet. Repleted lytes as necessary. . # PPX: The patient was ambulatory, tolerating a regular diet on the floor. He used nicotine patches for tobacco abuse. . # CODE: full . # Patient was instructed to follow up with sobriety program. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Quetiapine 25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for anxiety for 2 weeks. Disp:60 Tablet(s) Refills:0 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for anxiety. Disp:80 Tablet(s) Refills:0 8. Nicotine 21-14-7 mg/24 hr Patch Daily, Sequential Sig: One (1) patch Transdermal once a day. Disp:1 box Refills:0 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication with subsequent withdrawal Cocaine abuse Secondary: Dilated cardiomyopathy Hypothyroidism History of head/neck cancer status post resection and radiation History of C. diff colitis History of bilateral cavitary lung lesions Discharge Condition: Afebrile, normotensive, comfortable on room air Discharge Instructions: You have been evaluated for alcohol intoxication and alcohol withdrawal. CONTINUING TO DRINK ALCOHOL WILL JEOPARDIZE YOUR HEALTH. We recommend treatment at a Sober House. It is your responsibility to establish yourself at this facility. You should not take your carvedilol or clonidine any more. Taking this medication in conjunction with using cocaine is dangerous. Call your doctor or return to the emergency room should you develop any of the following symptoms: fever > 101, chills, seizure, passing out, nausea or vomiting with inability to take liquids or medications, or any other concerns. Followup Instructions: You should follow up at the [Hospital ] Community Health Center within one week. A program which will help you remain sober should be a priority. You should also follow up at the [Hospital ] Community Health Center. Please call [Telephone/Fax (1) 23520] for an appointment. Completed by:[2102-6-6] ICD9 Codes: 4254, 4280, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5027 }	Medical Text: Admission Date: [2147-8-6] Discharge Date: [2147-8-16] Date of Birth: [2087-6-30] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 371] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: ORIF right wrist [2147-8-13] History of Present Illness: 60 yo male restrained driver of car vs building with 3 ft intrusion into car. No LOC. Past Medical History: Type II DM Hypertension Cataracts s/p cataract surgery Social History: Married and lives with wife. [Name (NI) ] tobacco, no ETOH. Family History: Father died in 80's from CHF Physical Exam: VS on admission to trauma bay: 100.8 180/92 120 100% on NRB mask Gen: GCS 15 HEENT: PERRLA, EOMI Chest: + seatbelt sign; CTA bilat Cor: tachy Abd: LUQ pain; no ecchymosis Back: no CVA tenderness Rectum: Normal tone; guaiac negative Extr: 2+ bilat LE edema; tenderness/swelling bilat wrists. Skin discolored bilat LE's(venous stasis changes) Pertinent Results: [2147-8-6] 04:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2147-8-6] 03:13PM CK(CPK)-624* [2147-8-6] 03:13PM CK-MB-3 cTropnT-0.01 [2147-8-6] 03:09AM GLUCOSE-246* UREA N-16 CREAT-0.9 SODIUM-139 POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-16 [2147-8-6] 03:09AM ALT(SGPT)-39 AST(SGOT)-39 CK(CPK)-506* ALK PHOS-80 AMYLASE-83 TOT BILI-0.7 [2147-8-6] 03:09AM CK-MB-6 cTropnT-<0.01 [2147-8-6] 03:09AM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-1.5* [2147-8-6] 03:09AM WBC-21.0* RBC-4.88 HGB-13.7* HCT-39.9* MCV-82 MCH-28.0 MCHC-34.3 RDW-13.7 [2147-8-6] 03:09AM PLT COUNT-321 [2147-8-6] 03:09AM PT-12.4 PTT-20.5* INR(PT)-1.0 CT ABDOMEN W/CONTRAST [2147-8-5] 10:56 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: trauma Field of view: 50 Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 60 year old man with REASON FOR THIS EXAMINATION: trauma CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Motor vehicle trauma. COMPARISON: No previous studies. TECHNIQUE: Axial multidetector CT images of the chest, abdomen and pelvis were obtained with 150 cc of intravenous Optiray. Multiplanar reconstructions were performed. CHEST CT WITH INTRAVENOUS CONTRAST: The aorta appears intact. There is no mediastinal hematoma. There is no pleural or pericardial effusion. Aortic calcifications are noted. The airways are patent to the level of segmental bronchi. There is dependent atelectasis at the lung bases. Subcentimeter, nonpathologically enlarged pretracheal and precarinal lymph nodes are present. Multiple right and left lateral rib fractures are present, extending from the second at least through the sixth ribs bilaterally. Several ribs are noted to be broken in more than one location. This appearance is consistent with a flail chest. Multifocal hematomas are noted in the soft tissues of the anterior chest wall. There is a hematoma in the left upper intercostal muscles. ABDOMEN CT WITH INTRAVENOUS CONTRAST: There is a focal calcification in the right hepatic lobe, likely representing a granuloma. There is no evidence of contusion or laceration in the liver, spleen, pancreas, or kidneys. Multiple right renal cysts are present. The gallbladder and adrenal glands appear unremarkable. Unopacified bowel loops appear unremarkable. There is no free air or free fluid. There is a hematoma in the subcutaneous soft tissues of the left lower anterior abdominal wall. PELVIS CT WITH INTRAVENOUS CONTRAST: There is a Foley catheter in the bladder. The prostate, seminal vesicles, and rectum appear unremarkable. There is a fat-containing left inguinal hernia. There is no free fluid. BONE WINDOWS: Multiple bilateral rib fractures are present, as described in the chest CT section of this report. No fractures are identified in the abdomen or pelvis. CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the findings demonstrated on the axial images. They are also useful in evaluating the spine. There are no spinal compression deformities. Overall value grade is 3. IMPRESSION: 1. Multiple bilateral rib fractures, consistent with a flail chest. No pneumothorax. Associated anterior chest wall hematoma and a hematoma in the left upper intercostal muscles. 2. Hematoma in the soft tissues of the left lower anterior abdominal wall. No evidence of an acute traumatic injury within the abdomen or pelvis. CT C-SPINE W/O CONTRAST [2147-8-6] 2:21 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: assess for fx [Hospital 93] MEDICAL CONDITION: 60 year old man with s/p mvc w/ bilat ue fx, rib fx, inadequate plain films REASON FOR THIS EXAMINATION: assess for fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 60-year-old in motor vehicle accident with inadequate plain radiographs. Patient has bilateral upper extremity fractures and rib fractures. TECHNIQUE: VCT images of the cervical spine without IV contrast. Coronal and sagittal reformatted images were obtained. No prior studies. FINDINGS: In the sagittal projection, the C1 through T1 vertebral bodies are visualized. There is normal vertebral body alignment. There is slight loss of height of C5 and C6 with disc space narrowing at C5-6 and C6-7 as well as superior and posterior osteophyte formation at these levels. Vertebral body height and disc space height elsewhere in the cervical spine is normal. A small well corticated fragment is seen posterior to the C7 spinous process, and may be a sequela of prior trauma. No acute fractures are identified. Prevertebral soft tissues are normal. The visualized portions of the upper lung fields are clear. The spinal canal appears essentially normal in caliber other than at C5-6 where it is moderately narrowed. Carotid artery calcifications are seen bilaterally. IMPRESSION: Degenerative changes in the mid cervical spine. No evidence of acute fracture. WRIST(3 + VIEWS) BILAT [2147-8-6] 2:06 AM WRIST(3 + VIEWS) BILAT Reason: trauma [Hospital 93] MEDICAL CONDITION: 60 year old man with REASON FOR THIS EXAMINATION: trauma HISTORY: Trauma. COMPARISON: No previous studies. RIGHT WRIST: AP, oblique and lateral views. There are fractures of the distal radius and distal ulna, with probable intra-articular extent. There is volar angulation of the distal fracture fragments. Degenerative changes are noted in the first carpometacarpal joint. LEFT WRIST: AP, oblique and lateral views. There is a fracture of the distal radius with probable intra-articular extent. There is volar angulation of the distal fracture fragment. Mild degenerative changes are noted in the first carpometacarpal joint. IMPRESSION: Fractures of the right distal radius and ulna and the left distal radius. CHEST (PORTABLE AP) [2147-8-7] 5:22 PM CHEST (PORTABLE AP) Reason: assess interval change [Hospital 93] MEDICAL CONDITION: 60 year old man with rib fractures, episodes of desaturation REASON FOR THIS EXAMINATION: assess interval change HISTORY: Rib fractures, desaturation. COMPARISON: [2147-8-6]. UPRIGHT AP VIEW OF THE CHEST: A right subclavian central venous catheter remains in stable and satisfactory position. Cardiomediastinal contours remain unchanged. There has been interval worsening of the right lower lobe patchy airspace opacity, and continued opacification of the left lower lobe. Small bilateral pleural effusions are present. Multiple left-sided rib fractures are again demonstrated. No pneumothorax. IMPRESSION: Slight interval worsening of right lower lobe air space opacity and continued opacification of the left lower lobe. The assymetry of these findings suggests the presence of aspiration or aspiration pneumonia, however, dependent pulmonary edema is also a possibility. CHEST (PORTABLE AP) [2147-8-10] 4:53 AM CHEST (PORTABLE AP) Reason: ASSESS FOR INTERVAL CHANGE [Hospital 93] MEDICAL CONDITION: 60 year old man with rib fractures, episodes of desaturation REASON FOR THIS EXAMINATION: ASSESS FOR INTERVAL CHANGE INDICATION: 60-year-old male with rib fractures and episode of desaturation. Assess for interval change. COMPARISONS: Comparison is made to serial chest radiographs from [2147-8-6] to the most recent of [2147-8-8]. TECHNIQUE/FINDINGS: Single AP upright chest radiograph. A right subclavian catheter tip projects over the mid SVC. There is no pneumothorax. Bedside chest radiography is not adequate to evaluate the chest cage, particulary with large patients. Standard PA and lateral radiographs, bone detail views, or CT are better suited for this purpose, as clinically warrented. A new ill- defined patchy opacity obscuring the right heart boarder could be pneumonia or possible dependent edema. Mild interval improvement in left lower lobe atelectasis is noted. IMPRESSION: Possible new right middle lobe pneumonia, atelectasis or dependent edema, alone or in combination. Interval mild improvement of left lower lobe atelectasis. CHEST (PA & LAT) [2147-8-11] 9:29 AM CHEST (PA & LAT) Reason: eval infiltrate/effusion [Hospital 93] MEDICAL CONDITION: 60 year old man with rib fx, SOB REASON FOR THIS EXAMINATION: eval infiltrate/effusion INDICATION: Rib fracture. Shortness of breath. PA AND LATERAL CHEST: Comparison is made to [2147-8-10]. Right subclavian central venous line tip remains in the distal SVC in satisfactory position. There is no pneumothorax. Lung volumes remain low accentuating the size of the cardiac silhouette, which is likely within normal limits. There has been improvement in the right perihilar opacity. Minimal upper lung zone redistribution persists. There are small-to-moderate bilateral pleural effusions with associated bilateral lower lobe atelectasis. Brief Hospital Course: Patient admitted the trauma service. Orthopedic service consulted for patient's wrist injuries; he was taken to the OR on [2147-8-13] for ORIF of his right wrist fracture. Cardiology was consulted for intermittent LBBB noted on EKG on admission; felt not due to myocardial injury. Recommendations made to consider beta blockade. The Acute Pain Service was consulted for patient's rib fractures; epidural pain management was initiated; his epidural catheter was eventually discontinued and patient started on oral pain medications with favorable response at this time. A Dermatology consult was placed because of a rash that developed on patient's face, back and left arm; facial rash felt likely seborrheic dermatitis treated with Ketoconazole; rash on back felt secondary to drug rash which was treated with Triamcinolone cream, Sarna lotion and Benadryl prn; and rash on left arm felt c/w contact dermatitis, treatment same as for rash on back. Patient with h/o HTN, has been a home regimine of Cozaar and Clonidine; Cardiology recommendations made to increase these meds; add Atenolol and change to extended release form Nifedipine. His blood pressures have improved slightly with this regimine, but remain elevated. Medications on Admission: Glyburide Metformin Clonidine Cozaar ASA Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 10. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 12. Clonidine 0.2 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 13. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 14. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <100 & HR <60. 15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day as needed for per sliding scale: see attached sliding scale. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: s/p Motor vehicle crash Right ulnar fracture Left radial fracture Bilateral T2-T6 rib fractures Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedics after your discharge. Follow up with your primary care doctor after your discharge from rehab regarding your blood pressures Followup Instructions: Call for an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (Hand Orthopedics)[Telephone/Fax (1) 4845] in next 1-2 weeks. Follow up with your primary docotr for your high blood pressures after your discharge from rehab. Completed by:[2147-8-16] ICD9 Codes: 4241, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5028 }	Medical Text: Admission Date: [2140-12-22] Discharge Date: [2141-1-5] Date of Birth: [2060-11-17] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 15676] is a 80 year old Russian-speaking female with 45 admissions since [2131] and with a history of diastolic CHF, COPD (5L home oxygen), HTN, pulmonary hypertension, A. Fib, obstructive sleep apnea, renal insufficiency, bilateral lower extremity discomfort, and an atrial septal defect. She is a poor historian and information was obtained in part from her medical record. Ms. [Known lastname 15676] was admitted on [2140-12-22] for hypoxia and reported recent orthopnea and paroxysmal nocturia dyspnea, but [Date Range 15797] fever/chills, N/V/D, chest pain or cough. . In the ED, Ms. [Known lastname 15798] initial vitals were: T: 98, P: 60, BP: 145/60, R: 20, O2 Sat: 100% on NRB. A [2140-12-22] CXR indicated unchanged cardiomegaly and low lung volumes as well as mild pulmonary edema. Lasix (80 mg IV) was given which led to some improvement in her symptoms. Ms. [Known lastname 15676] received IV Vanco, but refused Bipap. . In the MICU, Ms. [Known lastname 15676] was given additional Lasix (80 mg IVx2) which led to a diuresis of a 3.2 L. A [2140-12-22] ECG revealed left axis deviation, non-specific intraventricular conduction delay and non-specific ST-T wave changes -- findings considered to be similiar to her [2140-11-20] ECG. A [2140-12-23] CXR indicated mild edema, mostly in her right lung as well as a possible small right pleural effusion. She received 6L of O2 as well as morphine sulfate (2-4 mg) for her left lower extremity pain. She weighed 103.7 kg (228.1 lbs) when she was transfered to [Doctor Last Name ]. . When she was transfered to [Doctor Last Name ] on [2140-12-23], Ms. [Known lastname 15798] vitals were: T96.9 BP 110/56 HR 65 RR 28 O2 86-88% on 6L. Her heart rate was paced and her oxygen was weaned down to 5L, her pre-admission level. Her [2140-12-24] CXR revealed findings consistent with worsening CHF as well as an increased density at the right base suggestive of pneumonia or pulmonary edema. While on [Doctor Last Name ], Ms. [Known lastname 15676] [Last Name (Titles) 15797] SOB, chest pain/tightness, and mentated appropriately. Past Medical History: #HYPERTENSION #DIASTOLIC CONGESTIVE HEART FAILURE -estimated dry weight of 94kg -last TTE [4-/2140]; LVEF >55%; 3+ tricuspid regurg #ATRIAL FIBRILLATION -s/p cardioversion x 2 -previously on amiodarone, discontinued due to paced rhythm during hospitalization in [2140-4-23] -not anticoagulated due to history of hemorrhagic CVA #PULMONARY HYPERTENSION -RSVP 75 in [11/2139] -thought secondary to longstanding ASD #COPD -home O2 (5L NC) -baseline saturation high 80's-low 90's on 5L O2 #OSA, -nonadherent to CPAP therapy Microcytic anemia #CHRONIC RENAL INSUFFICIENCY -baseline Cr 2-2.5 #GERD #ATRIAL SEPTAL DEFECT - s/p repair [6-/2133] - complicated by sinus arrest - with PPM placement. #Hypothyroidism #Hx of hemorrhagic CVA on Coumadin #Hx of Gallstone pancreatitis s/p ERCP, sphincterotomy #Frequent hospitalizations -admitted almost monthly since [2132] #Surgeries -s/p APPY -s/p CHOLE ([2133]) -s/p TAH/BSO ([2133] for fibroids) Social History: Lives alone. Daughter-in-law visits frequently and helps out around house and c groceries. VNA comes once a week to set medications out in a pill box. No tob, EtOH, IVDU. Family History: NC Physical Exam: Vitals: T: 96.9 BP: 110/56 P: 65 R: 28 O2: 86-88% on 6L General: NAD, alert and able to express simple commands HEENT: Sclera anicteric, no conjunctivitis, poor dentition Neck: Appropriate ROM, unable to assess JVP Lungs: Bilateral crackles in lower 2/3rds of posterior lung fields Heart: Regular rhythm, 2/6 SEM at LUSB, no gallops or rubs Ext: RLE/LLE: 2+ pitting edema, erythema and warmth; Erythema & warmth greater in LLE than RLE. Pertinent Results: [2140-12-22] 01:01PM LACTATE-0.8 [2140-12-22] 01:03PM PT-13.9* PTT-28.3 INR(PT)-1.2* [2140-12-22] 01:03PM PLT COUNT-154 [2140-12-22] 01:03PM NEUTS-74.0* LYMPHS-17.2* MONOS-6.3 EOS-2.2 BASOS-0.3 [2140-12-22] 01:03PM WBC-5.1 RBC-3.70* HGB-11.0* HCT-34.6* MCV-94 MCH-29.7 MCHC-31.7 RDW-16.0* [2140-12-22] 01:03PM proBNP-3750* [2140-12-22] 01:03PM estGFR-Using this [2140-12-22] 01:03PM GLUCOSE-111* UREA N-60* CREAT-1.9* SODIUM-144 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-38* ANION GAP-11 [2140-12-22] 01:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2140-12-22] 01:13PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.008 [2140-12-22] 01:31PM O2 SAT-97 [2140-12-22] 01:31PM LACTATE-0.7 K+-4.1 [2140-12-22] 01:31PM TYPE-ART O2-96 PO2-109* PCO2-60* PH-7.36 TOTAL CO2-35* BASE XS-6 AADO2-537 REQ O2-87 COMMENTS-NRB [2140-12-22] 04:18PM O2 SAT-91 [2140-12-22] 04:18PM TYPE-ART O2-90 O2 FLOW-4 PO2-65* PCO2-68* PH-7.36 TOTAL CO2-40* BASE XS-9 AADO2-529 REQ O2-86 [2140-12-22] 10:25PM O2 SAT-18 [2140-12-22] 10:25PM LACTATE-1.3 TCO2-39* [2140-12-22] 10:25PM TYPE-[Last Name (un) ] PH-7.36 Brief Hospital Course: 1) Hypoxia: CHF exacerbation, likely a combination of medication and fluid restriction non-compliance. The patient was afebrile on admission making infection an unlikely etiology. Her CXR was consistent with fluid overload. Also it may be the case that her underlying pulmonary HTN/cor pulmonale is worse (she has not been followed in pulmonary clinic as an outpatient for some time). She also has COPD, however given absence of wheezing, cough, or sputum production COPD exacerbation was not thought to be the cause of her hypoxemia. In the ICU, IV lasix was started and the patient diuresed 3.2L. She required oxygen via nasal cannula, up to 6L to maintain O2 Sat between 84-91%. Once stable she was transferred to the medical service. Combivent nebulizer treatments, tiotropium were continued for her COPD. Her metoprolol was increased and lasix was started on 80po daily and IV as needed for further diuresis. She was maintained on O2 nasal cannula between 5-6L and did not use cpap at night. She did well for 3 days on the medical service but began to be more somnolent and again was hypoxic on exam and ABG. Pain medication was held (percocet, fentanyl patch) but this did not improve her mental status. She was transferred back to the ICU and further diuresed 2L on lasix drip, acetazolamide (for metabolic alkalosis) and bumex, and maintained on bipap (the patient intermittently refused). She was also started on digoxin at 0.125mg qd for her RV disfunction. Her respiratory status improved significantly. Once transferred back to the floor it became clear that, once off bipap or cpap for an extended amount of time she becomes sleepy. Bipap was ordered for use overnight. The patient refused several times however once she would become more tired and less alert she was amenable to using the mask. This immediately improved her respiratory status, and in the morning she would be able to tolerate nasal cannula with improved saturation. During rehabilitation she would benefit from cpap (or bipap if available) at night and nasal cannula during the day. . 2) Lower Extremity Erythema & Pain: Chronic [Doctor First Name 15799] statis issues for several months. There were no open wounds concerning for active infection. The patient remained afebrile. Her edema improved with diuresis and compression stockings, topical ointment and leg elevation. Her pain was treated with morphine and percocet as needed, however given her somnolence from hypoxia/hypercarbia this was switched to a fentanyl patch. A wound care consult was called to ensure proper treatment of her skin. Her pain improved and the fentanyl patch was discontinued, also given her altering mental status at times. On discharge she was not complaining of pain, however if this continues to be an issue it would be reasonable to restart a fentanyl patch at low dose. . 3) Atrial fibrillation: Patient currently paced in the 60s. No [Doctor First Name ] due to prior hemmorhagic CVA on Coumadin. Her pacemaker was interrogated and found to be functioning well without recent episodes of arrhythmia. She was continued on metoprolol and digoxin, and remained on telemetry during admission. . 4) Pulmonary Hypertension: It is likely that this is a large contributor to her hypoxia and worsening pulmonary status. She would benefit greatly from complying with her cpap while at home. She was previously followed in pulmonary clinic but was not compliant with treatment. She would benefit from a sleep study once stable to establish her new NIPPV settings and perhaps a more comfortable mask for home. In the future she could potentially be started on sildenafil if appropriate. . 5) Hypothyroidism: During her ICU stay TSH was 5.0. Her synthroid was increased to 112mcg. . 6) Nutrition: Continue cardiac heart healthy diet and fluid restriction of 1200ml/day. She required potassium repletion intermittently over the course of her admission. . 7) Code: Full code. . 8) Follow-up: appointment with Dr.[Last Name (STitle) 3357] on [1-12] 12:15pm. She would benefit from pulmonary clinic follow-up for a sleep study if agreeable. . Medications on Admission: Metoprolol 12.5mg [Hospital1 ] Aspirin 81 mg daily Paroxetine 10mg daily Calcium Acetate 667 mg TID with meals Ferrous Sulfate 325 mg daily Senna 8.6 mg [Hospital1 ] Levothyroxine 100 mcg daily Furosemide 80 mg [Hospital1 ] Tiotropium Bromide 18 mcg daily Gabapentin 100 mg (3 tabs qam and 1 tab qpm) . Discharge Medications: 1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: [11-18] Caps Inhalation DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [11-18] Sprays Nasal QID (4 times a day) as needed. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 12. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary: Acute exacerbation of chronic diastolic congestive heart failure Secondary: Chronic obstructive pulmonary disease, atrial fibrillation, hypertension, pulmonary hypertension, chronic renal insufficiency, obstructive sleep apnea, hypothyroidism Discharge Condition: Stable, with 5L Oxygen Requirement Discharge Instructions: You were admitted to the hospital because your heart failure was worsening and you were having trouble breathing. Your condition improved with medications to remove water from your body and with oxygen. It is very important that you use your oxygen all the time at home. It is also very important that you take all of your medications as prescribed. It is important that you weigh yourself every morning and call Dr. [Last Name (STitle) 3357] at ([Telephone/Fax (1) 4606]) if your weight increases by more than 3 pounds. You must also have a healthy diet and can not eat more than 2 grams of sodium each day. If you eat more salt than this, your body will start storing up fluid and you may problems breathing, requiring another admission to the hospital. Because of your heart failure, it is important that you limit the amount of liquids that you take, including ice. You should not take more than 1.2 Liter of fluids each day. Please return to the emergency room if you have worsening trouble breathing or chest pain. You should seek medical attention if you have fevers and chills or other symptoms that are concerning to you. The emergency room is open 24 hours every day. Followup Instructions: Followup Instructions: Please follow up with Dr. [Last Name (STitle) 3357]. Please call [Telephone/Fax (1) 4606] if you need to change your appointment. [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] ICD9 Codes: 5849, 2762, 4280, 496, 5859, 4168, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5029 }	Medical Text: Admission Date: [2105-9-20] Discharge Date: [2105-10-12] Date of Birth: [2079-9-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2817] Chief Complaint: Admit to MICU for Resp distress, Dyspnea and HCT of 11 Major Surgical or Invasive Procedure: 1)Intubation ([9-20]) 2)Right IJ central line (placed [9-20], removed [9-21] for HD catheter placement) 3)Double-lumen hemodialysis catheter (placed [9-20]) History of Present Illness: Mr. [Known lastname ] is a 25yo male who presented with ARF and HCT 11 from OSH; pt has baseline muscular dystrophy and renal disease of unclear etiology, non-hemorrhagic anemia in [2-/2105] (s/p transfusion of 4 units pRBC) with poor follow-up. For the past week, the patient's per oral intake decreased secondary to new dysphagia, fatigue increased, and pt began gagging w/ nausea and emesis. The patient has chronic watery nonbloody diarrhea. Notably he had worsening dyspnea today. He lives with an aide who stopped his medications a week ago (toprol, paxil, norvasc) because they "make his stomach sick." The patient was brought to OSH in respiratory distress, at [Location (un) ], he was found to have HCT 11, creatinine 12.1, HCO3 6. His ABG 7.03/ 13/157. He was intubated for severe respiratory distress, his bicarbonate stabilized, and transferred to [Hospital1 18] via [Location (un) 7622] for further workup and care, including a for presumed GI bleed. In ED, nasogastric lavage was negative and stool was guaiac negative X1, slightly positive the second time. CT of the abdomen and chest radiograph were unrevealing. He was also thrombocytopenic on admission. Renal was consulted in ED, bicarbonate deficit was 400 mEq and he received 150 mEq in ED. Renal recs ([Telephone/Fax (1) 73499]): monitor potassium during bicarbonate infusion, check lytes q2h during bicarb infusion, and replete with 20 mEq potassium. [4-19] g CaGluc was provided for transfusions. Renal U/S and spot urine prot/cr ratio were performed. When he was admitted to the ICU at [Hospital1 18] he had a Hgb of 5.1, WBC of 6.8 (83% neutrophils, no bands), Plt of 90, BUN/Cr of 202/12.6, bicarb of 6, glucose of 160, and anion gap of 37. Upon arrival at the MICU, the patient was given 3 amps bicarbonate in 1L D5W between units of blood. The patient was hyperventilated to blow off CO2. Of note, the patient had an admission beginning on [2105-2-16] at an outside hospital for a very similar clinical picture: metabolic acidosis, acute renal failure, and anemia. On admission at that time, his hemoglobin and hematocrit were 7.5 and 22. He received 2 units of PRBCs which increased his counts to 10.5/31.7 on [2105-2-23]. He did not receive close follow-up in the interval to the present day. Past Medical History: 1)Facioscapulohumeral dystrophy, diagnosed at age 5, (baseline in wheelchair) 2)Admission to [Location (un) ] in [2-/2105] for ARF and metabolic acidosis 3)Hypertension 4)Chronic kidney disease, ?IgA nephropathy (hx of kidney bx, results unknown) 5)History of proteinuria 6)Chronic diarrhea (work-up in [2-/2105] unrevealing, results of endoscopic biopsies unknown at this time) 7)Anemia Social History: Single. No tobacco, no ETOH, no drugs. Family History: -Mother, and both siblings have facioscapulohumeral dystrophy (autosomal dominant inheritance) -No known history of cancer -No known history of bleeding or clotting disorders Physical Exam: VITALS: Temp 93, BP 186/104, HR 86, RR 28 GENERAL: obese male fatigued/malaised, hypothermic HEENT: Head normotraumatic, acephalicPEERLA, pale conjunctiva, nonedematous sclera, endotracheal tube in place; teeth and gums WNL, moist MM. CARDIOVASCULAR: RRR, no MRG RESPIRATORY: lung clear to ausculation bilaterally. Ventilated. ABDOMEN: absent bowel sounds, soft to palpation SKIN: cold periphery, warm core skin, nonmottled EXTREMITIES: 1+ peripheral edema, absent cyanosis, absent clubbing, MUSCULOSKELETAL: unable to assess secondary to patient's altered mental status NEUROLOGICAL: Unresponsive. No spontaneous movement. Sedated. Pertinent Results: Laboratory results: [2105-9-20] 07:40PM URINE AMORPH-FEW [2105-9-20] 07:40PM URINE RBC-0-2 WBC-[7-26]* BACTERIA-FEW YEAST-NONE EPI-<1 [2105-9-20] 07:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [2105-9-20] 07:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.014 [2105-9-20] 07:40PM FIBRINOGE-455* D-DIMER-1522* [2105-9-20] 07:40PM PT-14.2* PTT-32.5 INR(PT)-1.3* [2105-9-20] 07:40PM PLT SMR-LOW PLT COUNT-90* [2105-9-20] 07:40PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL FRAGMENT-OCCASIONAL [2105-9-20] 07:40PM NEUTS-82.3* BANDS-0 LYMPHS-12.4* MONOS-2.8 EOS-2.4 BASOS-0.1 [2105-9-20] 07:40PM WBC-6.8 RBC-1.73* HGB-5.1* HCT-14.6* MCV-84 MCH-29.3 MCHC-34.7 RDW-17.3* [2105-9-20] 07:40PM ALBUMIN-3.2* CALCIUM-7.4* MAGNESIUM-2.6 [2105-9-20] 07:40PM CK-MB-51* MB INDX-12.0* [2105-9-20] 07:40PM LIPASE-114* [2105-9-20] 07:40PM ALT(SGPT)-15 AST(SGOT)-10 CK(CPK)-425* ALK PHOS-80 [2105-9-20] 07:40PM LD(LDH)-347* TOT BILI-0.2 [2105-9-20] 07:40PM estGFR-Using this [2105-9-20] 07:40PM GLUCOSE-160* UREA N-202* CREAT-12.6* SODIUM-143 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-6* ANION GAP-37* [2105-9-20] 08:20PM LACTATE-0.7 [2105-9-20] 08:38PM freeCa-1.0* [2105-9-20] 08:38PM HGB-5.1* calcHCT-15 O2 SAT-97 [2105-9-20] 08:38PM GLUCOSE-145* LACTATE-1.0 NA+-140 K+-4.7 CL--115* [2105-9-20] 08:38PM TYPE-ART RATES-/24 TIDAL VOL-500 O2-100 PO2-524* PCO2-18* PH-7.13* TOTAL CO2-6* BASE XS--21 AADO2-188 REQ O2-39 INTUBATED-INTUBATED VENT-CONTROLLED [2105-9-20] 11:39PM PT-13.6* PTT-31.9 INR(PT)-1.2* [2105-9-20] 07:40PM LIPASE-114* [2105-9-20] 07:40PM ALT(SGPT)-15 AST(SGOT)-10 CK(CPK)-425* ALK PHOS-80 [2105-9-20] 07:40PM LD(LDH)-347* TOT BILI-0.2 [2105-9-20] 07:40PM estGFR-Using this [2105-9-20] 07:40PM GLUCOSE-160* UREA N-202* CREAT-12.6* SODIUM-143 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-6* ANION GAP-37* [2105-9-20] 08:20PM LACTATE-0.7 [2105-9-20] 08:38PM freeCa-1.0* [2105-9-20] 08:38PM HGB-5.1* calcHCT-15 O2 SAT-97 [2105-9-20] 08:38PM GLUCOSE-145* LACTATE-1.0 NA+-140 K+-4.7 CL--115* [2105-9-20] 08:38PM TYPE-ART RATES-/24 TIDAL VOL-500 O2-100 PO2-524* PCO2-18* PH-7.13* TOTAL CO2-6* BASE XS--21 AADO2-188 REQ O2-39 INTUBATED-INTUBATED VENT-CONTROLLED [2105-9-20] 11:39PM OSMOLAL-369* [2105-9-20] 11:39PM CALCIUM-7.2* PHOSPHATE-13.3* MAGNESIUM-2.4 [2105-9-20] 11:39PM LIPASE-107* [2105-9-20] 11:39PM CK(CPK)-375* AMYLASE-56 [2105-9-20] 11:39PM GLUCOSE-271* UREA N-186* CREAT-12.1* SODIUM-144 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-8* ANION GAP-36* [2105-9-20] 11:40PM URINE HOURS-RANDOM UREA N-340 CREAT-28 SODIUM-76 TOTAL CO2-<5 MICROBIOLOGY: 8/5 BLOOD CULTURES x2: negative [9-23] AND [9-25] C. DIFFICLE EIA: negative [9-24] SPUTUM GRAM STAIN AND CULTURES: negative [9-26] AND [9-27] BLOOD CULTURES x4: pending U/A: (+) protein, (+) ketones Relevant Imaging: [2105-9-20] CT ABDOMEN AND PELVIS WITHOUT INTRAVENOUS CONTRAST: CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: 1. Limited study due to lack of intravenous or oral contrast. No radiographic findings to explain the patient's drop in hematocrit. No evidence for intraperitoneal hematoma. 2. Atrophic kidneys and trace ascites. 3. Marked lumbar scoliosis. 4. Nodular opacities at the lung bases may represent evolving infectious etiology. Recommend follow up imaging to ensure resolution after appropriate treatment. [2105-9-20] EKG: Sinus tachycardia. Cannot rule out old anterolateral myocardial infarction. Modest lateral ST-T wave changes which are non-specific. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 102 150 96 370/428.85 48 -9 79 [2105-9-21]: NON-CONTRAST CT CHEST: Multiple ground glass foci and worsening bibasilar consolidation all worrisome for an infectious process. 2. Small pericardial and bilateral pleural effusions. 3. Heterogeneous-appearing thyroid with surrounding fluid density incompletely imaged. Correlate soft tissue edema clinically with symtpoms of infection versus fluid overload. The thyroid gland could be further evaluated with ultrasound as clinically warranted. [2105-9-22] CHEST XR: New right upper lobe collapse. 2. New mid left lung airspace opacity that could represent pneumonia. 3. New mild-to-moderate left pleural effusion. [2105-9-22] ECHOCARDIOGRAPHY: EF>55%. Mild symmetric left ventricular hypertrophy with preserved overall left ventricular systolic function (cannot exclude subtle focal regional dysfunction given subooptimal image quality). Small circumferential pericardial effusion without echocardiographic evidence of tamponade. [2105-9-26] CT HEAD WITHOUT CONTRAST: No intracranial hemorrhage, mass effect, or major vascular territorial infarction. MR is more sensitive for the evaluation of the brain ischemia in patients with seizures. Small amount of fluid in the sphenoid sinus. [2105-9-28] ELECTROENCEPHALOGRAM: This telemetry captured no pushbutton activations. Routine sampling and spike and seizure detection programs demonstrated a normal background rhythm during wakefulness with no focal, lateralized, or epileptiform features. There were no electrographic seizures recorded. [9-30] CHEST xray: No new infiltrates or CHF. Improving left basal densities. Gas distended bowel. [2105-9-29] ABDOMINAL XR, SUPINE ONE VIEW: Moderately dilated loops of small and large bowel, which is suggestive of an ileus. However, a more centered film including erect views may provide better evaluation for obstruction and the presence of free air. Brief Hospital Course: Mr. [Known lastname ] is a 26yo male with fascioscapulohumeral muscular dystropy and renal failure secondary to end-stage IgA nephropathy, who presented with respiratory failure, profound anemia, and profound acidosis, now s/p tracheostomy and PEG. 1)End stage IgA nephropathy: Acute on chronic renal failure secondary to IgA nephropathy, likely complicated by hypertension. Of note, no renal biopsy done here; IgA diagnosis per renal team's communication with Mr. [Known lastname 4675] primary nephrologist. Full renal failure workup on presentation included: urine sediment analysis: granular casts, multiple red blood cells. Burr cells seen on peripheral smear c/w renal failure and uremia (BUN 186). Negative UDS. Normal urine lytes, except protein/creatinine ratio 24.6. Renal u/s in ED ruled out obstruction. BUN:Creatinine ratio <20 but patient with chronic diarrhea, therefore prerenal azotemia could contribute to renal failure. It was felt that most likely intrarenal pathology underlied the patient's current renal failure, as explained by prior diagnosis of IgA nephropathy. [Hospital1 18] renal team consulted and followed patient throughout stay. Patient's electrolyte and consequent clinical status much improved on HD and patient was maintained on a Tuesday, Thursday, Saturday HD schedule. PTH (1077 pg/mL) is increased which is consistent with renal osteodystrophy. Please continue cinacalcet as an outpatient to prevent further osteodystrophy. Patient will likely need vitamin D supplementation in future. Vitamin D deficient: 25-OH, total 7 NG/ML, D3 7 NG/ML, D2 <4 NG/ML. Continue HD on T Th Sa HD schedule. Next HD on Tuesday, will likely be at rehabiliation facility. Of note, renal used 30 bicarbonate (vs. 25) due to alkalemia (ABG 7.51/35/116), with improved blood gas s/p HD (7.45/39/179). Also, last weight prior to HD was 96.9 kg on [2105-10-10]. 2)Anemia: Profound anemia at presentation but much improved with epogen begun with HD. Multi-factorial and largely related to the anemia of chronic renal failure. At [Hospital1 18], he received 4 units of PRBCs on [8-5] which increased his HCT from 14.6 to 23.6; his HCT was 11 at his initial presentation on [9-20] at [Hospital3 7569]. Originally, differential diagnosis included: GI bleed vs. occult bleed vs. anemia of chronic disease. Trace guiac. Negative NGT lavage in ED. CT abdomen negative for RP bleed or pooled blood. Peripheral smear also significant for hypochromic, microcytic anemia . MCV=83 c/w normochromic anemia of chronic disease or mixed anemia (RDW elevated 16.9). No evidence of acute bleed on CT, rectal exam, or hemodynamically. Hematology was consulted to evaluate the patient for TTP-HUS in the setting of anemia and thrombocytopenia. Patient's peripheral blood smear showed no evidence of intravascular hemolysis, as only rare schistocytes and no bite cells were seen. Hematology thus felt it was very unlikely that patient has TTP-HUS. Additionally, the smear shows no evidence of microangiopathic pathology such as DIC. Furthermore, B12 and folate normals are normal. Iron studies do not show deficiency, but reflect chronic inflammatory state. The multifactoral causes of his anemia include: bilateral atrophic kidneys on imaging which do not appropriately secrete epogen. Fascioscapulohumeral dystrophy, which along with his chronic kidney disease, may also have contributed to an anemia of chronic inflammation/disease. His reticulocyte count indicated that his marrow is not producing an appropriate reactive reticulocytosis, likely reflecting some marrow suppression secondary to chronic inflammation. Workup for other chronic diseases included: negative HBV, HCV, HIV, UPEP, SPEP. Since [9-29], hematocrits have peaked at 34.5-->26.1 [2105-10-7])-->23 yesterday ([2105-10-8])-->24.4 ([2105-10-11]). He will need close follow-up as an outpatient and serial hematocrits to be monitored at rehabilitation; of note, transfusion threshold at [Hospital1 18] was HCT <21. Continue Epogen at 3000 units 3X/week at HD, increasing dose of epogen with HD as needed; renal recommendations include pRBCs with HD as well. 3)Respiratory distress with hypoxia and hypercarbia: Pneumonia on CXR. Repeat CT chest on [9-21] showed worsening bibasilar consolidation and multiple ground glass foci worrisome for an infectious process. Sputum cultures with 3+ GPC in pairs in clusters on sputum gram stain yesterday. Labile nature of hypoxia not consistent with pulmonary edema but respiratory status improved with fluid removal by HD. Patient was more consistently hypercarbic vs. hypoxic. Extubation goal achieved. Treated for 13 days with antibiotics for empiric PNA. Treatment included 6 days azithromycin/ceftriaxone; 4 days levofloxacin; 3 days vancomycin, cefepime, flagyl. The patient developed notably poor lung volumes secondary to ileus causing abdominal distension. Ileus was thought to be due to muscular dystrophy and ICU myopathy. Pt also with poor cough reflex which has caused intermittent mucous plugging with acute oxygen desaturations and partial lung collapses. Pt desaturated and became apneic with hypotension and was intubated ([10-4]) secondary to unresolving respiratory distress. The patient was intubated for apnea in setting of hypotension. The patient's respiratory muscles were thought to be severely deconditioned and the patient also had increased secretions. A percutaneous tracheostomy was placed by interventional pulmonology on [2105-10-7] to assist with secretion suctioning. Of note, metabolic alkalosis was thought to contribute to apnea. Renal adjusted bicarbonate in dialysate but recommended we consider further workup. Of note, pH normalized s/p HD with adjusted bicarb. At rehabilitation, continue to wean patient on pressure support ventilation. Awaiting speech consult for PMV. Continue Ipratropium nebulizers. Weaned midazalam and fentanyl drips. Bolus fentanyl as needed and continue fentanyl patch at 50 mg/hour. Passy muir valve placed by speech. Patient should be continued to be followed by speech at the rehab facility. 4)L eye injection: Likely conjunctivitis. Continue erythromycin drops to L eye planned course to be discontinued on [10-13]. 5)Hypertension: Blood pressures better controlled on current regimen, but the patient was in esmolol drip for a short time. Hypertension partly related to worsening renal failure as well as [Name8 (MD) 73500] MD related to hypertension. Upon discharge the patient's regimen included the following medications per PEG: Metoprolol 75 mg PO/NG QID and Amlodipine 10 mg PO/NG daily. HTN covered with metoprolol 5 mg IV if needed between metoprolol dosages. 6)Depression/anxiety: Patient has stated multiple times overnight "let me die", denies suicidal ideation, tearful, scared due to his situation. Patient was on Paxil as outpatient. Psychiatry service consulted. Olanzapine given PRN for agitation, max dose of 30mg/24hrs; now 5 mg q HD only. Once mental status returns fully to baseline, consider reinitiation of Zoloft for depression. Pt will require outpt psychiatric follow up and likely would benefit from partial hospital program/day program after done with rehab. [Doctor Last Name ] Huppuch, the psychiatry case manager at [Hospital3 ] will be in contact with the rehab facility regarding outpatient follow-up. 7)Mental status changes: Patient s/p seizure-like activity vs. agitation in setting of agitation preceded by psychoses (deity delusions). Pt stated he is god. EEG, CT head negative for seizure focus. Ammonia level 20. Discontinued flagyl and avoiding quinolones and sertraline as it lowers seizure threshold and C. dificle negative X2. Also, the patient has been waxing and [Doctor Last Name 688] and was yelling throughout the night. Neuro and psych consulted; psych believes patient is delirious. Delirium improved prior to intubation but was difficult to assess s/p reintubation on sedation. Reassessment of mental status upon discharge as weaning sedation (including a benzodiazepene) reveals baseline delirium. Olanzapine PRN for agitation/psychoses as above. Appears to be at baseline at time of discharge. 8)Thrombocytopenia (resolved)- Sequestration versus consumption. DIC panel: D-dimer 1522, fibrinogen 455, PT 14.2, INR 1.3. Haptoglobin Pending. Not likely DIC as patient not oozing from IV sites, mucous membranes, will continue to monitor thrombocytopenia closely. Even though platelets are low, Hematology felt they were they are relatively stable at 75-90 and fibrin degradation products are within normal limits. Consumptive platelet process could not be ruled out but there was no evidence of splenomegaly on exam, and peripheral blood smear does not have cell types indicative of hypersplenism. During hospital stay platelets slowly trended upward and upon discharge were within normal limits. 9)Acute acid base disorder (resolved)- At presentation, the patient p/w anion gap metabolic acidosis (AG approx. 32). He has chronic diarrhea and may have had a superimposed non-AG metabolic acidosis as well though delta, delta ratio approx. 1 and did not suggest this. Anion gap metabolic acidosis was likely secondary to profound uremia (BUN 202). In addition the patient compensated via respiratory alkalosis at presentation, with RR 32 at presentation; the patient's respiratory failure was likely related to tachypnea in setting of acid-base disorder. Calculated osmolar gap 7 (Osm measured 369, calculated 363) inconsistent with ingestions or other etiologies of metabolic acidosis. Bicarbonate infusion was given. Hyperventilation was begun with a ventilator (Goal pH>7.25). Until the patient's acid-base status stabilized, the lytes were followed serially and ABGs q 2 hours to adjust respiration on ventilator and/or bicarbonate infusion. The patient was resuscitated and the acute acid base imbalance resolved with the above interventions. 10)FEN: PEG tube placed prior to discharge. Tolerating tube feeds appropriately. Continue Nutren via PEG tube. Na stable at 138 today with free water decreased from 200 to 50 q6 hr. 11)Prophylaxis: Continue heparin SQ, PPI. 12)Full code. Medications on Admission: Paxil Norvasc Toprol Discharge Medications: 1. Zyprexa 2.5 mg Tablet Oral 2. Acetaminophen 160 mg/5 mL Solution Sig: Six [Age over 90 1230]y (650) milligrams PO Q6H (every 6 hours) as needed. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Fentanyl Citrate 25-100 mcg IV Q2H:PRN 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 10. Erythromycin 5 mg/g Ointment Sig: 0.5 inch Ophthalmic QID (4 times a day). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units units Injection TID (3 times a day). 12. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day). 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 17. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 18. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) milligrams PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Primary diagnoses: 1)Renal failure 2)Respiratory failure 3)metabolic acidosis 4)Anemia 5)Mental status changes 6)Hypertension Secondary diagnoses: 1. Fascioscapulohumeral muscular dystrophy Discharge Condition: Stable Discharge Instructions: 1)You were admitted to the intensive care unit with renal failure. You were placed on hemodialysis and subsequently improved. During your stay, a chest x-ray was concerning for pneumonia and you were treated with antibiotics. 2)Please take all medications as listed in your discharge instructions. 3)You were started on eye drops for an eye infection. You should stop using these drops on [2105-10-13]. 4)Please scheduled follow-up with your primary care physician after being discharged from the hospital. 5)If you experience any fevers, chills, chest pain, shortness of breath, fevers, chills, or any other concerning symptoms please return to the emergency department. Followup Instructions: Please follow up with your outpatient nephrologist and primary care doctor within several days of discharge from rehabilitation. ICD9 Codes: 5849, 2762, 5856, 486, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5030 }	Medical Text: Admission Date: [2114-1-31] Discharge Date: [2114-2-10] Date of Birth: [2049-8-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11495] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is a 64 year old male with past medical history significant for CAB s/p CABG in [2111] (LIMA-LAD and SVG-OM), dyslipidemia, peripheral vascular disease (s/p multiple stents to bilateral iliacs, femoral), hypertension, s/p CVA, left carotic artery occlusion who presents with crescendo shortness of breath and chest pressure. Three days prior to admission, the patient was awakened from sleep short of breath, diaphoretic, and with 3/10 chest pressure radiating to both shoulders. These symptoms resolved upon sitting up. Similar episodes ocurred more frequently over the next few days, and the patient decided to seek medical attention. He denies nausea, vomiting, abdominal pain, lower extremity edema, increased abdominal girth. He has been sleeping with 2 pillows, which is unchanged. At baseline, the patient is able to walk without shortness of breath or chest pressure. At the OSH ED, he was noted to be hypertensive and mildly hypoxic. CXR showed mild to moderate CHF/pulmonary edema. Initial EKG was NSR, 92BPM, slight ST depression inferolaterally. Initial troponin was .309. Repeat troponin 8 hours later was 3.07 with CPK of 159. Repeat EKG revealed inverted T waves across the precordium. He was given Lasix and nitroglycerin with complete symptom relief. Despite improvement in cardiac symptoms, the patient experienced black heme positive stools with a HCT drop from 31.7 to 25. He received 2 units PRBC. The GI service was consulted who deferred endoscopy until completion of cardiac catheterization at [Hospital1 18]. Past Medical History: * CABG at [Hospital1 ] [May 2111] - LIMA to LAD and SVG to OM * Dyslipidemia. * Renal artery stenosis, status post bilateral stents. * Peripheral vascular disease, status post stents to bilateral iliacs, femoral. * Hypertension. * Cerebrovascular accident in [2095], with right leg numbness, weakness and dysarthria. * Left carotid artery occlusion. * gastric ulcer * PVD s/p iliac stent Social History: Retired police officer. Ex-smoker of 1.5-2 packs/day. Quit 5 years ago. Does not drink ethanol. Family History: Several family members on both sides of the family have significant vascular disease. Two brothers with extensive history of MI and PVD. Generations of men on father's side have not lived beyond 50 secondary to cardiac/vascular disease Physical Exam: VS: 98 138/60 70s 18-20 96%RA GEN: pleasant, NAD, comfortable appearing male appearing his stated age, well-nourished HEENT: PERRL, EOMI, sclera anicteric, no conjuctival injection, mucous membranes moist, no lymphadenopathy, no thryroid nodules or masses, no supraclavicular lymph nodes, no posterior lymphadenopathy, neck supple, full ROM, neg JVD, bilateral carotid bruits [Last Name (un) ]: fine crackles at bases right>left, slight dullness to percussion right>left COR: RRR, S1 and S2 wnl, 3/6 SEM ABD: non-distended with positive bowel sounds, non-tender,no guarding, no rebound or masses BACK: neg CVA tenderness EXT: no cyanosis, clubbing, edema NEURO: Alert and oriented x3. CNII-XII are intact, and patient with 5/5 strength throughout, normal sensation throughout. No pronator drift. Pertinent Results: [2114-1-31] 09:25PM GLUCOSE-138* UREA N-40* CREAT-1.8* SODIUM-137 POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13 [2114-1-31] 09:25PM CK(CPK)-54 [2114-1-31] 09:25PM CK-MB-NotDone cTropnT-0.78* [2114-1-31] 09:25PM CALCIUM-9.0 PHOSPHATE-4.7* MAGNESIUM-2.3 [2114-1-31] 09:25PM WBC-10.4 RBC-3.67* HGB-10.3* HCT-32.2* MCV-88 MCH-28.2 MCHC-32.1 RDW-15.1 [2114-1-31] 09:25PM PLT COUNT-345# [2114-1-31] 09:25PM PT-12.9 PTT-24.4 INR(PT)-1.1 [2114-2-9] 10:07PM BLOOD Hct-32.0* [2114-2-9] 01:15PM BLOOD WBC-7.8 RBC-3.42* Hgb-9.5* Hct-29.8* MCV-87 MCH-27.8 MCHC-31.9 RDW-14.5 Plt Ct-350 [2114-2-9] 01:15PM BLOOD Plt Ct-350 [2114-2-9] 06:55AM BLOOD Plt Ct-318 [2114-2-9] 06:55AM BLOOD Glucose-117* UreaN-34* Creat-1.6* Na-137 K-4.0 Cl-101 HCO3-27 AnGap-13 [2114-2-8] 06:25AM BLOOD Glucose-119* UreaN-34* Creat-1.5* Na-135 K-4.3 Cl-101 HCO3-24 AnGap-14 [2114-2-2] 06:21AM BLOOD LD(LDH)-195 TotBili-0.4 DirBili-0.2 IndBili-0.2 [2114-2-2] 04:47AM BLOOD CK(CPK)-40 [2114-2-1] 11:00AM BLOOD CK(CPK)-52 [2114-1-31] 09:25PM BLOOD CK(CPK)-54 [2114-2-9] 06:55AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.2 [2114-2-2] 04:47AM BLOOD CK-MB-2 cTropnT-0.88* [2114-2-1] 04:30PM BLOOD cTropnT-0.53* [2114-2-1] 11:00AM BLOOD CK-MB-NotDone cTropnT-0.75* [2114-1-31] 09:25PM BLOOD CK-MB-NotDone cTropnT-0.78* [2114-2-1] 03:26PM BLOOD Glucose-127* K-3.0* [2114-2-3] 11:17AM BLOOD Hgb-8.9* calcHCT-27 O2 Sat-73 Brief Hospital Course: * CAD: In light of significant family history, other cardiac risk factors, known CAD s/p CABG, crescendo shortness of breath and chest pressure, positive troponin, and EKG changes, the patient was sent to cardiac catheterization. His cardiac catherization demonstrated a right dominant system with 80% stenosis of the LMCA distally, bilateral 60% renal artery re-stenoses along with a diffuse 40% occlusion of his left subclavian resulting in 50 mmHg drop in his peripheral blood pressures compared to his central blood pressure. He also had an elevated PCWP of 35 mm Hg. He was thus admitted to the CCU for agressive blood pressure management and diuresis with lasix and niseritide. On return to the floor, the patient continued to have poorly controlled hypertension and recurrent congestive heart failure exacerbations. Lasix and niseritide were employed again with good effect. After several family meetings to explain the [Hospital 228] medical status to both the patient himself and his family, the patient agreed to accept home oxygen supplementation in light of his tenous fluid status. He will be followed by Dr. [Last Name (STitle) ] in 2 weeks to discuss renal MRA and possible vascular intervention because it was not possible to accurately assess the patient's renal arteries with ultrasound. * HYPERTENSION: The patient had difficult to control hypertension as documented above. The patient was discharged on maximal doses of blood pressure medications with the exception of starting an ace-inhibitor or [Last Name (un) ] in light of his poor renal function secondary to renal artery stenosis. The patient's underlying etiology of hypertension is unclear but likely related to renal artery stenosis. This issue will be addressed as an outpatient with Dr. [Last Name (STitle) ] and Dr. [First Name (STitle) 14966], the patient's cardiologists. * PUMP: The patient had a cardiac echo which demonstrated an EF of 60-65% and a moderately dilated atrium. Cardiac catheterization revealed severely elevated left and right sided filling pressures which were indicative of the congestive heart failure described above. * RHYTHM: The patient had no episodes of arrythmias. * GI BLEED/ANEMIA: The patient reportedly had a Hct drop from 35 to 27.5 at the OSH. There was no evidence of GI bleeding at this hospital. Further analysis of the patient's Hct over the last few years reveals a chronic anemia. The patient was transfused a total of 4 units while in the unit and just prior to discharge. In the long term, it may be considered to send the patient for colonoscopy or endoscopy to evaluate for GI pathology that could account for chronic slow bleeding. With respect to etiology of the patient's chronic anemia, iron studies are pending at the time of this discharge summary. * ACUTE ON CHRONIC RENAL INSUFFICIENCY: After his cardiac catherization the patient's creatinine rose to a peak of 3.8 from his admission creatinine 1.8. With aggressive diuresis, the patient's dye nephropathy resolved and creatinine returned to his baseline of 1.6 prior to discharge. The patient did not require hemodialysis. * CODE: DNR/DNI. This status was confirmed with the patient, his son, and his daughter. Medications on Admission: aspirin 325 mg daily lopressor 75 mg twice daily hydralazine 25 mg twice daily norvasc 10 mg twice daily hctz 12.5 mg daily lisinopril 40 mg daily iron crestor 10 mg daily folic acid Discharge Medications: 1. Folic Acid 1 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 5. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 8. Hydralazine HCl 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 9. SUPPLEMENTAL OXYGEN SUPPLEMENTAL OXYGEN. Rate 2L continuous. ROOM AIR OXYGEN SATURATION 86%. For portability, provide pulse dose system 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 12. Iron 50 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:30 Tablet Sustained Release(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: coronary artery disease, hypertension, congestive heart failure, acute on chronic renal failure, anemia Discharge Condition: stable Discharge Instructions: 1. Please take all of your medications. 2. Please seek medical attention should you experience any of the following: shortness of breath, chest pain, palpitations, sudden weakness, lightheadedness, dizziness, loss of consciousness, fainting, nausea, vomiting, fever, chills 3. Please see your PCP and Cardiologist (Dr. [First Name (STitle) 14966] [Telephone/Fax (1) 14967]within 1-2 weeks 4. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. 5. Adhere to 2 gm sodium diet 6. Do not list objects more than 5 pounds. Do not return to work involving physical labor for at least 6 weeks. At that point, consult your cardiolgist to reassess whether physical activity is safe. Followup Instructions: See Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14966] on [2114-2-15] at 1:15 pm ([Telephone/Fax (1) 14967]) Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 10548] Date/Time:[2114-3-8] 2:30 Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 10548] Date/Time:[2114-3-22] 1:00 ICD9 Codes: 4280, 5849, 5789, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5031 }	Medical Text: Admission Date: [2115-2-24] Discharge Date: [2115-3-13] Date of Birth: [2043-3-18] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6346] Chief Complaint: Bright Red Blood Per Rectum, unstable Major Surgical or Invasive Procedure: Intubation Angiography Endoscopy and Colonoscopy History of Present Illness: 71 yo with Afib on anticoagulation, CAd s/p MI, and HTN, Hyperlipiedmia presents with gas pain followed by bloody BM associated with dizziness, but no n/v, no hx of GI bleeding in past. Has been on coumadin for many years, but dose constantly being adjusted. At [Last Name (un) 4068] where he presented, found to initially Hct of 37, but with 4Liters hydration for BP support, Hct 29 and patient with 2bloody BMs at [Last Name (un) 4068] as well. He notes he cannot control BMs with all the blood. At [Last Name (un) 4068] he received FFP, Vitamin K and 1uPRBC and was transferred here for eval. DEnies any hx of GIbleeding in past and notes that has had sigmoidoscopy in past which was esssentially nl except [First Name8 (NamePattern2) ] [Last Name (un) 4068] report for possible diverticuli. Over last few weeks had prolonged course with sore throat and congestion. Past Medical History: PMHx: HTN Afib on anticoag CAD s/p MI, but no intervention per pt Hyperlipidemia NIDDM Gout s/p TURP [2111] Social History: lives alone at home. Occ ETOH, quit tobacco 3y ago (prior smoked for 50y) Family History: Noncontributary Physical Exam: axo NAD CTA B/L S-NT-ND, S1,S2, no M/R/G EXT, WNL, Guiac + Pertinent Results: [2115-2-25] 12:00AM TYPE-ART TEMP-37.7 RATES-14/ TIDAL VOL-750 PEEP-5 O2-40 PO2-82* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [2115-2-25] 12:00AM TYPE-ART TEMP-37.7 RATES-14/ TIDAL VOL-750 PEEP-5 O2-40 PO2-82* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [2115-2-24] 08:14PM TYPE-ART RATES-16/ TIDAL VOL-750 PEEP-5 O2-50 PO2-118* PCO2-31* PH-7.45 TOTAL CO2-22 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [2115-2-25] 12:00AM TYPE-ART TEMP-37.7 RATES-14/ TIDAL VOL-750 PEEP-5 O2-40 PO2-82* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [2115-2-24] 01:15PM WBC-11.5# RBC-4.01 HGB-11.8* HCT-34.4* MCV-86 MCH-29.4 MCHC-34.3 RDW-15.4 [2115-2-24] 12:09PM HGB-11.2* calcHCT-34 [2115-2-24] 11:04AM HGB-11.0* calcHCT-33 O2 SAT-98 [2115-2-24] 09:04AM HGB-11.0* calcHCT-33 [2115-2-24] 08:00AM WBC-5.3# RBC-3.29* HGB-9.7* HCT-29.6* MCV-90 MCH-29.4 MCHC-32.7 RDW-14.8 [2115-2-24] 06:16AM WBC-13.0* RBC-3.30* HGB-9.4* HCT-29.7* MCV-90 MCH-28.4 MCHC-31.6 RDW-14.2 Brief Hospital Course: [Known firstname 9241] was markedly unstable in the ER, invasive monitoring was placed and angiography was emergently performed. He had no obvious bleeding site. He was intubated prior to the procedure for airway protection secondary to large volume support. His bleeding resolved with coagulation correction and he was supported in the ICU while intubated. Post procedure he developed fevers and failed extubation twice. Sputum cultures yielded MRSA. He as treated for the pneumonia and was extubated successfully on the third attempt. He was transfered to the floor. Upper endoscopy and colonoscopy revealed only severe diverticulosis. He was discharged to rehab. to complete his vancomycins for the MRSA pneumonia. Medications on Admission: Meds / Labs / Radiology: Meds: Heparin, Insulin, metoprolol Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 9. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 10 days: Please complete 10 days. Disp:28 Recon Soln(s) Refills:0 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 511] [Hospital 4094] Hospital Discharge Diagnosis: GI bleed Discharge Condition: stable Discharge Instructions: Please wait one week prior to starting coumadin Followup Instructions: F/U in 1- 2 weeks, please F/U with primary care physisicn regarind GI bleed and colonascopy results and need to F/U with Gastroenterology Completed by:[2115-3-13] ICD9 Codes: 4271, 4019, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5032 }	Medical Text: Admission Date: [2158-7-14] Discharge Date: [2158-7-14] Date of Birth: [2130-3-31] Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 2763] Chief Complaint: EMS call for aggression Major Surgical or Invasive Procedure: None History of Present Illness: This is a 28 year old gentleman who was brought in by EMS after assaulting someone and was found to be combative on the seen. The patient is spanish speaking only and an initial history was very limited. He reported to ED physicians only drinking beer and denied drug use. In the ED, initial VS were: 125 107/69 99%. his physicial exam was notable for large pupils, diaphoresis. He was otherwsie completely uncooperative with an exam. He was given 5mg haldol, 2mg ativan and 10mg zyprexa and placed in 4 point restraints. Initial labs demonstrated wbc 10.5, hct 49.3, plts 231, Na 140, hco3- 18, creatinine 0.9. An ABG demonstrated 7.31/43/77. A UA was negative. A tox was positive benzos and negative and serum tox demonstrated a serum etoh 109 and serum acetamino[phen of 69. A toxicology consult was placed who recommended emergent initiation of NAC, in addition to further investigation of the patients AG acidosis. An EKG demonstrated a wtc of 476. A CT head was negative for intracranial process. He was afebrile throughout his ED visit. On arrival to the MICU, initial vitals were: 98 36.7 138/98 18 100% on RA. THe patient had 1 episode of emesis. He reported he was walking on the street with a friend in [Name (NI) 82055]when he was apporached by 2 people he did not know who attacked him demanding his supply of percocet. He states he defended himself when the police arrived. He reports taking multiple medications for multiple medical problems including PTSD, bipolar disease, and WPW syndrome in addition to tylenol twice daily which he takes for chronic pain. He does not take any medications in addition to these and denies other ingestions. He reports having [5-21] large beers last night and no illicits. He reports his PCP is [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57717] at [Hospital1 2177] and gave permission to contact her office for his medical history. He provided with his personal belongs his identity. His primary care provider, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57717] at [Hospital1 2177] was contact[Name (NI) ] who provided collateral information regarding his PMHx, Medication list and recent office visits. Past Medical History: 1. [Doctor Last Name 79] Parkinson White s/p Pacemaker placement. Has had multiple attempts at ablations at [Hospital1 2177]. 2. PTSD (assault) 3. Bipolar 4. Neuropathic pain ([2-16] assault) Social History: - Tobacco: [5-21] cigg/day - Alcohol: 4-5 beers per day - Illicits: denies - Housing: lives witha group of friends - Social Hx: Recently moved from [Male First Name (un) 1056] after assault. Has been living w/ friends on disability in [Name (NI) 86]. Family still in [Male First Name (un) 1056]. Receives psychiatric, primary care and cardiology care all at [Hospital1 2177] and has good follow-up with these providers. Family History: Unable to obtain Physical Exam: Vitals: 98 36.7 138/98 18 100% 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-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, Discharge exam unchanged Pertinent Results: [2158-7-14] 11:54AM LACTATE-1.4 [2158-7-14] 10:36AM GLUCOSE-99 UREA N-11 CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18 [2158-7-14] 10:36AM ALT(SGPT)-37 AST(SGOT)-39 ALK PHOS-57 TOT BILI-0.4 [2158-7-14] 10:36AM CALCIUM-9.3 PHOSPHATE-2.6* MAGNESIUM-2.5 [2158-7-14] 06:50AM TYPE-ART PO2-77* PCO2-43 PH-7.31* TOTAL CO2-23 BASE XS--4 INTUBATED-NOT INTUBA [2158-7-14] 03:40AM GLUCOSE-100 UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-18* ANION GAP-23* [2158-7-14] 03:40AM ASA-NEG ETHANOL-109* ACETMNPHN-69* bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2158-7-14] 03:40AM OSMOLAL-317* [2158-7-14] 03:40AM ALBUMIN-5.1 [2158-7-14] 03:40AM LIPASE-55 [2158-7-14] 03:40AM ALT(SGPT)-35 AST(SGOT)-43* CK(CPK)-291 ALK PHOS-57 TOT BILI-0.2 [2158-7-14] 03:40AM PLT COUNT-231 [2158-7-14] 03:25AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2158-7-14] 03:25AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.020 [2158-7-14] 03:25AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2158-7-14] 03:25AM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 Brief Hospital Course: 28 year old gentleman who was brought in by EMS after assaulting someone and was found to be combative on the seen who is now admitted to the medical ICU for altered mental status. # Altered Mental Status: Ddx for initial agitation includes toxidrome from ingestion/intoxication vs psychosis; serum etoh and acetaminophen levels suggest ingestion and no localizing sx or fever to suggest infectious etiology, head CT without acute process. Toxicology called for possiblity of ingestion and may have been anticholinergic toxidrome vs sympathomimetic. Improved without intervention, mental status improved to baseline and patient elected to leave AMA despite elevated acetaminophen level, discussed below. Antipsychotics were held given potential for toxidrome but benzodiazepines continued. # Elevated serum acetaminophen level: Serum acetaminophen was 69 on arrival to ED. After improvement in mental status, the patient denied taking more than twice a day percocet or tylenol and denies taking more than directed. Denies any suicide attempt or intentional overdose. N-acetyl cysteine started for acetaminophen overdose without known time of ingestion. It was recommended by toxicology service that NAC continue for 24 hours, however patient insisted on leaving against medical advice after his mental status cleared, stating that he needed to go home to care for his pets and would rather he died than one of his pets. He was informed that by leaving against medical advice he was at risk for worsening liver function, liver failure, or possibly death and the patient was able to understand and verbalize our discussion with the assistance of an interpreter. Attempted to call PCP prior to patient leaving the hospital, however she was unavailable. Advised patient to call PCP as soon as possible for followup and to stop taking tylenol. # Anion Gap Acidosis - Anion gap on admission 19. Trace ketones in urine. Normal renal function. Serum aspirin level negative. Most likely [2-16] resisting restraints in the ED; improved on recheck after receiving fluids. # PTSD/Bipolar: Prior h/o trauma. Followed closely by psychiatry and his PCP at [Hospital1 2177]. Held antipsychotics during admission (seroquel 200 mg QHS) and Xanax was continued. He should discuss with his PCP when to restart. # [Doctor Last Name 79]-Parkinson-White: s/p several attempts at ablation at [Hospital1 2177] now s/p pacemaker placement. # Serum Etoh: Positive EtOH on tox screen however no signs of withdrawal during admission. Received IV thiamine and folate. Medications on Admission: 1. Xanax 1mg tid 2. Gabapentin 300mg qAM, noon 3. Gabapentin 600mg qHS 4. Seroquel 200mg qHS 5. Zoloft 150mg qDaily 6. Xomene??? 30mg qHS 7. Tylenol prn pain Discharge Medications: 1. ALPRAZolam 1 mg PO TID 2. Gabapentin 300 mg PO BID AM and Lunch 3. Gabapentin 600 mg PO HS Discharge Disposition: Home Discharge Diagnosis: acetaminophen intoxication Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for agitation and a high tylenol level in the blood. We recommended that you stay in the hospital to receive IV medications to treat the high level of tylenol in the blood and prevent damage to your liver, however you refused to stay in the hospital with the understanding that you could have further damage to your liver or possibly death from not receiving this treatment, called n-acetyl-cysteine, by the IV. Please call your primary care doctor in order to see her tomorrow to check your bloodwork. Please STOP taking tylenol (also called acetaminophen) until your primary care doctor tells you it is safe to continue taking it. Followup Instructions: Please call your primary care doctor tomorrow morning, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57717] Phone: ([Telephone/Fax (1) 57366]. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2158-7-15] ICD9 Codes: 2762, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5033 }	Medical Text: Admission Date: [2169-2-18] Discharge Date: [2169-2-21] Date of Birth: [2120-12-25] Sex: F Service: MEDICINE Allergies: Cipro Attending:[First Name3 (LF) 2751] Chief Complaint: transfer with PE Major Surgical or Invasive Procedure: . 1. Intraarterial thrombectomy with thrombolysis 2. IVC filter placement History of Present Illness: 48 year old F PMH obesity, HTN who developed left calf pain and swelling for 2 days duration. Patient had foot surgery 3 weeks prior. Today she began to develop shortness of breath and pleuritic chest pain. She called her pcp her referred to [Hospital1 ]. On presentation OSH VS 198/131 RR 22 SaO2 93% RA. Lab work-up pertinent for Troponin 0.353, positive d-dimer. CTA demonstrated large saddle pulmonary embolus. She was given 1.5 L and 2 mog ativan prior to transfer. Consequently patient was transferred to [Hospital1 18] for further management. On transport patient became hypotensive SBP 50 with symptomatic dizziness, however she received ativan prior to transfer. On arrival to our ED BP 70/40 which responded to SBP 130 with NS (unknown amount). During her ED stay blood pressure ranged from 125-138/60-86, HR 121-135. She required 4 L O2 by NC. EKG demonstrated right heart strain (S1Q3T3), mildly elevated troponin 0.04 and BNP 238. Due to episode of hypotension and evidence of right heart strain IR was consulted for possible intra-arterial thrombolysis/embolectomy who felt she would benefit. Vitals on transfer BP 128/60, HR 121, RR 20, O2 sat 98% 4L. On arrival patient anxious, continues to have shortness of breath with exertion only with pleuritic chest pain but appears comfortable. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: s/p foot surgery (Arthrodesis) in [1-/2169] Hypertension Hyperlipidemia Social History: Works as bookkeeper. - Tobacco: Denies - Alcohol: Social - Illicits: Denies Family History: Father 87 y/o M ? CAD/AAA. Mother 85 y/o F glaucoma. Physical Exam: VS: BP 128/60, HR 121, RR 20, O2 sat 98% 4L 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 On discharge: SBPs in 110s-130s, HR 70s-90s, satting well on room air and able to ambulate approximately 100' with crutches Pertinent Results: . LABS ON ADMISSION: . [2169-2-18] 01:52AM BLOOD WBC-12.1* RBC-5.02 Hgb-13.8 Hct-40.2 MCV-80* MCH-27.5 MCHC-34.3 RDW-14.0 Plt Ct-299 [2169-2-18] 01:52AM BLOOD PT-12.6 PTT-129.0* INR(PT)-1.1 [2169-2-18] 01:52AM BLOOD Fibrino-553* [2169-2-18] 01:52AM BLOOD Glucose-118* UreaN-16 Creat-0.9 Na-141 K-4.2 Cl-108 HCO3-24 AnGap-13 [2169-2-18] 01:52AM BLOOD Amylase-75 [2169-2-18] 01:52AM BLOOD Lipase-47 [2169-2-18] 01:52AM BLOOD cTropnT-0.04* [2169-2-18] 01:52AM BLOOD proBNP-238* [2169-2-18] 05:50AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8 [2169-2-18] 01:54AM BLOOD Glucose-118* Lactate-1.3 Na-141 K-4.6 Cl-106 calHCO3-22 . [2169-2-18] 02:30AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.023 [2169-2-18] 02:30AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2169-2-18] 02:30AM URINE RBC-0-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0-2 . LABS ON TRANSFER FROM ICU: . [2169-2-19] 12:39AM BLOOD WBC-11.4* RBC-4.26 Hgb-11.5* Hct-33.6* MCV-79* MCH-27.1 MCHC-34.4 RDW-13.8 Plt Ct-254 [2169-2-19] 09:02AM BLOOD PTT-60.5* [2169-2-19] 09:02AM BLOOD PTT-60.5* [2169-2-19] 12:39AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-139 K-4.1 Cl-107 HCO3-24 AnGap-12 . LABS ON DISCHARGE: . [2169-2-21] 07:50AM BLOOD WBC-8.9 RBC-4.91 Hgb-13.0 Hct-38.3 MCV-78* MCH-26.5* MCHC-33.9 RDW-13.9 Plt Ct-289 [2169-2-21] 07:50AM BLOOD Plt Ct-289 [2169-2-21] 07:50AM BLOOD PT-14.1* PTT-27.3 INR(PT)-1.2* [2169-2-21] 07:50AM BLOOD Glucose-92 UreaN-13 Creat-0.8 Na-138 K-4.0 Cl-104 HCO3-25 AnGap-13 [2169-2-21] 07:50AM BLOOD Mg-2.1 [2169-2-20] 06:45AM BLOOD calTIBC-300 Ferritn-103 TRF-231 . STUDIES: . ECG [2169-2-19] 12:44:42 PM Sinus tachycardia. Low precordial lead QRS voltage. Delayed R wave progression with late precordial QRS transition. Low right precordial lead T wave amplitude. Findings are non-specific. Since the previous tracing of [2169-2-18] sinus tachycardia rate is faster. Intervals Axes Rate PR QRS QT/QTc P QRS T 121 144 74 296/402 45 34 13 . BILAT LOWER EXT VEINS PORT Study Date of [2169-2-18] 3:51 AM 1. Occlusive thrombus in the left peroneal and popliteal veins. 2. No right lower extremity DVT. . [2169-2-18] Radiology PULMONARY ANGIO, IVC GRAM/FILTER, FEMORAL LINE PLACEMENT - IMPRESSION: 1. Pulmonary angiogram and successful chemical and mechanical thrombolysis. A total of 15 mg of TPA was injected (5 mg in the left pulmonary artery, 5 mg in the main pulmonary artery and 5 mg in the right pulmonary artery). Mechanical thrombectomy was performed with pigtail catheter, angled glide catheter and a 0.0.35 soft-tip [Last Name (un) 7648] wire. 2. Successful placement of a G2 retrievable IVC filter in the infra-renal position. The filter can be removed anytime in the future if clinically indicated once the risk of PE is abated. 3. Successful placement of a 7 French x 16 cm double lumen central venous catheter via right common femoral venous access. The tip of the catheter is terminating in the right common iliac vein and the line is ready for use. . [2169-2-18] ECG Study Date of [2169-2-18] 1:45:54 AM Sinus tachycardia. Vertical axis. Anterior T wave abnormalities. No previous tracing available for comparison. Rate 139 PR 136 QRS 72 QT/QTc 270/408 P 55 QRS 72 T 22 Brief Hospital Course: 48 year old F PMH HTN, dyslipidemia recent left foot arthrodesis who presented with acute SOB and chest pain found to have saddle pulmonary embolism. . Pulmonary embolism: The patient presented from OSH with large saddle PE on CTA with evidence of right heart strain on EKG (S1Q3T3), supported by elevated troponin/BNP. Patient had one episode of hypotension during transportation and on initial arrival. Upon arrival in the ICU the patient was tachycardiac and hypertensive with a 4L oxygen requirement. LENI demonstrated left popliteal DVT. Due to large clot burden, episode of hypotension and evidence of right heart strain patient underwent IR-guided pulmonary angiography with mechanical and chemical (tPA) thrombolysis. A G2 retrivable IVC filter and temporary dual lumen central venous line were placed via right femoral access. The patient was subsequently transitioned to lovenox and started on coumadin with resolution of her tachycardia and oxygen requirement. Her clot was thought to be most likely provoked by her recent surgery and immobilization, with her estrogen-based contraceptive (used for endometriosis) also a risk factor. She discontinued her NuvaRing on day prior to discharge; she was counseled on alternative contraception and indicated that her husband is s/p vasectomy. Of note the patient has had a previous partial hypercoagulability workup for history of cotton-wool spots. On discharge the patient was able to ambulate with 2 crutches without desaturating on RA. . The patient was on warfarin 5 mg daily beginning the afternoon of [2-18]. The patient had the following INRs: [2-18] 1.1 (am prior to warfarin initiation) [2-19] 1.0 [2-20] 1.0 [2-21] 1.2 . #. The patient was instructed to follow up with her PCP on the day following discharge for coagulation monitoring with goal INR [1-11]. We recommend overlap of therapeutic INR with lovenox for several days. The patient was instructed to make an appointment with an outpatient hematologist for long-term anticoagulation planning in consultation with her PCP (she will most likely require at least 6 mos and possibly lifelong anticoagulation). The patient was also instructed to make an appointment with an outpatient pulmonologist, which her PCP will refer her to. IR (Dr. [First Name8 (NamePattern2) ] [Name (STitle) ]) indicated that their PA will contact the patient within 2-3 months regarding potential IVC filter removal; the patient was given his number for follow up if she doesn't hear from them by then. . # Arthrodesis - per her outpatient podiatrist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16905], the patient bore weight on her left foot with physical therapy (s/p arthrodesis in [1-18]) in boot with 2 crutches on the day prior to discharge. She will follow up with her podiatrist regarding physical therapy and weight bearing. . # Concern for OSA: patient noted to have slightly reduced oxygen saturations at night (93%-94%) and to be audibly snoring. Given h/o obesity concern for OSA. Appropriate for outpatient workup. . # Hypertension: HCTZ had initially been held in the setting of hypotensive episode on presentation and outpatient regimen was restarted on discharge. . # Hyperlipidemia: Continued Pravastatin 20 mg daily. . # Anxiety/Depression: Continued Citalopram 20 mg daily. Medications on Admission: HCTZ 12.5 mg Provastatin 20 mg qd Citalopram 20 mg qd Novaring Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours) for 7 days. Disp:1120 mg Refills:0 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:0 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO as directed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Submassive saddle pulmonary embolus DVT Secondary: Hypertension Discharge Condition: . Mental status: Alert and oriented x 3 Ambulatory status: partial weight bearing on left (foot is postsurgical) in consultation with podiatrist Dr. [Last Name (STitle) 16905]. Discharge Instructions: You were admitted to the hospital and found to have a large blood clot in your lungs (pulmonary embolism) related to a clot in your leg (deep vein thrombosis). You underwent removal of clot (thrombectomy) with administration of a drug to dissolve it (thrombolysis) as well as placement of an inferior vena cava filter. You were monitored in the intensive care unit. We initiated treatment with blood thinning medications (anticoagulants), of which lovenox and warfarin will be continued at discharge. Warfarin takes several days to kick-in and become therapeutic while the lovenox works right away so it is important to overlap these medications for several days. Please see your PCP tomorrow and follow up with her as directed, and she will discontinue the lovenox in the coming days and will follow your "INR" lab which is a measure of how thin your blood is. This number should be between 2 and 3 while on warfarin. You likely developed these blood clots in the setting of surgery and while on an estrogen based contraceptive (NuvaRing). You should not take estrogen based contraceptives in the future. In addition, you should be seen by a clotting specialist (hematologist) within the next few months to determine how long you should be on anticoagulation. You will need to remain on coumadin for AT LEAST 6 months and possibly longer. We made the following changes to your medications: 1. Added enoxaparin 80 mg subcutaneously twice daily 2. Added warfarin 5 mg daily 3. STOP NuvaRing Please continue to take your other medications as directed. Followup Instructions: . Please see your PCP [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Location (un) 15749] Family Practice tomorrow [2-21] at 11:45am. She will arrange for monitoring of your INR and adjust your coumadin dose if necessary, as well as advise you on how long to take the lovenox. She can also help to arrange follow up with a clotting specialist to determine how long you should be on warfarin/coumadin. Please also follow up with your podiatrist Dr. [Last Name (STitle) 16905] this week about resuming physical therapy. Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6745] at [Hospital1 ] interventional radiology in [1-11] months at [Telephone/Fax (1) 6747] regarding removal of your IVC filter. Please keep your appointment with your ob/gyn on [2169-3-18] to discuss follow up for your endometriosis now that you have discontinued your Nuvaring. Completed by:[2169-2-22] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5034 }	Medical Text: Admission Date: [2151-2-17] Discharge Date: [2151-3-2] Date of Birth: [2072-10-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5119] Chief Complaint: Confusion Major Surgical or Invasive Procedure: Brain Abscess drainage Bronchoscopy with biopsy History of Present Illness: 78 F presents from [Hospital3 ] for acute mental status changes and bilateral frontal mass lesions. She began prednisone therapy for 4 days ago for BOOP. She complained of a headache on over the weekend, which was unusual for her. Her family noted increasing confusion x a few days, then yesterday she was noted to have some slurred speech and then this morning she couldn't speak - could only say "[Last Name (un) 46536]..." and "no." She was not able to bathe herself this AM as she forgot what to do. She normally cares for herself and is high functioning. She was taken to her PCP (Dr [Initials (NamePattern4) ] [Last Name (NamePattern4) 80583]), where a mini mental was given, she could only do about half the items on the test -- this is a dramatic change for her. Therefore, she was sent to the [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 4117] ED. CT revealed 2.4 cm lesion in the L frontoparietal region and a 20 mm lesion in the Right frontal lobe. At OSH ED given decadron 24 mg x1. Transferred to [Hospital1 18] for neurosurg eval. The patient developed what was thought to be "the flu" in [Month (only) 359]; this then developed into pneumonia in [Month (only) 1096]. The pneumonia did not go away despite a few rounds of antibiotics. A biopsy was performed [2151-2-5] which showed "metaplastic alveolar epithelial cells, fibroblasts and rare inflammatory cells" thought to be consistant with BOOP. She was started Prednisone 4 days prior to admission. She has not had a colonoscopy. She has yearly mammograms that have been fine. Her daughter is not sure about her [Name (NI) ] history. In the [Hospital1 18] ED: Neurosurgery was consulted. She was loaded with dilantin. She was admitted to medicine for further workup. Past Medical History: 1. COPD 2. BOOP- diagnosed 3 weeks ago by CT guided biopsy 3. Pneumonia ([1-22]) 3 days admission- [Hospital1 ] 4. Glaucoma 5. Anxiety 6. Bipolar D/O -- well controlled x 20 years 7. Cataract 8. fluid retention 9. Neuropathy 10. hyperlipidemia Social History: Lives at home with daughter, completes most ADLs. Smoked 3ppd for many years, quit over 20 years ago. No EtOH. Family History: Father- lung ca, CAD Physical Exam: Gen: NAD HEENT: MMM. PERRL, EOMI. CV: RRR Pulm: CTA, minimal fine crackles at bases Abd: obese, soft, NT/ND LE: warm, no edema Neuro: alert, oriented to person and place. speech is slow, mostly limited to yes and no responses. seems to have some wordfinding difficulty. cranial nerves grossly intact. moves all 4 ext with good strength, no gross sensory deficits. Pertinent Results: [2151-3-2] 06:10AM BLOOD WBC-13.2* RBC-3.62* Hgb-11.2* Hct-33.2* MCV-92 MCH-31.1 MCHC-33.8 RDW-16.5* Plt Ct-135* [2151-3-1] 05:49AM BLOOD WBC-14.0* RBC-3.62* Hgb-11.1* Hct-33.2* MCV-92 MCH-30.5 MCHC-33.3 RDW-16.2* Plt Ct-143* [2151-2-28] 06:54AM BLOOD WBC-19.7* RBC-3.86* Hgb-11.9* Hct-35.4* MCV-92 MCH-30.8 MCHC-33.5 RDW-16.2* Plt Ct-163 [2151-2-27] 05:29AM BLOOD WBC-14.9* RBC-3.87* Hgb-11.7* Hct-35.0* MCV-91 MCH-30.2 MCHC-33.4 RDW-16.3* Plt Ct-171 [2151-2-26] 05:40AM BLOOD WBC-14.0* RBC-3.67* Hgb-11.1* Hct-33.2* MCV-91 MCH-30.3 MCHC-33.4 RDW-15.7* Plt Ct-163 [2151-2-28] 06:54AM BLOOD Neuts-64 Bands-0 Lymphs-21 Monos-7 Eos-5* Baso-0 Atyps-2* Metas-1* Myelos-0 [2151-3-2] 06:10AM BLOOD Glucose-86 UreaN-14 Creat-0.5 Na-143 K-4.2 Cl-105 HCO3-33* AnGap-9 [2151-3-1] 05:49AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-143 K-4.2 Cl-104 HCO3-33* AnGap-10 [2151-2-28] 06:54AM BLOOD Glucose-67* UreaN-14 Creat-0.6 Na-145 K-4.0 Cl-104 HCO3-31 AnGap-14 [2151-2-27] 05:29AM BLOOD Glucose-105 UreaN-12 Creat-0.5 Na-139 K-4.0 Cl-102 HCO3-32 AnGap-9 [2151-2-27] 05:29AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1 ========================================================== MICROBIOLOGY: [2151-2-17]: Bld Culture x 1 Negative [2151-2-17]: Urine Cx x 1 negative [2151-2-18]: Tissue Cx Left Frontal Brain Abscess Wall: PMN Leukocytes 2+, no micro-organisms. [2151-2-23] BAL: PMN Leukocytes, no microorganisms, no Fungus, No AFBs [2151-2-23] RUL Tissue (during bronchoscopy) GRAM STAIN: POLYMORPHONUCLEAR LEUKOCYTES, NO MICROORGANISMS SEEN. NO GRWOTH ANAEROBIC CULTURE: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. [2151-2-18] BRAIN ABSCESS DRAINAGE GRAM STAIN (Final [2151-2-19]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Doctor Last Name 80584] @ 00:08A [2151-2-19]. SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final [2151-2-25]): VIRIDANS STREPTOCOCCI. SPARSE GROWTH. NOT VIABLE FOR SENSITIVITIES. VIRIDANS STREPTOCOCCI. RARE GROWTH. SECOND MORPHOLOGY. NOT VIABLE FOR SENSITIVITIES. ANAEROBIC CULTURE (Final [2151-2-25]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [2151-2-19]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. Brief Hospital Course: ## Brain Abscess: Pt was admitted to [Hospital1 18] from an outside hospital following her history of altered mental status as well evidence of frontal bilateral masses. Pt underwent a CT scan and MRI which showed the appearance of cystic lesion. Pt was started on IV steroids and neurosurgery were consult. On the night of admission pt underwent an open bone flap and drainage to assess whether lesion was metastatic versus an infection. Pus was noted and drained noted to have brain abscess on biopsy/drainage performed on [2-18]. Pt was then admitted and observed in the Neurosurgical ICU where she underwent a second procedure to remove her remaining rt sided lesion. Streptococcus Viridans was cultured and pt was started on a course of Vancomycin and then transitioned to Ceftriaxone per Infectious disease recommendations 2gm IV q 12hrs on [2-26]. Per Neurosurgery recommendations pt was started on Keppra for seizure prophylaxis. Pt currently has two sutures in place at time of discharge, the largest will dissolve, the second will need to be removed during a follow up visit to Dr.[Name (NI) 12757] office on [2151-3-8] 11:30. Pt will need a repeat CT scan as an outpatient which has been scheduled for [2151-3-23] 2:00, after CT head scan pt will see Dr. [Last Name (STitle) ]. Pt will need a minimum of a 4 week course of Ceftriaxone 2gm IV q12hrs. Pt will have, during this duration, a follow up Infectious Disease Clinic appointment where they will decide whether she needs additional treatment. Pt underwent a TTE that did not show any endocarditis. TEE was deferred as it would not change management and was felt to be a high risk procedure per our cardiology team. The most likely etiology of her brain abscesses is seeding from her lung infection (see below) or from endocarditis. ## Lung Lesion: Pt underwent a biopsy of lung mass recently that was positive for BOOP. As the possibility of malignancy still existed the pt's RUL mass went to the bronchoscopy suite where she underwent 6 biopsies, BAL, brush examination. Biopsies showed alveolar and peribronchial tissue with mixed inflammatory infiltrate, suggestive of acute pneumonia. Bronchial mucosa with mildly increased goblet cells and focal acute inflammation. No malignancy was identified. Pt was discharged with a 7 day steroid taper per Interventional Pulmonary. Pt will f/u with a repeat CT chest with contrast scan on [2151-4-9] 1030 to check the RUL mass. Results will be faxed to Dr. [Name (NI) 80585], pt will follow up with Dr. [Last Name (STitle) 80585] on [2151-4-15] 17:15. ##. Mobility: Pt had bone flap removed for abscess drainage. She will need to wear the helmet whenever she is mobile. She will later need a graft however this will not be performed until several months from now. ## Leukocytosis: Pt's WBC was noted to trend up and then down prior to discharge. Pt noted to have thrush as well as yeast in her urine. Pt was started on a 14 day course of oral Fluconazole. - continue total 14 days Course of Fluconazole ## Endometrial thickening: On CAT scan pt's endometrial lining. Recommend pt undergo a transvaginal U/S to evaluate endometrial thickening as an outpatient. ## FEN: pt underwent bedside and swallow evaluation. Per speech and swallow recommendations pt was started and tolerated a soft diet with thin liquids. ## Psych: Pt has history of bipolar disorder, for which she usually takes Thoridazine. After discussion with Neurosurgery it was decided that the Thoridazine would have a potential to interfere with the pt's neurological examination. Pt will be re-evaluated by Dr. [Last Name (STitle) ] on [3-23], at that time a decision will be made whether Thoridazine can be restarted. - Recommend discussing with Dr. [Last Name (STitle) ] on [3-23] whether pt can start her Thoridazine again. ## COPD: Pt noted intermittently to be wheezing on examination during the first days of admission. Pt was discharged on Tiotropium Bromide. ## Code status: FULL CODE Medications on Admission: Prednisone 20 mg Daily (Started [2151-2-13]) Gabapentin 300 mg TID HCTZ 25 mg Daily Simvistatin 20 mg Daily Spiriva 18 mg Daily Albuterol Betaxolol Ophth Susp 0.25% Thioridazine 40 mg qHS Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours) for 33 days: Your last day of antibiotics will be on [2151-4-3]. 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 11. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 28 days: Your last dose will be [2151-3-29]. 12. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 13 doses: Please follow taper. [Date range (3) 80586] Please take 15mg of Prednisone once a day. [Date range (1) 80587] Please take 10mg of Prednisone once a day. [Date range (1) 52680] Please take 5mg of Prednisone once a day. [Date range (1) 80588] Please take 2.5mg of Prednisone once a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Bilateral Brain Abscesses Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after it was found that you had two brain abscesses. You were taken to the operating room by the Neurosurgeons who drained your abscesses. The abscesses were positive for a bacteria called Streptococcus Viridans. We checked your blood cultures, performed an echo of yor heart check for a source of the infection, all were negative. We consulted the infectious disease specialists who recommended a minimum 4 weeks of antibiotics. They will see you as an outpatient to see whether you will need more antibiotics. Prior to leaving the hospital you were fitted for a helmet which you will need to wear whenever you are walking as a part of you skull was removed for the abscess drainage. Please take your medications as prescribed: You will be on a Prednisone taper:- [Date range (3) 80586] Please take 15mg of Prednisone once a day. [Date range (1) 80587] Please take 10mg of Prednisone once a day. [Date range (1) 52680] Please take 5mg of Prednisone once a day. [Date range (1) 80588] Please take 2.5mg of Prednisone once a day. You were also started on two antibiotics: 1. Ceftriaxone 2gm IV every 12 hours, your last dose currently will be given on [2151-4-3]. 2. Fluconazole for the yeast in your urine and oral thrush. Please take 100mg Fluconazole once a day day. Your last dose will be [2151-3-29]. Please follow up with all of your appointments. You have been scheduled for 2 CAT scans. Your first scan is of your head and will be followed by Dr. [Last Name (STitle) ], This is to check the progression of your abscesses and if they have come back. It is scheduled for [2151-3-23] 14:00 and it will be on the [Location (un) ] of [Hospital Ward Name 23]. The second CAT scan is of your chest to see the progression of the mass in your chest that was biopsied by Dr. [Last Name (STitle) 80585] and us. The results will be faxed to Dr. [Last Name (STitle) 80585]. It is scheduled for [2151-4-9] 10:30 and it will be on the [Location (un) ] of the [Hospital Ward Name 23] building. If you experienced any seizures, fevers, chills, difficulty breathing please call your doctor or return to the ED. Followup Instructions: You will continue to receive antibiotics for a total of 4 weeks. You can call [Telephone/Fax (1) ] to reach the infectious disease doctors [First Name (Titles) ] [Hospital1 ] for any questions. SUTURE REMOVAL APPOINTMENT: (DR.[Doctor Last Name ] OFFICE) [2151-3-8] 11:30 OFFICE Located aT [Doctor First Name ] Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2151-3-23] 2:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12760], MD Phone:[Telephone/Fax (1) 1669] Date/Time:[2151-3-23] 2:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2151-4-2] 11:30 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2151-4-9] 10:30 Provider: [First Name4 (NamePattern1) 177] [Last Name (NamePattern1) ], MD Date/Time: [2151-4-15] 17:15 [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122] ICD9 Codes: 486, 496, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5035 }	Medical Text: Admission Date: [2193-9-7] Discharge Date: [2193-9-17] Date of Birth: [2115-4-11] Sex: F Service: MEDICINE Allergies: Diovan / Mavik / Norvasc / Diclofenac Attending:[First Name3 (LF) 1881] Chief Complaint: Hypercapnic resp. failure/AMS Major Surgical or Invasive Procedure: None. History of Present Illness: 78 F with CHF, HTN, DM admitted [2193-9-7] after 3 episodes of vomiting in AM, Ruled out x 3. On day 3 of admission ([2193-9-9]), the patient triggered at 4:30 am for right-sided twitching in the bed. The patient was found on her stomach with her legs dangling over the side of the bed and her whole right -side twitching which self-resolved in <5 minutes (prior to arrival of nightfloat). At that time the patient's oxygen level was 78% on 2LNC. The patient was placed on 6LNC with sats recovering to 100%. . Earlier in the same day(9:40AM), the patient developed a new oxygen requirement 80% on RA, and 97% on 2LNC. Then at 7pm the patient who was previously AOx3 had become AOx1. At the same time the patient was noted to have an increasing distended abdomen and was felt to have SBO. The patient was signed out as AMS, negative UA, to night float. Nightfloat repeated abdominal x-ray which showed gas throughout and the patient was noted to be passing gas. At the time of the twitching event, on exam by the night float intern, the patient was found to be alert and oriented to self, but not location or date. The patient was able to follow commands to move all 4 extremities, take deep breaths, and open her eyes. Her pupils were equal, round and reactive to light. She was taken for a stat head CT to rule out intracranial process, it was prelim negative. Her ABG was 7.18/104/121, Lactate 0.5. She was transferred to the MICU for further care. . While in the MICU, the patient was found to be in hypercarbic respiratory failure on serial ABGs. BIPAP was initiated and the patient tolerated this well. Pulmonary/Sleep consult was initiatied, and the patient is to undergo study while in hospital with formal study once discharged Past Medical History: diabetes on insulin hypertension peripheral neuropathy hyperlipidemia osteoarthritis congestive heart failure in [3-/2185] - unknown EF. peripheral [Year (4 digits) 1106] disease - left SFA stent and angioplasty hysterectomy [2152] Social History: Lives home alone. Widowed [10-8]. Family History: n/c Physical Exam: Vitals - T: 97.4 BP:177/72, HR:74 RR:20 02 sat:94% RA GENERAL: AO x 3, NAD HEENT: NC, AT, MMM, oropharynx clear, PERRLA, right IJ intact CARDIAC: RRR, nl s1 s2, no mgr LUNG: CTA b/l, no WRR ABDOMEN: S, NT, distended and tymphanic, +BS EXT: no noted edema. palpable pulses NEURO: CN 2-12 intact, decreased sensation b/l LE, Pertinent Results: [2193-9-7] 02:30PM BLOOD WBC-6.3 RBC-4.96 Hgb-14.6 Hct-44.0 MCV-89 MCH-29.5 MCHC-33.3 RDW-13.5 Plt Ct-254 [2193-9-10] 03:39AM BLOOD WBC-7.1 RBC-3.89* Hgb-11.4* Hct-34.9# MCV-90 MCH-29.3 MCHC-32.6 RDW-13.1 Plt Ct-209 [2193-9-12] 05:47AM BLOOD WBC-6.3 RBC-4.16 Hgb-12.2 Hct-37.1 MCV-89 MCH-29.3 MCHC-32.9 RDW-13.6 Plt Ct-225 [2193-9-13] 06:22AM BLOOD WBC-6.6 RBC-4.31 Hgb-12.9 Hct-40.0 MCV-93 MCH-30.0 MCHC-32.4 RDW-13.5 Plt Ct-239 [2193-9-7] 02:30PM BLOOD Neuts-63.5 Lymphs-28.7 Monos-5.5 Eos-1.9 Baso-0.4 [2193-9-7] 02:30PM BLOOD Plt Ct-254 [2193-9-10] 03:39AM BLOOD PT-13.9* PTT-40.7* INR(PT)-1.2* [2193-9-11] 03:19AM BLOOD PT-13.8* PTT-49.3* INR(PT)-1.2* [2193-9-13] 06:22AM BLOOD Plt Ct-239 [2193-9-7] 02:30PM BLOOD Glucose-75 UreaN-9 Creat-1.0 Na-136 K-5.3* Cl-96 HCO3-32 AnGap-13 [2193-9-10] 03:39AM BLOOD Glucose-86 UreaN-14 Creat-0.9 Na-137 K-4.7 Cl-96 HCO3-39* AnGap-7* [2193-9-13] 06:22AM BLOOD Glucose-221* UreaN-15 Creat-1.0 Na-138 K-3.8 Cl-92* HCO3-40* AnGap-10 [2193-9-7] 02:30PM BLOOD cTropnT-<0.01 [2193-9-8] 12:51AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2193-9-8] 06:33AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2193-9-8] 06:33AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1 [2193-9-9] 05:30AM BLOOD Albumin-4.6 Calcium-9.3 Phos-5.5* Mg-2.3 [2193-9-13] 06:22AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0 [2193-9-10] 03:39AM BLOOD TSH-0.56 [2193-9-9] 05:22AM BLOOD Type-ART pO2-121* pCO2-104* pH-7.18* calTCO2-41* Base XS-6 [2193-9-9] 06:59AM BLOOD Type-ART pO2-73* pCO2-90* pH-7.24* calTCO2-41* Base XS-7 [2193-9-9] 12:35PM BLOOD Type-ART pO2-87 pCO2-86* pH-7.27* calTCO2-41* Base XS-9 [2193-9-9] 06:54PM BLOOD Type-CENTRAL VE pO2-41* pCO2-96* pH-7.26* calTCO2-45* Base XS-11 Intubat-NOT INTUBA [2193-9-9] 10:00PM BLOOD Type-ART pO2-107* pCO2-83* pH-7.30* calTCO2-43* Base XS-11 Intubat-NOT INTUBA [2193-9-11] 12:41AM BLOOD Type-ART pO2-53* pCO2-68* pH-7.39 calTCO2-43* Base XS-12 [2193-9-13] 09:16AM BLOOD Type-ART Temp-36.8 O2 Flow-90 pO2-63* pCO2-61* pH-7.42 calTCO2-41* Base XS-11 Intubat-NOT INTUBA [2193-9-9] 06:54PM BLOOD Glucose-147* Lactate-0.7 Brief Hospital Course: 78 y.o. F with CHF, HTN, DM transeferred back to MED/[Doctor First Name 147] from MICU on [9-11] s/p hypercapnic respiratory failure and altered mental status. . #Delta MS/hypercapnic respiratory failure: Likely due to severe obesity hypoventilation syndrome coupled with sleep apnea. Her baseline pCO2 appears to be ~60-70. The addition of nasal cannula oxygen on the floor likely decreased her hypoxic drive leading to hypoventilation and hypercapnic failure. Autotitration was performed in the ICU recommending CPAP 7 at night. The patient's bicarb remained at 40 for 3 days but trended down to 37 prior to discharge. The patient's lasix was held throughout her admission and she was discharged on HCTZ. The patient was discharged home on BiPAP. . # Abdominal distension: The patient had normoactive bowel sounds throughout admission. The distension is thought to be likely due to gastroparesis. Upon initiation of aggressive bowel regimen, the patient moved her bowel regularly while admitted. The patient was discharged home on a bowel regimen. . #HTN: The patient's blood pressure was poorly controlled on atenolol. Nifedipine was added [9-11] and the patient was discharged on 60mg daily. . #DM: The patient's blood glucose was covered with 1/2 of her home dose NPH. She was also covered with a sliding scale insulin while in house. . Medications on Admission: Clopidogrel 75mg 1 tab PO QD Humilin N 100 u/ml 82u am 37u pm Atenolol 50mg 1 tab PO BID Lasix 20mg 2 tab PO BID Zocor 40mg 1 tab PO QD Omeprazole 20mg 1 cap PO daily - pt is holding Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:90 Tablet(s) Refills:2 5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty (40) units Subcutaneous qAM. 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous qPM. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY. Disp:30 Tablet Sustained Release(s) Refills:0 9. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO three times a day as needed for constipation. Disp:1 bottle Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: OSA Secodary:HTN, DM2, Hyperlipidemia Discharge Condition: Stable. Discharge Instructions: You were admitted and treated at [Hospital1 18] for nausea, vomiting, and abdominal discomfort. Labratory data and heart monitoring showed that you did not have a heart attack. A CT scan of your head revealed no hemorrhage of edema. Your chest x-ray was negative. An x-ray of your abdomen showed no evidence of bowel obstruction. On the 3rd day of your admission, your mental status changed and your oxygen levels decreased rapidly, and you were transferred to the ICU. In the ICU, you were found to be in respiratory failure and a BiPAP machine was initiated which you tolerated well. Sleep medicine saw you and you are now being discharged with a machine to help you breath at night. Please note the changes to your medications: Atenolol was increased to 75 mg twice daily. Nifedipine CR 30 mg PO daily was added. Your lasix was stopped per Dr. [Last Name (STitle) ] Your nortriptyline was stopped . Please make note of your follow-up appointments listed below. . If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2193-10-1] 12:30 . Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2193-12-6] 10:30 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2193-12-6] 11:15 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882] MD, [MD Number(3) 1883] Completed by:[2193-9-29**] ICD9 Codes: 2762, 5990, 3572, 4019, 2724, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5036 }	Medical Text: Admission Date: [2112-10-25] Discharge Date: [2112-11-4] Date of Birth: [2049-12-4] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [10-28] S/P Coronary Artery Bypass Graft x4 (Left internal mammary artery -> left anterior descending, Saphenous vein graft -> diagonal, saphenous vein graft -> obtuse marginal, saphenous vein graft -> posterior descending artery) History of Present Illness: 62 year old female presented to OSH with shortness of breath and cough for two days. Denied chest pain but had [6-28] back pain - cardiac enzymes with peak troponin 6.88. Underwent cardiac catherization at OSH which revealed 3 vessel disease. Past Medical History: Asthma Hypertension Cerebral vascular accident Gastroesophageal Reflux disease Diabetes mellitus Neuropathy Renal insufficiency Social History: Primary language spanish, lives with spouse denies alcohol denies tobacco Family History: NC Physical Exam: Admission Vitals: 97.8, 140/72, HR 70, RR 18, RA sat 97% wt 71.5kg General well developed, no acute distress Skin: red nonraised rash under bilateral breast, feet with dry scaly skin no breakdown HEENT: PERRLA, EOMI Neck: Full ROM, supple, no lymphadenopathy Lungs: Clear to auscultation bilaterally anterior and posterior decreased at right base Cardiac: RRR no murmur/rub/gallop Abdomen: Soft, nontender, nondistended, no palpable mass Ext: warm, CR < 3 sec, trace lower extremity edema, pulses palpable Neuro: alert and oriented nonfocal Pertinent Results: [2112-10-25] 09:03PM BLOOD WBC-9.6 RBC-3.93* Hgb-11.6* Hct-33.2* MCV-85 MCH-29.4 MCHC-34.7 RDW-16.7* Plt Ct-202 [2112-10-25] 09:03PM BLOOD PT-11.5 PTT-23.2 INR(PT)-1.0 [2112-10-25] 09:03PM BLOOD Plt Ct-202 [2112-10-25] 09:03PM BLOOD Glucose-389* UreaN-33* Creat-1.5* Na-134 K-5.0 Cl-97 HCO3-26 AnGap-16 [2112-10-25] 09:03PM BLOOD ALT-27 AST-39 LD(LDH)-245 AlkPhos-239* TotBili-0.3 [2112-10-25] 09:03PM BLOOD %HbA1c-9.8* [Hgb]-DONE [A1c]-DONE GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: PRE-BYPASS: 1. Overall left ventricular systolic function is low normal (LVEF 50-55%). 2. Mild to moderate ([1-11]+) mitral regurgitation is seen. 3. Aortic valve leaflets (3) are mildly thikened. 3. Mild spontaneous echo contrast is present in the left atrial appendage with no evidence of a clot. 4. No atrial septal defect is seen by 2D or color Doppler. 5. Right ventricular chamber size and free wall motion are normal. 6. There are simple atheroma in the descending thoracic aorta. Trace aortic regurgitation is seen. POST-BYPASS: 1. Preserved biventricular function, LVEF 50-55% 2. No change in wall motion 3. Mitral regurgitation remains [1-11]+ (mild to moderate) 4. Aortic contours remain intact 5. Remaining exam unchanged 6. All findings discussed with surgeons at the time of the exam Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD on [2112-10-30] 15:16. [Location (un) ] PHYSICIAN: Brief Hospital Course: Transferred in from OSH after undergoing cardiac catherization that revealed 3 vessel disease. She underwent preoperative work up and [Last Name (un) ] was consulted for diabetes management. On [10-28] she was tranferred to the operating room and underwent coronary artery bypass graft surgery without complications, please see operative report for further details. She was then transferred to CSRU for hemodynamic monitoring. Within the next 24 hours she was weaned from sedation, awoke neurologically intact, and was extubated. She was wened from vasopressors and milirone. She remained in CSRU for respiratory, glucose, and hemodynamic management. On post operative day 3 she was transferred to [Hospital Ward Name ] 2 and continued to progress. Medications were adjusted for blood pressure management. Physical therapy worked with her and evaluated for rehab. Continued to diuresis and [Last Name (un) 387] continued to follow for diabetes management. She continued to do well and on [2112-11-4] she was ready for discharge to rehab for continued physical therapy. Medications on Admission: [Last Name (LF) 6196], [First Name3 (LF) ], Aldactone, Lisinopril, Lasix, Labetolol, Norvasc, Catapress, Iron Sulfate, Hydrochlorothiazide, Metformin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. 15. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) Units Subcutaneous at bedtime. 16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) vial Injection four times a day: sliding scale AC & HS: BS 120-150 = 3U 151-200 = 5U 201-250 = 7U 251-300 = 10U. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) 1110] Discharge Diagnosis: Coronary artery disease Diabetes Mellitus Hypertension Gastroesophageal reflux disease Neuropathy Renal insufficiency h/o CVA Asthma Discharge Condition: good Discharge Instructions: [Month (only) 116] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 23070] in 1 week ([Telephone/Fax (1) 69090]) please call for appointment Cardiologist in [2-12] weeks please call for appointment Completed by:[2112-11-4] ICD9 Codes: 4280, 5859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5037 }	Medical Text: Admission Date: [2101-3-14] Discharge Date: [2101-3-28] Service: MEDICINE Allergies: Codeine / Statins-Hmg-Coa Reductase Inhibitors / Zetia / Minipress Attending:[First Name3 (LF) 2195] Chief Complaint: chest pain, hemoptysis. Major Surgical or Invasive Procedure: s/p IVC filter placement [2101-3-17]. s/p bronchoscopy [2101-3-20]. History of Present Illness: Mr. [Name14 (STitle) 20179] is a 85 yo male with a history of CAD, PVD, cerebral vascular disease, chronic kidney disease (BL Cr 1.8), who was orignally admitted to [Hospital3 1443] Hospital on [2101-2-19] with right lower extremity infected gouty arthritis and hemoptysis in the setting of an INR of 9. He was also diagnosed with a penicillin senstitive enterococcus UTI. His INR was reversed with vitamin K. The 1st right MP joint was aspirated and a right foot xray and MRI were negative for osteomyelitis. He was started on colchicine which he did not tolerate, so then was switched to a prednisone taper in addition to IV Vancomycin for presumed MRSA infection. He was discharged to rehab on [2101-3-8] on a 7 day course of Keflex with diagnoses of UTI and right foot superinfected MSSA gouty arthritis (uric acid level 8.4). On [3-12], he was readmitted from rehab with scrotal cellulitis; scrotal U/S at OSH showed normal intrinsic blood flow in both testes. He was started on 3g [Hospital1 ] Unasyn for this with improvement. . On [2101-3-13], he started to experience hemoptysis, SOB, and chest pain. An EKG showed ST depressions in the lateral leads and troponins were trending up: 0.11 --> 0.18. An echo done on [2101-3-13] at the OSH showed LVEF 35-40% (BL 55%) and global LV hypokinesis. . Of note, for his hemoptysis, at OSH AFBs were negative during his first admission. On [3-13], he was noted to have a low Hgb of 7.8 (BL 10), which was 9 on repeat blood draw. Most recent Hgb/HCT on day of transfer: 9.2/29.1. He received no transfusions at OSH. On [3-6], iron studies at OSH revealed: Fe 24, TIBC 146, Ferritin 600, B12 616, and folate 12.1. Pulmonary saw him and felt the hemoptysis was secondary to a pneumonia. Follow-up CXR showed a resolving RLL infiltrate at OSH. Patient denied any BRBPR or black tarry stools but does have history of colon cancer, s/p resection. His stools were guaiac negative x 1 at OSH. . At the time of transfer, vitals were: 97.5, HR 84 sinus, RR 22, BP 152/92, O2 sat 94% 4LNC. CXR at OSH showed right lung pulmonary edema. He was given lasix 60mg IV then another 20mg IV and has had no chest pain or dyspnea on the morning of transfer on SL NG. He received 3 doses of mucomyst, xopenex nebulizers, and 3 grams of ampicillin for his scrotal cellulitis. He was also clopidogrel loaded: received 75mg on AM of transfer and got 300mg x 2 the day prior. He is being transferred to the floor prior to cath for evaluation given his multiple active medical issues. . On evaluation on the floor, Mr. [Name14 (STitle) 20179] reports feeling well. He states that he has had no chest pressure since this morning. He states that he continues to have red hemoptysis multiple times per day along with a productive cough which has been new the past week. He denies fevers, chills, nightsweats or weight loss. He reports feeling well up until late last week when he began having SOB and chest pain at rehab after doing PT exercised in bed. Prior to that, he had not had chest pain for many years per his report. He is not aware that he has ever had an MI in the past. He denies palpitations, current chest pain, PND, but does endorse orthopnea and DOE. . REVIEW OF SYSTEMS: He has a history of ischemic stroke >10 years ago and multiple TIAs and is s/p R carotid endarterectomy. He denies history of deep venous thrombosis, pulmonary embolism, myalgias, or joint pains except for his R toe gout. He endorses new cough and hemoptysis, but denies black tarry stools or BRBPR. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Paroxysmal atrial fibrillation, diagnosed in [10-9], s/p amiodarone tx. Coronary artery disease, s/p 2 caths, but unknown intervention or findings. Congestive heart failure, diagnosed [10-9]. . 3. OTHER PAST MEDICAL HISTORY: Abdominal aortic aneurysm, s/p 2 repairs most recently [3-/2094] at [Hospital1 336]. Carotid stenosis, s/p R endarterectomy. Chronic renal insufficiency (BL Cr 1.8). History of colon cancer, s/p colectomy with reanastamosis in [2071]. PPD positive. Gouty arthritis. Chronic obstructive pulmonary disease (restrictive and obstructive, no oxygen requirement at home). Peripheral vascular disease. Cerebral vascular disease, h/o ischemic stroke in [2080] at [Hospital1 2025]. Status post left arm amputation after WWII combat injury. Social History: Lives with his wife of 63 years in [Location (un) 1468]. He is a WWII veteran and retired field [Doctor Last Name 360] of the Veterans Association. He has a 10 pack year smoking history but quit in the [2060]. He rarely drinks alcohol. He denies current or past drug use. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ON ADMISSION: VS: T= 98.0 BP= 180/57 HR=84 RR=20 O2 sat=94% on 4LNC. GENERAL: [First Name9 (NamePattern2) 86883] [Last Name (un) ] in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: ?Ventricular trigeminy, dropped beat noted after every three beats, otherwise regular rhythm. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. +Crackles bilaterally up to mid lung fields. No wheezes or rhonchi. Decreased breath sounds RLL. ABDOMEN: Soft, NTND. NABS. EXTREMITIES: WPP bil LEs. Healing gouty wound R first metatarsal without e/o infection. 1+ DP pulses bil LEs. +2 pitting pretibial edema. SKIN: No stasis dermatitis, scars, or xanthomas. Small stage 2 pressure ulcers on sacrum x 2. . Pertinent Results: Admisison labs: [2101-3-14] [2101-3-14] 04:40PM BLOOD WBC-6.2 RBC-2.91* Hgb-9.0* Hct-26.8* MCV-92 MCH-31.0 MCHC-33.7 RDW-17.0* Plt Ct-118* [2101-3-14] 04:40PM BLOOD PT-13.2 PTT-27.2 INR(PT)-1.1 [2101-3-14] 04:40PM BLOOD Glucose-109* UreaN-39* Creat-1.7* Na-144 K-4.0 Cl-105 HCO3-27 AnGap-16 [2101-3-14] 04:40PM BLOOD ALT-14 AST-17 LD(LDH)-298* AlkPhos-79 TotBili-0.6 [2101-3-14] 06:21PM BLOOD CK-MB-NotDone cTropnT-0.10* [2101-3-14] 06:21PM BLOOD ALT-13 AST-19 LD(LDH)-284* CK(CPK)-30* AlkPhos-76 TotBili-0.6 [2101-3-14] 04:40PM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.6 Mg-2.0 [2101-3-14] 06:21PM BLOOD Triglyc-55 HDL-48 CHOL/HD-3.0 LDLcalc-84 . Cardiac Enzymes: [2101-3-15] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.10* [2101-3-15] 07:30AM BLOOD CK(CPK)-25* [2101-3-17] 04:09AM BLOOD CK-MB-NotDone cTropnT-0.10* [2101-3-17] 04:09AM BLOOD CK(CPK)-36* [2101-3-20] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.12* [2101-3-20] 03:00AM BLOOD CK(CPK)-35* . Discharge Labs: [2101-3-28] 06:49AM BLOOD WBC-5.1 RBC-2.62* Hgb-8.3* Hct-24.9* MCV-95 MCH-31.8 MCHC-33.5 RDW-17.2* Plt Ct-133* [2101-3-28] 06:49AM BLOOD Glucose-90 UreaN-35* Creat-1.9* Na-141 K-4.2 Cl-100 HCO3-34* AnGap-11 [2101-3-22] 05:39AM BLOOD ALT-10 AST-19 AlkPhos-64 TotBili-0.5 [2101-3-28] 06:49AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0 . [1-11] 2D-ECHOCARDIOGRAM (OSH): Mild inferior wall hypokinesis, mild aortic insufficiency. LVEF 50-55%. . [2101-3-13] 2D-ECHOCARDIOGRAM (OSH): Normal RV function, global LV hypokinesis, LVEF 35-40%. . [8-10]: Adenosine Myoview (OSH): medium in size, moderate in degree, predominantly reversible inferior wall defect and inferior wall hypokinesis. LVEF 50%. . [2101-3-19] CXR: IMPRESSION: Improving multifocal airspace opacities superimposed upon emphysema. This could be due to either multifocal pneumonia or pulmonary hemorrhage. . [2101-3-27] CXR: Compared to the previous radiograph, there is marked improvement with regression in extent and severity of the pre-existing predominantly right parenchymal opacities. However, the opacities are still clearly seen. Unchanged moderate cardiomegaly. Unchanged appearance of the left lung, including a small zone of parenchymal opacity projecting over the left costophrenic sinus. . [2101-3-21] RUQ Ultrasound: 1. Multiple gallstones. 2. left intrahepatic biliary dilatation. No obvious mass seen. . [2101-3-15] ECHO: LVEF: 45% to 50%. The left atrium is moderately dilated. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferolateral/inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [2101-3-14] CTA Chest: IMPRESSION: 1. No pulmonary embolism. 2. Extensive pneumonia or pulmonary hemorrhage. No obvious bleeding site with the exception of possible incipient broncholiths in the right hilus. No bronchial obstruction. 3. Pulmonary hypertension, severe emphysema. 4. Severe atherosclerosis including coronary arteries and shallow plaque ulcerations in the left subclavian artery and aorta.Upper abdominal aortic aneurysm, total extent not imaged. 5. Global cardiomegaly and in particular left ventricular enlargement. 6. Possible localized biliary obstruction, recommend biliary ultrasound. 7. Calcific cholelithiasis. No evidence of cholecystitis. . [2101-3-14] LENIs: IMPRESSION: Left calf vein DVT in one of two posterior tibial veins. . Brief Hospital Course: Mr. [Known lastname ] is an 85 yo male with multiple medical problems including COPD, PVD, and PAF, admitted to an OSH in mid-[Month (only) 958] for hemoptysis in setting of supratherapeutic INR of 9.0, and readmitted with scrotal cellulitis several days later. He began having chest pain on [2101-3-13] and was noted to have an NSTEMI with elevated troponins and ST depressions on EKG. He was transferred to [Hospital1 18] for further evaluation and cardiac catheterization. . MICU COURSE [2101-3-19] - [2101-3-20]: The patient was transferred to the MICU following an episode of non-massive hemoptysis, tachypnea and tachycardia. He was monitored overnight and received humidified oxygen via NRB and then face tent as needed. He was kept NPO overnight in anticipation of bronchoscopy. The hemoptysis subsided, and Hct remained stable at 23-24. The following morning, he underwent bedside bronchoscopy which revealed multiple blood clots in the larger airways (chiefly right-sided) but no evidence of active bleeding. No mass or lesion was noted. The patient tolerated the procedure well. His vital signs remained stable and oxygen requirement returned to recent baseline. He was therefore transferred back to the floor team on the afternoon following admission to the ICU. . His hospital course is outlined by problem below: . # Hemoptysis: Most likely etiology is from supratherapeutic INR and fluid in lungs. Patient's coumadin was temporarily held and patient was diuresed. CTA ruled out PE. Per OSH records, antiGBM was negative, ANCA negative. [Doctor First Name ] at [Hospital1 18] negative. Patient was free of hemoptysis for 5+ days prior to discharge. Pulmonary was consulted during this admission and followed the patient closely. He should follow up with the pulmonologist listed in the discharge paperwork after rehab. . # CORONARIES: Patient had a NSTEMI this admission. Given his risk factors for bleeding, it was decided to treat the patient with medical managment. Cardiology was consulted. His Aspirin was increased to 325mg once a day. Given the risk of bleeding the consulting cardiologist did not feel that the benefits of Plavix outweighed the risks, therefore he was not discharged on Plavix. Continued ASA, metoprolol and nitrate. Increased home statin to rosuvastatin 40 mg daily. Patient was chest pain free at discharge. . # PUMP: The patient was noted to have inferior thallium defect at OSH; also had dyspnea and CXR at OSH c/w pulmonary edema and CHF. Repeat echo [3-15] shows mild regional left ventricular systolic dysfunction with inferolateral/inferior hypokinesis (LVEF 45-50%), mild MR, and mild AR. Diuresed with lasix. Cr slighly bumped from 1.6 on [3-26] to 1.9 on [3-27]. Cr was stable at 1.9 on day of discharge. Patient was euvolemic on day of discharge. He was discharged on his home dose of lasix. Daily labs, including Cr, strict I/Os, and daily weights are needed. Titrate lasix to keep euvolemic while monitoring Cr. . # RHYTHM: Patient has history of PAF. Rate controlled with beta blocker. Once hemoptysis was stable from pulmonary perspective, coumadin 3mg po qday was restarted. . # Scrotal cellulitis: Patient noted to have scrotal cellulitis on [2101-3-12]. Treated with IV Unasyn with improvement. . # Deep vein thrombosis: Left posterior tibial vein with thrombus noted on HD#1 ultrasound. Patient started on heparin drip initially, but discontinued given increasing hemoptysis and respiratory instability. Now s/p IVC filter placement on [2101-3-17]. Patient should continue on Coumadin 3mg po qday with goal INR between [1-5] for DVT treatment. . # Sacral decubitus ulcers: Noted to be stage 2 at OSH, stable. . # Chronic renal insufficiency: Patient has BL creatinine of 1.8. Cr increased to 1.9 as stated above after diuresis. Please monitor Cr with daily labs, especially if titrating lasix dose. . # COPD: Continued home medication regimen of Advair [Hospital1 ] and added standing xopenex nebulizer treatments while inpatient. Also added ipratropium inhaler PRN for shortness of breath/wheezing. . CODE STATUS: Confirmed as FULL CODE this admission. He will be discharged to a rehab facility and will need close follow-up with his PCP, [Name10 (NameIs) 2086], and pulmonary within 2 weeks of discharge. Medications on Admission: Doxazosin 4 mg po BID Cilostazol 100 mg po BID (for PVD) Furosemide 40 mg daily. Metoprolol tartrate 25 mg po BID. Isosorbide mononitrate 60 mg po daily. ASA 81 mg po daily. Coumadin 3 mg po daily. Lorazepam 0.5 mg prn. Ambien 5 mg prn. Rosuvastatin 10 mg po daily. Advair prn. Latanoprost drops both eyes daily. Hydrocodone 1 tab prn pain. Ocuvite 1 tab daily. Allopurinol 100 mg [Hospital1 ]. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 1-2 puffs Inhalation [Hospital1 ] (2 times a day). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 7 days. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Latanoprost 0.005 % Drops Sig: 1-2 Drops Ophthalmic HS (at bedtime). 13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation QID (4 times a day) as needed for SOB, wheezing. 14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 15. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Ocuvite Tablet Sig: One (1) Tablet PO once a day. 17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 21. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 22. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: PRIMARY: Non-ST-Elevation myocardial infarction. Hospital acquired pneumonia. Left posterior tibial vein deep vein thrombosis. Infected gouty arthritis of the right hallux. . SECONDARY: Hypertension Hyperlipidemia Coronary artery disease Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair (pt is independently ambulatory at baseline). Discharge Instructions: Dear Mr. [Name14 (STitle) 20179], you were admitted to the hospital with chest pain and blood in your sputum. Your chest pain was due to a small heart attack, called an NSTEMI. You were treated medically for this. The blood in your sputum was most likley due to fluid in your lungs and excessively high INR. It improved with holding your blood thinning medications. An ultrasound of your legs was done and showed a clot in one of the veins in your left leg. You had a filter, called an IVC filter, placed to prevent this clot from traveling to your lung. You are now deemed medically stable and fit for discharge to a rehabilitation facility. . The following changes have been made to your home medications: 1. Continue Coumadin 3mg by mouth every day 2. STOP HYDROCODONE. 3. Aspirin 81 mg by mouth daily CHANGED TO Aspirin 325 mg by mouth daily. 4. Allopurinol 100 mg by mouth twice a day CHANGED TO Allopurinol 100 mg by mouth once a day. 5. Rosuvastatin (Crestor) 10 mg by mouth daily CHANGED TO Rosuvastatin (Crestor) 40 mg by mouth daily. 6. Continue Lasix 40mg by mouth once a day 7. START Ferrous Sulfate 325 mg by mouth twice a day. . It was a pleasure caring for you during this hospital stay. You should be weighed every day and have your urine output measured. If your weight increases by more than 3lbs or you do not urinate enough your lasix dose should be increased. The physicians at your next facility will help you monitor this. Followup Instructions: Please call your primary care doctor, DR. [Last Name (STitle) ] at [0-0-] to schedule an appointment within two weeks of discharge from rehab. . Please also call DR. [Last Name (STitle) ] at [Telephone/Fax (1) 11554] to schedule an appointment within 1-2 weeks of discharge from rehab. . Please follow up with a pulmonologist. You should follow up with Dr. [Last Name (STitle) 86144] at [Hospital1 2025]. Please call [0-0-] and ask for registration. You will need to register with [Hospital1 2025] first before making the appointment. Then call the Pulmonolgist's office at [Telephone/Fax (1) 86145] to book an appointment. The soonest available appointment is sufficient. Completed by:[2101-3-28] ICD9 Codes: 486, 4280, 496, 5859, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5038 }	Medical Text: Admission Date: [2110-3-4] Discharge Date: [2110-3-12] Date of Birth: [2034-8-22] Sex: F Service: MEDICINE Allergies: vancomycin / Sulfamethizole Attending:[Doctor First Name 3298] Chief Complaint: s/p ERCP for gallstones Major Surgical or Invasive Procedure: [2110-3-4] ERCP with sphincterotomy, stent removal and stone extraction History of Present Illness: 75 yo F with afib/TIA on coumadin, systolic heart failure (unknown EF), COPD on 3L NC, DM2, gastroparesis and gastritis who was admitted in [2109-9-26] with cholangitis from stones in CBD s/p stent placement only due to anticoagulation presents from rehab for repeat ERCP for stent removal and sphincterotomy. Patient has been off anticoagulation x 5 days. Sphincterotomy performed today with removal of old stent. A large 14 mm stone and large amount of sludge were extracted. The CBD was free or stone or debris at the end of the procedure. Patient tolerated the procedure well. Currently patient complains of severe [9-5] lower back pain. She denies any radiation, states it is similar to her usual coccyx pain however "more extreme". Denies any abdominal pain or bowel/bladder incontinence. No nausea or vomiting. No cp or sob. Patient a poor historian and unable to provide further history due to severity of pain. ROS as per HPI, 10 pt ROS otherwise negative Past Medical History: Diabetes-II with complications Atrial fibrillation Systolic heart failure Asthma/ COPD on 2 L O2 OSA Arthritis, currently wheelchair bound Gastritis Gastroparesis Hypertension GIB Chronic kidney disease, baseline creatinine is 1.0 Constipation Morbid Obesity Anxiety state Peripheral vascular disease CHF, unknown EF H/o TIA without residual deficit Social History: Currently resides at [Hospital 9188] Rehab Center. Wheelchair bound. Quit tobacco 25 years ago, 60 pack year history. No etoh or illicits. Family History: mother and father with DM Physical Exam: On Admission: VS: 97.1 128/78 98P 18 97%2LNC Appearance: aaox3, in moderate distress due to pain Eyes: eomi, perrl, icteric ENT: OP clear s lesions, mm very dry, no JVD, neck supple CV: irreg irreg, bilateral arm edema, [1-27]+ LE edema with chronic venous stasis changes, feet are mildly cool to touch but with 1+ pulses bilateral feet Pulm: clear bilaterally although difficult exam due to patient distress Abd: soft, mild RUQ ttp, no distension, no rebound/guarding, +bs Msk: 5/5 strength upper extremities, moving lower extremities with 5/5 plantar flexion/extension but 3/5 strength hip flexors/extensors (unchanged from [2109-9-26] exam) Neuro: cn 2-12 grossly intact, no focal deficits Skin: chronic venous stasis change of legs, + palpable ? port left chest, non-tender Psych: appropriate Heme: no cervical [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]: ++ tenderness of coccyx, no other spinal ttp, no ecchymoses On Discharge: VS: T 96.1 (afebrile >72 hrs), BP 134/81, P 60, RR 20, O2 100% on 2L Gen: Obese woman in NAD sitting in chair HEENT: OP clear, mucous membranes moist CV: Slow, irregular, no murmurs/rubs/gallops; port a cath in left upper chest without any erythema, purulence, or fluctuance appreciated Pulm: Clear to auscultation bilaterally without wheezes, rhonchi, or rales Abd: Obese, soft, nontender, nondistended, bowel sounds positive Extrem: 1+ edema to knees bilaterally with changes of chronic venostasis, dark brown/black discoloration of anterior shins bilaterally Neuro: Alert, responsive, appropriate, speech is fluent GU: foley in place Pertinent Results: =================== LABORATORY RESULTS =================== On Admission: WBC-5.2 RBC-2.67* Hgb-9.3* Hct-27.3* MCV-102* RDW-13.5 Plt Ct-163 --Neuts-75* Bands-18* Lymphs-0 Monos-4 Baso-3* Atyps-0 Metas-0 Myelos-0 PT-17.0* PTT-44.1* INR(PT)-1.6* UreaN-25* Creat-0.9 Na-140 K-3.8 Cl-98 HCO3-38* ALT-26 AST-42* AlkPhos-287* Amylase-14 TBili-1.7* DBili-1.2* IndBili-0.5 Lipase-9 Calcium-7.8* Phos-3.1 Mg-1.1* On Discharge: WBC-4.3 RBC-3.00* Hgb-9.4* Hct-29.3* MCV-98 RDW-14.9 Plt Ct-115* PT-12.1 PTT-36.8* INR(PT)-1.1 Glucose-79 UreaN-12 Creat-0.7 Na-139 K-4.0 Cl-104 HCO3-32 AnGap-7* ============== MICROBIOLOGY ============== Blood Culture 4/4 bottles [2110-3-5] at 3:20 lood Culture, Routine (Final [2110-3-9]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Trimethoprim/Sulfa sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060] sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. ESCHERICHIA COLI. SECOND MORPHOLOGY. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ESCHERICHIA COLI \| \| AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I 16 I CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R Anaerobic Bottle Gram Stain (Final [2110-3-5]): GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [2110-3-6]): GRAM NEGATIVE ROD(S). Blood Culture [2110-3-5] at 12:26 and blood culture from [2110-3-6]: NGTD Urine Culture [1-27] [2110-3-5]: URINE CULTURE (Final [2110-3-6]): ESCHERICHIA COLI. ~7000/ML. PRESUMPTIVE IDENTIFICATION. ============== OTHER STUDIES ============== TTE [2110-3-5]: IMPRESSION: Preserved regional and global left ventricular function. Mild right ventricular dilatation with mild global hypokinesis. Moderate pulmonary systolic hypertension. [2110-3-4] ercp: The ampulla was bulging and fleshy. (biopsy) The old stent was removed with a snare. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. A straight tip .035in guidewire was placed. At least one large, 14 mm, stone and large amount of sludge were seen in CBD. CBD measured 18 mm. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Given the large size of stone, sphincteroplasty was performed with a 12 mm balloon. A large 14 mm stone and large amount of sludge were extracted successfully using a 15 mm balloon. At the end of procedure CBD was free of stone or debris. Otherwise normal ercp to third part of the duodenum. Chest Radiograph [2110-3-5]: IMPRESSION: AP chest compared to [10-1]: Severe cardiomegaly has worsened and there is mild interstitial edema, but most significant change is new moderate right pleural effusion. Infusion port catheter ends in the right atrium. No pneumothorax. CT Abdomen and Pelvis w/o Contrast [2110-3-7]: IMPRESSION: 1. Bilateral nonhemorrhagic pleural effusions, moderate on the right and small on the left. 2. Unchanged moderate cardiomegaly with a catheter terminating in the right atrium. 3. Moderate intra- and extra-hepatic pneumobilia, findings consistent with recent ERCP and sphincterotomy. 4. Vascular calcifications with moderate plaque seen at the origins of the celiac axis and right renal artery. 5. No free fluid within the peritoneal cavity or retroperitoneum to suggest hematoma. 6. Stable small uncomplicated ventral hernia. 7. Unchanged hepatic steatosis. Brief Hospital Course: 75 yo F with afib/TIA on coumadin, systolic heart failure (unknown EF), COPD on 3L NC, DM2, gastroparesis and gastritis who was for planned biliary stent removal with course complicated by cholangitis/sepsis. 1) Cholangitis/E coli sepsis: The patient was admitted for scheduled stent removal and had stent and stone removal with sphincterotomy prior to being admitted to the medical floor. Soon after presenation to the medical procedure post procedure developed hypotension requiring pressor support and was transferred to the MICU. Presumed source of sepsis was her biliary tree given interventions so she was empirically covered with IV piperacillin-tazobactam. She improved with antibiotic therapy and was weaned off pressors to be transferred back to the medical floor on [2110-3-7]. When final blood cultures grew two species of E coli both sensitive to ceftriaxone she was transitioned to this [Doctor Last Name 360] as well as metronidazole to cover any occult anerobes given source. She should continue her antibiotics until [2110-3-20]. ID was consulted and agreed with this duration of therapy. Discussion regarding removing her port-a-cath was carried out between IV team, ID, and medicine and given that this was not likely the source of her transient bacteremia and gram negatives less likely to seed port immediate removal was not pursued. ULTIMATELY HER PORT DOES SERVE AS A POTENTIAL PORTAL OF INFECTION HOWEVER AND REMOVAL SHOULD BE CONSIDERED ELECTIVELY AFTER SHE COMPLETES HER CURRENT COURSE OF THERAPY. 2) Acute blood loss anemia: Patient had gastrointestinal blood loss in the context of sphinctertomy and received three units of pRBC's in the MICU with improvement of her hematocrit, which was stable thereafter. Given no obvious large volume bleed CT scan of abdomen was performed to rule out RP bleed and this was negative. 3) Bacteriuria: Though initial urine culture was negative repeat culture with small organism burden of E coli. ID and team felt possibly due to hematogenous spread from bacteremia. Patient does have an indwelling foley for chronic incontinence and habitus, which could serve as a portal for infection. Risks and benefits of indwelling foley should be continued with the patient and her caretakers. 4) Dysphagia: Pt reported dysphagia in the AM notable of accumulation of a "ball of spit" in the throat. Pt had ERCP and passage of large scope for this procedure essentially rules out significant peptic stricture (and none was seen). Video swallow study showed no clear dysphagia and patient had no choking, coughing, or worsened hypoxemia so no suggestion of aspiration. Given this was mild and only occurred with breakfast further work up was deferred. Pt was instructed to eat upright and to sip - bite-sip. If this continues to be an issue barium swallow should be considered. 5) OSA: Patient with known OSA and echo with pulmonary hypertension. She has refused CPAP in past due to intolerance. She offered to attempt to use again but was unable to tolerate this in house and asked for it to be removed. She understands this poses a risk of long term damage to her heart. This should continue to be addressed with the patient. 6) Atrial fibrillation: She remained in slow afib throughout her hospitalization. Coumadin and aspirin were held for 7 days post sphincterotomy and should both be restarted on [3-12]. Her digoxin was continued as was atenolol. 7) COPD, without exacerbation: Patient without signs of worsening of baseline COPD, she was kept on her normal 2L O2 by nasal cannula. She was continued on tiotroprium and bronchodilators. 8 )Chronic diastolic CHF: Patient with EF of 55 but given pulmonary hypertension high suspicion of some degree of diastolic CHF. She was continued on atenolol and digoxin. Her lasix was held in house but should be restarted at discharge. She was not on ACEi but starting this was deferred given complicated medical situation and lack of acute issues with her dCHF. 9) Hypertension: Remained well controlled. She was continued on amlodipine and atenolol. 10) Neuropathy/ Chronic lower extremity pain: She was continued on her gabapentin and oxycodone. 11) Depression: She was continued on venlafaxine. 12) Gastritis/ GERD: She was continued on her home [Hospital1 ] pantoprazole Code status was full throughout hospitalization. Her HCP is [Name (NI) ] [Name (NI) 51307] (sister) [Telephone/Fax (1) 51308]. Transitional Issues: -She should have further conversations about risk and benefits of removal of chronic foley and port a cath as these both increase risks of infection. -She should have PT to work on increasing functionality and ability to ambulate independently -She should complete here course of antibiotics for cholangitis. Medications on Admission: Albuterol inh prn Amlodipine 2.5mg daily Ascorbic acid 500mg daily Atenolol 25mg daily Digoxin 0.125mg daily Duoneb qid prn Lasix 60mg daily Loperamide prn Loratadine 10mg daily MVI Neurontin 100mg [Hospital1 ] Omeprazole 20mg [Hospital1 ] Oxybutynin ER 15mg daily Phenazopyridine 200mg [Hospital1 ] Tiotropium daily Coumadin 4mg daily Venlafaxine 37.5mg daily Colace 100mg [Hospital1 ] Mag oxide 400mg daily Miralax 17gm daily Senna q2 sYA Tylenol 650mg q6h prn Oxycodone 5mg q4h prn Oxycodone 10mg qhs Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: hold for sedation. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 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). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 14. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 15. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, flush with 10 mL Normal Saline followed by Heparin as above per lumen. 16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 17. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 18. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 19. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 8 days: Last day of therapy [2110-3-20] . 20. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) gm Intravenous Q24H (every 24 hours) for 8 days: Last day of tehrapy is [3-20] . 21. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 22. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. 23. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 24. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 25. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 26. multivitamin Tablet Sig: One (1) Tablet PO once a day. 27. oxybutynin chloride 15 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 9188] Care and Rehab Discharge Diagnosis: Gram negative bacteremia and septic shock from cholangitis Chronic Obstructive Pulmonary Disease Obesity Chronic Systolic Heart Failure Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for a severe infection related to an obstruction of your biliary tree. You had a stone removed and a stent replaced and improved. You are being discharged to complete a course of antibiotics and your recovery. Your medications have been changed. You have been started on ceftriaxone and metronidazole to treat the bloodstream infection. You will complete your course of these antibiotics on [3-20]. Please take all other medications as prescribed. Followup Instructions: You should be scheduled to resume care with your usual providers as an outpatient. ICD9 Codes: 2851, 4280, 3572, 5990, 5859, 4439, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5039 }	Medical Text: Admission Date: [2153-11-19] Discharge Date: [2153-12-3] Date of Birth: [2078-9-11] Sex: F Service: CCU HISTORY OF THE PRESENT ILLNESS: This 75-year-old woman was admitted to the CCU for decompensated heart failure. She has a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and coronary artery disease. She had a myocardial infarction in [2152-2-24] and received a catheterization with stent placement to the LAD that re-stenosed. In [2152-4-23], she had an ICD placed for nonsustained ventricular tachycardia. She had a repeat catheterization in [2153-9-23] revealing 70% lesions in LAD and first diagonal as well as a totally occluded proximal right coronary artery. She underwent three vessel bypass on [2154-10-15] (LIMA to LAD, SVG to first diagonal, SVG to PDA) with a bioprosthetic mitral valve replacement for severe mitral regurgitation. She was discharged from [Hospital1 18] on [2153-10-26]. Of note, she was discharged off of levothyroxine which she had been prescribed for hypothyroidism. An echocardiogram on [2153-10-23] revealed an LVEF of [11-11]%, dilated left ventricle, 1+ aortic regurgitation, and 4+ tricuspid regurgitation. The patient presented to [Hospital3 ] Hospital on [2153-11-16] after three days of progressive dyspnea. Her laboratories were notable for an INR of greater than 5.8 and a TSH of 42. The patient developed respiratory distress and was intubated on [2153-11-18]. The same day, the patient reportedly had an episode of ventricular tachycardia with rate in the 140s to 150s, systolic blood pressure in the 50s to 60s. She was started on Amiodarone, Vasopressin, and transferred to [Hospital1 18] for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease with history of MI, LAD stent and re-stenosis, CABG with bioprosthetic mitral valve replacement, congestive heart failure with LVEF of [11-11]%, 4+ TR, 1+ AR, paroxysmal atrial fibrillation with rapid ventricular response, ICD placement for nonsustained ventricular tachycardia. 2. Diabetes mellitus type 2. 3. Hypercholesterolemia. 4. Chronic renal failure with baseline creatinine 1.3 to 1.9. 5. Anemia. 6. Peptic ulcer disease. 7. Hypothyroidism. 8. Peripheral arterial disease. MEDICATIONS ON TRANSFER: 1. Amiodarone 0.5 mg per hour. 2. Vasopressin drip. 3. Nisiritide drip. 4. Levothyroxine 0.075 mg IV q.a.m. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Positive for smoking. The patient lives with her husband. LABORATORY DATA AT [Hospital3 ] ON [2153-11-19]: Sodium 134, potassium 3.8, chloride 95, total C02 28, BUN 77, creatinine 2.6, glucose 169. CK 158, 126, 125, 141. TSH 41.6, free T4 6.7. ABG with pH 7.53, PC02 31, P02 76. INR greater than 5.8. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.0, heart rate 71, blood pressure 105/48, weight 75.6 kilograms. Ventilator settings with assist controlled with 500 cc: Tidal volume respiratory rate 18, FI02 50%, and oxygen saturation 97%. General: The patient was intubated, responsive to voice, and in no acute distress, pale. HEENT: Pupils 3 mm in diameter, light reactive. Oral mucosa was moist. Extraocular motility intact. Neck: Supple, no carotid bruits, JVP difficult to asses. Lungs: Scattered crackles bilaterally. Heart: Soft heart sounds, regular rate and rhythm, with normal S1, S2, positive S3. Abdomen: Obese, soft, nondistended, normal sounds. Extremities: Cool, 1+ pitting lower extremity edema. Neurologic: Cranial nerves II through VIII intact, IX through XII not assessed. The patient moves four extremities spontaneously. HOSPITAL COURSE: 1. CARDIOVASCULAR: A. Pump: The patient was admitted with known systolic dysfunction and decompensated heart failure with multiple possible contributing factors including uncontrolled hypothyroidism, Rosiglitazone use, and dietary indiscretion. She was taken off of Vasopressin and started on dopamine for its inotropic effects and blood pressure support. She was placed on Carvedilol 6.25 mg b.i.d. and diuresed with a furosemide drip so as to lower her preload. She diuresed well in response to the furosemide and was extubated on [2153-11-24] without event. At this time, the dopamine drip was also taken off and the patient maintained mean arterial pressures over 60 mmHg off of dopamine. The furosemide drip was weaned off and furosemide was started at a dose of 80 mg p.o. q.d. On [2153-11-27], low-dose Captopril (6.25 mg) was initiated for afterload reduction. The furosemide was titrated to a dose of 160 mg p.o. q.d. and spironolactone was initiated on [2153-11-29]. On [2153-11-30], the patient received a Heart Failure Service consultation. They recommended holding the beta blocker while the patient was fluid overloaded and re-initiating it once she is in compensated heart failure. The patient was seen by a nurse practitioner for heart failure teaching and arranged for follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for further management of her heart failure as an outpatient. Prior to discharge, the patient's furosemide was decreased to 80 mg p.o. q.d. and her ACE inhibitor was changed to lisinopril at a dose of 2.5 mg q.d. B. Rhythm: As aforementioned, the patient had a reported episode of ventricular tachycardia while at [Hospital3 ] Hospital. On transfer here, she was taken off of intravenous Amiodarone and placed on oral Amiodarone at a dose of 200 mg p.o. t.i.d. She received an interrogation of her ICD on [2153-11-20]. She was placed on heparin for anticoagulation in the setting of her paroxysmal atrial fibrillation and diffuse akinesis. Her rhythm remained A-sensed, V paced throughout admission. She completed an Amiodarone load for her ventricular tachycardia totaling 6 grams prior to conversion to a dose of 200 mg q.d. 2. PULMONARY: On admission, the patient was noted to have significant pulmonary edema as well as bilateral pleural effusions, left-sided greater than right-sided. Despite her aggressive diuresis, she had a persistent large left pleural effusion. After she was extubated, the CT Surgery Service was consulted to place a chest tube and this was done successfully. The cytology of the pleural fluid was negative for malignant cells. Fluid contained blood, lymphocytes, and neutrophils, and was exudative on the basis of Light's criteria. After the placement of the chest tube with drainage of pleural fluid, it was noted that the patient had an elevated left hemidiaphragm likely secondary to postsurgical diaphragmatic paralysis. On [2153-11-28], the chest tube was discontinued. On [2153-11-30], she received chest fluoroscopy which revealed that her left hemidiaphragm was indeed paralyzed. However, by this point in her hospitalization, the patient was breathing much better with oxygen saturations over 95% on room air. 3. RENAL: The patient was noted to have a creatinine of 2.6 on admission as compared with her baseline creatinine of 1.3 to 1.9. The differential diagnosis for the increase in GFR was felt to include prerenal insufficiency from decreased effective intravascular volume as well as ATN from hypotension and decreased renal perfusion. She did not have casts in her urine sediment. With successful diuresis and inotropic support, the patient's renal function improved, with creatinine downtrending consistently until it reached a level of 1.6 on [2153-12-2]. 4. ENDOCRINE: The patient's endocrine issues at the time of admission included severe hypothyroidism by TSH at the outside hospital as well as type 2 diabetes mellitus. She was placed on oral levothyroxine for the hypothyroidism and a regular insulin sliding scale for her type 2 diabetes. The Endocrine Service was consulted for evaluation and management of her hypothyroidism and they recommended continuing levothyroxine at 175 micrograms p.o. q.d. and checking a free T4 and TSH level in six weeks. DISCHARGE DIAGNOSIS: 1. Decompensated heart failure. 2. Paroxysmal atrial fibrillation. 3. Coronary artery disease. 4. Severe tricuspid regurgitation. 5. Left diaphragm paralysis with pleural effusion. 6. Hypothyroidism. 7. Type 2 diabetes. 8. Status post acute on chronic renal failure of prerenal etiology. 9. Anemia. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: To home with home services. FOLLOW-UP: The patient is to follow-up with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ]. DISCHARGE MEDICATIONS: 1. Lisinopril 2.5 mg p.o. q.d. 2. Furosemide 80 mg p.o. q.d. 3. Spironolactone 25 mg q.d. 4. Coumadin 5 mg q.h.s. 5. Amiodarone 200 mg q.d. 6. Aspirin 81 mg q.d. 7. Lipitor 10 mg q.d. 8. Levothyroxine 175 micrograms q.d. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 5596] MEDQUIST36 D: [2154-5-16] 05:52 T: [2154-5-19] 17:50 JOB#: [Job Number 34161] ICD9 Codes: 5119, 5990, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5040 }	Medical Text: Admission Date: [2168-11-8] Discharge Date: [2168-11-15] Date of Birth: [2106-3-16] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: Right carotid stenosis. Major Surgical or Invasive Procedure: Right carotid endarterectomy and bovine pericardial patch angioplasty along with right cervical carotid arteriogram and stenting of right carotid endarterectomy repair with a 9 x 30 carotid Wallstent. History of Present Illness: This is a 63-year-old gentleman with right carotid stenosis who underwent a right carotid endarterectomy by Dr. [Last Name (STitle) ]. He had a lesion in the distal ICA noted on completion angiography, performed due to poor distal signal. This appeared to be possibly a clamp injury. This was in an area of the ICA that was not surgically accessible and therefore, intraoperative consultation was requested for possible carotid stenting. Past Medical History: PAST MEDICAL HISTORY: # CAD s/p CABG [2157] (LIMA-LAD, SVG-PDA, SVG-PL) # DM2 # Hypertension # Hypercholesterolemia # Hiatal hernia # Muscle Schatzki's ring # Diabetic neuropathy # s/p shoulder surgery # R carotid stenosis s/p CEA and stenting [11-8] Social History: Retired, used to work in a clothing warehouse. No known exposure to asbesthos. Lives at home with wife and 2 dogs and 1 cat. Tobacco: quit five days ago, 50 year history of [11-20] ppd. EtOH: h/o abuse, quit in [2150]. Denies illicits. Family History: Father died of MI at 40. Mother died from MI in 70s. No SCD. Physical Exam: Vitals: T: 99.0 degrees Farenheit, BP: 155/79 mmHg supine, HR 72 Gen: Pleasant, fatigued appearing, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD. Cannot appreciate JVP d/t habitus. Surgical incision over right neck. CV: PMI in 5th intercostal space, mid clavicular line. RRR. nl S1, S2. No murmurs, rubs, clicks, or [Last Name (un) 549] LUNGS: Decreased BS at bases. Fine rales bilaterally 1/2 up. ABD: Obese. NABS. Soft, NT, ND. No HSM. EXT: WWP, trace LE edema. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Moving all extremities Pertinent Results: [2168-11-14] 06:15AM BLOOD WBC-5.9 RBC-3.53* Hgb-10.5* Hct-32.3* MCV-92 MCH-29.8 MCHC-32.6 RDW-13.6 Plt Ct-190 [2168-11-10] 09:50AM BLOOD PT-13.1 PTT-28.4 INR(PT)-1.1 [2168-11-14] 06:15AM BLOOD Glucose-177* UreaN-31* Creat-1.6* Na-140 K-3.6 Cl-104 HCO3-26 AnGap-14 [2168-11-14] 06:15AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0 [2168-11-10] 05:01PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 URINE Blood-MOD Nitrite-NEG Protein-75 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 PORTABLE AP CHEST: Comparison made to [2168-11-13]. Scattered ill-defined bilateral airspace opacities again show slight improvement. Cardiomediastinal contours are unchanged. There is no pleural effusion or pneumothorax. CT SCAN: IMPRESSION: 1. No evidence of pulmonary embolism till the level of [Last Name (un) ] and part of the segmental arteries . 2. Extensive pulmonary abnormalities, differential diagnosis includes infection, hemorrhage desquamative interstitial pneumonia; radiographically, pulmonary edema is another possibility, even though this does not correlate with the clinical picture. 3. Mediastinal lymphadenopathy, which is likely reactive in the setting of extensive pulmonary abnormality. Brief Hospital Course: Mr. [Known lastname 21973],[Known firstname ] was admitted on [11-8] with Carotid Artery Stenosis. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. It was decided that she would undergo a: Right carotid endarterectomy and bovine pericardial patch. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. But during the procedure the patient had a higher lesion that was not amendable to endarectomy. Dr [Last Name (STitle) ] was called into the case: Angioplasty along with right cervical carotid arteriogram and stenting of right carotid endarterectomy repair with a 9 x 30 carotid Wallstent. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. Plavix was started for the stent. He was then transferred to the VICU for further recovery. While in the VICU he received monitored care. Pt did have episodes of SOB. Pt was heavy smoker. He did require oxygen. Pt developed PNA. Treated appropriately. DC on PO antibiotics. This event did require a cardiology consult. Originally thought to be CHF. Echo showed preserved EF, but some right sided heart failure.. BNP was close to normal. He was originally diuresed. Was thought to be a PE, received a CT scan: IMPRESSION: 1. No evidence of pulmonary embolism till the level of lobar and part of the segmental arteries . 2. Extensive pulmonary abnormalities, differential diagnosis includes infection, hemorrhage desquamative interstitial pneumonia; radiographically, pulmonary edema is another possibility, even though this does not correlate with the clinical picture. 3. Mediastinal lymphadenopathy, which is likely reactive in the setting of extensive pulmonary abnormality. To note pt does have CRI. His creatinine did bump with the Lasix. On DC his creatine is at baseline. His nephrotoxic drugs were held, on DC they have been restarted. Pt also had a pulmonary consult: Levaquin alone to cover for community-acquired aspiration if Cxs negative. Pt to be discharged on Levaquin. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabilized from the acute setting of post operative care, she was transferred to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home in stable condition. To note he does not require home )@. He was weaned off of 02 on DC. Medications on Admission: amlodipine 10', lasix 40', glipizide 10", lansoprazole 30', lisinopril 40", metformin 1000", metoprolol 50", percocet prn, actos 30', lyrica 75", simvastatin 40', KCl 10', ASA 81', niacin 500' Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. Amlodipine 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day: home med. 3. Pregabalin 75 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day: home med. 4. Simvastatin 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily): [Last Name (un) ] emed. 5. Aspirin 81 mg Tablet, Chewable [Last Name (un) ]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet [Last Name (un) ]: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:30 Tablet(s) Refills:2 7. Acetaminophen 325 mg Tablet [Last Name (un) ]: Two (2) Tablet PO every [4-25] hours as needed for pain. 8. Furosemide 40 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). 9. Glipizide 10 mg Tablet [Month/Day (3) ]: One (1) Tablet PO twice a day: home med. 10. HOLDING: Do not take - Metformin 1000mg 1 tab by mouth twice daily while your creatinine is elevated. You will be taking insulin for now. You will need to follow up with your pcp/ diabetic provider to have blood work and medications adjusted 11. Pioglitazone 30 mg Tablet [Month/Day (3) ]: One (1) Tablet PO once a day: home med. 12. Levofloxacin 750 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 13. Oxycodone 5 mg Tablet [Month/Day (3) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:30 Tablet(s) Refills:0 14. Metoprolol Tartrate 50 mg Tablet [Month/Day (3) ]: 1.5 Tablets PO TID (3 times a day): * this is an increased dose * . Disp:135 Tablet(s) Refills:2 15. Niacin 500 mg Capsule, Sustained Release [Month/Day (3) ]: One (1) Capsule, Sustained Release PO DAILY (Daily). 16. Lisinopril 40 mg Tablet [Month/Day (3) ]: Two (2) Tablet PO once a day: home med - . 17. Potassium Chloride 10 mEq Capsule, Sustained Release [Month/Day (3) ]: One (1) Capsule, Sustained Release PO once a day. 18. Metformin 1,000 mg Tablet [Month/Day (3) ]: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Right carotid stenosis Secondary: Post operative pneumonia COPD CAD, s/p CABG [2150] Ongoing Tobacco Abuse HTN Hyperlipidemia Obesity Non Insulin Dependent Diabetes Mellitus x 17 years Peripheral neuropathy Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of [Year (4 digits) ] and Endovascular Surgery Carotid Endarterectomy Surgery Discharge Instructions What to expect when you go home: 1. Surgical Incision: ?????? It is normal to have some swelling and feel a firm ridge along the incision ?????? Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness ?????? Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery ?????? Try ibuprofen, acetaminophen, or your discharge pain medication ?????? If headache worsens, is associated with visual changes or lasts longer than 2 hours- call [Year (4 digits) 1106] surgeon??????s office 4. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? 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! 5. 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 ?????? No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit ?????? You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Temperature greater than 101.5F for 24 hours Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions ** YOU SHOULD QUIT SMOKING IMMEDIATELY - Check your blood sugars three to four times per day and record them - Follow up with your primary care/ diabetes provider [Name Initial (PRE) 176] 10 days regarding blood sugar trends and your treatment plan Followup Instructions: Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2168-12-1] 2:30 Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2168-12-1] 3:00 Pulmonology Clinic: [Location (un) 436] of [Location (un) 8661] Building on [2168-12-28] Come in at 1145 and go to the radiology dept in the [Location (un) 8661] Building for a chest xray Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2168-12-28] 12:40 You will then see the doctor around 1pm Completed by:[2168-11-15**] ICD9 Codes: 5070, 5849, 3572, 496, 5859, 2724, 3051, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5041 }	Medical Text: Admission Date: [2103-6-19] Discharge Date: [2103-7-11] Date of Birth: [2048-8-9] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 54 year old Ethiopian gentleman who fell at work on [6-1] and sustained a back and neck injury. He was at [Hospital6 2910] having physical therapy on [6-19] when he had a sudden onset of severe nausea, vomiting and vertigo. He was transferred to [Hospital1 69] Emergency Room for further evaluation after a non contrast head CT showed a cerebellar hemorrhage. The patient was intubated on arrival for airway protection. PAST MEDICAL HISTORY: He has a past medical history of back pain. ALLERGIES: None. PHYSICAL EXAMINATION: On physical examination, he was sleepy but easily arousable to voice. The pupils were 4 to 3 mm on the left and 3.5 to 2.5 on the right. The right eye was down and he had a skewed deviation, right fourth nerve palsy. He had a right facial droop. His tongue was midline. His palate rose symmetrically. His tone was up in his lower extremities, left greater than right. He had full power [6-13] throughout. Sensation localizes to pain in all four extremities. Reflexes - he was hyperreflexic, left greater than right. Toes were upgoing bilaterally. Coordination - he had dysmetria bilaterally, left greater than right. His head CT showed a cerebellar hemorrhage, right greater than left with blood in the third and fourth ventricles and no hydrocephalus. The bleed was 1.9 x 3.4 x 3 cm with left temporal [Doctor Last Name 534] ventricular dilation. HOSPITAL COURSE: He was admitted to the ICU for close neurologic observation. The patient's mental status deteriorated upon admission to the ICU and a ventricular drain was placed without complication. It was leveled at 12 cm above the tragus. On [6-20], his eyes remained closed. He had disconjugate gaze. He localizes the pain on the right briskly and on the left. Toes were mute bilaterally. He did withdraw his lower extremities. Pupils were 3 to 2 mm and reactive. His blood pressure was kept less than 140. He had an MRI scan that showed no enhancing lesions. The patient had a repeat head CT on [2103-6-21] that was unchanged and continued to show a large cerebellar hemorrhage with extension into the third and fourth ventricles with slight interval enlargement of the lateral ventricles. On [2103-6-22], the patient underwent a diagnostic angiogram to rule out presence of an AVM. The procedure was negative for aneurysm or AVM. On the 15th, the patient continued to have his eyes closed the majority of the time, opens with voice. The pupils were 3 mm, localizing to pain in both upper extremities, left greater than right. The patient remained intubated this whole time. The patient had a chest x-ray on [6-25] that showed right lung opacity. The patient was started on Levo for suspected pneumonia and remained intubated. The patient was extubated on [2103-6-26], continuing to have his vent drain in place. He was evaluated by Speech and Swallow. The patient had C-spine plain films that showed no fracture or dislocation but multilevel degenerative changes. His initial swallow evaluation was unsuccessful in swallowing on his own. Therefore, an NG tube was placed. On [2103-6-28], the patient's strength on the right side was less than previous exams. He had a 4-/5 grasp on the right and incomplete elevation of the right eye. He had an MRI scan of the brain that showed signal change in the right greater than left colliculi and central pons but no obvious cortical infarct. His MRI of the cervical spine showed no injury but just narrowing. On [2103-6-29], Stroke/Neurology was consulted regarding the patient's right-sided weakness. Stroke/Neurology recommended starting aspirin 10 days after stroke for stroke prophylaxis and getting an echo, a lipid panel with homocysteine and keeping his blood pressure less than 140. On [7-2], the patient continued to have lateral gaze nystagmus mainly on the right with slight right ptosis. His grasp was [4-13] on the right, 4-/5 on the left. IPs were 4. He continues to have diffuse weakness. The drain was elevated to 20 cm above the tragus. Neurology recommended an EMG. The patient continued to be followed by Physical Therapy and Occupational Therapy. The patient had a head CT on [2103-7-5] that showed no evidence of increased hydrocephalus with drain being clamped. Therefore, on [2103-6-6], the vent drain was discontinued. The patient had EMG study which just showed evidence of ICU myopathy. He remained neurologically unchanged with brisk antigravity strength on the left and antigravity delay distally on the right. Grasp was [4-13] on the right, [6-13] on the left. IPs - the right [3-13] and the left 4. He neurologically remained stable. He had a repeat video swallow study that showed the patient could tolerate nectar- thick liquids and soft solids, hold giving meds and hold on puree. His feeding tube was discontinued and the patient was transferred to the regular floor on [2103-7-7] where he has continued to be evaluated by Physical Therapy and Occupational Therapy and felt to require Acute Rehab prior to discharge to home. DISCHARGE MEDICATIONS: Metoprolol 75 mg po bid, hold for SBP less than 100 and heart rate less than 55, Captopril 75 mg po tid, hold for SBP less than 100, Percocet one to two tablets po q4h, prn, Colace 100 mg po bid, citalopram hydrobromide 10 mg po qd, nicardipine 20 mg po q8h, hold for SBP less than 120, heparin 5000 units subcu q12h, Tylenol 650 po q4h prn. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. FOLLOW UP: He will follow up with Dr. [Last Name (STitle) 1132] in one month with repeat head CT. [Name6 (MD) ] [Last Name (NamePattern4) 1359], [MD Number(1) 1360] Dictated By:[Last Name (NamePattern1) 6583] MEDQUIST36 D: [2103-7-10] 11:53:22 T: [2103-7-10] 13:15:55 Job#: [Job Number 111104] ICD9 Codes: 431, 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5042 }	Medical Text: Admission Date: [2151-7-18] Discharge Date: [2151-7-30] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: Gastric volvulus and incarceration, Major Surgical or Invasive Procedure: [2151-7-23]: Laparoscopic repair of paraesophageal hernia with graft reinforcement, [Last Name (un) ] gastroplasty, Nissen fundoplication, flexible gastroscopy. History of Present Illness: Mrs. [Known lastname ] is an 89 y/o female with a history of hiatal hernia who presented to [Hospital 8641] Hospital late [2151-7-17] with severe chest and abdominal pain, with approximately 1.5 liters of coffee ground vomiting and hematemsis. She underwent a CT of the chest, which showed a large portion of the stomach in the left chest. She then underwent an EGD, which showed incarceration of the stomach without evidence of necrosis. She was transferred to [Hospital1 18] as a direct admit for a question of gastric volvulus. Past Medical History: Past Medical History: Pacer for heart block, rheumatoid arthirtis/osteoarthritis, polymyalgia, diverticulosis, hypertension, history of frequent UTI. Past Surgical History: Cholecystectomy, Hysterectomy, 2 prior knee surgeries, carpal tunnel release. Social History: Denies alcohol and smoking history, Family History: non-contributory Physical Exam: PHYSICAL EXAMINATION Vitals: T 98.6, BP 128/48, HR 55, RR 18, O2 9. Gen: Pleasant, well appearing elderly female. NAD. HEENT: No conjunctival pallor. No icterus. NECK: Supple, no LAD. Normal carotid upstroke without bruits. No thyromegaly. CV: Irregularly irregular rhythm. No murmurs, rubs, clicks, or [Last Name (un) 549] LUNGS: Few bibasilar wet crackles. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: warm, good capillary refill. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [12-4]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Mood and affect were appropriate. Pertinent Results: [2151-7-18] Chest CT: intrathoracic stomach, colonic diverticulosis without evidence of diverticulitis. [2151-7-19] UGI series: Normal peristaltic esophageal contractions with an intrathoracic stomach, configuration consistent with gastric volvulus. Lack of passage of contrast from the gastric lumen into the duodenum indicating hypomotility or a component of obstruction due to the known volvulus. [2151-7-23] stomach pathology specimen: Fundic segment with focally prominent submucosal edema, vascular dilation and congestion, consistent with clinical history of gastric volvulus. Overlying mucosa with focal and mild chronic, inactive inflammation; no intrinsic mucosal abnormalities otherwise recognized. [2151-7-27] ECHO: Low normal left ventricular systolic function. Mild to moderate aortic regurgitation. Atrial fibrillation. Mild pulmonary hypertension. [2151-7-26] BEDSIDE SWALLOWING EVALUATION Pt presents without s/sx of prandial aspiration during today's evaluation. These results do not rule out post-prandial issues such as aspiration of reflux. Given documentation of mild-moderately ineffective esophageal motility, pt was educated on aspiration precautions including sitting fully upright while eating and remaining upright after meals. She appears safe from an oropharyngeal standpoint to return to a PO diet of regular solids and thin liquids with meds whole with thin liquids. Brief Hospital Course: Mrs. [Known lastname ] was transferred to [Hospital1 18] as a direct admit for a question of gastric volvulus after she presented to [Hospital 8641] Hospital late [2151-7-17] with severe chest and abdominal pain, with approximately 1.5 liters of coffee ground vomiting and hematemsis. At [Hospital 8641] Hospital, she underwent a CT of the chest, which showed a large portion of the stomach in the left chest, and then underwent an EGD, which showed incarceration of the stomach without evidence of necrosis. On arrival to [Hospital1 18], she had green bilious non-bloody fluid draining from her NGT, and was non-tender on exam with positive bowel sounds in all 4 quadrants. Her vital signs on admission were 99.2, 62, 138/58, 17, 96% Oxygen saturation on 2L. Given her stable status on admission, she was initially treated with nasogastric decompression and fluid resuscitation. She underwent an upper GI series on [2151-7-19], revealing a configuration consistent with gastric volvulus with lack of passage of contrast from the gastric lumen into the duodenum, indicating hypomotility. She underwent esophageal manometry on [2151-7-21], revealing mild to moderate ineffective esophageal motility. She then underwent Laparoscopic repair of paraesophageal hernia with graft reinforcement, [Last Name (un) ] gastroplasty, Nissen fundoplication, and flexible gastroscopy on [2151-7-24]. Post-operatively, she passed a swallowing evaluation on [2151-7-26] for regular solids and thin liquids and her diet was advanced. An ECHO performed on [2151-7-27] showed low normal left ventricular systolic function, mild to moderate aortic regurgitation, and atrial fibrillation. She was seen by Cardiology on [2151-7-28], who recommended an outpatient follow up with her cardiologist to manage her AF and anticoagulation. Upon discharge, the patient is tolerating a regular soft diet and has had several bowel movements. Medications on Admission: Prednisone 2mg qd, Vitamin D 1000 U TID, Bactrim 200 mg qd, Lasix 20 mg qd, Tylenol/codein 300mg as needed, Vitamin C qd, Micardis 20 mg qd, Vit. B12 500mg qd, Fosamax 70 mg once/week, Aspirin 81mg qd Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for polymyalagia rheumatica. 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/cough/wheeze. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/cough/wheeze. 5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Gastric volvulus and incarceration of a hiatal hernia Discharge Condition: good, hemodynamically stable, tollerating a soft regular diet Discharge Instructions: You have been treated for a hiatal hernia that showed signs of incarceration with surgical repair. Please call your doctor or return to the ED if you experience any of the following. Any nausea or vomiting. Any signs and symptoms of infection, including fevers, chills, increased swelling, discharge from wound. Any shortness of breath or chest pain. Please resume all your other home medications. Followup Instructions: Please follow up with Dr.[Name (NI) 1482] office in 2 weeks. Call [Telephone/Fax (1) 25782] for an appointment. Completed by:[2151-7-30] ICD9 Codes: 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5043 }	Medical Text: Admission Date: [2175-10-3] Discharge Date: [2175-10-5] Date of Birth: [2101-11-10] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1] Chief Complaint: Scheduled total thyroidectomy due to multinodular goiter Major Surgical or Invasive Procedure: 1. S/P total thyroidectomy 2. reexplored thyroid for bleeding & edema 3. obstructed airway requiring reintubation History of Present Illness: Mrs. [Known lastname ] is 73 year old female with a h/o hypertension and Left breast cancer who was found to have a multinodular goiter on exam. She was referred to Dr. [Last Name (STitle) ] for resection of the entire thyroid gland, and surgery was arranged. Past Medical History: Hypertension History of L breast cancer Social History: Patient denies use of tobacco, alcohol or recreational drugs. Lives with son. Family History: No familial history of thyroid abnormalities Physical Exam: Per Dr. [Last Name (STitle) ] on [2175-10-3] Physical Exam: V: 96.1F HR 98 BP 109/59 98 % on AC 400 x 10/40%/5peep Gen: intubated, sedated HEENT: eyes closed, but pupils reactive, anicteric sclera, MMM, intubated Neck: wound dressing intact, some bruising around wound dressing CV: RRR, S1, S2, no murmurs appreciated Pulm: CTA-ant Abd: Normoactive BS, soft, ND/NT, no HSM appreciated Ext: WWP, no edema, with pneumoboots Pertinent Results: [2175-10-4] 03:04AM BLOOD WBC-11.7* RBC-3.19* Hgb-10.8* Hct-30.4* MCV-95 MCH-33.8* MCHC-35.4* RDW-12.6 Plt Ct-226 [2175-10-5] 06:40AM BLOOD Calcium-8.3* [2175-10-4] 03:04AM BLOOD Albumin-3.4 Calcium-8.1* Phos-3.5 Mg-1.8 . [2175-10-3] Pathology Tissue: Total Thyroid-pending Brief Hospital Course: This is a 73 year old female admitted for total thyroidectomy complicated by hematoma post-operatively resulting in airway obstruction necessitating intubation and reexploration. Arterial bleed found and clipped. Patient placed in ICU overnight. Extubated morning of [2175-10-4] and transferred to floor. Calcium and HCT levels stable. Problems 1. Hematoma/Hemorrhage - Arterial bleed clipped. Hematocrit stabilized 2. Hypertension - Will resume medication regime at home. 3. Electrolytes - Last calcium 8.3* Medications on Admission: Lisinopril 20 mg daily Levothyroxine 25 mcg daily MVI daily Fish oil 1 daily Albuterol Inhaler prn wheeze Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain or fever. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Synthroid 25 mcg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary: multinodular goiter Post-op bleed . Secondary: Hypertension Breast cancer Discharge Condition: stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Instructions after thyroid surgery: Avoid driving while taking pain medication. Continue taking stool softeners with pain medication to prevent constipation. You may feel tingling around your lips, arms & legs. Take TUMS (2 tabs four times for a few days until tingling goes away). emergency room if unable to reach MD. You may return to work once you feel comfortable. Avoid physical/strenuous activity until you feel comfortable. You may shower. Avoid swimming or bath for 5-7 days. Followup Instructions: 1.Please call Dr.[Name (NI) 10946] office for appointment next Tuesday [2175-11-10] for staple removal ([Telephone/Fax (1) 9011] 2.Follow-up with primary care provider regarding need for pneumococcal vaccine. Completed by:[2175-10-5] ICD9 Codes: 5185, 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5044 }	Medical Text: Admission Date: [2105-1-7] Discharge Date: [2105-2-3] Date of Birth: [2037-8-20] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 13256] Chief Complaint: Worsening abdominal distention and ascites Major Surgical or Invasive Procedure: - Multiple paracenteses History of Present Illness: On admission to the service completing the d/c summary: 67 year old female with HCV, DM2 c/b neuropathy, retinopathy and gastroparesis, and h/o seizure disorder who initially presented on [2105-1-7] with progressively worsening ascites over the past two months. She initially presented to her PCP who started her on furosemide with no improvement. An ultrasound performed by her PCP [Last Name (NamePattern4) ] [1-2] revealed massive ascites - she was told to go [Hospital1 18] for further evaluation. Upon admission to the medical [Hospital1 ], she was started on furosemide and spironolactone. When these proved ineffective in reducing her ascites, on [1-8] she received a large volume therapeutic paracentesis of 9 L and received albumin. She developed fevers at this time, and peritoneal fluid cell counts and culture did not support an SBP diagnosis. Chest x-ray, blood cultures, UA, and urine cultures were negative. Her mental status was also described to be more somnolent; lactulose and rifaximin were initiated. Ceftriaxone was administered. On [1-11], her abdomen was again distended and a repeat paracentesis (about 5 L) was performed was again not supportive of SBP. Her renal function since admission has continued to deteriorate, with admission creatinine of 1.3 with a creatinine of 1.5-1.8 after the second paracentesis, eventually rising to 2.3 on [1-14] and 2.9 on [1-15]. Renal had been consulted who spun her urine and saw muddy brown casts suggestive of ATN, although hepatorenal syndrome was not excluded. She was started on octreotide, midodrine, and albumin on [1-13]. Her electrolytes and acid-base status remained within normal limits. Her total bilirubin was observed to be rising from 0.4 on admission. She continued to have intermittent fevers between [Date range (1) 33280] with no obvious source despite culturing blood, peritoneal fluid, and urine, along with negative chest-xrays. Her antibiotics were broadened to vancomycin and zosyn. On [1-15], a third therapeutic paracentesis was attempted, following this, her WBC count increased from 9-> 12.7. She was felt to be more somnolent despite lactulose and rifaximin and successful bowel movements. Her abdomen remained distended despite multiple paracentesis, and the medical team became concerned that she had potential bowel perforation given leukocytosis, distension, and mental status. She was transferred to the MICU for further evaluation. A CT head, chest, and abdomen were obtained prior to transfer which were significant for ascites and without evidence of abdominal perforation. . In the MICU, the patient had an EEG that was consistent with encephalopathy. Her dilantin levels were found to be therapeutic (when corrected for albumin), diuretics were held in the setting of renal failure, and midodrine was discontinued after the patient developed hypertension. She has had some left sided weakness and twitching, which has improved. TTE was not suggestive of endocarditis. Of note, the patient received albumin, though she is a Jehovah's witness. . Currently, she is without complaint. She notes her abdomen is less distended than previously. She is unsure if her thinking has improved, and does not remember if she is confused or not. She denies a full ROS including SOB, cough, abdominal pain, hematuria. Past Medical History: -End stage liver disease secondary to HCV, c/b cirrhosis, varices, hepatic encephalopathy -Chronic kidney disease -Diabetes mellitus type 2 complicated by retinopathy and neuropathy -Breast cancer -Hypertension -Heart murmur -Hepatitis C -Seizure disorder -Status-post surgery on left foot for Charcot's joint Social History: Patient lives alone, but son [Name (NI) 33281] is her personal care assistant and helps take care of her. They had previously paid for health aides in the past, however they discovered that these aides were stealing from the patient (one stole a set of silverware that the patient's son found at the Pawn shop next store, and the next one they hired withdrew all the money from the patient's savings account). The patient uses a cane and walker at baseline. Family History: No early CAD. Mother deceased from colon CA, diagnosed in 60s. Father deceased from prostate CA and daughter deceased from lung CA. Physical Exam: Adm: VS - 98.2, 220/110 --> 178/85, 86, 22, 98% GENERAL - comfortable-appearing at rest, lying back in bed HEENT - NCAT, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - unlabored respirations, CTAB in throughout posterior lung fields HEART - RRR, normal S1 and S2, faint holosystolic murmur, II/VI, loudest at RUSB ABDOMEN - +caput medusa, unable to appreciate any spider angiomas, firm, distended, tense, tender to deep palpation EXTREMITIES - WWP, 2+ DP/PT pulses, 2+ pitting edema SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, sensation grossly intact, no asterixis . Discharge: VS: 98.2 150/70 81 100%RA GENERAL: Pleasant woman in no acute distress HEENT: Sclera icteric. MMM. CARDIAC: RRR with systolic murmur at LUSB LUNGS: Faint bibasilar crackles. ABDOMEN: Distended but soft, and non-tender. EXTREMITIES: 1+ edema b/l. NEURO: 2-3 beats asterixis, few myoclonic movements Strength 4/5 Left UE, 3-4/5 LLE Psych: Very awake, alert, and interactive today. Pertinent Results: Admission labs: [2105-1-7] 08:35PM BLOOD WBC-5.2 RBC-3.38* Hgb-9.0* Hct-28.1* MCV-83 MCH-26.7* MCHC-32.1 RDW-15.1 Plt Ct-153 [2105-1-7] 08:35PM BLOOD Neuts-56.9 Lymphs-33.0 Monos-6.1 Eos-2.7 Baso-1.3 [2105-1-7] 08:35PM BLOOD PT-11.4 PTT-31.3 INR(PT)-1.1 [2105-1-7] 08:35PM BLOOD Glucose-268* UreaN-21* Creat-1.3* Na-128* K-4.5 Cl-96 HCO3-30 AnGap-7* [2105-1-7] 08:35PM BLOOD ALT-23 AST-43* AlkPhos-70 TotBili-0.5 [2105-1-8] 05:35AM BLOOD Calcium-8.4 Phos-3.2# Mg-1.9 . Pertinent labs: [2105-1-12] 04:15PM BLOOD Cryoglb-NO CRYOGLO [2105-1-12] 12:50PM BLOOD Cryoglb-NO CRYOGLO [2105-1-8] 05:35AM BLOOD Ferritn-237* [2105-1-8] 05:35AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [2105-1-8] 05:35AM BLOOD AMA-NEGATIVE [2105-1-18] 12:50PM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:40 [Last Name (un) ] [2105-1-8] 05:35AM BLOOD AFP-4.5 [2105-1-17] 07:00AM BLOOD IgG-1829* [2105-1-12] 05:50AM BLOOD C3-57* C4-17 [2105-1-18] 12:50PM BLOOD C3-61* C4-16 [2105-1-15] 05:35AM BLOOD Phenyto-10.8 [2105-1-8] 05:35AM BLOOD HCV Ab-POSITIVE* . Urine: [2105-1-8] 02:27PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.008 [2105-1-8] 02:27PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2105-1-8] 02:27PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [2105-1-8] 02:27PM URINE CastHy-3* [2105-1-8] 02:27PM URINE Hours-RANDOM UreaN-334 Creat-85 Na-16 K-33 Cl-15 [2105-1-8] 02:27PM URINE Osmolal-244 [2105-1-18] 12:19PM URINE Color-Red Appear-Cloudy Sp [Last Name (un) ]-1.025 [2105-1-18] 12:19PM URINE Blood-MOD Nitrite-NEG Protein->300 Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-0.2 pH-5.0 Leuks-NEG [2105-1-18] 12:19PM URINE RBC-15* WBC-15* Bacteri-FEW Yeast-FEW Epi-1 TransE-<1 [2105-1-18] 12:19PM URINE CastHy-6* [2105-1-14] 04:44PM URINE Hours-RANDOM Creat-180 Na-10 K-62 Cl-<10 . ASCITES: [2105-1-7] 09:00PM ASCITES TotPro-1.0 Glucose-206 Albumin-LESS THAN [2105-1-7] 09:00PM ASCITES WBC-100* RBC-838* Polys-6* Lymphs-64* Monos-0 Mesothe-6* Macroph-24* [2105-1-8] 01:12PM ASCITES TotPro-1.0 Glucose-103 LD(LDH)-52 [2105-1-8] 01:12PM ASCITES WBC-10* RBC-170* Polys-3* Lymphs-70* Monos-1* Mesothe-7* Macroph-18* Other-1* [2105-1-14] 04:49PM ASCITES TotPro-1.8 Glucose-143 Creat-2.3 LD(LDH)-64 Amylase-18 TotBili-0.3 Albumin-1.1 [2105-1-14] 04:49PM ASCITES WBC-210* RBC-315* Polys-16* Lymphs-40* Monos-0 Mesothe-1* Macroph-42* Other-1* [2105-1-11] 01:58PM ASCITES WBC-255* RBC-1900* Polys-38* Lymphs-31* Monos-22* Mesothe-7* Other-2* . MICRO: Ascites: [1-7] Cx: Negative [1-8] Cx: Negative [1-14] Cx: Negative [1-22] Cx: Negative . All BCx from this admission were negative. All UCx from this admission were negative. CDiff negative [1-11] and 2/10 [1-8]: HBV core and surface antibody POSITIVE [1-8] HCV viral load: >1,000,000 . Studies: -[1-16] TTE: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is moderate thickening of the mitral valve chordae. There is mild functional mitral stenosis (mean gradient 8 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Mild calcific mitral stenosis. Moderate mitral regurgitation. Moderate pulmonary hypertension. No valvular vegetations seen . [1-11] CT: 1. New moderate ascites without loculated fluid collections. 2. New small bilateral pleural effusions and small pericardial effusion. 3. Nodular cirrhotic liver incompletely evaluated on this non-contrast study. 4. Dependent gallstones within the gallbladder. 5. Diffuse anasarca. . [2105-1-15] CT Chest, abd, pelvis: 1. No perforation. 2. Dependent ascites, which has increased slightly since prior exam. 3. Improvement of the small bilateral pleural effusions and resolution of a small pericardial effusion. 4. Cholelithiasis without cholecystitis . [2105-1-15] CT HEad: 1. No acute intracranial process. 2. Stable chronic small vessel ischemic disease . The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is moderate thickening of the mitral valve chordae. There is mild functional mitral stenosis (mean gradient 8 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Mild calcific mitral stenosis. Moderate mitral regurgitation. Moderate pulmonary hypertension. No valvular vegetations seen. . [1-15] EEG: ABNORMALITY #1: Throughout the recording the background rhythm was mildly slow, typically reaching a 7 Hz maximum in any given area. ABNORMALITY #2: There were occasional bursts of generalized or bifrontal slowing, as well. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient appeared to remain awake throughout the recording. No stage II sleep was evident. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal EEG due to the mild to moderate slowing of the background rhythm with occasional bursts of symmetric slowing. These findings indicate a widespread encephalopathy involving both cortical and subcortical structures. There were no areas of prominent focal slowing, and there were no epileptiform features. . [1-12] Renal u/s: Normal renal ultrasound. Ascites . Discharge labs: [2105-2-3] 05:30AM BLOOD WBC-6.1 RBC-2.60* Hgb-7.3* Hct-22.3* MCV-86 MCH-28.2 MCHC-33.0 RDW-18.4* Plt Ct-117* [2105-2-3] 05:30AM BLOOD PT-11.4 PTT-29.6 INR(PT)-1.1 [2105-2-3] 05:30AM BLOOD Glucose-88 UreaN-43* Creat-2.6* Na-132* K-4.8 Cl-101 HCO3-24 AnGap-12 [2105-2-3] 05:30AM BLOOD ALT-22 AST-44* AlkPhos-241* TotBili-0.9 [2105-2-3] 05:30AM BLOOD Calcium-8.4 Phos-4.4 Mg-1.9 [2105-1-31] 05:50AM BLOOD calTIBC-122* Ferritn-336* TRF-94* [2105-1-30] 06:10AM BLOOD Phenyto-12.4 [2105-1-8] 05:35AM BLOOD HCV Ab-POSITIVE* Brief Hospital Course: Summary: 67-year-old female with HCV cirrhosis c/b ascites, encephalopathy and varices, DM2 c/b neuropathy and retinopathy, who was admitted for worsening liver and renal failure. . # Liver failure: Initially admitted on [2105-1-7] with progressively worsening ascites over the past two months. An ultrasound performed by her PCP [Last Name (NamePattern4) ] [1-2] revealed massive ascites - she was told to go [Hospital1 18] for further evaluation. Upon admission to the medical [Hospital1 ], she was started on furosemide and spironolactone. When these proved ineffective in reducing her ascites, on [1-8] she received a large volume therapeutic paracentesis of 9 L and received albumin. On [1-11], a repeat paracentesis was performed with removal of 5L. She became increasingly encephalopathic, with worsening liver and kidney disease, so the medical team transferred the patient to the MICU for further evaluation. The patient was monitored in the ICU, a head CT was negative, and she was transferred to the Liver-Kidney ([Doctor Last Name 3271]-[Doctor Last Name 679]) service. On the ET service, the patient was noted to have worsening liver and kidney failure, and ongoing goals of care discussions were had with the patient and her two sons, [Name (NI) 33281] and [Name (NI) ]. Based on her multiple co-morbidities, the patient was not felt to be a transplant candidate. After multiple family meetings, it was decided to send the patient to rehab, before discharging home with services. She will follow-up with her liver specialist, and if her kidney function continues to improve, her diuretics could potentially be restarted to reduce ascites. In the interim, 3L paracenteses can be performed as needed for comfort. Though the patient received albumin early in her hospital course, her preference, based on her religion (Jehovah's Witness) is NOT to receive any transfusions or blood products. However, if the patient requires increasing paracenteses, the patient and her family may consider large volume paracentesis with subsequent albumin treatment. . # Encephalopathy: Acute on chronic hepatic encephalopathy. During this admission, the patient had waxing and [Doctor Last Name 688] mental status. Occasionally AAOx3, very alert, very insightful, othertimes AAO x1-2, more tired, less alert. Most likely this was related to a combination of hepatic encephalopathy and uremia. She needs high doses of lactulose and rifaximin to help prevent worsening encephalopathy. For the 5-7 days prior to discharge, her mental status was much improved, and she was bright, clear thinking, and pleasant. . # Acute on Chronic Renal Failure: Her renal failure (peak Cr 5.8) was suspected to be due to a combination of ATN and HRS, likely from large volume paracenteses and aggressive blood pressure control leading to hypoperfusion of the kidneys. Work-up included cryoglobulins (negative) and a renal consult. Her ACE-I and diuretics were stopped, and her pressures were kept largely in the 150-180 systolic range. There was much discussion regarding the potential for dialysis, and the patient frequently changed her mind on this point. She generally expressed her desire to NOT have HD, however when speaking with her sons she would often change her mind. In the end, the patient's renal function improved, and she did not have any indication for consideration of dialysis at discharge. . # Hyponatremia: No symptoms, likely related to liver failure. Stable at the time of discharge, on a PO fluid restriction. . # Hypertension: On admission, had systolic pressures in the 220s range. There was a period of time where her systolic pressures were in the 120s early in her course, and this likely contributed to ATN/HRS and worsening renal failure. Upon transfer to the Liver service, her pressures were allowed to remain in the systolic 140s-180s range, to prevent further renal hypoperfusion. Lisinopril was held, amlodipine was continued, and metoprolol was restarted . # Fevers/leukocytosis: At several points in her hospital stay, the patient developed low grade temperatures and mildly elevated leukocytosis. No infectious source was pinpointed, and the patient improved without intervention. . # Type II DM: The patient's appetite was decreasing, and a nutrition consult was called. Her blood glucose was low on multiple dates, and her insulin was greatly reduced. She was tolerating PO better at the time of discharge, and she will need close follow-up and monitoring of her finger sticks, with further titration of her insulin. . # Seizure disorder: The patient has occasional myoclonus, which is worse when more encephalopathic. Neurology was consulted, and her dilantin was held while supratherapeutic. Her levels were therapeutic upon discharge on 300mg dilantin at night. The neurology consult team did not feel further work-up was warranted (she had a head CT and EEG early in her hospital course). . # Cirrhosis: Likely related to hepatitis C. Her cirrhosis has been complicated by ascites, encephalopathy and varices (grade I in [2101]). Not a transplant candidate due to multiple medical co-morbidities. See above discussion. . # Anemia: Chronic. Likely anemia of chronic disease. Stable hematocrit in the 22-28 range for much of this admission. No Blood transfusions as patient is Jehovah's Witness and this is currently against her wishes. Could consider EPO in the future as an outpatient as other options are limited. . # CVA: Patient had a CVA in the past, and developed recrudescence of this as her liver decompensated. Aggressive physical therapy was needed upon discharge to rehab given her left sided deficits and her deconditioning from this hospitalization. . # H/o breast cancer: Stopped letrozole. This medication can be restarted if the family desires, however given her decompensated liver disease, it was stopped during this admission. . #CODE: DNR/DNI, confirmed with healthcare proxy on [2105-1-21] #CONTACTS: Jehovah's witness advocate, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 33282] [Telephone/Fax (1) 33283] Brother [Name (NI) ] [Name (NI) ] (Church): [Telephone/Fax (1) 33284] Son, [Name (NI) ]: [Telephone/Fax (1) 33285]; Son, [Name (NI) 33281]: [Telephone/Fax (1) 33286] . ============= TRANSITIONAL ISSUES: -Pt was DNR/DNI during much of this admission after a discussion with her son and healthcare proxy [Name (NI) 33281] -For ascites, can consider restarting diuretics if renal function continues to improve. 3L paracentesis as needed for tense, symptomatic ascites (do not give albumin unless discussed with family first; patient is Jehovah's Witness and may not accept albumin) -Monitoring of mental status, with adequate lactulose for [2-16] bowel movements daily -Close monitoring of blood sugars is necessary, as is titration of her insulin. -Consider restarting letrozole if patient and her family desires this -OMR order for therapeutic paracentesis (3L) placed, hospital will contact to coordinate setting this up with appointment scheduled with Dr. [Last Name (STitle) ]. . ##Given her decompensated liver failure, the patient's prognosis is poor, and the patient and her family demonstrated a good understanding of this during this admission. On potential future admissions, would consider a goals of care discussion with the patient and her healthcare proxy and son, [Name (NI) 33281], if invasive procedures are being considered. Medications on Admission: 1. AMLODIPINE 5 mg PO daily (only dose uncertain) 2. DULOXETINE 60 mg PO daily 3. GABAPENTIN 600 mg PO TID 4. INSULIN NPH/Aspart 70/30 48 units SC QAM and 25 units SC QPM 5. INSULIN LISPRO 2 units starting for FSG of 250 6. LETROZOLE 2.5 mg PO daily 7. LISINOPRIL 20 mg PO daily 8. Metoclopramide 5 mg PO QIDAC 9. METOPROLOL SUCCINATE 25 mg PO BID 10. PHENYTOIN SODIUM EXTENDED 300 mg PO QHS 11. ASPIRIN 81 mg PO daily 12. Docusate sodium (dosage uncertain, son not sure if taking) 13. Folic acid 1 mg PO daily 14. Multivitamin 1 tab PO daily 15. Furosemide 40 mg PO daily Discharge Medications: 1. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO once a day. 3. phenytoin sodium extended 100 mg Capsule Sig: Three (3) Capsule PO QHS (once a day (at bedtime)). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. lactulose 10 gram/15 mL (15 mL) Solution Sig: Thirty (30) mL PO four times a day: Increase or decrease for goal [2-16] bowel movements daily, confusion level. . 10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day. 11. trazodone 50 mg Tablet Sig: Half-one Tablet PO at bedtime as needed for insomnia. 12. Ultram 50 mg Tablet Sig: Half Tablet PO every six (6) hours as needed for pain: Do not give if patient is sleepy or confused. 13. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous with breakfast. 14. NPH insulin human recomb 100 unit/mL Suspension Sig: Six (6) units Subcutaneous with dinner. 15. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous with meals, before bed (QID): See attached scale. 16. Walker with Chair and Breaks Misc Sig: One (1) unit once a day: Rollator. Disp:1 unit Refills:2 17. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 18. Outpatient Lab Work Weekly CBC/Diff, AST, ALT, TBili, Alk phos, full chemistry panel, with results sent to Dr. [Last Name (STitle) ] at fax # [Telephone/Fax (1) 4400] Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Cirrhosis Chronic kidney disease Hypertension Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You came to the hospital because of abdominal swelling which was found to be due to accumulation of fluid (ascites) in your abdomen due to cirrhosis (severe scarring of your liver that develops over time). Your kidney function also worsened, which can be seen with severe liver disease, and may have also been due to low blood pressures during the time you spent in the hospital. Your kidney function was improving at the time of discharge, although it is unlikely that your kidney function will return back to normal. You should make sure to follow-up at the appointments we have made for you below. You should talk with your doctors about whether to re-start diuretics (water pills) to help remove fluid. We are not giving you these medicines at this time because pills can hurt your kidneys. . Please note the following medication changes: - STOP gabapentin, lisinopril, furosemide - DECREASE metoprolol succinate to 50mg once daily dosing - DECREASE insulin to NPH 20 units in the morning, 6 units at dinner - START Humalog insulin sliding scale (included) - START rifaximin twice daily, lactulose 30mL four times daily (take this medication so that you have at least [2-16] bowel movements daily, take an extra dose if confused) - START trazodone before bed as needed for insomnia - START tramadol as needed for pain - Consider restarting Femara (breast cancer medication) after discussing this with your family and outpatient physicians Followup Instructions: You have an order in the computer system for a paracentesis. The hospital will contact you at rehab about setting this appointment up at the time of your follow-up with Dr. [Last Name (STitle) ] . Department: LIVER CENTER When: THURSDAY [2105-2-12] at 8:15 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2105-2-4] ICD9 Codes: 5849, 3572, 5715, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5045 }	Medical Text: Admission Date: [2182-9-3] Discharge Date: [2182-9-10] Date of Birth: [2101-11-23] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1271] Chief Complaint: ataxia and dizziness Major Surgical or Invasive Procedure: Right Craniotomy for SDH evacuation ([2182-9-4]), no complications History of Present Illness: Patient is a very poor historian and largely uncooperative and slightly demented. Patient c/o long standing dizzyness, but reportidly has been increasingly ataxic with falls [Name6 (MD) ] home RN. Past Medical History: DM (full PMH not known, and patient is unable to relate) Social History: Patient reports he lives alone, visiting nurse: [Doctor First Name ] [Telephone/Fax (1) 87229] HCP is a nephew who lives in [State 8842]. (photocopied HCP form is in chart)[Name (NI) 3065] [Name (NI) 43672] [Telephone/Fax (3) 87230] Mr. W's friend [Name (NI) 3979] [Name (NI) ] and his wife have visited him several times here in the hospital. They live nearby [Telephone/Fax (1) 87231], very helpful, concerned. Family History: NC Physical Exam: Gen: WD/WN, comfortable, NAD. HEENT: Pupils:3 to 2 EOMs: intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, agitated at times. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3to2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [6-5] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: Left FTN dysmetria Pertinent Results: * Initial CT Head on presentation [2182-9-2]: FINDINGS: There is a large mixed-density loculated collection layering over the right frontoparietal convexity measuring up to 20 mm in greatest thickness. Mass effect on the subjacent sulci is noted. In addition, there is 9 mm of leftward shift of the normally midline structures. Along the inferior aspect of the right frontal convexity, there is a hyperdense component (67 [Doctor Last Name ]) measuring 4 mm which likely represents a superimposed more acute hemorrhage. Overall, this collection is unchanged over the roughly six hour interval, and no new hemorrhage is identified. There is no evidence of entrapment of the left ventricle. Basilar cisterns are preserved and the fourth ventricle is patent. No major vascular territorial infarction. Prominent hypodense foci in the right parieto-occipital region and occipital pole likely represent established encephalomalacia related to previous infarcts, perhaps embolic. In the left cerebral hemisphere, there is diffuse prominence of the sulci consistent with parenchymal volume loss, age-appropriate. Mild mucosal thickening in the left maxillary sinus. The remainder of visualized paranasal sinuses and mastoid air cells are well aerated. No osseous abnormality is identified. Dense calcification of the vertebral and cavernous carotid arteries is noted. IMPRESSION: No overall short-interval change in large mixed-density collection overlying the right frontoparietal convexity, compatible with acute superimposed on subacute-to-predominantly chronic subdural hematoma causing subfalcine herniation. No new hemorrhage compared to study performed six hours earlier. * POST-operative NCHCT [2182-9-5] (after SDH evacuation [9-4]): FIDNINGS: There has been interval right frontal craniotomy and evacuation of a mixed density subdural collection. There is a large amount of expected post-surgical pneumocephalus with mass effect on the frontal lobes. There is a linear hyperdensity in the right frontal extra-axial space measuring 4 mm in greatest width and consistent with acute blood products in the surgical bed. Bifrontal extra-axial isodense collections remain measuring up to 11 mm on the right, compatible with chronic subdural or CSF hygromas. There is interval decreased shift of the normally midline structures leftward which now measures 5 mm compared to 9 mm previously. Basilar cisterns are preserved. Mucosal thickening in the left maxillary sinus and bilateral ethmoid sinuses is noted. Remainder of the visualized paranasal sinuses and mastoid air cells are well aerated. Calcification of the vertebral and cavernous carotid arteries is again noted. IMPRESSION: Interval right frontal craniotomy with expected post-surgical change. 4 mm linear rim of hyperdensity in the surgical bed consistent with acute blood products. Decreased shift of the normally midline structures leftward now measuring 5 mm compared to 9 mm previously. NOTE ON ATTENDING REVIEW: Right parietal and occipital hypodense areas with fluid attenuation representing evolution of the previously noted infarct/insult is again visualized and unchanged.( se 2, im13). Moderate amount of pneumocephalus with some mass effect on the frontal lobes. Attention on close follow up to exclude tension pneumocephalus. Atherosclerotic vascular calcifications are noted in the distal vertebral and internal carotid arteries. * ECG [2182-9-6]: Probable ectopic atrial rhythm. Left axis deviation, likely due to left anterior fascicular block. Compared to the previous tracing of [2182-9-4] the rhythm appears to be coming from a non-sinus origin on the current tracing. The other findings are similar. Rate Intervals: PR QRS QT/QTc axes:P QRS T 74 110 114 394/[Telephone/Fax (2) 87232] * CXR (pre-op [2182-9-4]): Small left retrocardiac atelectasis. Mild cardiomegaly. Brief Hospital Course: Pt was admitted after c/o dizzyness and ataxia. CT imaging revealed right sided SDH. The pt was unable to consent for himself and family was contact[Name (NI) ]. [Name2 (NI) ] was brought to the OR on [2182-9-5]. His post operative imaging was stable. His postoperative course was uneventful except for occassional sundowning that responded well to seroquel. Geriatrics was consulted for assistance with aggitation and polypharmacy. Their recommendations were followed. They recommended also that the pt is not to drive unless cleared by the DriveWise program. He advanced in his diet and activity. Social work and PT were consulted. He was deemed appropriate for subacute rehab. Medications on Admission: Antivert, metformin, Glucophage Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Oxycodone 5 mg Tablet Sig: .5 tab Tablet PO Q4H (every 4 hours) as needed for pain. 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours): taper to off as clinically indicated. 5. Cyanocobalamin (Vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Life Care Center of [Location 15289] Discharge Diagnosis: Right Subdural hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. / YOU NEED TO BE [Street Address(1) 87233] WISE / IT IS RECOMMENDED THAT YOU DO NOT DRIVE UNLESS YOU ARE CLEARED TO DO SO. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in 4 weeks. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2182-10-9] 1:15 Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 1669] Date/Time:[2182-10-9] 1:30 PLEASE SEE YOUR PRIMARY CARE PHYSICIAN AND UPDATE HIM/HER REGARDING YOUR HOSPITALIZATION. IT HAS BEEN ADVISED BY THE GERIATRIC SERVICE THAT YOU DO NOT DRIVE UNLESS YOU ARE CLEARED TO DO SO. YOU CAN [Street Address(1) 87234] WISE PROGRAM AT [Telephone/Fax (1) ] [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2182-9-10] ICD9 Codes: 2930, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5046 }	Medical Text: Admission Date: [2138-3-14] Discharge Date: [2138-3-17] Date of Birth: Sex: Service: CHIEF COMPLAINT: Headache. HISTORY OF PRESENT ILLNESS: The patient is a 63 year old man who was involved in a motor vehicle accident 1 week prior to presentation, who then presented to the emergency room with a persistent headache. He also noted a visual haze on the left side. He denied any double or blurry vision. He did have a pressure sensation in the right eye. He went to an outside hospital and had an MRI done, which did show a subdural hematoma and he was transferred to the [Hospital1 190]. MEDICATIONS: Meds upon admission were Plavix, Toprol, Diovan, and Lexapro. ALLERGIES: He had no known drug allergies. PAST MEDICAL HISTORY: Remarkable for atrial fibrillation, mitral valve prolapse, urinary tract infection for the 2 weeks prior to admission, and question of hypertension. SOCIAL HISTORY: Shows he was a non-smoker and drank alcohol socially. PHYSICAL EXAMINATION: Vitals are 98.2, 71, 191/82, 97% on room air. The patient was in no apparent distress. Head showed no signs of trauma. Neck was supple. Chest was clear to auscultation bilaterally. Heart showed a regular rate and rhythm. Abdomen was soft and nontender. Extremities were warm without edema. Neuro exam: He was awake, alert and oriented x3. Language was fluent. There was no dysarthria. Pupils were equal, round and reactive to light and accommodation. Extraocular movements were full. Visual fields were full to confrontation. There was no nystagmus. Face was symmetrical. Tongue was midline. Motor exam showed normal bulk and tone and was [4-10] throughout. Sensory exam was intact to light touch throughout. Reflexes were 2+ bilaterally at biceps, triceps, knees and ankles. Toes were downgoing. Coordination left finger to nose showed some mild dysmetria. Head CT that was done in the emergency room did show a right frontal convexity with a sub-falcine subdural hematoma. HOSPITAL COURSE: The patient was admitted to neurosurgery to the intensive care unit for close neurological monitoring with q.1h neurochecks. His blood pressure was kept less than 140 systolic. He continued to be neurologically intact. He had a repeat CAT scan the next day which was stable. He was seen by physical therapy, who felt that he was doing fine and did not need any services other than perhaps future follow up in outpatient physical therapy. His headache did improve. He was discharged to home on [2138-3-17]. He was scheduled to follow up in 2 weeks with Dr. [Last Name (STitle) 1327] with head CT. He was advised not to restart Plavix. He was also advised to follow up with his cardiologist. DISCHARGE MEDICATIONS: 1. Valsartan 80 mg 1 po daily. 2. Percocet 5/325 mg 1 to 2 tablets q.4-6h p.r.n. 3. Famotidine 20 mg 1 tablet po twice a day. 4. Metoprolol 50 mg sustained release, 1 tablet twice a day. 5. Escitalopram oxalate 10 mg 1 po daily. 6. Colace 100 mg 1 po twice a day. 7. He has a prescription for outpatient physical therapy. DISCHARGE CONDITION: Neurologically stable. [Name6 (MD) ] [Last Name (NamePattern4) ], [MD Number(1) 12001] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2138-6-4] 11:18:33 T: [2138-6-4] 11:43:28 Job#: [Job Number 12371] ICD9 Codes: 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5047 }	Medical Text: Admission Date: [2198-5-16] Discharge Date: [2198-5-22] Date of Birth: [2134-1-12] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Stent re-occlusion Major Surgical or Invasive Procedure: 1)Two vessel coronary artery bypass grafting utilizing saphenous vein graft to left anterior descending and saphenous vein graft to obtuse marginal 2)Re-exploration of bleeding History of Present Illness: This is a 64 year old female with known coronary disease who has undergone multiple PCI/stent procedures over the past year. Repeat cardiac catheterization in [2198-4-18] revealed a 40-50% left main lesion; 90% in-stent stenosis in the LAD; 60-70% in-stent stenosis in the circumflex and a normal right coronary artery. Her ejection fraction was normal, estimted at 60%. Based on the above results, she was referred for surgical coronary revascularization. Past Medical History: Non-small cell lung cancer - s/p left upper lobe resection in [2190] followed by chemotherapy and radiation, Thyroid cancer - s/p thyroidectomy in [2182] now hypothyroid, Hypertension, Elevated cholesterol, Former smoker, Hypopharyngeal soft tissue mass(followed at [Hospital3 328]), varicose veins - s/p left leg vein stripping Social History: Former smoker - quit tobacco 40 years ago. Denies excessive ETOH. Family History: Non contributory Physical Exam: Afebrile, Vital signs stable General: well developed female in no acute distress HEENT: oropharynx benign Neck: supple, no JVD Chest: regular rate and rhythm, normal s1s2 without murmur or rub Lungs: clear bilaterally Abdomen: benign Ext: warm, no edema Neuro: grossly intact; no focal deficits Pertinent Results: [2198-5-20] 04:20AM BLOOD WBC-6.7 RBC-3.51* Hgb-10.6* Hct-30.7* MCV-87 MCH-30.1 MCHC-34.5 RDW-14.8 Plt Ct-132* [2198-5-20] 04:20AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-137 K-3.9 Cl-101 HCO3-29 AnGap-11 [2198-5-20] 01:30PM BLOOD TSH-27.8* [2198-5-21] 09:44AM BLOOD T4-3.1* T3-36* [2198-5-18] 04:07PM BLOOD Cortsol-19.6 Brief Hospital Course: Mrs. [Known lastname 49957] [Known lastname ] was admitted and underwent two vessel coronary artery bypass grafting(vein graft to left anterior descending and vein graft to obtuse marginal) by Dr. [Last Name (STitle) 1290]. Following the operation, she was brought to the CSRU. On postoperative day one, she developed hypotension with increasing pressor requirements. Echo performed at appr.16 hours post-op showed signs of tamponade and was taken back to the OR emergently for re- exploration of the mediastinum. A large amount of clot was evacuated, both pleura were irrigated and clot also removed, and all surgical sites were inspected. There remained only a small amount of oozing from the OM graft with no active bleeding. POD #2- on levophed drip at 0.08 and improving. Swan removed , in sinus tachycardia, received 2 units of PRBCs, and lasix diuresis was started.HCT rose to 33 post- transfusions.Levophed was weaned, and the pt. was transferred out to the floor. Started working with PT on ambulation. O2 sat 95% on room air.Alert and oriented. Continued to improive and increase ambulation. Pacing wires pulled on POD #6, chest tubes had been removed the day prior. Treated with benadryl and [Doctor Last Name ] lotion for skin itchiness.Low dose beta blockade decreased HR to 95 in sinus and synthroid had been restarted.Had good pain control with percocet.On day of discharge, BP 100/44, o2 sat 96% RA, T 98.3, T4 3.1, T3 36, TSH done on [5-20] 27.8. Discharged in good condition with specific instructions to follow-up with PCP for thyroid condition in the next week. Medications on Admission: Aspirin 325 qd, Plavix 75 qd, Toprol 25 qd, Lipitor 80 qd, Synthroid, Vitamin D Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:120 Capsule, Sustained Release(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:14 Tablet(s) Refills:0 8. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Coronary artery disease - s/p CABG X2 s/p re-exploration for mediastinal bleeding hypothyroidism lung CA with XRT s/p left leg vein stripping hypertension elev. cholesterol thyroid cancer with thyroidectomy Discharge Condition: Good, stable Discharge Instructions: You should seek medical attention if you have increasing chest pain, drainage from your wound, palpitation, lightheadedness or any other concering sign. You need to see your cardiologist in the next 1-2 weeks. [Last Name (NamePattern4) 2138]p Instructions: See your cardiologist in the next week or two. See your primary care doctor in the next week as well to have your thyroid medication followed. See Dr. [Last Name (Prefixes) ] in [1-19] weeks. Call his office for an appointment [Telephone/Fax (1) 1504] Completed by:[2198-6-13] ICD9 Codes: 412, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5048 }	Medical Text: Admission Date: [2101-3-9] Discharge Date: [2101-3-16] Date of Birth: [2028-10-27] Sex: F Service: SURGERY Allergies: Penicillins / Nickel / Morphine Attending:[First Name3 (LF) 1] Chief Complaint: Obstructing recurrent Crohn disease, status post former ileocolectomy. Major Surgical or Invasive Procedure: Exploratory laparotomy, extensive lysis of adhesions, resection of prior anastomosis and pelvic phlegmon, and reanastomosis of neo terminal ileum to colon. History of Present Illness: This patient had previously undergone surgery for Crohn disease many years ago followed by an incisional hernia and repair with mesh. She presented with a 17-cm segment of diseased bowel distally which was causing recurrent obstruction. She was warned that because she had so much bowel removed on her first occasion, she might, indeed,end up with a short bowel syndrome at this operation; but every attempt would be made for conservative surgery. Past Medical History: -Crohn's disease, s/p ileal resection, dx ~[2080] -Hx of lymphoma, tx with resection, dx ~[2080], recent PET with no recurrence of disease -Colon CA, dx [2084], left sided, s/p resection -left breast cancer s/p lumpectomy and radiation tx -colonoscopy and small bowel follow through with 2 strictured areas in distal ileum, at the ileocolic anastomosis and one proximal to it -upper endocopy with gastritis -CAD, stent placed [2094] -CVA [2096] with no residual defects -DMII -HTN -Hysterectomy and bilateral oophorectomy [2057] with ovarian cyst -Ventral hernia repaired with mesh -Anemia Social History: She does not drink or currently smoke but did smoke for over 35 years but gave it up several years ago. She is married with healthy children and is retired from working at the [Company 94443]. Family History: Her mother died at 82 of heart disease. Her father died at 60 of an MI. Two brothers are deceased, one from liposarcoma and one from lung cancer and she has one sister who is alive and well. Physical Exam: Vitals: T: 98.3, BP: 1157/78 HR: 66, RR:20,O2 sat98% room air NEURO:pleasant alert and oriented x3 GEN: no acute distress HEENT: PERRL, sclera anicteric, MMM NECK: No JVD, visible carotid pulsations, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, normal S1/S2, III/VI holosystolic murmur heard best over LSB, no rubs or gallops PULM: Lungs CTA anteriorly and laterally, no W/R/R, Abdomen:non distended,nontender, positive bowel sounds Incision vertical midline incision clean, dry, intact with staples no erythema, no edema EXT: No C/C/E, 2+ DP and radial pulses SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2101-3-15] 06:51AM BLOOD WBC-12.3* RBC-3.27* Hgb-9.8* Hct-29.1* MCV-89 MCH-29.9 MCHC-33.7 RDW-13.4 Plt Ct-274 [2101-3-14] 06:30AM BLOOD WBC-9.3 RBC-3.27* Hgb-9.8* Hct-29.2* MCV-89 MCH-29.8 MCHC-33.5 RDW-13.4 Plt Ct-231 [2101-3-9] 08:09PM BLOOD WBC-8.1 RBC-3.08* Hgb-9.7* Hct-27.8* MCV-90 MCH-31.3 MCHC-34.8 RDW-13.3 Plt Ct-212 [2101-3-10] 03:14AM BLOOD Neuts-62 Bands-27* Lymphs-6* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2101-3-10] 03:14AM BLOOD PT-13.7* PTT-20.6* INR(PT)-1.2* [2101-3-9] 08:09PM BLOOD PT-15.1* PTT-21.3* INR(PT)-1.3* [2101-3-16] 06:30AM BLOOD Glucose-124* UreaN-9 Creat-0.8 Na-135 K-3.1* Cl-100 HCO3-27 AnGap-11 [2101-3-15] 06:51AM BLOOD Glucose-129* UreaN-8 Creat-0.8 Na-138 K-3.1* Cl-101 HCO3-27 AnGap-13 [2101-3-9] 08:09PM BLOOD Glucose-193* UreaN-20 Creat-1.0 Na-141 K-3.5 Cl-109* HCO3-21* AnGap-15 [2101-3-10] 03:14AM BLOOD ALT-22 AST-28 AlkPhos-32* TotBili-0.6 [2101-3-9] 08:09PM BLOOD CK(CPK)-52 [2101-3-16] 06:30AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.3 [2101-3-15] 06:51AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.9 [2101-3-9] 08:09PM BLOOD Calcium-7.0* Phos-4.1 Mg-1.5* [2101-3-9] 09:44PM BLOOD Type-ART pO2-102 pCO2-42 pH-7.32* calTCO2-23 Base XS--4 Brief Hospital Course: This is a 72 year-old female with a history of severe Crohn's disease and ileocolic stricture who was admitted to the [Hospital Unit Name 153] s/p ex-lap and bowel resection with extensive lysis of adhesions. Patient required intubation and sedation. # Ventilation s/p surgery: Patient was not extubated in the OR and arrived on Assist Control upon transfer to the FIU. Initial ABG showed a respiratory acidosis, resulting in a rate increase with Vt of 450. She has a >35 year smoking history, but does not have any reported baseline lung disease. CXR does not show any infiltrates with only a possible small right pleural effusion (slight blunting of the right CPA). Once sedation began to wore off and she was overbreathing the ventilator, she was taken down to pressure support. She was able to follow commands, lift her head off the pillow, and was able to cough. She passed a SBT and her RSBI was 38, prompting extubating about 5-6 hours s/p arrival to the ICU. # Metabolic acidosis: ABG showed an acidemic picture with rising lactate and dropping UOP s/p operation complicated by bowel contents contaminating the field. AG of 11. Stable pressures and creatinine steady at 1.0. We watched closely for development of sepsis and noticed decreased UOP and expected 3rd spacing. She was given LR boluses to support her UOP, which improved. Her blood pressures remained stable and she was afebrile upon transfer to the surgery floor. # Bowel resection/lysis of adhesions: She has a history of multiple previous abdominal surgeries, which made for a difficult and extensive surgery with lysis of adhesions in addition to the planned stricture resection. EBL during case was 500 cc and she received 1 unit pRBCs perioperatively with stable Hct on admission to [Hospital Unit Name 153]. Case also complicated by bowel puncture and frank stool in surgical field. She was given about 1.5L of LR and her hematocrit was monitored with no significant changes. Nasogastric tube was kept to suction, it was self discontinued and patient remained NPO. By POD 5 had return of bowel function with flatus and bowel movement and was started on clear sips and advanced to clears. On POD 6 the diet was advanced to regular and was tolerated well. # Hx of hypertension: Normotensive on transfer and did not require any pressors peri-or postoperatively. While she was NPO was started on cardioprotective IV metoprolol 5mg q6h. By postoperative day 5 was transition back to her PO antihypertensive medications. # Neuro Postoperative day [3-10] she had altered mental status and was started on Seroquel for delirium. By postoperative day 4 her mental status returned to baseline and she was lucid. # GI: On postoperative day 5 she was passing flatus and had a bowel movement. Thus was started on clear liquids and intravenous fluids were discontinued. On postoperative day 6 the diet was advanced to regular which was tolerated well. # GU: On postoperative day 4 the foley catheter was discontinued and voided spontaneously without any difficulty. # Pain: Her pain was initially controlled with Fentanyl boluses, and was transitioned to a Dilaudid PCA once she was awake enough. She was transitioned from intravenous to oral analgesia and has adequate pain control. # ID:Due to bowel puncture during procedure, she was continued on prophylactic Vancomycin, Cipro, and Flagyl for broad coverage of intra-abdominal/GI tract organisms.She is being discharged to rehabilitation center on Cipro and Flagyl for 7 days. Medications on Admission: Imdur (isosorbide mononitrate) 30mg qday Amlodipine 10mg qday Protonix 40mg [Hospital1 ] Vitamin D [Numeric Identifier 1871] MWF (?) Pentasa (mesalamine) 500 mg QID Avapro (irbesartan) 300mg qday Diphenoxylate (lomotil) 5mg [Hospital1 ] Tricor 48mg qday Plavix 75mg qday Triamterene/hydrochlorothiazide 37.5 MWF Effexor 150mg Folic acid 1mg qday Potassium 20 mEq qday ASA 81mg qday Arimidex (anastrozole) 1mg qday Metroprolol succinate 25mg qday Simvastatin 20mg qday VESIcare (solifenacin) 5mg qday Nitroglycerine p.r.n. Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. insulin lispro 100 unit/mL Solution Sig: 100/ml Subcutaneous ASDIR (AS DIRECTED). 3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMOWEFR (Monday -Wednesday-Friday). 9. mesalamine 250 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO QID (4 times a day). 10. irbesartan 150 mg Tablet Sig: Two (2) Tablet PO daily (). 11. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 12. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO QMOWEFR (Monday -Wednesday-Friday). 13. venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 21. magnesium oxide 140 mg Capsule Sig: Two (2) Capsule PO ONCE (Once) for 1 doses. 22. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 23. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 24. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days: avoid alcohol while taking medication. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Woodbriar of [Hospital 4444] Rehab & S.N. Center Discharge Diagnosis: Obstructing recurrent Crohn disease, status post former ileocolectomy. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the General Surgery Unit after your surgery. You have tolerated a regular diet and are ready to be discharged to the Rehabilitation Center. If you develop nausea, vomitting, abdominal pain or abdominal distension, or if you have increase pain not relieved by pain medication, contact Dr. [Last Name (STitle) ] office. We have started you on antibiotics which you will continue to take for 7 days. You have an abdominal incision with staples in place, the staples will be removed at your follow-up visit with Dr. [Last Name (STitle) ]. Please monitor for signs and symptoms of infection which include fever, redness, swelling, foul odor or drainage. If you develop any of these signs or symptoms contact Dr.[Last Name (STitle) ] office or go to emergency room. Please call and schedule a follow-up appointment with Dr. [Last Name (STitle) ] in [8-14] days. Followup Instructions: Dr. [Last Name (STitle) ] in [8-14] days [Telephone/Fax (1) 9] Completed by:[2101-3-16] ICD9 Codes: 2762, 2851, 2930, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5049 }	Medical Text: Admission Date: [2128-7-15] Discharge Date: [2128-7-17] Date of Birth: [2071-10-19] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male with a history of hypertension and diabetes mellitus type 2, hypercholesterolemia, who presented to his primary care physician with complaints of chronic nonproductive cough times the past seven months, coinciding with initiation of ACE inhibitor therapy. He also complained of dizziness, fatigue, and occasional diaphoresis, not related to exertion. He reports that he can walk up two flights of stairs and ride a bike without any shortness of breath, dyspnea on exertion, chest pain, chest pressure. Additionally, he denies edema, paroxysmal nocturnal dyspnea, orthopnea, syncope, presyncope. He was recently on antibiotics for cough with some relief. He had a recent admission in [2128-4-8] for a laminectomy. Patient's primary care physician ordered an exercise tolerance test/Myoview to rule out cardiac cause of his cough. He exercised 18 minutes per standard [Doctor First Name ] protocol. He had a blunted heart rate response and got 0.5 mg of atropine at 16.5 minutes. He had no complaints of chest pain. He achieved 74% maximal heart rate. Myoview imaging revealed anterior ischemia. Therefore, the patient was sent for cardiac catheterization on [2128-7-15]. Catheterization revealed severe diffuse LAD disease with proximal tandem 70% stenosis, subtotally occluded mid vessel, very small apical LAD. Left ventricular ejection fraction was preserved at 65%. He underwent successful PTCA, stenting of the LAD with two overlapping Cypher stents. Additionally, the left main coronary artery was noted to be nonobstructed. Left circumflex was nonobstructed. OM-1 was large vessel with an eccentric mid 40% stenosis. RCA showed a 50% mid stenosis. Initially, the patient tolerated coronary catheterization well. He was transferred to the holding area. He then developed episode of hypotension to BP of 70s after femoral sheath removal. He received IV fluid therapy, Integrilin was discontinued, and dopamine drip was started. He was taken to CT scan to rule out retroperitoneal hematoma. CT scan revealed a psoas hematoma. PAST MEDICAL HISTORY: 1. Diabetes mellitus x5 years. 2. Hypertension. 3. Hypercholesterolemia. 4. Gout. 5. Glaucoma. 6. History of struck by lightening in [2092]. PAST SURGICAL HISTORY: 1. Status post laminectomy 05/[2127]. 2. Status post hernia repair. 3. Status post multiple knee and shoulder surgeries. ALLERGIES: Patient reports allergies to Morphine resulting in rash, and amoxicillin resulting in diarrhea. MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 325 mg po q day. 2. Atenolol 50 mg po q day. 3. Triamterene/hydrochlorothiazide 75/50 mg po q day. 4. Glucophage 1,000 mg po bid. 5. Lisinopril 40 mg po q day. 6. Pravachol 60 mg po q day. 7. Betoptic one drop each eye [Hospital1 ]. FAMILY HISTORY: Patient reports that his mother died at age 58 from complications of congestive heart failure and diabetes. Father deceased from stroke. SOCIAL HISTORY: Patient is married. He is semiretired from sales. He denies any alcohol use. Denies illicit drug use. Reports one pack per day smoking history for many years having quit in [2111]. PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 99.0, blood pressure 113/43, pulse 70, respiratory rate 20, and oxygen saturation 98% on 4 liters O2 nasal cannula. General appearance: Well-developed, well-nourished male lying flat, denying pain, plethoric face, in no acute distress. HEENT: Normocephalic, atraumatic. Sclerae are anicteric. Mucous membranes moist. No jugular venous distention or increased jugular venous pressure noted. Carotids with normal upstroke and amplitude. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular, rate, and rhythm. S1 heart sound obscured by 3/6 systolic murmur heard best at right upper sternal border. Murmur did not radiate to carotids. No carotid, abdominal, femoral bruits. Abdomen: Obese, soft, nontender, and nondistended, positive bowel sounds, no hepatosplenomegaly. Extremities: Cool, pale, no edema noted. Groin: Ecchymotic lesion 1 x 3" noted in right groin. No masses. No oozing from catheterization site. Slightly nontender, no bruit auscultated. PERTINENT LABORATORIES, X-RAYS, AND OTHER STUDIES: Laboratories on admission showed complete blood count with white blood cells 15.0, hematocrit of 36.8, platelet count of 239. Serum chemistries showed sodium of 139, potassium 4.5, chloride 103, bicarbonate 26, BUN 23, creatinine 1.6, glucose 97. Additional electrolytes showed phosphorus 2.2, magnesium 1.5, CK 47. Exercise tolerance test/Myoview ([2128-7-14]): Showed blunted heart rate response, so patient was given 0.5 mg of atropine to increase heart rate. Myoview images revealed anterior wall ischemia. ELECTROCARDIOGRAM: Shows sinus rhythm, first degree A-V prolongation. [Street Address(2) 4793] elevations in leads V2 through V5, no left ventricular hypertrophy noted. Left atrial abnormality. Incomplete right bundle branch block. CATHETERIZATION ([2128-7-15]): Showed ejection fraction approximately 65% with normal left ventricular function. No mitral regurgitation. Left main coronary artery without significant disease. Left LAD with proximal tandem 70% stenosis, subtotally occluded mid vessel, the left circumflex with nonobstruction. OM-1 with eccentric mid 40% lesion. RCA with 50% mid lesion. LAD lesion was stented x2 with Cypher stents. CT SCAN OF THE ABDOMEN/PELVIS WITHOUT CONTRAST ([2128-7-15]): Showed moderate to large right pelvic hematoma, originating in the region of the right psoas muscle. BRIEF SUMMARY OF HOSPITAL COURSE: 1. Coronary artery disease: Patient with three vessel disease on cardiac catheterization and status post PCI with two Cypher stents placed in his left anterior descending artery. Plan was to continue aspirin, Plavix, statin, and beta blocker/ACE inhibitor, if the patient's blood pressure tolerated. Namely, the patient should be on aspirin and Plavix for nine months post-stent. As he had complications, hematoma development, Integrilin was discontinued. He was managed and monitored for symptoms of chest pain or dyspnea, and this was of concern for possible stent thrombosis. He remained chest pain free throughout the remainder of his hospital course, and cardiac enzymes were ruled out for myocardial infarction. Ventriculogram performed during coronary catheterization showed an ejection fraction of 65%. Therefore, the patient's cardiac decompensation was likely secondary to diastolic dysfunction secondary to a longstanding history of hypertension. Initially, plan was made to continue ACE inhibitor and beta blocker therapy if the patient's blood pressure tolerated. However, he arrived to the floor in need of pressor support on a dopamine drip. He was weaned off the dopamine slowly as the blood pressure tolerated, and atenolol 50 mg po q day, and Valsartan 240 mg po q day were added to his medication regimen. Please note, that the patient had been on an ACE inhibitor prior to admission, however, it was felt that the side-effects from the ACE inhibitor therapy could be contributing to his complaint of cough, and therefore an angiotensin receptor blocker was substituted in place of the ACE inhibitor. 2. Right psoas muscle hematoma: Vascular Surgery was consulted. They recommended serial hematocrit values, hemodynamic monitoring, and serial peripheral pulse checks. The patient was transfused 2 units of packed red blood cells for a drop in his hematocrit from 37 to 27. He tolerated this well. Additionally, Heparin and Integrilin were discontinued as this is felt to be contributed to bleeding complications. At time of discharge, the patient's hematocrit value had been stable for greater than 24 hours. Value at discharge was 36.3. 3. Diabetes mellitus: Patient's outpatient metformin dose was held after receiving an intravenous contrast load during cardiac catheterization, out of concern for possible acute tubular necrosis, exacerbation of renal insufficiency, and possible development of lactic acidosis. He was monitored with serial fingerstick blood glucose testing and covered on regular insulin-sliding scale. He was started on a diabetic diet. Postcatheterization, he was given Mucomyst 600 mg po bid due to his history of renal insufficiency. 4. Renal insufficiency: On admission, the patient's creatinine was elevated. It was not clear if this was his baseline or the results of intervention. It was felt that it was multifactorial given his history of hypertension and diabetes. Postcatheterization, he was hydrated aggressively with IV fluid therapy. Initially, his ACE inhibitor was held for renal production. After two days of fluid therapy, the patient's creatinine value returned to stable level of 0.9, and this was the level at the time of discharge. 5. GI: As the patient's chronic cough could be secondary to gastroesophageal reflux disease, he was started on Protonix 40 mg po q day. 6. Activity level: Prior to discharge, the patient was cleared by Physical Therapy staff, is not needed Physical Therapy services after discharge. At time of discharge, he was ambulating independently. CONDITION ON DISCHARGE: Good. Right groin hematoma stable with hematocrit stable at 36.3 at time of discharge. Cleared by Physical Therapy for discharge to home. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post catheterization, status post stent placement. 2. Right groin hematoma. 3. Heart failure, diastolic dysfunction. 4. Diabetes mellitus type 2. 5. Hypertension. 6. Hypercholesterolemia. 7. Gout. 8. Glaucoma. DISCHARGE MEDICATIONS: 1. Pravastatin 20 mg three tablets po q day. 2. Betaxolol 0.25% solution one drop each eye [Hospital1 ]. 3. Aspirin 325 mg one po q day. 4. Metformin 500 mg two po bid. 5. Clopidogrel 75 mg po q day for nine months. 6. Atenolol 50 mg one po q day. 7. Valsartan 80 mg one po q day. 8. Outpatient occupational therapy, patient with history of coronary artery disease, status post cardiac catheterization and stent placement. He is given a prescription to institute a program of outpatient cardiac rehabilitation therapy. FOLLOW-UP PLANS: Patient was told that he must make follow-up appointments with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] and with his cardiologist, Dr. [Last Name (STitle) ]. He can call [Telephone/Fax (1) 3183] to make an appointment with each of those providers. He was instructed to make an appointment within the next 1-2 weeks. Additionally, he was told to notify his primary care physician or visit an Emergency Room immediately if he experienced any chest pain, shortness of breath, dizziness, or lightheadedness, palpitations, back pain, pain in his catheterization site, or fainting. He is instructed that we had changed some of his medications. He was told to discontinue his triamterene/hydrochlorothiazide and his lisinopril. He was instructed that he was started on the new medications of valsartan 80 mg po q day and Plavix 75 mg po q day. Finally, he was told not to operate any heavy machinery, including a motor vehicle for the next one week. [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ], M.D. [MD Number(2) 2139] Dictated By:[Last Name (NamePattern1) 257] MEDQUIST36 D: [2128-7-17] 17:56 T: [2128-7-21] 09:42 JOB#: [Job Number 44223] cc:[Last Name (NamePattern4) 44224] ICD9 Codes: 4280, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5050 }	Medical Text: Admission Date: [2153-12-19] Discharge Date: [2153-12-22] Date of Birth: [2085-7-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac cath [12-19] s/p PCI to LAD History of Present Illness: 68 yo male with Parkinson's disease and no known CAD presented to outside hospital with acute chest pain. Pt states that around 2am, he developed substernal chest pain with associated SOB and diaphoresis while picking up granddaughter. [Name (NI) ] nausea, vomiting, radiation. Pain persisted and her called 911. Arrived at OSH at 3am, where he was hemodynamically stable with EKG that showed 2-4mm ST elevations in V2-5 and 1/avl with reciprocal inferior depressions. No cardiac enzymes. He was given asa, IV lopressor, and heparin. Started on nitro gtt, given MSO4. Transferred here to cath lab. Cath demonstrated proximal occlusion of LAD, intervened with 2 cypher stents with no residual stenoses. R heart cathw ith mildly elevated filling pressures. (RA 19, RV 45/17, PA 45/26, wedge 25 and cardiac indez 2.16. Received IV heparin, integrillin, 10 I lasix, nitro gtt, and plavix 300. Transferred to CCU for further mgmt. Past Medical History: cataracts Parkinson's disease x 2 years Social History: Lives in trailer with wife. quit tobacco 50 years ago; only smoked for a few years. Denies etoh, drugs Family History: No hx of CAD Physical Exam: VS: t98, p81, 144/85, rr18, 98% on 2L Gen: elderly male lying on back, comfortable, NAD CVS: soft heart sounds, RRR, nl s1, s2, no m/g/r Lungs: CTAB no c/w/r Abd: soft, NT, ND, +BS Groin site: no hematoma, no bruits Ext: no edema bilatearlly, 2+DP Pertinent Results: [2153-12-19] 05:30AM WBC-10.6 RBC-4.81 HGB-14.6 HCT-42.1 MCV-88 MCH-30.3 MCHC-34.6 RDW-12.7 [2153-12-19] 05:30AM GLUCOSE-136* UREA N-18 CREAT-0.8 SODIUM-137 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-10 [2153-12-19] 05:32AM TYPE-ART PO2-102 PCO2-49* PH-7.31* TOTAL CO2-26 BASE XS--2 COMMENTS-4L NP [2153-12-19] 05:30AM PT-18.0* PTT-150* INR(PT)-2.0 [2153-12-19] 04:42AM HGB-15.9 calcHCT-48 O2 SAT-98 . EKG: Baseline artifact. Sinus rhythm @79. QS configuration in leads VI-V2 - probable anteroseptal myocardial infarction with ST-T wave configuration suggesting acute/recent/in evolution process. Clinical correlation is suggested. No previous tracing available for comparison. . CXR: no chf, infiltrate . Cath: FINAL DIAGNOSIS: 1. Severe one vessel coronary artery disease. 2. Moderately elevated right sided filling pressures. 3. Moderately elevated left sided filling pressures. 4. Successful PCI of the LAD. . Echo: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the distal half of the septum, mid anterior wall and apex. The distal anterior and lateral walls are hypokinetic. No left ventricular aneurysm is seen. . No masses or thrombi are seen in the left ventricle. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid LAD lesion). Mild mitral regurgitation. Brief Hospital Course: 1. CAD: Pt is s/p acute anterior STEMI with peak CK of 1349. Pt was started on ASA, Lipitor 80, Plavix. Integrillin was not used during cardiac cath [2-26] recent cataract surgery. However, after ophtho stated that anticoagulation was okay, pt was started on heparin. Pt was started on beta-blocker and ACE which were tirated up. . 2. Pump: Pt was found to EF of 35% without aneurysm or thrombus. Initially pt was slightly volume overloaded with elevated filling pressures in cath lab. Fluid goal was even to slightly negative. Pt was continued on heparin for depressed EF. Coumadin was started with heparin bridge. INR on discharge is 1.5. . 3. Rhythm: Stable without any issues. . 4. s/p cataract surgery: Stable without issues. Pt was told to follow-up with outpatient ophthamologist. . 5. Parkinson's disease: Stable. Pt's only home meds is coenzyme Q. Pt recently discontinued Vitamin E. Pt was told to follow up with outpatient neurologist for further evaluation of Parkinson's disease. Medications on Admission: coenzyme Q Vitamin E Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:3 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:3 6. Diclofenac Sodium 0.1 % Drops Sig: One (1) Ophthalmic qid (). 7. Econopred Plus 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 8. Vigamox 0.5 % Drops Sig: One (1) Drop Ophthalmic QID (4 times a day). 9. Outpatient Lab Work prescription for INR on [12-25] - have results faxed to PCP. goal INR is 2.0 10. Outpatient Lab Work prescription for lab work on [12-26] and have results faxed to PCP 11. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:3 Discharge Disposition: Home Discharge Diagnosis: anterior ST elevation MI s/p PCI/stent to LAD stable CHF stable Parkinsons cataracts - s/p surgery [12-18] Discharge Condition: stable Discharge Instructions: Call your PCP if you experience chest pain or shortness of breath. If you have symptoms like before, call 911 to take you to the ER. Take all your medications as directed. Never stop taking the Plavix. Followup Instructions: You need to call your PCP on [Name9 (PRE) 766], [12-24]. Go to your PCP's office on Tuesday [12-25] to have your blood drawn to check your INR. The result will go to your PCP and he will change your coumadin dose if needed. Make sure you have an appointment with your PCP [Last Name (NamePattern4) ] 1 week. Make an appoitnemnt with a cardiologist within 1 month. You may call Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7047] at ([Telephone/Fax (1) 16005]. Alternatively, you may call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 10548] for appt in several weeks. ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5051 }	Medical Text: Admission Date: [2178-10-9] Discharge Date: [2178-10-14] Date of Birth: [2141-10-11] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6743] Chief Complaint: CC:[CC Contact Info 95926] Major Surgical or Invasive Procedure: Total Abdominal Hysterectomy Bilateral salpingo-oophorectomy Appendectomy Cystoscopy Lysis of Adhesions History of Present Illness: HPI: Ms. [Known lastname 1661] is a 36 y/o F with PMH of recent ongoing abdominal pain and prior endometriomas who presents to the [Hospital Unit Name 153] following surgical exploration with 1750 cc of blood loss. Per prior OMR notes, the patient has multiple recent primary care and ED visits/admissions due to ongoing abdominal pain which began in mid-[2178-9-2]. At that time, the patient presented to the emergency room and was found to have bilateral multiloculated cysts in the adnexae. At that time, she also had a leukocytosis and left-shift; she was discharged home to follow up with her gynecologist. She was subsequently admitted to the medical service from [2093-9-20] for abdominal pain and transient transaminitis which was attributed to a passed gallstone. She was treated during this admission for presumed PID with one dose of ceftriaxone and a course of doxycycline; GC/Chlamydia cultures were negative at that time. She was admitted a second time from [2102-9-26] for abdominal pain; she was treated with IV antibiotics for a short time for presumed PO antibiotic failure. Infectious workup (including TTE) was negative at that time. She was not discharged home on any antibiotics. . Apparently, her abdominal pain persisted throughout this time and she presented again to the emergency room on [10-8]. Repeat CT scanning demonstrated stable appearance of the multiloculated cystic mass with new fat stranding and fluid in the R paracolic gutter. She was admitted to the Gynecology team, and given her known intraabdominal pathology with fever and leukocytosis, the patient was taken to the OR for exploration earlier this evening. She underwent supracervical hysterectomy, bilateral salpingoopherectomy, appendectomy, lysis of adhesions, and cystoscopy. Her surgery was complicated by estimated blood loss of 1750 cc; she was transfused 2 U PRBCs intraoperatively, and her immediate post-transfusion Hct was 32 (from ABG). . On arrival to the [Hospital Unit Name 153], the patient is drowsy following her procedure. Per anesthesia notes, the patient received 250 mcg fentanyl, 17 mg morphine, 2 mg midazolam, and 200 mg propofol in the OR. At this time, the patient is pointing to her abdomen and indicating that she is having pain. She denies difficulty breathing or pain elsewhere. . Past Medical History: PMH: Endometriosis History of past chlamydia infection History of polycystic ovaries Social History: . SH (per prior notes): Lives with 2 sons (16, 14). Sexually active with 2 male partners, does not consistently use barrier protection. Has [2-3] alcoholic beverages per month. Denies illicits, tobacco. Family History: . Family History (per prior notes): Patient has limited knowledge. Mother with hypertension, asthma. Father died at 56 of "natural causes". Older brother with diabetes. Physical Exam: PE: T: 98.1 BP: 133/70 HR: 83 RR: O2 100% on face mask (half on) Gen: drowsy middle-aged female who appears in pain HEENT: MMM, OP clear NECK: Supple, JVD < 10 cm. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [Last Name (un) 549] appreciated. LUNGS: clear to auscultation anteriorly, no wheeze or crackles ABD: no bowel sounds auscultated, midline abdominal incision with covering bandage, minimal serosanguinous drainage at inferior aspect, abdomen tender to minimal palpation diffusely EXT: warm and well perfused, DP pulses 2+ bilaterally, SCDs in place SKIN: No rashes/lesions, ecchymoses. NEURO: face symmetric, moving upper extremities without difficulty, Gait assessment deferred PSYCH: Nodding appropriately to answer questions. Brief Hospital Course: A/P: This is a 36 y/o F s/p supracervical hysterectomy, BSO, LOA, appendectomy, and cystoscopy for tubo-ovarian abscess, now in ICU for monitoring given severe pelvic infection and intraoperative blood loss. . Tubo-ovarian abscess. The patient was taken to the OR on [2178-10-10] and found to have a large tubo-ovarian abscess and significant adhesions. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, cystoscopy and lysis of adhesions. Given the extent of the abscess, the patient was monitored in the ICU on POD 0. She was transferred to the floor in stable condition on ampicillin/gentamicin and metronidazole IV. She remained afebrile until [10-11] when she had a fever. An ID consult was obtained which recommended that the patient's antibiotics be switched to Vancomysin and Zosyn. An intraoperative culture returned pan-sensitive E.coli. No anaerobes were isolated. Due to the nature of polymicrobial abscesses, the patient's antibiotics were kept broad but narrowed slightly to Levofloxacin/Flagyl. THe patient remained afebrile from [10-11] until discharge home. She was sent home with 2 week course of PO Levofloxacin and Flagyl. Blood cultures were negative from the Emergency department and ICU. Most recent blood cultures pending from this admission. No growth to date. Urine culture negative. . Pain: Controlled with Dilaudid PCA. The patient was transitioned to PO Dilaudid when tolerating adequate oral intake. Ileus: The patient had an NG tube placed that was discontinued on post-operative day 1. The patient developed an ileus on post-operative day [3-7]. She was kept NPO and her diet was advanced when she had return of bowel function. The patient was tolerating regular diet at time of discharge home. Drains: The patient's JP drain was discontinued on POD 5. Prophylaxis: Protonix, Pneumoboots, Heparin sc 5000 mg TID, ambulation TID . Discharge: The patient was discharged in stable condition on POD 5 ([2178-10-14]) tolerating regular diet Medications on Admission: MEDS 1. Ibuprofen 600mg 2. Senna 1 tab [Hospital1 ] 3. Biotin 4. Docusate 1 tablet [Hospital1 ] 5. Simethicone 6. Doxycycline 100mg PO bid 7. Tylenol prn 8. Cod liver oil and biotin prn 9. OCP unspecified . Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:14 Tablet(s) Refills:0 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:42 Tablet(s) Refills:0 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID (2 times a day) for 1 days. Disp:20 ML(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Tubal Ovarian Abscess Post operative Ileus Thrush Discharge Condition: Stable Discharge Instructions: Please call if fever > 100.5, chills, severe abdominal pain not relieved by pain medicine, redness around incision, chest pain or shortness of breath or other worrisome signs. No heavy lifting for 6 weeks. Do not lift anything more than 10 pounds. You may walk and go upstairs. No heavy exercising. No intercourse for 6 weeks. For thrush you may use Nystatin "Swish and Swallow" one teaspoon twice a day. Continue to take your antibiotics, Levofloxacin and Flagyl, for 2 weeks as prescribed. For pain: You may take Dilaudid 1-2 tablets every 4 hours. Please take Colace (stool softener) while on Dilaudid. No driving while on Dilaudid. You may also take Motrin 600 mg every 6 hours Followup Instructions: 9:15am [10-19] Monday Follow up for Staple removal with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2028] [Hospital Ward Name 23] Clinical Center [Location (un) 858] Provider: [First Name8 (NamePattern2) 95925] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 2664] Date/Time:[2178-10-30] [Location (un) ] [Hospital Ward Name 23] Center 9:00 am [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6753] ICD9 Codes: 2851, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5052 }	Medical Text: Admission Date: [2174-1-20] Discharge Date: [2174-2-3] Date of Birth: [2105-11-30] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: Alcoholic cirrhosis Major Surgical or Invasive Procedure: OLT ([2174-1-22]), Abdominal wall closure and liver biopsy ([2174-1-22]) History of Present Illness: 67 year-old female with alcohol-induced cirrhosis and hepatocellular carcinoma. Patient diagnosed with cirrhosis & HCC in [11-14]. She denies any EtoH since [Month (only) ] of '[72]. She is s/p radiofrequency ablation of hepatoma. Patient has been [Year (2 digits) ] listed with a MELD score of over 20. She is now admitted for liver transplantation. Past Medical History: Pulmonary hypertension Osteoporosis Cirrhosis Hepatocellular Carcinoma Social History: 50 pack per year smoker (currently smokes 10cigs/day) Abstaining from EtOH since [11-14] Family History: Mother died from CHF @ 80 yrs old Father died of CVA in his 70's Pertinent Results: ADMISSION LABS ---> [2174-1-20] 10:30PM BLOOD WBC-5.5 RBC-3.95* Hgb-13.6 Hct-37.7 MCV-95 MCH-34.5* MCHC-36.1* RDW-13.3 Plt Ct-116* [2174-1-20] 10:30PM BLOOD PT-13.6* PTT-30.5 INR(PT)-1.2* [2174-1-20] 10:30PM BLOOD Plt Ct-116* [2174-1-20] 10:30PM BLOOD Fibrino-261 [2174-1-20] 10:30PM BLOOD Glucose-123* UreaN-25* Creat-1.1 Na-138 K-3.9 Cl-102 HCO3-25 AnGap-15 [2174-1-20] 10:30PM BLOOD estGFR-Using this [2174-1-20] 10:30PM BLOOD ALT-26 AST-30 AlkPhos-79 TotBili-0.8 [2174-1-24] 02:32AM BLOOD Lipase-10 [2174-1-20] 10:30PM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.5 Mg-1.7 [2174-1-23] 06:44AM BLOOD FK506-7.8 [2174-1-21] 05:22AM BLOOD Type-ART pO2-432* pCO2-45 pH-7.35 calTCO2-26 Base XS-0 [2174-1-21] 05:22AM BLOOD Glucose-108* Lactate-1.0 Na-137 K-3.9 Cl-104 [2174-1-21] 05:22AM BLOOD Hgb-13.9 calcHCT-42 [2174-1-21] 05:22AM BLOOD freeCa-1.10* . . DISCHARGE LABS ---> [2174-2-3] 05:30AM BLOOD WBC-10.7 RBC-3.15* Hgb-9.6* Hct-28.4* MCV-90 MCH-30.5 MCHC-33.8 RDW-16.8* Plt Ct-252 [2174-2-3] 05:30AM BLOOD Plt Ct-252 [2174-1-26] 03:00AM BLOOD Fibrino-423# [2174-2-3] 05:30AM BLOOD Glucose-73 UreaN-9 Creat-0.7 Na-137 K-4.2 Cl-102 HCO3-26 AnGap-13 [2174-2-3] 05:30AM BLOOD ALT-41 AST-17 AlkPhos-115 Amylase-26 TotBili-0.5 [2174-2-3] 05:30AM BLOOD Lipase-12 [2174-2-3] 05:30AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.3* [2174-2-3] 05:30AM BLOOD FK506-11.3 [2174-1-26] 04:55PM BLOOD Type-ART pO2-113* pCO2-39 pH-7.49* calTCO2-31* Base XS-5 Brief Hospital Course: This is a 68 year old female who was admitted to [Hospital1 18] for a liver [Hospital1 ] on [2174-1-22]. The patient was prepared and consented as per standard for her procedure; please see operative note for furthur details. During the surgery, she received 12 units of packed cells, 7 units of FFP, 2 of platelets, 1 of cryo, and 14 liters of crystalloid. The case was complicated by inability to close the anterior abdominal wall - the patient was brought to the SICU and 24 hours later, taken back to the OR for abdominal wall closure and a washout. At the same time, a liver biopsy was performed. . On [1-23], the patient was extubated - she was confused and experienced mental changes and as a result, Neurology was consulted. A CT of her head was negative for any pathology. A chest xray showed mild-moderate pulmonary edema. Per neurology, her neurological exam was normal aside from hyper-reflexia with myoclonus in her legs. . An echo was obtained on POD5 ([1-26]) which showed moderate-severe pulmonary hypertension, a Dilated right ventricle and preserved right ventricular systolic funcion. She was started on Viagra to improve her pulmonary hypertension. On mental exam, the patient had some disorientation to year and difficulty with complex pictures but otherwise, was attentive, appropriate with intact recall. Neurology felt she was clearing from sedation and anesthesia appropriately. . On [1-27] (POD6), Ms [Known lastname 54392] was transfered out of the ICU and to the floor. She was seen by physical therapy on POD7 ([1-28]); a CTA of her abdomen was done to evaluate the blood vessels and assess status of a known bile leak; the CT showed "Patent hepatic artery which originates from the aorta, Patent portal veins and hepatic veins; Small thrombus seen at the confluence of the middle and left hepatic veins; Small fluid collection anterior to the aorta, and larger fluid collection extending from the superior surface of the liver posteriorly. Multiple peripheral low attenuation regions, small scattered throughout the liver". The patient was started on Unasyn for a total of 3 days from POD7. . On POD8 ([1-29]), the patient was ambulating without assistance and maintaining her oxygen saturation > 94% while ambulating and climbing stairs. She was tolerating a regular diet. . On POD10 ([1-31]), the patient was weaned off from oxygen. She was started on Lasix for diruesis. The medially located JP was discontinued without complications, leaving a single JP in her abdomen. The JP fluid for the lateral JP was sent for bilirubin returning at 1.2. . On POD11 ([2-1]) she was continued on the furosemide with diuresis. . On POD12([2-2]), a HIDA scan was done to assess for bile leak given bilious drainage in lat JP noted on prior days. This was normal and showed no bile leak. She was deemed stable for discharge home with services. She was instructed to follow-up as directed and to continue to record the output from her JP for her follow-up visits. . On POD13 ([2-3]), she was discharged in a stable condition. Medications on Admission: vit B12', multivmn', vit c 500', Ca with vit D 600', Chantix 1', viagra 20''', spironolactone 50', lasix 20', prilosec 20', Mg oxide 300' Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pulm HTN. Disp:90 Tablet(s) Refills:0 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for Pain. Disp:40 Tablet(s) Refills:0 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day. Disp:1 Refills:2 12. syringes insulin syringes 1 box refill:2 13. lancets 1 box refill:2 14. One Touch Ultra test stips 1 box refill:2 15. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: ESLD [2-11] etoh & HCC Pulmonary Hypertension Discharge Condition: good Discharge Instructions: Call [Month/Day (2) 1326] office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, inability to take medications, increased drainage from drain, redness/bleeding/pain at drain site, jaundice or abdominal pain. Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin, and trough prograf level. fax to [Telephone/Fax (1) 697] Empty drain when half full. Record drain output and bring record of outputs to next appointment Followup Instructions: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] CENTER - NON BILLING Phone:[Telephone/Fax (1) 673] Date/Time:[2174-2-2] 11:00 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2174-2-16] 10:30 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2174-2-21] 8:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2174-2-7] 1:30 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 156] [Name11 (NameIs) ] SOCIAL WORK Date/Time:[2174-2-7] 2:30 Completed by:[2174-2-3] ICD9 Codes: 3051, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5053 }	Medical Text: Admission Date: [2158-5-8] Discharge Date: [2158-5-10] Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 4765] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with drug eluting stent to the SVG to right coronary artery. History of Present Illness: Mr. [Known lastname 93130] is a 85 yo M with a history of CAD (s/p PTCA [2137], CABG x5 [2143] with LIMA to LAD, SVG to diag, SVG to OM1 jump to OM4, SVG to RPL), stent x2 [1-/2153], BMS LCx and jump from OM1 to OM4 [12/2156]) who presented with intermittent burning in his chest lasting a few miutes and SOB with exertion. Of note, he underwent his last cardiac catheterization for recurrent and progressive angina in [1-3] which showed reocclusion of his graft and progression of native LCx to 80% and jump segment disease. He had bare-metal stenting of the proximal circumflex and a jump SVG segment from Circumflex OM to LPL branch at that time. . He denies any prior history of deep venous thrombosis, pulmonary embolism, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He last saw Dr. [Last Name (STitle) ] in [7-/2157] for follow-up. Since then had felt much better with resolution of angina and no dyspnea, orthopnea, or PND. His Plavix was discontinued as it had been 6 months since his procedure and he has had some bleeding problems with this. . Two weeks prior to presentation the patient developed exertional substernal chest burning that turned into tightness. It was associated with SOB. It progressed in intensity and by admission was nearly rest pain and would occur with only minimal exertion (walking 10 feet). The pain was nonradiating and was always relieved by rest. It was not associated with nausea, vomitting, diaphoresis (however, he did have 1 episode of vomitting on [2158-5-5]). Because of the worsening severity, he decided to come to the ED. Past Medical History: 1) CAD s/p angioplasty in [2137], s/p MI [2143] followed by CABGX5 ([Hospital1 336]) 2) Hypercholesterolemia 3) Pernicious Anemia 4) Tubular adenomas in colon 5) BPH - s/p TURP, last PSA [10/2147] 6) Testicular nodule 7) s/p L Tic MVD 8) Memory loss / Dementia 9) Hearing loss 10) Appendectomy Social History: denies tobacoo, alcohol, intravenous drug use; married w/ 4 children 4 grandchildren; retired from Mark Pharmaceutical Company (designed cyclotron labs) Family History: Sister w/ breast CA, no family history of colon/prostate CA. 2 brothers w/ aneurysms. No CAD or known heart disease Physical Exam: VS: T=98.4 BP=144/76 HR=81 RR=26 O2 sat=96% 3LNC GENERAL: Elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry MMM. NECK: Supple with flat JVPs CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Anteriorly CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. NABS. Abd aorta not enlarged by palpation. No abdominial bruits. No pulsatile mass. EXTREMITIES: No c/c/e. Slightly cool 1+ DP bil LEs. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: CBC [2158-5-8] 11:20AM BLOOD WBC-8.2# RBC-4.84 Hgb-15.0 Hct-44.0 MCV-91 MCH-31.0 MCHC-34.1 RDW-14.5 Plt Ct-203 [2158-5-9] 04:05AM BLOOD WBC-9.1 RBC-4.34* Hgb-13.6* Hct-40.1 MCV-92 MCH-31.4 MCHC-34.0 RDW-13.7 Plt Ct-250 [2158-5-10] 06:10AM BLOOD WBC-12.9* RBC-4.17* Hgb-13.1* Hct-38.8* MCV-93 MCH-31.4 MCHC-33.8 RDW-14.0 Plt Ct-248 Coags [2158-5-8] 11:20AM BLOOD PT-12.1 PTT-25.4 INR(PT)-1.0 Differential [2158-5-8] 11:20AM BLOOD Neuts-71.4* Lymphs-20.4 Monos-6.1 Eos-1.6 Baso-0.4 Chem 7 [2158-5-8] 11:20AM BLOOD Glucose-86 UreaN-19 Creat-1.0 Na-141 K-4.3 Cl-102 HCO3-28 AnGap-15 [2158-5-9] 04:05AM BLOOD Glucose-148* UreaN-20 Creat-1.1 Na-138 K-5.2* Cl-105 HCO3-24 AnGap-14 [2158-5-9] 12:21PM BLOOD Glucose-154* UreaN-24* Creat-1.1 Na-139 K-4.3 Cl-103 HCO3-26 AnGap-14 [2158-5-10] 06:10AM BLOOD Glucose-75 UreaN-26* Creat-1.0 Na-141 K-4.3 Cl-105 HCO3-27 AnGap-13 Cardiac biomarkers [2158-5-8] 06:40PM BLOOD CK(CPK)-52 [2158-5-9] 04:05AM BLOOD CK(CPK)-95 [2158-5-8] 11:20AM BLOOD cTropnT-<0.01 [2158-5-9] 04:05AM BLOOD CK-MB-NotDone cTropnT-0.05* Other chemistry [2158-5-8] 11:20AM BLOOD Calcium-9.8 Phos-2.9 Mg-2.0 [2158-5-9] 04:05AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8 [2158-5-9] 12:21PM BLOOD Calcium-9.0 Phos-2.7 Mg-2.6 [2158-5-10] 06:10AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.2 Cardiac catheterization [2158-5-8]: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated severe native coronary artery disease. The LMCA had an 80% restenosis in the LCx, with a 60% stenosis in the distal stent. The LAD was occluded proximally. The RCA was occluded proximally. 2. Selective angiography of venous conduits revealed an SVG-RCA with diffuse disease up to 99%. Selective angiography of arterial conduits showed a patent LIMA-LAD. 3. Successful PTCA and stenting of the SVG-RCA with a 4.0x15mm Promus stent. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). 4. During the case, the patient was noted to be in high grade AV block and a temporary pacing wire was inserted into the right ventricle. At the completion of the case, ECG revealed Mobitz I block, and the pacing wire was removed. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA-LAD, high grade lesion in SVG-RCA. 3. Successful PCI of the SVG-RCA. 4. High grade AV block requiring temporary pacemaker, resolved after completion of intervention. 5. Mobitz I AV block. [2158-5-8] Chest x ray FINDINGS: Portable upright view of the chest is obtained. Midline sternotomy wires and mediastinal clips are noted. There is an external pacing wire noted. Low lung volumes limit the evaluation. There is no evidence of pneumonia. There is mild CHF evidenced by Kerley B lines. No large pleural effusions are seen. Cardiomediastinal silhouette is stable. No pneumothorax is present. Bones appear intact. IMPRESSION: Findings suggesting mild congestive heart failure. Echocardiogram [2158-5-9]; The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is probably basal to mid inferolateral/inferior hypokinesis although views are suboptimal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is a mild resting left ventricular outflow tract obstruction. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2154-1-14], no regional wall motion abnormalities were detected in the prior report. Brief Hospital Course: ASSESSMENT AND PLAN: Mr. [Known lastname 93130] is a 85 yo M with a history of CAD (s/p PTCA [2137], CABG x5 [2143] with LIMA to LAD, SVG to diag, SVG to OM1 jump to OM4, SVG to RPL), stent x2 [1-/2153], BMS LCx and jump from OM1 to OM4 [12/2156]) who presented with intermittent burning in his chest lasting a few miutes and SOB with exertion concerning for unstable angina. . # Chest pain: The patient's history was most consistent with unstable angina. In the ER, the patient's vitals were: T 96 HR 98 BP 146/76 RR 16 O2 sat: 98% RA. EKG showed no ST or T wave changes. He was given lasix and ASA. The patient had an episode of bradycardia in the ED to the 30s-40s, with some associated angina but no change in BP. He was transferred directly to the cath lab as a result. Cardiac cath in this right dominant system revealed a patent LIMA-LAD, occluded RCA (known), occluded LAD (known), LMCA with 80% instent restenosis into LCX, 60% distal instent restenosis, SVG-RCA with diffuse disease, and a DES was placed in this graft with distal protection leading to 0% residual stenosis. The patient also developed some symptomatic bradycardia and was transvenously paced (see below). The pacer wire was pulled prior to leaving the cath lab. He was started on integrillin for 18 hrs, apirin 325 mg, plavix 75 mg, and his simvastatin was changed to atorvastatin given his last LD was 85 in [8-4]. An echo was performed which showed that there is probably basal to mid inferolateral/inferior hypokinesis although views were suboptimal. He was not initially started on a beta blocker given his bradycardia, but eventually was started on 12.5 mg [Hospital1 ] (half his home dose). This resulted in bradycardia overnight with a question of wenkebach. His metoprolol was discontinued, but he was discharged on aspirin, plavix, and atorvastatin. . # Bradycardia: As stated above the patient had an episode of bradycardia in the ED. The etiology of this was unclear although it may have been secondary to a combination of beta blocker, increased vagal tone in setting or sinus or AV nodal ischemia given culprit lesion was in the right system, as well as progressive calcific degenerative disease of the conduction system. He had another episode in the cath lab. A small dose of beta blocker was tried, however it caused bradycardia overnight so it was discontinued. He was discharged with a holter monitor and will need to follow up with Dr. [Last Name (STitle) ] on [6-13]. Medications on Admission: Multivitamin Metoprolol Tartrate 25 mg [Hospital1 ] Nitroglycerin 0.4 mg SL PRN Simvastatin 80 mg QHS Aspirin 325 mg daily Cyanocobalamin 1,000 mcg [Hospital1 ] FLAXSEED OIL 1000MG [Hospital1 ] Glucosamine-Chondroitin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO twice a day. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 min for total of 3 [Hospital1 4319] as needed for chest pain: If you still have chest pain after 3 [Hospital1 4319], call 911. 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Flaxseed Oil 1,000 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Glucosamine Chondroitin MaxStr Oral 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Bradycardia . Secondary Diagnosis Hypertension Dyslipidemia Pernicious Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest burning/angina indicating another artery in your heart was blocked. You had a cardiac catheterization with a drug eluting stent to your right coronary artery graft. You will need to take Plavix every day for at least one year and probably longer. Do not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking Plavix unless Dr. [Last Name (STitle) ] tells you to. You did not have a heart attack. We also noted that your heart rate was low so we did not restart your Metoprolol. Please hold that drug for now. You will need to have a holter monitor to go home with. They will instruct you on how to send strips. Dr. [Last Name (STitle) ] will follow up the results of this monitor. . Medication changes: 1. Start taking Plavix every day to prevent clots in the stents 2. continue to take Aspirin every day with the Plavix. 3. Stop taking Metoprolol Followup Instructions: [Last Name (LF) 1576],[First Name3 (LF) 1575] Phone: [Telephone/Fax (1) 1579] Date/time: Wednesday [5-17] at 11:00am [Last Name (STitle) 17290]. Provider: [First Name4 (NamePattern1) 1575] [Last Name (NamePattern1) 1576], MD Phone:[Telephone/Fax (1) 1579] Date/Time:[2158-8-23] 8:30 . Cardiology: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 62] Date/Time: Tuesday [6-13] at 9:00 am ICD9 Codes: 9971, 4111, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5054 }	Medical Text: Admission Date: [2119-12-8] Discharge Date: [2119-12-23] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valve replacement(#25 [Company 1543] mosaic ultra)Coronary artery bypass graft x3(left internal mammary-left anterior descending, saphenous vein graft-Obtuse marginal, saphenous vein graft-diagonal) [12-11] History of Present Illness: 88yo man with known aortic stenosis. Progressively worsening dyspnea on exertion, now referred for cardiac surgery Past Medical History: Aortic Stenosis Atrial Fibrillation Chronic renal insufficiancy Hypertension Hiatal hernia s/p repair Hyperparathyroidism s/p transurethral resection prostate Social History: retired pharmacist. lives with wife in [Name (NI) 21037], MA Remote tob-quit 25 years ago Rare ETOH use Family History: Father dies of cardiac problems @53yo Physical Exam: VS: 98.1, 97.8, 94/58, 96 a-fib, 22, 100% 2L nc Gen: NAD elderly male HEENT: unremarkable CV: irregularly irregular, no murmur Chest: lung sounds are diminished throughout with crackles Abd: NABS, soft, non-tender, non-distended Ext: 2+pitting edema Incisions: sternal incision healing nicely- c/d/i without erythema or drainage, Right EVH: c/d/i Pertinent Results: [2119-12-23] 05:40AM BLOOD WBC-14.0* RBC-3.76* Hgb-11.7* Hct-34.4* MCV-92 MCH-31.0 MCHC-33.9 RDW-16.0* Plt Ct-250 [2119-12-23] 05:40AM BLOOD PT-16.1* INR(PT)-1.4* [2119-12-23] 05:40AM BLOOD Glucose-117* UreaN-45* Creat-1.8* Na-141 K-4.1 Cl-101 HCO3-29 AnGap-15 Brief Hospital Course: The patient was admitted on [12-8] for cardiac catheterization in preparation for aortic valve replacement. He was found to have left main coronary artery disease, as well as stenoses in the right, and LAD coronary arteries. Heparin was initiated and the patient was admitted for AVR, CABG. The patient was brought to the operating room on [12-11] where he underwent AVR, CABGx3. Vancomycin was administered for perioperative antibiotic prophylaxis due to prolonged [Hospital ] hospital stay. Please see dictated operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for further recovery and invasive monitoring. The patient was initially extubated on POD 0, however required reintubation for respiratory failure. He was re-extubated on POD 1. Vasoactive drips were weaned off. The patient was diuresed toward his preoperative weight. Chest tubes and pacing wires were discontinued without complication. Physical therapy was consulted for assistance with post-operative strength and mobility. Coumadin was resumed for atrial fibrillation. The patient had an episode of bradycardia which progressed to a PEA arrest on POD 6. ACLS protocol was initiated. The patient was re-intubated, CPR was performed, multiple drips were started and the patient was resuscitated. The patient stabilized, pressors were weaned and he was extubated again. The electrophysiology service was consulted and determined that the patient was not a candidate for a permanent pacemaker. The patient was eventually transferred to the floor and the remainder of the hospital course was uneventful. He was discharged on POD 12 to [Hospital1 15454] Rehab Hospital for pulmonary rehabilitation. Medications on Admission: coumadin 5mg (5days), 2.5mg (2 days), atenolol 50'', enalapril 5', simvastatin 40', zemplar 1' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): Target INR 2-2.5 (Received 2.5mg 12/24&25. 5mg on [12-22]&[12-23]). Tablet(s) 9. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. 10. Zemplar 1 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) tx Inhalation Q6H (every 6 hours) as needed. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) tx Inhalation Q4H (every 4 hours) as needed. 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-28] Sprays Nasal TID (3 times a day) as needed. 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: s/p AVR(Tissue)CABGx3. [12-11] s/p Bradycardic arrest-EP evaluation. [12-18] PMH: Atrial Fibrilllation Hypetension Chronic renal Insufficency hyperparathyroid Hyperlipidemia, Rheumatic fever(child) S/p TURP S/P Hiatal hernia repair 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. Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 1504] Dr [First Name (STitle) 6164] in [2-28] weeks [Telephone/Fax (1) 4475] Patient to call for appointments Completed by:[2119-12-23] ICD9 Codes: 4241, 4275, 5185, 5849, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5055 }	Medical Text: Admission Date: [2141-4-18] Discharge Date: [2141-5-15] Date of Birth: [2075-9-6] Sex: M Service: MEDICINE Allergies: Penicillin G / Azithromycin Attending:[Last Name (NamePattern4) 290] Chief Complaint: transfer from OSH for multiple issues Major Surgical or Invasive Procedure: C1-2 posterior decompression, evacuation abcess Ventriculostomy placement History of Present Illness: 65 yo M with PMHx of asthma who presented to OSH for confusion and bizzare behavior, found to have fevers, neck stiffness, abnormal LP, MSSA bacteremia with hospital course c/b aspiration event and intubation and acute hemiparesis episode concerning for CVA now transferred for ongoing management for medical issues. . Patient was admitted to [Hospital3 10310] on [4-12] after friends found him confused in his home after not showing up to work for 2 days. Friends report he was confused with slurred speech, unsteady on feet, and letting something burn on his oven. Per report of brother, pt had visited PCP twice in prior 10 days for neck pain and apparently co-workers and reported he was feeling less well, complaining of neck pain, and perhaps acting more confused or unusual than normal. PCP is reported to have treated neck pain with flexeril, benzos, and vicodin. When arrived at [Hospital3 10310] on [4-12], temp was 101.2 and pt was confused. Zosyn was started emperically but on HD #2 pt appeared worse and LP was done showing high protein, low glucose, with elevated WBC of PMN predominance but gram-stain showed no organisms and CSF Cx was still negative at time of transfer. Gram-stain from Bcx on admission grew GPCs and Vancomycin started -> cultures ultimately grew 4/4 bottles MSSA on [4-14] and ID saw pt in consult and started cefazolin to which the MSSA was sensative. Later on HD #3 ([4-14]), he had an aspiration event that required intubation and transfer to MICU although hemodynamically stable at time. Pt was placed back on Vancomycin and started on Cefepime (unclear but zosyn possibly stopped somewhere in this interval). Highest temp of hospitalization was also on this day to 104.0 in AM [4-14]. On intubation and ICU transfer, pt given propofol with resulting BP drop and was started on dopaminem with RIJ CVL placed. He underwent TTE which showed small hyperechoic 3mm lesion in RV trabeculations and 1.5 cm isoechoic RV apical septum lesion. Neither were thought suggestive of a vegetation/endocarditis and no left-sided valvular lesions were noted. He was also noted to have infiltrate on CXRs during admission and sputum Cx from [4-14] grew MSSA. He was maintained on [Month/Day (4) 621] but failed extubation on [4-17] with immediate reintubation. [Month/Day (4) ] changed to Vanc/Meropenem on [4-17] but continued to spike fevers. On early Tues ([4-18]) he developed right arm weakness and a CT head was noted to have new right cerebellar infarcts (one hypodense lesion in pons and one large non-hemorrhagic R cerebellar infacrtion with partial effacement of 4th ventricle). No hemorrhage or midline shift. Hard to oxygenate since requiring Fi02 of 100% and Peep of 12 to maintain sats in the 80s. Receiving SQH only for DVT ppx. . Brother [Name (NI) ] speaks to pt every few weeks. Confirms that pt is somewhat of a recluse but reports that he volunteers some at a senior center. Confirms that sent co-workers of pt to find him on [4-12] due to pt seeming confused via phone and due to reports that pt was confused at the senior center where he volunteered. for neck pain but brother did not recognize torticollus. Brother mentioned that two weeks prior pt had reported a rash on his body but did not give further discription. Pt also says that he did not recognize the name torticollus in reference to his brother's neck problem. . In the ICU, pt minimally responsive to some questions and commands but unable to speak due to endotracheal tube so further information could not be elicited. . Review of sytems (unable to obtain due to intubated state): Past Medical History: (per OSH records and brother) -asthma/allergic rhinitis -depression -dyslipidemia -question of intermittent torticollus since a teenager Social History: (some per OSH records, some per brother): Works as a technician at [Name (NI) 2475]. Apparently also volunteers at a elder center. Single. Reported to be somewhat reclusive and lives alone. No reported history of smoking, alcohol, or drug use per brother. Family History: (per OSH records) One sister died of lung CA. Brother with asthma and some mental health issues as well. Mother died at 87 and Father died at 52 (either liver or kidney CA) Physical Exam: Admission Physical Exam Vitals: T: 100.5 / BP: 123/57 / P: 79 / R: 19 / O2: 99% on vent General: opening eyes and responsive to some simple comands, intermittently losing concentration on surroundings HEENT: Sclera anicteric, no evidence of conjunctival hemorrhage, MMM, ET in place, tongue questionably deviated to the L Neck: supple, R IJ in place but kinked Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: soft heart sounds difficult to hear above ventilatory, RRR, soft S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Skin: no rashes or areas of skin break noted GU: no foley Ext: very arm, well perfused, 2+ pulses bounding pulses at DP and radial, no clubbing, cyanosis or edema, no evidence of [Last Name (un) 62745] lesions or Osler's nodes on exam. Neuro: 4+/5 strength to grip in L hand, 3/5 strength to grip in L hand, able to squeeze hands on command (L>R) and able to move L toes but not R toes to command, difficulty with eye tracking but unsure if due to CN deficits or concetration issue, pupils equal and reactive, tounge questionably deviated to the left Pertinent Results: [2141-4-18] 11:40PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.035 [2141-4-18] 11:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2141-4-18] 11:40PM URINE RBC-7* WBC-3 BACTERIA-NONE YEAST-NONE EPI-1 [2141-4-18] 11:40PM URINE GRANULAR-4* HYALINE-1* [2141-4-18] 11:40PM URINE MUCOUS-RARE [2141-4-18] 10:36PM GLUCOSE-115* UREA N-21* CREAT-0.7 SODIUM-149* POTASSIUM-4.1 CHLORIDE-117* TOTAL CO2-28 ANION GAP-8 [2141-4-18] 10:36PM estGFR-Using this [2141-4-18] 10:36PM ALT(SGPT)-54* AST(SGOT)-67* LD(LDH)-287* ALK PHOS-101 TOT BILI-0.8 [2141-4-18] 10:36PM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-2.5 IRON-19* CHOLEST-65 [2141-4-18] 10:36PM calTIBC-140* FERRITIN-720* TRF-108* [2141-4-18] 10:36PM TRIGLYCER-156* HDL CHOL-11 CHOL/HDL-5.9 LDL(CALC)-23 LDL([Last Name (un) ])-<50 [2141-4-18] 10:36PM WBC-15.3* RBC-2.88* HGB-9.0* HCT-27.1* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.0 [2141-4-18] 10:36PM NEUTS-89.3* LYMPHS-6.7* MONOS-2.7 EOS-0.9 BASOS-0.3 [2141-4-18] 10:36PM PLT COUNT-321 [2141-4-18] 10:36PM PT-14.9* PTT-32.7 INR(PT)-1.3* [2141-4-18] 10:30PM TYPE-ART PO2-285* PCO2-41 PH-7.43 TOTAL CO2-28 BASE XS-3 Brief Hospital Course: 65 year-old M with high grade MSSA bactermia, MSSA positive sputume with CXR concerning for infiltrate, LP concerning for bacterial meningitis, and new posterior circulation cerebellar infarcts with background story and diagnostics unclear as to where is initial location of infection. . # Respiratory Failure: Seems to have been triggered by aspiration event on [4-14] per OSH records. CXR showing bilateral lung field opacifications most pronounced at bases concerning for consolidation plus pleural effusions. In setting of MSSA in sputum, likely has staph aureus PNA as this is rarely a contaminant/colinizer although likely that this bug seeded from another source or from bacteremia. Had reported difficulties ventilating at OSH, but gas on arrival to [Hospital1 18] on 100% FiO2 and PEEP 12 was pH 7.43 pCO2 41 pO2 285 HCO3 28 and pt tolerated initial wean to PEEP 10 and FiO2 50% with sats in high 90s. Pt has history of significant asthma which may contribute to difficulty weaning off vent down the road. Infectious Disease was consulted and recommended..... . # Fevers with MSSA bacteremia: Known MSSA 4/4 bottles from OSH Bcx on [4-12] although only reported in transfer summary and no attached micro cultures. TTE questionably negative for endocarditis at OSH. Supposedly surveliance cultures negative since [4-12] although no lab reports. Pt has been on Vanco since [4-12], [4-13], or [4-14] and received doses of zosyn before then. Has also received cefepime or meropenem over last few days but still febrile. Unclear if CNS infection primary with later bacteremia and possible heart valve seeding or if primary endocarditis with septic embolic causing CNS seeding and positive LP. Despite fact that all inital symptoms CNS in nature, more likely that primary endocarditis with CNS seeding as could have sub-clinical symptoms for endocarditis and MSSA endocarditis much more common than MSSA meninigitis. Depending on location of heart involvement could also better explain lung seeding. Other possiblity is that MSSA bactermia was primary even (although no obvious portals of entry on history/exam) and heart, lung, and CNS are all [2-15] areas of seeding. ID contact[Name (NI) ] overnight for initial [Name (NI) ] recs - Will continue Vanco/Meropenem (at increased Vanco dose) due to concern for nafcillin CNS penetration if meningitis were primary insult. Is suboptimal of MSSA endocarditis but will still cover organism and reasonable to continue in short term while CNS issues clarified (Vanco 1g IV Q12 and Meropenem 1000mg IV Q8). Lactate 0.9 - ID consult team will see in AM - TTE [4-19] since none here and desire to eval R heart which TEE won't - Plan for TEE tomorrow if possible by cards (ID strongly recommends) - NPO for possible TEE in AM - Survelliance Bcx and initial Ucx and Sputum Cx - Holding tylenol initially to eval fever curve - Card TEE c/s in AM . # LP suggestive of meningitis with new head CT findings: As mentioned above, unclear if meningitis primary event or seeding although think seeding more likely. LP very suggestive of bacterial process with high WBC with PMN predominance, low glucose, and high protein. Very unlikely viral process and less likely that had full-blown meningitis in [7-23] days of symptoms Concern that new CT findings at OSH from AM [4-18] along with R sided weakness caused by new stroke or mycotic aneurysm. However, CNS findings of R sided weakness do not correlate with R sided cerebellar findings on head CT so picture repains unclear. Images sent with patient on transfer do not include most recent head CT. - MRI/MRA of brain to eval reported acute head CT findings at OSH - Per neuro, if will take any time to get MRI/MRA, would get head CT here since we do not have image and picture per report unclear - Checking FLP and [Name (NI) ] with next labs per neuro recs - Neuro c/s in AM - ID c/s and infectious management as above . # Anemia: Hgb on admission at 9.0. No prior records to compare for baseline. No evidence of bleeding on exam and no suggestive reports on history. Lactate 0.9 indicating that anemia likely not causing significant hypoperfusion. LDH slightly up which could be indicative of mild hemolysis especially if invoking endocarditis. However, may have underlying issues that explain anemia more than acute illness. - iron studies - check hapaglobin and retic count with AM labs - trend Hct and maintain active T&S . # Hypernatremia: Sodium on admission is 149. Was trending up at OSH from 134 on [4-14] likely because pt NPO and not receiving fluid. Free water defecit 2.5-3.0L based on todays labs/weights. - Start D5W at 125ml/hr for 1.5L and recheck AM labs - Plan to correct total deficit over 24hrs . # Anxiety/Depression: long history of anxiety and depression that apparently also runs in family. Pt is somewhat of [Initials (NamePattern4) ] [Last Name (NamePattern4) 68185] per reports and may be component of personality disorder although no way to evaluate this at this time. On significant home regimen of anti-anxiety and anti-depressant medications and would be at risk for withdrawal if all stopped suddently. - cont buproprion 200mg [Hospital1 ] (home dose) -> low threshold to stop if any concerning seizure activity in light of new CNS findings - cont buspar at 15mg daily - hold home celexa, aderal, and xanax . FEN: No IVF, replete electrolytes, regular diet Prophylaxis: Subcutaneous heparin Access: IJ [4-14] from OSH Code: Full presumed Communication: Next of [Name (NI) ] - Brother [Doctor First Name ] Cell:[Telephone/Fax (1) 89897] / Work: [Telephone/Fax (1) 89898] PCP: [Name10 (NameIs) 13309], [Name11 (NameIs) ] [Name Initial (NameIs) ].D. phone: [Telephone/Fax (1) 8572] Disposition: ICU pending clinical improvement . MICU Green Course [Date range (1) 89899]: 1. Hemoptysis: Patient had bronch on admission which demonstrated no active bleeding in lungs but significant secretions LMSB with all subsegments plugged. Suctioned for many thick plugs until subsegments distally were patent. Source felt to be nasopharyngeal given reports of NGT attempts and bleeding from trach just after cuff dropped. - Recommend frequent suctioning due to mucous plugging and coughalator - NAC prn for secretions . 2. Pneumonia: Cultures have repeatedly grown out Enterobacter Aerogenes, pan-sensitive. - Continued Cefepime for total 2 weeks of therapy . 3. C2-C3 Abscess: Per ID discontinued Nafcillin and started Vancomycin (due to lowering the seizure threshold with 2 B-lactam agents) . 3. Shoulder pain: Mild pain with passive range of motion bilaterally. No localized tenderness or overlying erythma. - If worsens consider imaging for ? effusion and tap due to MSSA infection . 4. Nutrition: Recommend S&S consult and consideration of PEG if appropriate. . Otherwise prior care continued and patient transferred back to Neurology team. Medications on Admission: Home medications: -Simvastatin 40mg -Advair 250/50 [Hospital1 ] -Zolaire Q month (anti-IgE) -Singular 10 -Flonase -Celexa 20mg Qd -Bupropion 200mg [Hospital1 ] -Xanax 0.5mg qd -Aderal XR 15mg qd -Buspar 15mg qd -Albuterol PRN . Transfer meds: 1. D5 1/2NS with 20KCL at 125ml/hr 2. [Last Name (un) ] 500mg Q6 3. Vanco 750mg Q12 4. Aderal 10mg in AM and 5mg in PM 5. Buspar 15mg 6. Singular 10mg 7. Bupropion 200mg [Hospital1 ] 8. Simva 40mg Qd 9. Protonix 40mg IV BID 10. SQH 5000 units Q8 11. Propofol gtt 12. Ativan 1-2mg PRN 13. Advair 250/50 [Hospital1 ] 14. Morphine 1-2mg PRN Discharge Medications: 1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. buspirone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours). 4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 5. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. bupropion HCl 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for skin lesion. 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 14. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 18. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 21. Vancomycin 1000 mg IV Q 12H 22. CefePIME 2 g IV Q8H 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 24. Morphine Sulfate 2-4 mg IV Q4H:PRN pain 25. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 26. HYDROmorphone (Dilaudid) 0.5 mg IV Q6H:PRN pain 27. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 28. Outpatient Lab Work Chem 7, ESR, CRP, LFTs Weekly Please fax results to Dr. [Last Name (STitle) 9461] Fax [Telephone/Fax (1) 1419] 29. Outpatient Lab Work Vancomycin trough on [2141-5-15] please fax results to Dr. [Last Name (STitle) 9461] [Telephone/Fax (1) 89900] 30. nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every four (4) hours: **THIS MEDICATION IS TO BEGIN ON [5-5] of Vancomycin and Cefepime. 31. MRI C spine with and without contrast Re epidural abscess. This should be done in 4 weeks. Ordered as an outpatient in the [Hospital1 18] system. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Location (un) 1121] ([Hospital3 1122] Center) Discharge Diagnosis: Epidural Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the [Hospital1 18] an episode of confusion and bizarre behavior. Your PCP said that you had been experirncing neck pain for approximately 10 days. You had a a lumbar puncture that was suggestive of a bacterial meningitis and you were started on broad spectrum antibiotics. On examination you were found to have R>L sided weakness and ataxia. An MRI revealed a cerebellar infarct in addition to an epidural abscess. Neurosurgery evacuated your abscess posteriorly but could not access the anterior portion. Infectious disease was involved and kept you on antibiotics for treatment. A follow-up MRI showed possible worsening of the abscess, however it was felt by neurosurgery to be related to granulation tissue and they wished for you to receive a longer course of antibiotics and follow-up as an outpatient. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 548] on [2141-5-30] at 11:15am in Spine Center on [Hospital Ward Name 516], [Hospital Ward Name 23] 2. If you need to change this appt, please call [Telephone/Fax (1) 2992]. You will also need a repeat cervical MRI with and without gadolinium when you finish your course of antibiotics, this can be arranged by calling Dr [Name (NI) ] office. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2141-5-22] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6214], MD Phone:[Telephone/Fax (1) 3736] Date/Time:[2141-5-30] 11:15 Provider: [Name10 (NameIs) 9462] FLASH, MD Phone:[Telephone/Fax (1) 457] Date/Time:[2141-6-14] 11:00 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2141-5-15**] ICD9 Codes: 5070, 2760, 2724, 2859, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5056 }	Medical Text: Admission Date: [2157-12-2] Discharge Date: [2157-12-4] Date of Birth: [2078-6-1] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues / Benadryl Decongestant / Erythromycin Base / Aztreonam / Diatrizoate Meglumine Attending:[First Name3 (LF) 3705] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 41058] is a 79 year old female with a complex past medical history significant for ANCA vasculitis on chronic prednisone 15mg, essential thrombocytosis and hypertension who presents with a 10 day history of congestion, 5-day history of throbbing headache, cough, pleuritic chest pain and worsening dyspnea. The patient was reportedly in her normal state of health until approximately 10 days ago, when she began to experience nasal congestion which is like her usual ANCA vasculitis flare. She was told to increase her prednisone to 20mg daily and was started on azithromycin by her PCP for her flare. She improved over next few days but started worsening five days ago with cough, pleuritic chest pain and worsening shortness of breath. She started another course of azithromycin along with continuation of her steroids. Last night at dinner, she had acute worsening of her shortness of breath which prompted her to call EMS. She required 100% NRB and thus was transferred to [Hospital1 18] ED as she was thought too unstable to make it to [Hospital1 336]. Of note, she describes this episode of acute SOB/cough/congestion as similar to past "flares" of her vasculitis. These episodes usually occur every 3 months for which her dose of prednisone is increased and she takes a z-pack. Her symptoms were not responsive this time to this regimen. She does not take Bactrim for regular PCP pneumonia prophylaxis. Additionally, she reports she took a long flight to [State 108] 2 weeks ago. No sick contacts or travel out of the country. ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: * right greater trochanteric bursitis * Myeloproliferative disease - essential thrombocythemia; Regimen of hydroxyurea x2 weeks alternating with cellcept x4 weeks * p-ANCA associated vasculitis: disease in her kidneys, lungs, sinuses, and blood. First dx 20yrs ago. Regimen of prednisone 15mg daily. Followed by Dr. [First Name (STitle) 1557]. * history of LGIB - diverticulosis ([8-22]) * Hypertension * Hypothyroidism * Chronic renal insufficiency, baseline 1.6 * CAD s/p angioplasty [2150] of D1 * Cataract bilaterally * S/P open Cholecycstectomy in [9-/2153] Social History: School teacher; lives in [Location ] with partner, [Name (NI) 2048] who is very supportive. She has not had alcohol in years. Never smoked. Family History: HTN (brother, mother) MI (mother)- died at 88 Physical Exam: Physical Exam on Admission to the MICU: VS: 99.3 129/89 103 99% 70%NRB GEN: Female in moderate respiratory distress HEENT: Anicteric. Moist mucous membrane. PERRLA. EOMI NECK: Supple neck PULM: Bibasilar crackles. L > R. No wheezing appreciated. CARD: Regular rate and rhythm. No mumurs or gallops appreciated ABD: Soft, nontender and nondistended. Splenomegaly. NABS EXT: No edema NEURO: Alert and oriented to person, place and time. CN 2-12 intact. Sensation intact. Moving all extremities Physical Exam on Admission to the General Medicine Floor: VS - Temp 99.3F, BP 127/51 , HR 88 , RR21 , O2-sat 97% 4L NC GENERAL - well-appearing, NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, no LAD LUNGS - Bibasilar crackles, but otherwise clear. Breathing is not labored. HEART - RRR, nl S1/S2, no M/R/G ABDOMEN - BS+, soft, NT/ND, no rebound, no guarding, spleen tip palpable with inhalation EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, grossly in tact Physical Exam on Discharge: VS: T99.2, BP 131/56, HR 83, RR 18, O2Sat 97% 1L GENERAL - well-appearing, NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, no LAD LUNGS - Bibasilar crackles, but otherwise clear. Breathing is not labored. HEART - RRR, nl S1/S2, no M/R/G ABDOMEN - BS+, soft, NT/ND, no rebound, no guarding, spleen tip palpable with inhalation EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, grossly in tact Pertinent Results: Blood on Admission: [2157-12-2] 09:36PM BLOOD WBC-5.5# RBC-4.39 Hgb-12.5# Hct-37.6 MCV-86# MCH-28.4# MCHC-33.2 RDW-20.8* Plt Ct-1129# [2157-12-2] 09:36PM BLOOD Neuts-63 Bands-3 Lymphs-20 Monos-4 Eos-0 Baso-0 Atyps-8 Metas-1* Myelos-1* [2157-12-2] 09:36PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-2+ Polychr-1+ Ovalocy-1+ Blood on Discharge: [2157-12-4] 05:14AM BLOOD WBC-3.4* RBC-3.24# Hgb-9.0# Hct-27.6# MCV-85 MCH-27.7 MCHC-32.5 RDW-20.9 Plt Ct-584* Electrolytes on Admission: [2157-12-2] 09:36PM BLOOD Glucose-160* UreaN-60* Creat-1.4* Na-139 K-4.5 Cl-97 HCO3-27 AnGap-20 [2157-12-2] 09:36PM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1 [2157-12-2] 09:46PM LACTATE-3.5* Electrolytes on Discharge: [2157-12-4] 05:14AM BLOOD Glucose-114* UreaN-51* Creat-1.7* Na-138 K-3.7 Cl-99 HCO3-30 AnGap-13 [2157-12-4] 05:14AM BLOOD Calcium-7.6* Phos-2.9 Mg-2.0 Heart through hospital course: [2157-12-2] 09:36PM BLOOD proBNP-1899* [2157-12-2] 09:36PM BLOOD cTropnT-<0.01 [2157-12-3] 11:20AM BLOOD CK-MB-2 cTropnT-0.06* [2157-12-3] 10:45PM BLOOD CK-MB-2 cTropnT-0.04* [2157-12-3] 11:20AM BLOOD CK(CPK)-37 [2157-12-3] 10:45PM BLOOD CK(CPK)-24* ABG: [2157-12-3] 01:36AM BLOOD Type-ART pO2-92 pCO2-35 pH-7.47* calTCO2-26 Base XS-1 Urine: [2157-12-3] 12:32AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.014 [2157-12-3] 12:32AM URINE Blood-NEG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2157-12-3] 12:32AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 [2157-12-3] 12:32AM URINE AmorphX-MOD Cultures: Blood culture ([2157-12-2]) x2 pending MRSA Swab ([2157-12-3]) x1 pending . STUDIES: CXR ([12-2]): Fullness of the hila and prominence of the interstitial markings, suggest mild pulmonary edema. Patchy retrocardiac opacity may relate to edema, although underlying consolidation cannot be excluded. . CXR ([12-4]): Mild pulmonary vascular congestion. Increased density in the left lower lobe suspicious for underlying pneumonia. Clinical correlation is recommended. Brief Hospital Course: 79 year old female with ANCA vasculitis on chronic prednisone, essential thrombocythemia and hypertension who presents with a 10 day history of congestion, 5-day history of cough, pleuritic chest pain and worsening dyspnea admitted on [2157-12-3] and discharged on [2157-12-4]. # Worsening dyspnea, multifactorial. Likely flare of vasculitis in the setting of possible community acquired pneumonia. This is also complicated by pulmonary edema seen on CXR, elevated BNP, and plateaued troponin values. Her initial symptoms were similar (rhinorrhea, post-nasal drip, ear pain) to prior vasculitis flare. Because of her requirement of NRB, she was transferred to the MICU for respiratory status management. She was ruled out of MI given unchanged EKG and initial negative troponin. Repeat troponins were mildly elevated, but likely in the setting of her CKD and possible demand that she had initially. PE was considered given her underlying ET and sudden onset, but her symptoms improved with treatments of pneumonia, pulmonary edema, and vasculitis. Patient's symptoms improved with antibiotics (vancomycin and levofloxacin in the ED and then levofloxacin for the rest of her stay), prednisone, as well as diuresis with IV lasix. Her Norvasc was held briefly. Her O2 requirement improved to 1-2L NC at the time of discharge. On the day of discharge, she received increased prednisone dose 25 mg and another lasix 40 mg IV bolus. She was discharged home with 60 mg po lasix, renally dosed levofloxacin for a total of 7 day course for the possible CAP, as well as an increased dose of her prednisone to 25 mg daily given vasculitis flare. # ANCA vasculitis: Discussed above in worsening dyspnea. Prednisone dose was increased to 25mg daily. Patient was urged to follow up with Dr. [First Name (STitle) 1557] within one week of discharge. # Essential thrombocytosis: She reports she usually gets hydroxyurea 2x week for two weeks alternating with cellcept x4 weeks. She is currently scheduled to get hydroxyurea soon. Her aspirin was increased to 325 mg po qdaily from 81 mg po qdaily while in the hospital. # Anemia. Likely result of dilution given patient was given IVF initially and IV antibiotics. All cell lines decreased. Her vitals were stable. There was no clear source of bleeding and BUN was not elevated above baseline to suggest any underlying GI bleeding. It could also be a part of her underlying myelodysplatic syndrome and therapy. This should be followed up closely by her hematologist, Dr. [First Name (STitle) 1557]. # Hypertension: Blood pressure was stable in the 130s throughout her stay. She was continued on home Torpol XL 100 mg po BID but her Norvasc was held (5 mg po qdaily). She was continued on Catapres 3 qweekly on Sunday. She is discharged to continue with all three medications since low blood pressure was no longer an issue. This can be followed by her primary care physician. # Hypothyroidism: This issue was stable throughout hospitalization. She was continued on home Levothyroxine 50 mcg po qdaily # Chronic kidney disease. Baseline Crt ~ 1.7. Stage 3. Patient received fluid while in the ED. She received antibiotics and lasix while in the hospital, likely to account for the increase in creatinine to 1.8 from admission. She was discharged on levofloxacin that is dosed renally. This should continue to be followed. Medications on Admission: 1. Toprol 100 mg [Hospital1 ] 2. Prilosec 40 mg [Hospital1 ] 3. Furosemide 60 mg daily 4. Levothyroxine 50 mcg daily 5. Prednisone 12.5 mg daily 6. Norvasc 5 mg daily 7. Bicitra IT [Hospital1 ] 8. Vitamin D 1000 mg daily 9. Tylenol (2 extended release) daily 10. Allopurinol 200 mg qhs 11. MVI qhs 12. Metamucil qhs 13. Folic acid 1 mg qhs 14. Catapres 0.3 mg qweek (Sunday) Discharge Medications: 1. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. 4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. prednisone 2.5 mg Tablet Sig: Ten (10) Tablet PO DAILY (Daily): Please have 25mg per day until directed otherwise by your PCP. 6. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. sodium citrate-citric acid 500-300 mg/5 mL Solution Sig: Fifteen (15) ML PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 9. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. acetaminophen 650 mg Tablet Sustained Release Sig: [11-20] Tablet Sustained Releases PO once a day as needed for pain or fever. 12. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 3 days: Please take one pill on [2157-12-6], one pill on [2157-12-8]. Disp:2 Tablet(s) Refills:0 15. Oxygen Continue home O2 2L at night and as needed during the day to maintain SpO2 great than 90%. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Pneumonia - P-ANCA vasculitis flare Secondary Diagnosis: - Essential Thrombocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear. Ms. [Known lastname 41058], It was a pleasure taking care of you at [Hospital1 827] in [Location (un) 86]. You came to the hospital by ambulance for worsening shortness of breath after a 10 day history of congestion and a 5 day history of cough and pleuritic chest pain not responsive to increased steroids and z-pack use. On chest X-ray, you were found to have fluid in your lungs and pneumonia. You were treated with oxygen for your shortness of breath, a diuretic to clear the fluid in your lungs and an antibiotic for your pneumonia. Over the course of your stay, you also developed a post-nasal drip and ear pain, thought to likely be due to a flare of your vasculitis. Your prednisone dose was increased to 25mg daily. Please note the following changes in your medication. -Please START levofloxacin 750mg by mouth, once on [2157-12-6] and another one on [2157-12-8]. -Please INCREASE your dose of predinsone to 25mg per day until otherwise directed by your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 1557] [Name (STitle) 21421] START using oxygen supplement at 1-2L for at least 16 hours a day until you see Dr. [First Name (STitle) 1557] who will help to assess your oxygen level. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 1557] ([Telephone/Fax (1) 6309]) within one week of discharge for follow up care of your vasculitis and high platelets. Completed by:[2157-12-6] ICD9 Codes: 4280, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5057 }	Medical Text: Admission Date: [2175-3-21] Discharge Date: [2175-3-24] Service: [Company 191]/Medicine Intensive Care Unit HISTORY OF PRESENT ILLNESS: This is an 87 year old woman who presents from [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Nursing Home who is nonverbal at baseline with fevers to 102.0, an elevated lactate, borderline tachycardia and now hemodynamically instability. At the nursing home his temperature has been noted to be increased for the past four days. The patient was started on Levaquin on [2175-3-14], at the nursing home, however, continued to spike a fever. Diagnosis was presumptive pneumonia at that time. Given continued fevers, Clindamycin was added at 300 mg t.i.d. for question of aspiration coverage. She was also started on nebulizers on [2175-3-14]. The family states that she was recently hospitalized for an infection at [Hospital6 2910] and her discharge summary from [Hospital6 2910] noted that the patient had Staphylococcus septicemia, however, blood cultures were only 1 out of 2 positive for coagulase negative Staphylococcus. The patient per family has been in the hospital, in and out four times this year, initially since [Month (only) 404] and in [Month (only) 956] and then in [Month (only) 958], and then here. Mostly she goes to [Hospital6 2910]. She has had infections including Clostridium difficile colitis in [Month (only) 404], pneumonias and fevers over the course of her stay and over the course of this year. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes. 3. Status post pacer in [2168-1-16]. 4. History of pelvic fracture. 5. Gastroesophageal reflux disease. 6. Alzheimer's versus multi infarct dementia. 7. Inferior myocardial infarction by electrocardiogram. 8. Schizophrenia. ALLERGIES: No known drug allergies. MEDICATIONS AT NURSING HOME: Tylenol 325 q. 4 hours prn pain, Fleets enemas prn, milk of magnesia prn, Levaquin 500 mg times one times ten days started on [2175-3-14], Clindamycin t.i.d. times four days, started [3-14] and Sunday's. Sliding scale insulin, Glucophage 5 mg p.o. q. day, Zantac 150 mg p.o. q.h.s. tears, [Male First Name (un) ]-Tussin 10 cc p.o. q. 6 hours prn for cough. SOCIAL HISTORY: She is a resident of the [Hospital ] Nursing Home where at baseline she is nonverbal. She is Do-Not-Resuscitate, Do-Not-Intubate confirmed with family. Her primary care physician is [Last Name (NamePattern4) ]. [Last Name (STitle) ] at the [Hospital ] Health Center, Admission Health. PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.8, temperature maximum 102.0, pulse 79, blood pressure 126/54, respiratory rate 24, saturations 100% on 4 liters, nasal cannula. In general, she was nonverbal, noncooperative in no acute distress. Head, eyes, ears, nose and throat, unable to examine eyes. Oropharynx was clear. Membranes were dry. Cardiovascular, regular rate and rhythm. Distant heart sounds, no murmurs, rubs or gallops. Pulmonary, clear air movement with expiratory grunts. Rhonchi bilaterally. Abdomen was soft, obese, tympanitic, nontender, active bowel sounds. Extremities, no cyanosis, clubbing or edema, contracted extremities and palpable dorsalis pedis bilaterally. Neurological, noncooperative examination and nonverbal. Skin was warm, dry and intact with no evidence of any breakdown. LABORATORY DATA: Laboratory data on admission revealed a white count of 10.0 with 60% neutrophils, 33% lymphocytes, hematocrit 45.7, platelets 137, sodium 152, potassium 4.1, chloride 119, bicarbonate 21, BUN 35, creatinine 0.9, glucose 180, calcium 9.6, magnesium 35.5, phosphorus 2.4. AST, ALT of 44 and 53. Lactate of 4.4. INR 1.2. Urine cultures pending, blood cultures pending. Urinalysis with small leukocytes, large blood, 30 protein, trace ketones, greater than 50 red blood cells, 11 to 20 white blood cells and 6 to 10 epithelial cells. Chest x-ray, the patient was markedly rotated. Lungs clear with no pleural effusions. Marked osteopenia. Elevation of the right hemidiaphragm. HOSPITAL COURSE: This was an 87 year old woman who presents from a nursing home with fevers to 102, tachypnea and lactate of 4.4. 1. Fevers - The patient came in with fevers to 102, elevated lactate and was initially admitted under the sepsis protocol, and she had right subclavian line placed for access and was hydrated aggressively initially. Source of infection was initially unclear, most likely from positive urinalysis. She had a urinary tract infection. Urine cultures have been negative to date and blood cultures have been negative to date. Sputum cultures did show coagulase positive Staphylococcus aureus, however, this was a bad sample and likely represents colonization. The patient was not treated for this. There were no plans to treat. The patient's chest x-ray and repeat showed no evidence of pneumonia and were otherwise stable. Otherwise the patient defervesced after her initial temperature. The patient was started on the Vancomycin and Ceftriaxone which she tolerated without difficulty. These were dosed for her creatinine clearance. As the patient remained afebrile and no clear source of an infection was identified except for a positive urinalysis, the patient's antibiotics of Vancomycin and Ceftriaxone were discontinued. 2. Hyponatremia - The patient was hyponatremic on admission with sodium of 152 likely secondary to hypovolemia in light of the patient's fevers and ..................... The patient was hydrated aggressively initially and then was gentle intravenous hydration. Her sodium improved to 138 and her fluids were discontinued. 3. Dementia and nonverbal state - Per family back at baseline she does not communicate, can grimace to pain and will eat with urging of family members. The patient's family confirmed her functional status and the patient was back to her baseline per her family. She was continued on her Zoloft, her Depakote and prn Haldol were on hold during the course of her admission here. The patient continued to eat when encouraged by her family or nursing staff and was taking reasonable p.o. and her intravenous with hydration was discontinued. 4. Diabetes - The patient is stable with initially elevated blood sugars on admission, likely secondary to response from her infection is possible. The patient's family notes that her blood sugar was only out of control on her initial admission to the hospital and then resolved. The patient's blood sugars by the end of her stay were in the 1-teens to 120s, and will be discharged on home on Glyburide with sliding scale insulin as needed. 5. Coronary artery disease - The patient is status post inferior myocardial infarction per history. She was started on a statin here at 80 mg dosed, because of the light troponin leak on admission which was attributed to demand ischemia. She had no electrocardiogram changes. Eventually may consider starting the patient on beta blocker, ACE inhibitor as blood pressure will tolerate. 6. Anemia - The patient had a stable hematocrit during the course of her stay and has no anemia of chronic disease and will continue to follow upon discharge. 7. Chronic obstructive pulmonary disease - The patient was stable, no evidence of wheezing on examination. She was continued on prn Albuterol/Atrovent nebulizers as needed. 8. Gastroesophageal reflux disease - The patient was continued on her dosing of her Zantac. 9. Aspiration - The patient was aspiration risk, had speech and swallow evaluation for which she passed and just recommend p.o. diet consisting of pureed solids and thin liquids and she requires one to one assistance with all p.o. and medications be crushed if possible or in liquid form, and she is only to take thin liquids through a straw and basically maintain basic aspiration precautions including sitting upright after meals. Otherwise the patient was stable on this regimen and the patient's p.o. intake improved over the course of her stay. 10. Code status was confirmed in a family meeting to be Do-Not-Resuscitate, Do-Not-Intubate. DISCHARGE MEDICATIONS: 1. Albuterol nebulizers one q. 4 prn. 2. Atrovent nebulizers one q. 6 prn. 3. Subcutaneous heparin 5000 units q. 12. 4. Zoloft 500 mg p.o. q. day. 5. Milk of magnesia 30 mg p.o. q. 6 hours prn constipation. 6. Ranitidine 150 mg p.o. q. day. 7. Sliding scale insulin. 8. Bisacodyl 10 mg p.o. p.r. q. day. 9. Colace 100 mg p.o. b.i.d. 10. Aspirin 325 mg p.o. q. day. 11. Atorvastatin 80 mg p.o. q. day. 12. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn pain in liquid form. DISCHARGE DIAGNOSIS: 1. Sepsis. 2. Dementia. 3. Hypernatremia. 4. Diabetes. 5. Coronary artery disease. 6. Anemia. 7. Chronic obstructive pulmonary disease. DISCHARGE FOLLOW UP: The patient is to follow up with her primary care physician at her nursing home. DISCHARGE CONDITION: Fair. The patient's ....................will have her eat with encouragement on minimal oxygen requirement and without pain. DISCHARGE STATUS: Discharged to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2175-3-24] 09:51 T: [2175-3-24] 10:29 JOB#: [Job Number 95506] ICD9 Codes: 0389, 5070, 5990, 2760, 496, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5058 }	Medical Text: Admission Date: [2155-9-16] Discharge Date: [2155-9-16] Date of Birth: [2077-8-17] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: sepsis Major Surgical or Invasive Procedure: placement of arterial line, femoral TLC, subclavian TLC. History of Present Illness: HPI: 78yo woman with history of HTN, DM2, GI bleeding, and spinal stenosis presented to [Hospital3 934] Hospital with nausea/vomiting/diarrhea for 3 days. On admit to Caritas ED, her vitals were 97.3, 65, 20, 134/51, and 100% on RA. There, she underwent CT of abdomen with oral contrast, which was read as significant for the following: small hiatal hernia, markedly distended stomach with distal gastric wall thickening (inflammation vs. infectious process), small amount of ascites, s/p cholecystectomy, moderate amt of stool in colon, apparent thickning of rectal wall, "possible thickening of the large bowel wall, but not certain due to lack of oral contrast". She was also diagnosed with urinary tract infection. At Caritas ED, she was given volume resuscitation with NS 2L, levaquin 500mg, Dilaudid 0.5mg x 2, reglan, pepcid, and ativan. She had WBC count of 23.9, UA with mod blood, 30 prot, Lg LE, numerous WBC. . On transfer to [Hospital1 18] ED, she was afebrile, hemodynamically stable and a/o x 3. . Upon arrival to [Hospital1 18] ED, she quickly was noted to be apneic, with right facial droop, and slumping over to right side. She was apneic and cyanotic. She was intubated. Given 3L NS for hypotension. Given Vancomycin 1g, levaquin 500mg IV, and flagyl 500mg IV. She was given 3amps of bicarbonate. Given Insulin, D50, kayexalate, HCO3 for hyperkalemia. . Abdominal CT reviewed by Surgery and Radiology, who both feel that the CT clearly reveals some mucosal thickening, which could be consistent with C. Diff colitis. . Discussion with her family reveals that she has been in and out of [Hospital ] hospital and Rehab for significant GI bleed from UGI ulcer one month ago, has had CHF, and has had C. diff colitis; has completed 8 day course of flagyl. She had returned to home from rehab and was doing well, but then complained of mild nausea/vomiting/diarrhea for past 3 days. Past Medical History: Past Medical History: 1. DM2 2. Hypertension 3. Spinal stenosis 4. Congestive heart failure 5. h/o GI bleeding Social History: - Family History: - Physical Exam: . Physical exam: 92.9, 76, 122/56, 100% on mech vent (AC, 24 x 600, FiO2 100%) gen: intubated, sedated; following commands heent: PERRLA, eomi neck: no JVD cv: irregular; regular rate; no m/r/g resp: clear to auscultation bilaterally abd: soft, minimally distended; hypoactive bowel sounds; no peritoneal signs. Guaiac negative in ED. extr: cool extremities; no peripheral edema neuro: no focal deficits per limited exam Pertinent Results: [2155-9-16] 08:30AM TYPE-ART TEMP-32.8 RATES-24/ TIDAL VOL-600 PEEP-5 O2-50 PO2-177* PCO2-12* PH-7.08* TOTAL CO2-4* BASE XS--24 INTUBATED-INTUBATED [2155-9-16] 08:13AM LACTATE-17.7* [2155-9-16] 07:57AM GLUCOSE-136* UREA N-30* CREAT-1.8* SODIUM-138 POTASSIUM-6.5* CHLORIDE-110* TOTAL CO2-LESS THAN [2155-9-16] 07:57AM ALT(SGPT)-137* AST(SGOT)-427* LD(LDH)-2423* ALK PHOS-355* TOT BILI-0.5 [2155-9-16] 07:57AM ALBUMIN-1.5* CALCIUM-7.8* PHOSPHATE-6.6* MAGNESIUM-2.1 [2155-9-16] 07:57AM WBC-35.5* RBC-2.70* HGB-7.5* HCT-25.0* MCV-93 MCH-27.9 MCHC-30.1* RDW-19.2* [2155-9-16] 07:57AM PT-20.9* PTT-90.8* INR(PT)-3.1 [2155-9-16] 07:57AM FIBRINOGE-413* [2155-9-16] 07:07AM LACTATE-16.6* [2155-9-16] 06:11AM LACTATE-15.6* [2155-9-16] 06:10AM LACTATE-15.8* [2155-9-16] 06:10AM O2 SAT-52 [2155-9-16] 05:06AM LACTATE-15.3* [2155-9-16] 02:56AM WBC-34.5* RBC-2.75* HGB-7.6* HCT-25.0* MCV-91 MCH-27.8 MCHC-30.6* RDW-19.3* [2155-9-16] 02:56AM PLT COUNT-258 [2155-9-16] 02:56AM FDP-160-320* [2155-9-16] 02:56AM FIBRINOGE-487* [2155-9-16] 02:56AM RET AUT-3.4* [2155-9-16] 01:12AM TYPE-ART PO2-536* PCO2-22* PH-7.18* TOTAL CO2-9* BASE XS--18 [2155-9-16] 01:12AM LACTATE-15.0* NA+-136 K+-4.7 CL--107 TCO2-9* [2155-9-15] 10:44PM ALT(SGPT)-15 AST(SGOT)-38 LD(LDH)-401* CK(CPK)-28 ALK PHOS-140* AMYLASE-128* TOT BILI-0.4 [2155-9-15] 10:44PM NEUTS-30* BANDS-15* LYMPHS-34 MONOS-5 EOS-1 BASOS-0 ATYPS-0 METAS-13* MYELOS-2* [2155-9-15] 10:44PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-1+ BURR-1+ TEARDROP-1+ [2155-9-15] 10:44PM PLT SMR-NORMAL PLT COUNT-343 PLTCLM-1+ [2155-9-15] 10:44PM PT-18.2* PTT-85.7* INR(PT)-2.3 [2155-9-15] 10:46PM cTropnT-0.01 [2155-9-15] 10:44PM ALT(SGPT)-15 AST(SGOT)-38 LD(LDH)-401* CK(CPK)-28 ALK PHOS-140* AMYLASE-128* TOT BILI-0.4 [2155-9-15] 10:44PM LIPASE-19 [2155-9-15] 10:44PM ALBUMIN-2.1* CALCIUM-8.4 PHOSPHATE-7.0* MAGNESIUM-2.5 [2155-9-15] 10:44PM WBC-38.4* RBC-3.41* HGB-9.6* HCT-33.1* MCV-97 MCH-28.3 MCHC-29.1* RDW-19.2* [2155-9-15] 10:44PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-1+ BURR-1+ TEARDROP-1+ [2155-9-15] 10:44PM PLT SMR-NORMAL PLT COUNT-343 PLTCLM-1+ [2155-9-15] 10:44PM PT-18.2* PTT-85.7* INR(PT)-2.3 [2155-9-15] 10:35PM LACTATE-13.9* Brief Hospital Course: 78yo woman with complicated medical history presented from outside hospital with sepsis, and likely lactic acidosis from bowel ischemia. She was aggressively managed with volume resuscitation, pressors, broad spectrum antibiotics, and mechanical ventilaiton in the intensive care unit. . Over her course, she had worsening hypotension and increasing pressor requirements. Ultimately, family meeting was held, and it was decided to make her comfort measures only. She thereafter passed away. A post-mortem examination will be performed per the family's request. Medications on Admission: Medications: Atenolol 100mg [Hospital1 ] lisinopril 40mg qD MVI Effexor 75mg qD Allopurinol 100mg [Hospital1 ] KCL 40 qD Hydralazine 10mg TID Ativan 0.5mg prn (Flagyl 250mg TID x 8 days - done) anusol lasix 40mg qD protonix 40mg qD Procardia XL 30mg qD Vicodin prn Duragesic 50mcg q72hrs Discharge Disposition: Expired Discharge Diagnosis: deceased; sepsis Discharge Condition: - Discharge Instructions: - Followup Instructions: - ICD9 Codes: 0389, 5849, 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5059 }	Medical Text: Admission Date: [2120-4-15] Discharge Date: [2120-4-26] Date of Birth: [2059-4-26] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2120-4-18] Cardiac Cath [2120-4-19] Urgent coronary artery bypass graft times 5; left internal mammary artery to left anterior descending artery, saphenous vein grafts to diagonal, obtuse marginal, posterior left ventricular branch and posterior descending arteries History of Present Illness: 60M with history of MI, DM (all prior care received in [Country 651]), who presents with one week of exertional CP. Patient recently ran out of medications, and has since experienced worsening of his chronic pain, which occurs with exertion. He moved to the US from [Country 651] two months ago, and has never been seen by a physician in the US. He describes his chest pain as [6-1] intensity, sharp, radiating to bilateral shoulders L>R, and lasting about ten minutes at a time. It comes on early in the morning, or when walking up 4-5 stairs. He does not specifically notice a decrease in ET, but does feel that this pain has worsened over the past week. It is associated with shortness of breath, and resolves with rest, chest massage and with SL nitro. He has had this pain in the past (prior to being started on his current medications in [Country 651]). Today, patient presented to a clinic in order to obtain refills of meds, and was told to come to the ED for workup of his chest pain. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction ~ 2 years ago in [Country 651] Hypertension Hyperlipidemia Type II Diabetes Mellitus Seasonal allergies Hepatitis B - ? liver hemagioma per family Social History: Moved from [Country ] to US 2 months ago to be near his daughters. Currently living with one of his daughters. -[Name2 (NI) 1139] history: 35 pack year smoking history, stopped 1.5 years ago -ETOH: denies any recent EtOH, never heavy drinker -Illicit drugs: none Family History: Mother died of MI age 73. No family history of diabetes Physical Exam: VS: T=97.7, BP=115/67, HR=68, RR=14, O2 sat=95% on RA, FS 241 GENERAL: WDWN middle aged chinese male in NAD. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no JVD CARDIAC: RRR, normal S1, S2. No m/r/g. No reproducible ttp over chest wall LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2120-4-16] ETT: Fair exercise tolerance. Anginal-LIMITING symptoms with ischemic ST segment changes with resolution of ST segment changes noted late post-exercise. Flat blood pressure response to exercise. [2120-4-18] cardiac cath: 1. Coronary angiography in this right dominant system revealed left main coronary artery disease, with 3 vessel disease. The LMCA had an 80% distal stenosis. The LAD had a 95% stenosis in the mid-portion, with a 90% stenosis of the diagonal branch. The LCX had a 80% stenosis at the origin. The RCA had a long 70% proximal stenosis, with an 80% stenosis at the origin of the PDA. 2. Resting hemodynamics revealed systemic normotension, with SBP of 132 mmHg. [2120-4-18] carotid u/s: Minimal plaque with bilateral less than 40% carotid stenosis. [2120-4-19] Echo: 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. Right ventricular chamber size is normal. with mild global free wall hypokinesis. There are focal calcifications in the aortic arch. LEFt venticular systolic function is 45% with dynamic focal abnormalities in the mid and apical inferior and anterior septum. The descending thoracic aorta is markedly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+)aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with no flail or prolapsing segments. The mitral annulus is 3.3 cm. Moderate (2+) mitral regurgitation is seen and varied with dynamic intraoperative ischemia. There is no pericardial effusion. Dr. [First Name (STitle) ] was notified in person of the results on the patient before surgical incision. POST-BYPASS: Normal RV systolic function. LVEF 50%. Mild MR [First Name (Titles) ] [Last Name (Titles) ]I. Intact thoracic aorta. Mild apical septal wall motion abnormalities seen. [2120-4-15] 12:01PM BLOOD WBC-6.4 RBC-5.25 Hgb-15.4 Hct-45.4 MCV-86 MCH-29.4 MCHC-34.0 RDW-12.8 Plt Ct-247 [2120-4-25] 04:30AM BLOOD WBC-10.7 RBC-3.58* Hgb-10.7* Hct-31.5* MCV-88 MCH-29.8 MCHC-33.8 RDW-14.3 Plt Ct-381 [2120-4-17] 05:22AM BLOOD PT-12.9 INR(PT)-1.1 [2120-4-26] 05:20AM BLOOD PT-13.1 INR(PT)-1.1 [2120-4-15] 12:01PM BLOOD Glucose-143* UreaN-13 Creat-0.9 Na-138 K-4.2 Cl-101 HCO3-25 AnGap-16 [2120-4-25] 04:30AM BLOOD Glucose-137* UreaN-12 Creat-0.9 Na-132* K-4.1 Cl-97 HCO3-28 AnGap-11 [2120-4-15] 08:00PM BLOOD CK(CPK)-68 [2120-4-16] 05:29AM BLOOD ALT-47* AST-31 LD(LDH)-130 CK(CPK)-65 AlkPhos-59 TotBili-0.8 [2120-4-25] 04:30AM BLOOD ALT-102* AST-37 [2120-4-24] 03:26AM BLOOD Albumin-3.4* Calcium-8.3* Phos-3.0 Mg-2.3 Brief Hospital Course: 60 year old Chinese male with history of hypertension, hyperlipemia, diabetes mellitus, and myocardial infarction who presents with one week of exertional chest pain in the setting of running out of medications, most consistent with angina. He was ruled out for a myocardial infarction with three sets of negative cardiac enzymes. ECG showed septal q waves, possibly consistent with old anteroseptal infarct but no ST segment changes. He was monitored on telemetry without arrhythmic events. ETT was significant for ischemic ST changes and anginal symptoms. Consequently, the patient underwent cardiac cath showing 3 vessel disease and left main disease. He was maintained on ASA, statin, beta blocker, and SL Nitro prn. After his cath he was placed on a Nitro gtt due to recurrent pain. After appropriate pre-operative work-up he was taken to the operating room on [4-19] where he underwent a coronary artery bypass graft x 5. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Beta blockers and diuretics were initiated and he was diuresed to his pre-op weight. On post-op day one he was transferred to the telemetry floor for further care. On post-op day two he had an episode of atrial fibrillation which was converted to sinus rhythm with amiodarone and beta blockers. Chest tubes and epicardial pacing wires we removed on post-op day three. On post-op day four EP was consulted d/t post conversion pause following a fib to sinus rhythm. On post-op day five he had recurrence of atrial fibrillation and was treated with Lopressor and started on Coumadin (per EP recommendation). Keflex was given for left arm phlebitis. During post-op period he worked with physical therapy for strength and mobility. Over the next couple days Coumadin was titrated for a goal INR between 2-2.5 (day of discharge INR was 1.1). Coumadin follow-up was arranged with PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3321] at [Hospital1 778] health and will have first blood draw on [Last Name (LF) 766], [4-29]. He was claered for discharge to home by Dr. [First Name (STitle) ] [Name (STitle) 85517] with VNA services on post-op day seven with the appropriate follow-up appointments and medications. Medications on Admission: Chinese Medications: -alginic sodium 50 mg TID --?? -rhizoma 40 mg as needed for chest pain -Betaloc 25 mg TID --? possibly beta blocker -Isosorbide mononitrate 20 mg TID -ASA 300 mg daily -Novanorm/repaglinide 2 mg TID -Fluvastatin 40 mg daily -Vasorel/trimetazidine 20 mg daily - ?? med for angina -Acipimox 0.25 grams TID -- ??med for lipids Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 7. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): needs lft in 1 week . Disp:30 Tablet(s) Refills:2 10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:28 Capsule(s) Refills:0 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): 200mg TID x 2 wks, then 200mg daily until stopped by cardiologist. Disp:60 Tablet(s) Refills:2 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Indication: post-op atrial fibrillation Goal INR 2.0-2.5 PCP: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3321] NP will follow INR and adjust dose accordingly. Disp:30 Tablet(s) Refills:2 13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Welpole VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 Past medical history: Hypertension Hyperlipidemia Type II Diabetes Mellitus s/p Myocardial Infarction ~ 2 years ago in [Country 651] Hepatitis B - ? liver hemagioma per family Seasonal allergies Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Oxycodone Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage Left arm phlebitis 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 766] [5-20] @ 1:00 pm [Telephone/Fax (1) 170] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Lauglin [Hospital1 778] health [4-29] at 2pm - [Hospital1 ] in [11-25] weeks Please call to schedule appointments with your: Cardiologist Dr. [Last Name (STitle) 73] [Telephone/Fax (1) 62] in [11-25] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication: post-op atrial fibrillation Goal INR 2.0-2.5 First draw [2120-4-29] at [Hospital1 ] health during pcp appointment [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3321] to follow coumadin - spoke with [Doctor First Name ] in office [4-25] Will also need LFT's in 1 week from discharge. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2120-4-26] ICD9 Codes: 4019, 2724, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5060 }	Medical Text: Admission Date: [2191-7-4] Discharge Date: [2191-7-8] Date of Birth: [2130-7-4] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 60-year-old gentleman with a history of elevated cholesterol and hypertension and positive family history and HIV positive status with history of angina and known coronary artery disease with prior catheterization in [2186]. He has been medically managed since then, but he has now recently begun to have some chest pain with meals, which is relieved by Tums and rest. On [2191-6-7], he had a positive exercise tolerance test with left ventricular ejection fraction of 48 percent. His ejection fraction in [2186] on catheterization was 50 percent. He underwent cardiac catheterization on [2191-6-28], which showed normal left main diffuse disease in his LAD with serial 60 to 80 percent lesions. His circumflex artery had a high OM branch with a 90 percent stenosis and 80 percent mid stenosis. His RCA had a 100 percent proximal occlusion. Ejection fraction was 58 percent with no mitral regurgitation. He was referred to Dr. [Last Name (STitle) ] for a coronary artery bypass grafting. PAST MEDICAL HISTORY: Coronary artery disease, status post catheterization in [2186]. Hypertension. Hypercholesterolemia. HIV positive. Status post cerebral aneurysm clipping, [2171]. GERD. Status post right total hip replacement times 4, last one in [2182] secondary to Staphylococcus infection. Status post appendectomy. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg p.o. q.d. 2. Univasc 15 mg p.o. b.i.d. 3. Norvasc 5 mg p.o. q.d. 4. Lipitor 20 mg p.o. q.d. 5. Aspirin 81 mg p.o. q.d. 6. Prevacid 30 mg p.o. q.d. 7. Zyrtec 10 mg p.o. q.d. 8. Rhinocort nasal spray as needed. 9. Celebrex 200 mg p.o. q.d. 10. Ziagen 300 mg p.o. b.i.d. 11. Viread 300 mg p.o. q.d. 12. Epivir 300 mg p.o. q.d. 13. Sustiva 600 mg p.o. q.d. 14. AndroGel topical patch. 15. Folate 400 mg p.o. q.d. 16. Vitamin C 1000 mg p.o. q.d. 17. Vitamin E 400 units p.o. q.d. 18. Fish oil q.d. ALLERGIES: He had no known allergies. FAMILY HISTORY: His family history was positive for CAD. SOCIAL HISTORY: He quit smoking 30 years ago. He has 1 to 2 glasses of wine per night and lives with his partner. REVIEW OF SYSTEMS: On examination, his review of systems is unremarkable. He is in no apparent distress. Please refer to his medical history above. PHYSICAL EXAMINATION: He is 5 foot 10 inches tall with a weight of 157 pounds. His pupils were equal and reactive to light and accommodation. EOMs were intact. His oropharynx was benign. His neck was supple. He had no lymphadenopathy or thyromegaly. His carotids were 2 plus bilaterally. His lungs were clear to auscultation. His heart had normal sounds with S1 and S2, and no murmur, rub, or gallop. His abdomen was soft and nontender without any masses or hepatosplenomegaly, with positive bowel sounds. His extremities had no clubbing, cyanosis, or edema. His pulses were 2 plus bilaterally throughout. His neuro exam was nonfocal. He was referred to Dr. [Last Name (STitle) ]. PREOPERATIVE LABORATORY DATA: White count 4.7, hematocrit 37, and platelets count 123,000. PT 14.6, PTT 25.2, and INR 1.4. His urinalysis was negative. Glucose 97, BUN 26, creatinine 0.8, sodium 139, potassium 3.8, chloride 106, bicarbonate 24 with an anion gap of 13. ALT 21, AST 21, alkaline phosphatase 68, amylase 53, total bilirubin 0.3, and albumin 4.2. His vitamin B12 level was 836. His preoperative chest x-ray showed no acute cardiopulmonary abnormality. HOSPITAL COURSE: On [2191-7-4], he underwent coronary artery bypass grafting times 3 with LIMA to the LAD, a vein graft to the OM1 and a vein graft to OM2. He was transferred to the cardiothoracic ICU in stable condition on titrated phenylephrine drip and propofol drip. On postoperative day 1, he was atrial paced at a rate of 90. Another cardiac index was 3.47. Blood pressure of 123/50 on CPAP with postoperative labs of hematocrit 24.8 and white count 5.5 with the platelet count of 80,000. Sodium was 141, potassium 4.2, chloride 109, CO2 28, BUN 11, creatinine 0.6 with blood sugar of 91. He had breath sounds bilaterally. His abdomen was soft. His heart was regular in rate and rhythm. He was weaned to extubation and pulmonary toilet was begun. He was on insulin drip, neo drip, and nitroglycerin drip as well as propofol at that time, and also continued with his perioperative antibiotics. He was extubated. The patient was transferred to the floor on the afternoon of [2191-7-5] on postoperative day 1. On postoperative day 2, the patient had some complaints of nausea, which was relieved by Zofran. He otherwise had no complaints. He had a good pain control. He was in sinus rhythm at a rate of 80 with blood pressure of 130/80. His hematocrit rose slightly to 27.9 with a white count of 6.8, and creatinine of 0.7. His lungs were clear bilaterally with decreased breath sounds at the left base. His sternum was stable. His heart was regular in rate and rhythm with normal sounds. His left endoscopic harvesting sites for saphenectomy were clean, dry, and intact. His chest tubes were discontinued. His Lopressor was increased to 25 mg p.o. b.i.d. as he began beta-blockade. He was seen by physical therapy and begun ambulation. He was also seen by case management for evaluation of VNA services when he goes home. On postoperative day 3, the patient was doing extremely well, ambulating, he was alert, awake, and oriented with a nonfocal exam. His heart was regular in rate and rhythm with no murmur. His lung sounds were clear bilaterally. He had bowel sounds. He had no edema in his extremities. All of his incisions were clean, dry, and intact. On the evening of [2191-7-7], he did have a little bit of serosanguinous drainage from his left pleural tube site. Of note, also his platelet count decreased to 93, his pacing wires were discontinued. He did have flight of stairs and his Lasix was decreased for diuresis, as he was rapidly approaching his preoperative weight. On postoperative day 4, the day of discharge, [2191-7-8], his Lopressor was increased to 50 mg p.o. b.i.d. His exam was as follows: Temperature 97.2 degrees, blood pressure 138/76, heart rate 82 and regular, respiratory rate 18, and saturating 95 percent on room air. His weight today at discharge was 71.4 kg, this is approximately half kilogram below his preoperative weight. His heart was in regular rate and rhythm. He had S1 and S2, normal heart sounds with no murmur. His lungs were clear bilaterally except for decreased breath sounds at both bases. His abdomen was soft, nontender, and nondistended with hypoactive bowel sounds. His left leg saphenectomy IVH sites were clean, dry, and intact with no erythema. He had no peripheral edema that was detected. Sternum was stable, clean, dry, and intact with no erythema. He had minimal serosanguinous drainage at his left pleural tube site. His chest x-ray from [2191-7-6] showed a smaller pleural effusion and question of a left small apical pneumothorax. On the day of discharge, his labs were as follows, white count 6.8, hematocrit 29.6, and platelet count rose to 136, so the patient was restarted on his aspirin. Sodium 142, potassium 3.9, chloride 105, CO2 28, BUN 9, creatinine 0.8, with a blood sugar of 101, and magnesium 2.2. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Percocet 5/325 1 to 2 tablets p.o. p.r.n. q. 4-6h. for pain. 3. Efavirenz 600 mg p.o. q.h.s. 4. Lamivudine 300 mg p.o. q.d. 5. Tenofovir 300 mg p.o. q.d. 6. Testosterone 2.5 mg 24-hour patch 1 patch q.d. 7. Abacavir 300 mg p.o. b.i.d. 8. Lipitor 20 mg p.o. q.d. 9. Vitamin C 1000 mg p.o. q.d. 10. Lansoprazole 30 mg p.o. q.d. 11. Vitamin E 400 units p.o. q.d. 12. Metoprolol 50 mg p.o. b.i.d. 13. Lasix 20 mg p.o. q.d. times 5 days. 14. KCl 20 mEq p.o. q.d. times 5 days. DISCHARGE INSTRUCTIONS: The patient was given discharge instructions to follow up with Dr. [First Name11 (Name Pattern1) 449] [Initial (NamePattern1) ] [Last Name (NamePattern4) 2392], his primary care physician, [Last Name (NamePattern4) ] 1 to 2 weeks and to see Dr. [Last Name (STitle) ] in the office for postoperative visit in approximately 4 weeks. DISCHARGE DIAGNOSES: Status post coronary artery bypass grafting times 3. History of coronary artery disease. Hypertension. Hypercholesterolemia. Positive human immunodeficiency virus status. Status post cerebral aneurysm clipping, [2171]. Gastroesophageal reflux disease. Status post right total hip replacement times 4 secondary to staphylococcus infection. Status post appendectomy. CONDITION ON DISCHARGE: The patient was discharged to home in stable condition on [2191-7-8]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2191-7-8] 09:57:49 T: [2191-7-8] 18:23:27 Job#: [Job Number 32144] ICD9 Codes: 4111, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5061 }	Medical Text: Admission Date: [2193-4-18] Discharge Date: [2193-4-24] Date of Birth: [2126-1-13] Sex: F Service: MEDICINE Allergies: A.C.E Inhibitors Attending:[First Name3 (LF) 443] Chief Complaint: CHF Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 67 year old patient transferred from [Hospital 25368] [Hospital 107] Hospital, well known to Dr.[Name (NI) 3536] heart failure service, hx of dilated cardiomyopathy with an LVEF less than 10% and bioprosthetic mitral valve replacement for severe MR, admitted to OSH on [2193-4-6] with acidemia, SOB, hypotension, requiring intubation 3 days after admission. She was treated for CHF with IV lasix and Milrinone. Transferred to step down floor on [2193-4-14] where she went into respiratory distress, stridorous breath sounds (no arrythmia). Required reintubation. Initially thought this was due to heart failure but CVP was 2. Placed back on IV milrinone and extubated two days later (on [2193-4-16]). Currently with sats 98-100% on 2 liters. Getting treated with antibiotics for UTI and ? infiltrate on initial CXR. Also with stage I decubutis ulcer on buttocks covered with duoderm. . Prior to transfer vitals were HR 70-90's AF with paced beats, PVC's, BP 80/40-110/60, sats 98-100% on 2 liters, RR 20, afebrile. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She does note some swelling of her ankles. Also notes left pointer finger DIP pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, cannot assess dyspnea on exertion as pt has been bed-bound in hospital, denies paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. As above, ROS + for mild orthopnea, ankle edema. Past Medical History: -Valvular heart disease s/p bioprosthetic MVR and ASD repair in [2188] -Dilated CM with an LVEF < 10% (secondary to rheumatic heart dx) -S/p BiV ICD -Type 2 DM -HTN -Hyperlipidemia -CRI -GERD -PAF -S/p TAH -sleep apnea Social History: Lives with her husband, has 2 adult children. Used to work as a nurse's aid, now retired. She is a pastor. Never smoked, denies etoh, denies illicit drugs. Originally from [Male First Name (un) 1056]. Family History: There is no known family history of premature coronary artery disease or sudden death. Sister had uterine cancer. Mother with DM died of "[Last Name ] problem." Physical Exam: Vitals - T , HR 70, BP 91/67, RR 20, O2 99% 2L NC General - awake, alert, NAD HEENT - PERRL, EOMI, OP clear Neck - no carotid bruit b/l, no LAD, JVP at approx 10cm CVS - Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. Lungs - The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. Abd - The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Skin - Inspection and/or palpation of skin and subcutaneous tissue showed Stage I decubitus ulcer on buttocks, otherwise 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: TELEMETRY demonstrated: NSR at 70 bpm. . 2D-ECHOCARDIOGRAM performed on [2192-11-1] demonstrated: Conclusions: The left atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. The estimated pulmonary artery systolic pressure is normal. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2192-3-12], there is more tricuspid regurgitation. Otherwise, the findings are similar. . CARDIAC CATH performed on [2192-11-1] demonstrated: COMMENTS: 1. Right heart catheterization revealed severe elevation of left sided filling pressures with low cardiac index (wedge 34. CI 1.87). The right sided filing pressures were severely elevated with RA of 13mmHg. There was pulmonary hypertension to 58/27. With infusion of 1mcg/kg/min of nitroprusside the wedge fell to 19 with cardiac index up to 2.16. The PVR fell from 123 to 85. The systemic blood pressure fell slightly from 107/57 to 89/50. Dobutamine and milrinone were not used. 2. Patient transferred to CCU for tailored therapy. FINAL DIAGNOSIS: 1. Severe low output heart failure with elevated filling pressures responsive to vasodilator. . HEMODYNAMICS: SEE Above . LABORATORY DATA: [2193-4-17]: wbc 7.9, hct 33.1, plt 212, K 3.9, bun 51, creat 1.8, BNP 844, INR 1.6 . OSH microbiology data: [2193-4-8] Sputum cx - oropharyngeal flora [2193-4-15] Blood cx - NGTD [2193-4-15] Sputum cx - gram stain negative [2193-4-15] Urine cx - + enterococcus, [Last Name (un) 36] to ampicillin, nitrofurantoin, vancomycin, resistant to levofloxacin. . Reports: CXR upon admit to OSH: CHF, ? infiltrate . CXR on admission [2193-4-18]: Stable cardiomegaly, left base atelectasis, no PTX, small left pleural effusion. . Cardiac cath [2193-4-19]: The right sided filling pressures were mildly elevated. The left sided filling pressures were severely elevated. There was moderate pulmonary hypertension. The cardiac index was reduced. . TEE [2193-4-19]: Severe nearly static spontaneous echo contrast is seen in the left atrial appendage and there is probable thyombus formation. The left atrial appendage emptying velocity is depressed (<0.2m/s). No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed. There is right ventricular free wall is hypokinetic. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral leaflets appear normal. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis (although gradient difficult to judge in setting of low output state). Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Brief Hospital Course: Pt is a 67 yo woman with history of severe dilated cardiomyopathy (EF 10%), bioprosthetic mitral valve replacement, HTN, hyperlipidemia, DM2, who initially presented to OSH w/ SOB, acidemia, hypotension, found to have likely heart failure exacerbation, UTI, and ?pna, transferred here for further w/u and management per Dr. [First Name (STitle) 437]. Hospital course by problem: . 1) Cardiac: A. Pump: Pt w/ h/o severe dilated cardiomyopathy, EF 10%, h/o recurrent exacerbations, now w/ apparent re-exacerbation. She was initially treated on milrinone, aldactone, coreg, digoxin. She underwent right heart cath to assess hemodynamics. Finding on right heart cath (on milrinone): RA 7, RV 59/9, PA 59/22, wedge 30/39, co/ci 3.3/1.9, SVR 1770, PVR 121. In the CCU, when milrinone was turned off, there was a significant reduction in the CO (approx 4 to 2). Therefore, milrinone was restarted. However, patient improved considerably so that milrinone was discontinued again. We were able to start a low dose captopril and titrate up. She tolerated this very well and we changed her to lisinopril prior to discharge. Her symptoms markedly improved and she was reportedly back to her baseline. PT saw her prior to discharge and did not recommend home PT. * As an outpatient, please be aware that patient has systolic BPs in the high 80s-low 100s. This is normal for her, given her low EF and substantial heart failure. Her cardiac meds should not be held if her BP is in this range, per d/w Dr. [First Name (STitle) 437] * . B. Rhythm: Pt w/ h/o AF, s/p PM and ICD. She was treated with coreg, dig, amiodarone. The initial plan was to DCCV, however, a pre-cardioversion TEE showed [Name Prefix (Prefixes) ] [Last Name (Prefixes) 2966], therefore, amiodarone was stopped, she was started on a heparin GTT and the plan was for the pt. to return in 6 weeks to repeat a TEE and consider cardioversion at that time. In the interim she is to be anti-coagulated. We started lovenox and coumadin. Patient and her family underwent lovenox teaching and she will remain on it [Hospital1 ] until INR therapeutic. She has f/u with her PCP in two days for an INR check. She will need outpatient followup for a TEE and possible cardioversion after approx 6 weeks of adequate anticoagulation. C. Cor: No h/o CAD. Continued cardiac management as above. . 2) UTI: Enterococcus in urine, resistant to levofloxacin, sensitive to ampicillin. She was treated with 7d course of amox prior to discharge. . 3) ?Pneumonia: Per report ?infiltrate on CXR at OSH. No indication of pna on CXR at [Hospital1 18]. We did not treat . 4) Stage I Decub Ulcer: Wound care assisted with management of wounds. . 5) GERD: continued protonix . 6) FEN: Low salt, diabetic diet, monitored and repleted lytes PRN. . 7) Access: R subclavian placed at OSH [2193-4-17]. RH catheter placed at BIMDC. This was discontinued prior to discharge. . 8) Code: Full . . Medications on Admission: Mag oxide Unasyn 2 IV q 12 Aldactone 25mg daily Amiodarone 400mg daily Digoxin .125mg daily Coreg 3.125 [Hospital1 ] Asa 81 Protonix 40mg IV Coumadin has been on hold Milrinone 5cc/hour (.28mcg/kg/min) Heparin at 780u/hour. Discharge Medications: 1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:14 Tablet(s) Refills:0 8. LAB WORK Please have your INR checked on [4-26] at your PCP's office. You can discontinue your lovenox injections when your INR is between [12-29] 9. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous twice a day for 7 days. Disp:14 syringes Refills:0 Discharge Disposition: Home With Service Facility: [Location 45673]VNA & Hospice Discharge Diagnosis: Primary Diagnosis: -Severe dilated cardiomyopathy with CHF exacerbation -Atrial fibrillation with thrombus noted in LA on recent echo -Stage I decub ulcer treated with wound care -GERD . Secondary Diagnosis: -valvular heart disease s/p bioprosthetic MVR and ASD repair in [2188] -s/p BiV ICD -DMII -HTN -Hyperlipidemia -CRI -sleep apnea Discharge Condition: Afebrile. Hemodynamically stable. Ambulating. Tolerating PO. Discharge Instructions: You were admitted for further treatment of your heart failure. We treated you with medications to imporve your heart function. You also had a urinary tract infection which we treated. . Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. . Please take all your medications as directed. Notably: 1. Please take lovenox injections twice daily until your coumadin level becomes between [12-29]. This may take up to [4-1] days. 2. We started lisinopril 10mg daily 3. We started metoprolol 12.5mg [Hospital1 ] 4. We restarted your coumadin at 5mg per day. please adjust per your PCPs recommendations. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 ml . Please keep you follow up appointments as below. Followup Instructions: Please follow up with your primary care doctor (ABDELKADER,KHALED M. [Telephone/Fax (3) 45678]) on Friday [2193-4-26] at 10:45am to have your INR checked and to have a followup appt. . Please also follow up with: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2193-6-12] 9:30 Provider: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 1240]:[Telephone/Fax (1) 3512] Date/Time:[2193-6-12] 10:00 . You will also need an appointment with Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. They can be reached at ([Telephone/Fax (1) 13786]. Please followup with them within 2 weeks. You are tentatively scheduled for an appt on [5-7] at 2:30pm ICD9 Codes: 4254, 5856, 5990, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5062 }	Medical Text: Admission Date: [2119-11-10] Discharge Date: [2119-11-23] Date of Birth: [2042-9-24] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Intraventricular - Cerebellar hemorrhage Major Surgical or Invasive Procedure: Cerebral angiography External ventricular device placement History of Present Illness: The pt is a 77F with PMH s/f HTN, hypercholesterolemia, and recent GI srugery (unclear from records/no family present) who presents with posterior circulation SAH. EMS was called at aproximately 10pm on [2119-11-9] when the patient suddenly became nauseated, vomited, and had sudden onset dizzyness. She was brought to the ED at [Hospital 1474] Hospital. She recieved NS, zofran and protonix. A head CT revealed blood in the 3rd and 4th ventricles. Patient was transferred to [Hospital1 18]. In the ED here the patient was initially noted to be awake, alert, conversant. This deteriorated and her alertness was noted to decrease such that her responses even to noxious stimuli were blunted. The patient was intubated. ROS - unable to perform ROS with patient intubated and sedated. Past Medical History: HTN Hypercholesterolemia Recent GI surgery - unclear what. Social History: Unknown - appears to live with daughter - [Name (NI) 76031],[Name2 (NI) 76032] Phone: [Telephone/Fax (1) 76033] Family History: Unknown Physical Exam: Vitals: T:101.7 P:98 R:30 BP:187/83 SaO2:96%on 3L ---->intubated. BP seen to normalize on propofol gtt. General: intubated and sedated. ----> On d/c= A&O x 3 HEENT: NC/AT. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA anteriorly 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. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Inutbated sedated. Eyes close even to noxious stimuli. -Cranial Nerves: PERRL 1.5-1mm bilaterally. Corneal reflexes intact. Cough reflex to ETT manipulation intact. -Motor: Moving legs spontaneously. Moves all four extremities to noxious stimuli. --> on d/c motor = full [5-13] throughout -Sensory: Intact as above to noxious stimuli. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -DTRs:not tested. Plantar response untested. -Gait: untested. Pertinent Results: Laboratory Data: Lactate:2.5 140 103 23 ---I----I---< 162 3.8 23 0.8 CK: 96 MB: Pnd Trop-T: Pnd Ca: 9.9 Mg: 1.7 T4: Pnd 10.8 11.4>----< 332 32.7 PT: 11.6 PTT: 20.5 INR: 1.0 EKG: Autoread as abberrant atrial beat. Old anteroseptal infarct. Non-specific inferior ST-Twave abnormalities. Radiologic Data: NCHCT here (AM [2119-11-10]) Compared with OSH CT scan - this scan shows probably stable amount of blood in the 3rd and 4th ventricles, but likely increasing volume of the 4th ventricle and temporal horns of the lateral ventricles. [2119-11-15] CTH No significant interval changes. No change in ventricles. Unchanged appearance of the left cerebellar and intraventricular hemorrhage. Brief Hospital Course: Patient is a 77 year old female transfered from [Hospital 1474] Hospital admitted to Neurosurgery for hydrocephalus and cerebellar hemorrhage. The patient was admitted to the SICU and an EVD was placed. On [11-10] Angio was done and showed no vascular malformation in posterior fossa. On [11-11] she was started on Nimodipine, and repeat CT showed a stable bleed. On [2119-11-12] EVD was raised to 20cm above tragus and she was reintubated for agitation and respiratory distress. On [11-13] EVD was clamped and echo done which showed EF>55 and no vegetations. On [11-15] CT stable, EVD was d/c'd. On [11-17] patient was transfered to stepdown. On [11-18], it was discovered that she had a UTI and was started on cipro. On [11-22] sutures and staples were discontinued. Patient has been evaluated by physical therapy and recommends rehabilitation. Upon discharge, the patient is alert and oriented x 3, afebrile with all vitals stable, tolerating po feeds, and with activity per physical therapy. Medications on Admission: metoprolol 12.5 [Hospital1 ] Lisinopril 40 daily Imdur 30 daily Protonix 40 daily Percocet 5mg q3h PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Tablet(s) 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Lisinopril 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 6. Racepinephrine 2.25 % Solution for Nebulization Sig: One (1) ML Inhalation PRN (as needed). 7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO three times a day: hold for SBP<100 or HR < 60. Discharge Disposition: Extended Care Facility: [Hospital3 4339] Discharge Diagnosis: Intraventricular and Cerebellar hemorrhage Discharge Condition: Neurologically Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ??????Check your incision daily for signs of infection ??????Take your pain medicine as prescribed ??????Exercise should be limited to walking; no lifting, straining, excessive bending ??????Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ??????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 WITHOUT CONTRAST Completed by:[2119-11-23] ICD9 Codes: 5990, 431, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5063 }	Medical Text: Admission Date: [2178-5-10] Discharge Date: [2178-5-20] Date of Birth: [2129-10-18] Sex: M Service: [Last Name (un) ] ADMISSION DIAGNOSES: Chronic hepatitis B cirrhosis, liver hepatoma status post RFA. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old male, Cantonese speaking with chronic hepatitis B cirrhosis resistant to lamivudine and a documented hepatoma status post RFA [2177-9-8] with good response. Repeat CAT scan on [3-22] documented no tumor recurrence and two satellite lesions. The patient presents on [2178-5-10] for liver transplant. PAST MEDICAL HISTORY: Includes non insulin dependent diabetes mellitus, hypercholesterolemia, history of hepatoma. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS: Include propanolol, ________, vitamin E, and insulin. SOCIAL HISTORY: Patient is married with three children and has had no alcohol since [2168]. PHYSICAL EXAMINATION: On examination, the patient was afebrile at 98.7 degrees with blood pressure at 142/78, heart rate of 58, respirations 18 and 97 percent on room air. Patient's examination was remarkable for a liver border of 6 cm inferior to the costal margin. Patient's abdomen was soft, nontender, nondistended with bowel sounds. LABORATORY DATA: Patient's preoperative labs were: White count 6.9, hematocrit of 41.6, and platelets of 80. INR was 1.4 and PTT was 35.3. Chemistries were unremarkable and ALT was 45, AST was 34, alkaline phosphatase was 121, total bilirubin 0.6. HOSPITAL COURSE: Patient was started on immunosuppressant and is status post cadaveric liver transplant, piggyback technique with bile duct to bile duct, portal vein to portal vein, and hepatic artery to hepatic artery transplant. Findings included no arteriohepatic disease and a small nodule next to the RFA site in the left lobe. Please see the operative note for details. Patient was transported to the intensive care unit postoperatively in a stable condition. On postoperative day 2, the patient was extubated and an NG tube was discontinued. The patient went into atrial fibrillation overnight, was rate controlled with beta blockade. Patient was in rate control, atrial fibrillation for first few days postoperatively, which subsequently became controlled with Lopressor 50 mg orally twice daily upon discharge. Patient was transferred to the floor on postoperative day 5 in a stable condition. The lateral JP was discontinued at this time. With high JP output and high JP bilirubin, there was concern for a biliary leak. However, the patient's JP output had decreased steadily and a CAT scan was obtained which showed no fluid collection. In addition, a hiatus scan was obtained which showed no leak. As mentioned, the patient's JP output decreased and was clear in color. [Initials (NamePattern4) ] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain was discontinued on the day of discharge without problem. On discharge, patient was afebrile with stable vital signs. The patient was tolerating a regular diet, passing flatus, and having bowel movements. The patient was ambulating on his own without problems and voiding appropriately. Patient's examination was remarkable for a soft, nontender, nondistended abdomen with a clean, dry, and intact incision. DISCHARGE DIAGNOSES: Chronic hepatitis B cirrhosis, end- stage liver disease status post cadaveric liver transplant on [2178-5-10]. Comorbidities are non-insulin dependent diabetes, hypercholesterolemia, hepatoma status post RFA. FOLLOW UP: Patient is to follow up at Liver [Hospital 1326] Clinic next Wednesday, given instructions to call for an appointment. Patient is to follow up with [Hospital ] [Hospital 982] Clinic regarding insulin control. CONDITION ON DISCHARGE: Patient's discharge condition is stable. DISCHARGE MEDICATIONS: 1. Fluconazole 400 mg p.o. q.day. 2. Adefovir 10 mg p.o. q.day. 3. Lopressor 25mg p.o. b.i.d. 4. Humalog 75/25 22 units q.am, 26 units at dinner. 5. Protonix 40 mg p.o. q.day. 6. Neoral 275 mg the night of discharge and 275 mg in the morning with levels to follow. 7. Bactrim one tablet p.o. q.day. 8. CellCept [Pager number ] mg p.o. b.i.d. 9. Protonix one to two tablets p.o. q.4 to 6 hours p.r.n. pain. 10. Prednisone 20 mg p.o. q.day. DISPOSITION: Home with services, physical therapy, home CT evaluation. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], [MD Number(1) 3432] Dictated By:[Last Name (NamePattern1) 4881] MEDQUIST36 D: [2178-5-20] 17:54:14 T: [2178-5-21] 16:35:01 Job#: [Job Number 13306] ICD9 Codes: 5715, 2851, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5064 }	Medical Text: Admission Date: [2189-3-3] Discharge Date: [2189-3-7] Date of Birth: [2153-1-6] Sex: M Service: TRANSPLANT HISTORY OF PRESENT ILLNESS: This is a 36 year old gentleman with end stage renal disease secondary to type 1 diabetes mellitus who presents for a living related renal transplant from his father. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus times nineteen years treated with an insulin pump. 2. Hypertension. 3. Retinopathy. 4. Cardiomyopathy with global hypokinesis and an ejection fraction of 25% (stress test was normal). MEDICATIONS ON ADMISSION: 1. Lasix 80 mg p.o. three times a day. 2. Atenolol 100 mg p.o. once daily. 3. Norvasc 5 mg p.o. twice a day. 4. Isordil 30 mg p.o. once daily. 5. Hydralazine 50 mg p.o. three times a day. 6. Nephrocaps one tablet p.o. once daily. 7. Iron. 8. TUMS two to three tablets p.o. three times a day. 9. Rocaltrol 0.25 mg p.o. once daily. 10. Procrit 4000 units q.week. 11. Insulin pump. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies use or abuse of tobacco, alcohol or illicit drugs. He is a HBAC engineer for local police department. PHYSICAL EXAMINATION: On admission, the patient is a 160 pound gentleman appearance consistent with his stated age. He looks well. His blood pressure is 142/82 on examination. His lungs are clear to auscultation bilaterally. His heart is regular. His abdomen is soft, nontender, nondistended. Insulin pump is in place. He has 3+ bilateral femoral pulses with all palpable peripheral pulses. He has 1+ pitting edema bilaterally. HOSPITAL COURSE: On the day of admission, the patient underwent a living related kidney transplant from his father, [Name (NI) ]. The procedure was performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 15473] and assisted Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ]. The procedure was performed without complications. Intraoperatively he received six liters of fluid and made 700 ccs of urine. The patient tolerated the procedure well and was extubated in the operating room and was transferred to the Post Anesthesia Care Unit in stable condition. Please see previously dictated operative note for more details. The patient had a Swan-Ganz catheter placed in the operating room in anticipation of large volume shifts and an ejection fraction of 25%. He spent the evening of postoperative day number one extubated in the Intensive Care Unit for hemodynamic monitoring. Throughout the entire night, his filling pressures all remained within normal limits and he continued to have pericardiac output without any evidence of failure. On postoperative day number one, his Swan-Ganz catheter was discontinued. His home antihypertensive medications were all restarted and these are sufficient to maintain a systolic blood pressure in the 140s. His postoperative course was uneventful with the exception of difficult to control blood sugar. This was anticipated in light of the high dose steroids given per the transplant protocol. The [Hospital ] Clinic was consulted and assisted in our management of his insulin pump. The patient made phenomenal urine output during his entire hospitalization and his renal function laboratories reflected this. For immunosuppression, the patient was started on CellCept [Pager number ] mg p.o. twice a day and that continued throughout his hospitalization. He was also started on FK506, and he receives the standard Solu-Medrol and Prednisone taper. Additionally, he received the three doses of antithymoglobulin. By postoperative day number four, the patient was able to ambulate. His pain was well controlled. He was making adequate urine. He was taking all p.o. medications. He was ready to be discharged to home. Laboratory values on discharge included complete blood count with a white blood cell count of 2.7, hematocrit 32.7, platelet count 189,000. Chemistries revealed a sodium 138, potassium 4.2, chloride 102, bicarbonate 26, blood urea nitrogen 37, creatinine 1.6, glucose 175. DISCHARGE DIAGNOSIS: Status post living related kidney transplant. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. CellCept [Pager number ] mg p.o. twice a day. 2. FK506 5 mg p.o. twice a day. 3. Prednisone taper, today Saturday, he will receive 40 mg p.o. twice a day, tomorrow 30 mg p.o. twice a day, Monday he will receive 20 mg p.o. twice a day, and on Tuesday, he will start 20 mg p.o. once daily. This will be maintained until he goes to clinic. 4. Valganciclovir 450 mg p.o. once daily. 5. Bactrim one tablet p.o. once daily. 6. Dilaudid 2 mg p.o. q4-6hours p.r.n. 7. Hydralazine 50 mg p.o. q8hours. 8. Norvasc 5 mg p.o. once daily. 9. Atenolol 100 mg p.o. once daily. 10. Isosorbide Dinitrate 10 mg p.o. three times a day. 11. Colace 100 mg p.o. twice a day. 12. Insulin pump per recommendations made by [Hospital ] Clinic and the patient. 13. Protonix 40 mg p.o. once daily. FOLLOW-UP: The patient will follow-up with [Hospital 1326] Clinic next week. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15475], M.D. [MD Number(1) 15476] Dictated By:[Last Name (NamePattern1) 6355] MEDQUIST36 D: [2189-3-7] 12:45 T: [2189-3-7] 14:29 JOB#: [Job Number 45077] ICD9 Codes: 4254
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5065 }	Medical Text: Admission Date: [2129-3-3] Discharge Date: [2129-3-7] Date of Birth: [2053-4-13] Sex: M Service: CHIEF COMPLAINT: Carotid artery stenosis. HISTORY OF PRESENT ILLNESS: This is a 75-year-old white male with bilateral carotid endarterectomies. The right was done in [2116] and the left was done in [2124] with a proximal stenosis of the left internal carotid artery and 90% distal stenosis of the right carotid. The patient denies Transient ischemic attack, weakness, upper or lower extremity changes, vision changes, dizziness. Denies short of breath, fever, sweats, chills, occasional constipation. He has rare chest pain, last episode of 5 months ago. On an average two to three times per year associated with stress. Denies any lower extremity claudication. PAST MEDICAL HISTORY: No known drug allergies. MEDICATIONS: 1. Diazepam 5 mg four times a day p.r.n. 2. Nitroglycerin 0.4 mg p.r.n. 3. Pravachol 20 mg q day. 4. Aspirin 325 mg q day. 5. Percocet tablets one q 4 to 6 hours p.r.n. for pain. PAST ILLNESSES: Anxiety, history of gout, history of malacia for which she was treated with Prednisone and this has been asymptomatic times five years. Myocardial infarction in [2113-10-8]. Lumbar stenosis, benign prostatic hypertrophy. PAST SURGICAL HISTORY: Scrotal hydrocele repair, a right carotid endarterectomy, a left carotid endarterectomy. HABITS: 50 pack year smoker, quit one year ago, likes a drink per day. PHYSICAL EXAMINATION: Vital signs stable. General: This is an alert oriented male in no acute distress. Head, eyes, ears, nose and throat: Unremarkable. Neck: Well healed carotid incisional scars. Chest is clear to auscultation. Heart: Regular rate and rhythm. No murmurs, gallops or rubs. Extremities show 1+ pitting edema bilaterally of ankles and feet. There are no abdominal aortic aneurysm on palpation of the abdomen. The femoral pulses are 1+. The dorsalis pedis pulses are monophasic bilaterally. The neurological is nonfocal except for anxiety. HOSPITAL COURSE: The patient was admitted to the Vascular Service on [2129-3-3]. Routine labs were obtained. Plavix load of 300 mg with aspirin was given and 325 mg of aspirin was started 24 hours after it. Intravenous hydration was begun for anticipated angiography, a Mucomyst protocol. The patient was seen by Neurology. Their neurological exam, mental status awake, alert and oriented times three. Language fluent with good comprehension and repetition of the months of the year backwards accurate. Can perform simple calculations. Construction intact. No neglect, no frontal release signs. Cranial nerves: Visual fields are intact. Extraocular movements intact. Pupils are 1 mm and minimally reactive bilaterally. Facial sensation is intact. Right facial droop with synkinesis. Hearing is decreased bilaterally to finger rub. Palatal elevation is symmetric. Shoulder shrug, head turning symmetric. Tongue midline. Muscle strength is [4-11] bilaterally upper and lower extremities. Reflexes show biceps 1+ bilaterally, triceps 1+ bilaterally. Radial reflexes 1+ Paroxysmal atrial tachycardia reflex is 0, toes are up. Sensation is decreased to pinprick in stocking distribution. Intact to pain, touch and proprioception. Coordination: Finger-to-nose, heel to tibia and rapid alternating movements are intact. There is no rebound. Gait is normal base. LABORATORY: Showed a white count of 5.8,hematocrit 40.8, platelets 231. Potassium 3.7, BUN 16, creatinine 1.4, glucose 145. PT/INR were normal. Preoperative Duplex of the Carotids demonstrated the right with minimal plaque, the left is significant wall thickening but does not appear to be a heterogenous plaque. On the right the systolic velocities are 117, 82, 105. In the internal carotid, common carotid and external carotid arteries respectively. The internal carotid artery to common carotid artery ratio is 1.4, this is consistent with 40 to 69% stenosis. On the left the internal carotid artery is peak systolic velocity over 374/147. The remainder of the vessel peak systolic velocities are 69, 65 in the common carotid and external carotid artery respectively. The Internal carotid artery and CC ratio is 5.4, this is consistent with 80 to 99% stenosis. There is antegrade flow via both vertebral arteries. Head CT showed no acute hemorrhage or infarct. Repeat postoperative ultrasound results of the carotids showed left carotid patent. The right carotid was with 40% stenosis. Velocities results were pending at the time of dictation. On [3-4] the patient went to surgery and underwent angioplasty with stent placement of a single 10x20 mm Smart Stent to the left internal carotid artery post dilatation with a 6 mm balloon. The patient tolerated the procedure well and was transferred to the Post Anesthesia Care Unit for continued monitoring. Aspirin was begun and Heparin was begun at 800 units per hour with bolus to maintain the PTT between 60 and 80 overnight and maintain a systolic blood pressure equal or less than 160 systolic. The patient was admitted to the Neurological SICU for monitoring. Postoperatively he was hemodynamically stable. There were no focal deficits. Her pressure was well controlled on Nipride at 0.7 mcgs per kg per minute. It was noted the right groin required additional manual pressure times 20 minutes. Heparin was held times one hour and then restarted at 600 units. Cardiac enzymes were obtained which showed a total CPK of 130 and a Troponin of less than .30 which were normal. The electrocardiogram was without ischemic changes. The patient's groin hematoma remained stable. Ambulation was begun but was difficulty secondary to patient's right foot pain. He was begun on Indocin for his pain. He was seen by physical therapy and they felt he was safe to be discharged to home. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q day for six weeks. 2. Pravastatin 20 mg q day. 3. Acetaminophen 325 mg one to two tablets q 4 to 6 hours p.r.n. for pain. 4. Aspirin 325 mg q day. 5. Diazepam 2 mg to 5 mg q 6 hours p.r.n. DISCHARGE DIAGNOSIS: 1. Left carotid stenosis, status post angioplasty with stent placement. Stable. 2. Hypertension controlled. 3. Right groin hematoma, stable. In regards to follow-up the patient should be seen by Dr. [Last Name (STitle) 3124] in one month time with Duplex of the carotids done and should be seen by Dr. [Last Name (STitle) 1132] in [Hospital 4695] Clinic in two months. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 7252] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2129-3-7] 13:01 T: [2129-3-7] 15:33 JOB#: [Job Number 27028] ICD9 Codes: 2749, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5066 }	Medical Text: Admission Date: [2186-7-25] Discharge Date: [2186-7-27] Date of Birth: [2138-7-21] Sex: M Service: MEDICINE Allergies: Iodine Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 48 yom with PMH of hypertension, hyperlipidemia presents with chest pain radiating across left chest to back, arm, shoulder, with diaphoresis, shortness of breath and pain on inspiration, lightheadedness, and palpitations. Pain began at 1200 yesterday when patient was 15 minutes in to his usual walk. Describes pain as starting substernally. The patient stopped to rest and the pain subsided but did not end completely. He took maalox with no relief. He returned home on bus and tried to eat dinner later that night but had no appetite. At roughly 2300 he described new onset of the pain more intensly while at rest. Pain continued as he was lying down, along with sweating, muscle spasms, palpitations, shortness of breath. Pain was [8-3] in intensity and radiated to the left shoulder, arm, and back. Patient went to hospital next to [Location (un) ] where he lives and had an EKG, which demonstrated ST changes, and was immediately transferred to [Hospital1 18] for cardiac catheterization with aspirin. His pain improved with nitroglycerin but was not fully relieved. The patient states that he underwent a work-up for chest pain at the VA roughly 2 years ago and was told that it was GI-related. He had exercise stress test at that time, but does not know result. He has not had chest pain since then. At baseline, his main activity is walking, being limited by history of back injury at previous job. He is unable to climb stairs or run. Past Medical History: HTN Hyperlipidemia seasonal allergies Back surgeries: discectomy x 2 Social History: Lives at Soldiers Home, retirement community for disabled vets Not married. Works as writer. Minimal EtOH, nonsmoking, no illicit drugs. Family History: HTN, CABG in father at age of 70 Physical Exam: Vitals: T 98.7 BP 129/78 HR 62 R 18 Sat 99% RA PE: G: NAD, conversant HEENT: Clear OP, MMM Neck: Supple, No LAD, JVD not measured as patient post cath Lungs: clear bilaterally, No W/R/C Cardiac: RR, NL rate. NL S1S2. No murmurs Abd: Soft, ND. NL BS. No HSM. Mild tenderness at RUQ. Ext: No edema. 2+ DP pulses BL. Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact. Pertinent Results: [2186-7-25] 02:45AM WBC-9.9 RBC-4.84 HGB-14.1 HCT-39.9* MCV-82 MCH-29.1 MCHC-35.3* RDW-13.2 [2186-7-25] 02:45AM CALCIUM-9.9 MAGNESIUM-2.1 [2186-7-25] 02:45AM GLUCOSE-138* UREA N-23* CREAT-1.7* SODIUM-136 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-26 ANION GAP-18 [2186-7-25] 02:45AM cTropnT-2.84* [2186-7-25] 02:45AM CK(CPK)-1215* [2186-7-25] 02:45AM CK-MB-44* MB INDX-3.6 [2186-7-25] 06:43AM CK-MB-35* MB INDX-3.5 [2186-7-25] 01:35PM CK-MB-24* MB INDX-3.2 [2186-7-25] 01:35PM CK(CPK)-740* [2186-7-25] 07:56PM CK-MB-15* MB INDX-2.9 cTropnT-1.71* [2186-7-25] 07:56PM CK(CPK)-514* [2186-7-25] 02:45AM BLOOD CK-MB-44* MB Indx-3.6 [2186-7-25] 02:45AM BLOOD cTropnT-2.84* [2186-7-25] 06:43AM BLOOD CK-MB-35* MB Indx-3.5 [2186-7-25] 01:35PM BLOOD CK-MB-24* MB Indx-3.2 [2186-7-25] 07:56PM BLOOD CK-MB-15* MB Indx-2.9 cTropnT-1.71* [2186-7-26] 05:42AM BLOOD CK-MB-10 MB Indx-2.9 [2186-7-26] 05:42AM BLOOD PT-12.5 PTT-51.8* INR(PT)-1.1 [2186-7-26] 05:25PM BLOOD PTT-57.3* [2186-7-27] 06:40AM BLOOD PT-12.6 PTT-68.5* INR(PT)-1.1 [2186-7-26] 10:25AM BLOOD PT-12.5 PTT-53.6* INR(PT)-1.1 * Cardiac catheterization [7-25]: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated a fresh thrombus in the distal portion of the left main coronary artery extending into the ostium of the LAD. In addition to the 90-95% proximal occlusion, the distal portion of the LAD demostrated embolized clot extending out to the apex. The RCA was a large dominant vessel with no flow limiting lesions. The LCX was a large nondominant vessel without any angiographic evidence of any significant coronary artery disease. 2. LV ventriculography was deferred. 3. Limited resting hemodynamics demonstrated a cardiac output/index via the Fick method of 4.5 / 2.0 respectively. The left heart filling pressures were mildly elevated with a mean PCWP of 16 mmHg. 4. Successful thrombus extraction from the proximal LAD using the guide with complete clearence of it. The final angiogram showed TIMI III flow with no dissection and no embolization. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Anterior ST elevation myocardial infarction 3. Successful thrombus extraction from the proximal LAD * Echo [2186-7-25]: Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with akinesis of the distal [12-27] of the left ventricle and the true apex. The rest of the walls exhibit compensatory hyperkinesis. No definite thrombus is seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root, ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Symmetric left ventricular hypertrophy with mild regional systolic dysfunction. Mildly dilated thoracic aorta. * EKG [2186-7-25] Pre intervention Sinus rhythm Anterolateral myocardial infarct with ST-T wave configuration consistent with acute/recent/in evolution process. Consider also inferior myocardial infarction, age indeterminate No previous tracing available for comparison * Femoral vascular ultrasound [7-27]: FINDINGS: In the right groin superficial to the artery and vein, note is made of an area of low echogenicity with higher echogenic material within it. This is a well-circumscribed area and measures 1 x 1 x 1.36 cm. There is no connection with the artery or the vein. There is no flow within this lesion. It is located away from both vessels. It most likely represents a small lymph node. No evidence of any pseudoaneurysm. CONCLUSION: Small lymph node identified. No definite pseudoaneurysm. Brief Hospital Course: Chest pain: The patient presented with classic coronary chest pain, elevated enzymes, and ST segment elevations in leads I, II, aVL, V2-V6. He reported an allergy to iodine and so on presentation was pretreated with methylprednisone 100mg, benadryl 50 mg and famotidine 40 mg in preparation for cath. He also began heparin gtt, [Month/Day (4) 4532] 600 mg, and morphine 2 mg IV. During cath procedure he received integrillin and heparin boluses. As noted in the cath report enclosed, the patient had a large clot removed from his LAD, and the proximal end of the clot overlapped partially with the take-off point of the left circumflex artery. No stenting was required given the good result after clot extraction. Notably there was distal clot in the LAD seen at the apex, which was bolused directly with integrillin but could not be further treated. Following the procedure the patient developed a small hematoma at the groin catheter site which was non-expanding. His hematocrit was stable on discharge and he had a doppler study that showed no pseudoaneurysm. * Coronary artery disease: The patient was discharged on aspirin 325 mg QD, Statin 80 mg QD. Although the patient had been on a beta blocker prior to admission, his pulse was in the 50s-low 60s throughout his post cath period. A beta blocker was not started for this reason. An ACE inhibitor, Lisinopril at 5 mg, was started. It is noted that the patient was on a much higher dose of ACE inhibitor as an outpatient, but in general his systolic blood pressure has ranged from 110s to 130s while in the hospital. His dose of Lisinopril or an equivalent drug could be titrated upward in the future as the blood pressure allows. All of the patient's other hypertension medications were discontinued: atenolol, famlodipine, hctz, fosinopril. It is noted that these medications may become necessary in the future. The patient was also educated on the importance of low salt diet in controlling his hypertension. * Cardiac pump: On the day following his cardiac catheterization the patient had an echocardiogram to assess his left heart function. His ejection fraction was found to be 45% and he had akinesis of the apex of his heart. No left ventricular thrombus was seen, but in order to prevent a clot forming, the patient was started on coumadin and heparin gtt. He was discharged on lovenox 100 mg sq every 12 hours and his physicians at the Soldiers' Home were informed about the need to help with administering these shots and measuring his INR. He was discharged on 5 mg coumadin, but his INR was not therapeutic at discharge. His therapeutic goal INR is 2.0 to 2.5. * Also, the patient should have a repeat echo in six weeks or more to see if he has regained some of his heart function. * Medications on Admission: atenolol 100 famlodipine 10 fosinopril 40 loratidine hctz 25 statin 10 mg percocet 2 tabs every 4 hours for back pain Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q800, Q1200, Q1600, Q2000 () as needed for pain. 7. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:10 syringes Refills:2 8. Outpatient [Name (NI) ] Work PT and INR laboratory check. 9. Outpatient [Name (NI) ] Work PT and INR [Name (NI) ] check 10. Outpatient [Name (NI) ] Work PT and INR [Name (NI) ] check Discharge Disposition: Extended Care Facility: Soldiers Home in [State 350] - [Location (un) ] Discharge Diagnosis: 1. Myocardial Infarction 2. Left Ventricular Akinesis 3. Hypertension Discharge Condition: Stable, ambulating, tolerating PO. Small stable hematoma in right groin. Discharge Instructions: You had a cardiac catheterization that revealed a blockage to one of your coronary arteries, which was treated. You should not lift anything greater than 10 pounds for the next two weeks to allow complete healing of the catheter site in your groin. If you continue to feel pain at this site several days after going home, or if you feel numbness, tingling or pain in your right leg that is different from any pain you had before, you should contact your physician. [Name10 (NameIs) ] should walk frequently and remain active but avoid strenuous activity. * In order to prevent a clot forming in your heart, you have been placed on blood thinners. You should take coumadin (also called warfarin) for the next six months. You have already been started on coumadin, but it will take a few days to reach a therapeutic level. In order to make sure it is therapeutic, you should have your "INR" level checked in two days after you go home (Saturday - if this can't be done, have it checked Friday, then Monday). This is performed by a blood draw at a [Name10 (NameIs) ] or health clinic. You should have your INR checked every other day thereafter until you are on the correct standard dose. For the time that you are taking coumadin, you should not eat green leafy vegetables such as broccoli, spinach and collard greens, because this will interfere with the medication. * While you are taking coumadin, you will be more prone to bruising. * In order to prevent against blood clots in the short term, you must use lovenox shots. You must use these shots until your INR level and coumadin level are adequate (INR 2-2.5). You will administer the shots to yourself twice a day. You may get assistance in these shots from the health clinic at the [Location (un) 18437]. For the first day, a nurse from the [Location (un) 19404] should assist you performing the shots. * Your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 69537], has been contact[Name (NI) ] and has been faxed the report from your hospital stay. He has requested that you schedule an appointment with him in [2-25] weeks time. Between now and then, it is very important that you follow up with the health care clinic at [Location (un) 18437]. * You should have an echocardiogram of your heart performed in six weeks time to assess your heart function. * You have had a change in your medication regimen. In addition to starting coumadin and lovenox, you should also take: 1) Lisinopril 5 mg once a day. 2) Your other blood pressure medications should be STOPPED until you meet with your primary care physician. [Name10 (NameIs) ] will make the decision on whether to restart them. The medications that you should stop until further notice are fosinopril, famlodipine, hydrochlorothiazide, and atenolol. 3) You may continue to take loratidine for allergies and percocet for pain. 4) Your statin dose has been increased. You have a prescription for atorvastatin 80 mg every day. 5) You should take an aspirin 81 mg every day. 6) You have been started on a new medication, named [Name (NI) ] 75 mg, to be taken once a day. * It is very likely that a high-salt diet has been part of the reason for your high blood pressure. Salt is contained in high amounts in many restaurant foods (including chinese food) and in pre-prepared foods. You have been provided with a list of foods that are high in salt and should be avoided, such as canned meats, soups, ketchup and many other foods. * Please come to the nearest emergency department if you develop chest pain, shortness of breath or any other complaints. Followup Instructions: You should go to the 'treatment room' at the [Location (un) ] as soon as you arrive home from the hospital. They will help you with your lovenox shot. * On Saturday (or Friday if the [Location (un) ] is closed Saturday), you should have your INR level checked at the [Location (un) 18437] and continue checking it every other day. Your target INR is 2.0-2.5. You have been given prescriptions to get this [Location (un) ] test. * You should visit with the doctors at the [Name5 (PTitle) 18437] clinic on a regular basis to discuss your case and continue your care. * You should call your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 69537], tomorrow at [Numeric Identifier 69538] to discuss your recent hospitalization. You have an appointment with Dr. [Last Name (STitle) 69537] scheduled for [8-18]. Dr. [Last Name (STitle) 69537] should help you to schedule an appointment with a cardiologist. * You should have an echocardiogram performed at the VA in six weeks time from now. This is important to monitor your heart function. Dr. [Last Name (STitle) 69537] will help you to schedule this echocardiogram. * Completed by:[2186-7-28] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5067 }	Medical Text: Admission Date: [2150-7-27] Discharge Date: [2150-8-1] Date of Birth: [2085-9-6] Sex: F Service: MEDICINE Allergies: Benadryl / Penicillins / Morphine Attending:[First Name3 (LF) 1936] Chief Complaint: bilateral flank pain Major Surgical or Invasive Procedure: Left percutaneous nephrostomy placement ([2150-7-27]) History of Present Illness: Ms. [Known lastname 17301] is a 64 yo female h/o urinary retension, stroke, cardiac arrest, hypertension who presents from her [Hospital 4382] facility with bilateral flank pain. This pain began on [7-25] and has progressively worsened. She also noted subjective fevers and chills and mild nausea though no vomiting. Patient's aid called 911 given concern. . In the ED, vitals were: 101.4 128/80 87 24-28 97% RA. CT ABD/PELV showed Left UPJ and UVJ stones, with associated left mild hydroureter and mild pelvocaliectasis with surrounding stranding. Seen by urology who recommended percutaneous nephrostomy tube by IR. She received 1 L NS and Cipro IV x 1 an flagyl. Highest fever was 101.4. . On the floor, patient describes mainly L sided flank pain. Otherwise feeling thirsty. Past Medical History: MEDICAL HISTORY: 1. hypertension 2. gait disorder s/p CVA 3. urinary incontinence x12 months 4. hydronephrosis 5. chronic kidney disease: crt low to mid 2's 6. post-menopausal vaginal bleeding with thickened endometrial stripe 7. remote deep venous thrombosis 8. hypothyroidism s/p partial thyroidectomy 9. cardiac arrest 1/05 per report 10. depression 11. pvd ?: seen by Dr. [Last Name (STitle) ] of vascular surgery [8-27] but no note from that visit, arterial studies normal [4-/2146] 12. Basal cell carcinoma of the left upper lip, s/p Mohs' surgery in [1-/2149] Social History: The patient is [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Scientist. She lives alone in a facility for handicapped senior citizens; her boyfriend lives two blocks away. She denies tobacco, alcohol, or illicit drug use or abuse. Family History: She was adopted; her mother died when she was very young, and her father abused alcohol. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, 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, + LLQ tenderness and mild RLQ tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: Warm, well perfused, 2+ pulses, 2+ LE edema, no clubbing or cyanosis Neuro: AOx3, CN II-XII grossly intact, 5/5 strength bilateral UEs, [3-24] in RLE, 4+/5 LLE CHANGES ON DISCHARGE 1) Left Nephrostomy in place 2) Less tender abdomen Pertinent Results: Labs on admission: [2150-7-27] 02:45PM GLUCOSE-83 UREA N-66* CREAT-4.0* SODIUM-133 POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-17 [2150-7-27] 11:20AM WBC-32.7# RBC-4.73 HGB-13.2 HCT-40.3 MCV-85 MCH-28.0 MCHC-32.9 RDW-13.4 [2150-7-27] 11:20AM NEUTS-96.1 LYMPHS-2.3* MONOS-0.8* EOS-0.4 BASOS-0.3 [2150-7-27] 11:20AM PLT COUNT-207 [2150-7-27] 11:20AM PT-14.9* PTT-29.6 INR(PT)-1.3* [2150-7-27] 11:20AM ALT(SGPT)-23 AST(SGOT)-43* CK(CPK)-205* ALK PHOS-77 TOT BILI-0.5 [2150-7-27] 11:50AM URINE RBC-[4-29]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [2150-7-27] 11:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD LABS ON DISCHARGE: [2150-7-29] 08:20AM BLOOD WBC-15.4* RBC-4.00* Hgb-11.2* Hct-34.3* MCV-86 MCH-28.1 MCHC-32.7 RDW-14.1 Plt Ct-182 [2150-7-28] 05:08AM BLOOD PT-13.3 PTT-26.8 INR(PT)-1.1 [2150-7-29] 08:20AM BLOOD Glucose-94 UreaN-68* Creat-3.8* Na-138 K-3.3 Cl-103 HCO3-25 AnGap-13 Micro: [2150-7-28] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2150-7-28] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2150-7-27] 10:44 pm FLUID,OTHER NEPHROSTOMY FLUID. GRAM STAIN (Final [2150-7-28]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. GRAM NEGATIVE ROD(S). SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. PROBABLE ENTEROCOCCUS. SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): [2150-7-27] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [2150-7-27] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2150-7-27] 12:00 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2150-7-27] URINE URINE CULTURE-PENDING EMERGENCY [Hospital1 ] Imaging: CT abd/pelvis ([2150-7-27]): IMPRESSION 1. Left UPJ and UVJ stones, with associated left mild hydroureter and mild pelvocaliectasis. 2. Left perinephric and periureteric inflammatory stranding. 3. Cholelithiasis without evidence of cholecystitis. CXR ([2150-7-28]): Left lower lobe opacity. Considerations include atelectasis, infection, or combination of the two. Percutaneous Nephrostomy ([2150-7-27]): Successful replacement of left percutaneous nephrostomy with 8-French Flexima nephrostomy tube under fluoroscopic guidance. Mild left hydronephrosis and hydroureter noted. There is a partially obstructing left UVJ stone and nonobstructing left UPJ stone. Brief Hospital Course: IN SUMMARY This is a 64 yo female with a history of urinary retention and indwelling foley who presents with bilateral flank pain and found to have L obstructing ureteral stones, leukocytosis to 32, fever and acute on chronic renal failure. She has responded to Meropenem and nephrostomy placement. That nephrostomy was not putting out, so she had a nephrostogram that showed no problems with the system but confirmed a large obstructing stone BY PROBLEM # Pyelonephritis/Peri-Urosepsis: The reason for her presentation. Related to obstructing ureteral stones. Given the stones seen on CT, her high WBC (33) and ARF (4.0 from 2.2) in the setting of her multiple medical problems, she received ICU care. She [Last Name (un) ] required pressors. She was started on cipro and flagyl and given PCN allergy was transitioned to Meropenem. Cultures of urine and blood were positive for enterococcus and ecoli. These were sensitive to ciprofloxacin. The patient was kept on meropenem because of penicillin allergy and transitioned to cipro. Surveilance cultures were negative. Pt defervesced rapidly and WBC fell slowly. . # L ureteral stones: Seen by urology who rec urgent decompression of L collecting system with PCN by IR. PCN blocked up on [2150-7-28], IR assessed with nephrostogram that confirmed the stone. She require more definitive management after this emergent intervention. She will f/u on [8-10]. She was discharged with a PCN that drained clear, bloody fluid. . # Acute on Chronic Renal Failure: Baseline 2-2.6. Acutely related to ureteral stone obstruction in setting of poor renal reserve vs pre-renal or even ATN in setting of evolving infection and continued diuresis. She fell from 4.0 to 2.8 by the time of discharge. . # HTN: Pressures currently in the 110's systolic, baseline around 150's in setting of peri-sepsis. Continue Labetalol and Furosemide on d/c or outpatient; was held inpatient . # LLL Opacity: CXR read as infection vs atelectasis. Very possible this represents atelectasis given pt describes splinting past few days. Could also be a sympathetic effusion. No cough, hypoxia. Most likely atelecasis . # Depression: Mood stable. Cont outpt regimen of sertraline and nortriptyline. . ISSUES TO BE RESOLVED OUTPATIENT 1) Pyelonephritis - cipro 500 mg until [8-11] 2) Kidney Stones - Urology appointment on [8-10] 3) Hypertension - Labetalol and furosemide were held inpatient. [Month (only) 116] consider restarting if clinically indicated. Medications on Admission: Lasix 160 mg TID Labetolol 300mg TID Nortriptyline 25mg QAM, 50mg QPM Sertraline 100mg daily ASA 81 mg daily (not compliant) Ergocalciferol 50,000 IU qmonthly Discharge Medications: 1. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) standard injection Injection TID (3 times a day): As long as immobile . 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Transport Patient will need transportation to medical appointments on [2150-8-6] and - especially - [2150-8-10] 8. Outpatient Physical Therapy If indicated after rehab discharge, patient will need physical therapy outpatient 9. Outpatient Lab Work Please check chemistry (sodium, potassium, BUN, creatinine) on Monday, [8-3]. If less than 2.0, can switch to 750 mg Ciprofloxacin daily until [2150-8-11] 10. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days: Last Day is [2150-8-11]. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 12. Labetalol 300 mg Tablet Sig: One (1) Tablet PO three times a day: THIS MEDICATION WAS HELD FOR SEPSIS AND THEN PERSISTENT NORMOTENSION. Can restart if clinically indicated. 13. Lasix 80 mg Tablet Sig: Two (2) Tablet PO three times a day: WAS HELD THIS ADMISSION FOR SEPSIS AND THEN ACUTE RENAL FAILURE. Discharge Disposition: Extended Care Facility: [Hospital1 4860] - [Location (un) 4310] Discharge Diagnosis: PRIMARY Pyelonephritis Ureteral Stone SECONDARY Diarrhea s/p Stroke Discharge Condition: afebrile, stable, left nephrostomy draining some bloody urine Discharge Instructions: You were admitted with flank pain. This was caused by a serious kidney infection related to a stone blocking the flow of urine. You received antibiotics and a procedure to relieve the blockage. You did well. You will have to follow up with a urologist to address the stone. . NEW MEDICATION CIPROFLOXACIN - this is the antibiotic, take it as directed SARNA LOTION - this will help with your rash and itch . Return to the hospital if you experience high fevers, severe pain or any symptoms that concern you. . Follow ups: 1: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2150-8-10] 10:15 2: After being discharged, follow up with [Company 191] POST [Hospital 894] CLINIC Phone:[Telephone/Fax (1) 250] Followup Instructions: Upon discharge, please follow up with [Company 191] POST [Hospital 894] CLINIC Phone:[Telephone/Fax (1) 250] Provider: [First Name8 (NamePattern2) 161] [Name11 (NameIs) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2150-8-10] 10:15 Completed by:[2150-8-1] ICD9 Codes: 5849, 5180, 5859, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5068 }	Medical Text: Admission Date: [2197-6-4] Discharge Date: [2197-6-12] Service: CARDIOTHORACIC Allergies: Vicodin / Propoxyphene Attending:[First Name3 (LF) 4679] Chief Complaint: Pneumothorax -chest pain and Shortness of Breath Major Surgical or Invasive Procedure: Right thoracoscopy and wedge resection of bulla involving right lower and right middle lobe. History of Present Illness: Pt is an 89 yo F originally admitted to an OSH on [5-23] w/ c/o 1 episode of hemoptysis w/ assoc chest pain, SOB. Pt was admitted w/ diagnosis of secondary spontaneous PTX. Initial CXR showed a 50% right sided PTX. Her initial EKG showed sinus tachy (HR = 113) but no evid of ischemia, and her SpO2 was 98% on 100% nonrebreather. A right sided chest tube was placed and the patient had resolution of her PTX, but maintained a persistent air leak. CT Chest was obtained and indicated two Aveolar-pleural fistulas, and a bronchoscopy was performed w/ no major pathology. The outside hospital evaluated her and determined that she would not tolerate a thoracatomy and requested transfer and evaluation for bronchopleural fistula at [Hospital1 ]. Past Medical History: COPD, Emphysema. Pt on 3L home o2 Social History: Quit tob [2191], prior 1ppd x 70 years Denies EtOH No illicits Lives with daughter Family History: +HTN +EtOH abuse +Cancer Pertinent Results: [2197-6-4] 09:40PM BLOOD WBC-8.3 RBC-3.67* Hgb-11.2* Hct-35.2* MCV-96 MCH-30.6 MCHC-31.9 RDW-14.5 Plt Ct-162 [2197-6-4] 09:40PM BLOOD Neuts-86.7* Lymphs-10.1* Monos-2.4 Eos-0.6 Baso-0.2 [2197-6-4] 09:40PM BLOOD Plt Ct-162 [2197-6-4] 09:40PM BLOOD PT-12.9 PTT-22.1 INR(PT)-1.1 [2197-6-4] 09:40PM BLOOD Glucose-237* UreaN-21* Creat-0.7 Na-143 K-4.1 Cl-99 HCO3-34* AnGap-14 [2197-6-4] 09:40PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1 [2197-6-9] 03:54AM BLOOD WBC-11.1* RBC-3.23* Hgb-10.1* Hct-32.6* MCV-101* MCH-31.4 MCHC-31.1 RDW-14.8 Plt Ct-202 [2197-6-10] 05:53AM BLOOD Glucose-96 UreaN-11 Creat-0.5 Na-142 K-3.6 Cl-102 HCO3-33* AnGap-11 [2197-6-8] 02:40AM BLOOD Type-ART pO2-96 pCO2-43 pH-7.52* calTCO2-36* Base XS-11 [2197-6-7] 09:01PM BLOOD Type-ART pO2-68* pCO2-50* pH-7.43 calTCO2-34* Base XS-7 [2197-6-7] 02:34PM BLOOD Glucose-188* Lactate-1.1 Na-139 K-3.6 Cl-96* Brief Hospital Course: 89 yo female with an extensive smoking history with COPD on home oxygen, osteoporosis s/p recent hip fracture s/p ORIF, sacral decub, who presents from an OSH for evaluation of surgical intervention of a R bronchopulmonary fistula. According to OSH records, the patient reported to the OSH on [5-23] with complaints of hemoptysis x 1. Pt reports she was in rehab x 3 days and then discharged home from rehab on [5-23]. That night, she went home and had hemoptysis x 1 while eating dinner-- never happened before. Denied any increased SOB at this time. Her son in law witnessed the event, and then brought her to the OSH ED. In the OSH ED, a CXR then revealed a large R sided PTX with >50 percent of the R lung involved. A chest tube was placed and pulmonary was consulted. The patient's PTX failed to improve, and a CT chest subsequently revealed two bronchopulmonary fistulas. A BAL was performed, which according to ID notes grew aspergillus and Stenotrophomonas, and the patient was started on voriconazole for presumptive invasive aspergillus infection. She was started on empiric Flagyl for diarrhea. The patient was then transferred to [Hospital1 18] on [2197-6-4] for further management and possible surgical intervention. [2197-6-5] a the chest tube placed to water seal, patient did not tolerate this with SOB and chest pain. On CXR 30% PTX noted patient placed back to suction. [2197-6-6] ID consult and rec commended to continue voriconazole and Flagyl. Also Palliative care meet with patient to discuss up coming surgery and post-op plan. Patient is a DNR/DNI and does not with to have prolonged life support. Family meeting was also held to review surgery risks benefits and post-op course. On [2197-6-7] to operating room for:Right thoracoscopy and wedge resection of bulla involving right lower and right middle lobe. admitted to the ICU intubated and sedated. POD#1 Chest tube trial to water seal failed with continued air leak, placed back to suction. Continued with sedation and mechanical ventilation. POD#2 patient extubated, chest tube continued with air leak also continued requiring pressors. POD#3 Air leak in chest tube continues, BP, hr and uop labile, remains on pressors. POD#4 Continue with labile BP, HR and UOP requiring pressors, also patient having increased o2 requirement and less responsive. On POD#5 [2197-6-12] Patient non responsive, requiring more pressors and oxygen. Daughter at bedside, after discussion with Dr. [First Name (STitle) ] following patients wishes life supportive measures stopped and patient deceased. Medications on Admission: Advair 250/50 Norvasc Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Discharge Condition: death Completed by:[2197-6-12] ICD9 Codes: 5185, 4275, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5069 }	Medical Text: Admission Date: [2109-7-5] Discharge Date: [2109-7-8] Date of Birth: [2056-5-20] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 759] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: 1. NG lavage [2109-7-5] 2. Colonoscopy [2109-7-8] History of Present Illness: This is a 53 female with a medical history of [Last Name (un) 865] esophagus who had an upper endoscopy for [Last Name (un) 15532]'s on [2109-7-2] with 8 bxs sent, who developed abdominal cramping BRBPR on day of admit. She was in her usual state of health after her EGD, but on day of admit developed abdominal pain and at 9pm had 3 small bloody bowel movements. She called her GI doc who instructed her to go to the ED. Of note, a few days before her EGC she did note that she had mild diarrhea ([3-21] bowel movements per day) and a low grade temp of 99 on Monday prior to admission. Patient did not have any black or bloody bowel movements. Pt did have occasional nausea over past few days, but no hematemesis, vomiting, abdominal pain. She has not been taking any NSAIDs or aspirin. In the ED initial vitals were: 98.9 123 162/111 16 100%. Patient was typed and crossed for 4 units of PRBC. Labs were notable for a hct of 36. Patient was given zofran for nausea and ativan for ???. Two large bore IVs were placed. An NG lavage was negative. While in the ED she had two bowel movements with an estimated 1.5L of blood loss. 1 units of PRBC was transfused. On transfer vitals were: 102, 146/84, 16, 97% ra. . On the floor, patient is comfortable. She denies abdominal pain, nausea, vomiting, further bowel movements. No lightheadedness, chestpain, dyspnea. . Review of systems: (+) Per HPI (-) Denies 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 vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -[Month/Day (3) 15532]'s Esophagus -Plantar fasciitis -Rosacea -Dry eye -Fibroid embolization ~[2101] -Fibroid removal [2090] Social History: - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Lives with husband. Retired, lives in [State 108] for winter. Family History: Father - stomach cancer Physical Exam: Admission exam: Vitals: T: 97.6 BP: 160/93 P: 87 R: 14 O2: 100% on 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 Ext: warm, well perfused, 2+ pulses, no clubbing, trace lower extremity edema Discharge exam: Vitals: 98.4 97.1 118/82 118-132/72-92 100 82-100 18 100%RA 8H 775/BRP + BM's clear 24H 1360/2625 +loose marroon/tarry stools x3 General: sleeping, awakens to voice, pleasant female, appears comfortable HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, Abdomen: +NABS, soft, non-tender, non-distended, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no edema Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities, no focal deficits, gait deferred Pertinent Results: Admission labs: [2109-7-5] 11:00PM BLOOD WBC-9.5 RBC-4.09* Hgb-12.9 Hct-36.5 MCV-89 MCH-31.7 MCHC-35.5* RDW-12.3 Plt Ct-335 [2109-7-5] 11:00PM BLOOD Neuts-57.9 Lymphs-32.9 Monos-4.1 Eos-3.3 Baso-1.8 [2109-7-5] 11:00PM BLOOD PT-12.4 PTT-21.6* INR(PT)-1.0 [2109-7-5] 11:00PM BLOOD Glucose-146* UreaN-13 Creat-1.0 Na-140 K-3.5 Cl-103 HCO3-24 AnGap-17 [2109-7-6] 04:28AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9 [2109-7-6] 12:23AM BLOOD Lactate-1.9 DISCHARGE LABS: [2109-7-8] 10:45AM BLOOD WBC-8.3 RBC-3.59* Hgb-11.1* Hct-32.0* MCV-89 MCH-31.0 MCHC-34.8 RDW-12.7 Plt Ct-297 [2109-7-8] 10:45AM BLOOD Glucose-101* UreaN-7 Creat-0.8 Na-140 K-3.4 Cl-108 HCO3-23 AnGap-12 STUDIES: CTAP [2109-7-5]: IMPRESSION: 1. Diverticula, with no site of [Month/Day/Year ] within the colon identified. 2. Inferior right liver lobe lesion which is suggestive but not diagnostic of hemangioma. This should be further evaluated with MRI on a non-emergent basis. 3. Fibroid uterus. COLONOSCOPY [2109-7-8]: Findings: Flat Lesions A single medium localized angioectasia that was not [Month/Day/Year ] was seen in the ascending colon. An Argon-Plasma Coagulator was applied for tissue destruction successfully. Protruding Lesions Small non-[Month/Day/Year ] grade 1 internal hemorrhoids were noted. Excavated Lesions Multiple non-[Month/Day/Year ] diverticula with mixed openings were seen in the sigmoid colon, descending colon and ascending colon. Diverticulosis appeared to be of moderate severity. Impression: Grade 1 internal hemorrhoids Diverticulosis of the sigmoid colon, descending colon and ascending colon Angioectasia in the ascending colon (thermal therapy) Otherwise normal colonoscopy to cecum and terminal ileum Recommendations: The findings may account for the blood in the stool. Her GI [Month/Day/Year ] is most likely secondary to diverticular disease . Additional notes: The procedure was performed by the fellow and the attending. The attending was present for the entire procedure. The patient's reconciled home medication list is appended to this report. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology MICRO: STOOL CX [2109-7-6]: [2109-7-7] 7:10 am STOOL CONSISTENCY: LOOSE Source: Stool. FECAL CULTURE (Preliminary): CAMPYLOBACTER CULTURE (Preliminary): FECAL CULTURE - R/O YERSINIA (Preliminary): FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2109-7-8]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2109-7-8]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: Ms. [Known lastname 9381] is a 53 year old female with history of [Known lastname 15532]'s esophagus who developed bright red blood per rectum four days after EGD with biopsies. Pt had NGL in the ED with no evidence of [Known lastname ]. She was transfused 1 unit PRBC's, 1LNS and monitored in the ICU overnight. GI was consulted and recommended colonoscopy. She was transferred to the medicine floors where her hematocrit remained stable. She had a colonoscopy which showed no active [Known lastname ], but diverticulosis, thought to be the most likely etiology of the bleed. She was discharged to home with PCP [Last Name (NamePattern4) 702]. # BRBPR: Most likely lower GIB. Pt had recent biopsies with EGD, but unlikely to be source as [Last Name (NamePattern4) ] was bright red rather than melanotic. NG lavage in ED was negative for bleed. Lower GI source more commonly presents with BRBPR with of possible differentials including angiodysplasia, diverticular bleed, AVM, hemmorhoidal, or infectious etiology. Patient had CTA in ED which showed diverticuli, but did not localize bleed. She was transfused 1 unit of PRBC and 1L NS prior to transfer to the ICU. Her HCT initially trended down but subsequently remained stable. She was initially placed on IV PPI [Hospital1 ] in the ICU. She remained hemodynamically stable in ICU and was transferred to the floor. On the medicine floor, orthostatics were checked and negative. She had one more bloody-melanotic bleed on HOD#3, thought to be old blood in lower GI tract. She remained HD stable and Hct was stable. She was taken for colonoscopy, which showed grade 1 internal hemorrhoids, diverticuli, angioectasia (thermal ablation performed), but no active signs of [Hospital1 ]. Stool cultures were sent and were negative for C. diff but with final stool cultures pending at the time of discharge. She was advised to follow-up with her PCP. [Name10 (NameIs) ] she rebleeds, then she would need follow-up with GI. # [Doctor Last Name 15532]??????s Esophagus: Patient with recent biopsies showing focal active esophagitis, gastric type mucosa with focal mild acute and chronic inflammation and and rare intestinal type goblet cell suggestive of [Doctor Last Name 15532]??????s, no dysplasia. Patient was started on IV PPI on admission. On the medicine floor, this was switched to po PPI. She was discharged on her home dose of Omeprazole 20mg daily. # Right hepatic lesion: Seen on CT, suggestive of hemangioma. Pt should follow-up with PCP for further management. TRANSITIONAL CARE: 1. CODE: FULL 2. FOLLOW-UP: - PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] - GI as needed, otherwise for [Last Name (NamePattern1) 15532]'s as previously scheduled 3. MEDICAL MANAGEMENT: no change, continue Omeprazole 20mg daily - f/u of hepatic lesion seen on CT 4. Outstanding tasks: - Will need outpatient follow-up for right hepatic lesion see on CT - Stool cultures pending Medications on Admission: Omeprazole 20 mg daily Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Outpatient Lab Work Please check potassium level in [3-21] days, check Chem 7. Please fax results to Dr.[Name (NI) 64316] office at [Telephone/Fax (1) 64317]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Lower gastrointestinal bleed 2. Diverticulosis Secondary Diagnoses: 1. [Telephone/Fax (1) 15532]'s Esophagus Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. [Known lastname 9381], It was a pleasure taking care of you during this admission. You were admitted for bright red blood from the rectum. You were transfused one unit of blood and monitored closely in the intensive care unit. You did well, and were transferred to the medicine floors. You had a colonoscopy, which showed diverticuli (small outpouchings), internal hemorrhoids, and a small abnormal blood vessel that they ablated. The GI doctors think the [Name5 (PTitle) ] was from the diverticuli. You will need to adhere to a diet to help with this (see handout provided). You will not need to follow-up with the GI doctors after this [Name5 (PTitle) 648], except with your regular GI doctor [First Name (Titles) ] [Last Name (Titles) 15532]'s. If you do have more [Last Name (Titles) ], then you will need to see the GI doctors [Name5 (PTitle) 46451]. Your potassium level was slightly low. This is probably from the GI prep and loose stools. Have your blood drawn in [3-21] days and have the results faxed to Dr.[Name (NI) 64316] office. No medications were changed during this admission. Please continue to take the Omeprazole 20mg by mouth daily for the [Name (NI) 15532]'s Esophagus. Again, please see the handout we provided to help with dietary changes for the diverticulosis. Followup Instructions: Please follow-up with the following appointments: Name:[First Name11 (Name Pattern1) 539] [Last Name (NamePattern4) 64318], MD Specialty: Primary Care [Street Address(2) 64319], [Location (un) 10059], [Numeric Identifier 64320] Phone: [Telephone/Fax (1) 64321] When: Wednesday, [7-17] at 1:40pm Completed by:[2109-7-8] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5070 }	Medical Text: Admission Date: [2125-4-17] Discharge Date: [2125-5-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4980] Chief Complaint: failure to thrive Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] yo male nursing home resident transferred to [Hospital1 ] for w/u of WBC of 58 and SBP in the 90's without fevers. Pt. was treated with Levofloxacin for UTI and began having diarrhea for a week. Patient also had decreased appetite, but had been mentating well. Per rehab, on the AM prior to admission, he appeared weaker than usual. On [4-17], his SBP was 80/50, HR was 68. He came in with WBC 58.5 with presumed C.diff. He was on the floor for a day and was then transferred to the ICU for hypotension, sepsis, and acidosis. * ICU Course: He was hypotensive to 80/50 and was on pressors (Levophed and Vasopressin) and received intermittent D5W/HCO3 boluses as pt had gap and nongap acidosis. He had received large amount of fluid (+22L in the ICU) with most fluid accumulating in his abdomen. He remained on PO Vancomycin and IV Flagyl and Flagyl was just switched to PO on [4-26] as pt can now tolerate po with pureed thick liquids. After aggressive IVF, pressors were weaned off. He still requires intermittent LR boluses to maintatin CVP. He had some episodes of a-fib with RPR. he was also found to be thrombocytopenic with negative HIT Ab. He was initially DNR/DNI, but after the ICU team discussed with his nephew [Name (NI) ] [Name (NI) 4640], he became full code as he wants the pt to "make it" until Victory Europe Day in [Month (only) 116]. He was started on TPN via the central line as he initially failed swallow eval. However, on [4-26] repeat swallow eval showed that pt could tolerate some Pureed, honey thick liquid. However, since he can't take adquate nutrition via PO, the idea of tube feed via PEG was brought up and the nephew is in agreement with it. Past Medical History: CRI Heel Ulceration Hip Fracture CHF Cataracts Post herpetic neuralgia Mult BCC IDDM Hx CDiff Hx UTI Hyperkalemia Anemia Social History: Russian speaking, [Name (NI) 14125] Contact - [Name (NI) ], [Name (NI) ]: HCP - [Telephone/Fax (1) 14126]; [Telephone/Fax (1) 14127] Physical Exam: PE - 100 87 126/28 17 97 RA GEN: Awake, alert, lying in bed covered with stool. HEENT: NC/AT, PERRL, EOMI, MM-dry COR: RRR, nl S1, S2 LUNGS: CTA bilaterally ABD: +BS, soft, NTND, no rebound GU: Large scrotal edema EXT: Bilateral heel ulcers, legs with support, 4+ edema bilateral LE. Brief Hospital Course: Mr. [Known lastname 14128] was admitted with hypotension and c. dif enterocolitis. He was intubated and continued to decline in the ICU, and grew anasarcic from fluid resusitation. He was kept comfortable and care was withdrawn once the family was ready. 1. Hypotension/Fluid status- His pressure was initially controlled with Levophed (0.5 mcg/kg/hr). He continually required increasing doses of Levophed, which became a concern with regard to his already compromised renal function (presumed ATN). He was transitioned to vasopressin and tolerated this well. After the pressors were discontinued, he maintained his systolic blood pressure >100. He also received both normal saline and Na/HCO3 boluses to manage his pressures. He received total of 22 L in the ICU to keep his BP and urine output. Most of these fluids have extravasated into third space as his albumin was 1.5-1.6. These extra fluids were evidecned by his remarkable scrotal edema and 4+ pitting diffuse edema. He initially went into ATN from hypotension, but once it resolved, he started to get IV Lasix 40 [Hospital1 ] to diuresis. The main issue to mobilize his fluid is his nutritional status. He was initially getting TPN but later received post-pyloric tube and was started on tubefeeds with Nepro. He will need to be on minimal IV meds, and standing Lasix 40 mg IV bid and PRN Lasix with a goal to keep him negative 1 L/day. 2. Infectious- He was admitted with WBC ~69 and peaked to 76 which progressively trended down. Pt had severe C.diff colitis and sepsis. He was treated with double coverage empirically with IV flagyl and PO vancomycin (14 day course). Flagyl was changed to PO once he was able to take PO with thick liquids. Stool C.diff were negative x 2 after the treatment. However, he continued to have loose stools, likely since his bowel mucosa was severealy injured from the colitis. WBC trended down to 10, but had an episode of vomiting and likely aspiration pneumonia as WBC came back up and pt with congested lungs. He was started on Levofloxacin in addition to Flagyl which he'll take for total of 2 week course. 3. Acid/Base status- Initially came in with an anion gap metabolic acidosis that improved. Prior to discharge from the [Hospital Unit Name 153], he had a hyperchloremic non-anion gap. He was treated with Na/HCO3, which also helped with his pressures. On the floor, he mainitatined normal acid/base status. 4. Acute on chronic renal failure- Initially pt had ARF, likely ATN from prerenal insult due to shock. Creatinine peaked at 2.5 but eventually came down to 1.5-1.6 with good urine output. 5. Thrombocytopenia- Platelet count dropped to 55 from 480 within 1 week. HIT antibody was negative x 2. Platelet count improved once his infection was treated and once he was hemodynamically stable. Hematology was consulted and agreed that transient thrombocytopenia was related to sepsis. 6. Atrial fibrillation with rapid ventricular response- EKG on [4-18] showed atrial fibrillation. Has one episode of A. fib/RVR with heart rate to 150s. He received 5 mg diltiazem with good response, but his pressures dropped. He was adequately rate controlled with metoprolol. Since he had guiac positive stool, we decided not to start Coumadin in a setting of hemodynamic instability. However, once he is more stable and not having any more guiac positive stool, he should be started on coumadin at the rehab. 7. CHF- Echo EF >55% ([4-18]), moderate TR, mild MR, small pericardial effusion. As pt was 22L fluid overloaded, he had pulmonary edema and had to be diuresed with standing Lasix as noted above. 8. IDDM- Initially on an insulin drip, but was transitioned to sliding scale and glargine. He was initially on glargine 30 units and then cut down to 15 units while he was receiving the TPN. However, he had two episodes of hypoglycemia. One episode, where he was found unresponsive with myoclonic jerk and deviated eyes to the left. Finger stick was 14, and reversed with one amp of D50. It was thought that he got his glargine at noon and was not scheduled to get TPN until later that night. Since he likely has no glycogen reserve, he rapidly went into hypoglycemia (FS 140's to 14) within few hours. Therefore, glargine was stopped. TPN was eventually stopped as tube feed was started. As he tolerates tubefeed and as his intestinal wall mucosa heals and have better resorption, his insuling dose needs to be adjusted. He will likely need either NPH or glargine later. However at the time of discharge, he was only covered with insulin sliding scale. 9. Skin breakdown- Pt with bilateral pressure ulcers on his heel, buttock/perineal skin breakdown. He was getting miconazole powder for dryness/fungus, and lidocaine jelly/decitin to the buttock/scrotal area. For his heel ulcer, he got wet to dry dressing change once/day, and the feet were elevated by multipodis boots. 10. Anemia of Chronic disease- Hct remained stable at low 30's. He did require 2 units of PRBC in the ICU. 11. Elevated alkaline phosphatase- CT abdomen showed "distended gallbladder". Increased ggt so likely liver or biliary source. Consider RUQ U/S as an outpatient. 12. FEN- Initially, he received TPN in the ICU as he could not tolerate any PO's based on swallow evaluation. However, as his clinical status improved, he was able to tolerate some thick liquids. As noted above, he has very poor nutitional status with albumin of 1.5. Initially, his HCP/nephew agreed on PEG tube placement, but we later agreed to avoid the invasive measure. Post-pyloric tube was placed by the IR on [4-30] and tubefeed was started. TPN was discontinued once tubefeed was started as TPN as we were trying to minimize his fluid intake while we were trying to diurese him. Per nutrition, Nepro was started as it is more concentrated than other tubefeeds. As noted above, his glucose level should be monitored very closely. Once he is at a stable tubefeed rate, he should be on longer acting insulin to maintain adequate glucose level. 13. CODE: He was initially DNR/DNI. However, the code status was reversed by his nephew [Name (NI) ], as he thinks that the patient would want to live till Victory Europe day which is [2125-6-10]. However, pt continued to decline and after discussing with the family, [Doctor First Name ] decided to withdraw care on Mr. [Known lastname 14128]. Medications on Admission: Tylenol ASA Proscar 5 Folate Levo 250 Topamax XL 100 ISS Discharge Disposition: Extended Care Discharge Diagnosis: deceased Discharge Condition: deceased ICD9 Codes: 5070, 5845, 2762, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5071 }	Medical Text: Admission Date: [2167-4-18] Discharge Date: [2167-4-28] Date of Birth: [2101-9-20] Sex: F Service: SURGERY Allergies: Penicillins / Sulfur Attending:[First Name3 (LF) 473] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 65-years-old female was in usual state of health upon awakening this morning. She developed epigastric pain acutely after breakfast. Pain radiates to both sides and is sharp, stabbing, and constant, positive nausea/vomiting. Last bowel movement normal, without blood. No fevers. positive subjective chills. Pt has had episodes of pain similar to this, but states they did not last this long. Past Medical History: GERD Anxiety Obesity Allergic sinusitis HTN Hep C Thyroid nodule Osteoporosis Vertigo Colonic adenoma Social History: Originally from Sicily, moved to US [2117]. Married to 2nd husband since [2128]; previous marriage [2119]-65, divorced. Homemaker. Lives with husband and sons. Non-[Name2 (NI) 1818], occasional wine with dinner. Does not exercise. Family History: Father died @ 77 - "old age", mother is 78 - a&w, 3 children - 2 sons, 1 daughter. Physical Exam: On Admission: VS: 98.7 117 117/78 17 98%RA Gen: in obvious pain CVS: tachy, reg rhythm Pulm: CTA b/l Abd: soft, diffusely & exquisitely tender, ND, +BS Ext: no c/c/e On Discharge: VS: 96.5, 78, 110/80, 16, 96% RA GEN: Appropriate, pleasant, NAD NEURO: Alert and oriented x 3. Follows all commands. HEENT: NC/AT, PERRL, Oropharynx clear, Neck supple HEART: RRR, no m/r/g LUNGS: CTAB ABD: Soft, nontender, slightly distended, + BS x 4 EXT: MAE, positive peripheral pulses, no c/c/e Pertinent Results: [2167-4-18] 10:30AM GLUCOSE-114* UREA N-22* CREAT-1.0 SODIUM-141 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15 [2167-4-18] 10:30AM ALT(SGPT)-102* AST(SGOT)-121* ALK PHOS-85 AMYLASE-637* TOT BILI-0.8 [2167-4-18] 10:30AM CALCIUM-7.5* PHOSPHATE-3.6 MAGNESIUM-2.0 [2167-4-18] 10:30AM LIPASE-424* [2167-4-18] 10:30AM WBC-18.0* RBC-4.63 HGB-13.6 HCT-41.2 MCV-89 MCH-29.5 MCHC-33.1 RDW-13.5 [2167-4-28] 06:15AM BLOOD WBC-8.5 RBC-3.44* Hgb-10.7* Hct-31.6* MCV-92 MCH-31.1 MCHC-33.8 RDW-14.0 Plt Ct-354# [2167-4-24] 06:00AM BLOOD Glucose-83 UreaN-8 Creat-0.5 Na-135 K-3.9 Cl-106 HCO3-22 AnGap-11 [2167-4-24] 06:00AM BLOOD ALT-67* AST-119* AlkPhos-81 Amylase-188* TotBili-1.0 [2167-4-17] CT ABDOMEN: 1. Extensive peripancreatic inflammatory fat stranding with surrounding fluid in the retroperitoneum extending along the anterior pararenal spaces bilaterally as well as in the right paracolic gutter. No organized fluid collection at this time. These findings are compatible with acute pancreatitis. 2. Small amount of free fluid in the perihepatic space and within the root of the mesentery. 3. Bilateral renal hypodensities consistent with renal and parapelvic cyst. Smaller hypodense lesions within both kidneys are too small to characterize. 4. Fat-containing umbilical hernia (2, 57). No evidence of obstruction. 5. No abdominal aortic aneurysm. [2167-4-18] LIVER OR GALLBLADDER US : Single 6 mm mobile stone identified within the dependent portion of the gallbladder which is otherwise unremarkable. Distal CBD stone not excluded due to limited evaluation of the distal CBD. No intra- or extra-hepatic biliary ductal dilatation. [2167-4-20] MRCP: 1. Peripancreatic edema and fluid, most compatible with acute pancreatitis. No evidence of pancreatic necrosis. No biliary ductal dilatation or obstructing stone or mass. Subcutaneous flank edema or hemorrhage, possibly related to pancreatitis. 2. Unchanged appearance of simple and likely hemorrhagic renal cysts. 3. Liver cirrhosis. 4. Small-moderate ascites. [2167-4-23] URINE CULTURE: Methicillin-resistant Staphylococcus aureus Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation of the acute abdominal pain. On admission, the patient underwent: CT abdomen which revealed acute pancreatitis; gallbladder ultrasound which demonstrated single 6mm mobile stone; MRCP which revealed peripancreatic edema and fluid, most compatible with acute pancreatitis without evidence of pancreatic necrosis. Patient was admitted for pain control, she was kept NPO, started on IV fluid resuscitation and prophylactic antibiotics. Patient was evaluated by Dr. [Last Name (STitle) 468] and she was scheduled for elective laparoscopic cholecystectomy on [2167-5-7]. The patient was hemodynamically stable during her hospital course. . During this hospitalization, patient's pain was well controlled, her diet was advanced slowly as patient tolerates, BP was controlled with Lopressor, she received SC Heparin for DVT prophylaxis, and blood sugar was controlled with sliding scale insulin. Patient ambulated frequently, actively participated with pulmonary toilet. Hospital course was complicated by urinary tract infection with MRSA, patient was treated with IV Vancomycin for three days total. 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. Patient will return on [2167-5-7] for elective laparoscopic cholecystectomy. Her pre-op screening was completed during this admission, all questions were answered. Medications on Admission: 1. Tums 750 mg PO BID 2. Lisinopril 10mg PO Daily 3. Alendronate 70 mg PO QMON 4. Antivert 25 mg PO Q8H prn dizziness 5. Vitamin D 800 units PO Daily 6. Clotrimazole 1% topical cream prn rash Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Meclizine 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for dizziness. 5. Tums 300 mg (750 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 6. Clotrimazole 1 % Cream Sig: One (1) application Topical twice a day as needed for rash. 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:60 Capsule(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1. Acute Pancreatitis 2. Urinary track infection with Methicillin-resistant Staphylococcus aureus s/p IV Vancomycin x 3days Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Do NOT take any Aspirin or NSAIDS (i.e. Ibuprofen, Motrin, Aleve, Naprosyn, etc) before your surgery, otherwise 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 driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: 1. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6887], MD Phone:[Telephone/Fax (1) 1144] Date/Time:[2167-7-6] 10:30 . 2. You will be returning to the Hospital on [5-7] for laparoscopic cholecystectomy with Dr. [Last Name (STitle) 468]. Dr.[Name (NI) 9886] Office will contact you prior surgery with detailed instructions. If you have any questions regarding the coming procedure, please call [Telephone/Fax (1) 2835]. Completed by:[2167-4-28] ICD9 Codes: 0389, 5990, 5180, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5072 }	Medical Text: Admission Date: [2186-2-25] Discharge Date: [2186-4-1] Date of Birth: [2128-4-19] Sex: M Service: MED DATE OF EXPIRATION: [2186-4-1] HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old male with past medical history of coronary artery disease, status post 4-vessel CABG in [5-4], status post pacemaker placement who was admitted for evaluation of elevated white blood cell count. In [2-2], he noticed fatigue, decreased energy, diffuse body aches, swollen gums, and swollen glands. He did not note any gum bleeding. He experienced extreme dyspnea on exertion, initially only while walking uphill or exerting himself, but progressively increasing to the point that he was having dyspnea with walking on level ground for distances greater than [9-20] feet. The fatigue came gradually and unexpectedly and was progressing. He went to the outpatient primary care physician on the day prior to admission for routine blood work. CBC there showed white blood cell count of approximately 128,000. He was advised to go to the hospital. He first went to an outside hospital and was transferred to [Hospital1 69] on [2186-2-25] for full workup. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Coronary artery disease, status post CABG times 4 vessels in [5-4]. No history of myocardial infarction. Basal cell carcinoma, status post excision. Nephrolithiasis, status post surgical removal. Status post pacemaker placement in [5-4], recently interrogated. ALLERGIES: THE PATIENT REPORTS ALLERGIES TO AMOXICILLIN RESULTING IN SENSATION OF SWELLING WITHIN HIS MOUTH AND FINGERS. MEDICATIONS PRIOR TO ADMISSION: 1. Amiodarone. 2. Lisinopril. 3. Toprol XL. 4. Lipitor. 5. Aspirin. SOCIAL HISTORY: The patient works for an insurance company. He denies any tobacco use, but reports occasional alcohol use. FAMILY HISTORY: The patient's father was deceased from [Name (NI) 4278] lymphoma and diabetes mellitus 2, mother deceased from a colon cancer, and sister with cervical cancer. PHYSICAL EXAMINATION UPON ADMISSION: Vital signs - temperature 101.3 degrees, heart rate 86, blood pressure 119/63, and respiratory rate 20. Generally, this is a well- developed, thin, chronically ill-appearing male, no acute distress. Head and neck exam had pupils equal, round, and reactive to light. No scleral injection or icterus. There was positive lymphadenopathy at the right and left submandibular, soft, mobile lymph nodes approximately 1 cm in diameter and matted lymph nodes in the anterior cervical neck chain. Cardiovascular exam, was regular rate and rhythm with normal S1 and S2 heart sounds and crescendo/decrescendo murmur at the right upper sternal border. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with no hepatosplenomegaly. There was a surgical scar noted from his kidney surgery. Extremities were warm and well perfused without clubbing, cyanosis or edema. Neurologically, he was alert and oriented times 3. Cranial nerves II through XII intact. Strength 5/5 throughout and sensation grossly intact to light touch. PERTINENT LABORATORY, X-RAY, OTHER STUDIES: Complete blood cell count on admission was 128,000 white blood cells, 32.8 hematocrit, platelets of 76. Chemistry was remarkable for sodium 138, potassium 2.7, BUN 20, creatinine 1.3, and glucose 61. BRIEF SUMMARY OF HOSPITAL COURSE: Leukemia: The patient underwent bone marrow biopsy, result consistent with acute myelogenous leukemia. He started induction chemotherapy with 7 plus 3. His post chemotherapy course was complicated by multiple events. Notably, on admission, he had febrile neutropenia with an ANC less than 500. For this, he was started on broad spectrum antibiotics. Status post subclavian line placement for chemotherapy, he had increased bleeding and oozing from line site on [2186-2-27] and was found on laboratories to be in acute DIC. He had a prolonged period of neutropenia from [2186-3-2] to [2186-3-24]. He was supported with blood products including platelets and serial blood transfusions to keep platelet count greater than 10 and hematocrit greater than 25. However, he had a transfusion- dependent anemia and low platelets that was concerning for antiplatelets antibodies. Additionally, towards the end of his hospital course, a peripheral smear started to reveal presence of immature cells. This was concerning for recurrence of his disease. Dyspnea/hypoxia: Starting on [2186-3-6], the patient became more dyspneic with increasing oxygen requirement. CT scan of the chest at that time demonstrated right upper lobe ground glass opacities concerning for infection versus hemorrhage. He underwent bronchoscopy on [2186-3-7] with grossly bloody lavage fluid concerning for diffuse alveolar hemorrhage. For this, he was treated with 1 g of IV Solu-Medrol times 3 days. As part of the workup for his dyspnea, he also underwent echocardiogram, which showed a depression of his ejection fraction to 40 percent. The patient's dyspnea remained with very minimal improvement. In light of this, repeat CT scan was performed on [2186-3-20], which demonstrated persistent bilateral diffuse interstitial opacities concerning for atypical versus fungal infection versus cryptogenic organizing pneumonia. He underwent repeat bronchoscopy on [2186-3-21] with cultures growing budding yeast, which was speciated as [Female First Name (un) 564] albicans. He had already been on prophylactic doses of ampicillin at that time, but ampicillin was increased to treatment dose of 5 mg/kg. During this period of time, the patient was profoundly neutropenic. However, as his counts came back up, he had an increasing oxygen requirement concerning for engraftment syndrome. Therefore, he was treated with Solu-Medrol 60 mg IV times 2 on [2186-3-25] and [2186-3-26] for engraftment. He continued to be treated on cefepime, ampicillin, and Flagyl. There was a concern whether he had some evidence of aspiration versus hospital acquired pneumonia as serial chest x-rays demonstrated left lower lobe and lingular opacities. He continued to have increasing oxygen requirement and had an episode of acute respiratory distress on [2186-3-28], necessitating transfer to the Medical Intensive Care Unit. After transfer to the Medical Intensive Care Unit, he underwent a CT angiogram of the chest. This was felt to be a limited study secondary to consolidation, atelectasis, and due to patient movement. It showed a slight decrease in previously noted bilateral pleural effusions. There was patchy consolidation bilateral diffusely mostly in the peripheral lung zones. There was increasing atelectasis at the right greater than the left bases. There are bilateral lower lobe opacities with question of airway collapse. There were no filling defects concerning for a pulmonary embolus noted. The patient's pre and subcarinal lymph nodes remained prominent in spite of his recent courses of chemotherapy. The patient continued to be in profound respiratory distress and was managed in the Intensive Care Unit with noninvasive ventilation mode. There was some concern that perhaps some of his respiratory compensation was due to amiodarone toxicity, as he had been on amiodarone in the past. He was continued on oxygen, chest physical therapy, aggressive pulmonary toilet. He was also evaluated for a possible VATS procedure. He continued to have episodes of hypoxia and desaturation, which responded to repositioning, anxiolytics, and noninvasive ventilation. VATS was planned for [2186-3-31]. The patient was intubated prior to the procedure. However, post intubation, he became unstable from the hemodynamic standpoint. Therefore, VATS was postponed. His degree of hypotension ultimately necessitated initiation of pressors. On [2186-3-31], a discussion including the Medical Intensive Care Unit team, the Oncology Service, and the patient's family was held. At this time, it was felt that the patient's prognosis was very poor given his increased need for hemodynamic support via pressors in his prolonged persistent hypoxia unresponsive to ventilation techniques, and broad spectrum antibiotics for possible pulmonary process. At that time, it was decided that VATS could not be performed due to the patient's instability as well as due to his overall prognosis. At that time, additionally, the family decided to withdraw aggressive care and focus instead on comfort measures only. The patient was made DNR/DNI. He expired on [2186-4-1]. Congestive heart failure: On admission, the patient's EKG showed a paced rhythm. He had a cardiac history consisting of status post coronary artery bypass grafting times 4 grafts in [5-4]. As part of the workup for his dyspnea, cardiac components were evaluated as well. Echocardiogram showed an EF of 40 percent with inferolateral hypokinesis and anteroseptal hypokinesis, which was a new finding. Therefore, the patient was started on management for congestive heart failure. Review of his weight and volume status during this admission noted that he had gained over 20 pounds status post initiation of the chemotherapy from early [Month (only) 547] to mid [Month (only) 547]. Therefore, he was diuresed aggressively with Lasix. He was also started on metoprolol and lisinopril. He was diuresed to close to his dry weight. However, diuresis was complicated by development of a drug reaction, which was felt to be due to Lasix. Therefore, Lasix was discontinued. During the diuresis period, the patient's dyspnea was much improved. However, around this time, his white blood cell counts returned. As noted, in the management of his dyspnea, return of his white blood cell count was felt to result in some element of engraftment syndrome, which necessitated treatment with steroids. At this standpoint, [2186-3-25] and [2186-3-26], the majority of his dyspnea was felt to be related to pulmonary issues and not to heart failure issues. He was managed as such. Question of disseminated candidiasis: On bronchoscopy, the patient's bronchoalveolar lavage fluids grew [Female First Name (un) 564]. It was unclear whether this was a colonizer or an actual infectious organism. He was on prophylactic doses of AmBisome at that time and had AmBisome increased to 5 mg/kg for treatment doses. This resulted in elevations in his liver transaminases concerning for drug reaction versus hepatic involvement of the [Female First Name (un) 564]. An ultrasound was done to assess the hepatobiliary system and there was no evidence of hepatic involvement. Throughout his hospital course, he was continued on antifungal therapy. Status post treatment with Lasix, the patient developed a diffuse maculopapular rash. He was seen by Dermatology, who felt that several of his medications could be the culprit. He was continued on his antibiotics due to his profound neutropenia and immunocompromised state. Lasix was held, however; and with discontinuation of Lasix, his rash improved. At no time was there any mucosal involvement, blistering, or bullae formation. Hypophosphatemia: On serial electrolyte studies, the patient was found to be profoundly hypophosphatemic. Urinary electrolytes were evaluated and felt to be consistent with Fanconi's syndrome. His phosphorus loss was exacerbated by diarrhea as well as respiratory alkalosis. Therefore, he was aggressively repleted. Evaluation of his parathyroid hormone found it to be markedly elevated. He was followed by Endocrine Service, who recommended checking vitamin D. His vitamin D was low. He was started on calcitriol. Disposition: The patient was initially full code. However, due to multiple complicating events status post initiation of chemotherapy for his AML, including worsening cardiopulmonary status and need for higher level of care in the Medical Intensive Care Unit, code status was re-addressed to his family on [2186-3-31]. At that time, it was felt that his prognosis was poor and family wished to focus on comfort measures only. At that time, the patient was made DNR/DNI/comfort measures only. Intravenous pressors, which were being used for hemodynamic support were slowly weaned. He remained intubated, but had morphine added to his medication regimen for respiratory distress. He ultimately expired on [2186-4-1]. The patient's family was at bedside; attending was notified appropriately. [First Name11 (Name Pattern1) 122] [Last Name (NamePattern4) 24325], [MD Number(1) 24326] Dictated By:[Last Name (NamePattern1) 14378] MEDQUIST36 D: [2186-5-22] 15:40:35 T: [2186-5-23] 03:27:25 Job#: [Job Number 55000] cc:[Last Name (NamePattern4) ] [First Name11 (Name Pattern1) 122] [Last Name (NamePattern4) 24325], MD ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5073 }	Medical Text: Admission Date: [2157-12-15] Discharge Date: [2158-1-6] Date of Birth: [2083-5-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2751] Chief Complaint: Fall Major Surgical or Invasive Procedure: Endotracheal Intubation Central Venous Line Placement [Last Name (un) 1372]-Intestinal Dobhoff Feeding Tube Placement History of Present Illness: Mr. [Known lastname ] is a 74 year old gentleman with dementia, COPD, HTN, CAD, PVD, seizure d/o, distant EtOH abuse admitted on [2157-12-15] from nursing home after mechanical fall from his bed. Per outside hospital records, he fell from bed, approximately 2 feet to the ground. He was found on the floor complaining of left hip pain. He presented to the [Location ] where a CT abdomen/pelvis revealed a left acetabular and iliac crest fracture with a retroperitoneal hematoma. He was given IV fentanyl and dilaudid for pain and transferred to [Hospital1 18] for further management. In the ED his VS were HR 88 BP 136/73 RR18 SpO2 99. He had a distended abdomen and was tender to palpation over his right hip. He has one episode of coffee ground emesis. A CT abdoemn pelvis showeda comminuted, intra-articular left acetabular fracture with extension into left superior pubic ramus, ischium, and inferior left iliac bone with surrounding large retroperitoneal hematoma. HCt was 28 and he was given 2U of PRBC. He was admitted to the trauma SICU for management of his pelvic fracture and retroperitoneal bleed. Past Medical History: COPD HTN PVD, s/p fem-fem bypass Seizure Disorder Anemia Dysphagia s/p c1-c2 fusion Social History: Metoprolol 25mg [Hospital1 ], Lidoderm Patch 5% daily, Tramadol 50mg tid, Simvastatin 5mg ? qhs, Terazosin 5mg qhs, Aspirin 325mg daily, Folic Acid 1mg daily, MVI, Celexa 30mg daily, cilostazol 100mg [Hospital1 ], Prilosec 20mg [Hospital1 ], Colace 100mg [Hospital1 ], Advair Diskus 1 puff [Hospital1 ], Levetiracetam 500mg [Hospital1 ], Albuterol prn, Vit B1 100mcg daily Family History: Unable to obtain Physical Exam: VITAL SIGNS: T= 99.5 BP= 164/77 HR= 114, RR 22, SATS= 98% on face mask GEN: frail elderly man, lying on bed, not in acute distress, follows simple commends, moaning when repositioned HEENT: PERRL, oral mucosa dry, NG in place on tube feeding NECK: no LAD, no JVD CV: RRR, tachy, no mumurs RESP: poor inspirtary effort, no wheezes, no crackles ABD: + BS, soft, +distended, non-tender, no masses, no guarding or rebound PULSES: 2+radial B, 2+ PT/DP B GU: Foley catheter EXT: no edema, no cyanosis, no clubbing SKIN : no rash, no ulceration, no erythema in decubiti NEURO: awake alert to person only, no tremor; no rigidity, gait= not assessed CAM: A/F: Y Inat: ? Disorg: ? Consc: N total:/4 Attention test: demented, unable to test at this time Pertinent Results: [12-15] CT c-spine: s/p post c1-c2 fusion. metallic nail through L lat C2 extends w/tip in retropharnyngeal/prevertebral jxn soft tissues ant to C1. mild anterolisthesis of C4 over C5. very min retrolisthesis C5 over C6. mult-level [Last Name (un) ] change. no acute fx seen. pulmonary emphysema. coarse vertebral and carotid artery calcs. 6mm R thyroid lobe hypodensity. [12-15] CT torso: 1.6 x 1.2 cm focal hypodensity in ant mediastinum (S2:im15). ?focal hematoma vs thymic cystic lesion. No overlying sternal fx or aortic injury. dense aortic calcs. LLL atelect/scarring. comminuted, intra-art L acetabular fx involv ant &post columns and ext to L sup pubic ramus. adj mod pelvic hematoma w/out active extrav. hematoma crosses midline, extends superiorly ant to L psoas muscle and iliacus. mild loss of ht of L2 & L3 vert bodies. Grade 1 spondylolisthesis L5/S1. bladder diverticula . [12-15] CT head: No acute ICH. opacification of inf L maxillary sinus w/focal loss of ant inf L max sinus/ant L alveolar bone, adj soft tissue swelling and foci of gas. ?infectious process involving L alveolar process of maxilla, dental in nature vs chronic sinusitis vs injury. recommend direct visualization. [12-17] CXR: No consolidation [12-17] CXR (pm): Increased lung volumes c/w emphysema. Peribronchial cuffing and predominantly R-sided interstitial opacities likely fluid overload. Subtle opacity @R apex ?superimposition of external ventilator apparatus vs. consolidation. [1-1] CXR: The Dobbhoff tube tip is in the stomach. Cardiomediastinal silhouette is stable. There is no change in upper lobe interstitial opacities in this patient with hyperinflated lungs. The lower lungs are unremarkable. There is no pleural effusion. There is no pneumothorax. [2158-1-4] ECG: Normal sinus rhythm. Q waves in leads V1-V2 consistent with prior anteroseptal myocardial infarction. Compared to the previous tracing of [2157-12-19] there has been no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 88 168 78 378/427 81 57 52 Admission Labs: [2157-12-15] 06:00PM BLOOD WBC-6.6 RBC-3.25* Hgb-9.7* Hct-28.3* MCV-87 MCH-29.8 MCHC-34.3 RDW-15.6* Plt Ct-269 [2157-12-15] 06:00PM BLOOD Neuts-88.2* Lymphs-6.2* Monos-4.9 Eos-0.6 Baso-0.1 [2157-12-15] 06:00PM BLOOD PT-12.8 PTT-26.9 INR(PT)-1.1 [2157-12-15] 06:00PM BLOOD Glucose-120* UreaN-18 Creat-0.8 Na-128* K-4.2 Cl-97 HCO3-22 AnGap-13 [2157-12-21] 02:18PM BLOOD ALT-14 AST-16 CK(CPK)-50 AlkPhos-61 TotBili-0.6 [2157-12-15] 09:47PM BLOOD Calcium-8.3* Phos-4.9* Mg-1.9 [2157-12-16] 10:07PM BLOOD TSH-3.8 [2157-12-16] 07:59PM BLOOD Lactate-0.9 Discharge Labs: [2158-1-5] 05:05AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-28.3* MCV-90 MCH-29.4 MCHC-32.7 RDW-14.6 Plt Ct-607* [2158-1-5] 05:05AM BLOOD Glucose-110* UreaN-18 Creat-0.6 Na-139 K-3.2* Cl-105 HCO3-22 AnGap-15 [2158-1-4] 06:10AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.3 Brief Hospital Course: #. Pelvic fracture. He was initially admitted to the trauma surgery service. He was seen by orthopedic surgery and a pin was placed through the distal femur and the leg was placed in traction in anticipation of possible surgery. 3d reconstructive CT imaging of the pelvis was performed. Ultimately, it was decided to treat this fracture non operatively given his baseline functional status and the severity of his fracture on imaging. The pin was removed. Pain was controlled with IV morphine and PO oxycodone. # Retroperitoneal Bleed. On CT, retroperitoneal and pelvic bleeding was discovered. Interventional radiology was consulted and patient was monitored clinically. He remained hemodynamically stable and his hematocrit remained stable and no intervention was necessary. His hematocrit remained stable for the remainder of his hospitalization. # Hospital Acquired Pneumonia - On [2149-12-21], patient developed a fever, hypoxia and an infiltrate was noted on CXR. He was started on empiric therapy for hospital acquired pneumonia of vancomycin, ciprofloxacin, and cefepime IV. A 7 day course was completed with an improvement in his breathing, and a reduction in his oxygen requirement. On the floor he was given standing albuterol and Atrovent nebs, and was had regular chest PT with respiratory therapy with a significant improvement in function. # Tachycardia - Patient had tachycardia, alternating between sinus tachycardia and multifocal atrial tachycardia in the range of 110-140 early in his SICU course. Cardiology was consulted and recommended up titration of his metoprolol. His metoprolol was gradually up titrated to 200mg PO tid. As his clinical picture improved, this dose was gradually reduced to 50mg PO bid, with rates in the 80s-90s on discharge. # Nutrition - Initial speech and swallow evaluation found that it was unsafe for him to take anything PO due to aspiration risk. A Dobbhoff feeding tube was placed for nutrition and given tube feeds. He pulled the feeding tube once, and it needed to be replaced. Repeat speech/swallow evaluation with video swallow found him to be safe to eat pureed solids with nectar thickened liquids. Feeding tube was removed and he was started on the recommended diet on discharge. #. Goals of care - The patient had severe dementia, and had no health care proxy on admission. Guardianship was obtained emergently given the patient initially tenuous clinical status. [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 80570] ([PO Box 84306], [Location (un) 47] [Telephone/Fax (1) 84307]) has agreed to be Mr. [Known lastname ] guardian. On discussion with Mr. [Last Name (Titles) 80570], [First Name3 (LF) 282] tube placement was declined and it was decided to change Mr. [Known lastname ] code status to DNR/DNI. Medications on Admission: metoprolol 25mg PO bid tramadol 50mg PO tid simvastatin 5mg PO qhs hytrin 5mg PO qhs celexa 30mg PO daily cilostazol 100mg PO bid omeprazole 20mg PO bid colace 100mg PO bid advair 250/50 proair 90mcg IH q4prn keppra 500mg PO bid asa 325 po daily folic acid 1mg po daily multivitamin 1 tablet daily vitamin b1 100mg po q daily Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 9. Celexa 10 mg Tablet Sig: Three (3) Tablet PO once a day. 10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 14. Simvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 17. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 18. Vitamin B-1 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Resident Care Rehab & Nursing Discharge Diagnosis: Pelvic Fracture Retroperitoneal Bleed Multifocal Atrial Tachycardia Pneumonia COPD Dementia Discharge Condition: Baseline dementia, not oriented to place or time. Ambulating with assistance. Discharge Instructions: You were admitted for a fall. You were found to have a pelvic fracture, and surgery was not needed. You developed a bleed into your back and pelvis that resolved. You also developed a high heart rate which was controlled with medications. You developed a pneumonia which was treated with intravenous antibiotics. Your pain was controlled with oxycodone. Followup Instructions: Please arrange a follow up appointment with your PCP. ICD9 Codes: 486, 5070, 496, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5074 }	Medical Text: Admission Date: [2194-1-11] Discharge Date: [2194-1-19] Date of Birth: Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 76 year-old male with a history of coronary artery disease status post coronary artery bypass graft times two, diabetes mellitus, with DDD and AICD placement, history of cardiac arrest, history of abdominal aortic aneurysm repair, mechanical mitral valve, chronic renal insufficiency, congestive heart failure and recent [Hospital Unit Name 196] admission from [12-28] to [1-8] for decompensated congestive heart failure was readmitted from [Hospital3 39496] with question unresponsive episode and clots at rehab. He has no memory of the event and recalls waking up last p.m. at [Hospital3 24768] with an increase in pain and rapid swelling of his increased right lower extremity. His prior admission course was notable for a fall two day, status post catheterization with resultant right groin hematoma. Initially a 2 by 1 cm pseudoaneurysm was seen at the right groin, but repeat ultrasound was negative for such. The patient discharged to rehab and had persistent mild right groin pain at rehab and no swelling. Right lower extremity swelling acutely worsened the day of admission and hematocrit dropped to 21, was 31. Transfused 1 unit of packed red blood cells at [Hospital3 24768] prior to transfer. INR was 4.0 for mechanical valve. Course at [Hospital3 24768] complicated by hypoglycemia to 30 by report and acute on chronic renal failure, supratherapeutic INR and hyperkalemia. PAST MEDICAL HISTORY: Significant for coronary artery disease, status post coronary artery bypass graft times two, diabetes mellitus, chronic renal insufficiency, congestive heart failure, abdominal aortic aneurysm, mechanical valve, status post V fibrillation arrest. MEDICATIONS: 1. Amiodarone 200 b.i.d. 2. Protonix. 3. Aspirin. 4. Quinapril 20. 5. Lipitor. 6. Coumadin. 7. Lasix 80 once a day. SOCIAL HISTORY: He quit smoking twenty years ago. PHYSICAL EXAMINATION ON ADMISSION: Vital signs 97.7. Pulse 72. Blood pressure 118/58. 18, 98% on room air. He is an elderly man in no acute distress, lying in bed. His heart had a regular rate and rhythm with normal S1 and S2. He had a positive 2 out of 6 systolic murmur at the right upper sternal border with mechanical heart sounds heard best at the apex. His lungs were clear to auscultation bilaterally. His abdomen was soft, nontender, nondistended with a positive reducible, nontender hernia in the right mid abdominal. His groin he had bilateral femoral bruits, 2+ femoral pulses bilaterally and extensive hematoma with tense involving the right medial thigh. Ecchymosis and hematoma extended to the midline to involve the left groin. He had 2+ pitting edema of right lower extremity to knee, right thigh much larger then left. He had trace pitting left lower extremity edema. Full range of motion on the left, but right lower extremity is limited at the hip and knee by pain. He had dopplerable dorsalis pedis pulses and posterior tibial pulses bilaterally. His neurological examination was nonfocal. HOSPITAL COURSE: He was monitored in the Coronary Care Unit and transfused packed red blood cells. His Coumadin was initially held, however, then he was placed on a heparin drip, because of a subtherapeutic INR given his mitral valve. He was evaluated by vascular surgery who determined that his hematoma was thus stable and no intervention was needed to evacuate. His hematocrit remained stable and he was transferred out of the unit to the floor. His hospital course was complicated by acute renal failure thought to be secondary to initial hypotension event. His Lasix was originally held and monitored for improvement of his kidney function. When his creatinine became stable and his hematoma was determined stable he was resumed on his Coumadin and he remained in house until his Coumadin became of therapeutic range. His Lasix and ace inhibitor were held. His creatinine trended down to baseline prior to discharge. He was discharged to rehab. DISCHARGE MEDICATIONS: 1. Coumadin 7.5. 2. Metoprolol 50 b.i.d. 3. Ambien prn. 4. Glipizide XL 10. 5. Atorvastatin 10. 6. Aspirin 325 mg. 7. Amiodarone 200 twice a day. 8. Sliding scale insulin. 9. Protonix. 10. Colace. His Lasix and ace inhibitor will resume once his function stabilized as an outpatient. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-661 Dictated By:[Last Name (NamePattern4) 16198] MEDQUIST36 D: [2194-5-17] 02:26 T: [2194-5-20] 11:50 JOB#: [Job Number 39497] ICD9 Codes: 2851, 4280, 2767, 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5075 }	Medical Text: Admission Date: [2148-2-20] Discharge Date: [2148-2-29] Date of Birth: [2104-4-9] Sex: F Service: MICU-B HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old female with a past medical history significant for severe COPD ([12-15] - FEV1 0.36 and FVC 1.13), asthma, anxiety, recently hospitalized at [Hospital3 ] [Date range (1) 23086]. The patient presented at that time with shortness of breath and hypoxia. She was intubated for hypercapnic respiratory failure. Unsuccessful weaning trials from ventilator, and tracheostomy placed. The patient was reported to have a episodes in which she became dyssynchronous from the ventilator and required paralysis for adequate ventilation. The etiology of episodes unknown. The patient was placed on standing doses of BNZ. In addition, the patient had frequent episodes of tachycardia and hypertension which were thought to be secondary to anxiety. Also, MSSA bacteremia secondary to line placement developed and was treated with oxacillin. Discharged [2-11] to [Hospital1 ] for slow wean from ventilator. At [Hospital1 ], the patient had multiple episodes of respiratory distress. On day of discharge, the patient was noted to be tachycardic to the 140s, but in sinus. She was also tachypneic while on pressure support on the ventilator. Her blood gas at that time was 7.40/45/55 and satting 88%. Vent settings were not recorded. On exam, the patient had poor air movement. She was difficult to bag. She was transferred to [Hospital1 18] for further management. Prior to transfer, she was given continuous nebs and Solu-Medrol 60 mg IV x 1. In the Emergency Department, the patient was difficult to bag. She was asynchronous with the vent while on pressure support. Her tidal volumes were in the 100s. She was given ativan 4 mg IV without effect. Fentanyl 100 mcg without effect. She was started on propofol drip with improved compliance, but transient blood pressure drop developed. In the Intensive Care Unit on pressure support with poor tidal volumes, the patient was given 2 mg of dilaudid IV. It was discovered that repositioning the trach by hyperextending the neck improved compliance and patient's tolerance of pressure support. In addition, white blood cell count 22, from 8.7 at time of last discharge. The patient was given a dose of vancomycin, Levaquin and Flagyl. A chest x-ray was without pneumothorax or pneumonia. There was presence of left basilar atelectasis. ECG showed only sinus tachycardia. PAST MEDICAL HISTORY: 1) COPD/asthma, 2) Anxiety, 3) Mitral valve prolapse, 4) Hypertension, 5) Positive PPD, treated with INH x 6 months. MEDICATIONS ON ADMISSION: 1) prednisone 15 mg po qd, 2) fentanyl 25 mcg patch q 72 h, 3) risperidone 2 mg po bid, 4) ativan 1 mg po q 6 h and q 4 h prn, 5) cardizem 30 mg po q 6 h, 6) Ambien 5 mg po q hs prn, 7) Celexa 60 mg po qd, 8) iron sulfate 300 mg po qd, 9) potassium chloride 20 mEq po qd, 10) captopril 50 mg po tid, 11) Singulair 10 mg po qd, 12) Flovent MDI 110 mcg 2 puffs [Hospital1 ], 13) nafcillin 2 mg IV q 6 h through [2148-2-21]. ALLERGIES: Compazine. SOCIAL HISTORY: Patient is estranged from her husband, with one son, age 5. [Name2 (NI) 6961] are very involved in her care. She has a history of tobacco use. She is a full code. PERTINENT DATA ON ADMISSION - LABS: White blood cell count 12.8, hematocrit 27.2, platelets 314, 94% neutrophils, 0 bands, INR 1.3. Urinalysis negative. BUN 13, creatinine 0.5, potassium 4.1, magnesium 1.5. Arterial blood gas showed pH 7.38, PCO2 42, PAO2 423 on R8 TV800 PEEP 20 and FIO2 100%. HOSPITAL COURSE - 1) PULMONARY: The patient was continued on around-the-clock nebulizers, MDI Flovent and Singulair. She was started on Solu-Medrol 60 mg IV q 8 h and then was changed on hospital day two to prednisone 60 mg po qd, and was immediately started on a quick taper back to 15 mg po qd. She was maintained on the vent on pressure support with PEEP, and at the time of discharge was tolerating well pressure support 10&5 with a FIO2 of 40%. Positioning of her head which would cause occlusion of the opening to her trach tube was found to be the source of her acute episodes of dyspnea and anxiety. A new trach piece was ordered, and on the day of transfer the patient was dilated by interventional pulmonology and fitted with this new trach. For her anxiety, she was maintained on Valium 5 mg q 6 h which was increased to 7.5 mg IV q 6 h, with extra Valium prn. 2) INFECTIOUS DISEASE: The patient grew pan sensitive Klebsiella in [2-17] blood culture bottles. Blood cultures were drawn because of the patient's elevated white blood cell count which was most likely secondary to steroids and/or stress reaction. She was started on Levofloxacin and ceftazidime. PICC line was pulled on the morning of [2148-2-22]. Urine culture also grew greater than 100,000 [Last Name (LF) 23087], [First Name3 (LF) ] the patient's Foley was changed, and she was treated with oral fluconazole, her last dose of which was on [2148-2-25]. 3) CARDIOVASCULAR: The patient was maintained on diltiazem and captopril for blood pressure and heart rate control. 4) GASTROINTESTINAL: The patient was maintained on tube feeds. DISCHARGE STATUS: The patient is stable for discharge back to [Hospital1 ], after placement of her new trach. DISCHARGE MEDICATIONS: 1) Levofloxacin 500 mg po qd to complete a 14-day course; her last dose should be on [2148-3-6], 2) prednisone taper 15 mg po qd x 7 days, started on [2148-2-26], then 10 mg po qd x 7 days, then 5 mg po qd x 7 days, 3) Valium 7.5 mg po q 6 h; maximum Valium given should not exceed 30 mg in 8 h, 4) captopril 50 mg po tid, 5) citalopram 40 mg po qd, 6) iron sulfate 325 mg po qd, 7) risperidone 2 mg po bid, 8) fluticasone 110 mcg 2 puffs [Hospital1 ], 9) Montelukast 10 mg po qd, 10) diltiazem 30 mg po qid, 11) heparin 5,000 U subcu q 12 h, 12) Zantac 150 mg po bid, 13) Atrovent nebulizer 1 nebulizer q 6 h prn, 14) albuterol nebulizers 1 nebulizer q 3-4 h prn, 15) Atrovent MDI 2 puffs qid, 16) albuterol MDI 1-2 puffs q 6 h prn, 17) salmeterol inhaler 2 puffs [Hospital1 ]. DISCHARGE DIAGNOSES: 1) Respiratory distress secondary to mechanical obstruction of tracheostomy. 2) Anxiety. 3) Gram-negative bacteremia. 4) [Female First Name (un) 564] urinary tract infection. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[MD Number(1) 23088] MEDQUIST36 D: [2148-2-27] 10:15 T: [2148-2-27] 09:07 JOB#: [Job Number 23089] ICD9 Codes: 7907, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5076 }	Medical Text: Admission Date: [2179-5-16] Discharge Date: [2179-5-20] Service: CCU CHIEF COMPLAINT: The patient was transferred to [Hospital1 18] from [Hospital 4199] Hospital for ST elevation MI. HISTORY OF THE PRESENT ILLNESS: The patient is an 85-year-old female transferred from [Hospital 4199] Hospital after originally being admitted there on [2179-5-13] for treatment of right foot fracture and left ankle sprain which she sustained during a fall at home. The patient was in the rehabilitation unit of the hospital today when she had a syncopal episode while using the commode after a brief loss of consciousness. An EKG was done and the patient was found to be bradycardiac with 5 mm ST segment elevations in V3 through V6, II, III, and aVF. The patient also complained of chest pressure and had an episode of emesis. The episode occurred at 10:20 a.m. The patient was started on heparin and was administered Retavase. The patient was also given aspirin, Percocet, and IV nitroglycerin. Her chest pressure resolved on presentation to [Hospital1 18]; however, the patient continued to complain of dyspnea and diaphoresis. She also reported additional nausea but had no emesis since the morning. The patient cites no history of bleeding disorders. She had an EGD two years ago which revealed mild gastritis. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Multiple bilateral rotator cuff surgeries. 3. Total abdominal hysterectomy. 4. Right foot fracture on [2179-5-13]. MEDICATIONS AT HOME: 1. Synthroid 50 micrograms p.o. q.d. 2. Aspirin 81 mg p.o. q.d. MEDICATIONS ON TRANSFER: 1. Darvocet. 2. Restoril 50 mg h.s. p.r.n. 3. Synthroid 50 mg p.o. q.d. 4. Aspirin 81 mg p.o. q.d. ALLERGIES: The patient is allergic to iodine. SOCIAL HISTORY: The patient denied the use of tobacco, alcohol, or drugs. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.9, blood pressure 116/58, heart rate 73, respiratory rate 20, 02 saturation 95% on room air. General: The patient was mildly uncomfortable, in no acute respiratory distress, lying flat in bed. HEENT: Mucous membranes moist. Oropharynx clear. The pupils were equally round and reactive to light. Neck: No JVD, supple. Chest: Fine crackles at the bases bilaterally. No wheezes. Heart: Regular rate and rhythm, II/VI systolic murmur at the apex. No S3 or S4. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: Bilateral feet and ankles wrapped in bandages. Ecchymoses present on the lower extremities. Neurologic: Alert and oriented times three. Examination otherwise nonfocal. LABORATORY DATA FROM THE OUTSIDE HOSPITAL: CK 43, troponin less than 0.01. Hematocrit 41. The initial EKG at the outside hospital showed 5 mm ST segment elevations in V3 through V6, 2 mm ST segment elevation in II, III, and aVF. Prior to lysis, EKG disclosed 2 mm ST segment elevation in V3 through V6, 1 mm ST segment elevation in II, III, and aVF. Following the administration of thrombolytic agents, the patient had 1 mm ST segment elevation in II, III, aVF, V3 through V6. IMPRESSION: This is an 85-year-old female with ST elevation MI, status post lytic therapy with continued symptoms of chest pain. The patient was admitted to [Hospital1 18] for cardiac catheterization and transferred to the CCU for further management. HOSPITAL COURSE: 1. CARDIOVASCULAR: A. CAD: The patient was taken to the Cath Lab for cardiac catheterization. Coronary angiography of the right dominant circulation revealed no significant residual coronary artery disease. The LMCA was short and had no significant stenosis. The LAD had no significant narrowing but flow down the arteries seemed to pause in the midvessel. The LAD supplied a single bifurcating V1 that had no significant disease. The left circumflex was free of significant disease and gave rise to a moderate sized OM1 and a large OM2 before terminating in the AV groove. The RCA had mild luminal irregularities and supplied small PDA and PLV branches. Resting hemodynamics revealed moderately elevated left ventricular filling pressure with an LVEDP of 22 mmHg in the setting of normal systemic arterial blood pressure. There was evidence of moderate pulmonary hypertension with PA pressures of 43/13/26 mmHg. The cardiac output was preserved at 5.1 liters per minute. No significant gradient across the aortic valve was detected. Left ventriculography demonstrated anterolateral, apical, and inferior apical akinesis with a calculated left ventricular ejection fraction of 53% but a visually observed left ventricular ejection fraction of 30%, severe 3+ mitral regurgitation was seen. The patient returned to the CCU for further observation. She was administered aspirin, heparin, and beta blocker. Her cardiac enzymes were cycled and CKs peaked around 300. Lipid profile split disclosed an HDL of 66, LDL of 113. Since the patient did not have any demonstrable CAD, she was not started on a statin. ACE inhibitor was initiated when the patient's blood pressure could tolerate this. B. PUMP: The patient underwent an echocardiogram on [2179-5-17]. Echocardiogram disclosed resting regional wall motion abnormalities including akinesis of the lower half of the LV with a dyskinetic apex. There was a moderate resting left ventricular outflow tract gradient observed. There was no LV apical thrombus. There was moderate to moderately severe mitral regurgitation ([3-15]+). The patient ejection fraction was 25%. As mentioned above, the patient was started on a beta blocker and ACE inhibitors. C. RHYTHM: The patient remained in normal sinus rhythm during her hospital stay. D. ANTICOAGULATION: Due to the patient's poor ejection fraction and apical akinesis, it was decided that the patient should be started on Coumadin. The patient's goal INR is [3-15]. 2. HEMATOLOGIC: On [2179-5-17], it was noted that the patient's hematocrit dropped to 27.3. A CT scan of the abdomen did not disclose evidence of retroperitoneal bleed. A right groin ultrasound did not show evidence of hematoma. There was, however, a small AV fistula observed. The patient was given a total of 3 units of packed red blood cells during her hospital stay. 3. VASCULAR: As noted above, the right groin ultrasound disclosed a small AV fistula. There was no evidence of hematoma or pseudoaneurysm. A Vascular Surgery consult was obtained. The vascular surgeons noted that the patient had excellent distal flow with good dorsalis pedis and posterior tibial pulses. There was no indication for operative intervention. The patient will undergo follow-up right groin ultrasound in six weeks. 4. MUSCULOSKELETAL: As noted above, the patient had been admitted to [Hospital 4199] Hospital due to right third metatarsal fracture. An Orthopedics consult was obtained for evaluation of the patient's fracture. It was recommended that the patient wear a cast shoe on her right foot for comfort and support. She may weightbear as tolerated. In addition, the patient was noted to have a left ankle sprain. She was given an air cast for her left foot. The patient was instructed to rest, elevate, and weightbear with this foot as tolerated. The patient may walk with assistance. She will follow-up with Dr. [Last Name (STitle) 284] from Orthopedic Surgery in two weeks. 5. NUTRITION: The patient was maintained on a Heart Healthy Diet during her hospital stay. 6. ENDOCRINE: The patient continued on levothyroxine 50 mg p.o. q.d. 7. GASTROINTESTINAL: The patient was maintained on a bowel regimen during her hospital stay. DISPOSITION: The patient is to be discharged to a rehabilitation facility. DISCHARGE CONDITION: Good. DISCHARGE MEDICATIONS: 1. Lisinopril 2.5 mg p.o. q.d. 2. Levothyroxine 50 mg p.o. q.d. 3. Enteric coated aspirin 325 mg p.o. q.d. 4. Lopressor 12.5 mg p.o. b.i.d. 5. Coumadin 5 mg p.o. q.d. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [Last Name (STitle) 284] from Orthopedic Surgery in one to two weeks, phone number is [Telephone/Fax (1) 49447]. 2. The patient is to undergo a right femoral groin ultrasound on [2179-7-9] at 10:30 a.m. Ultrasound is required to confirm that right femoral AV fistula has resolved. The patient should follow-up with Dr. [Last Name (STitle) ], from Vascular Surgery. The phone number is [Telephone/Fax (1) 1784]. 3. The patient will follow-up with her primary care physician in two weeks. The patient's primary care doctor is Dr. [First Name (STitle) ] [Name (STitle) 49448] at [Telephone/Fax (1) 49449]. 4. The patient will be referred to a cardiologist with whom she will follow-up within two weeks. DISCHARGE DIAGNOSIS: 1. Nerve-limiting coronary artery disease. 2. Moderate systolic and diastolic ventricular dysfunction. 3. Moderate pulmonary hypertension. 4. Severe 3+ mitral regurgitation. 5. Acute myocardial infarction. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. [MD Number(1) 1014] Dictated By:[Last Name (NamePattern1) 5092] MEDQUIST36 D: [2179-5-19] 03:43 T: [2179-5-19] 16:02 JOB#: [Job Number 49450] ICD9 Codes: 4240, 4168, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5077 }	Medical Text: Admission Date: [2185-4-4] Discharge Date: [2185-4-6] Date of Birth: [2102-9-13] Sex: M Service: NEUROLOGY Allergies: Latanoprost Attending:[First Name3 (LF) 618] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The patient is an 82 year old man (unknown handedness) with a history of Parkinson's disease, hypercholesterolemia, and right hip fracture s/p fall [2-2] s/p ORIF who presents with altered mental status for whom neurology was consulted when head CT showed a right MCA infarct. The following history is taken from a nurse ([Doctor Last Name ] [Telephone/Fax (1) 7233]) from the [Hospital3 2558]. Yesterday, the patient coughed up a large mucus plug, and was tired ever since then. It was not documented when the patient went to bed last night. At 6:00 am, he was able to take his medications normally. At 8:00 am, the patient wasn't able to take his medications due to difficulty swallowing and had a productive cough. The charge nurse saw the patient, and he was still tired but was able to squeeze hand on the right on cue (but the left hand was not checked) and open his eyes, saying a few words ("yes/no"). Vitals were bp 138/70, HR 86, RR 18, FSBG 136, SaO2 88% on RA so was placed on 2L NC which improved to 91%. Over a 3 hour period, he became less responsive and wasn't talking as much, and had a low grade temp to 99.9 axillary so labs were ordered given concern for aspiration. They did not notice any focalities or asymmetry. Per the ED staff, Narcan was given without response. The ambulance was called and came at 11:15 pm, and by that time he was completely unresponsive. At baseline, speaks in complete sentences slowly and can be difficult to understand, tries to get out of bed, oriented x2 (not always sure where he is). There have been no recent medication changes in the past 2 weeks. Of note, he was listed on a mechanical soft diet with nectar thickened liquids. He has been non-weightbearing since his [Hospital3 ] discharge on [2185-2-16] to just 2 days ago (was set to start PT today). Per the patient's ex-wife, he has been coughing a lot more than usual since Friday. Past Medical History: Parkinson's disease, followed by Dr. [Last Name (STitle) 65301] at [Hospital 882] Hospital Dementia Right hip fracture s/p fall and ORIF with trochanteric nail: admitted to [Last Name (un) 1724] [Date range (1) 86884] Hypercholesterolemia Bilateral shoulder fracture Glaucoma Impulse control disorder BPH Positive PPD Obsessive-compulsive personality trait Right 5th metacarpal fracture Social History: He has been in the [Hospital3 2558] x2 months after a right hip fracture (and he has been weight bearing only over the past 2 days). He is a former professor and chair in English and theology at [Hospital1 3278], and has written 42 books on literary history. His ex-wife, [Name (NI) ] [Name (NI) ], is active in his healthcare, but his HCP is his daughter [Name (NI) 794] ([Name2 (NI) 3235]) [Last Name (un) 86885] in [Name (NI) ]. His PCP is [Last Name (NamePattern4) ]. [First Name (STitle) ] at [Last Name (un) 10526] [Hospital1 ]. Family History: Unable to obtain. Physical Exam: PHYSICAL EXAM AT ADMISSION VS: temp 102.2, HR 101, bp 111/52, RR 32, SaO2 92% on NRB Genl: Eyes closed, NRB in place, does not open eyes to sternal rub HEENT: Sclerae anicteric, no conjunctival injection CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: Tachypnic, right basilar crackles, no wheezes or rhonchi Abd: Increased BS, soft, NTND abdomen Neurologic examination: Mental status: Eyes closed. Does not open eyes on command or to sternal rub, only briefly groans to nailbed pressure. Squeezes right hand and wiggles right toes on command, does not move the left hand or toes on command. Does not show 2 fingers or his thumb on the right. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Does not move the left side of his face as well when he groans. Motor/Sensation: Pill-rolling tremor of his right hand, worse with noxious stimulus. Decreased tone in his left arm, cogwheel rigidity in his right arm. Increased tone in his bilateral legs. No observed myoclonus. Does not keep his bilateral arms or legs lifted against gravity. Briskly withdraws his right arm to nailbed pressure, only slightly flexes his left forearm to nailbed pressure. Withdraws his right>left leg to nailbed pressure. Reflexes: 2+ right biceps, brachioradialis, triceps, knees; 1+ in right ankle. Trace left biceps, 1+ left brachioradialis and triceps, 3+ left knee, 2+ left ankle. Toes upgoing bilaterally. Pertinent Results: Admission Labs: 147 \| 106 \| 22 ---------------< 144 3.6 \| 25 \| 0.7 14.1 14.3 >-----< 235 41.2 CK-MB-NotDone cTropnT-0.13* PT-13.1 PTT-29.9 INR(PT)-1.1 . URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG . IMAGING . CT Head ([2185-4-4]) IMPRESSION: Findings consistent with acute right MCA territory ischemic infarction with hyperdense thrombus in the right MCA. No intracranial hemorrhage. . CTA Chest ([2185-4-4]): IMPRESSION: 1. Extensive bilateral pulmonary embolus with resulting hypoperfusion/developing infarction at lung bases. 2. Early right heart strain. Brief Hospital Course: Mr. [Known firstname ] [Known lastname ] was an 82 year old man (unknown handedness) with a history of Parkinson's disease, hypercholesterolemia, and right hip fracture s/p fall [2-2] s/p ORIF who presented to the [Hospital1 18] with altered mental status and was found to have a right MCA infarct. He was admitted to the stroke service from [2185-4-4] to the time of his death on [2185-4-6]. . HOSPITAL COURSE BY SYSTEM: . #Neuro - A non-contrast CT of the head done to evaluate altered mental status revealed a large infarct in the right Middle Cerebral Artery territory. The stroke was thought to be secondary to a large embolic event, possibly in the context of prolonged immobilization and a patent foramen ovale. Initial plans were to obtain a CTA of the head and neck in addition to an echocardiogram. However, these tests were not ultimately performed as goals of care were transitioned to comfort in the setting of a poor prognosis. . #Resp - On admission the patient was noted to be in significant respiratory distress, requiring a non-rebreather to maintain oxygen saturation. Intubation was discussed but not ultimately pursued given the patient's overall poor prognosis. He was started on broad spectrum antibiotics for presumed pneumonia, and underwent a chest CT to evaluate for possible pulmonary embolism. CT showed large multiple bilateral emboli. However, given the large cerebral infarct, he would have been at significant risk for hemorrhagic conversion were he to undergo anticoagulation. An IVC filter was briefly discussed. Since a filter would not address the significant clot burden or associated heart strain already present, it was not pursued. . #CV - On admission Mr. [Known lastname ] was noted to have an elevated troponin of 0.13, as well as signs of right heart strain on EKG. This was thought to be secondary to the large pulmonary embolism. . #Goals of Care - Extensive discussions were held with the patient's ex-wife, who was in communication with his daughter and health care proxy. [Name (NI) 227] the patient's overall poor prognosis, the decision was made to transition goals of care from cure to comfort. He was transferred to the floor on [4-5]. Members of the palliative care team participated in his care. On [2185-4-6], he died. Medications on Admission: Carbidopa-Levodopa 25/100: 1.5 tabs PO q6AM and 10 am; 1 tab q2 pm and 6 pm Comtan 200 mg PO q6 am, 10 am, 2 pm, 6 pm Namenda 10 mg [Hospital1 ] Prozac 40 mg qAM Seroquel 25 mg qhs Remeron 30 mg qhs Tylenol 650 mg qid Colace [Hospital1 ] Timoptic 0.5% OU daily Xalatan 0.005% drop OU qhs Vitamin D3 50,000 U qweekly (last dose 4/8) Calcium carbonate 600 mg [Hospital1 ] Natural tears prn Oxycodone 5-10 mg q4 hr prn Milk of magnesia prn Discharge Medications: - none Discharge Disposition: Expired Discharge Diagnosis: Stroke Right Middle Cerebral Artery Territory Bilateral Pulmonary Emboli Discharge Condition: Expired Discharge Instructions: Not Applicable Followup Instructions: Not Applicable [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 5070, 2720, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5078 }	Medical Text: Admission Date: [2190-10-11] Discharge Date: [2190-10-13] Date of Birth: [2118-3-22] Sex: M Service: SURGERY Allergies: Morphine Attending:[First Name3 (LF) 2777] Chief Complaint: Greater than 6-cm aneurysm of the descending thoracic aorta Major Surgical or Invasive Procedure: PROCEDURES: 1. Stent graft repair of descending thoracic aortic aneurysm with the [Doctor Last Name 4726] tag endoprosthesis x2. The first endoprosthesis is the following: Catalog number [Serial Number 65878], lot number [Serial Number 65879]; second one is catalog number [Serial Number 65880], lot number [Serial Number 65881]. 2. Thoracic aortography. History of Present Illness: History of Present Illness: Mr. [Known lastname 28221] is a 72 year old male with known thoracic aortic aneurysm who recently underwent endovascular repair of his abdominal aortic aneurysm in [2190-2-28]. His past medical history is also notable for coronary artery disease and he is status post coronary artery bypass grafting surgery. His postoperative course since [2190-2-28] has been unremarkable and he has made excellent recovery. Given his thoracic aortic aneurysm has now slightly increased in size since previous study, he presents for endovascular repair of his descending thoracic aortic aneurysm. Past Medical History: -MIx3, status-post stent [98] years ago, and CABG and [Hospital3 ] 5 years ago. -Diabetes Mellitus II, not on medication. -s/p Cholecystectomy -s/p Colon CA, status-post resection x2 (no radiation) -Manic depression -History of pneumothorax (at age 35) s/p thoracotomy -OSA Social History: SOCIAL HISTORY: Quit smoking 5 years ago, social EtOH, lives in [Location (un) ] alone; performs all activities of daily living. Family History: FAMILY HISTORY: Dad had 2 aortas (?) and cerebral aneurysms, Diabetes, manic depression and colon cancer in dad Physical Exam: Physical Exam: Pulse: 74 Resp: 16 B/P Right: 132/60 Left: 128/62 Height: 71" Weight: 209 General: WDWN in NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] OP benign Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] I/VI systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Well healed laparotomy and cholecystectomy incisions. Extremities: Warm [X], well-perfused [X] No Edema. Right groin incision well healed Varicosities: Left GSV surgicall absent above knee Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right: None appreciated Left: None appreciated Pertinent Results: [2190-10-12] 04:00AM BLOOD WBC-7.0 RBC-4.02* Hgb-11.7* Hct-34.3* MCV-85 MCH-29.0 MCHC-34.0 RDW-13.0 Plt Ct-194 [2190-10-12] 07:13AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [2190-10-12] 04:00AM BLOOD Glucose-127* UreaN-17 Creat-0.9 Na-140 K-4.1 Cl-107 HCO3-27 AnGap-10 [2190-10-12] 04:00AM BLOOD ALT-37 AST-41* AlkPhos-63 TotBili-0.4 [2190-10-11] 12:05PM BLOOD Glucose-141* Lactate-1.2 Na-139 K-4.4 Cl-106 [2190-10-11] 08:30AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.016 [2190-10-11] 08:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ECHO: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. The descending thoracic aorta is markedly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic wall is thickened consistent with an intramural hematoma. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Torn mitral chordae are present. There is no systolic anterior motion of the mitral valve leaflets. No mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: Mr. [Known lastname ],[Known firstname ] was admitted on [10-11] with Thoracic aortic aneurysm. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. Pre hydrated with bicarb and mucomyst. It was decided that she would undergo a Endovascular repair of thoracic aortic aneurysm. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the CVICU for further stabilization and monitoring. Perioperative AB given. He was then transferred to the VICU for further recovery. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabalized from the acute setting of post operative care, he was transfered to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home in stable condition. Medications on Admission: Zetia 10mg daily Gemfibrozil 600mg twice daily Lithium 600mg daily Toprol 50mg daily Omeprazole 20mg daily Simvastatin 80mg daily Aspirin 81mg daily Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day for 10 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Thoracic aortic aneurysm. Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Aortic Aneurysm 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 [3-2] 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 [5-3] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [MD Number(3) 1240]:[Telephone/Fax (1) 7477] Date/Time:[2190-11-17] 8:00 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2190-11-18] 10:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2190-11-18] 11:15 Completed by:[2190-10-13] ICD9 Codes: 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5079 }	Medical Text: Admission Date: [2126-9-10] Discharge Date: [2126-10-5] Date of Birth: [2069-3-12] Sex: M Service: SURGERY Allergies: Tetracycline / Doxycycline Attending:[First Name3 (LF) 2597] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [2126-9-10] - 1. Repair of thoracoabdominal aortic aneurysm with a 28-mm Vascutek multibranched graft with separate anastomoses to the celiac artery, superior mesenteric artery, right and left renal arteries. The graft is a Vascutek Gelweave graft (catalog number [Numeric Identifier 86715], lot number [Serial Number 86716], serial number [Serial Number 86717]).2. Aortobi-iliac graft with a 24 x 12 Hemashield graft. [2126-9-11] - Exploratory laparotomy, evacuation of hematoma and suture repair of bleeding right graft to common iliac artery anastomosis. [2126-9-12] - Left lower extremity four compartment fasciotomy. [2126-9-12] - Exploratory Laparotomy [2126-9-20] - 1. Placement of gastrojejunostomy tube. 2. Abdominal wall closure. 3. Open tracheostomy. History of Present Illness: This is a 57 yo male s/p aortic dissection repair in [2117] followed distal arch repair via left thoractomy in [2119]. He recently presented to the [Hospital1 18] in [2126-2-1] for a subdural hematoma following a fall. This was managed conservatively by the neurosurgery service. CTA at that time revealed a large thoracic/abdominal aortic aneurysm with associated dissection. The dissection extended distally from the area that was previously repaired in [2119]. Vascular surgery was consulted and they did not recommend surgery at that time but arranged for him to be seen as an outpatient by both vascular and cardiac surgeons. He was seen in [Month (only) ] for surgical discussion and planning presents today for preadmission testing for surgery tomorrow. Currently, he denies chest, abdominal and back pain and is feeling well. Past Medical History: Past Medical History: - Thoracoabdominal Aneurysm with Chronic Type B Dissection - Hypertension - Recent History of Subdural Hematoma s/p Fall(improved on past CT scan) - History of Elevated PSA(normal now per patient) - Left Eye Sclera Scar from trauma Past Surgical History: s/p Aortic Dissection Repair [2117] at [Hospital1 112](median sternotomy) s/p Arch Replacement [2119] at [Hospital1 112] [2119](left thoractomy) Social History: Last Dental Exam: No recent exam Lives with: Wife(in [State 5887]) Occupation: Pastor Tobacco: Denies ETOH: Denies Family History: No premature coronary artery disease Physical Exam: Pulse: 85 Resp: 20 O2 sat: 100% BP Right: 138/94 Left: 130/84 General: WDWN male in no acute distress Skin: Dry [x] intact [x] - well healed sternotomy and thoracotomy scars. Axillary and left groin incisions also noted and well healed. Significant scar noted on right neck from bite. HEENT: PERRLA [x] EOMI [x], Sclera anicteric, OP Benign. Obvious left scleral scar Neck: Supple [x] Full ROM [x] No JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Nl S1-S2, Soft I/VI systolic ejection murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] ventral and small umbilical hernia noted Extremities: Warm [x], well-perfused [x] Edema: Trace bilateral LE Varicosities: None [x] Neuro: Grossly intact, No focal deficits, MAE, Gait steady. Pulses: Femoral Right: 2 Left: 2 DP Right: 2 Left: 2 PT [Name (NI) 167]: 2 Left: 2 Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none Pertinent Results: [2126-9-10] ECHO 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. A patent foramen ovale is present. A small amount of intermittent left-to-right shunt across the interatrial septum is seen at rest. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild global left ventricular hypokinesis (LVEF = 40-45 %). Right ventricular free wall function is borderline normal. The descending thoracic aorta is markedly dilated and tortuous. There are simple atheroma in the descending thoracic aorta. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. There is flow in the false lumen. 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. POST BYPASS The patient is on infusions of epinephrine, norepinephrine, and nitroglycerin and is in sinus rhythm. Left ventricular function is globally improved (LVEF=50-55%). Mild aortic regurgitation and mild mitral regurgitation remain. The descending aortic graft which measures approximately 2.8-2.9 cm in diameter is seen with good flow. Proximal ascending aorta is intact. [2126-9-13] CT of spine 1. No obvious intraspinal pathology. Evaluation of the spinal canal is markedly limited without intrathecal contrast. If there is clinical concern for cauda equina or cord compression, MRI should be performed. 2. Lines and tubes as described with changes of recent aortic surgery. 3. Bilateral lower lobe atelectasis/consolidation [2126-9-24] Ultrasound The left internal jugular vein demonstrates fairly extensive thrombus inferiorly, which is incompletely occlusive. This is essentially unchanged since the prior study without propagation or interval lysis. The left subclavian vein appears normal with normal color flow and respiratory variation. [2126-9-24] CT Scan 1. Bilateral lung infiltrates worse on the right that are consistent with aspiration or infection. Left pleural effusion and atelectasis. 2. Marked inflammatory change throughout left chest wall and anterior abdominal wall, and findings that suggest extravasation of oral contrast from the stomach into the base of the anterior wall incision consistent with enterocutaneous fistula. There may be tracking of oral contrast into the chest wall as well. 3. Free fluid is seen in the abdomen and retroperitoneum without evidence of organized fluid collections. 4. Postoperative changes associated with thoracoabdominal AAA repair, not well evaluated on this noncontrast examination [2126-9-14] MRI Spine There is no evidence of hematoma within the spine seen in the lumbar region. Evaluation of the conus is slightly limited but no abnormal signal or compression seen. Paraspinal soft tissues are unremarkable. There is no significant disc bulge or herniation. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2126-9-10] for surgical management of his thoracoabdominal aortic aneurysm. He was taken to the operating room where he underwent a Repair of his thoracoabdominal aortic aneurysm with a 28-mm Vascutek multibranched graft with separate anastomoses to the celiac artery, superior mesenteric artery, right and left renal arteries and an aortobi-iliac graft with a 24 x 12 Hemashield graft. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He was noted to be hypotensive following his surgery, hematocrit down to 19 from 29 preop in first hour post-op, transfused 5 units of blood to a Hct of 23 and ultimately was returned to the operating room on [2126-9-11] for a re-exploration for bleeding with evacuation of hematoma and suture repair of the bleeding right graft to common iliac artery anastomosis. Please see operative note for additional details. Post-operatively, the Mr. [Known lastname ] was hemodynamically stable. His Cr was elevated to 3.2 but urine output was stable. A renal consult was obtained indicating no need for dialysis but close monitoring. He was intubated, sedated and paralyzed in the ICU with a chest tube, NGT and JP drain. On physical exam, b/l leg edema had developed and was worsening. He was taken back to the OR on [2126-9-12] for another washout of the abdomen along with a [State 19827] patch closure and four compartment fasciotomy for to prevent compartment syndrome. He remained intubated and sedated but it was observed that he was unable to move his legs when off of the sedation. A CT and MRI of spine were negative for hematoma or ischemia. The rest of his hospitalization, by systems: Neuro: Mr. [Known lastname ] was intubated, sedated and paralyzed immediately post-operatively. Early in his post-op course (HD 4), he was noted to not be moving his legs when lifted off of sedation. A CT and MRI of spine were negative for hematoma or ischemia. He continued to have some sensation in his lower extremities but no motor function. Neurology was consulted amd eventually he was determined to have spinal cord infarct despite negative imaging. His sedation was decreased and he was awake, alert, oriented and conversing during his last week of admission. Renal: Mr. [Known lastname 86718] Cr bumped to 3.2 post-operatively. Renal was consulted. In the setting of AAA repair and labs indicative of rhabdomyolysis, he was thought to have acute tubular necrosis. Both Creatinine and CPK trended upwards initially (Cr peaked 5.6, then to 2.0 on discharge; CPK peaked to 50,000s on then downward to [2116] on [2126-9-29]). He was managed with both fluids and lasix drip diuresis. Discharge creatinine 1.8. Resp: Mr. [Known lastname ] was on a ventilator post-op on CMV. His lung exam was benign until HD 6 with the note of some crackles at the bases b/l. Sputum cultures were ultimately obtained and antibiotics started (see ID section). On HD 10, his O2 sats dropped on vent, a CXR showed near-total left sided lobar collapse prompting bedside bronchoscopy which resulted in improvement. He was bronched again on HD 11 and received a tracheostomy with the G-J/abdominal closure procedure by general surgery. Additional bronchoscopy on HD 13 showed copious secretions on left side but therafter started to show signs of clinical improvement. Continued fever spikes led to a chest CT on HD 16 consistent with infection/aspiration. He continued to have bronchs as needed throughout his hospitalization and continued to improve clinically. CXR on [2126-10-2] showed improvement respiration. He was discharged on 6 days of PO ciprofloxacin. CV: Received initial transfusion post operatively. Received another unit of PRBCs on HD 11 for a hct of 24.1 to which he responded appropriately. GI: Mr. [Known lastname ] was initially kept NPO with an NGT and eventually (one week into hospitalization) started on tube feeds. On HD 11 with abdominal closure, G-J tube was placed, started on tube feeds gradually advanced to goal. His LFTs started to trend upwards, with Tbili peaking to 5.0 on [9-22]. RUQ ultrasound was negative for cholecystitis, TBili returned to [Location 213] when checked on [9-29]. He was started on PO intake with thin liquids/ground solids on [2126-10-1]. ID: Mr. [Known lastname ] started to spike low grade fevers while on the ventilator starting about 1 week into his hospitalization. He was started empirically on vancomycin and zosyn and sputum culture growed enterobacter cloacae, pan-sensitive, for which antibiotics were continued and ciprofloxacin was added to the mix on [9-19] and stopped on [2126-9-25]. Sputum cultures from sample on [9-19] grew yeast. Since patient continued to spike fevers through the multi-antibiotic therapy, decision was made to add fluconazole to the treatment. Blood cultures remained negative. Wounds: Upon re-exploration the abdominal wound was kept open for inability to close. General surgery was consulted and involved with the surgery and placement of a [State 19827] patch abdominal. He was taken back to the OR on [2126-9-20] for abdominal closure. LLE fasciotomy site was managed with wet dressings until vac application on HD 9. Vac sponge was replaced every three days and the wound was deemed appropriate for closure attempt on [2126-10-2]. The medial incision was closed with horizontal matress sutures. The lateral incision was too tight for closure at this time and was instead fitted with sutures for a partial closure and packed with moist gauze. On day of discharge, patient is AAOx3, NAD, conversing, tolerating PO intake during the day with tube feeds at night, afebrile, WBC 11.3, Cr 1.8. Medications on Admission: Enalapril 10mg daily, Fluticasone nasal spray, Norvasc 10mg daily, Labetolol 600mg four times daily, Cozaar 50mg twice daily, Minoxidil 10mg daily, Claritin 10mg twice daily, Prilosec PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: [2-2] PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal EVERY OTHER DAY (Every Other Day). 8. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 14. HydrALAzine 10 mg IV Q6H:PRN sbp>180 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Ascorbic Acid 500 mg/5 mL Syrup Sig: One (1) PO DAILY (Daily). 19. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: - Thoracoabdominal Aneurysm with Chronic Type B Dissection - Hypertension - Recent History of Subdural Hematoma s/p Fall(improved on past CT scan) - History of Elevated PSA(normal now per patient) - Left Eye Sclera Scar from trauma Discharge Condition: Stable Discharge Instructions: 1. 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 2. Please NO lotions, cream, powder, or ointments to incisions 3. Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4. No driving for approximately one month and while taking narcotics 5. 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: Please call to confirm follow-up appointments in 10 days-2 weeks from discharge. Cardiac Surgeon: Dr. [Last Name (STitle) 914] Phone: ([Telephone/Fax (1) 1504] Vascular Surgeon: Dr. [Last Name (STitle) ] Phone: ([Telephone/Fax (1) 18181] General Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 36338] Cardiologist: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 32215] Please call to schedule appointments with your Primary Care Dr. [First Name4 (NamePattern1) 4768] [Last Name (NamePattern1) 86719] 1-2 weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2126-10-5] ICD9 Codes: 5845, 486, 5180, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5080 }	Medical Text: Admission Date: [2116-6-12] Discharge Date: [2116-6-21] Service: MED HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old man who originally presented to an outside hospital on [2116-6-9] after falling at home while getting out of bed. No trauma was noted. Pelvic and spine x-rays were normal. The patient was found to have a urinary tract infection at the outside hospital and was started on Levaquin. This grew enterococcus resistant to Levaquin, therefore, he was switched to Unasyn on [2116-6-11]. The patient was also noted to be febrile to 101.8. On hospital day two, the patient was noted to be in respiratory distress with dyspnea, tachypnea and diaphoresis. The patient was noted to have difficulty clearing secretions and responded to aggressive suctioning. On hospital day three, he had recurrent respiratory distress and became hypoxic with 88 percent oxygen saturation on room air, which improved to 100 percent on a non-rebreather. A chest x-ray after each episode showed infiltrates consistent with aspiration. The patient continued to have difficulty clearing secretions. Upon his family's request, he was transferred to the [Hospital6 256]. Upon arrival, he was noted to be very agitated, tachypneic and had large amounts of thick, yellow secretions on suctioning. The patient had a weak cough and no gag reflex. PAST MEDICAL HISTORY: Osteoarthritis, asthma, first degree atrioventricular block, paroxysmal atrial fibrillation, hyponatremia, hypertension, coronary artery disease, status post myocardial infarction, peripheral neuropathy, colonic polyps, status post esophageal stricture dilation times two, status post left nephrectomy several years ago secondary to renal cell carcinoma, glaucoma, hyperlipidemia, anxiety, status post cholecystectomy, status post appendectomy, status post cataract surgery, status post carpal tunnel surgery, constipation, cystoscopy last week for work-up of nocturia, urgency and frequency. Cardiac catheterization in [2110]: One- vessel branch coronary artery disease, moderate systolic and diastolic ventricular dysfunction, inferior hypokinesis and mild anterolateral hypokinesis with an ejection fraction of 46 percent. MEDICATIONS: 1. Unasyn 3 gm intravenously q six hours. 2. Zocor 10 mg. 3. Alphagan 0.5 percent, one drop b.i.d. 4. Xalatan, one drop O.U. b.i.d. 5. Claritin 10 mg q d. 6. Metoprolol 25 mg p.o. b.i.d. 7. Dulcolax p.r.n. 8. Ativan 0.5 mg p.o. b.i.d. p.r.n. 9. Albuterol. ALLERGIES: Iodine. SOCIAL HISTORY: Lives with wife in [Name (NI) 106657]. Daughter is an R.N., [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) ]. PHYSICAL EXAMINATION: Temperature 99.2, heart rate 100, blood pressure 100/53, respiratory rate 22, assist control 660 times 18, 50 percent FIO2, 10 of PEEP. General: Intubated, sedated man. HEENT: Anicteric. Cardiovascular: Irregularly irregular, tachycardiac. Lungs: Rhonchi upper airway sounds, but otherwise clear to auscultation bilaterally. Abdomen: Soft, nondistended, nontender. Extremities: No edema. HOSPITAL COURSE: The patient was admitted to the [Hospital3 ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] Medical Intensive Care Unit for further management. On presentation, he was noted to have difficulty clearing secretions. He had only a very weak cough and no gag reflex. After discussion with the patient, a mutual decision was made to intubate the patient. The patient was intubated and did very well on mechanical ventilation. He consistently had RSBI under 100. He only needed minimal pressure support and did well on ten and five. However, he had a persistently weak cough and copious amounts of secretions. In order to see if he had a central process resulting in his weak cough, the patient went for a magnetic resonance imaging scan on [2116-6-16]. Unfortunately, during the magnetic resonance imaging scan, the patient self- extubated himself and had to be re-intubated. Magnetic resonance imaging was a technically limited study, but did not show any evidence of acute infarct. However, the images did not extend through the brainstem. The patient continued to do well on pressure support and because he had an increased cough, the decision was made to extubate the patient in a controlled setting with Interventional Pulmonary and Anesthesia at bedside. The patient was extubated and unfortunately, did not tolerate extubation and became stridorous and had to be re-intubated. At the time of this dictation, the patient is doing well again on pressure support having passed several spontaneous breathing trials and with a RSBI of 80. The plan is to give him perioperative steroids and to have the ENT service take him to the Operating Room for planned extubation and possible tracheostomy if the patient fails extubation. Enterococcal urinary tract infection: The patient was treated for enterococcal urinary tract infection with ten days of Unasyn. He had been started on Unasyn at the outside hospital. The course was completed for ten days as the patient also had multiple aspiration events at the outside hospital and it was felt that a ten day course would cover him for these events as well. Renal failure: At presentation, the patient's kidney function was markedly reduced. His baseline creatinine was 1.4 and at presentation, it was 2.7. This was felt to be mainly pre-renal and with hydration, his creatinine quickly improved to 1.4. Atrial fibrillation: The patient was well rate controlled and started on aspirin therapy. He was noted not to be a Coumadin candidate from prior notes. He spontaneously converted to normal sinus rhythm and at the time of this dictation, he had been in normal sinus rhythm for several days. Volume overload: During the [Hospital 228] hospital course, he became several liters positive. At the time of this dictation, he was successfully diuresed almost to his baseline. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-761 Dictated By:[Doctor Last Name 2020] MEDQUIST36 D: [2116-6-23] 16:31:34 T: [2116-6-23] 17:51:32 Job#: [Job Number 106658] ICD9 Codes: 5070, 5119, 5849, 2761, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5081 }	Medical Text: Admission Date: [2100-12-24] Discharge Date: [2100-12-31] Date of Birth: [2039-8-1] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 30] Chief Complaint: ETOH withdrawal seizure, c. diff diarrhea Major Surgical or Invasive Procedure: Intubated prior to hospital transfer. History of Present Illness: The patient is a 61-year-old woman with a history of alcoholism, alcoholic withdrawal, and possible seiziure disorder and on Keppra. The patient reports to her PCP in the setting of recent increase in alcohol use, although her tox screens have evidently been negative for alcohol and it is unknown when her last drink was. The patient had an episode of tremulousness and a staring episode at her PCP's office, for which she was transferred to [Hospital 4199] Hospital. At [Hospital 4199] Hospital, she experienced a generalized seizure for approximately 20 minutes, for which she was given Versed, Ativan, magnesium. The patient was intubated and given some Ativan and midazolam. She has been on propofol for sedation since. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) 4199] hospital non-contrast head CT was negative for acute intracranial process. The patient received 1g Keppra. . In the ED, the patient's initial neurological exam was nonfocal. Neurology was consulted. An EEG was obtained which showed no status and changes consistent with her propofol sedation. The patient spiked a temperature of 102 in the ED and received acetaminophen. An LP was then obtained, along with a non-contrast head CT. She was also started on 2g ceftriaxone for possible meningitis. The patient's potassium, calcium, and magnesium were all replenished. Her NG tube was advanced. The patient is currentl sedated with a propofol drip. . On arrival to the MICU, the patient is sedated on propofol and intubated. She appears to be quite cachectic. Her heart rate is in the 80s, blood pressure systolic low 100s, diastolic low 60s. Past Medical History: COPD EtOH dependence and history of withdrawal seizures C. diff colitis CAD Diverticulitis Social History: - Tobacco: at least 2 packs per day - Alcohol: "as much as I can get" - Illicits: denies Has boyfriend of 10years who she lives with in ?[Hospital1 8]. Family History: Noncontributory Physical Exam: Admission Exam: General: Intubated, sedated, cachectic HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, no LAD, right EJ IV in place CV: S1, S2, no murmurs auscultated Lungs: Clear to auscultation anteriorly Abdomen: Soft, non-tender, non-distended, bowel sounds present, midline scare running vertically from umbilicus Ext: warm, well perfused, 2+ pulses, no edema Neuro: PERRL, but left pupil less brisk in response to right. Discharge Exam: VS: 96.5, 140/96, 65, 20, 95%RA I/O: none recorded. General: cachectic, sitting on edge of bed in NAD, breathing comfortably on RA HEENT: Sclera anicteric, dry MM, OP clear, poor dentition Neck: Supple CV: RRR, S1/S2nml, no murmurs/rubs/gallops Lungs: Clear to auscultation bilaterally, no wheezes, rhonchi, rales Abdomen: thin, soft, non-tender, non-distended, +BS, midline scare running vertically from umbilicus Ext: cachectic, warm, well perfused, 2+ pulses, no edema Neuro: cranial nerves grossly intact, 5/5 strength throughout, sensation to light touch intact throughout. Relatively stable walking around without any aid Pertinent Results: Admission Labs: [2100-12-24] 05:25PM BLOOD WBC-10.7 RBC-3.39* Hgb-11.6* Hct-33.4* MCV-98 MCH-34.1* MCHC-34.7 RDW-13.0 Plt Ct-127* [2100-12-24] 05:25PM BLOOD Neuts-86.3* Lymphs-9.7* Monos-3.1 Eos-0.7 Baso-0.2 [2100-12-24] 05:25PM BLOOD PT-9.8 PTT-22.7* INR(PT)-0.9 [2100-12-24] 05:25PM BLOOD Glucose-85 UreaN-9 Creat-0.4 Na-142 K-3.0* Cl-117* HCO3-20* AnGap-8 [2100-12-24] 05:25PM BLOOD CK(CPK)-34 [2100-12-24] 05:25PM BLOOD Calcium-6.0* Phos-2.3* Mg-1.5* [2100-12-24] 05:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2100-12-24] 05:25PM BLOOD Osmolal-286 [2100-12-24] 05:48PM BLOOD Type-ART Tidal V-400 FiO2-40 pO2-181* pCO2-33* pH-7.45 calTCO2-24 Base XS-0 -ASSIST/CON [2100-12-24] 10:19PM BLOOD Lactate-0.9 Depression labs: [2100-12-27] 07:00AM BLOOD VitB12-1260* [2100-12-27] 07:00AM BLOOD TSH-0.78 [2100-12-27] RPR negative Microbiology: [2100-12-24] LP suggestive of traumatic tap, culture negative. [2100-12-24] Blood culture NGTD. c. diff positive. [2100-12-26] urine culture negative [2100-12-28] Stool Cultures: no salmonella, shigella, campylobacter, cryptosporidium or giardia [2100-12-27] RPR negative CSF tap: [2100-12-24] 09:50PM CEREBROSPINAL FLUID (CSF) WBC-67 RBC-[Numeric Identifier 91970]* Polys-64 Bands-8 Lymphs-19 Monos-4 Eos-3 Atyps-2 [2100-12-24] 09:50PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-4770* Polys-65 Bands-10 Lymphs-11 Monos-12 Atyps-2 [2100-12-24] 09:50PM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-73 Urine: [2100-12-24] 07:25PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2100-12-24] 07:25PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2100-12-24] 07:25PM URINE RBC-17* WBC-19* Bacteri-NONE Yeast-NONE Epi-<1 [2100-12-24] 07:25PM URINE Mucous-FEW [2100-12-24] 07:25PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Discharge Labs: (no labs drawn on day of discharge) [2100-12-29] 06:45AM BLOOD WBC-3.8* RBC-3.77* Hgb-12.0 Hct-36.0 MCV-96 MCH-31.9 MCHC-33.4 RDW-12.9 Plt Ct-185 [2100-12-30] 07:20AM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-143 K-4.1 Cl-104 HCO3-32 AnGap-11 [2100-12-30] 07:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.6 Images: OSH Head CT: 1. No intracranial hemorrhage or acute fracture. Chronic involutional changes. 2. Moderate paranasal sinus opacification, secondary to intubation. [2100-12-24] EEG: This is an abnormal routine EEG due to the presence of a diffusely slow background consistent with a moderate to severe encephalopathy which is etiologically non-specific. There was also superimposed generalized, frontally predominant beta frequency activity likely due to medication effects such as benzodiazepines or barbiturates. There were no clear electrographic seizures or epileptiform discharges. [2100-12-24] ECG: rate 96, sinus arrhythmia. Poor R wave progression. No previous tracing available for comparison. [2100-12-24] CXR: 1. Endotracheal tube in appropriate position. 2. Nasogastric tube high in position, terminating in the distal esophagus. Recommend advancement so that it is well within the stomach. 3. Hyperinflated but clear lungs. 4. Subacute-to-old left ninth rib fracture with opacity projecting over it, which is felt to more likely be related to osseous change. Recommend comparison with priors and if the opacity has increased, consider chest CT to evaluate for underlying pulmonary nodule. 5. Old fracture deformity and severe degenerative change at the right shoulder with possible loose body. [2100-12-24] Head CT: 1. No intracranial hemorrhage or acute fracture. Chronic involutional changes. 2. Moderate paranasal sinus opacification, secondary to intubation. [2100-12-25] Portable AP radiograph of the chest was reviewed in comparison to [2100-12-24]. The ET tube tip is 6 cm above the carina. The NG tube is coiled in the proximal stomach continuing up towards the esophagus with its tip being at the level of the distal esophagus and should be readjusted. The heart size and mediastinum are unremarkable. Lungs are hyperinflated but essentially clear. Calcified right paratracheal lymph node is unchanged in appearance. Old rib fractures are noted on the left. Overall, within the limitations of this study technique, no other abnormalities are demonstrated. Brief Hospital Course: Ms. [Known lastname ] is a 61-year-old woman with a history of heavy alcohol abuse and withdrawal seizures who was transferred to the ICU following the experience of a generalized 20-minute seizure at outside hospital necessitating airway protection and sedation. Found to be C. diff positive with diarrhea. . # Seizure, likely secondary to alcohol withdrawal. Confirmed with partner that patient had been without alcohol for at least 24 hours prior to admission due to a recent hospital admission for COPD. Lumbar puncture was traumatic, so WBC counts not suggestive of infection. CT head not suggestive of seziure focus; report of MRI from outside hospital also not suggestive of epileptic focus. EEG showed no clear electrographic seizures or epileptiform discharges. CSF VDRL negative from OSH. She was sedated with midazolam and then intubated for airway protection; she quickly was weaned and then self-extubated. She was given keppra for seizure prophylaxis, and neurology was consulted. She was given a "banana bag" for vitamin repletion. During her course in the hospital she did not experience any additional seizures. Was monitored on a CIWA scale, but did not score. Patient has a history of seizure disorder NOS, and has been maintained on Keppra as an outpatient, which was additionally continued throughout admission per neurology recs. . # History of C. diff. colitis: Patient was on a vancomycin taper as an outpatient. Per PCP, [Name10 (NameIs) ] was first diagnosed with c.diff in [8-19], treated twice with flagyl (incomplete treatment in [Month (only) 359] as patient had a seizure given flagyl/etoh use), was started on vanco course with taper on [12-8] after unrelated hopsital admission. Followed up with OSH infectious disease specialist in mid [Month (only) ] who recommended continuing taper and trying fidaxomycin should she have another recurrence. Having diarrhea here which tested c.diff positive, restarted vancomycin PO and IV flagyl in the unit (flagyl d/c'd on the floor). Ruled out other etiologies of diarrhea as the toxin assay can often stay positive even after effective treatment for c. diff (stool cultures negative for salmonella, shigella, campylobacter, cryptosporidium or giardia). However, our suspicion for non-compliance is high and we feel that she likely never completed a course for her c. diff and therefore has continuing infection and not recurrence. Patient is being discharged on full course of fidaxomycin as it is only [Hospital1 ] dosing with less chance of recurrence. She will have VNA and her boyfriend to help ensure she takes her medication. . # Possible urinary tract infection: UA mildly suggestive of urinary tract infection. Patient received 2g ceftriaxone in ED for suspected meningitis. Follow up urine culture negative. Patient was not continued on antibiotics for UTI. . # Alcohol abuse: The patient appears, from both physical appearance and laboratory values, to have chronic malnutrition from her alcohol use. Social work met with her many times and her electrolytes were closely monitored and repleted as necessary. Patient was monitored on a CIWA scale, but was not [Doctor Last Name ]. . Transitional Issues: Patient has a follow up appointment with PCP in early [Name9 (PRE) 404]. We are not confident she is able to complete a treatment course on her own and so we have given her fidaxomycin which is only [Hospital1 ] dosing and has a lower chance of recurrence when compared to Vanc PO. VNA will observe her take one dose, and boyfriend will hopefully ensure she takes the second dose. She additionally has Neurology follow up for her recurrent seizures. Overall, she is very low functioning, however did not qualify for a higher level of care. Medications were minimized on discharge as patient clearly cannot manage a complicated regimen. Medications on Admission: Combivent 18-103 inhaler 2 puffs per 6 weeks ASA 81 mg daily folic acid 1mg PO daily Keppra 750mg [Hospital1 ] mirtazapine 15mg qhs thiamine 100mg daily vancomycin PO 125mg PO (on taper, appears to only need a single dose) vitamin B-12 100 mcg daily Discharge Medications: 1. fidaxomicin 200 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 2. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: amedisys homehealth care Discharge Diagnosis: Primary Diagnosis: Alcohol Withdrawal Seizure and C. Diff diarrheal infection Secondary Diagnosis: COPD EtOH dependence and history of withdrawal seizures C. diff colitis CAD Diverticulitis 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 at [Hospital1 827]. You were transferred here after you had a seizure. You seizure was likely caused because you were going into alcohol withdrawal from not having had any recent alcohol. While here, you were stable and able to breathe on your own, however you were noted to have persistent diarrhea. It appears that your recent diarrheal infection has not been fully treated. Youshould be treated with an antibiotic called fidaxomycin and it is extremely important that you take this medication twice daily for 10 days. DO NOT miss any of these doses. Please make the following changes to your medication regimen: TAKE Fidaxomycin 200mg by mouth twice daily for 10 days. STOP Vancomycin CONTINUE Keppra 750mg (1 tablet) by mouth twice daily Please continue home mirtazipine as prescribed. Followup Instructions: Primary Care Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] When: [1-19] at 11:15am Location: [Location (un) ] FAMILY HEALTH CENTER Address: 454 [Location (un) ] [Apartment Address(1) 3745], [Location (un) ],[Numeric Identifier 30452] Office Number: #[Telephone/Fax (1) 30453] Department: NEUROLOGY When: THURSDAY [2101-1-20] at 1 PM With: DRS. [Name5 (PTitle) 43] & [Last Name (un) 10365] [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: COGNITIVE NEUROLOGY UNIT When: MONDAY [2101-2-21] at 1 PM With: DRS. [Name5 (PTitle) ] & [Doctor Last Name ] [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage ICD9 Codes: 496, 2768, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5082 }	Medical Text: Admission Date: [2136-6-3] Discharge Date: [2136-6-8] Date of Birth: [2098-3-29] Sex: M Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 348] Chief Complaint: Found down and unresponsive. Major Surgical or Invasive Procedure: Intubation. History of Present Illness: 38 yr old male with hx of bipolar d/o who was found down, unresponsive by his roommate at 10am with questionable seizure activity; [11-27] empty bottle of TCA and lithium at bedside. Pt did not wake up to narcan or amp of D50. Pt was brought to [Hospital1 18] [Location (un) 620] where fingerstick was 130. Pt was given 3 amps of bicarb and then started on a bicarb drip. He was also given activated charcoal and Ceftriaxone for leukocytosis and altered mental status. On exam, pt noted to have increased tone, hyperreflexia and bilateral gaze up and out. He was intubaed and then transferred to [Hospital1 18] for further management. In [Hospital1 18], pt received another amp of bicarbonate and then was started on IVF with 3 amps of bicarbonate. A CT of the head and c-spine were done to rule out trauma during fall and were read as normal. Past Medical History: Depression Bipolar disorder hx of previous suicide attempts with overdose [2-28] yrs ago Social History: tobacco abuse question of alcohol abuse works as landscaper Family History: non-contributory Physical Exam: temp 99.2, BP 145/77, HR 120, R 16, O2 100% on AC 600/16/5/100% Gen: intubated, sedated, occasional twitching HEENT: PERRL, gaze forward and equal bilaterally Neck: in c-collar CV: regular, tachy, no murmurs Chest: clear Abd: hypoactive bowel sounds; soft, nontender Ext: no edema, warm, 2+ DP Neuro: hyperreflexic, lower>upper ext; upgoing toes bilaterally Pertinent Results: Blood Chemistry [2136-6-3] 12:00PM BLOOD Glucose-123* UreaN-6 Creat-0.8 Na-144 K-4.9 Cl-109* HCO3-26 AnGap-14 [2136-6-4] 05:00PM BLOOD Glucose-99 UreaN-8 Creat-1.0 Na-154* K-3.4 Cl-119* HCO3-30 AnGap-8 [2136-6-7] 03:10AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-143 K-3.6 Cl-111* HCO3-25 AnGap-11 Ca/Mg/PO4 [2136-6-3] 12:00PM BLOOD Calcium-7.7* Phos-1.6* Mg-1.8 [2136-6-5] 04:47AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.6 [2136-6-7] 03:10AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.9 CBC [2136-6-3] 12:00PM BLOOD WBC-20.2* RBC-4.90 Hgb-15.1 Hct-44.1 MCV-90 MCH-30.9 MCHC-34.3 RDW-13.1 Plt Ct-337 [2136-6-7] 03:10AM BLOOD WBC-9.0 RBC-3.98* Hgb-11.7* Hct-35.5* MCV-89 MCH-29.5 MCHC-33.1 RDW-12.7 Plt Ct-237 Lithium [2136-6-3] 12:00PM BLOOD Lithium-0.2* [2136-6-3] 03:00PM BLOOD Lithium-<0.2 [2136-6-3] 06:54PM BLOOD Lithium-<0.2 Brief Hospital Course: This 38 yr old male with hx of bipolar d/o and possible alcohol abuse who was found down, unresponsive with half empty bottles of nortriptyline and lithium. Intubated at OSH and transferred to this hospital where he was admitted to MICU for suspected TCA and lithium toxicity. CT performed ruled out trauma. Found to have prolonged QT interval on EKG. MICU course characterized by hypernatremia from aggressive NS therapy to overcome Na blockade. Was on HCO3 drip for respiratory acidosis. Acidosis, hypernatremia resolved and EKG returned to [Location 213] and pt ws extubated [2136-6-6]. Transferred to general medicine service on [6-7]. Since transfer pt has been stable. No events noted on telemetry. He has had no signs of delirium tremens denying tremors and hallucinations. Pt currently denies suicide ideation. The major issues of this patients hospital course and treatment plan are as follows. A/P: 38M with hx of bipolar disorder and depression who was found down, unresponsive, suspected TCA overdose . 1. Overdose: Likely TCA, Lithium initially a concern bu level never elevated. Pt s/p activated charcoal in ED. Initially on D5W with 3 amps of bicarb and then switched to NS with 3 amps of bicarb. Pt became hypernatremic but this was goal to overcome Na channel blockade. ABGs checked frequently and goal pH of 7.5, overventilated to breathe down pCO2 to keep alklemic. Initially, received ativan and propofol gtt to prevent sz. - HCO3 gtt stopped on [6-4] and QRS remained <120 - EKG has remained stable over the last 48 hours with no events noted on telemetry. -electrolytes remain stable. . 2. Airway protection: Pt intubated at OSH due to unresponsiveness, for airway protection. As above, pt hyperventilated to keep alkalemic. - extubated on [6-6] over cook catheter . 3. Leukocytosis with bandemia: Likely stress response but also likely that pt aspirated. CXR neg, UA neg. - pan cx on [6-5] for temp of 100.9 . 4. Suicide risk: -after pt came off of sedation, he was placed with 24 h 1:1 sitter -no suicide attempt while on medicine service, pt has denied suicide ideation -Now medically stable, patient to inpatient psychiatry unit for suicide risk and assessment for treatment of bipolar disorder . 5. Code: Full Medications on Admission: Paxil Lithium Nortryptyline Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: Tricyclic antidepressant overdose. Suicide attempt. Bipolar disorder. Discharge Condition: Stable, no sign of heart rhythm abnormalities by clinical exam and by EKG, electrolytes within normal limits. Patient is medically clear for transfer to inpatient psychiatric facility. Discharge Instructions: Please return pt to medical service if pt experiences chest pain or palpitations. Followup Instructions: Inpatient psychiatric unit. Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2136-6-14] 1:30 ICD9 Codes: 2760, 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5083 }	Medical Text: Admission Date: [2134-1-17] Discharge Date: [2134-1-25] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 14964] Chief Complaint: Chest Pain, Presenting from outside hospital after NSTEMI Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 3 History of Present Illness: Pt is an 81 yo male w/ h/o HTN, hyperlipidemia who presented to [Hospital 46] Hosp with complaints of mid-sternal chest pain while at rest. Chest pain at that time was non-radiating and much more severe then his typical angina. There was no associated SOB, N/V, or diaphoresis. He did have HA with mild cough. He denies any F/C, rigors, melena, BRBPR. He has a long standing history of stable angina which has progressed as of late. Normally he gets pain on exertion, which resolves with rest. At OSH ECG revealed NSR, first degree AVB, no significant ST changes(isolated ST elevation in V2). Initial CPK, trop were negative, however second set was w/ CPK 155 and trop I 0.594 which ruled him in at this OSH. He was started on lovenox, BB, and [Hospital ] at OSH and transferred for cariac cath. Pt had fever at OSH however both UA and CXR were negative, pt was on ceftriaxone on transfer. Cardiac Cath revealed 2VD - LM 30%, LAD 90% ostial 80% mid, RCA 90%, LCx-no dz. CXR negative. Pt. underwent carotid U/S on [1-19] which revealed less than 40% bilateral ICA stenosis. Past Medical History: HTN Hyperlipidemia AAA repair '[28] Stable Angina GERD BPH Social History: Lives alone. Denies toabcco however former smoker. Quit 20 yrs ago, smoked [1-30] ppd times 30 yrs. Occasional ETOH. No illicit drugs. Divorced, has 1 son. Family History: Denies any early CAD, cardiac death. No DM Physical Exam: T 98.6 BP 134/62 HR 67 RR 18 O2sats 98% RA Gen: Comfortable, NAD HEENT: clear OP, PERRL, mmm Neck: supple, no carotid bruits, no JVD Lungs: CTAB Heart: RRR, + S1/S2, no m/r/g Abd: Soft, NT, ND, +BS Ext: no edema, 2+ DP/PT bilaterally Neuro: No motor/sensory deficit Pertinent Results: OSH: Hct 41.5 BUN/Cr 26/1.2 [2134-1-17] 08:27PM GLUCOSE-188* UREA N-24* CREAT-1.2 SODIUM-140 POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-26 CALCIUM-8.5 PHOSPHATE-2.4* MAGNESIUM-1.7 ALT(SGPT)-17 AST(SGOT)-29 [2134-1-17] 08:27PM CK(CPK)-151 cTropnT-0.13* [2134-1-17] 08:27PM WBC-6.9 RBC-3.91* HGB-12.1* HCT-34.8* MCV-89 MCH-31.0 MCHC-34.8 RDW-12.3 PLT COUNT-144* [2134-1-17] 08:27PM PT-14.4* PTT-39.3* INR(PT)-1.3 ECG- NSR, resolved V1-V2 ST elevations [2134-1-25] 09:55AM BLOOD WBC-6.6 RBC-3.23* Hgb-10.0* Hct-29.5* MCV-91 MCH-30.8 MCHC-33.8 RDW-13.3 Plt Ct-287# [2134-1-25] 09:55AM BLOOD Plt Ct-287# [2134-1-25] 09:55AM BLOOD Glucose-120* UreaN-31* Creat-1.2 Na-141 K-3.6 Cl-100 HCO3-32* AnGap-13 Brief Hospital Course: Pt consented to surgical intervention and on hospital day 3, pt. was brought to the operating room and underwent a coronary artery bypass graft x 3 by Dr. [Last Name (STitle) 70]. Grafts were as follows - LIMA to LAD, SVG to DIAG, and SVG to PDA. Bypass time was 53 minutes and Cross-clamp time was 30 minutes. Pt. tolerated the procedure and was transferred to CSRU on Neo-Synephrine 0.4 ug/kg/min and Propofol 15 ug/kg/min. Vitals at transfer were - MAP 66, CVP 8, PAD 10, [Doctor First Name 1052] 14, rate of 92 being A-paced. Later that day pt. was extubated successfully. On POD #1 Lasix and Lopressor was started. On POD #2, pt was transferred to [Hospital Ward Name 121] 2, CT's removed and he was hemodynamically stable. On POD #3 pt continued to improve and plan was to just continue activity level, OOB, and incentive spirometry. Pt. continued to do well, Pacing wires were D/C'd and Lopressor was increased to 25 mg [Hospital1 ] on POD #5. And he was discharged on [2134-1-25]. Physical Exam on discharge-Neuro: Alert, Oriented, no focal deficits. Pulm: Lungs clear bilat. Cardiac: RRR with no Clicks/rubs/murmurs/gallops. Sternal incision was clan and dry with no drainage of erythema. Abd: Soft, NT/ND with +bowel sounds. Ext: Negative C/C/E. Incision was Clean and Dry. Medications on Admission: at home: [Last Name (LF) 17339], [First Name3 (LF) ], maxide 40mg qday, diovan 80mg qday, flomax 0.4mg qday, zantac 150mg [Hospital1 ] at OSH: metoprolol 12.5mg [Hospital1 ], lovenox, diovan 80mg qday, ECASA 81mg qday, [Hospital1 17339] 40mg qday, maxide 40mg qday, flomax 0.4mg qday, ceftriaxone 1mg iv qday Discharge Medications: 1. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two (2) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 5. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. 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 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. 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 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 11. 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 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Abdominal Aortic Aneurysm s/p repair in 99' Hypertension Hyperlipidemia BPH GERD Discharge Condition: Good Discharge Instructions: Take medications listed on sheet. Do not apply lotions or ointments to incisions. Do not lift anything greater than 10 pounds for 3 months. Do not drive for 4 weeks. You can take a shower, lightly rub incisions with soap and water. Followup Instructions: Follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] in 6 weeks. Follow-up with Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] in 1 week. Follo-up with Dr. [First Name4 (NamePattern1) 487] [Last Name (NamePattern1) ] in 2 weeks. Completed by:[2134-1-25] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5084 }	Medical Text: Admission Date: [2187-12-13] Discharge Date: [2187-12-18] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1654] Chief Complaint: mouth bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 85F with extensive medical history most notable for CVA with residual left hemiparesis, and PCV had 5 teeth pulled in upper gum on day prior to admission. She experienced persistent bleeding. She was reportedly seen by her dentist, who stated that the suture line was intact and there is no further intervention possible. Pt c/o swallowing blood but denies n/v/light-headedness. . In ED, her initial vitals were 97.6, 78, 121/66, 16, and 99% on RA. She remained hemodynamically stable throughout her time there. She did spike a temp to 100.8 at 11:30 pm on [12-12]. There, multiple attempts were made at stopping the bleeding; she had near-constant pressure, placement of gelfoam, vitamin K 5mg SC, 4 units of FFP, surgicel, afrin, silver nitrate, suture placed, and she received 2units of PRBC for a Hct drop of 42.4 to 31.5. She was also agitated and was placed in restraints and given Haldol 2.5mg IV. She was also started on several antibiotics, including flagyl, unasyn, levoflox, clinda, ceftriaxone, [1-31] findings of UTI and possible aspiration PNA. . Concerning her persistent bleeding, Dental/OMFS was consulted and there was no response. ENT was consulted, but reported that there was no further intervention to be done other than correcting her coagulopathy. . She has not had any known history of bleeding disorder. ED and Heme/Onc have been in touch with her PCP, [Name10 (NameIs) 1023] confirmed that she has not had any history of bleeding before. She was transferred to the [Hospital Unit Name 153] for management with Heme/Onc following. Past Medical History: -polycythemia [Doctor First Name ]: information obtained by heme/onc fellow: - hydrea x at least 5 years; oncologist's name is [Name (NI) ] [Name (NI) 4223] -CVA with L hemiparesis -HTN -CHF, last EF 55% in [2182] -GERD, h/o duodenal ulcer -vertigo -depression -h/o VRE in urine -dementia -hemorrhoids -cataracts -L temple squamous cell carcinoma [8-2] -L facial basal cell carcinoma [8-2] -? gout -osteoarthritis Social History: resident of [Hospital 100] Rehab. She is a hemiplegic s/p CVA. Uses standing lift for transfers. Incontinent of urine. Is usually alert and oriented. She takes a soft diet with supplemental drink at meals. Family History: NC Physical Exam: 97.6 78 121/66 16 99% RA GEN: lying in bed with blood covering mouth and chin, yelling out for help repeatedly, R arm restrained. HEENT: pupils reactive, EOMI Mouth: + bleeding from upper gums diffusely, sutures in place. Gelfoam extruding from side of mouth. CV: RRR Abd: s/nt/nd Rectal: pt refused. Lungs: pt would not cooperate with exam. clear to anterior auscultation Ext: no c/c/e. Neuro: alert and agitated. Oriented to person and "hospital" but not to date or time. Full ROM on R, L hemiparesis in upper and lower extremities. Pertinent Results: CXR: 1. Focal consolidation at right base and patchy consolidation at left base concerning for aspiration pneumonia Vs. aspiration. CT Abd/Pelvis: 1. No evidence of retroperitoneal hematoma. No intra-abdominal fluid. 2. Splenomegaly measuring up to 15 cm, consitent with history of polycythemia [Doctor First Name ]. 3. Low attenuation within the vessels consistent with moderate/severe anemia. 4. Gallstones. 5. Multiple high and low attenuation lesions in bilateral kidneys, which are inadequately characterized on this non-contrast study. 6. Bilateral adrenal adenomas. 7. Atherosclerosis. TTE: 1. The left atrium is normal in size. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. [2187-12-12] 07:05PM BLOOD WBC-35.8 RBC-4.97 Hgb-13.0 Hct-42.4 MCV-85 MCH-26.1* MCHC-30.6* RDW-18.0* Plt Ct-416 [2187-12-13] 06:00AM BLOOD WBC-34.2* RBC-3.69# Hgb-9.6# Hct-31.5# MCV-85 MCH-25.9 MCHC-30.3* RDW-18.2* Plt Ct-408 [2187-12-13] 05:00PM BLOOD WBC-36.0* RBC-2.86* Hgb-7.2* Hct-24.1* MCV-84 MCH-25.3* MCHC-30.0* RDW-18.8* Plt Ct-525* [2187-12-14] 04:53PM BLOOD WBC-33.6* RBC-3.69* Hgb-10.2* Hct-31.4* MCV-85 MCH-27.5 MCHC-32.3 RDW-17.6* Plt Ct-348 [2187-12-16] 09:00AM BLOOD WBC-38.4* RBC-4.20 Hgb-11.6* Hct-36.8 MCV-88 MCH-27.5 MCHC-31.5 RDW-18.5* Plt Ct-343 [2187-12-14] 04:11AM BLOOD Neuts-91.0* Bands-0 Lymphs-6.4* Monos-1.5* Eos-0.5 Baso-0.6 Atyps-0 Metas-0 Myelos-0 [2187-12-12] 07:05PM BLOOD PT-15.8* PTT-38.7* INR(PT)-1.7 [2187-12-16] 02:30PM BLOOD PT-15.5* PTT-31.1 INR(PT)-1.6 [2187-12-12] 07:05PM BLOOD Fibrino-186 [2187-12-13] 09:35AM BLOOD FDP-0-10 [2187-12-13] 04:05PM BLOOD Thrombn-18.4 [2187-12-14] 04:11AM BLOOD Ret Aut-2.0 [2187-12-12] 07:05PM BLOOD Glucose-92 UreaN-36* Creat-0.7 Na-141 K-4.9 Cl-104 HCO3-25 AnGap-17 [2187-12-14] 04:11AM BLOOD LD(LDH)-421* TotBili-0.7 [2187-12-12] 07:05PM BLOOD ALT-17 AST-27 LD(LDH)-339* AlkPhos-145* TotBili-0.5 [2187-12-13] 09:35AM BLOOD Hapto-54 [2187-12-13] 01:10AM BLOOD Lactate-1.8 [2187-12-13] 01:07AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2187-12-13] 01:07AM URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2187-12-13] 01:07AM URINE RBC-0 WBC-[6-8]* Bacteri-MANY Yeast-NONE Epi-0-2 Urine Culture: E. Coli, pansensitive Blood cultures: NGTD at discharge C. diff negative x 1 Brief Hospital Course: [Hospital Unit Name 153] Course: . No evidence of DIC or hemolysis (LDH (277 -> 421), bili (0.7), retic (2) haptoglobin (54 -> 71)). FDP 0-10, Fibrinogen 190->283. Hct continued to slowly drop, requiring several additional transfusions of PRBC. Pt remained hemodynamically stable throughout. Smear w/o evidence of hemolysis except for rare schistos. Platelets normal. No evidence of liver disease on smear (no targets, etc). LFTs normal. Has no h/o liver disease or problems w/ synthetic function. No report of poor nutrition from [Hospital 100] Rehab records. No recent h/o heparin, coumadin, or other anticoagulants. ASA and hydrea held. continued allopurinol. . Vitamin K SC initially given, then started on vitamin K 10mg IV qD x 3 days (started on [12-14]). Also given Amicar 4-5g IV bolus over one hour, followed by 1g/hr for 8hrs. Visible bleeding resolved on [12-14] and has not recurred since. . Wbc count quite elevated throughout [Hospital Unit Name 153] course, up to 40. Possibly [1-31] infection (UTI or aspiration PNA) vs stress response from bleed, though by report, chronically elevated. Tx with levo (started [12-13]) and flagyl (started [12-15]) for possible aspiration PNA (10 day course). No evidence of progression to AML/MDS on smear. . Ms. [Known lastname ] also experienced hypernatremia to 150. Given D5W. She was kept NPO for first day in-house out of concern of gingival bleeding. Was started on liquid diet on [12-15]. She was transferred to the floor on [12-15], and continued to do well. She had no additional bleeding. Her hydrea and ASA were restarted. A mixing study was sent, with results pending at time of d/c. Received 3 days IV vitamin K, with slight improvement of her INR. INR should be f/u, and Vit K given as necessary. Hct should be checked periodically to ensure Ms. [Known lastname ] has no additional bleeding. . Ms. [Known lastname ] also continued to be treated for pan-sensitive UTi and possible aspiration PNA. Blood cultures continued to be negative at time of D/c, and pt was C. diff negative. She is being discharged on Levo/Flagyl, and should continue this course until [2187-12-24]. . Ms. [Known lastname ] had slight worsening of mental status, thought to be delerium [1-31] infection. Her psych meds were held, and foley catheter was d/c'ed. Ms. [Known lastname ] also had a few episodes of tachycardia on telemetry on [12-17], thought to be atrial tachycardia with variable block. Her VS were stable, and she was asymptomatic. She was started on metoprolol 12.5mg PO bid, and this arrhythmia has not recurred. A TTE was done that showed no regional WMAs, and preserved EF>75%. Pt is DNR/DNI - discussed with Dr. [Name (NI) 14936], pt's PCP; also confirmed with daughter who is health care proxy. . Medications on Admission: MEDS: hydroxyurea 500 qd remeron 45 [Name (NI) ], kcl 10 qd sorbitol 15 [Name (NI) ] tramadol 50 [Hospital1 ] trazodone 25 [Hospital1 ] allopurinol 200 [Hospital1 ] asa 81 qd wellbutrin 50 [Hospital1 ] oscal lasix 20 qam fosamax 70 qwk tylenol 650 [Hospital1 ] methylcellulose powder (citrucel) 1 heaping tbsp qd MOM prn [Name2 (NI) ] hydrocortisone cream to rectal area prn hemorrhoid pain artificial tears tid esomeprazole 40mg qd fleet enema 1 pr qd prn Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days: End date: [2187-12-24]. 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days: End date: [2187-12-24]. 4. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 9. Protonix 40 mg Recon Soln Sig: One (1) Intravenous once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Prolonged gingival bleeding after dental procedure, probably due to vitamin K deficiency vs inhibitors Discharge Condition: Stable. Hct stable, no bleeding since [12-14]. Discharge Instructions: Your care is being transferred to the [Hospital1 5595]. please have repeat speech and swallow once you have returned to [Hospital ] rehab WITH YOUR DENTURE IN PLACE to see if nutrition consistency can be upgraded. You should have periodic hematocrit checks to ensure you are not having any occult bleeding. Followup Instructions: You should continue to follow up with your geriatrics attendings at [Hospital1 5595]. You should f/u with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 14936] after your stay at [Hospital1 5595]. ICD9 Codes: 5990, 5070, 2851, 2760, 4280, 2762, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5085 }	Medical Text: Admission Date: [2192-8-13] Discharge Date: [2192-8-17] Date of Birth: [2114-8-9] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: headache and eyelid droop Major Surgical or Invasive Procedure: [8-14]: Cerebral angiogram with coil embolization of Right PCOMM Artery Aneurysm History of Present Illness: HPI: 78 eyar old female who has been otherwise healthy who developed an inability to open her right eye since wednesday. She also notes that she began experiencing blurry vision about a week and a half prior to the first noticing the ptosis. At the time of the onset of the right ptosis she was evaluated in the emergency department of an OSH where a Head CT was done as well as lab work and she was sent home. Last evening she developed a sharp shooting headache above her right orbit that radiated slightly posteriorly and has worsened overnight into today. She also noted that her ability to move her right eye to the left, up, and down was limited. She presented again to an OSH where MRI/A of the head and neck were done which showed an 8mm x 5mm Right PCOMM aneurysm. After the results of the imaging she was sent to [Hospital1 18] for further evalaution. She denies nausea, vomiting, dizziness, alteration in bowel or bladder, sensation deficits. Past Medical History: DVT's 20 years ago, Uterine tumor 15 years ago Social History: Lives with husband, + tobacco, occasional etoh Family History: non-contributory Physical Exam: O: T:98.6 BP: 163/61 HR:61 R:18 O2Sats:100% Gen: WD/WN, comfortable, NAD. HEENT: NCAT Pupils: Right ptosis, right pupil 5mm and NR L pupil [1-17] EOMs: no up or leftward gaze with Right eye, limited downgaze with right eye, full left gaze. left pupils EOM's full Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Right ptosis, R pupil 5mm and NR, Left pupil 3mm/2mm III, IV, VI: Right eye no up or leftward gaze, limited downward gaze, full righward. Left eye full EOM's. No nystagmus bilaterally V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [3-21] throughout. No pronator drift Sensation: Intact to light touch and proprioception bilaterally Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin PHYSICAL EXAM UPON DISCHARGE: A&Ox3 R eye ptosis R 6 NR, L [2-18] EOMs: intact Face symmetrical Tongue midline Motor: Full No pronator drift Pertinent Results: CPK ISOENZYMES CK-MB MB Indx cTropnT [2192-8-16] 08:55AM 9 0.05* Import Result [2192-8-15] 05:00PM 9 0.07* Import Result [2192-8-15] 08:15AM 13* 10.0* 0.08* Import Result [2192-8-15] 12:39AM 12* 11.7* 0.10* Import Result [2192-8-14] 05:11PM 3 <0.01 Import Result CAROTID/CEREBRAL UNILAT [2192-8-14] 1. Successful coil embolization of the right posterior communicating artery aneurysm. 2. Small ophthalmic artery aneurysm. 3. The patient will return for followup MRI/MRA in one month. Brief Hospital Course: Pt admitted from the emergency room to the ICU for blood pressure control and close neuro checks. On [8-14] she underwent cerebral angiography with coil embolization of a right PCOMM artery aneurysm. Embo was without complication. Pt returned to the ICU on a heparin drip overnight. Post operative EKG revealed ST changes therefore cardiac enzymes were cycled. First 2 sets were negative, but the 3rd set Troponin was 0.1. Pt was kept NPO and heparin continued until 4th set was checked and Trop was 0.08. EKG remained stable and patient denied CP, palpitations, SOB etc. On [8-15] she was cleared for transfer to the stepdown unit. heparin was discontinued. PT and OT consults were requested for assistance with discharge planning. On [8-16] the patient developed HR in the 130-160's. SBP was stable in the 150's and the patient was asymptomatic. A fluid bolus was ordered but the patient did not have IV access therefore PO metoprolol was given. This helped temporarily but required further intervention with IV lopressor. EKG's were done revealing AFib with RVR. After the lopressor the patient converted into sinus rhythm and would occasionally have ventricular bigeminy as well. A medicine consultation was requested for assistance and they agreed with adding PO metoprolol [Hospital1 ]. They suggested asking cardiology for their input regarding anticoagulation and the need for further work up. The on call Cardiology Fellow agreed with the PO metoprolol, statin, ASA and recommended outpatient echocardiogram and [Doctor Last Name ] of hearts monitor, 2-3 weeks after discharge. This can be ordered by the patients PCP. [Name10 (NameIs) ] on the results of these, it can be determined as to whether the patient warrants anticoagulation. The patient was seen by PT and OT who recommended further sessions prior to discharge clearance. On [8-17], PT cleared patient for home, exam remained stable and medicine recommended metoprolol succinate 50mg QD. She should follow up with neuro ophthamology for her third nerve palsy and with her PCP for further [Name9 (PRE) 444] for her arrhythmia. Medications on Admission: lisinopril 40mg asa 81mg ? statin (pt doesnt know which one) something for gerd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right PCOMM artery Aneurysm- unruptured Discharge Condition: Neurologically Stable Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? 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 Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ?????? You will not need further imaging prior to this appointment. You need to follow up with your PCP 1-2 weeks after discharge. The on call Cardiology Fellow agreed with the PO metoprolol, statin, ASA and recommended outpatient echocardiogram and [Doctor Last Name ] of hearts monitor, 2-3 weeks after discharge. This can be ordered by the patients PCP. [Name10 (NameIs) ] on the results of these, it can be determined as to whether the patient warrants anticoagulation You also need an appointment with the Neurophthalmologists. Their phone number is ([Telephone/Fax (1) 18621]. This should be made within 1-2 weeks of discharge Completed by:[2192-8-17] ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5086 }	Medical Text: Admission Date: [2177-1-20] Discharge Date: [2177-1-25] Date of Birth: [2093-1-8] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valve replacement, coronary artery bypass grafting times three [2177-1-20] History of Present Illness: Mr. [Name13 (STitle) 68941] is an 83 year old male complaining of dyspnea on exertion and decreased exercise tolerance. He had an abnormal ETT and subsequently [Name13 (STitle) 1834] echo and cardiac cath which showed aortic stenosis and coronary artery disease. He was referred for surgical intervention. Past Medical History: Aortic Stenosis Hypertension Hypercholesterolemia Ventricular arrhythmia/PVC's Left Thalamic CVA [2174] Nephrolithiasis BPH right inguinal hernia ventral hernia Past Surgical History: s/p Laparotomy-adhesions bilateral cataract surgs Social History: Occupation: Retired clergy Lives with: Wife [Name (NI) ]: Caucasian Tobacco: very remote 2 pack year history ETOH: [2-19] glasses of wine per week Family History: Family History: non-contributory. Physical Exam: General: Weight changes-none;usually very active Skin: Eczema [] Psoriasis [] Skin Cancer [] Other-none HEENT: Hearing aide(s) [] Glasses [x] Other-no glaucoma Respiratory: Asthma [] COPD [] Pneumonia [] Cough [] Sputum [] Other:no hemoptysis Cardiac: Chest pain [] SOB [] DOE [x] Orthopnea [x] PND [] Other:no palpitations GI: Nausea [] Vomiting [] Diarrhea [] Constipation [] Heartburn/GERD [] Other:no melena GU: Dysuria [] Frequency [] Prostate [x] GYN [] other-BPH, no hematuria Musculoskeletal: Arthritis [] Peripheral Vascular: Claudication [] Other- no v.v.dz Psych anxiety [] depression []-none Endocrine Diabetes [] thyroid []-none Heme/ID:no bleeding disorders Neuro: TIA [x] CVA [x] Neuropathy [x] Seizures []- residual right hand and foot paresthesias Pertinent Results: [2177-1-24] 07:05AM BLOOD WBC-9.9 RBC-3.51* Hgb-11.0* Hct-32.5* MCV-93 MCH-31.3 MCHC-33.8 RDW-15.0 Plt Ct-132* [2177-1-22] 03:00AM BLOOD PT-13.4 PTT-33.3 INR(PT)-1.1 [2177-1-24] 07:05AM BLOOD Glucose-110* UreaN-36* Creat-1.2 Na-134 K-3.7 Cl-99 HCO3-25 AnGap-14 [2177-1-24] 07:05AM BLOOD Mg-2.4 [Known lastname ], [Known firstname 1955] [Hospital1 18] [Numeric Identifier 68942] (Complete) Done [2177-1-20] at 9:29:39 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2093-1-8] Age (years): 84 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Chest pain. Congestive heart failure. Coronary artery disease. Hypertension. Palpitations. Shortness of breath. ICD-9 Codes: 428.0, 402.90, 786.05, 786.51, 424.1 Test Information Date/Time: [2177-1-20] at 09:29 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5209], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.8 cm <= 4.0 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 45% to 55% >= 55% Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 3.5 cm <= 3.4 cm Aortic Valve - Peak Gradient: 31 mm Hg < 20 mm Hg Aortic Valve - Valve Area: 1.0 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the LAA. Depressed LAA emptying velocity (<0.2m/s) No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Mildly dilated aortic arch. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Mild PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mid inferolateral hypokinesis. 4. . Right ventricular chamber size and free wall motion are normal. 5. The aortic arch is mildly dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened with calcification and limited motion of the noncoronary cusp. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results. POST-CPB: On infusion of phenylephrine. AV pacing. Well-seated bioprosthetic valve in the aortic position. No AI. Gradient post CPB is 32 mmHg. Preserved biventricular systolic function. LVEF is now 50%. Trace MR. [First Name (Titles) ] aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD, Interpreting physician [Last Name (NamePattern4) ] [2177-1-20] 12:39 Brief Hospital Course: On [2177-1-20] Mr. [Known lastname ] [Last Name (Titles) 1834] an Aortic valve replacement and coronary artery bypass grafting times three. This procedure was performed by Dr. [Last Name (STitle) ]. Please see the operative note for details. He tolerated the procedure well and was transferred to the surgical intensive care unit in critical but stable condition. He was extubated and weaned from his drips. His chest tubes and wires were removed. He was transferred to the surgical step down floor and was seen in consultation by the physical therapy service. By post operative day 5 he was ready for discharge to home. Medications on Admission: Toprol XL 50mg qd, HCTZ 12.5mg qd, Amlodipine 5mg qd, Simvastatin 40mg qd, Flomax 0.4mg qd, Aspirin 325mg qd, MVI 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. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg daily for 1 week and then decrease to 200mg ongoing. Disp:60 Tablet(s) Refills:2 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day. Disp:60 Tablet Sustained Release 24 hr(s) Refills:2 7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain.fever. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: aortic stenosis coronary artery disease Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr [First Name8 (NamePattern2) 30623] [Last Name (NamePattern1) ] in [1-18] weeks ([Telephone/Fax (1) 68943] Cardiologist Dr [First Name4 (NamePattern1) 2174] [Last Name (NamePattern1) 2912] in [1-18] weeks ([Telephone/Fax (1) 68944] Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2177-1-25] ICD9 Codes: 4241, 2859, 2875, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5087 }	Medical Text: Admission Date: [2178-12-30] Discharge Date: [2179-1-6] Date of Birth: [2101-5-27] Sex: F Service: #58 ADMISSION DIAGNOSIS: Coronary artery disease. DISCHARGE DIAGNOSIS: Coronary artery disease status post coronary artery bypass graft times three ([2179-1-1]). HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old woman who had repeated episodes of chest pain radiating to the left chest without nausea, vomiting, diaphoresis. She had two recent admissions for chest pain to the [Hospital3 ] at which time she ruled out for myocardial infarction. The patient did rule in for myocardial infarction at this admission to [Location (un) ] and the patient was transferred to the [Hospital1 69]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Peripheral vascular disease. 3. Increased cholesterol. 4. Breast cancer. 5. Status post lumpectomy. MEDICATIONS: Atenolol 50 mg po q day, Imdur 30 mg po q day, aspirin 325 mg po q day, Benadryl prn. PHYSICAL EXAMINATION: The patient is an elderly Hispanic woman in no acute distress. She appears comfortable. Vital signs are stable. Afebrile. Chest is clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm without murmurs, rubs or gallops. Abdomen is soft, nontender, nondistended. No masses or organomegaly. Extremities are warm, noncyanotic, nonedematous times four. Neurological is grossly intact. LABORATORIES ON ADMISSION: 8.4/32.8/243. Chemistry 136/4.0/103/23/16/0.7/181/calcium 8.4. PT 29.3, INR 1.2. ALT 16, AST 19, alkaline phosphatase 64, total bilirubin 0.3, amylase 98, albumin 3.3. HOSPITAL COURSE: The patient was transferred from the [Hospital3 ] to the [Hospital1 69]. Upon arrival the patient had cardiac catheterization, which revealed severe coronary artery disease of all vessels with large dominant left anterior descending coronary artery that collateralizes large posterior descending coronary artery. Subsequent to this the patient was begun on nitroglycerin drip. Cardiac consultation was obtained. Cardiac surgery consultation was obtained. The patient was then added on for revascularization. The patient had a coronary artery bypass graft times three performed on [2179-1-1]. Anastomoses were as follows left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to RPL, saphenous vein graft to ramus intermedius. The patient was transferred to the Recovery Room on neo and Propofol drips. In the Intensive Care Unit setting the patient was found to have significant bloody chest tube output and the patient was emergently taken back to the Operating Room for reexploration. In the reexploration, small chest wall bleeder was found and hemostasis was achieved. The patient subsequently went back to the Intensive Care Unit after the reexploration. At that time the chest tube drainage continued to be thin and bloody and a unit of packed red blood cells was given for a hematocrit of 27. The patient at that time was hypertensive even on a nitroglycerin drip. The Nipride drip was added. Insulin drip was also added. On postoperative day number one the patient remained on a Nipride drip, but was otherwise comfortable. The patient was given 500 cc of Hespan for hypertension and low filling pressures. The patient tolerated extubation after being given Presidex. Subsequent to this the patient's Intensive Care Unit stay was essentially unremarkable. The patient was then transferred to the floor on postoperative day number three. Chest tubes were removed on postoperative day number three. The patient continued to work with physical therapy and had no difficulties progressing with her conditioning. The patient was then subsequently discharged to home on postoperative day number five, tolerating a regular diet and adequate pain control on po pain medications and having no anginal symptoms or significant arrhythmia. PHYSICAL EXAMINATION ON DISCHARGE: No acute distress. Vital signs are stable, afebrile. Regular rate and rhythm without murmurs, rubs or gallops. There is no sternal click. There is no incisional drainage. Abdomen is soft, nontender, nondistended. Extremities are warm, noncyanotic with 1+ bilateral pedal edema. Neurologically intact. DISCHARGE MEDICATIONS: 1. Percocet 5/325 prn. 2. Colace 100 mg po b.i.d. 3. Aspirin 325 mg q.d. 4. Lopressor 75 mg po b.i.d. 5. Lasix 20 mg b.i.d. times five days. 6. Potassium chloride 20 milliequivalents b.i.d. times five days. DISCHARGE CONDITION: Good. DISPOSITION: To home, which is an [Hospital3 ] facility. She will be sent with VNA. DIET: Cardiac. INSTRUCTIONS: The patient is to follow up with her cardiologist in one to two weeks. She is to follow up with Dr. [Last Name (STitle) 70] in six weeks. The patient was only given five days worth of diuretics. The need for diuretics and adjustment to cardiac medications should be addressed at first cardiology visit. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 14041] MEDQUIST36 D: [2179-1-6] 12:36 T: [2179-1-6] 12:43 JOB#: [Job Number 27708] ICD9 Codes: 4439, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5088 }	Medical Text: Admission Date: [2142-6-14] Discharge Date: [2142-6-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 495] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Mechanical ventilation History of Present Illness: 85 year-old female with CHF (right sided), pulmonary HTN, atrial fib, rheumatic heart disease s/p mechanical MVR, severe TR, HTN, who presents from [Hospital1 ] with lethargy and AMS. Recent history is remarkable for being discharged from [Hospital1 18] on [2142-6-4] after presenting with abdominal pain, being found to have SBO and undergoing lysis of adhesions and left inguinal hernia repair, with a course complicated by pneumonia for which she received vanc/zosyn and eventually required trach/PEG for difficulty weaning off ventilator (was unsuccessfully extubated during hospital stay). . She was doing well at [Hospital1 ] until the morning of admission when she was noted to be more lethargic and to have AMS. At baseline, she is alert and oriented x 3 but was less responsive. She was brought to [Hospital1 18] ED for further evaluation. . In the ED, initial vs were: [Age over 90 ]F->100.4 103 95/60->75/55 100% on trach mask. She had a RUQ U/S which was negative and a CXR which showed a RLL pneumonia, and she was given levo/flagly for possible c. diff, and vancomycin/ceftriaxone for healthcare-associated pna. Her mental status was waxing and [Doctor Last Name 688] but she was not felt to need an LP. Her SBP rose to 95 after infusion of 3L NS. Given her transient hypotension and concern for sepsis, she was admitted to the MICU for further management. . On the floor, she was able to answer simple questions. Her passy-muir valve had been removed but per report, even while it was in place in the ED, she was nonverbal. She denied chest pain, headache, shortness of breath, and pain in general. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Cerebellar infarcts Pancreatic cyst Diabetes Mitral valve disease s/p MVR with mechanical valve Severe tricuspid regurgitation (3+) Aortic regurgitation (1+) History of rheumatic fever Chronic atrial fibrillation Congestive heart failure Iron deficiency anemia Hypertension Seizure disorder CCY Left inguinal hernia Social History: No alcohol. No cigarette smoking. Physical Exam: Vitals: T: 97 BP: 93/48 P: 100 R: 13 O2: 100%trach mask General: Alert but waxing and [Doctor Last Name 688] ability to follow simple commands, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decreased BS worse on right than left CV: irregular rate and rhythm, normal S1 + S2, [3-2] sys murmur Abdomen: soft, non-tender, + distended, midline scar in lower abdomen c/d/i Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2142-6-14] 06:15PM GLUCOSE-121* UREA N-38* CREAT-1.0 SODIUM-148* POTASSIUM-4.1 CHLORIDE-114* TOTAL CO2-24 ANION GAP-14 [2142-6-14] 06:15PM CALCIUM-8.9 PHOSPHATE-4.0 MAGNESIUM-1.9 [2142-6-14] 06:15PM WBC-9.6# RBC-3.28# HGB-9.4# HCT-29.3* MCV-89 MCH-28.5 MCHC-32.0 RDW-18.2* [2142-6-14] 06:15PM PLT COUNT-238 [2142-6-14] 02:28PM HCT-28.8# [2142-6-14] 06:30AM GLUCOSE-121 UREA N-40* CREAT-1.0 SODIUM-145 POTASSIUM-5.7* CHLORIDE-113* TOTAL CO2-23 ANION GAP-15 [2142-6-14] 06:30AM ALT(SGPT)-80* AST(SGOT)-126* ALK PHOS-413* TOT BILI-0.4 [2142-6-14] 06:30AM CALCIUM-7.8* PHOSPHATE-4.5 MAGNESIUM-2.0 [2142-6-14] 06:30AM WBC-6.2 RBC-2.47* HGB-7.2* HCT-22.6* MCV-91 MCH-29.1 MCHC-31.8 RDW-19.2* [2142-6-14] 06:30AM PLT COUNT-270 [2142-6-14] 06:30AM PLT COUNT-270 [2142-6-14] 06:30AM PT-33.3* PTT-33.8 INR(PT)-3.5* [2142-6-14] 04:39AM TYPE-ART O2-100 PO2-158* PCO2-53* PH-7.32* TOTAL CO2-29 BASE XS-0 AADO2-520 REQ O2-85 INTUBATED-NOT INTUBA [2142-6-14] 04:39AM LACTATE-0.8 [2142-6-14] 04:39AM O2 SAT-100 [2142-6-14] 01:35AM AMMONIA-50* [2142-6-13] 10:25PM LACTATE-0.9 [2142-6-13] 10:10PM GLUCOSE-120* UREA N-48* CREAT-1.1 SODIUM-147* POTASSIUM-5.0 CHLORIDE-111* TOTAL CO2-30 ANION GAP-11 [2142-6-13] 10:10PM ALT(SGPT)-81* AST(SGOT)-125* ALK PHOS-430* TOT BILI-0.3 [2142-6-13] 10:10PM LIPASE-51 [2142-6-13] 10:10PM LIPASE-51 [2142-6-13] 10:10PM CALCIUM-8.7 PHOSPHATE-4.7# MAGNESIUM-2.2 [2142-6-13] 10:10PM VIT B12-592 [2142-6-13] 10:10PM TSH-1.7 [2142-6-13] 10:10PM WBC-7.7 RBC-2.96 HGB-8.6* HCT-26.4* MCV-89 MCH-28.9 MCHC-32.5 RDW-19.3* [2142-6-13] 10:10PM WBC-7.7 RBC-2.96* HGB-8.6* HCT-26.4* MCV-89 MCH-28.9 MCHC-32.5 RDW-19.3* [2142-6-13] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2142-6-13] 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2142-6-13] 10:10PM URINE RBC-0-2 WBC-[3-29] BACTERIA-FEW YEAST-MOD EPI-0-2 FINAL REPORT [2142-6-19] GRAM STAIN (Final [2142-6-16]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2142-6-19]): OROPHARYNGEAL FLORA ABSENT. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. RARE GROWTH. SECOND COLONY TYPE. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA \| STENOTROPHOMONAS (XANTHOMONAS) MALTOPH \| \| TRIMETHOPRIM/SULFA---- <=1 S <=1 S -------------------- CT CHEST W/O CONTRAST Study Date of [2142-6-14] 11:47 AM IMPRESSION: 1. Severe multi-chamber cardiomegaly. Pulmonary hypertension. 2. Suspected tracheobronchomalacia. 3. Bibasilar extensive consolidations accompanied by volume loss that might be considered for a combination of atelectasis and pneumonia. Small bilateral pleural effusions. 4. Upper lung opacities that might represent infection versus pulmonary dema. Pulmonary hemorrhage cannot be excluded but should be correlated with clinical findings. 5. Extreme kyphosis due to the presence of multiple thoracic fractures is described in detail within the text. ECHO [2142-6-14] The left atrium is markedly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with normal free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The prosthetic mitral valve disks appears slightly thickened, but open normally. The mean gradient (9 mmHg) is higher than expected for this type of prosthesis. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen. Given estimated RA pressures, pulmonary artery systolic hypertension is estimated as severe. There is no pericardial effusion. IMPRESSION: Dilated right ventricle. Normal global and regional left ventricular systolic function. Mild aortic regurgitation. Bileaflet mitral valve prosthesis with higher-than-normal gradients. Severe tricuspid regurgitation. Probably severe pulmonary hypertension. Brief Hospital Course: 85 year-old female with CHF (right sided), pulmonary HTN, atrial fib, rheumatic heart disease s/p mechanical MVR, severe TR, HTN, who presents with AMS and question sepsis. # Pneumonia/respiratory failure: She was admitted with altered mental status and met SIRS criteria with fever and tachycardia, with infiltrates later seen on chest CT. She was treated for healthcare-associated pneumonia with vancomycin and ceftazidime. Cultures eventually grew stenotrophomonas sensitive to bactrim but this was thought to repesent colonization rather than infection. She is to complete a seven day course of antibiotics with last doses on [6-21], and a PICC was placed to facilitate this. She continued to require intermittent respiratory support with mechanical ventilation, particularly overnight when there was concern for tiring. During the day time, she was typically placed on trach collar. She was also diuresed intermittently because her chest x-ray demonstrated some pulmonary edema and pleural effusions. However, at times her systolic blood pressure fell to the 80s with diuresis. Her lasix dose will need continued adjustment to optimize her volume status. # Altered mental status: She was lethargic and minimally arousable at presentation but had an arterial blood glass that demonstrated a normal pH. Her altered mental status was thought to be secondary to infection and improved with treatment of pneumonia. TSH, B12, and RPR were negative. # Atrial fibrillation: She was previously on metoprolol but was started on digoxin during [Month (only) 547]-[2142-5-25] hospitalization after cardiology consultation. Digoxin level at presentation was normal at 1.7. However, because her ventricular rate was high in the 120s at times, she was started on metoprolol. Her warfarin was initially held in the setting of antibiotics and an INR>3 but restarted. # Mitral valve replacement: Mechanical valve per report and history of rheumatic heart disease. She was continued on warfarin as described above. # Communication: Son is [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 21092], [First Name4 (NamePattern1) ] [Known lastname ] is daugther [Telephone/Fax (1) 21093]. Medications on Admission: Digoxin 0.125 mg daily Colace, Senna MVI Insulin SS Coumadin 5 mg po qd Bactrim 800-160 q12 hr Discharge Medications: 1. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig: One (1) ML Injection ASDIR (AS DIRECTED). 2. Digoxin 50 mcg/mL Solution Sig: 0.125 mg PO DAILY (Daily): PEG TUBE. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): PEG TUBE. 4. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily): PEG TUBE. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG PO BID (2 times a day): PEG TUBE. 6. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for bm: PEG TUBE. 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: PEG TUBE. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): PEG TUBE. 9. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 2 days: LAST DOSE 5/28. 10. Vancomycin 500 mg Recon Soln Sig: Seven [Age over 90 1230]y (750) MG Intravenous Q 12H (Every 12 Hours) for 2 days: LAST DOSE [6-21]. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: PEG TUBE. 12. Insulin Lispro 100 unit/mL Solution Sig: PER INSULIN SLIDING SCALE Subcutaneous ASDIR (AS DIRECTED): PER INSULIN SLIDING SCALE (NO CHANGES MADE DURING ADMISSION). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Ventilator associated pneumonia Respiratory failure Right ventricular failure Atrial fibrillation Secondary: Mitral valve replacement Discharge Condition: Good Discharge Instructions: You were admitted because of a change in your mental status. We diagnosed you with pneumonia and treated you with antibiotics. We also helped remove some fluid from your lungs. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Continue your antibiotics until [6-21]. 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. Followup Instructions: Please contact your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] an appointment within the next one week. Completed by:[2142-6-19] ICD9 Codes: 0389, 4280, 4241, 4168, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5089 }	Medical Text: Admission Date: [2204-8-13] Discharge Date: [2204-9-17] Date of Birth: [2148-10-18] Sex: M Service: MEDICINE Allergies: Penicillins / Adhesive Tape Attending:[First Name3 (LF) 8388] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: None History of Present Illness: 55 year old male with HCV cirrhosis s/p liver [First Name3 (LF) ] complicated by ascites/ encephalopathy/ varices (3 cords Grade I varices)/ portal hypertensive gastropathy/chronic portal and splenic venous thrombosis, recently discharged from [Hospital1 18] with a GI bleed who presented on [8-13] with an HCT of 21.7, dizziness and hypotension. . Pt has had a complicated history of recurrent GI bleeding with no clear source being found after an extensive work up that included: [2204-5-11]: GI Bleeding study [2204-5-12]: Sigmoidoscopy [2204-5-18]: GI Bleeding study [2204-5-20]: Colonoscopy and EGD [2204-5-21]: Angiogram, no intervention [2204-5-24]: Exploratory laparotomy, intraoperative endoscopy. . Pt was most recently admitted to [Hospital1 18] from [8-1] to [8-9] with continued GI bleeding. Tagged RBC scan was negative. The result of that admission was to manage his chronic GI bleeding as an outpatient. He was undergoing twice weekly HCT checks, his HCT was 30.9 four days prior to admission, and 21.9 on [8-13]. He also had some associated lightheadedness at home. Over the weekend he had been having [4-26] melanotic stools per day, that were streaked with bright red blood. He was having his chronic abdominal pain, but no changes from his baseline. After getting his HCT checked, he was referred to the ER for further evaluation. . In the ED, initial BP-82/52. Patient was given 3L NS, 2 units of PRBC's. Given his hypotension he was admitted to the ICU for further monitoring. . Follow up HCT in the ICU 20.7 after 2u [Last Name (LF) ], [First Name3 (LF) ] 2 additional units were given. Tagged red cell scan was negative. AM HCT was 27.8. He had 1 episode of melena on the morning of transfer. On transfer patient is resting comfortably. He's quite worried about where he might be bleeding from, but has no other complaints. . Review of systems: (+) Per HPI (-) Denies fever, chills. Denies headache. Denies cough, shortness of breath. Denies chest pain. Denies nausea, vomiting. Denies dysuria, frequency, or urgency. Past Medical History: PMH: - Hepatitis C s/p liver Tx [2198-5-20], s/p revision [12-27]; complicated with rejection and steroid use since [2199-4-20] to present; also complicated with Hep C recurrence and restarted peg interferon [2199-6-17]. Hep C possibly contracted from tattoo [2171] - Chronic pancreatitis - History of peripancreatic abscess [8-/2203] - Diabetes: steroid induced, managed at [Hospital ] Clinic, recent HBA1C 5.1% - ITP - SVT last episode approximately [1-30], medically managed at this time (atenolol) - Secondary hyperparathyroidism due to CKD managed by Dr. [Last Name (STitle) 4090] at [Last Name (un) ] - Depression/anxiety - Primary hypogonadism - Thoracic compression fractures ([5-26]) - H/o post hypoxic encephalopathy ([2190]) - Neutropenia and infections including c. diff x3, streptococcal septicemia, anal fistula s/p fistulectomy([11-24]) - Left sided hydronephrosis due to obstruction from splenomegaly, s/p left ureteral stent placement ([5-28]) - Chronic pain especially rectal pain . PSH: - Cholecystectomy - Appendectomy - Splenectomy, distal pancreatectomy, c/w fistula, s/p stent and then removal [2201] - Bilateral inguinal hernia s/p hernia repair which has failed - Umbilical hernia repair ([11-22]) - Tonsillectomy Social History: Pt was recently at rehab and was discharged home on [7-26]. He lives with mother in [Name (NI) 583]. He has a sister who is a nurse and is very involved in his care. Patient sates he smoked in high school socially (only in parties), but quit since then. Denies any current or past alcohol intake. Denies recreational drug use. Family History: Mother has DM2 and HTN. Uncle with cancer in his 80s (unknown site). Denies any family history of MI, sudden cardiac death, stroke and lung diseases has DM2. Physical Exam: ON ADMISSION: Vitals: Afebrile BP: 102/58 P: 56 R: 18 O2: 99% on 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: ADMISSION LABS: [2204-8-13] 09:50AM BLOOD WBC-7.4 RBC-2.06# Hgb-7.1# Hct-21.9# MCV-106 MCH-34.7* MCHC-32.6 RDW-23.0* Plt Ct-224 [2204-8-13] 09:50AM BLOOD Neuts-66 Bands-0 Lymphs-18 Monos-7 Eos-8* Baso-0 Atyps-0 Metas-1* Myelos-0 [2204-8-13] 09:50AM BLOOD Plt Smr-NORMAL Plt Ct-224 [2204-8-13] 09:50AM BLOOD UreaN-40* Creat-1.1 Na-139 K-5.4* Cl-111* HCO3-19* AnGap-14 [2204-8-13] 09:50AM BLOOD ALT-26 AST-41* AlkPhos-211* TotBili-1.1 [2204-8-13] 09:50AM BLOOD Albumin-2.6* Calcium-8.5 Phos-3.9 Mg-2.3 [2204-8-13] 09:50AM BLOOD tacroFK-3.1* . DISCHARGE LABS: . MICRO: none . STUDIES: Bleeding study ([2204-8-13]): No evidence for lower GI bleed. . Portable CXR ([2204-8-13]): Small bilateral pleural effusions with associated atelectasis. . EGD: . Colonoscopy: Brief Hospital Course: 55 y/o M with a h/o HCV cirrhosis, s/p liver [Month/Day/Year ] complicated by recurrence of HCV cirrhosis and ascites/ encephalopathy/ varices (3 cords Grade I varices)/ portal hypertensive gastropathy/chronic portal and splenic venous thrombosis, who presents with recurrence of GI bleed. . # GI bleed: Pt has a h/o GI bleeds of unknown etiology despite numerous studies including EGDs, colonoscopies, bleeding studies, and an intraoperative endoscopy. He was recently admitted from [Date range (1) 30471], w/o identifying the bleeding source. He was discharged with a plan to have twice weekly outpatient CBCs with transfusions as needed. However, he continued to have numerous large bloody stools and a large drop in Hct, so he was again admitted to the hospital. A repeat tagged RBC scan failed to show the source of the bleed. He was then challenged with heparin, however he did not bleed and so he was reversed with protamine. He then had a large melanotic stool, so he was taken to angio and challenged with intra-artrial heparin to the SMA and [Female First Name (un) 899]. Again, no source of bleeding was found. Colonoscopy and EGD were performed with no bleeding source identified. He was started on Amicar. He remained hemodynamically stable and was transferred to the floor. On the floor, patient continued to have intermittent episodes of bleeding requiring transfusions. He underwent red blood cell scan which showed possible delayed bleed around hepatic flexure. He subsequently underwent colonoscopy which was essentially negative, showing one non bleeding diverticulum. He had a brief trial of octreotide, which was d/c-ed after one day secondary to cramping. He was finally started on a trial of estrogen therapy. Underwent a capsule study which was also negative. As of [2204-8-25] he had required 17 units of [Date Range ] during this hospitalization. During this time he was also treated for a complicated UTI with a course of cipro. Pain and palliative care were consulted. Family meeting was held with patient's three sisters, pain and palliative care, outpatient hepatologist, attending on service, housestaff and social work. Mr. [Known lastname 4042] expressed that he nolonger wished to be intubated or recussitated and DNR/DNI status was initiated. On [9-15], patient developed shortness of breath, chest discomfort and continued to complain of abdominal discomfort. Throughout the day, multiple discussions were held in the presence of the family and the patient. Mr. [Known lastname 4042], stated that he nolonger wanted any blood products. He also complained of discomfort with taking in of medications. Comfort measures was initiated and patient was placed on a morphine drip titrated to comfort. Family support was provided. Mr. [Known lastname 4042] passed on [9-17], with family present at his bedside. Medications on Admission: ALENDRONATE - 70 mg weekly ATENOLOL - 50 mg once a day ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit weekly LAMIVUDINE [EPIVIR HBV] - 100 mg once a day LATANOPROST [XALATAN] - 0.005 % Drops - 1 Drops(s) in each eye HS LIPASE-PROTEASE-AMYLASE [PANCREASE] - 20,000 unit-[Unit Number ],500 unit-[Unit Number ],000 unit Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth three times a day with meals OMEPRAZOLE - 40 mg twice a day SERTRALINE - 50 mg - 1.5 Tablet(s) by mouth once a day SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM DS] - 800 mg-160 mg Tablet - 1 Tablet(s) by mouth twice a day TACROLIMUS - 0.5 mg Capsule - 1 Capsule(s) by mouth twice a day TRAZODONE - 50 mg HS URSODIOL - 300 mg twice a day CALCIUM CITRATE-VITAMIN D3 - 315 mg-200 - 1 Tablet twice a day FLUDROCORTISONE 0.1mg daily FOLIC ACID 1mg daily LACTULOSE 30mL daily RIFAXIMIN 400mg TID LASIX 20mg daily SPIRONOLACTONE 25mg daily MULTIVITAMIN 1 tablet daily THIAMINE 100mg daily Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Pt expired Discharge Condition: Pt expired Discharge Instructions: Pt expired Followup Instructions: Pt expired Completed by:[2204-9-18] ICD9 Codes: 5180, 5990, 5789, 5715, 5859, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5090 }	Medical Text: Admission Date: [2149-4-8] Discharge Date: [2149-5-15] Date of Birth: [2074-9-22] Sex: M Service: NEUROLOGY Allergies: Codeine / NSAIDS / lamotrigine Attending:[First Name3 (LF) 20506] Chief Complaint: seizures Major Surgical or Invasive Procedure: [2149-4-25] Dr. [Last Name (STitle) ] [Name (STitle) 2325] craniotomy for open brain biopsy History of Present Illness: The pt is a 74 yoM with a history of complex partial seizure and sometimes secondary generalization. Presented with [2149-4-5] by his wife with mental status change, at 11am was confused with slurred speech, there noted to be hypertensive 210/106 (patient not taking medications as prescribed), NCHCT was normal and then admitted for management of seizures and HTN. Zonegran was decreased to 100mg daily, continue keppra and started Topamax 25mg daily, EEG showed PLEDs every 1- 1.5 seconds followed by generalized slowing, --> thought to be in partial complex status, Keppra 500mg and loaded with Dilantin 250mg IV and 200mg PO. Topamax was further increased to 50mg [Hospital1 ]. [Hospital1 18] was called and patient transferred for further management. Past Medical History: SEIZURE Hx: Multiple complex partial seizures sometimes with secondary generalization: 1st Sz [10/2144], Semiology: garbled speech, disorientation, currently on: Keppra, Zonegran, AEDs in past: Lamictal --> d/c [12-19] tremors T8-T9 extramedullary intradural thoracic meningioma sp resection in [2143] c/b seroma at the site of his surgical incision found to be growing MRSA. DVT in [2144-10-17]; ? PE (no documentation) ? PRES : [2144-10-17] (MRI of the brain that showed increased T2 hyperintensities in the bilateral occipital and posterior right parietal lobe consistent with posterior reversible encephalopathy syndrome) Vertebral artery stenoses (b/l) Tremor (thought to be medication related and not parkinsonian, large amplitude) Neuropathy: burning in toes bilaterally HTN - Amitriptyline HL - Lipitor, PVD - left leg bypass done by Dr. [First Name (STitle) 10378] in [Hospital1 1474] for 65% stenosis of a right leg artery. Hx of asystole 30secs, requiring chest compressions Social History: He finished high school. He was a former butcher. He is retired. He is married to [Doctor Last Name 2048]. Does not smoke cigarettes, drink alcohol, or use any illegal drugs. He did skip the first grade. He had no learning disabilities. Family History: His maternal uncle had 2 children and both of these cousins had epilepsy. The patient himself has no history of birth complications, or head trauma. Physical Exam: At admission: Vitals: T: Afebrile P: 76 R: 16 BP: 142/72 SaO2: 96%RA General: Alert, comfortable, confused and perseverative HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx 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. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to person only. NOT able to relate history given perseveration and confusion. Attentive but not able to follow commands "stick out your tongue, show me your teeth". Language is fluent with impaired repetition and impaired comprehension. Pt. was NOT able to name both high and low frequency objects. Speech was not dysarthric. NOT Able to follow both midline and appendicular commands. Memory was not assessed. Apraxia / neglect could not be assessed. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Low frequency tremor in the right finger/hand, also demonstrated intermittent larger amplitude low frequency rhythmic jerking in his RLE. Pronator drift could not be assessed. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 4- 4+ 4 NA NA NA 5 5 5 5 5 5 5 -Sensory: No deficits to light touch or noxious stimuli. No extinction to DSS. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R could not be assessed given the ongoing rhythmic activity Plantar response was extensor on the right and flexor on the left. -Coordination: defered -Gait: defered Pertinent Results: [2149-4-8] 05:39PM BLOOD WBC-7.9 RBC-4.81 Hgb-14.9 Hct-45.3 MCV-94 MCH-30.9 MCHC-32.8 RDW-13.0 Plt Ct-156 [2149-4-8] 05:39PM BLOOD PT-28.7* PTT-37.7* INR(PT)-2.8* [2149-4-8] 05:39PM BLOOD Glucose-121* UreaN-25* Creat-1.5* Na-141 K-4.3 Cl-106 HCO3-25 AnGap-14 [2149-4-10] 05:51AM BLOOD Glucose-154* UreaN-19 Creat-1.3* Na-137 K-6.0* Cl-104 HCO3-22 AnGap-17 [2149-4-20] 05:20AM BLOOD Glucose-141* UreaN-13 Creat-1.3* Na-143 K-3.7 Cl-105 HCO3-28 AnGap-14 [2149-4-8] 05:39PM BLOOD ALT-27 AST-20 LD(LDH)-168 AlkPhos-73 TotBili-0.8 [2149-4-8] 05:39PM BLOOD Calcium-10.5* Phos-2.3* Mg-2.0 [2149-4-9] 07:30PM BLOOD Albumin-4.1 [2149-4-15] 08:38AM BLOOD calTIBC-160* TRF-123* [2149-4-8] 05:39PM BLOOD Phenyto-7.7* [2149-4-16] 03:44PM BLOOD Lactate-1.7 [2149-4-15] 08:38AM BLOOD PREALBUMIN-Test [2149-4-18] 04:58AM BLOOD VGKC ANTIBODY -PND [2149-4-18] 04:58AM BLOOD GLUTAMIC ACID DECARBOXYLASE-PND [2149-4-8] 05:38PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.018 [2149-4-8] 05:38PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [2149-4-8] 05:38PM URINE RBC-50* WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 [2149-4-13] 01:37PM URINE Hours-RANDOM Creat-52 Na-63 K-10 Cl-58 [2149-4-13] 12:30PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-4* Polys-0 Lymphs-67 Monos-26 Macroph-7 [2149-4-13] 12:30PM CEREBROSPINAL FLUID (CSF) TotProt-69* Glucose-121 [2149-4-17] 12:30PM CEREBROSPINAL FLUID (CSF) 14-3-3-PND [2149-4-13] 12:30PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name [2149-4-13] 11:37 am CSF;SPINAL FLUID Source: LP TUBE #3. GRAM STAIN (Final [2149-4-13]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2149-4-16]): NO GROWTH. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [2149-4-11] 3:13 pm URINE Source: Catheter. FINAL REPORT [2149-4-13] URINE CULTURE (Final [2149-4-13]): CITROBACTER KOSERI. 10,000-100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 79405], [2149-4-11]. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 347-5871C, [2149-4-11]. [2149-4-11] 11:39 am URINE Source: Catheter. FINAL REPORT [2149-4-14] URINE CULTURE (Final [2149-4-14]): CITROBACTER KOSERI. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S <=16 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 1 S [2149-4-8] 5:38 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2149-4-10] MRSA SCREEN (Final [2149-4-10]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. EEG: [2149-4-8]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of the diffuse encephalopathic features with focal and multifocal features. There is diffuse background slowing but also asymmetric slowing in the left parieto-occipital region and independently in the right parietal area. Superimposed upon the leftsided slow wave activity is an exceptionally active paroxysmal epileptiform transient with a frequency of 0.5-1 Hz. This appears to have both an electrical field effect in the right occipital pole as well as synaptic transmission to the right parietal-occipital region. There were several events that appear to be clonic seizures of the right leg but no clear electrographic correlate. [2149-4-9]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of diffuse encephalopathic slowing seen as a widely distributed abnormality but superimposed structural features in the left posterior quadrant and independently in the right central parietal regions. There is extremely active paroxysmal interictal discharge in the posterior quadrant on the left maximum at the O1 electrode. No sustained electrographic seizures or clinical events were reported or recorded. [2149-4-10]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of the persistent diffuse encephalopathy with superimposed more significant left hemisphere abnormality suggesting structural pathology in the more posterior aspects of the left hemisphere and possible independent structural pathology in the right parietal central region. Superimposed upon this is a very active interictal epileptic discharge in the left occipital pole. No sustained seizures were identified. [2149-4-11]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of diffuse encephalopathic changes and multifocal independent structural pathologic left greater than right. There continues to be an extremely active paroxysmal interictal epileptic discharge in the left occipital pole. [2149-4-12]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of both diffuse encephalopathic features as well as multifocal slow wave abnormalites suggesting multifocal structural pathology. The left hemisphere appears more involved than the right. There continues to be paroxysmal interictal epileptiform activity in the left occipital pole. [2149-4-13]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of a diffuse encephalopathy with multifocal superimposed slow wave features. This activity is over the left occipital parietal and the right central parietal regions. There continues to be an active interictal epileptiform transient in the left occipital pole. MR head with and without contrast: IMPRESSION: Restricted diffusion constrained to the left parietal and temporal cortical grey matter. The differential diagnosis for this pattern is broad and it is most commonly caused by vascular ischemia, however, in a patient with complex partial seizures originating from this location, post-ictal changes may present similarly. The findings of left cerebral atrophy and possible crossed cerebellar diaschisis is suggestive of [Doctor Last Name 73] syndrome. This can be further explored using MRI spectroscopy, perfusion, and tractography. Viral etiology must also be considered. The clinical significance of the relatively new microhemorrhages at these loci is unclear. Carotid US: IMPRESSION: Although there is plaque involving the proximal internal carotid arteries bilaterally, no hemodynamically significant stenosis noted. Flow in the vertebral arteries is prograde. TTE: Conclusions Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. 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. Physiologic mitral regurgitation is seen (within normal limits). The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality due to body habitus. No cardiac source of embolus seen. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen. No significant valvular abnormality. Unable to assess pulmonary artery systolic pressure. Paraneoplastic Autoantibody Eval, S Interpretive Comments No informative autoantibodies were detected in this evaluation. However, a negative result does not exclude neurological autoimmunity with or without associated neoplasia. Anti-Neuronal Nuclear Ab, Type 1 [Location (un) ]-1, S Negative titer <1:240 Anti-Neuronal Nuclear Ab, Type 2 [Location (un) ]-2, S Negative titer <1:240 Anti-Neuronal Nuclear Ab, Type 3 [Location (un) ]-3, S Negative titer <1:240 Anti-Glial Nuclear Ab, Type 1 AGNA-1, S Negative titer <1:240 Purkinge Cell Cytoplasmic Ab Type 1 PCA-1, S Negative titer <1:240 Purkinge Cell Cytoplasmic Ab Type 2 PCA-2, S Negative titer <1:240 Purkinge Cell Cytoplasmic Ab Type Tr PCA-Tr, S Negative titer <1:240 Amphiphysin Ab, S Negative titer <1:240 CRMP-5-IgG, S Negative titer --Reference Value-- Negative at <1:240 Titers lower than 1:240 may be detectable by recombinant CRMP-5 western blot analysis. CRMP-5 western blot analysis will be done by request on stored serum (held 4 weeks). This supplemental testing is recommended in cases of chorea, vision loss, cranial neuropathy and myelopathy. Contact [Name (NI) ] Laboratory Inquiry at 1-[Telephone/Fax (1) 79406] (internally [4-/5837]) to add-on CRMP-5-IgG Western Blot, Serum. Striational (Striated Muscle) Ab, S Negative titer <1:60 P/Q-Type Calcium Channel Ab 0.00 nmol/L <=0.02 N-Type Calcium Channel Ab 0.00 nmol/L <=0.03 ACh Receptor (Muscle) Binding Ab 0.00 nmol/L <=0.02 AChR Ganglionic Neuronal Ab, S 0.00 nmol/L <=0.02 Neuronal (V-G) K+ Channel Ab, S 0.00 nmol/L <=0.02 Test Performed at: [Hospital ] Medical Laboratories, [Street Address(2) 56325] SW, [Location (un) 15739], [Numeric Identifier 79407] Complete report on file in the laboratory. Comment: [Hospital3 ] PARANEOPLASTIC PANEL ANTI NMDA AB Anti-NMDA negative 14-3-3 negative Anti-GAD negative HIV Ab negative HCV ab negative Brief Hospital Course: 74yoM h/o complex partial seizures, DVT and PVD on warfarin, PRES, bilateral vertebral artery stenoses, thoracic meningioma, and HTN p/w suspected complex partial status epilepticus with right arm and leg myoclonus. . [] Seizures/Encephalopathy - The patient presented initially to an OSH with confusion, hypertension, and right arm and leg myoclonus superimposed on his baseline right thumb/finger flexion tremor. His medications were altered with the cessation of ZNS, initiation of TPX, and increased doses of LEV. His seizures did not abate, and so TPX and LEV were increased and PHT was added. When this did not control his seizures, he was transferred to [Hospital1 18] for further care. He was initially noted to be very inattentive, perseverative, and unable to follow complex commands (with perseveration of motor tasks). He also had a fluent aphasia. He had an extensive investigation including laboratory data, infectious workup (which did not reveal any signs of infection, including of the CSF) with empiric treatment for meningitis and encephalitis, and reimaging of the brain which revealed interval atrophy of the left cerebral hemisphere. This raised the question of possible atypical [Doctor Last Name ] encephalitis versus another in inflammatory encephalitis that might cause seizures. He was monitored on cvEEG which only showed one clear clinical seizure with several subclinical seizures while asleep. He was continued on LEV, PHT (with levels monitored) and standing LZP. A brain biopsy was performed by Neurosurgery on [2149-4-25] which only showed reactive changes without clear specificity in diagnosis. Given the concern for inflammatory encephalitis, he was given an empiric treatment of 5 days of IV methylprednisolone (1 gram) which correlated with some improvement in his seizures and clinical exam, though this also occurred simultaneously with an increase in his LZP from 0.25 [Hospital1 ] to 0.5 TID. Due to concerns for oversedation, his LZP was changed to Clonazepam 0.5 [Hospital1 ]. With limited improvement observed with IV corticosteroids, he also underwent 5 days of IVIG for treatment of presumed auto-immune or paraneoplastic inflammatory encephalitis. His clinical condition has gradually improved with hopes that his clinical condition will continue to improve as the effect of corticosteroids and IVIG may be delayed by days to weeks. . [] Chronic DVT - He was maintained on a continuous infusion of Heparin for chronic DVT and was transitioned back to warfarin. . [] HTN - His lisinopril had to be stopped due to [Last Name (un) ] in the setting of concurrent acyclovir therapy. He was switched to amlodipine alongside his metoprolol tartrate. . [] UTI - On [4-11] his UCx grew Citrobacter and Enterococcus which was treated with CTX 1 gm q24h x 7 days. . PENDING STUDIES: [ ] Anti-NMDA serum antibody [ ] Anti-[Last Name (un) ] serum antibody [ ] HHV6 CSF antibody . TRANSITIONAL CARE ISSUES: [ ] Neurology - Please monitor his seizure frequency. Please consider additional testing for etiologic investigation of his progressive epilepsy. Please adjust his Phenytoin, Levetiracetam, and Clonazepam doses. [ ] Neurology - Consider outpatient plasmapheresis or additional IVIG treatments if his condition is still thought to be secondary to autoantibody-mediated inflammatory encephalitis. [ ] Anticoagulation - Please maintain his INR between [12-20] with adjustments to his warfarin dose. [ ] Wound Care - Please continue Silvadene/xeroform [Hospital1 ] dressing changes to his left arm ulcer. . Wound care: Site: left forearm Type: Traumatic Ulcer / Skin Tear Change dressing: [Hospital1 ] Comment: Silvadene and Xeroform per Plastic Surgery Medications on Admission: Amitriptyline 10mg qhs Atorvastatin 80mg qhs Colchicine eszopiclone (lunesta) 3mg tab qhs Keppra 1500 [Hospital1 ] Lisinopril 20mg [Hospital1 ] Lorazepam 0.5 daily prn anxiety Metoprolol tartrate 50mg [Hospital1 ] Omeprazole 20mg EC daily Vitamin D3 warfarin 5mg daily Zonegran 100mg [Hospital1 ] OTC: B12 Flaxeed folic acid 0.4 qam Vit E 400 unit Turmeric root Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amlodipine 10 mg PO DAILY hold for SBP < 110 3. Atorvastatin 80 mg PO DAILY 4. Phenytoin Infatab 150 mg PO Q8AM AND Q4PM 5. Phenytoin Infatab 200 mg PO HS 6. Senna 1 TAB PO BID constipation hold for loose stools 7. Docusate Sodium 100 mg PO BID 8. Clonazepam 0.5 mg PO BID 9. LeVETiracetam 1500 mg PO BID 10. Metoprolol Tartrate 50 mg PO BID hold for SBP<100 and HR<55 11. Silver Sulfadiazine 1% Cream 1 Appl TP [Hospital1 ] left arm ulcer 12. Warfarin 5 mg PO DAILY16 13. Famotidine 20 mg PO Q12H 14. Vitamin D 400 UNIT PO DAILY 15. Colchicine 0.6 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: PRIMARY DIAGNOSIS: Seizure, Encephalopathy/Inflammatory Encephalitis SECONDARY DIAGNOSIS: Hypertension, Chronic Deep Venous Thrombosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 79408], You were hospitalized due to symptoms of RIGHT ARM AND LEG SHAKING and CONFUSION resulting from SEIZURES. The brain is the part of your body that controls and directs all the other parts of your body. It normally communicates with electrical signals. When an abnormal electrical signal develops and forms a short circuit, this produces a seizure. Seizures produce many different symptoms and can occur again. In particular, seizures that cause loss of consciousness (even if only temporary) can endanger you and place you at risk of harm. Accordingly, we would like to help you prevent the recurrence of seizures. We are changing your medications as follows: 1. Please take PHENYTOIN 150 mg in the morning, 150 mg in the afternoon, and 200 mg at night. 2. Please take LEVETIRACETAM 1500 mg in the morning and 1500 mg at night. 3. Please take CLONAZEPAM 0.5 mg in the morning and 0.5 mg at night. 4. Please take WARFARIN 5 mg each day (with goal INR [12-20]). This should be checked by the rehab facility and your primary care physician. Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek medical attention. Because of the risk of future seizures, you must take the following SEIZURE PRECAUTIONS: - You cannot drive a motor vehicle for at least 6 months after your last seizure during which you had impairment of consciousness (a staring spell or full loss of consciousness). - Avoid swimming in a pool or body of water unattended. - When using the bathroom at home, please do not lock the door (so that if you have a seizure someone can reach you). - Do not climb to high heights (e.g. trees, ladders, etc.). - Do not engage in activities where temporary impairment of consciousness might cause you to fall or be placed in a dangerous position. It was a pleasure providing you with care during this hospitalization. Followup Instructions: NEUROLOGY Provider: [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2149-5-19] 1:00pm, [Hospital1 69], [Location (un) 830], [Location (un) 86], MA ICD9 Codes: 5849, 5990, 2760, 4439, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5091 }	Medical Text: Admission Date: [2160-1-28] Discharge Date: [2160-2-2] Date of Birth: [2104-7-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 949] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: Paracentesis x3 (Two diagnostic, one theraputic with removal of 6L) History of Present Illness: Mr. [Known lastname 18823] is a 55 year old man with PMH of alcoholic cirrhosis who presented to ED on [2160-1-28] with fever to 102, hypotension and cough x one month. According to patient and his wife he has theraputic paracentesis every two weeks and for the last 2 times he has had hypotension following paracentesis. Most recent paracentesis was [2160-1-22], 6 L was removed (2L less than usual given recent hypotension, in addition he has been holding his diuretics). In addition, 2 days PTA he noted erythema and pain of his left leg and on the day PTA he developed fevers 100-101. He also reported cough which has been present for one month, completed one week course of levofloxacin about two weeks prior to admission. . On admission he went to MICU [1-5] SBP in 80's, T101.7 elevated lactate to 3.6 which came down with IVF to 1.9. He had a right IJ placed, was ruled out for SBP with a diagnostic paracentesis, and blood and urine cultures remained negative; his diuretics were held. He was started on vancomycin and levofloxacin out of concern for a possible RLL pneumonia that the MICU team interpreted on CXR, however no infiltrate was read on CXR. His hematocrit trended down during admission, and he was transfused 6 units pRBCs [1-5] poor response to transfusion and 1 unit FFP. Due to failure of his HCT to bump appropriately with transfusion and as his ascites fluid was blood tinged he had a abdominal CT scan which showed no hemorrhagic component of his ascites to account for his blood loss. He has been persistently Guaiac positive, but per pt report this is baseline due to gastropathy. With IV fluid resuscitation and holding of his diuretics, his blood pressure improved and he has been net positive 3.4 liters since admission. Past Medical History: # Alcoholic cirrhosis # Grade 2 esophageal varices # Hepatic sarcoidosis # Asymptomatic cholelithiasis # Anemia, recent baseline around 25 # Alcohol abuse # Gout # History of Henoch-Schonlein purpura # Hypertension # Colon adenoma - 6mm adenomatous polyp by biopsy [3-8] # Bilateral herniorrhaphies Social History: No smoking. Prior alcoholic. No Etoh since [Month (only) ]. No drug use. Lives w/ wife but is not working. Performs all ADLs but does not drive. He is married with a good social support system. He has two children living in [State ]. Family History: Father, brother with alcoholism. Father with alcoholic cirrhosis and multiple bypass surgeries, unknown age. Mother with kidney disease. Physical Exam: VS: Temp: 98.3 BP: 96/59 HR: 83 RR: 18 O2sat 100% on RA. GEN: tired appearing but pleasant, comfortable, NAD HEENT: PERRL, EOMI, MMM, op without lesions RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: abdomen distended w/ + fluid wave, hypoactive bs, soft, nt, no masses or hepatosplenomegaly EXT: asymmetric LE edema L>R SKIN: icteric, petechial rash on LLE w/ mild erythema NEURO: AAOx3. Cn II-XII intact. . Pertinent Results: [2160-1-28] 12:40PM WBC-10.6# RBC-2.58* HGB-7.9* HCT-23.6* MCV-91 MCH-30.6 MCHC-33.5 RDW-15.9* [2160-1-28] 12:40PM NEUTS-83.8* LYMPHS-8.3* MONOS-7.5 EOS-0.3 BASOS-0.1 [2160-1-28] 12:40PM PLT COUNT-131* [2160-1-28] 12:40PM GLUCOSE-107* UREA N-17 CREAT-1.3* SODIUM-129* POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-20* ANION GAP-15 [2160-1-28] 12:40PM ALT(SGPT)-22 AST(SGOT)-65* ALK PHOS-149* TOT BILI-3.0* [2160-1-28] 12:40PM LIPASE-75* [2160-1-28] 01:22PM LACTATE-3.6* [2160-1-28] 03:15PM ASCITES WBC-54* RBC-265* POLYS-3* LYMPHS-64* MONOS-9* MESOTHELI-24* [2160-1-28] 03:15PM ASCITES TOT PROT-0.8 GLUCOSE-117 LD(LDH)-30 [2160-1-28] 09:01PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR [2160-1-28] 09:01PM URINE RBC-[10-23]* WBC-3 BACTERIA-FEW YEAST-NONE EPI-0-2 [2160-1-28] 09:37PM LACTATE-1.7 . [2160-1-28] LLE Duplex - No DVT. . [2160-1-28] CXR - In comparison with the study of [1-28], there is no change in the appearance of the heart and lungs. Right IJ catheter has been introduced that extends to the level of the cavoatrial junction or into the upper portion of the right atrium itself. . [2160-1-30] CT ABD/PELVIS - 1. Moderate ascites without evidence of hemorrhagic component. 2. Cirrhosis with secondary signs of portal hypertension. 3. Gallstones are seen. . [2160-2-2] ABD U/S: Limited evaluation of the four quadrants demonstrates a moderate amount of ascites. A spot was marked in the left lower quadrant for paracentesis to be completed by the team. Brief Hospital Course: Mr. [Known lastname 18823] is a 55 year-old man with alcoholic cirrhosis initially admitted to MICU with fever, hypotension and concern for sepsis, treated with vancomycin and levofloxacin [1-5] concern for possible pneumonia. 1)fever, hypotension: Unclear etiology, very unlikely to be due to sepsis as no systemic/bacterial infection was identified during his admission. He was treated initially for pneumonia however his antibiotic course was stopped early as no infiltrate seen on several chest xrays. He may have had a minor cellulitis of left ankle, which also improved as he was on vancomycin during his MICU stay. He also may have had fever due to a viral illness. His hypotension may have been due to recent paracentesis and underlying liver disease. He was continued on vancomycin and levofloxacin during his ICU stay to cover for pneumonia, however this was stopped on tranfer to the liver service as he had no clear evidence of pneumonia on several chest xrays. He did not have any other evidence of bacterial infection on urine cultures, blood cultures, or peritoneal fluid analysis. He tested negative for influenza by nasal aspirate. He was afebrile with low/normal blood pressure prior to discharge. 2) Alcoholic cirrhosis: He has a history of persistant ascites requiring theraputic paracentesis every two weeks. Had 5 L paracentesis several days prior to admission which may have caused his hypotension possibly in the setting of a viral illness. He also has portal gastropathy and grade I esophageal varices seen on EGD 11/[2158]. He was continued on lactulose, rifaximin and nadolol during his admission. His diuretics were initially held but were restarted at home dose of lasix 20 and spironolactone 50mg prior to discharge. He also had a 6L theraputic paracentesis prior to discharge with 50 grams of albumin. His blood pressure was stable >95 following paracentesis. 3)Anemia: most likely due known portal gastropathy, seen on EGD [10-10] and continuous slow oozing. He was transfused a total of 6 units PRBC and 1 unit FFP during his hospital stay as his hematocrit was very slow to bump in response to transfusion. This may have been in part due to hemodilution in the setting of significant quantity of crystalloid that he was given for hypotension. His hematocrit was stable at 28 for three days prior to discharge. He was continued on ferrous sulfate, sucralfate and pantoprazole. 4) Left leg swelling, pain, erythema - possibly due to cellulitis, has improved since admission as he has been treated with vanc/levo for possible pneumonia. He had duplex which was negative for DVT. Resolved prior to discharge. 5) Non-gap metabolic acidosis - likely due to lactulose and resulting multiple loose stools daily, stable. 6) Code: full Medications on Admission: Rifaximin 400 mg tid Spironolactone 50 mg daily Sucralfate 1 g qid Mylanta 2 tabs [Hospital1 ] Calcium Vit D Iron MVI Vit A Zinc Lactulose 30 mg tid Nexium 80 mg daily Nadalol 20 mg daily Tessalon pearles Colchicine 0.6 mg tab q am Lasix 20 mg daily Dry wt 185 lbs Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Vitamin A Oral 10. Zinc Oral 11. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for cough. 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/ fever: do not exceed more than 2g/24 hours. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Hypotension ESLD [1-5] Alcoholic Cirrhosis . Secondary Diagnoses: Hepatic sarcoidosis Abdominal hernia inguinal hernia chronic kidney disease HSP Discharge Condition: good blood pressure 105/60 on discharge Discharge Instructions: You were admitted to the hospital because you were having fever and low blood pressure and we were concerned that you had an infection. In addition, you had a low blood count. You were initially admitted to the ICU for close monitoring. You were initially treated with antibiotics for a presumed pneumonia however there was no evidence of pneumonia on either of the two chest xrays that you had so your antibiotics were stopped. You had two paracentesis to rule out infection and bleeding in your abdomen. There was no evidence of either. You also had a cat scan of your abdomen to evaluate for any source for your low blood count, there was no evidence of bleeding on the cat scan. It is most likely that the bleeding is due to your known gastropathy caused by the cirrhosis. It is likely that your fever was caused by a viral illness. Please continue to check your blood pressure daily as you have been doing. You were evaluated by the dermatologist for the rash on your feet. They were not concerned by the rash and think that it is tiny bruises due to your low platelet count. They recommended a cream for you to put on the inside of your ankle over the area of dry/skaly skin. You were given a prescription for this cream on discharge. On the day of discharge you had a paracentesis in order to improve your symptoms of abdominal fullness and distention. You had 6L of fluid removed and there was no evidence of infection on the fluid studies. You were also given 5g of albumin following this. Medications: 1. You were restarted on your diuretics on the day before discharge. 2. Your cholchicine was held during your admission and on discharge. Please discuss with Dr. [Last Name (STitle) ] at your follow up appointment whether or not it is ok to restart this medicine. . Please call your doctor or return to the hospital if you experience any concerning symptoms including chest pain, persistant fevers, low blood pressure, fainting, difficulty breathing, bloody bowel movements. Followup Instructions: You have an appointment scheduled to see Dr. [Last Name (STitle) ], MD on [2160-2-5], as discussed please cancel this appointment and [Date Range ] one for the following week. Phone:[Telephone/Fax (1) 2422] Please call your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] an appointment to be seen within one to two weeks of discharge. Dr. [First Name (STitle) ] [Telephone/Fax (1) 7477]. ICD9 Codes: 4589, 5859, 2875, 2762, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5092 }	Medical Text: Admission Date: [2171-10-30] Discharge Date: [2171-11-18] Date of Birth: [2110-4-16] Sex: M HISTORY OF PRESENT ILLNESS: This 61-year-old male with a history of chronic obstructive pulmonary disease was admitted to [Hospital6 33] on [2171-10-20], for an exacerbation of her pulmonary problems. [Name (NI) ] underwent an substernal chest pain; however, he was only able to complete two minutes on [Doctor First Name ] protocol before having ST depressions and chest pain. On [10-24], he underwent cardiac catheterization which revealed a 60% to 70% stenosis of his left main, as well as greater than 90% stenosis of his right coronary artery, and greater than 60% of his left circumflex. [2171-10-25], where he underwent coronary artery bypass graft times three. His postoperative course was somewhat complicated by his chronic obstructive pulmonary disease; however, he was managed with bronchodilators and antibiotics for a left lower lobe consolidation and positive sputum for hemophilus. On [2171-10-29], the patient was discharged to a rehabilitation facility in stable condition. While at that facility, the patient and his wife were not satisfied with the quality of care being provided there, and was brought to [Hospital3 417] Hospital's Emergency Department with complaints of chest discomfort which was exacerbated with movement and coughing. The Emergency Department evaluation felt that his pain was due to his sternotomy incision and had planned to discharge him back to the rehabilitation facility. However, the patient and his wife did not agree to that. Since there was some questionable cellulitis of his right lower extremity, the patient was transferred to [Hospital1 346]. He had complained of low-grade fever but denied chills, sweats, or any discharge from his incision. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease with multiple hospitalizations and previous steroid use. 2. Hypertension. 3. Sleep apnea. 4. Gout. 5. Status post methicillin-resistant Staphylococcus aureus pneumonia. 6. Status post appendectomy. 7. Status post umbilical herniorrhaphy. MEDICATIONS ON ADMISSION: Medications upon admission to the hospital were Lopressor 12.5 mg p.o. b.i.d., Lasix 40 mg p.o. t.i.d., potassium chloride 20 mEq p.o. b.i.d., aspirin 81 mg p.o. q.d., levofloxacin 500 mg p.o. q.d. times eight days, Percocet one to two tablets p.o. q.3-4h. p.r.n. for pain, Colace 100 mg p.o. b.i.d., Paxil 20 mg p.o. q.d., allopurinol 100 mg p.o. q.d., Singulair 10 mg p.o. q.d., Serevent inhaler 1 puff to 2 puffs q.4h. p.r.n., and albuterol nebulizer treatment q.i.d. p.r.n. PHYSICAL EXAMINATION ON ADMISSION: Upon admission to the hospital temperature was 99.2, pulse 76, normal sinus rhythm, blood pressure 129/67, respiratory rate 20, oxygen saturation 91% on room air. The patient was a 61-year-old male in no apparent distress, was alert and oriented times three. His neck was supple with no bruits noted. Lungs revealed wheezes bilaterally. His sternum was stable. His incision was clean, dry, and intact. Coronary examination revealed a regular rate and rhythm, with no murmurs, rubs or gallops. The abdomen was soft, nontender, and nondistended. His extremities were warm and well perfused. His incision was clean, dry, and intact with no purulent discharge of significant erythema. LABORATORY DATA ON ADMISSION: Laboratory values upon admission to the hospital were white blood cell count 16.8, hematocrit 28.4. Potassium 4.6, BUN 18, creatinine 0.8. HOSPITAL COURSE: The patient was admitted to the hospital for physical therapy as well as wound checks and pulmonary toilet. In the early morning on hospital day two ([2171-10-31]), the patient had some problems with disorientation after receiving Ambien for sleep. The patient did receive some Haldol to treat this. The patient remained hemodynamically stable, and the patient was monitored by a one-to-one sitter in his room. Later in the day the patient was alert and oriented, in no apparent distress. He remained to be wheezing bilaterally, but otherwise had an unremarkable physical examination. On [2171-11-1], the patient continued to have intermittent periods of delirium. It was noted upon physical examination that day that there was a small sternal click at the inferior portion of his sternum which was elicited with coughing. The patient's incision had remained clean, dry, and intact. His white blood cell count had risen to 18.6, and the patient was fully cultured at that time. Two blood cultures which were obtained on [2171-11-1], revealed coagulase-negative Staphylococcus aureus. Sputum culture on that same day was unremarkable. Over the next few days, the patient had a low-grade fever between 99 degrees and 101 degrees and continued to have a sternal click without wound drainage or erythema. The patient was empirically started on vancomycin on [2171-11-2], due to Staphylococcus species. At that time the cultures were not finalized; however, they ultimately proved to oxacillin-resistant Staphylococcus aureus. On [2171-11-3], on hospital day five, postoperative nine, the patient complained of a clicking painful sensation in his chest. This persisted throughout the next day as well, on [11-4], when he continued to complain of sternal discomfort. The patient had completed his course of levofloxacin and was on day three of vancomycin at that time. On [2171-11-5], the patient continued to have a sternal click with pain at the site and positive blood cultures. The patient was taken to the operating room on [2171-11-5], due to sternal dehiscence. He underwent a sternal wound debridement with a Robicsek weave of his sternum by Dr. [Last Name (STitle) 70]. Please see the Operative Report for full details of surgical procedure. The patient was extubated and brought to the Intensive Care Unit where he remained for approximately 24 hours. He remained hemodynamically stable. His white blood cell count had dropped to 9.2. On [11-6], his pulmonary status was stable. His creatinine had elevated slightly from a baseline of 1.1 to 1.4 at this time. He had adequate urine output at the time and was transferred from the Intensive Care Unit to the telemetry floor, [Hospital Ward Name 121] Six, on [2171-11-6]. On [11-7], on postoperative day two, the patient still had complaints of pain; however, was hemodynamically stable. His white blood cell count at that time was 13.5. The patient had remained essentially afebrile to having a low-grade fever of about 100 degrees. His oxygen saturation was adequate, and his vital signs were stable. The patient was noted to have some serosanguineous drainage from the middle portion of his sternal wound at that time. The patient was maintained on intravenous vancomycin for the methicillin-resistant Staphylococcus aureus which was noted in his previous blood cultures. He was given morphine for pain control. He was on Lopressor and was continuing to diuresed. On [2171-11-8], a peripherally inserted central catheter line was inserted in the Interventional Radiology Department because it was felt that the patient would need to continue on a full 4-week to 6-week course of vancomycin. On [2171-11-8], the patient remained hemodynamically stable; although, he was beginning to have an elevated fever to 101.2, and he continued to complain of sternal pain. He was noted to still have mild amounts of serosanguineous drainage fro his sternal incision. On [11-9], on postoperative day four, the patient was more comfortable. He had been given Dilaudid for pain control. He was noted to have some degree of peri-incisional erythema of his sternotomy incision. His sternum was stable at that time. The patient had no other significant complaints. His white blood cell count was 12.4. His creatinine had risen again to 1.5 at this time. He was still being continued on vancomycin. On [2171-11-9], the house officer was called to see the patient due to agitation. Upon arrival for examination the patient was alert and oriented; however, he did state that he felt confused earlier, but this had resolved. This was felt likely to be a complication of the narcotics which he had been given for pain control. The narcotics were discontinued at this time, and he was started on Ultram and Toradol for pain control. On [2171-11-10], the patient's creatinine was noted to have risen from 1.4 on the previous day to 2.3. This was felt to be attributable to the Toradol which was discontinued at that time. The patient remained alert. His sternum remained dry with some peri-incisional erythema present. The patient stated he felt better. On [2171-11-11], a Renal Medicine consultation was obtained due to continued rise in creatinine which was 3.8 on [11-11]. It was their feeling that the patient had been exposed to nephrotoxic drugs, specifically nonsteroidal antiinflammatory drugs such as ibuprofen, Toradol, Celebrex, and Vioxx over the past number of days, and it was their recommendation to repeat urinalysis as well as urine cultures, to hold all nephrotoxic drugs, to follow the patient's electrolytes on a daily basis, to maintain a systolic blood pressure of 110, and to renally dose all of his medications as well as to follow strict measurements of intake and output. On [2171-11-12], the patient's creatinine continued to rise and was at 4.4. The patient's vancomycin level was 33.3, and his vancomycin was held with the plan of daily levels to be drawn, and for him not to be dosed again until his level dropped below 15. The patient was transfused packed red blood cells for a hematocrit which had drifted down over the previous two days to 21.1. It was the Renal Service's feeling that there was no indication for dialysis but to continue the treatments which had been initiated; that was to continue to hold all nonsteroidal drugs, and to renally dose medications, and to continue to follow electrolytes, urine output, and creatinine daily. The patient continued to receive bronchodilator treatments due to his underlying pulmonary disease. On [2171-11-13], the patient remained with a low-grade fever of about 100. His creatinine had leveled off at 4.5. He remained with no sternal drainage. His sternum was stable with no click; however, he continued to have some erythema of the sternal incision. On [2171-11-14], the patient had progressed somewhat with level of ambulation. His pain was fairly well controlled. His creatinine had stabilized at 4.5. While there was no drainage, there remained erythema at the sternal incision. The patient was started on levofloxacin empirically for what was presumed a sternal wound cellulitis. On [2171-11-14], the patient was noted to have more episodes of agitation and disorientation. The patient also began to start complaining of increased sternal pain exacerbated with cough and deep breathing which he had been encouraged to do because of his pulmonary status, and history of chronic obstructive pulmonary disease, and need for bronchodilators, and pulmonary toilet. On [2171-11-15], the patient was noted to have some increasing erythema over his sternal incision, and a Plastic Surgery consultation was obtained on [2171-11-15]. It was their assessment that the patient should return to the operating room for sternal wound debridement and vacuum-assisted dressing placement. On [11-15], the patient was also noted to have a slight increase in his creatinine despite holding of nephrotoxic drugs. He was up to 4.8 at this time; although, it was still felt that there was no indication to initiate dialysis since the patient was not acidemic nor hyperkalemic at that time. On [2171-11-14], the patient was seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 13797] (plastic surgeon). It was his recommendation at that time to consider a chest CT scan to rule out mediastinitis due to the continued erythema with the plan of taking him for surgical debridement if his erythema had not improved or had increased over the next few days. On [2171-11-16], the patient was noted to have increased erythema with some serosanguineous drainage beginning to come from the sternal incision, and this was sent for culture, and the Gram stain revealed Staphylococcus species at this time. Dr. [First Name (STitle) ] from the Plastic Surgery Service did evaluate the patient on [2171-11-16]. He reported that the CT scan showed no retrosternal collection, and he felt there was no urgency to do anything other than conservative treatment at that time. It was his recommendation that if the patient had increased draining or became febrile that he may need to return to the operating room for a wound debridement. On [11-16], the patient's serum creatinine had risen to 5.1, and while his renal function had been deteriorating there was still no indication for renal replacement therapy at that time. An Infectious Disease consultation was obtained on [2171-11-16]. Their recommendation was to continue treating the patient with intravenous vancomycin to be dosed by levels and to add gram-negative coverage only if there was a change in the patient's clinical status. On [2171-11-17], the patient was noted to have an increased amount of drainage from the middle portion of his sternal incision. The staples in that area had been removed, and there was continued erythema. Wet-to-dry normal saline dressings had been initiated. On [2171-11-17], the Plastic Surgery Service recommended at that time that the patient be taken to the operating room for an operative washout of his sternal incision. This was due to continued erythema and drainage. The patient's creatinine at this time had started to decline and was down to 4.3 on [2171-11-18], and his urine output had also begun to increase. The patient was taken to operating room on [2171-11-18], due to continued sternal wound erythema and drainage. The patient underwent a sternal debridement by Dr. [Last Name (STitle) 70] and Dr. [Last Name (STitle) 72] as well as placement of a vacuum device by plastic surgerye. Please see the Operative Report for full details of the surgical procedure. The patient was transported from the operating room to the Intensive Care Unit, extubated, and hemodynamically stable with a vacuum-assist device in place to the sternal wound. At approximately 9:20 that evening, the patient had a strong cough and the suction container attached to the vacuum-assist device began to fill with blood quickly. The house officers were called and responded to the bedside within minutes. The vacuum dressing was removed, and the patient's chest was opened completely, and it was noted at that time that there was a tear in the right ventricle that was felt to be possibly secondary to adhesions following the coughing. The patient did suffer a full cardiopulmonary arrest at that time. He was intubated, but he was unable to be resuscitated. Dr. [Last Name (STitle) 70] was notified and came to the hospital and spoke with the family at that time at length to notify them of the events which had occurred. The patient did expire on [2171-11-18]. Permission for autopsy was granted and arrangements for the autopsy were made. CONDITION AT DISCHARGE: Expired. DISCHARGE DIAGNOSES: Right ventricular rupture, status post sternal wound infection/dehiscence/sternal debridement. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2171-11-29] 13:41 T: [2171-11-30] 05:13 JOB#: [Job Number 34287] (cclist) ICD9 Codes: 496, 4019, 4275
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5093 }	Medical Text: Admission Date: [2122-10-12] Discharge Date: [2122-10-26] Date of Birth: [2122-10-12] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname 13959] [Name2 (NI) 37336] number one is a 2175 gram infant born at 33 and 3/7 weeks gestational age to a 31 year-old G3 P1 mother. Prenatal screens: blood type A negative, antibody negative, group B strep unknown, hepatitis B surface antigen negative, RPR nonreactive mother. Prenatal course remarkable for IUI pregnancy with a resulting triamniotic, trichorionic triplets. There was cervical incompetence diagnosed and cerclage placed at 20 weeks, briefly admitted at 20 [4-8] and 24 3/7 weeks for short cervix. Mother was beta complete at 24 and 1/2 weeks. On the day of delivery contractions were noted during routine testing and the decision was made to deliver. Spinal anesthesia with artificial rupture of membranes at delivery. Cesarean section with Apgars of 8 and 8. HOSPITAL COURSE: Respiratory: Initially required blow by oxygen for grunting, flaring and retracting, which improved he improved on his own. Did not require intubation. By the second day of life, the baby was breathing in room air comfortably. There have been no problems with apnea of prematurity. No caffeine has been required. There are no active respiratory issues at this time. Cardiovascular: There have been no active issues, with blood pressures maintained in normal ranges without need for either medications or volume boluses. No murmur has ever been noted. There are no active cardiovascular issues. FEN: Total fluids were initially at 80 cc per kilo per day of intravenous D10 water. Enteral feedings were started on the first day of life and advanced without problems. At the time of discharge [Known lastname ] was taking total fluids of 150 cc per kilogram per day of premature Enfamil supplemented to 26 calories per ounce half po/half pg. At discharge, the weight was 2425 grams up from the birth weight of 2175 grams, and between the 25th and 50th percentile. Length was 48.5 cm (75% percentile), head circumference was 33.5 cm (75 to 90th percentile). Gastrointestinal: Hyperbilirubinemia was not a problem for [Known lastname ]. The peak bilirubin was 8.3 on [10-16], phototherapy was not started and most recent bilirubin was 5.2 on [10-20]. The baby's blood type is A positive, direct antibody test negative. Hematology/infectious disease: Baby's blood type was A positive, direct antibody test negative. There were no known sepsis risk factors except prematurity, but given the initial respiratory distress a 48 hour sepsis evaluation was initiated. On admission the complete blood count showed a white blood cell count of 12.3 with 19% polys, 2% bands, 66% lymphocytes, hematocrit 43, platelets 184. Blood cultures were sent and baby was treated with Ampicillin and Gentamycin until the blood cultures were negative at 48 hours. Final results of blood cultures were negative. There have been no further hematology or infectious disease issues. Baby has not required any transfusions. Neurology: Given the baby's gestational age at birth and benign clinical course, no head ultrasound was performed. Sensory: Audiology, hearing screen was performed on [10-25] with automated auditory brain stem responses, which were normal. Ophthalmology examination is not required. Routine health care maintenance: Although the baby was greater then 2 kilograms at birth hepatitis B has not been administered to keep the triplets on the same immunization schedule. An initial PKU screen was sent, which showed an elevated 17 hydroxy progesterone level. However, [Known lastname ] has not shown any clinical evidence of congenital hydrenal hyperplasia and repeat PKU screening was sent on [10-20] with normal results. Another repeat PKU screen was sent on [10-26]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: [Hospital3 ]. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 1188] [Last Name (NamePattern1) ] in [Location (un) 7661], phone number [Telephone/Fax (1) 17355]. CARE/RECOMMENDATIONS: Feeds at discharge are premature Enfamil at 26 kilocalories per ounce at 150 cc per kilogram per day po pg. No medications. Car seat testing has not been done. State newborn screenings is normal. No immunizations have been given. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria, one born at less then 32 weeks; born between 32 and 35 weeks with two or three of the following day care during RSV seasons, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or three with chronic lung disease. Influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: 1. Prematurity at 33 and 3/7 weeks gestational age. 2. Immature feeding. [First Name8 (NamePattern2) 39464] [Last Name (NamePattern1) ], M.D. [MD Number(1) 37201] Dictated By:[First Name (STitle) 50321] MEDQUIST36 D: [2122-10-26] 11:27 T: [2122-10-26] 09:36 JOB#: [Job Number 54226] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5094 }	Medical Text: Admission Date: [2141-1-25] Discharge Date: [2113-2-27] Date of Birth: [2104-3-13] Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: The patient seen in preoperative Cardiac Surgery Clinic and found to be short of breath. Admitted to the Medicine Service for preoperative workup. HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old gentleman with a history of type 1 diabetes complicated by end-stage renal disease, status post failed renal transplant in [2137] (on hemodialysis three times per week) with deep venous thrombosis (status post bilateral below-knee amputations) and retinopathy. The patient had a recent admission in [2140-12-29] with dyspnea on exertion and was found to have severe aortic stenosis. The patient was discharged home with plans to have aortic valve replacement by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] at a future date. A dental examination determined the need for dental extractions in preparation for his aortic valve replacement. The patient was discharged home with two weeks of clindamycin and vancomycin. However, the patient did not take his antibiotics. Five days prior to admission, the patient was admitted to [Hospital3 7362] for fevers. He was given antibiotics and left that facility against medical advice because no doctor came to see him for an entire day. On the day of admission, the patient was seen in the clinic. In Dr.[Name (NI) 27686] office, the patient look unwell with complaints of dyspnea and was directly admitted to the Medicine Service. Initial vital signs revealed the patient had a temperature of 101.5 degrees Fahrenheit. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Type 1 diabetes mellitus. 2. Deep venous thrombosis; status post bilateral below-knee amputations. 3. End-stage renal disease (on hemodialysis). 4. Status post kidney transplant in [2137]; status post failure in [2138]. 5. Hypertension. 6. Severe aortic stenosis with an aortic valve area of 0.5 cm2. 7. Echocardiogram done on [2141-1-5] revealed an ejection fraction of 40% with an aortic valve area of 0.8 and a peak gradient of 76 mmHg. MEDICATIONS ON ADMISSION: (From discharge on [2141-1-7]) 1. Clindamycin 600 mg by mouth three times per day (times two weeks). 2. Prednisone 5 mg by mouth once per day. 3. NPH 22 to 34 units subcutaneously in the morning and 14 units subcutaneously at hour of sleep. 4. Regular insulin sliding-scale. 5. Colace 100 mg by mouth twice per day. 6. Protonix 40 mg by mouth once per day. 7. Metoprolol 50 mg by mouth twice per day. 8. Aspirin 81 mg by mouth once per day. 9. Plavix 75 mg by mouth once per day. 10. Lipitor 10 mg by mouth once per day. 11. Calcium acetate by mouth three times per day (with meals). 12. Amlodipine 10 mg by mouth once per day. 13. Vancomycin 1 gram dosed at dialysis (times two weeks). ALLERGIES: SOCIAL HISTORY: The patient states he quit tobacco one week ago. No alcohol use. He lives in an apartment by himself. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed his temperature was 101.6 degrees Fahrenheit, his heart rate was 90 (sinus), his blood pressure was 130/80, his respiratory rate was 18, and his oxygen saturation was 99% on room air. In general, a young male who was alert and oriented. In no acute distress. Head, eyes, ears, nose, and throat examination revealed the left pupil round and reactive to light. The right pupil was dilated. Slightly asymmetric pupils. The mucous membranes were moist. No oropharyngeal abscesses or lesions. The neck was supple. There was no lymphadenopathy. There was no pulsus paradox. Respiratory examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a harsh [5-4] holosystolic murmur with radiation to the carotids bilaterally. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds. There was no hepatosplenomegaly. The patient had a papular rash to his neck with pustules. The extremities were warm. Bilateral below-knee amputations with well-healed wounds. Right subclavian dialysis catheter was nontender. A few pustules beneath the Tegaderm. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 16, his hematocrit 42.5, and his platelets were 245. His sodium was 134, potassium was 5.1, chloride was 95, bicarbonate was 25, blood urea nitrogen was 46, creatinine was 6.7, and blood glucose was 135. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was seen by the Medicine Service as well, as the Infectious Disease Service, the Cardiology Service, and the Renal Service. The patient was treated for approximately 10 days preoperatively in an effort to determine the source of his fevers and to treat his hyperglycemia with an anion gap. Ultimately, on [1-30], the patient was transferred to the Medical Intensive Care Unit with elevated blood sugars to 665, but no acidosis, and a minimal anion gap. The initial diagnosis was felt to more HHNK rather than diabetic ketoacidosis. The patient continued to be followed by the Critical Care Service, the Renal Service, [Last Name (un) ] Service, Medicine Service, as well as Cardiology Service. Finally, on [2-5], it was felt that the patient's condition had improved enough to go to the operating room. On [2-6], the patient was brought to the operating room. Please see the Operative Report for full details. In summary, the patient had a minimally invasive aortic valve replacement with a 21-mm mosaic porcine bioprosthetic valve. The patient tolerated the procedure well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. The patient had a fair amount of bleeding from his chest tube following his surgery. The patient was treated with multiple units of packed red blood cells as well as some fresh frozen plasma and platelets. He arrived to the Cardiothoracic Intensive Care Unit on milrinone, Neo-Synephrine, and insulin drips. He did well in the immediate postoperative period. His Neo-Synephrine was quickly weaned to off, and he became hypertensive requiring nitroglycerin and Nipride infusions to maintain a systolic blood pressure below 140 mmHg. Given the patient's chest tube output the decision was made to keep him sedated until the morning on postoperative day one. However, he was weaned to continuous positive airway pressure [5-3] on the day of surgery. He also underwent hemodialysis following this surgery. On postoperative day one, the patient remained hemodynamically stable on low-dose milrinone, nitroglycerin, and Nipride infusions. He was successfully extubated. Again, he received hemodialysis. His mediastinal chest tubes were discontinued. On postoperative day two, the patient was started on beta blockade as well as an ACE inhibitor. His Nipride was weaned to off, and his nitroglycerin was also weaned. On postoperative day three, the patient was also started on Norvasc, his ACE inhibitor, and beta blockade. The doses were gradually increased. His remaining chest tubes were discontinued. However, the patient remained in the Intensive Care Unit for the next several days because of a remaining need for intravenous insulin infusions. Upon the recommendations of the [Hospital ] Clinic, the patient was begun on glargine. Finally, on postoperative day five, the patient was able to come off of his insulin drip and was transferred to [Hospital Ward Name 121] Two for continued postoperative care and cardiac rehabilitation. Over the next several days, the patient's insulin regimen continued to be modified. He was returned to his preoperative hemodialysis schedule. He continued to be followed by the Infectious Disease Service. Finally, on postoperative day 19, it was felt that that the patient would be stable and ready for transfer to rehabilitation on the following morning. At the time of this dictation, the patient's physical examination was as follows. Vital signs revealed his temperature was 98.4 degrees Fahrenheit, his heart rate was 79 (sinus rhythm), his blood pressure was 140/69, his respiratory rate was 20, and his oxygen saturation was 93% on room air. Weight preoperatively was 57 kilograms. Weight on discharge was 62 kilograms. Laboratory data revealed his white blood cell count was 16.7 (down from 17.7 previously), his hematocrit was 26.1, and his platelets were 431. Sodium was 137, potassium was 5.9, chloride was 95, bicarbonate was 28, blood urea nitrogen was 74, creatinine was 8.7, and blood glucose was 130. Physical examination revealed the patient was alert and oriented times three. He followed commands. Respiratory examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. The sternum was stable. Incision with staples, open to air, clean and dry. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. The extremities were warm with bilateral below-knee amputations. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Enteric-coated aspirin 325 mg by mouth every day. 2. Colace 100 mg by mouth twice per day. 3. Prednisone 5 mg by mouth once per day. 4. Metoprolol 75 mg by mouth three times per day. 5. Captopril 50 mg by mouth three times per day. 6. Amlodipine 10 mg by mouth once per day. 7. Calcium acetate [2137] mg by mouth three times per day. 8. Pantoprazole 40 mg by mouth once per day. 9. Multivitamin one tablet by mouth once per day. 10. Glargine insulin 40 units subcutaneously in the evening. 11. Humalog sliding-scale dosed four times per day at breakfast, lunch, dinner, and at hour of sleep. 12. Nephrocaps one tablet by mouth once per day. 13. Vancomycin 1 gram once per day as needed (for a blood level of less than 15). 14. Dilaudid 2 mg to 4 mg by mouth q.4h. as needed. DISCHARGE DIAGNOSES: 1. Aortic stenosis; status post minimally invasive aortic valve replacement with a 21-mm mosaic porcine bioprosthetic valve. 2. Type 1 diabetes mellitus. 3. Peripheral vascular disease; status post bilateral below-knee amputations. 4. End-stage renal disease (on hemodialysis). 5. Status post kidney transplant in [2137] and kidney transplant at the failure in [2138]. 6. Hypertension. CONDITION AT DISCHARGE: The patient's condition on discharge was good. DISCHARGE DISPOSITION: The patient was to be discharged to rehabilitation. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [Last Name (STitle) ] in the Infectious Disease Clinic on [3-6] at 10:30 a.m. 2. The patient was instructed to follow up with his primary care physician (Dr. [Last Name (STitle) ] in two to three weeks following his discharge from rehabilitation. 3. The patient was instructed to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 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: [2141-2-16] 16:27 T: [2141-2-16] 18:10 JOB#: [Job Number 49236] ICD9 Codes: 4241, 4280, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5095 }	Medical Text: Admission Date: [2115-11-12] Discharge Date: [2115-11-18] Date of Birth: [2070-10-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: left main coronary artery disease Major Surgical or Invasive Procedure: [2115-11-12] Coronary artery bypass graft x 4 (Left internal mammary artery to left anterior descending, Saphenous vein graft to diagonal, Saphenous vein graft to ramus, Saphenous vein graft to obtuse marginal) History of Present Illness: This 45 year old Hispanic male with history coronary artery disease and multiple interventions to the circumflex and a NSTEMI in [2108] who had recurrent chest pain with minimal exertion and a positive exercise MIBI. He underwent cardiac catheterization in [Month (only) 359] which revealed left main disease and he was referred for surgery. He was discharged after catheterization to allow Plavix washout and to stop smoking. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction (NSTEMI [12/2108]) and multiple PCIs to LCx [2107]-[2109] Hypercholesterolemia Gastroesophageal reflux disease Anxiety Depression Kidney stones s/p laser surgery Social History: Race: Hispanic Last Dental Exam: 2 months ago Lives with: partner Occupation: flight attendant Tobacco: + 0.5 ppd x 20 years ETOH: [1-4] glasses of wine/week Rec drug: denies Family History: Father died of MI age 67, Brother with [Name2 (NI) ] age 40 Physical Exam: Admission: Pulse:76 Resp:14 O2 sat:96%RA B/P Right:133/76 Left:133/83 Height:5'9" Weight:225 lbs General: Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: none Left: none Pertinent Results: [2115-11-13] 04:03AM BLOOD WBC-16.3* RBC-3.83* Hgb-11.0* Hct-33.8* MCV-88 MCH-28.6 MCHC-32.5 RDW-13.7 Plt Ct-235 [2115-11-13] 04:03AM BLOOD Glucose-125* UreaN-16 Creat-0.8 Na-139 K-4.5 Cl-106 HCO3-26 AnGap-12 [2115-11-12] 09:55AM HGB-13.8* calcHCT-41 [2115-11-12] 09:55AM GLUCOSE-104 LACTATE-1.9 NA+-136 K+-4.5 CL--98* [2115-11-12] 02:12PM GLUCOSE-118* LACTATE-2.8* NA+-134* K+-3.8 CL--106 [2115-11-12] 03:24PM PT-14.1* PTT-33.1 INR(PT)-1.2* [2115-11-12] 03:24PM PLT COUNT-235 [2115-11-12] 03:24PM WBC-16.4* RBC-3.91* HGB-11.6* HCT-34.1* MCV-87 MCH-29.6 MCHC-33.9 RDW-13.7 [2115-11-12] 03:24PM UREA N-17 CREAT-0.7 CHLORIDE-108 TOTAL CO2-27 [2115-11-12] Echo: Pre Bypass: The left atrium is moderately dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild to moderate central ([1-4]+) mitral regurgitation is seen, worse at pressures of 140's systolic. Vena contracta for mitral jet ranged from 0.2-0.4 cm. There is mild partial anterior prolapse and borderline annular dilation of the mitral valve. There is no pericardial effusion. [2115-11-17] CXR: There again is noted bilateral areas of consolidation throughout both lung fields, which are stable. Findings are worse within the lung bases. Cardiac silhouette is upper limits of normal, but stable. Brief Hospital Course: Mr. [Known lastname ] was a same day admit for coronary bypass grafting. He had previously undergone pre-operative work-up and cardiac catheterization on [11-1] which revealed severe left main coronary artery disease. On [11-12] he was brought to the Operating Room where he underwent coronary artery bypass graft x 4. Please see operative report for surgical details. In summary he had: Coronary artery bypass grafting x4; with left internal mammary artery grafted to the left anterior descending, reverse saphenous vein graft to the first marginal branch, ramus intermedius and first diagonal branch. His bypass time was 89 minutes with a crossclamp of 70 minutes. He tolerated the surgery well. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He was hemodynamically stable in the immediate post operative period and later that day he weaned from sedation, awoke neurologically intact and was extubated. On POD1 he was transfered to the floor for further recovery. Beta blockers were resumed and diuresis was initiated with a goal of matching his pre operative weight. All tubes lines and drains were removed according to cardiac surgery protocol. On POD3 he was noted to be febrile. A white blood cell couont was checked and found to be elevated, a chest Xray at that time revealed bilateral opacities, sputum cultures were sent. The eventually grew GRAM POSITIVE ROD(S) and he was begun on appropriate antibiotics. His fever and elevated White Count resolved. Physical Therapy worked with him for strengthening and mobilization. His antidepressents and anxiolytics were resumed post-operatively. The remainder of his post operative course was uneventful and he was discharged home with visiting nurses on post-operative day six. All medications, restrictions and follow up care was discussed with him prior to going home. Medications on Admission: Plavix 75mg po daily Amlodipine 5mg po daily Lipitor 80mg po daily Wellbutrin SR 150mg [Hospital1 ] Celexa 40mg daily Folic Acid Zestril 10mg po daily Trazodone 100mg po daily ASA 325mg po daily Omeprazole 40 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:60 Tablet Sustained Release(s) Refills:2 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 11. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass graft x 4 Hypercholesterolemia s/p multiple percutaneous interventions to circumflex [2107]-[2109] Gastroesophageal reflux disease Anxiety Depression Kidney stones- s/p laser surgery Discharge Condition: Good Discharge Instructions: Monitor wounds for signs of infection. These include redness, drainage or increased pain. Report any fever greater then 100.5. Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. Shower daily. Wash incision with soap and water. No lotions, creams or powders to incision for 6 weeks. No driving for 1 month and taking narcotics. No lifting greater then 10 pounds for 10 weeks. Please call with any questions or concerns. Take all medications as directed Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks([Telephone/Fax (1) 170]) Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] in [2-5] weeks Dr. [First Name4 (NamePattern1) 1356] [Last Name (NamePattern1) ] in [1-4] weeks ([Telephone/Fax (1) 250]) [Hospital Ward Name 121] 6 wound clinic in 2 weeks Please call for appointments Completed by:[2115-11-18] ICD9 Codes: 486, 2724, 311, 412, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5096 }	Medical Text: Admission Date: [2118-7-7] Discharge Date: [2118-7-11] Date of Birth: [2055-2-7] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: palpatations Major Surgical or Invasive Procedure: Coronary artery bypass grafting x 5 (left internal mammary artery grafted to the left anterior descending artery/Saphenous vein grafted to Diag1/Diag 2/Obtuse Marginal 1/Obtuse Marginal2)-[2118-7-7] History of Present Illness: 63 year old male whon underwent stress echo for symptoms of palpitations occurring at night, in temporal relation to alcohol intake, 3 times in the last 6 weeks or so. These episodes lasted from 30-90 minutes and resolve spontaneously. Stress echo images were consistent with ischemia in the RCA territory. He was referred by Dr [Last Name (STitle) 42388] for left heart catheterization. He was found to have coronary artery disease upon cardiac catheterization. Cardiac surgery was consulted for evaluation of coronary revascularization. Past Medical History: Coronary artery disease Secondary: Mitral valve prolapse Hypercholesterolemia Prostatic hypertrophy, benign Colonic polyp Social History: Race:Caucasian Last Dental Exam:1 month ago Lives with:wife Contact:[Name (NI) 2048] (wife) Phone #[Telephone/Fax (1) 111943] Occupation:Retired science educator Cigarettes: Smoked no [] yes [x] Hx:quit in [2077] Other Tobacco use:denies ETOH: 2 drinks/day Illicit drug use:denies Family History: Premature coronary artery disease- Father died of heart attack at age 42-44 while undergoing ECT; Grandfather died at 56 thought secondary to MI Physical Exam: Physical Exam Pulse:44 Resp:16 O2 sat:100/RA B/P Right:118/74 Left:128/75 Height:6'1" Weight:190 lbs General: NAD, WGWN 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 [] __none___ Varicosities: None [] minor varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: Pertinent Results: Intra-op TEE [7-7] Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. 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%). 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. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). POSTBYPASS Preserved biventricular systolic function. Study otherwise unchanged from prebypass 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) ] [2118-7-8] 11:19 ?????? [2109] CareGroup IS. All rights reserved. . [2118-7-11] 04:56AM BLOOD WBC-8.7 RBC-3.30* Hgb-10.2* Hct-30.5* MCV-93 MCH-31.0 MCHC-33.5 RDW-12.8 Plt Ct-165 [2118-7-10] 06:45AM BLOOD WBC-11.4* RBC-3.45* Hgb-11.1* Hct-31.9* MCV-93 MCH-32.1* MCHC-34.7 RDW-13.3 Plt Ct-137* [2118-7-11] 04:56AM BLOOD UreaN-20 Creat-0.8 Na-133 K-4.4 Cl-97 [2118-7-9] 06:45AM BLOOD Glucose-119* UreaN-18 Creat-0.8 Na-133 K-4.4 Cl-97 HCO3-27 AnGap-13 [2118-7-11] 04:56AM BLOOD Mg-2.0 Brief Hospital Course: On [2118-7-7] Mr. [Known lastname ] was taken to the operating room and underwent Coronary artery bypass grafting x 5 (left internal mammary artery grafted to the left anterior descending artery/Saphenous vein grafted to Diag1/Diag 2/Obtuse Marginal 1/Obtuse Marginal2)with Dr.[Last Name (STitle) ]. Please refer to operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU for invasive monitoring. He awoke neurologically intact and was extubated without incident. He weaned off pressor support. Beta-blocker, Statin and aspirin were initiated. He was diuresed towards his preoperative weight. All lines and drains were discontinued per protocol. POD#1 he transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. POD#2 he went into postoperative rapid atrial fibrillation requiring Amiodarone and a Diltiazem drip to break. He remained in RAF <24 hours and converted to normal sinus rhythm. His IV medications were transitioned to oral. He progressed and the remainder of his hospital course was essentially uneventful. He was ambulating freely and his wound was healing well by POD 4. Lisinopril should be resumed when blood pressure will tolerate. He was discharged to home with VNA services. All follow up appointments were advised. Medications on Admission: FLUTICASONE Dosage uncertain LISINOPRIL 5 mg Daily METOPROLOL TARTRATE 25 mg [Hospital1 ] SIMVASTATIN 20 mg Daily VITAMIN D Dosage uncertain ASPIRIN 81 mg Daily CALCIUM CARBONATE [CALCIUM 500] Dosage uncertain MULTIVITAMIN Dosage uncertain Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 1 week, then 400mg daily x 1 week, then 200mg daily. Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary artery disease Secondary: Mitral valve prolapse Hypercholesterolemia Prostatic hypertrophy, benign Colonic polyp Discharge Condition: Alert and oriented x3 non-focal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema- none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] Date/Time:[2118-8-17] 1:00 WOUND CARE NURSE Phone:[Telephone/Fax (1) 170] Date/Time:[2118-7-19] 10:30 Cardiologist: [Month/Day/Year 42388]- office will call you with appt. Please call to schedule appointments with your Primary Care Dr. [First Name (STitle) ],[First Name3 (LF) ] F. [Telephone/Fax (1) 36794] in [2-7] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2118-7-11] ICD9 Codes: 4240, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5097 }	Medical Text: Admission Date: [2148-6-10] Discharge Date: [2148-6-21] Date of Birth: [2092-10-17] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Celebrex / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2148-6-13] Three Vessel Coronary Artery Bypass Grafting utilizing left internal mammary artery to left anterior descending artery, vein grafts to ramus intermedius, and posterior descending artery. History of Present Illness: Mrs. [Known lastname 7710] is a 55 year old female with multiple cardiac risk factors who presented to [Hospital3 20284] Center with worsening chest pain. She ruled out for myocardial infarction. Cardiac catheterization revealed critical three vessel coronary artery disease. Surgical revascularization was recommended and she was subsequently transferred to the [Hospital1 18] for surgical intervention. Of note, prior to catheterization, patient did receive Plavix. Past Medical History: Coronary Artery Disease Diabetes Mellitus Type I Hypertension Hypercholesterolemia Hypothyroidism Right Bundle Branch Block Low Back Pain - prior Back Surgery Partial Thyroidectomy Hysterectomy Carpal Tunnel Surgery Pneumonia - early [2147] Social History: No tobacco for over 20 years. Admits to only social ETOH. She is married and lives with her husband. Family History: She denies history of premature coronary artery disease. Physical Exam: Vitals: T 97.9, BP 122/80, HR 70, RR 18, SAT 92% on room air General: well developed female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, full ROM, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally, right groin angioseal Neuro: nonfocal Pertinent Results: [2148-6-21] 09:05AM BLOOD WBC-9.9 RBC-3.55* Hgb-11.7* Hct-34.0* MCV-96 MCH-32.9* MCHC-34.4 RDW-14.6 Plt Ct-611* [2148-6-18] 02:33AM BLOOD PT-10.6 PTT-21.2* INR(PT)-0.9 [2148-6-21] 09:05AM BLOOD Glucose-305* UreaN-12 Creat-0.8 Na-136 K-4.9 Cl-97 HCO3-31 AnGap-13 [2148-6-19] 06:20AM BLOOD ALT-240* AST-208* LD(LDH)-299* AlkPhos-461* Amylase-24 TotBili-0.5 RADIOLOGY Final Report CHEST (PA & LAT) [2148-6-19] 6:10 PM CHEST (PA & LAT) Reason: evaluate effusion [Hospital 93] MEDICAL CONDITION: 55 year old woman with s/p CABG REASON FOR THIS EXAMINATION: evaluate effusion REASON FOR EXAMINATION: Followup of a patient after CABG. PA and lateral upright chest radiographs were compared to [6-15], [2147]. The heart size is normal. The mediastinal contours are stable. The post-surgery sternal wires and skin sutures are unchanged. There is slight increase in bilateral basal linear atelectasis accompanied by small bilateral pleural effusion which _____ increase in size. The rest of the lung is unremarkable, and there is no evidence of congestive heart failure. There is no pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] DR. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1508]Cardiology Report ECHO Study Date of [2148-6-13] PATIENT/TEST INFORMATION: Indication: Chest pain. Coronary artery disease. Left ventricular function. Right ventricular function. Status: Inpatient Date/Time: [2148-6-13] at 09:31 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW209-9:2 Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) 1112] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aorta - Ascending: 2.8 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 1.8 cm (nl <= 2.5 cm) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%). LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. Conclusions: PREBYPASS No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Preserved biventricular systolic function. Study otherwise unchanged from prebypass. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD on [2148-6-13] 11:14. Brief Hospital Course: Mrs. [Known lastname 7710] was admitted and underwent routine preoperative evaluation. Given her recent Plavix, surgery was delayed for several days. On [6-13], Dr. [Last Name (STitle) ] performed coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and weaned from inotropic support without difficulty. Her CSRU course was uneventful and she transferred to the SDU on postoperative day one. Despite resumption of preoperative Insulin dose, she remained hyperglycemic. She was started on Insulin drip and returned to the CSRU for closer observation. The [Last Name (un) ] service was consulted to assist in the management of her diabetes. Lantus was initiated along with Humalog sliding scale. Over several days, blood sugars were better controlled and she returned to the SDU for further care and recovery. The remainder of her hospital stay was uncomplicated. She remained in a normal sinus rhythm and continued to make clinical improvements with diuresis. Medical therapy was optimized and she was eventually cleared for discharge to home on postoperative day #8 in stable condition. Medications on Admission: Moexipril 15 qd, Zetia 10 qd, Fexofenadine 60 qd, Amlodipine 5 qd, Lipitor 20 qd, Folate, Toprol XL 25 qd, Levoxyl, Flexeril, Humalog SS, Humulin NPH 8 units [Hospital1 ], B12, Plavix - last dose [6-10] 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Lantus 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous QAM. Disp:1 month supply Refills:2 8. Humalog 100 unit/mL Cartridge Sig: 0-5 units Subcutaneous four times a day: Take as directed according to sliding scale. Disp:1 month supply Refills:2 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. 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 11. sliding scale Humalog 51-100 101-150 151-200 201-[Telephone/Fax (3) 20285] Breakfast 3 5 7 9 11 Lunch 3 5 7 9 11 Dinner 3 5 7 9 11 Bedtime 0 0 0 2 3 12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Disp:21 Tablet(s) Refills:0 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:10 Tablet(s) Refills:0 14. 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 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease - s/p CABG Postoperative Hyperglycemia Diabetes Mellitus Type I Hypertension Hypercholesterolemia Hypothyroidism Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Blood glucose monitoring please call [Last Name (un) 387] for blood glucose > 200 x2 or < 60 [Last Name (un) ] ([Telephone/Fax (1) 3537] Followup Instructions: Dr. [Last Name (STitle) ] in [2-29] weeks - call for appt, [Telephone/Fax (1) 170]. Dr. [Last Name (STitle) ] 1-2 weeks - call for appt, [Telephone/Fax (1) 2384]. Dr. [First Name (STitle) ] in [12-30] weeks - call for appt, [Telephone/Fax (1) 4775]. Dr. [Last Name (STitle) ] in [12-30] weeks - call for appt. Appointments already scheduled: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. Phone:[Telephone/Fax (1) 5003] Date/Time:[2149-1-28] 1:40 Dr [Last Name (STitle) 11679] ([Last Name (un) 387]) Thrus [6-27] at 10am [Hospital Ward Name 121] 2 wound check with [Initials (NamePattern4) ] [Last Name (NamePattern4) 20286] [6-27] at 9am [Telephone/Fax (1) 3633] Completed by:[2148-6-21] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5098 }	Medical Text: Admission Date: [2121-10-22] Discharge Date: [2121-10-30] Service: MEDICINE Allergies: Codeine / Motrin Attending:[First Name3 (LF) 2736] Chief Complaint: HYPOTENSION / BRADYCARDIA Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [Known lastname 10829] is an 89 year old woman with HTN, COPD, mild aortic stenosis, paroxysmal afib (on coumadin), hypothyroidism, and recent gram negative bacteremia (pseudomonas), presenting with nausea, vomiting, hypotension and bradycardia one day after discharge from [Hospital1 18] after a complicated stay. . Patient has had repeated admission in the recent past, most recently after presenting with dyspnea on exertion and nausea. She was found to have positive blood cultures, ([1-15]) for pseudomonas. She was treated with Ceftriaxone and Ciprofloxacin and discharged to rehab facility. . Today, patient was found hypotensive and bradycardic at her nursing home, with SBP in 80's and HR in the 50's. She was brought to the ED, where her vitals were T 100/9, HR 68, BP 130/40, RR 18, O2 sat 99% 6L NC. Shortly thereafter, patient became bradycardic with HR to 30's and BP to 80's. ECG obtained revealed complete heart block with junctional escape rhythm. Patient was given atropine x 2, glucagon with little improvement. Patient continued having nausea and vomiting, and was obtunded. She was intubated for airway protection and EP was consulted. Initially plan was to place temporary pacer wire, while she was bridged with Dopamine, with good improvement in heart rate, at which time decision not to pursue temp wire was made. Patient was given calcium gluconate, also with improvement in heart rate. CT Torso was obtained, which was only remarkable for a small left pleural effusion and bilateral shoulder effusions. Patient was transferred to CCU for further management. Review of systems not obtainable, patient intubated. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, Dyslipidemia, (-)Hypertension . 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: [2115] CARDIAC CATH WITHOUT CAD -PACING/ICD: . 3. OTHER PAST MEDICAL HISTORY: Peripheral vascular disease Mild Mitral regurgitation. Pulmonary artery hypertension Severe Tricuspid regurgitation Mild Aortic stenosis (Valve area 1.3cm2, peak gradient 19mm Hg) Aortic regurgitation Mild cognitive impairment. Paroxysmal atrial fibrillation. Hypothyroidism. COPD. IBS Legally blind GAD Social History: Pt lives in an [Hospital3 ] facility. Uses a walker for ambulation. Children nearby. -Tob:occasional 30+yrs ago. -EtOH: none -Illicits: None Family History: Non-contributory Physical Exam: VS: T= 94.9 BP= 141/52 HR= 47 RR= 12 O2 sat= 99% on AC, 60% 350 x 12 GENERAL: Sedated, intubated. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, soft S2. Systolic III/VI mid peaking crescendo murmur. LUNGS: No chest wall deformities, scoliosis or kyphosis. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Cold extremities, no splinter hemorrhages, no osler nodes or [Last Name (un) ] lesions. 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: [2121-10-22] 10:13PM LACTATE-1.6 [2121-10-22] 05:53PM GLUCOSE-125* UREA N-28* CREAT-1.3* SODIUM-135 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11 [2121-10-22] 05:53PM ALT(SGPT)-32 AST(SGOT)-37 LD(LDH)-188 CK(CPK)-30 ALK PHOS-105 TOT BILI-0.2 [2121-10-22] 05:53PM LIPASE-39 [2121-10-22] 05:53PM cTropnT-0.03* [2121-10-22] 05:53PM CK-MB-NotDone [2121-10-22] 05:53PM CALCIUM-7.2* PHOSPHATE-3.6 MAGNESIUM-1.8 [2121-10-22] 05:53PM DIGOXIN-0.7* [2121-10-22] 05:53PM WBC-9.9 RBC-4.07* HGB-12.2 HCT-38.0 MCV-93 MCH-30.0 MCHC-32.1 RDW-13.9 [2121-10-22] 05:53PM NEUTS-79.3* LYMPHS-14.7* MONOS-4.4 EOS-1.1 BASOS-0.4 [2121-10-22] 05:53PM PLT COUNT-297 [2121-10-22] 05:53PM PT-19.7* PTT-27.3 INR(PT)-1.8* [2121-10-21] 07:10AM GLUCOSE-92 UREA N-26* CREAT-1.0 SODIUM-134 POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-34* ANION GAP-9 . CTA Chest/Abdomen/Pelvis [2121-10-22]: 1. Fluid collections around both shoulders of unknown etiology. Recommend clinical correlation. 2. Interval improvement in bilateral small pleural effusions. 3. Small right renal hypodensity, too small to be fully characterized, likely represents a cyst. 4. Small amount of perihepatic fluid. 5. Endotracheal tube at 3 cm above the carina. Repositioning is recommended. . ECHO [2121-10-23]: The left atrium is moderately dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 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 (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of [2121-10-15], the findings are similar with less tricuspid regurgitation and lower estimated pulmonary artery systolic pressure. . LENI [2121-10-24]: 1. No evidence of DVT in either lower extremity. 2. Right sided [Hospital Ward Name 4675] cyst. . CTA Head/Neck [2121-10-24]: 1. Extensive right hemispheric infarct involving the anterior and middle cerebral artery distributions. CT perfusion demonstrates delayed transit time, reduced blood flow and reduced blood volume in this region. 2. Occlusion of the intracranial portion of the right internal carotid artery. . ART DUP EXT [2121-10-24]: Focal right brachial arterial thrombus at the level of the antecubital fossa. Findings reported to the referring physician. . CT HEAD W/O CONTRAST [2121-10-25]: Edema of the right hemisphere with mass effect upon the right lateral ventricle and 4 mm leftward shift of midline structures. Brief Hospital Course: Patient presented with hypotension, bradycardia, and hypothermia. Patient was intubated in ER due to concern of airway protection secondary to nausea, vomiting and decreased mental status. Bradycardia thought to be secondary to nodal medications (Metoprolol Tartrate 50 mg [Hospital1 ], Verapamil 120 mg Tablet PO Q24H) in setting of worsening renal function. Patient was on nodal agents for A Fib and history of tachycardia. Hypotension and hypothermia on admission were attributed to sepsis, supported by elevated white count and recent discharge for pseudomonas bacteremia. Patient was started on Vancomycin and Zosyn. Cipro was continued. Warfarin was held due to concern for DIC. Patient was extubated on [2121-10-23]. On [2121-10-24] patient entered A Fib and demonstrated decreased L sided movement. On exam, she had R preferential gaze with L hemiplegia and neglect. Stroke service was called. CT of head was obtained urgently showing R ACA/MCA infarct with dense R MCA most likely cardioembolic secondary to Afib. Given the extensive infarct with evidence of completion plus the fact that she was already anticoagulated with INR 2.0 she was not given lytics (IA tPA) due to high likelihood of hemorrhagic transformation with such intervention. CT head [2121-10-25] demonstrated mid-line shift. Patient became non-verbal. Family decided on comfort care measures only. Patient passed on [2121-10-30]. Medications on Admission: Warfarin 1 mg / 2mg Valsartan 160 mg Tablet PO BID Metoprolol Tartrate 50 mg [Hospital1 ] Verapamil 120 mg Tablet PO Q24H . Tramadol 25 mg [Hospital1 ] Donepezil 5 mg PO HS (at bedtime). Cholecalciferol (Vitamin D3) 400 unit Calcium Carbonate 500 mg Tablet [Hospital1 ] Levothyroxine 50 mcg PO DAILY Multivitamin Lorazepam 0.5 mg PO HS Gabapentin 100 mg PO TID Polyvinyl Alcohol 1.4 % Drops PRN Tiotropium Bromide Levalbuterol nebs . Lasix 20 mg Tablet daily Ciprofloxacin 500 mg [Hospital1 ] (end date: [2121-10-26]) Loperamide 2 mg Ranitidine HCl 150 mg PO BID . Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Right anterior MCA Stroke Right upper extremity thrombus Paroxysmal Atrial fibrillation Hypertension Sepsis? Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2121-10-30] ICD9 Codes: 7907, 5849, 4168, 2449, 4439, 4019, 2859, 4280, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 5099 }	Medical Text: Admission Date: [2103-8-31] Discharge Date: [2103-9-26] Date of Birth: [2037-12-25] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2724] Chief Complaint: found down Major Surgical or Invasive Procedure: [Last Name (un) 8745] bolt placement History of Present Illness: HPI:84F found down flight of stairs, cause and down time unknown, brought to OSH where she was aphasic, bruising over R eye, not following commands, localized to pain and moved all extremities. Was intubated and CT of Head done at OSH showed bilat frontal SDH and IPH, no shift or mass affect. Transferred here via Med Flight. Past Medical History: unknown Social History: lives alone Family History: nc Physical Exam: PHYSICAL EXAM: T:103 BP:100/86 HR:113 RR:16 O2Sats:100 Gen: Sedated with Fent/Ativan in Trauma Bay 23 HEENT: Normocephalic with eccymosis surrounding R eye. Pupils: PERRL EOMs:UTA Neck: C-collar in place Supple. Extrem: Warm and well-perfused. Positive clonus bilat Neuro: Mental status: Sedated on Fent/Ativan, does not open eyes to noxious stimuli, does not follow commands, localizes to pain bilat, moves UE bilat. Does not withdrawn lower extremities to pain. Internal rotation of LE bilat with noxious stimuli. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3.5 mm bilaterally. III, IV, VI: UTA V, VII: UTA pt sedated VIII: UTA pt sedated IX: UTA X: UTA [Doctor First Name 81]: UTA XII: UTA Motor: Moves upper extremities bilt. to noxious stimuli Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 3 2 Left 2 2 2 3 2 Toes upgoing bilaterally Coordination: UTA Pertinent Results: CT:No interval change from OSH study of 11am. SDH over left convexity. Extra-dural component cannot be entirely ruled out - lens-shaped collection over left frontal lobe. SAH at B/L midline and right parietal. No edema or shift.Extensive soft tissue hematoma over right posterior calvarium. No fractures. Brief Hospital Course: Pt was admitted to the neurosurgery service and [Initials (NamePattern4) ] [Last Name (NamePattern4) 8745] bolt to monitor ICPs was placed in the ED. Initial ICP was 10 and this remained in normal range. She was admitted to ICU were she was followed closely with neurologic exams. repeat CT showed stable hemorrhage. The [Last Name (un) 8745] bolt was removed [9-3].She began spiking temperatures - fever work up including CSF cxs, LENI's and abdominal ultrasound revealed no source. She was changed from dilantin to keppra for seizure prophylaxis. She was treated for ventilator acquired pneumonia. She was attempted pn multiple occasions to wean from the ventilator and ultimately underwent trach and PEG on [2103-9-11]. She still was difficult to wean from vent. She continued to spike fevers and only pneumonia was found as source. She had cervical collar on but had negative cervical CT and this was cleared. She did require transfusions for decreasing hematocrit. She had large hematoma on occipital scalp which was treated with wet to dry dressings and her head was kept on a donut to remove pressure from the hematoma. Her neuro exam slowly improved and she did open eyes and follow some commands, although this was inconsistent. The patient was tolerating a trach mask for several hours a day prior to discharge but did require the ventilator for most of the time, especially during the night. Medications on Admission: unknown Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: traumatic brain injury fever peg trach anemia Discharge Condition: stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have your incision checked daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) 548] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[2103-9-25] ICD9 Codes: 5185, 0389, 486, 2760, 2859, 311, 2720

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