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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5100
} | Medical Text: Admission Date: [**2101-2-25**] Discharge Date: [**2101-3-3**]
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: An 80-year-old female, with a
history of aortic stenosis, had recently had increase in
dyspnea on exertion. The patient had a cath today which
revealed severe AS with [**Location (un) 109**] 0.59, 1+ AR and a left
ventricular ejection fraction of 65%, with normal coronaries.
The patient was referred to the cardiac surgery service for
AVR. The patient had an echo in [**2100-11-20**] that showed
AS, [**Location (un) 109**] of 0.4, 2+ TR, 1+ MR, AV gradual peak at 93.
PAST MEDICAL HISTORY:
1. Hospitalized in [**2096**] with ?pneumonia versus CHF, and the
patient was intubated at that time. The patient had a
question of a history of AFIB at that time, and the patient
was on Coumadin for a brief period of time.
2. Status post tonsillectomy.
SOCIAL HISTORY: No smoking history. The patient denies
drinking alcohol. The patient is married and lives with
husband.
MEDICATIONS:
1. Atenolol 25 qd.
2. Multivitamins 1 tablet qd.
LABS ON ADMISSION: White count 5.9, hematocrit 35.2,
platelets 181, INR 1.1, sodium 137, potassium 3.3, chloride
104, bicarb 23, BUN 28, creatinine 0.6, glucose 132. UA was
negative. LFTs were normal.
REVIEW OF SYSTEMS: The patient denied TIAs, CVA, seizures,
no PND, no palpitations, no cough, no wheezes. The patient
states that she has occasional heartburn relieved with Tums.
The patient has a rare history of diarrhea, some hemorrhoids.
The patient denies claudication. Denies diabetes, thyroid
disease, or heme issues.
PHYSICAL EXAM: The patient is a healthy appearing
80-year-old female. Neurologically, the patient was grossly
intact without carotid bruits. Examination of the lungs
revealed clear to auscultation bilaterally. Examination of
the heart revealed a IV/VI systolic ejection murmur with S1
and S2. Abdomen was soft, nontender, nontender. Examination
of the extremities revealed warm with positive peripheral
pulses without any edema.
HOSPITAL COURSE: The patient was admitted to the cardiac
surgery service and underwent aortic valve replacement with a
#19 tissue valve. The patient was extubated and transferred
to the CSRU. The patient was on perioperative Kefzol,
remained afebrile with pulse at 100, and blood pressure
133/56, otherwise doing well. The patient's white count was
21.9, hematocrit 36.9. The patient was put on low dose
Lopressor 12.5 [**Hospital1 **], and the patient's Swan was switched to a
CVL.
On postop day #2, the patient was started on lasix for low
urine output. The patient remained afebrile with pulse
around 90, blood pressure 130s/40s, otherwise doing well.
The patient still had the chest tube, wires and Foley. The
chest tubes were removed. Lopressor was increased to 25 mg
[**Hospital1 **].
On postop day #3, the patient continued to remain afebrile.
Pulse was running around 88, normal sinus, blood pressure
120s/40s, otherwise doing well. Taking in good POs and
making good urine. White count was down to 13. The patient
was transferred to the floor in stable condition.
On postop day #4, the patient had no complaints. The
patient's Lopressor was at 50 [**Hospital1 **]. The patient had a
low-grade fever of 100.3, otherwise remained stable, pulse
around 87, and blood pressure 110s/60s. She was taking good
POs and making good urine. White count at 13. The patient's
wire was removed and had worked with physical therapist.
On postop day #5, the patient remained afebrile with stable
vital signs. Pulse still running around 90. The patient
worked with physical therapist and passed level 5, and it was
safe for the patient to return home.
On postop day #6, the patient had no complaints. The patient
was on Lopressor 100 [**Hospital1 **] for systemic ventricular
tachycardia. The patient's T-max was 100.1, pulse remained
at 99, and blood pressure 116/51. The patient was taking
good POs and making good urine. The patient was switched to
Lopressor 75 mg tid, and the patient was doing well.
Pressure and heart rate were better controlled. The patient
was discharged home in good condition.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Home with services.
FINAL DIAGNOSES:
1. Status post aortic valve replacement.
2. Severe aortic stenosis.
3. Pneumonia.
4. Status post tonsillectomy.
FO[**Last Name (STitle) **]P PLANS:
1. Please follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks; please
call his office for follow-up appointment.
2. Please follow-up with Dr. [**Last Name (STitle) 26191**], the PCP, [**Last Name (NamePattern4) **] [**1-21**]
weeks; please call for a follow-up appointment.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po bid for 7 days.
2. Potassium 20 mEq po q 12 h for 7 days.
3. Colace 100 mg po bid.
4. Metoprolol 75 mg po tid.
5. Aspirin 325 mg po qd.
6. Percocet 1-2 tabs po q 4 h prn pain.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 26192**]
MEDQUIST36
D: [**2101-3-3**] 08:52
T: [**2101-3-3**] 09:37
JOB#: [**Job Number 26193**]
ICD9 Codes: 4241, 9971, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5101
} | Medical Text: Admission Date: [**2190-10-4**] Discharge Date: [**2190-10-7**]
Date of Birth: [**2112-6-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
gentleman with coronary artery disease, diabetes mellitus,
and chronic renal insufficiency who presented with a chief
complaint of shortness of breath.
The patient presented to the Emergency Department and was
found to be bradycardia to the 20s. Per the patient's
family, the patient had complained of shortness of breath for
the past two days prior to admission. He was becoming
dyspneic with walking across the room.
On the day of admission, the patient had decreased oral
intake and one episode of vomiting. His wife his finger
blood sugar level to be 400 and called his primary care
physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) who advised the patient to go to
the [**Hospital1 69**] Emergency
Department.
In the Emergency Department, the patient's heart rate was in
the 20s with a stable blood pressure. Electrocardiogram
showed complete heart block. According to his wife, the
patient does not have any recent history of chest pain,
orthopnea, or paroxysmal nocturnal dyspnea. The patient did
complain of some lightheadedness earlier on the day of
presentation. He denies any recent history of fevers or
chills.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft in [**2181**] with stents times five in [**2189**].
2. Diabetes mellitus.
3. Hypercholesterolemia.
4. Hypertension.
5. Benign prostatic hypertrophy.
6. Congestive heart failure with left ventricular systolic
dysfunction.
7. Chronic renal insufficiency.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg by mouth once per day.
2. Lasix 80 mg by mouth once per day.
3. Hydralazine 25 mg by mouth four times per day.
4. Isordil 20 mg by mouth three times per day
5. Toprol-XL 100 mg by mouth once per day.
6. Zantac 150 mg by mouth twice per day.
7. Zestril 40 mg by mouth once per day.
8. Zocor 80 mg by mouth once per day.
9. Flomax 0.4 mg by mouth once per day.
10. Proscar 5 mg by mouth once per day.
11. Insulin (70/30) 40 units subcutaneously in the morning
and 35 units subcutaneously in the evening.
12. Procrit 7500 units subcutaneously every other week.
ALLERGIES: An allergy to PENICILLIN.
SOCIAL HISTORY: The patient is married. He denies any
history of alcohol, tobacco, or drug use.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient was afebrile, his blood
pressure was 164/58, his heart rate was in the 70s (following
temporary pacemaker placement), his respiratory rate was 20,
[**Hospital1 **]-level positive airway pressure [**6-22**] with an FIO2 of 60%,
and saturating 100%. The physical examination was notable
for an irregular rhythm with normal first heart sounds and
second heart sounds. No murmurs, rubs, or gallops were
appreciated. Extremity examination revealed no lower
extremity edema was present on examination. Chest
examination revealed crackles in the lungs bilaterally.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram on admission
revealed complete heart block with a rate of 30 and possible
anterior fascicular block.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
were notable for a creatinine of 4 and a potassium of 6.2.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was admitted to the Coronary Care Unit.
In the Emergency Department, prior to transfer to the
Coronary Care Unit, a temporary pacemaker was placed. The
patient was also placed on [**Hospital1 **]-level positive airway pressure
to assist with ventilation.
The following morning, the patient was taken for pacemaker
placement. The patient received a [**Company 1543**] SDR 303B
dual-chamber rate-responsive pacemaker. The patient
tolerated the procedure well.
Following the procedure, the patient was sent back to the
Coronary Care Unit for further monitoring. Following
pacemaker placement his heart rate remained stable in the 60s
with a systolic blood pressure ranging from the 120s to the
140s.
Due to his congestive heart failure and mild left ventricular
systolic dysfunction, the patient was diuresed with Lasix.
The patient required multiple blood pressure medications to
control his hypertension. He was also continued on aspirin,
statin, and beta blocker due to his history of coronary
artery disease. The patient was not placed on an ACE
inhibitor due to his elevated creatinine over his baseline.
His creatinine remained stable between 3.7 and 4 throughout
his hospitalization. However, his creatinine was elevated
from his previous known baseline of 3.
Following the pacemaker placement procedure, the patient was
restarted on his home insulin scheduled of 70/30. It was
found to cause excessive nocturnal hypoglycemia. His evening
insulin dose was decreased, and he had no further problems
with his blood sugars.
On hospital day four, the patient was found to have an
episode of shaking chills. He was afebrile, and his white
blood cell count was elevated. Blood cultures and urine
cultures were obtained but did not grow anything. Due to
concern for possible pacemaker pocket infection, the patient
was started on intravenous vancomycin; however, there were no
signs of infection at pacemaker site. Prior to discharge,
the patient was switched to a by mouth antibiotic.
Prior to discharge, the patient was given an injection of
Epogen 7500 units for anemia of chronic disease and chronic
renal insufficiency.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient's discharge status was to home
with home physical therapy.
DISCHARGE DIAGNOSES:
1. Complete heart block.
2. Status post pacemaker placement.
3. Congestive heart failure.
4. Systolic dysfunction.
5. Coronary artery disease; status post coronary artery
bypass graft and stent from prior hospitalization.
6. Hypertension.
7. Insulin-dependent diabetes mellitus.
8. Chronic renal insufficiency.
9. Benign prostatic hypertrophy.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Zantac 150 mg by mouth twice per day
3. Toprol-XL sustained release 100 mg by mouth once per
day.
4. Hydralazine 50 mg by mouth q.6h.
5. Amlodipine 5 mg by mouth once per day.
6. Isosorbide dinitrate 20 mg by mouth three times per day.
7. Furosemide 80 mg by mouth twice per day.
8. Docusate 100 mg by mouth twice per day as needed (for
constipation).
9. Insulin (70/30) 40 units subcutaneously in the morning
and 25 units subcutaneously in the evening.
10. Tamsulosin sustained release 0.4 mg by mouth at hour of
sleep.
11. Finasteride 5 mg by mouth once per day.
12. Zocor 80 mg by mouth once per day.
13. Clindamycin 150 mg by mouth q.6h. (times five days).
DISCHARGE INSTRUCTIONS/FOLLOWUP: (The patient's was
scheduled to follow up as follows)
1. The patient was instructed to follow up with the [**Hospital1 1444**] Cardiology Device Clinic on
[**2190-10-12**].
2. The patient was instructed to follow up with his primary
cardiologist (Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 32963**]) at the [**Hospital6 4193**] Cardiovascular Division.
3. The patient was instructed to follow up with his primary
nephrologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25699**]) at the [**Hospital6 15291**].
4. The patient was instructed to follow up with his primary
care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on [**10-12**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Name8 (MD) 32964**]
MEDQUIST36
D: [**2190-10-12**] 15:35
T: [**2190-10-14**] 11:39
JOB#: [**Job Number 32965**]
ICD9 Codes: 4240, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5102
} | Medical Text: Admission Date: [**2174-8-20**] Discharge Date: [**2174-8-26**]
Date of Birth: [**2104-3-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
s/p EGD and colonoscopy
s/p IVC filter placement
History of Present Illness:
Ms. [**Known lastname 4886**] is a 70 year old female with history of left leg DVT
on warfarin who presented with two days of bright red blood per
rectum. She complained of weakness and dizziness for the past
couple days and when her daughter visited her noticed she was
pale and diaphoretic.
.
In the ED, initial vs were: T 98 HR 155 BP 130/57 RR 18 SaO2
99%RA.
Patient was given 2 liters NS IVF, 2 units of FFP to reverse her
INR of 2.7, and one unit pRBCs. After a 500cc bolus, her SBP
increased from 70s to 130s and HR decreased from 150 to 100s.
NG lavage was weakly positive with pink saline and small clots
at end of suction. A central line was placed, and she received
IV PPI prior to transfer. Vitals at transfer were 130/90, 80,
20, 100% RA.
.
In the [**Hospital Unit Name 153**], she reports feeling better after being treated in
the ED. Patient reports having a week of BRBPR with clots
approximately three weeks ago that spontaneously resolved. Her
current bleeding episode started yesterday with 6 bloody bowel
movements. Afterwards, she had some palpitations with exertion
and felt fatigued. She had three episodes of non-bloody, yellow
emesis last night without any abdominal pain with some
associated cold sweats. Patient has had some intermittent
constipation (baseline [**1-27**]/day) with straining occasionally but
this does not always occur prior to bloody BM. No known sick
contacts, DOE, SOB. No current N/V or abdominal pain. She does
complain of discomfort from the NG tube.
.
Review of systems:
(+) Per HPI, 20 pound weight loss over last year.
(-) Denies fever or headache. Denies cough, shortness of breath,
or wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies current nausea, vomiting, diarrhea,
constipation, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias.
Past Medical History:
LLE Deep Venous Thrombosis, [**2170**] & [**2173**]
Hypertension
Type 2 Diabetes Mellitus A1c 6.7% 6/10
Schizoaffective Disorder
Hyperlipidemia
Social History:
Pt is widowed and lives at an [**Hospital3 **] facility. She is
a non-smoker and denies alcohol and illicit drug use.
.
Emergency Contact: [**Name (NI) 1439**] [**Name (NI) 4886**], daughter, ([**Telephone/Fax (1) 108712**],
work: ([**Telephone/Fax (1) 108713**], cell: ([**Telephone/Fax (1) 108714**]
Case Manager: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79685**], ([**Telephone/Fax (1) 108715**], cell: ([**Telephone/Fax (1) 108716**]
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.6 BP: 144/57 P: 84 R: 22 O2: 100% RA
General: Alert, oriented, pale African American female in no
acute distress
HEENT: EOMI, sclera anicteric with pale conjunctiva, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD, R IJ in place
Lungs: Clear to auscultation bilaterally with decreased BS at
bilateral bases, 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, small
reducible umbilical hernia
GU: foley in place
Ext: cool digits with normal cap refill, well perfused, 2+
pulses, no clubbing, cyanosis or edema, strength 5/5 in BLE
extremities
Pertinent Results:
WBC-9.8# RBC-2.62*# HGB-6.6*# HCT-19.8*# MCV-76* PLT COUNT-368
NEUTS-68.6 LYMPHS-24.4 MONOS-4.8 EOS-1.8 BASOS-0.3
GLUCOSE-195* UREA N-20 CREAT-1.2* SODIUM-141 POTASSIUM-3.4
CHLORIDE-106 TOTAL CO2-24
PT-27.3* PTT-25.6 INR(PT)-2.7*
.
[**8-20**] EKG: Sinus tachycardia at 117 with RBBB and LAFB (unchanged
from prior)
.
[**8-20**] CHEST X-RAY:Frontal view of the chest demonstrates
cardiomegaly. Right IJ catheter terminates in superior vena
cava. There is mild congestive failure.
.
[**2174-8-22**] Intervential Radiology IMPRESSION:
1. Normal anatomy of the IVC with a maximal caval diameter of
2.2 cm.
2. No evidence of caval thrombus or aberrant caval anatomy.
3. Successful placement of an infrarenal OptEase IVC filter.
.
[**8-23**] EGD: normal anatomy, no explanation for bleeding.
.
[**8-23**] [**Last Name (un) **]: Findings: Excavated Lesions, Multiple diverticula
were seen in the sigmoid colon. Diverticulosis appeared to be
severe.
Impression: Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
.
[**2174-8-22**] 02:50PM BLOOD WBC-9.7 RBC-3.68* Hgb-9.7* Hct-29.0*
MCV-79* MCH-26.4* MCHC-33.5 RDW-15.2 Plt Ct-283
[**2174-8-23**] 05:05AM BLOOD WBC-7.5 RBC-3.28* Hgb-8.7* Hct-26.9*
MCV-82 MCH-26.6* MCHC-32.5 RDW-15.7* Plt Ct-284
[**2174-8-24**] 05:55AM BLOOD WBC-7.8 RBC-3.15* Hgb-8.3* Hct-25.0*
MCV-80* MCH-26.2* MCHC-33.0 RDW-15.9* Plt Ct-245
[**2174-8-24**] 12:34PM BLOOD Hct-28.1*
[**2174-8-23**] 05:05AM BLOOD PT-13.6* PTT-24.4 INR(PT)-1.2*
[**2174-8-25**] 12:55PM BLOOD Glucose-96 UreaN-8 Creat-0.9 Na-140 K-3.9
Cl-104 HCO3-29 AnGap-11
[**2174-8-22**] 05:00AM BLOOD ALT-11 AST-13 LD(LDH)-180 AlkPhos-65
TotBili-0.7
Brief Hospital Course:
# Acute blood loss anemia/GI bleed: Pt was admitted to the ICU,
where she remained hemodynamically stable without evidence of
ongoing bleeding. Her INR had been reversed with 2units of FFP
and 10mg Vitamin K. She was transfused with 2 more units of
pRBCs for a total of 3 and her hematocrit bumped appropriately.
She was called out to the floor and underwent bowel prep on [**8-22**]
followed by EGD/[**Last Name (un) **] on [**8-23**] which did not show any evidence of
ongoing bleeding though severe diverticulosis of the colon. Pt
was monitored in house and remained hemodynamically stable with
stable Hct and no evidence of ongoing bleeding. She was started
on Ferrous Sulfate 325mg daily and continue on Omeprazol 20mg
daily, she will need follow up with GI following psychiatric
admission.
.
# History of DVT: Pt has had two DVTs, most recent was diagnosed
at an OSH in [**2174-5-26**] and has been on warfarin since that time.
INR was 2.7 in setting of acute GI bleed and it was reversed as
above. She underwent IVC filter placement on [**8-23**] given the
risk of anti-coagulation. After discussion with daughter/GI,
decision was made to avoid restarting coumadin given her risk to
rebleed and her delay in getting care in the setting of this
bleed. Pt is scheduled to see her PCP after discharge to
further discuss this issue.
.
# Schizoaffective disorder: Pt had a recent prolonged inpatient
psych admission and was seen by psychiatry in house. After
discussion with outpatient providers, decision was made to
transfer to inpatient psych facility for further care. Pt was
continued on Fluoxetine, Donepezil, Lamotrigine and Mirtazapine.
Further discussions regarding her ability to care for self at
home to be held at that time.
.
# HTN: stable, continue on home regimen of Lisinopril
.
# DMII: Stable, will resume home regimen of Metformin 500mg [**Hospital1 **].
Please continue BS checks and pt instructed to stop if not
taking regular meals.
.
Medications on Admission:
Aricept 5 mg qHS
Fluoxetine 20 mg qday
Lamotrigine 50 mg [**Hospital1 **]
Lisinopril 20 mg daily
GlycoLax 17 gram/dose daily
Mirtazapine 45 mg qHS
Multivitamin
Omeprazole 20 mg daily
Seroquel 300 mg qHS
Warfarin 6.5mg daily
Discharge Medications:
1. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
2. Mirtazapine 45 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
1. Acute blood loss anemia
2. Diverticulosis
3. DVT s/p IVC filter
.
Secondary:
DMII
Hypertension
Schizoaffective Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with acute blood loss anemia from a lower
gastrointestinal bleed in the setting of anti-coagulation for a
DVT.
You have been transfused with blood and your blood counts have
stabilized without any sign of further bleeding. You underwent
placement of an IVC filter to treat the DVT. Please note that
we have stopped the Coumadin. You should not take this
medication again unless you are instructed by a physician.
.
We have restarted your home regimen including Metformin 500mg
twice daily and two new medications
1. Ferrous Sulfate 325mg daily (in place of Multivitamin)
2. Omeprazole 40mg daily
.
Please continue to monitor your blood sugars at home, you should
not take the Metformin if you are not eating regular meals.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 2115**]
Appointment: Thursday [**2174-9-1**] 11:00am
.
Please call the [**Hospital **] clinic at ([**Telephone/Fax (1) 2233**] after discharge to
schedule a follow up appointment with them.
ICD9 Codes: 5849, 2851, 4589, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5103
} | Medical Text: Admission Date: [**2170-3-26**] Discharge Date: [**2170-4-16**]
Date of Birth: [**2101-3-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45556**]
Chief Complaint:
GI bleeding, respiratory distress
Major Surgical or Invasive Procedure:
s/p central line placement
History of Present Illness:
68-year-old male with a history of hypertension and gout who is
being treated on the biologics service with IL-2 for metastatic
melanoma. He began the protocol on Monday and had been
tollerating the TID IL-2 infusions, but had a decline in his
plts from 200 to 56 as well as a 11# weight gain attributed to
capillary leak. He also had significant electrolyte imbalances,
tachycardia, and tachypnea expected from this protocol.
On the day of [**Hospital Unit Name 153**] transfer, patient had some mild epigastric
discomfort and complained to his daughter of heartburn. Of
note, he was on daily indocin while on IL-2 therapy. At 10pm,
he developed some diarrhea and then had an episode of nausea and
vomiting. The covering MD noted 2 very large blood clotts in
the emesis. Noted increased RR of 40s, was 84% on RA and then
improved to 100% on 4L NC. Biologics attending was not
concerned about other parameters, but was worried abt bleeding
as patient may be at risk for bleeding given his plts have
dropped in the past few days.
Brought to [**Hospital Unit Name 153**], GI team asks for FFP, plts. Pt has guiac
positive brown stools, but complains of hemorrhoids and some
rectal irritation that may be contributing. Holding on NG
lavage unless patient becomes unstable. First two hcts are
stable.
Past Medical History:
Onc Hx per OMED notes:
Pt was diagnosed with melanoma in [**4-/2167**] when he was found to
have a mole on his left abdomen. He underwent wide local
excision and sentinel lymph node biopsy at that time which
revealed no residual melanoma and the 3 sentinel nodes were
negative. Two years later in [**4-18**], he developed a red raised
nodule under the scar of the local excision. This was reexcised
and he subsequently did well until [**8-/2169**] when he had another
satellite recurrence and reexcision. He then had a third
satellite recurrence and reexcision in [**10/2169**] and was then
started on interferon therapy that was stopped [**2-15**] side effects.
Recent PET/CT done revealed a left axillary lymphadenopathy as
well as 2 liver lesions.
..
..
PmHx: melanoma, Gout, Htn. Reports recent normal EGD and
colonoscopy
Social History:
Married, 4 kids, quit smoking 35 years ago (prior 7pk yr hx),
rare EtOH use, retired engineer
.
Family History:
Father with lung cancer
Physical Exam:
PE: 98.2 133-152/72-75 HR 132 RR 28 100% 4L NC
Gen: obese, breathing rapidly, no acute distress, comfortable,
alert
HEENT: mm dry, op clear, neck supple with tripple lumen in
place, eomi
CV: distant HS, tachy s1s2 no m/r/g
Lungs: crackles noted bilat, L>R, otherwise clear
Abd: obsese, multiple metastatic nodules palpable on L side of
abdomen, soft, nt/nd, active bs
Ext: 1+ edema bilat
Rectal: brown guiac positive stools
Pertinent Results:
CXR PORTABLE [**3-27**]
IMPRESSION: Minimal patchy basilar opacities likely due to
atelectasis. No evidence of pulmonary edema.
.
[**2170-3-31**] CXR PORTABLE
IMPRESSION: New diffuse bilateral parenchymal opacities
compatible with pulmonary edema.
.
[**2170-3-31**]
CHEST XR: A single AP supine view is compared to previous
examination earlier from the same day. Again seen extensive
bilateral parenchymal opacities suggesting pulmonary edema.
There is more dense consolidation in left lower lobe with air
bronchogram, compatible with pneumonia. There is a new
endotracheal tube with the tip overlying T3.
.
[**2170-4-2**]
BILATERAL LE DOPPLER
IMPRESSION: No evidence of lower extremity DVT.
.
ECHO [**2170-4-2**]: EF>60%
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. The right ventricular cavity is moderately dilated. Right
ventricular systolic function appears depressed.
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 a trivial pericardial effusion.
.
[**2170-4-4**] RENAL US
IMPRESSION:
1. Multiple left kidney stones, the largest measuring 2.1 cm in
the mid pole. No evidence of hydronephrosis. Multiple parapelvic
cysts.
2. Right kidney stone. No evidence of hydronephrosis.
.
[**2170-4-7**] LIVER/GB ULTRASOUND
IMPRESSION:
1. No evidence of intra- or extrahepatic biliary ductal
dilation. No evidence of cholecystitis. 1.3 cm shadowing
gallstone.
2. Two hypoechoic liver lesions likely corresponding to the
lesions seen on CT. Metastatic disease to the liver is within
the differential.
.
[**2170-4-9**] CXR
IMPRESSION: AP chest compared to [**4-2**] and 24:
Left lower lobe consolidation is clearing, probably resolving
atelectasis. Pulmonary vascular congestion is present but edema
has not returned. Azygous distention indicates volume overload.
Heart size is top normal. No pleural effusion or pneumothorax.
ET tube and right subclavian line are in standard placements and
a nasogastric tube passes through the mid stomach and out of
view.
.
*** CULTURE DATA ***
[**4-11**] urine cx neg
[**4-10**] blood cx X 6 pending
[**4-10**] sputum cx: 2+ GPC in pairs, sparse growth oropharyngeal
flora
[**4-10**] stool: O&P pending
[**4-7**] blood cultures neg
[**4-7**] worm macroscopic pending
[**4-6**] CMV VL not detected
[**4-6**] Crytococcus negative
[**4-5**] Rapid resp viral negative
[**4-5**] BAL: oropharyngeal flora, no PMN, no microorg, neg fungal,
AFB
Brief Hospital Course:
HOSPITAL COURSE: On the day of [**Hospital Unit Name 153**] transfer, [**2170-3-29**], patient
had some mild epigastric discomfort and complained to his
daughter of heartburn. Of note, he was on daily indocin while on
IL-2 therapy. At 10pm, he developed some diarrhea and then had
an episode of nausea and vomiting. The covering MD noted 2 very
large blood clots in the emesis. Noted increased RR of 40s, was
84% on RA and then improved to 100% on 4L NC. Biologics
attending was not concerned about other parameters, but was
worried about bleeding as patient may be at risk for bleeding
given his plts have dropped in the past few days.
.
Brought to [**Hospital Unit Name 153**], GI team requested FFP, plts. Pt has guiac
positive brown stools, and complained of hemorrhoids and some
rectal irritation that may be contributing. He was not scoped
emergently that night, and his vitals were closely followed,
along with Hct. His Hct was noted to be stable, with stable VS,
and no episodes of melena. GI felt no emergent need for EGD.
He is receiving PPI [**Hospital1 **]. On [**4-1**], the pt was intubated for
respiratory distress secondary to pulmonary edema thought to be
secondary to capillary leak syndrome from HD IL-2. He underwent
diuresis and was started on levo/flagyl for ?LLL PNA, started
[**3-31**]. On [**4-3**], levo/flagyl d/c'd as all cx negative, pt
afebrile. Another reason abx d/c'd was b/c pt developed a rash
thought to be a drug hypersensitivity reaction, which improved
post d/c abx. ID was consulted [**4-4**] for continued fevers and
recommended the initiation of broad spectrum abx incl.
Vancomycin, Aztreonam, and Flagyl (stopped [**4-8**]), RUQ US to r/o
cholangitis (b/c pt had elev LFTs), and stated would not give
steroids, and would do bronchoscopy/BAL for most likely pulm
source. Chest CT demonstrated b/l lower lobe infiltrates c/w
pulm edema vs. PNA. Pt underwent Bronch [**4-5**], showing limited
eval of right sided airways, lavage with RLL post segment,
result: no PMN, no microorg, grew OP flora, PCP negative, AFB
negative. Vancomycin was continued for ? line infection, and
b/c the pt had difficult access, his line was continued for 19
days. He has been on Vanco for 8 days. The pt's LFT elevation
was attributed to IL-2 therapy, a known side effect.
.
Also, he was noted to have renal insufficiency, with Cr to 1.6,
and eosinophilia, with presumed AIN. His creatinine continued
to rise to 2.6 (baseline 0.9). He was given prednisone, which
was subsequently d/c'd. Renal was consulted [**2170-4-5**] and
recommended for pt to increase free water intake. They felt he
had a number of reasons to have ARF, including: capillary leak
syndrome, NSAIDs, infection, contrast on [**4-2**], and drug reaction
though no eos or WBC in urine. The pt's creatinine demonstrated
slow improvement, was 1.4 [**4-7**], and on transfer from ICU, his Cr
was 0.9 (baseline).
.
Subjectively on transfer from [**Hospital Unit Name 153**] to the medical floor, the pt
felt well, is laughing and joking with family, and has no pain
complaints. States his breathing if fine. No cough, fever,
chills. No N/V. No abd pain. No diarrhea or constipation. No
dysuria. No chest pain or shortness of breath.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Impression: A/P: 69 M with metastatic melanoma s/p IL-2
therapy, last dose at 3 pm [**3-29**], now with fevers, resp failure
[**2-15**] non-cardiogenic pulm edema; now improving, extubated [**4-12**],
and satting well on NC. Resolved ARF. s/p Drug
hypersensitivity reaction with discontinuation of all
antibiotics and improvement.
.
#. Pulmonary status s/p respiratory distress: Mr. [**Known lastname 64730**] was
intubated initially [**3-31**] for resp distress, thought secondary to
non-cardiogenic pulm edema from capillary leak syndrome from
Il-2, with possible contribution from PNA. LLL inbfiltrate on
CXR, fevers, but sputum never grew anything, so unclear if PNA
vs atalectasis. He was intially started on levaquin and flagyl.
Chest CT showed lower lobe infiltrates c/w pulm edema vs PNA.
Lenis were neg, but he did not have a CTA because of renal
failure. He has no h/o CHF, COPD or asthma. No Echo on file. The
pt was then taken off all abx on [**4-11**] because all cx data was
negative and fevers seemed likely due to acute interstitial
nephritis given eosinophilia, ARF, rash versus due to his
melanoma and IL'2 treatment. ID was consulted, recommended
bronchoscopy and labs, empiric sntibiotics for presumed Hospital
acquired PNA vs. line infection, so he was started on
vancomycin. Bronchoscopy from [**4-5**] was negative. He remained on
vancomycin for 8 days until his central line was pulled. We
then discontinued Vancomycin IV.
-now on room air, sats stable
-nebs prn if needed
-chest PT, mobilize secretions
-IS to bedside and encourage pt to use
.
# ARF, resolved: this was thought to be acute interstitial
nephritis given fever, rash and ARF with peripheral
eosinophilia. However, eos negative in urine. Renal consulted
felt to be pre-renal also question contrast induced nephropathy.
This fully resolved with hydration, so finally appeared to be
most likely pre-renal and contrast related. His creatinine
continued to be at his baseline. We ended up restarting his
outpatient ACEI. Will see PCP [**Last Name (NamePattern4) **] 1 week.
.
# Fever: Unclear etiology still, all cultures negative. He has
been hemodynamically stable. ID was consulted in the setting of
contemplating starting steroids. ID recomended to r/o infection
BAL prior to starting empiric antibiotics, multiples serologies
histoplasma antigen, EBV viral load, CMV viral load, cryptococal
antigen, Strongiloides serology. RUQ u/s. All work up
unrevealing to date, and fevers tapered off. Afebrile for 6 days
prior to leaving ICU. Initial empiric a/b regimen with flagyl,
aztreonam and vanco was D/C'd . He has remained afebrile on the
medical floor and has been instructed to report to the ED for
fever, chills.
.
#. Hypernatremia, resolved: Likely due to increase insensible
lossess. Free water boluses and D5w was given with normalization
of sodium.
.
#. ?Line infection: Pt was continuing to spike fevers in the
ICU with a negative panculture workup and no infiltrate. Other
sources excluded, so IV vamco empirically given. His line was
pulled, no drainage and erythema at site. His blood cx are
negative to date. We stopped IV vancomycin on transfer to
medical floor, no evidence to support its use.
.
#. Metastatic Melanoma: Il-2 therapy on hold for now. Plan per
Onc team, attending Dr. [**Last Name (STitle) **] and [**Doctor Last Name **]. His restaging lung
CT, head CT showed only mediastinal nodes largest 1.7 cm, could
not assess for pulm nodules given pulm edema. The pt has follow
up with Dr. [**Last Name (STitle) **].
.
#. GI Bleed: The pt had emesis with large clots on [**3-28**]. No
further bleeding, hct has since remained stable stable. The pt
can continue his PPI. His Hct has remained stable, as well as
his vital signs.
.
#. Elevated LFTs: stable. This is a known side effect of IL-2
therapy. We held his IL-2, and trended his LFTs, which improved
over time.
.
# Confusion/ICU psychosis: Pt had vivid dreams as well as
hallucinations while in the ICU, and would often speak
inappropriately at times or answer questions with responses
unrelated. He was started on low dose haldol. On the medical
floor, the pt was appropriate in conversation, but would
occasionally state things that he was going to "[**Country 4194**] to herd
cattle." On questioning his family, they stated that he has no
plans for a trip. He is otherwise appropriate. He has an
appointment to follow up with his PCP [**Last Name (NamePattern4) **] 1 week. His haldol was
not given while he was on the medical floor.
.
#. Communication: with pt, wife and daughter [**Telephone/Fax (1) 64731**]
.
#. Nutrition:
The pt initially failed his speech and swallow study, however
the study was done a few hours post extubation, when the pt
still had copious secretions. At the time of transfer to the
medical floor, the pt was swallowing and chewing fine. He did
not experience any choking or coughing episodes with eating, and
he is tolerating a po diet well. We did not repeat his swallow
study. He does not appear to be an aspiration risk now.
.
#. Access: RSC multi-lumen [**3-26**] discontinued, now with pIV
.
#. Code: full
.
#. Proph: PPI, pneumoboots, heparin sq tid
.
#. Dispo: Home with physical therapy services. Follow up with
PCP. [**Name10 (NameIs) **] has a CAT scan scheduled for the last week in [**Month (only) 547**],
followed by a Heme/Onc appt on [**5-16**].
Medications on Admission:
hctz, atenelol, lisinopril, allopurinol, MVI
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*2*
2. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*2*
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. Atenolol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Primary Diagnoses:
1. Metastatic melanoma status post High dose IL-2 therapy
2. Capillary Leak Syndrome secondary to High dose IL-2
3. Acute Renal Failure
4. Fever
5. Hypernatremia
6. Elevated liver function tests secondary to high dose IL-2
Secondary Diagnoses:
1. Hypertension
2. Gout
Discharge Condition:
Stable
Discharge Instructions:
Notify Dr.[**Name (NI) 46582**] office for fever, chills, bleeding, shortness
of breath, persistent swelling or inability to take oral fluids.
Please take all of your medications as directed. Please follow
up with your doctors (see information below).
Followup Instructions:
You have a follow up appointment with your Primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 64732**], for Thursday, [**2170-4-26**]
at 1:30pm. His office number is: [**Telephone/Fax (1) 64733**] if you have any
questions.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2170-5-9**] 10:15
Provider: [**Known firstname **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2170-5-16**] 4:30
Provider: [**Name10 (NameIs) 13145**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2170-5-16**] 4:30
Completed by:[**2170-4-16**]
ICD9 Codes: 5849, 486, 2760, 4019, 2749, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5104
} | Medical Text: Admission Date: [**2100-11-4**] Discharge Date: [**2100-11-7**]
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a very active
80-year-old female with no prior history of coronary artery
disease, who presents with substernal chest pain. The
patient states that she was in her usual state of health,
taking daily walks around [**Country **] Pond, until day of
admission when she developed sudden onset of substernal chest
pain. The pain was characterized as pressure like in nature.
There was no radiation, no associated nausea or dizziness.
The patient was able to ask somebody to call an ambulance.
She was brought to the [**Hospital1 69**],
where she was noted to have ST segment elevations in II, III,
and aVF. She was taken emergently to the Catheterization
Laboratory, where she was found to have a total occlusion of
her RCA.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Osteoporosis.
3. High cholesterol.
4. History of breast lump status post excision.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Synthroid.
2. Fosamax.
3. Simvastatin.
SOCIAL HISTORY: The patient denies cigarette use or
significant alcohol use. She is very active at baseline.
FAMILY HISTORY: No known history of coronary artery disease.
PHYSICAL EXAMINATION: Blood pressure 134/70, heart rate 82,
respiratory rate 20, and satting 99% on room air. In
general, the patient was alert and oriented in no apparent
distress. HEENT: Oropharynx was clear. Mucous membranes
were moist. Neck was supple with no lymphadenopathy. Normal
thyroid. Lungs are clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm with no murmurs,
rubs, or gallops appreciated on examination. Abdomen was
soft, nontender, nondistended. Lower extremities: There was
no clubbing, cyanosis, or edema. Neurologic: Cranial nerves
II through XII were grossly intact.
ADMISSION LABORATORIES: Negative cardiac enzymes with a CK
of 49 and a troponin less than 0.01. Glucose was elevated at
222. BUN was mildly elevated at 25, creatinine was normal.
EKG: Normal sinus rhythm at 80, ST segment elevations in II,
III, and aVF with elevations in III greater than elevations
in II.
HOSPITAL COURSE: The patient was taken emergently to the
Catheterization Laboratory, where she underwent coronary
angiography. This demonstrated a right dominant system with
single vessel coronary artery disease. The RCA had a total
proximal thrombotic occlusion. Resting hemodynamics showed
mildly elevated right sided filling pressures with a RVEDP of
15 mm Hg. Cardiac index was normal at 2.3. The proximal RCA
thrombotic occlusion was successfully treated with a Hepakote
stent. There is no residual stenosis. The patient was noted
to have mild systolic and diastolic ventricular dysfunction.
She was started on Integrilin, aspirin, and Plavix, and
continued on her statin. Blood pressure medications were
held until the following day. Patient was admitted to the
CCU and remained stable overnight. She did have a short six
beat run of V-tach, but remained asymptomatic.
The following day the patient was started on an ACE and beta
blocker. She had an echocardiogram, which revealed an
ejection fraction of 45%. Mild left atrium enlargement.
There was mild regional left ventricular systolic dysfunction
with focal hypokinesis of the basal inferior and mid
inferolateral wall. The right ventricular chamber size and
free wall motion were normal. The ascending aorta was mildly
dilated. Moderate mitral regurgitation was also noted.
Aortic regurgitation was also noted. There is pulmonary
artery systolic hypertension.
The patient remained stable and was transferred to the
Medical floor for further observation. She had no complaints
of chest pain. It was consensus of the Cardiology team that
the patient was then stable for discharge home. The patient
was thus discharged.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Hyperlipidemia.
3. Status post inferior myocardial infarction and stenting to
right coronary artery.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Alendronate 10 mg p.o. q.d.
3. Simvastatin 10 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Lisinopril 5 mg p.o. q.d.
6. Timolol malleate ophthalmic drops.
7. Folic acid 1 mg p.o. q.d.
8. Sublingual nitroglycerin prn.
9. Ranitidine 150 mg p.o. b.i.d.
10. Toprol XL 25 mg p.o. q.d.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Last Name (NamePattern1) 9725**]
MEDQUIST36
D: [**2100-12-29**] 10:42
T: [**2100-12-29**] 12:07
JOB#: [**Job Number 101863**]
ICD9 Codes: 9971, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5105
} | Medical Text: Admission Date: [**2156-3-30**] Discharge Date: [**2156-4-15**]
Date of Birth: [**2109-2-1**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 year old female presents with 4 weeks of headaches,
dizziness, concentration difficulty, word finding difficulty,
and
fatigue. She has not had a physical since [**2147**]. She went to a
doctor for the headaches last week and was started on Fioricet;
however, this did not improve her symptoms. Today, while at
work,
she had the worst headache of her life and she was brought here
by a co-worker. The patient cannot recall all the events of this
morning but her co-worker reported that she had word finding
difficulty today as well. Currently, after receiving pain
medication in the ER, the headache is [**4-8**], down from [**8-9**] upon
arrival. The patient has had no gait disturbances, visual
changes, weight loss, numbness, or weakness.
She does not have any chest pain or SOB.
Past Medical History:
NONE
Social History:
lives with her partner, works as a creative director
for a medical supply company
Family History:
Noncontributory
Physical Exam:
T:98 BP:127/73 HR:72 RR:18 O2Sats:97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact with lateral nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria. Occasional word finding
difficulty.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally with
lateral nystagmus noted 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 [**4-3**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
[**2156-3-30**] 02:53PM K+-3.9
[**2156-3-30**] 02:53PM O2 SAT-91 CARBOXYHB-8*
[**2156-3-30**] 02:50PM GLUCOSE-119* UREA N-13 CREAT-0.7 SODIUM-136
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-26 ANION GAP-13
[**2156-3-30**] 02:50PM estGFR-Using this
[**2156-3-30**] 02:50PM WBC-9.1 RBC-4.81 HGB-14.7 HCT-43.1 MCV-90
MCH-30.5 MCHC-34.0 RDW-13.7
[**2156-3-30**] 02:50PM CALCIUM-9.3 PHOSPHATE-4.2 MAGNESIUM-2.1
[**2156-3-30**] 02:50PM PLT COUNT-200
[**2156-3-30**] 02:50PM PT-11.9 PTT-24.8 INR(PT)-1.0
[**3-30**] CT HEAD:
Large temporal lobe mass with significant associated edema and
mass effect including subfalcine, uncal and transtentorial
herniation. Appearance is most consistent with metastasis,
although at this time, there is no known underlying primary
tumor.
An MR is recommended to further characterize this mass.
[**3-30**] MR HEAD:
There is a large, 5.8 x 5.0 x 4.4 cm mass arising from the left
sphenoid [**Doctor First Name 362**]. This mass is hypointense on T1-weighted imaging
but enhances homogeneously following administration of
Gadolinium. Central hypointensity on T1-weighted images and
hyperintensity on T2-weighted images is likely secondary to
central necrosis. FLAIR images demonstrate significant
surrounding edema. There is extensive mass effect with rightward
shift of 8 mm and associated subfalcine herniation. There is
also uncal herniation secondary to local mass effect. Evaluation
of post-contrast images demonstrate enhancement of the [**Doctor First Name 500**]
adjacent to the mass suggesting that this mass is infiltrating
the [**Doctor First Name 500**] locally. Diffusion-weighted images reveal no associated
infarct. No definitive blood supply is identified based on these
images. The signal intensity values of brain parenchyma are
otherwise normal. The visualized portions of the paranasal
sinuses are unremarkable. The major vascular flow patterns are
normal.
IMPRESSION: Large, enhancing mass arising from the sphenoid [**Doctor First Name 362**]
on the left with MR characteristics of a meningioma. Significant
associated mass effect including subfalcine herniation,
rightward shift and uncal herniation.
Brief Hospital Course:
The patient is a 47 year old woman with headache of 4 weeks
duration associated with word finding difficulties and poor
concentration found to have large left temporal mass consistent
with meningioma arising from the left sphenoid [**Doctor First Name 362**] on MRI.
There was significant mass effect and 8mm shift adjacent to the
left temporal mass.
The patient was treated with dexamethasone and dilantin in
addition to analgaesia, and closely observed in hospital.
Symptoms and examination remained stable. Embolization of the
left temporal mass occurred on [**2156-4-6**]. She proceeded to
resection of left craniotomy and excision of left temporal mass
on [**2159-4-8**]. After the skull was removed, the brain was noted to
be acutely swollen and a bleed was noted behind the meningioma.
It took approximately 30 minutes to get to the tumor and stop
the bleeding, the patient was given Mannitol interoperatively.
Post operative CT scan showed there has been massive progression
of intracranial mass effect with approximately 12 mm of
subfalcine herniation with obliteration of most sulci
bilaterally. There is massive uncal transtentorial herniation
with involvement of the left temporal [**Doctor Last Name 534**]. A large collection
of air is noted along the frontal and temporal lobes with fluid
and air within the resection bed as well as foci of hemorrhage
within the left temporal lobe. She was kept intubated for first
24 hours given high dose Mannitol and steroids. A central line
was placed for poor access and unfornatley she suffered a
pneumothorax requiring a chest tube placement. On post
operative day 1 she was extubated and following commands, no
motor deficits with short term memory deficits and expressive
partial aphasia. Post Operative MRI showed: No evidence of
residual neoplasm on post-gadolinium sequences, though
evaluation in the immediate postoperative period is limited due
to intrinsic T1 hyperintense blood product and a follow up MRI
at a later date, as clinically indicated, would improve
sensitivity.
She moved to the neurostep down on Post op day 3, she remained
hemodynamically intact, with a chest tube in place followed by
general surgery. Her speech and ability to reason and follow
complex commands improved slowly.
On [**4-12**] she was transferred to the floor and the results of
her biopsy showed ANAPLASTIC (MALIGNANT) MENINGIOMA.WHO ([**2148**])
grade 3. An immediate radiation therapy consult was obtained.
She had her chest tube discontinued on [**2156-4-14**] by the thoracics
service. She had a minute ptx after it was discontinued.
She was tolerating regular diet and was cleared to go home with
PT/OT on [**4-15**].
Medications on Admission:
Fioricet
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Meningioma Grade 3
Right Pneumothorax
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Follow up in brain tumor clinic on
You should follow up with Dr [**Last Name (STitle) 3929**]. His office will call
you prior to your appointment on [**2156-4-28**].
Follow up in Dr[**Name (NI) 9034**] office in one week for your staples to
be removed. Call office at [**Telephone/Fax (1) 72651**] for your appointment.
Provider: [**Last Name (LF) 5302**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB)
Date/Time:[**2156-5-19**] 9:20
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2156-5-5**] 8:40
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] OB-GYN Date/Time:[**2156-4-21**] 8:45
Completed by:[**2156-4-15**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5106
} | Medical Text: Admission Date: [**2131-12-2**] Discharge Date: [**2131-12-24**]
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Peripherally insterted central catheter
Nasogastric tube
History of Present Illness:
85 M with h/o CVA s/p recent CEA, DM2, CKD and HTN who presents
from [**Hospital1 1501**] with respiratory distress. Although it is not clear
from discharge summary, recent hospitalization complicated by
SICU stay for PNA vs CHF. Unclear if patient was reintubated but
was started on levofloxacin and diamox. Discharged ([**11-28**]) to
complete 2 week course of ciprofloxacin.
.
ROS: denies shortness of breath, fevers, chest pain. reports
only feeling worn and not well. + achy, tired, malaise. Denies
DOE (walks >1 block prior to previous admission with cane), PND.
Stable 2 pillow orthopnea. No ankle edema.
.
ED Course:
In ED, afebrile but briefly hypotension and responded to small
fluid bolus. CXR showed likely PNA and the patient was given a
dose of vanc/CTx. Requiring non-rebreather to maintain
oxygenation. Prior to coming up to the ICU, the patient went
into a fib with RVR (HR to 140s). Started on dilt drip.
.
MICU Course:
Treated for HAP with vanc/levo/flagyl. Respiratory status
improved with decreasing O2 requirement and afebrile. Weaned off
dilt gtt, AFib remained well-controlled on PO beta blocker and
spontaneously converted to sinus. One episode OB+ 'black' stool
but stable Hct and hemodynamics stable.
.
[**Hospital1 **] Course:
He was called out to the floor on [**12-4**]. On the floor he appeared
dyspneic and was diuresed for pulmonary edema, but dyspnea not
completely resolved. He had negative LENIs and V/Q scan with
intermediate probability PE. He also continued to tell the team
that "I want to die". SW was consulted and ritalin was started.
Pt was not taking in POs and creatinine also started trending up
again. [**2131-12-12**] pt was found to have BP 72/40 and decreased UOP.
He was given a 500 cc bouls and Bps initially trended up to
82/50 and then down to 70/40. He then received an additonal 1 L
fluid bolus and was transferred to the ICU.
.
MICU Course:
He received 7 liters of IVF with improvement of his blood
pressure and subsequent improvement in his mental status.
Psychiatry and neurology were consulted; his perseveration on "I
want to die. Hurry up." did not seem consistent with a diagnosis
of depression, but his behavior did raise concern of frontal
release . Neurology Celexa was stopped as it has been reported
to cause hypotension and is without immediate benefit to the
patient, and at the recommendation of psychiatry, ritalin was
stopped as well.
Past Medical History:
CVA with residual L hemiparesis (R MCA stroke [**2110**])
OA
Gout
Hypertension
Bilateral Carotid stenosis s/p left CEA [**11/2131**]
Type II DM, diet controlled
Gastritis
CKD (2-2.2)
Recent PNA on Cipro
Right parafalcine late subacute subdural hematoma
Social History:
Was living with wife and son but currently in rehab. Retired
salesman, air force pilot. No current or past tobacco use, no
EtOH abuse. No illicit drug use.
Family History:
No family hx of stroke, CAD, cancer, DM, or other neurologic
disease
Physical Exam:
T 97.8 HR 86 BP 120/58 RR 28 SaO2 93% on 1L
General: WDWN, NAD, jovial, very pleasant, breathing comfortably
on RA
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD,
left CEA surgery site with sutures but no erythema or drainage
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: crackles at bases (L>R), occ wheeze
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema
Neuro: A&Ox3, speech slurred, CNII-XII intact, residual left arm
and leg weakness from prior CVA
Pertinent Results:
Hematology
[**2131-12-2**] 04:00AM WBC-37.4*# RBC-3.83* HGB-11.7* HCT-34.0*
MCV-89 MCH-30.5 MCHC-34.3 RDW-15.0
[**2131-12-2**] 04:00AM NEUTS-92* BANDS-1 LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2131-12-2**] 04:00AM PLT COUNT-316#
[**2131-12-2**] 04:00AM PT-15.6* PTT-29.6 INR(PT)-1.4*
.
Chemistry:
[**2131-12-2**] 04:00AM GLUCOSE-198* UREA N-120* CREAT-3.2*#
SODIUM-155* POTASSIUM-3.2* CHLORIDE-117* TOTAL CO2-20* ANION
GAP-21*
[**2131-12-2**] 04:00AM proBNP-2649*
[**2131-12-2**] 04:00AM CALCIUM-8.3* PHOSPHATE-5.9*# MAGNESIUM-2.3
.
EKG: sinus, 100bpm, LAD, freq PACs, IVCD similar to prior
.
CXR, portable ([**12-1**])- Large hiatal hernia. Increasing air space
opacities within the left lung and right lower lung zone. There
is no pneumothorax. There are no pleural effusions.
.
TTE ([**12-4**])- The left atrium is normal in size. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
CXR ([**12-6**])- The right PICC line tip terminates in the SVC. The
large hiatal hernia is again demonstrated. There is worsening
of bilateral infiltrates, suggesting increased degree of
pulmonary edema and also of the underlying pneumonia cannot be
excluded, especially in the right lower lobe and left upper
lobe. Bilateral pleural effusion is small-to-moderate.
.
Bilateral LE U/S ([**12-7**]): No evidence of deep venous thrombosis in
either lower extremity.
.
V/Q scan ([**12-7**]):
INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol
in 8 views demonstrate central deposition of the
radiopharmaceutical, due to the turbulent flow. There are
widespread ventilatory abnormalities in RML, RLL, LUL, LLL,
predominantly at lung bases. Perfusion images in the same 8
views show similar pattern of perfusion abnormaliies, also most
pronounced at the bases. Chest x-ray shows diffuse bilateral
infiltrates with similar distribution pattern.
IMPRESSION: Matched perfusion and chest X-ray findings.
Intermediate likelihood ratio for pulmonary embolism.
.
Chest CT, non-contrast ([**12-10**]):
1. Intrathoracic stomach.
2. Multifocal pneumonia, most likely aspiration. Small
bilateral pleural
effusions and subcarinal mediastinal adenopathy, presumably
reactive.
3. Calcific cholelithiasis. No evidence of cholecystitis.
.
Head CT, non-contrast ([**12-12**]):
FINDINGS: The posterior fossa is not well seen on today's
examination
secondary to patient motion artifact. There is no evidence of
intracranial hemorrhage. Old areas of hypodensity seen within
the left external capsule are unchanged compared to [**2131-11-24**],
consistent with chronic lacunar infarction. A lacunar infarct
within the right caudate nucleus is also unchanged in
appearance. There is no evidence of intracranial mass lesion,
hydrocephalus or shift of normally midline structures. The
density values of the brain parenchyma are within normal limits.
The surrounding soft tissues and osseous structures are
unremarkable. The paranasal sinuses appear clear.
IMPRESSION: No new areas of acute infarction identified. The
previously reported tiny left parafalcine subdural hematoma seen
on MRI is not seen on today's examination, likely secondary to
interval resorption.
.
Brain, Head, Neck MRI/MRA ([**12-15**]):
FINDINGS: BRAIN MRI:
Comparison was made with the previous MRI examination of
[**2131-11-23**]. The
previously seen subtle increased signal in the right parafalcine
region in the frontal lobe on diffusion images is again
visualized and appears to be due to T2 shine through. Mild
periventricular changes of small vessel disease are seen. There
is no evidence of midline shift, mass effect or hydrocephalus
seen. There is moderate brain atrophy seen. On diffusion
images no evidence of acute infarct is noted. The previously
identified interhemispheric parafalcine subdural hematoma has
also resolved since the previous MRI examination with subtle
changes remaining in this region.
IMPRESSION: No evidence of acute infarct or new finding since
the previous MRI study. Resolution of previously noted subdural
hematoma. No mass effect or hydrocephalus.
MRA OF THE HEAD:
MRA demonstrates a normal flow signal in the anterior
circulation. The A1
segment of the left anterior cerebral artery is hypoplastic but
both A2
segments are well visualized. There is mild irregularity of the
flow signal seen in the basilar artery which could indicate mild
atherosclerotic disease. The distal right vertebral artery is
not visualized which appears to be secondary to the artery
ending in posterior inferior cerebellar artery, a normal
variation.
IMPRESSION: Mild atherosclerotic disease otherwise unremarkable
study.
MRA OF THE NECK:
The 3D time-of-flight MRA of the neck is limited by motion. No
evidence of vascular occlusion or stenosis seen.
IMPRESSION: Somewhat motion-limited normal MRA of the neck.
.
Right upper extremity U/S ([**12-16**]): Occlusive thrombus in the
right basilic vein surrounding indwelling PICC line. No deep
venous thrombus in the right upper extremity is identified.
.
EEG ([**12-18**]):
FINDINGS:
BACKGROUND: A 9 Hz disorganized posterior predominant rhythm was
noted
in the waking state, which attenuated with eye opening.
HYPERVENTILATION: Contraindicated due to mental status.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient progressed from the waking to drowsy states,
but did
not attain stage II sleep.
CARDIAC MONITOR: A generally regular rhythm was noted, with an
average
rate of 90 beats per minute.
IMPRESSION: This is a normal EEG in the waking and drowsy
states. No
focal, lateralizing or epileptiform features were noted.
.
CXR ([**12-19**]): Multifocal opacities consistent with multifocal
pneumonia/aspiration are overall stable with slight clearing in
the left upper lobe and slight worsening in the right upper
lobe. Interval removal of the nasogastric tube. Left lower
lobe atelectasis is unchanged.
Brief Hospital Course:
85 M with h/o CVA s/p recent CEA, DM2, CKD and HTN who presented
with hypoxic respiratory distress [**1-4**] PNA and new-onset AFib
with RVR.
.
# Pneumonia: Multifocal PNA, treated for aspiration and HAP
given recent intubation / hospital stay with vanc/levo/flagyl x
11 days, vanc/zosyn/flagyl x 2 days, vanc/[**Last Name (un) 2830**]/flagyl x 4 days.
LENIs negative, V/Q scan intermediate probability PE. Pulm
consulted but rec no bronch as respiratory status improved. He
was taken off antibiotics x 2 days and spiked fever, tachypnic,
WBC increased from 10 -> 22 (C. diff negative), then decreased
11 after starting linezolid and levofloxacin (to complete 14 day
course on [**1-1**]). Respiratory status improved with diminished O2
requirement and resolution of tachypnea. Followup with PCP.
.
# Personality change: ?depression vs. frontal disinhibition.
Patient had been expressing wishes to die intermittently.
Occasional sundowning. Psych and neuro consulted. CT head shows
resorbed subdural hematoma, MR brain negative for acute CVA. EEG
was normal with no seizure activity. Intermittenly uncooperative
and somnolent, then spontaneously A&Ox3; likely [**1-4**] delerium
from toxic-metabolic cause in setting of significant frontal
atrophy noted on head CT. Tried on ritalin (d/c'd [**1-4**] concern
for MS change), celexa (d/c'd [**1-4**] concern for hypotension), and
remeron (d/c'd [**1-4**] concern for MS change, risk of serotonin
syndrome while on linezolid). Occasionally the patient developed
non-threatening hallucinations thought to be [**1-4**] toxic-metabolic
causes. If he develops agitation, psych recommends considering a
trial of haldol 0.5mg prn.
.
# Paroxysmal AFib: RVR to 140's at presentation, started on dilt
drip while in the ED, which was then weaned off in MICU.
Remained in sinus rhythm the rest of hospital course. No prior
h/o AFib per patient (confirmed with PCP). CHADS score 3, and
therefore would probably benefit from anticoagulation, but given
fall risk, recent SDH, comorbidites this was deferred (discussed
with PCP). Monitored on telemetry with no repeat events.
Continued metoprolol with good BP control; occasionally sinus
tachy likely [**1-4**] volume depleteion, stress, and infection.
.
# ARF on CRF: Resolved. Baseline Cre ~2.2; was 2.0 at discharge.
Most likely pre-renal azotemia in setting of hypovolemia (poor
intake, diarrhea) and responded to IVFs. Medications were
renally dosed.
.
# DM2: Diet-controlled. Hypoglycemic on transfer to MICU in
setting of starting NPH for persistant hyperglycemia; NPH was
then discontinued. Fingersticks were eventually discontinued as
serum glucose was well-controlled.
.
# CVA: s/p CEA, stable (followed by [**Doctor Last Name 1391**]). MR brain negative
for acute event. Vascular surgery made aware patient admitted,
no active issues. Cont ASA, Aggrenox.
.
# Cardiovascular: No documented h/o CAD or CHF but multiple risk
factors. Preserved EF on echo, although possible diastolic
dysfunction. CXR after MICU transfer with mild to moderate
volume overload and the patient was gently diuresed until
euvolemic. Cont ASA, statin, BB.
.
# Anemia: OB +ve stool noted while patient was in MICU, and then
intermittent positivity during rest of hospital stay.
?gastritis. Received 1 unit pRBC during admission with
appropriate increase in Hct, which remained stable. Started on
PPI [**Hospital1 **]. Recent c-scope (2 years ago per patient) negative;
denies ever having EGD or h/o GI bleeding. Would consider
pursuing outpatient GI followup.
.
# Coagulopathy: Elevated INR 1.4-1.5 at presentation likely
nutritional given poor PO intake. LFTs normal and
albumin/prealbumin low supporting nutritional deficiency.
Received vitamin K PO with slight improvement.
.
# Rash: Likely drug reaction [**1-4**] zosyn as this was only new
recent medication around the time the rash began. Serum eos
normal. The rash resolved after 1 week. Mild pruritis was
well-controlled with topical anti-itch cream.
.
# Hypernatremia: Resolved. Hypovolemic at presentation (~3.5L
H2O deficit), serum Na+ normalized with free water boluses but
recurred when stopped from poor PO intake and again improved
with free water (3L deficit). PO intake encouraged.
.
# Hypotension: Resolved after 8L of fluids in MICU. Likely [**1-4**]
hypovolemia from poor PO intake and diarrhea. Diarrhea also
resolved (C. diff neg x 3). Continued to supplement with IV
hydration and intermittent hypodermoclysis given poor POs.
.
# Hyperthyroidism: Mild with slighlty elevated free T4, slightly
depressed TSH. No thyroid nodules on exam. Difficult to
interpret in acute care setting, and therefore would suggest
rechecking as outpatient.
.
# Activity: PT worked with patient frequently. Goal OOB to chair
daily. Will likely need significant rehabilitation and will
benefit greatly from increased mobility and independence.
.
# FEN: Prethickened liquids / ground solids, PO intake
encouraged; Briefly with NG tube on tube feeds but d/c'd
according to family wishes due to somnolence and mental status
changes; Continue aspiration precautions; Repleted 'lytes prn
Medications on Admission:
1. Aspirin 81 mg QD
2. Folic Acid 1 mg QD
3. Simvastatin 20 mg QD
4. Metoprolol 25 TID
5. Ciprofloxacin 750mg Q48H for 2 weeks.
6. Dipyridamole-Aspirin 200-25 mg Cap, QD
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Insulin Regular QID PRN
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H (Every 3 to 4 Hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Artificial Saliva 0.15-0.15 % Solution Sig: 1-3 MLs Mucous
membrane PRN (as needed).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): apply to affected areas.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/wheeze.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed: apply to affected areas.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1-2H
() as needed.
12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 8 days: Please have blood counts (CBC) checked on
[**2131-12-31**].
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
18. CBC Sig: One (1) lab test once for 1 doses: Please have
blood counts (CBC) checked on [**2131-12-31**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 21341**] Rehab
Discharge Diagnosis:
Primary:
[**Hospital 7502**] hospital-acquired
Acute renal failure
Altered mental status
Hypotension
Hypernatremia
Acute blood loss anemia
Atrial fibrillation
.
Secondary:
Cerebrovascular accident with residual left hemiparesis
Osteoarthritis
Gout
Hypertension
Bilateral carotid stenosis status post carotid endarterectomy
Type II diabetes mellitus
Gastritis
Chronic renal insufficiency
Right parafalcine subacute subdural hematoma
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed.
.
New medications: levofloxacin, linezolid
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
Please schedule a followup appointment with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 40075**], at [**Telephone/Fax (1) 40076**] in 2 weeks.
ICD9 Codes: 486, 5849, 2760, 5990, 2749, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5107
} | Medical Text: Admission Date: [**2133-7-17**] Discharge Date: [**2133-7-20**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. [**Known lastname 18741**] is a 54 year old F with history of DMI, severe
gastroparesis, HTN, Grave's Disease and Hep C, who presents to
the ED with altered mental status. Of note, patient has been
admitted multiple times within the past year for DKA. Most
recent admission was [**Date range (1) 11768**] for DKA.
.
According to report the patient was brought in by EMS for change
in mental status and increased weakness. Glucose per EMS was
>800. According to ER notes, patient had spoken to PCP earlier
in the day regarding feeling lethargic. She was told to drink
lots of fluids. No trauma and no focal weakness. No further
history available in medical record.
.
In the ED, vitals were T 96, BP 171/85, HR 142, RR 18, O2sat
100% on FM. Initial labs showed a glucose of 872, AG 30 with
HCO3 3. Lactate was 5.9, K 7.0. She was combative and confused
and was intubated for airway protection. Intravenous access was
obtained with left femoral line. She received a total of 5L NS,
insulin bolus of 10U/hr followed by gtt at 6U/hr. CXR without
acute pulmonary process. Head CT was done due to altered mental
status and showed no evidence of ICH. Admitted to the [**Hospital Unit Name 153**] for
further management
.
On arrival to the [**Hospital Unit Name 153**] the patient is intubated, sedated. She is
tachycardic to the 120s.
Past Medical History:
1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**]
Several episodes of DKA (last one in [**2129**]), managed on 36U
Lantus plus HISS
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease s/p RAI [**2129**]
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
never been on antiviral therapy, acquired via blood transfusion
during surgery in [**2110**]
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-24**]
11.s/p TAH and pelvic floor surgery with bladder lift
12.Depression
13. Bone spurs in feet
Social History:
No smoking/EtOH/drugs. Lives at home with 2 daughters. [**Name (NI) **] lives
downstairs. She does not work.
Family History:
Mother: died of colon cancer
+ for DM-2
Physical Exam:
T 97.1 BP 123/87 HR 126 RR 16-18 O2 sat 100% on CPAP+PS 5/5,
FiO2 50%, RR 16
Gen: Patient is intubated, sedated.
[**Name (NI) 4459**] -
CV: Tachycardic, nl s1 s2, no m/r/g
Lungs: Clear bilaterally
Abd: Soft, NT, ND, +BS
Ext: No edema
Neuro -
Pertinent Results:
[**2133-7-17**] 06:15PM GLUCOSE-872* LACTATE-5.9* NA+-130* K+-7.0*
CL--97* TCO2-3*
[**2133-7-17**] 06:42PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2133-7-17**] 06:42PM GLUCOSE-937* UREA N-34* CREAT-2.0*#
SODIUM-128* POTASSIUM-5.2* CHLORIDE-90* TOTAL CO2-LESS THAN
[**2133-7-17**] 07:07PM GLUCOSE-747* LACTATE-5.4* NA+-136 K+-4.2
CL--106 TCO2-4*
[**2133-7-17**] 08:05PM GLUCOSE-664* LACTATE-3.7* NA+-138 K+-3.9
CL--111 TCO2-5*
[**2133-7-17**] 09:06PM GLUCOSE-588* LACTATE-2.7* NA+-140 K+-4.4
CL--112 TCO2-6*
[**2133-7-17**] 10:02PM GLUCOSE-526* LACTATE-2.2* NA+-140 K+-4.4
CL--115* TCO2-7*
[**2133-7-17**] 11:03PM GLUCOSE-468* LACTATE-1.9 NA+-139 K+-4.4
CL--114* TCO2-7*
Brief Hospital Course:
The patient was admitted to the ICU intubated due to DKA and
altered mental status. She was placed on an insulin drip and
her glucose steadily decreased from the 900's to the 200's, and
her anion gap closed from 20's to 10. She had a transient
decrease to blood glc of 33, but was given [**3-24**] an amp of D50 and
placed on D5W. Her glucose subsequently increased to 150,
stabilized throughout the next day, and was extubated. She then
was placed on Lantus [**Hospital1 **] with an insulin sliding scale which was
titrated to 20 units glargine [**Hospital1 **] by the [**Last Name (un) **] service with
plans for close outpt f/u.
Of note, the patient's ARF, severe electrolyte abnormalities and
acidosis had completely resolved at time of discharge.
The pt had low grade fevers and a mildly positive U/A (although
asymtomatic) and given her prior hx and DM, was discharged on a
7 day course of cipro.
Pt to f/u closely with [**Hospital **] clinic.
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg Tablet PO BID
Simvastatin 10 mg Tablet DAILY
Methimazole 15 mg Tablet PO BID
Amitriptyline 25 mg Tablet PO HS
Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device INH [**Hospital1 **]
Aspirin 81 mg Tablet, Delayed Release daily
Montelukast 10 mg Tablet PO DAILY
Pantoprazole 40 mg Tablet, daily
Sulfasalazine 500 mg Tablet PO TID
Albuterol 90 mcg 1-2 Puffs INH q6H PRN
Hyoscyamine Sulfate 0.125 mg Tablet, SL [**Hospital1 **]
Gabapentin 300 mg PO Q12H
Metoclopramide 10 mg Tablet PO QIDACHS
Metoprolol Tartrate 25 mg Tablet PO BID
Oxycodone-Acetaminophen 5-325 mg Tablet PO Q4H PRN
Insulin Glargine 20U [**Hospital1 **]
Humalog Insulin Per sliding scale.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Methimazole 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: [**1-21**]
Tablet, Delayed Release (E.C.)s PO once a day.
10. Sulfasalazine 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
11. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-21**] inh Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
12. Hyoscyamine Sulfate 0.125 mg Tablet, Rapid Dissolve Sig: One
(1) Tablet, Rapid Dissolve PO twice a day.
13. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
16. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: take per oupt rx.
17. Lantus 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous twice a day.
18. Humalog 100 unit/mL Cartridge Sig: per scale Subcutaneous
QACHS: Take QACHS per sliding scale given to pt at d/c.
19. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
Diabetic Ketoacidosis
DM 1 uncontrolled with Complications (neuropathy)
Diabetic Gastroparesis
HTN
Hep C
[**Doctor Last Name 933**] Disease s/p RAI
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to ED if having FS>500, SOB, light-headedness, chest
pain, fevers.
Followup Instructions:
Patient to f/u at [**Hospital **] Clinic with Dr. [**Last Name (STitle) 61114**] in 1 week.
Patient to schedule f/u PCP appt in 2 weeks.
ICD9 Codes: 5849, 2761, 4019, 2767, 2720, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5108
} | Medical Text: Admission Date: [**2193-7-28**] Discharge Date: [**2193-8-4**]
Date of Birth: [**2140-11-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
endotracheal intubation
femoral line placement
bronchoscopy
right bronchial artery embolization
History of Present Illness:
52M w/ hx of treated TB (3 years ago, in [**Country 651**], 3 meds, cannot
recall names, treated for 9 mos) w/ 1 episode of hemoptysis
earlier this evening. Reports coughing up a handful of blood,
all blood, no sputum. Over last week or so, has had a cough
productive of whitish sputum. No sick contacts. [**Name (NI) **] fevers, no
night sweats, no weight loss. Approx 1 mo ago, had a URI.
IN ER: Had repeat episode. hemodynamically stable. CT chest was
performed noting abnormal findings possibly consistant with
reactivated TB. Pulm c/s service notified.
ROS:
-Constitutional: [x]WNL []Weight loss []Fatigue/Malaise []Fever
[]Chills/Rigors []Nightweats []Anorexia
-Cardiac: [x]WNL []Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: see HPI
-Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain
[]Abdominal Swelling []Diarrhea []Constipation []Hematemesis
[]Hematochezia []Melena
-Skin: [x]WNL []Rash []Pruritus
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [x ]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
Past Medical History:
other than TB, no medical history. TB was found on routine
screening prior to migrating to US. He has never experienced
respiratory symptoms. He received nine months of therapy.
Social History:
now living in US, son is HCP and primary contact [**Telephone/Fax (1) 80531**].
patient is a non-smoker.
Family History:
no sick contacts. [**Name (NI) **] family members with active TB.
Physical Exam:
Exam:
VS: T 97.2 P 60 BP 101/56 O2 98%RA
Gen: Well, no acute distress, awake, alert, appropriate, and
oriented x 3
Skin: warm to touch, no apparent rashes.
HEENT: No conjunctival pallor, no scleral jaundice,OP clear, no
cervical LAD
CV: RRR no audible m/r/g
Lungs: clear to auscultation
Abd: soft, NT, normal BS
Ext: No C/C/E
Neuro: strength and sensation intact bilaterally.
Exam on discharge:
97.1 HR 72 BP 115/68 RR 20 99% RA
Gen: Well, no acute distress, awake, alert, appropriate, and
oriented x 3
Skin: warm to touch, no apparent rashes
HEENT: No conjunctival pallor, no scleral jaundice,OP clear, no
cervical LAD
CV: RRR no audible m/r/g
Lungs: clear to auscultation
Abd: soft, NT, normal BS
Ext: No C/C/E
Neuro: strength and sensation intact bilaterally
Pertinent Results:
[**2193-7-28**]
LACTATE-1.4
GLUCOSE-116* UREA N-13 CREAT-0.9 SODIUM-143 POTASSIUM-4.0
CHLORIDE-107 TOTAL CO2-26 ANION GAP-14
estGFR-Using this
WBC-6.8 RBC-4.95 HGB-14.1 HCT-42.6 MCV-86 MCH-28.5 MCHC-33.1
RDW-13.2
NEUTS-64.3 LYMPHS-27.6 MONOS-4.6 EOS-2.9 BASOS-0.6
PLT COUNT-267
PT-12.1 PTT-29.7 INR(PT)-1.0
Labs on discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
10.7 3.83* 11.0* 32.8* 86 28.7 33.5 13.0 230
Glucose UreaN Creat Na K Cl HCO3 AnGap
106* 13 1.2 139 4.1 107 26 10
Calcium Phos Mg
9.0 2.7 2.4
HIV Ab NEGATIVE
ASPERGILLUS GALACTOMANNAN ANTIGEN B-GLUCAN pending
urine histoplasma Ag pending
CXR [**2193-7-27**]
IMPRESSION: Multifocal airspace opacities in the right upper and
lower lobes, concerning for active infection. With evidence
suggestive of prior TB, current active TB infection is not
excluded.
CT CHEST [**2193-7-28**]
IMPRESSIONS:
1. Peribronchovascular opacities in the right upper and middle
lobes most
suggestive of bronchopneumonia. Given history of TB and a partly
calcified
mass in the right upper lobe which could represent a large
granuloma, active tuberculosis is an important differential
consideration. Hemorrhage is another consideration.
2. Calcified nodule in the right lung (20 x 10 mm), probably
sequela of prior infection versus a tumor. CT follow-up is
recommended to resolution of opacities and surveillance of the
lung nodule within three months. If
available, comparison to prior studies could also be helpful.
PET scanning
could also be considered once the more acute process has
resolved.
[**2193-8-2**] urine culture - no growth
[**2193-8-1**] blood culture pending on discharge
Brochoalveolar lavage results:
GRAM STAIN (Final [**2193-8-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). ~3000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
STAPH AUREUS COAG +. ~[**2183**]/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ACID FAST SMEAR (Final [**2193-8-2**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED
Respiratory Viral Culture (Final [**2193-8-4**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus.
Legionella Urinary Antigen (Final [**2193-7-31**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative
SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2193-7-30**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
ACID FAST SMEAR (Final [**2193-7-31**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR x 3
[**7-27**] and [**7-28**] blood culture showed no growth
Brief Hospital Course:
Mr. [**Known lastname **] presented to the ED with a chief complaint of hemoptysis
# Hemoptysis - Chest film demonstrated multifocal opacities in
the RUL and RLL. Given the patient's prior history of TB and the
inability to exclude this on presentation, he was admitted to a
negative-pressure room. On the floor, he remained
hemodynamically stable. He had three negative AFBs and was
removed from respiratory precautions. He had a CT scan on [**7-28**]
which showed peribronchovascular opacities and a 1cm x 2cm right
lung nodule felt to be chronic granuloma/prior infection
sequelae vs. malignancy. On [**7-29**], he again had moderate
hemoptysis and reportedly vomited blood and had black stools.
Pulmonary was consulted, and he was started on
Ceftriaxone/Azithromycin empirically for CAP on [**2193-7-31**].
Durnig his course, he had a recurrence of massive hemoptysis.
He was bronched on [**8-1**] and found to have substantial bleeding
from the posterior segment of right upper lobe. He then went to
IR and had embolization of the right bronchial artery and right
upper intercostal arterial branch. After the procedure, he was
intubated with a dual-lumen endotracheal tube to prevent
extravasation of blood into the left lung if bleeding recurred.
He remained stable and was extubated on [**8-2**]. Ceftriaxone was
replaced with Cefpodoxime on [**8-3**]. His pulmonary hemorrhage was
attributed to inflammation of prior eroded tissue from old TB,
with a new pneumonia as the precipitant.
# Elevated creatinine - He also had mild renal insufficiency
which was likely secondary to contrast nephropathy after the IR
procedure. The patient was transferred to the medical floor on
[**2193-8-3**], and his creatinine normalized with IV fluids and time.
He demonstrated continued clinical improvement, with small
amount of hemoptysis post-procedure. He remained afebrile with
normal vital signs after transfer from the ICU. He was
discharged on [**2193-8-4**] and will complete a 7 day course of both
azithromycin and cefpodoxime, to be completed on [**2193-8-6**]. He
will schedule a follow up appointment with Dr. [**Last Name (STitle) **], his PCP,
[**Name10 (NameIs) **] the week of discharge.
No other medications were started.
The patient is a full code.
Medications on Admission:
Patient takes no medications regularly
Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
hemoptysis
pneumonia
Secondary Diagnoses:
history of tuberculosis, treated with three drug regimen in
[**Country 651**] in [**2190**]
Discharge Condition:
stable and improved, no recurrence of hemoptysis post-procedure
Discharge Instructions:
You were admitted to the hospital after coughing up blood. You
were treated for a pneumonia with antiobiotics. Tests showed
that you did not have tuberculosis again. You had another
episode of coughing up blood while in the hospital, and you had
a short stay in the intensive care unit. At this time, a
procedure was performed to help stop the bleeding in your lungs,
which was successful. You continued to do well after the
procedure, and you were discharged on [**2193-8-4**].
Please call Dr. [**Last Name (STitle) **] to set up an appointment this week. You
should discuss with him when to have another exam of your chest.
This exam of your chest should be within the next 3 months.
The following changes were made to your medications:
you were not taking any medications before you came to the
hospital.
you will continue taking two antibiotics:
cefpodoxime 200 mg twice a day for two days, finish on Tuesday
azithromycin 250 mg once a day for two days, finish on Tuesday
Please call Dr. [**Last Name (STitle) **] or 911 if you have red or black urine, if
you cough up large amounts of blood, if you have trouble
breathing, if you develop fevers, chills, or chest pain or any
other concerning medical symptoms.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] J. [**Doctor Last Name **], at [**Telephone/Fax (1) 8236**] to set
up an appointment in the next week.
ICD9 Codes: 486, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5109
} | Medical Text: Admission Date: [**2126-8-13**] Discharge Date: [**2126-8-19**]
Date of Birth: [**2043-6-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
worsening shortness of breath, chest pressure
Major Surgical or Invasive Procedure:
[**2126-8-15**]
1. Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic
Ultra bioprosthetic valve.
2. Coronary artery bypass grafting x1 with a left internal
mammary artery to left anterior descending coronary
arteries.
3. Resection of left atrial appendage.
History of Present Illness:
Mr. [**Known lastname 87158**] is an articulate 82 year
old man with a history of aortic stenosis and progressive
shortness of breath. His past history is significant for a
history of diabetes mellitus, hypertension, hyperlipidemia, CAD
s/p MI in [**2099**] and [**2117**]. He had been in stable health over the
past 2-3 years until 6 months when he began to develop
significant dyspnea on exertion. His dyspnea on exertion has
recently worsened so that he can only walk approximately 50
yards
before he has to stop due to SOB and leg pain. Although he
reports SOB for the past 20 years, but states it has been
acutely
getting worse for the past 3-4 months. He denies any syncope,
presyncope, dizziness, or anginal CP. He is on coumadin for
recurrent atrial fibrillation. Pt denies any orthopnea or PND
but
does report ankle edema.
Past Medical History:
1. Severe critical symptomatic aortic stenosis.
2. Single-vessel coronary artery disease.
3. Atrial fibrillation
PMH:
- Diabetes Mellitus
- Pulmonary hypertension
- Hypertension on medications
- CAD
- hyperlipidemia
- Atrial fibrillation on warfarin
- "Post-polio syndrome" - he reports only orthopedic issues
that require chronic narcotics for pain control. He was
intermittently on an "iron lung" during the early stages of his
poliomyelitis
- Peripheral neuropathy multiple herniated disks s/p back
surgeries
- s/p pneumonia two years previously
- benign neoplasm lg bowel
Past Surgical History:
- s/p back surgeries
- s/p total knee replacement (right) x 2
- s/p surgery for lanryngeal cancer [**2104**]
-bilat cataract
-Appendectomy
-tonsillectomy
Social History:
Tobacco history: remote cigar hx
-ETOH: h/o heavy drinking, quit in [**2097**]
-Illicit drugs: denies
Family History:
Father with unknown hx, and mother with valvular disease
(unknown cause). No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
.
Physical Exam:
Pulse:53bpm Resp:20 O2 sat: 99%-RA
B/P: Right 132/55 Left 120/60
Height: 5'7" Weight: 82.1 kg
General:NAD A&O
Skin: Dry/intact
HEENT: NCAT
Neck: No LAD
Chest: CTAB
Heart: irreg irreg, Grade III Systolic Murmur
Abdomen: Soft NTND +BS
Extremities: Warm, well perfused. Distal pulses intact.
2+ edema BLE
Neuro: A&Ox3
Pulses:
Palp DP/PT/Fem bilat. Palp Radials
Carotid: radiated murmur bilat
Pertinent Results:
[**2126-8-18**] 06:40AM BLOOD WBC-7.9 RBC-4.06* Hgb-10.4* Hct-31.5*
MCV-78* MCH-25.8* MCHC-33.1 RDW-17.7* Plt Ct-150
[**2126-8-18**] 06:40AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-134
K-4.4 Cl-96 HCO3-29 AnGap-13
[**2126-8-18**] 06:40AM BLOOD PT-13.7* INR(PT)-1.2*PREBYPASS
TTE:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
valve leaflets are moderately thickened. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is a
small area of diastolic flow into the main PA distal to the PV.
There is no thrombus or SEC in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
POSTBYPASS
The LV is hyperdynamic. RV systolic function is preserved. There
is a well seated, well functioning bioprosthesis in the aortic
position. No AI is visualized. The LAA is no longer visualized.
The remaining study inchanged from prebypass
[**2126-8-19**] 05:40AM BLOOD WBC-7.1 RBC-4.04* Hgb-10.5* Hct-31.7*
MCV-79* MCH-26.1* MCHC-33.2 RDW-17.9* Plt Ct-157
[**2126-8-19**] 05:40AM BLOOD PT-14.7* INR(PT)-1.3*
[**2126-8-19**] 05:40AM BLOOD Glucose-116* UreaN-13 Creat-0.7 Na-135
K-4.4 Cl-94* HCO3-32 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 87158**] is a 83 yr old gentleman referred for CT surgery by
Dr. [**Last Name (STitle) **] for consideration of aortic valve replacement and
coronary artery bypass grafting. The patient was felt to be a
good candidate although higher risk than
normal. The patient understood the risks, benefits, possible
alternatives and wished to proceed. On [**8-15**] he underwent aortic
tissue valve replacement and CABG x 1 Lima to LAD and LAA
resection, bovine patch by Dr. [**Last Name (STitle) 914**]. Bypass time 116mins
cross clamp time was 100mins. Please see intraop note for
further details. He arrived from the unit intubated and sedated
on propofol, he was hypertensive as he was reversed and extubted
that evening and was started on Niacardipime. Oral
antihypertensive medications were initiated and nicardipine was
discontinued. He cotinued to progress well and was transferred
to the floor on POD#2. His chest tubes and pacing wires were
discontinued in timely fashion and without difficulty. His
post-operative CXR showed a small left pneumothorax that has
since resolved.
Pt remains in rate controlled a-fib tolerating beta-blocker
well. He is tolerating a full diet without swallowing
difficulty. He is a known diabetic and was resarted on his
pre-op diabetic regimen. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 4 the patient was
ambulating with assistance, the wound was healing and pain was
controlled with oral analgesics. The patient was discharged to
Langdon of [**Location (un) **] in good condition with appropriate follow up
instructions.
Medications on Admission:
Lipitor 10mg qhs
zetia 10 mg daily
valsartan 80 mg po daily
digoxin 0.25 mg po qhs
oxycodone 5/325 1tab tid/prn
zolpidem 10 mg po qhs prn insomnia
warfarin 5 mg PO daily -last dose 9/15
omeprazole 40 mg po daily
Diltiazem XL 180mg daily
metoprolol tartrate 50 mg [**Hospital1 **]
flurbiprofen 100 mg tid
diazepam 5 mg TID
glyburide 5 mg qpm
metformin 1000 mg POBID
KCl 10 Meq Qam
lasix 40 mg daily
MVI daily
docusate 200mg [**Hospital1 **]
senna 2 tabs [**Hospital1 **]/PRN
ASA 325 mg po daily
Alka Seltzer daily
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? Atrial Fibrillation
Goal INR 2-2.5
First draw [**2126-8-20**]
with PCP prior to [**Name Initial (PRE) **]/c from rehab.
2. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO HS (at bedtime).
5. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change daily for goal INR 2-2.5, dx: afib.
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
13. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
16. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
Clipper House
Discharge Diagnosis:
1. Severe critical symptomatic aortic stenosis.
2. Single-vessel coronary artery disease.
3. Atrial fibrillation
PMH:
- Diabetes Mellitus
- Pulmonary hypertension
- Hypertension on medications
- CAD
- hyperlipidemia
- Atrial fibrillation on warfarin
- "Post-polio syndrome" - he reports only orthopedic issues
that require chronic narcotics for pain control. He was
intermittently on an "iron lung" during the early stages of his
poliomyelitis
- Peripheral neuropathy multiple herniated disks s/p back
surgeries
- s/p pneumonia two years previously
- benign neoplasm lg bowel
Past Surgical History:
- s/p back surgeries
- s/p total knee replacement (right) x 2
- s/p surgery for lanryngeal cancer [**2104**]
-bilat cataract
-Appendectomy
-tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2126-10-1**] 1:30
Cardiologist: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2126-10-11**] 11:40
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 87159**],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 87160**] 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 ?????? Atrial Fibrillation
Goal INR 2-2.5
First draw [**2126-8-20**]
with PCP prior to [**Name Initial (PRE) **]/c from rehab.
Completed by:[**2126-8-19**]
ICD9 Codes: 4241, 4168, 412, 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5110
} | Medical Text: Admission Date: [**2127-9-13**] Discharge Date: [**2127-9-15**]
Date of Birth: [**2054-11-9**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
Clot evacuation, bladder fulgeration
History of Present Illness:
72yM with h/o mech aortic valve and atrial fibrillation on
coumadin as well as history of recurrent bladder cancer
(Transitional Ceel), status post TURBT on [**2127-8-15**]. His
post op course was complicated by urinary retention requiring
Foley replacement [**Date range (1) 9910**] with intermittent hematuria and
passage of small clots since. Was admitted to urology service on
[**9-2**] for this and underwent cystoscopy, fulguration, clot
evacuation, and catheter exchange. Underwent two days of CBI
with weaning and then had successful trial of foley removal. He
came to the ED today with 3-4h h/o urinary retention, bladder
spasms, and gross hematuria/clots. Patient denies other symptoms
including fever, chills, nausea, vomiting, SOB, CP. Reports
persisent dysuria since proceedure with one episode of urinary
incontinence.
.
Urology saw pt in ED and 20French 3-way foley was placed and
hand irrigated x2. CBI initiated but persistent light pink to
fruit punch output. Noted to have 6pt Hct drop and ED reporting
EKG changes with V3-V6 ST depressions in setting of elevated
rates from RVR. Other vitals okay. Pt given benzos, morphine,
oxybutin as well as 18L of CBI. Was continuing to have issues
with clots and requiring high levels of nursing care so this,
combined with Hct drop (although stable on recheck), and EKG
changes prompted [**Hospital Unit Name 153**] admission after urology had previously
accepted pt to the floor.
.
On ICU arrival pt in sporadic pain, but excruciating when
present. CBI running with bloody fluid in bag. Urology manually
irrigated when pt arrived to ICU. Urology potentially planning
for OR in AM. Pt feeling okay inbetween pain spasms except for
feeling tired.
Past Medical History:
Recurrent Bladder ca s/p multiple resections, BCG, mitomycin x8,
docetaxel and Adriamycin
AVR in [**2100**] with a mechanical valve
. Carbomedics Bileaflet (INR Goal = 2.5-3.5)
HTN
Atrial fibrillation
HLD
Erectile dysfunction
OSA -> CPAP
h/o diverticulitis
Surgical Hx:
Surgical History significant for AVR, hernia repair, tonsils,
hydrocelectomy [**2120**], TURBT [**12/2123**], Bladder biopsy [**2123**] and
7/[**2124**].
Social History:
Married. Retired barber. Denies tobacco, recreational drugs, or
alcohol excess although has alcohol hx
Family History:
Father with [**Name2 (NI) 499**] cancer in his 70s
Physical Exam:
Admission:
Vitals: 98.0 / 149 (Afib) / 124/83 / 20 and 99% on RA
General: Alert, oriented x 3, in distress when spasms present
HEENT: Sclera anicteric, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: IRIR, elevated rate in 120s, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
BS+
GU: foley in place with CBI running,
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge:
HR: 80s-90s
GU: No FOley, voiding spontaneously
Pertinent Results:
[**2127-9-13**] 07:25AM BLOOD WBC-5.1 RBC-3.75* Hgb-12.9* Hct-37.0*
MCV-99* MCH-34.4* MCHC-34.9 RDW-14.6 Plt Ct-184
[**2127-9-13**] 07:25AM BLOOD Neuts-52.4 Lymphs-37.8 Monos-7.2 Eos-1.9
Baso-0.7
[**2127-9-13**] 07:25AM BLOOD PT-21.0* PTT-34.7 INR(PT)-1.9*
[**2127-9-13**] 07:25AM BLOOD Glucose-110* UreaN-11 Creat-1.0 Na-144
K-4.6 Cl-106 HCO3-25 AnGap-18
[**2127-9-13**] 11:30AM BLOOD CK(CPK)-54
[**2127-9-13**] 11:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2127-9-14**] 06:05AM BLOOD CK-MB-2 cTropnT-<0.01
[**2127-9-14**] 06:05AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8
[**2127-9-15**] 04:09AM BLOOD WBC-3.4* RBC-2.90* Hgb-10.0* Hct-27.8*
MCV-96 MCH-34.5* MCHC-36.0* RDW-14.6 Plt Ct-139*
[**2127-9-15**] 04:09AM BLOOD PT-29.6* PTT-37.7* INR(PT)-2.9*
[**2127-9-15**] 04:09AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-143
K-4.0 Cl-111* HCO3-26 AnGap-10
[**2127-9-15**] 04:09AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.0
[**2127-9-13**] 07:25AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]->1.035
[**2127-9-13**] 07:25AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM
[**2127-9-13**] 07:25AM URINE RBC->50 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
Brief Hospital Course:
72yM with h/o mech aortic valve and atrial fibrillation on
coumadin as well as history of recurrent bladder cancer
(Transitional Ceel), status post TURBT on [**2127-8-15**]
presenting with recurrent hematuria and passage of clots since
proceedure, now improved s/p CBI.
.
# Hematuria with clots and urinary obstruction: Intermittent
since TURBT on [**8-15**]. Had been home for 10 days but had
sudden urinary retention likely due to clot obstructing bladder
outlet. Urology saw in ED and aggressively irrigated, started
oxybutin, and CBI. He underwent cystoscopy which showed a large
clot with bleeding. A vessel was cauterized. He was transfused 1
unit PRBC. He was given oxybutynin for spasm. His hematuria
resolved. FOley was removed and he voided spontaneously prior to
discharge. He was given Cephalexin while inpatient. He will
follow up with urology.
.
# Afib with RVR: RVR in ED resolved with diltiazem
administration. Rates actually down into 60s with one dose of
120mg (was on home dose equivalent to 120mg QID). Diltiazem was
decreased to 360mg daily at discharge. Warfarin was stopped and
he will have INR check on [**9-18**] and will call PCP with result to
restart warfarin [**9-18**]. INR therapeutic at time of discharge.
.
# Mechanical Aortic Valve: See above for anticoagulation
management.
.
# HTN: Well controlled on only diltiazem. Diltiazem dose
decreased as above.
Medications on Admission:
Coumadin 2.5mg every day except 5mg on Friday
Diltiazem 360mg q.a.m. and 120 q.p.m.
Simvastatin 5mg Qd
Percocet PRN
Amoxicillin PRN ppx
Docusate
Ascorbic Acid
Co-Enzyme Q
MTV
Niacin
Vitamin E
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. oxybutynin chloride 5 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO once a day as needed for
bladder spasms.
Disp:*20 Tablet Extended Rel 24 hr(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for headache, pain.
5. Macrobid 100 mg Capsule Sig: One (1) Capsule PO twice a day
for 3 days.
Disp:*6 Capsule(s)* Refills:*0*
6. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
Disp:*60 Capsule, Extended Release(s)* Refills:*1*
7. Outpatient Lab Work
INR and hematocrit check [**2127-9-17**], results to be faxed to
[**Telephone/Fax (1) 164**], warfarin dosing to be decided by PCP based on INR
goal 2.5-3.5.
8. niacin Oral
9. coenzyme Q10 Oral
10. vitamin E Oral
11. ascorbic acid Oral
12. Zocor 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Bladder cancer, gross hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume all of your pre-admission medications except as noted.
You have indicated that you NO longer take Iron tablets and that
you do NOT take zocor as prescribed (40mg/day) but take 5-10mg
day. Please review this with your PCP.
Your diltiazem has been decreased:
Prescribing: diltiazem HCl (Oral) 180 mg Capsule, Extended
Release
Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). Do NOT
take a dose at night unless your PCP tells you to at follow up.
Please do not take warfarin (coumadin) until you have your INR
checked on [**9-18**]. You will have your INR checked in the [**Hospital Ward Name 23**]
center and you should call your PCP with the result that day so
he may advise you what dose of warfarin to start taking the
evening of [**9-18**].
-Always call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery.
-If you have fevers > 101.5 F, vomiting, severe abdominal pain,
or inability to urinate, call your doctor or go to the nearest
emergency room.
Followup Instructions:
Call Dr[**Doctor Last Name **] office tomorrow to schedule/confirm your
follow-up
appointment AND if you have any questions.
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 164**]
Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 133**] regarding your medications and post operative
course and INR monitoring/coumadin dosing. You should call and
schedule an appointment to be seen in the next 1-2 weeks.
UPCOMING APPOINTMENTS:
Labwork in [**Hospital Ward Name 23**] center on [**2127-9-18**]-hematocrit and INR check.
Call Dr.[**Name (NI) 5049**] office with INR result on [**9-18**] to decide on
warfarin dosing which should begin [**9-18**].
Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2127-9-18**] 11:30
Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2127-9-25**] 12:30
Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2127-10-2**] 11:30
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5111
} | Medical Text: Admission Date: [**2114-2-4**] Discharge Date: [**2114-2-15**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
woman who presented with dyspnea on exertion. She had four
episodes of loss of consciousness over the past six months.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg per day.
2. Lopressor 12.5 mg b.i.d., increased recently to 25 mg
b.i.d.
3. Benadryl.
4. Trazodone.
5. Colace.
PAST MEDICAL HISTORY:
1. Macular degeneration. She is legally blind for three
years. Status post left cataract surgery.
2. Status post fall and fracture of the right arm and
shoulder.
3. History of narrow valve which was consistent with aortic
stenosis. Cardiac catheterization found an 80 millimeter
aortic valve gradient, moderate to severe mitral
regurgitation.
HOSPITAL COURSE: The patient was taken by the plastic
surgery service and went to the operating room on [**2114-2-8**],
for an AVR valve replacement, #21 tissue type. She tolerated
the procedure well and postoperatively was transferred to the
Intensive Care Unit where upon she was transferred to the
floor on postoperative day number one.
She did well on the floor and her capital was increased.
Physical therapy was involved in her care and she made
progress, however, was not making as good a try as possible
because of her comorbidities and her advanced age.
On [**2114-2-12**], in the morning, she complained of some shortness
of breath and chest x-ray showed a large pleural effusion for
which she was given Lasix and diuresed out. She had an
increased effusion on the left side after the chest tube pull
in the Intensive Care Unit. The patient was not acutely
unstable.
The patient resolved and her shortness of breath decreased
and her effusion went down. Follow-up chest x-ray was
obtained on [**2114-2-14**], which shows reduction in the effusion
as well as markedly better clinical examination. The patient
is comfortable.
Physical examination as of this day reveals no jugular venous
distention, no carotid bruits. The thoracic incision is
clean, no clicks, no discharge, no erythema. The heart has a
systolic ejection murmur. The lungs are mostly clear with
diminished sounds on the left bases in upright position.
The patient is being discharged to rehabilitation on Lasix,
dose treatment see page one and on 20 meq K-Dur b.i.d.,
Captopril 12.5 mg p.o. t.i.d., Lopresor 12.5 mg p.o. b.i.d.,
In addition, she will receive Amiodarone 400 mg p.o. b.i.d.
for one week and then 400 mg q.d. for brief arrhythmia which
she suffered in the Intensive Care Unit immediately
postoperative. She was also to be given Aspirin 325 mg p.o.
q.d. and Ranitidine 150 mg p.o. b.i.d.
[**Name6 (MD) 475**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 9632**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2114-2-14**] 19:42
T: [**2114-2-14**] 19:53
JOB#: [**Job Number 38883**]
ICD9 Codes: 4280, 5119, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5112
} | Medical Text: Admission Date: [**2119-5-21**] Discharge Date: [**2119-6-1**]
Date of Birth: [**2063-11-21**] Sex: F
Service: SURGERY
Allergies:
Morphine / Azithromycin / Erythromycin
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain, nausea, vomiting, and inability to pass flatus
Major Surgical or Invasive Procedure:
total abdominal colectomy with end ileostomy & mucous fistula
History of Present Illness:
55 y.o. woman with PMH of several bowel operations presents with
abdominal pain, nausea, vomiting and no flatus or bowel
movements x 1 day.
Past Medical History:
1. depression
2. bipolar disease
3. CHF
Past Surgical History
1. emergent sigmoidectomy for perforated diverticuli 4 years ago
2. reversal of ostomy 3 months later
3. emergent ostomy for SBO
4. reversal of ostomy
5. appendectomy
6. lumpectomy right breast
Social History:
1 PPD tob x 40 years, occasional EtOH
Family History:
noncontributory
Physical Exam:
T: 98.8 HR: 94 BP: 105/59 RR: 20 96%RA
Gen: awake, alert, NAD
HEENT: neck supple, no masses
CV: regular rate and rhythm, no m/r/g
Pulm: clear to auscultation bilaterally, no w/r/r
Abd: nondistended, nontender, ostomy intact on R side of
abdomen, mucous fistula intact on L
Ext: warm, well-perfused
Pertinent Results:
[**2119-5-21**] 04:20AM WBC-13.8* RBC-5.22 HGB-17.3* HCT-48.2* MCV-92
MCH-33.0* MCHC-35.8* RDW-14.4
[**2119-5-21**] 04:20AM ALT(SGPT)-56* AST(SGOT)-38 ALK PHOS-138*
AMYLASE-141* TOT BILI-0.6
CT abdomen [**5-21**]: Dilated large bowel proximal to the anastomosis
extending to the cecum measuring up to 9 cm in maximal diameter
without small bowel dilation.
Abd XRay [**5-21**]: Gas filled loops of dilated colon & minimally
distended loops of small bowel. Multiple air-fluid levels seen
within the large bowel.
[**2119-5-30**] 03:00AM BLOOD WBC-10.3 RBC-2.99* Hgb-9.6* Hct-27.7*
MCV-93 MCH-32.1* MCHC-34.7 RDW-15.0 Plt Ct-412
Brief Hospital Course:
Pt presented to the ED where abdominal CT and Xray demonstrated
dilated large bowel and she was found to have a WBC of 13.8. Pt
was admitted to the SICU. On HD1 endoscopy demonstrated no
obstruction and normal mucosa. On HD3 she was brought to the OR
for an ex-lap. Pt was found to have a gangrenous right colon
which was treated with a partial colectomy, ileostomy, and
mucous fistula with placement of a rectal tube. Pt returned to
the SICU postoperatively. On HD3 she was intubated and was
started on pressors. She was extubated on HD 10. Shortly
thereafter the pt's bowel function returned and her diet was
advanced. She was discharged home with VNA on HD12.
Medications on Admission:
1. Buspar 60 [**Hospital1 **]
2. Abilify 30 daily
3. Nexium 20 daily
4. Lasix 20 daily
5. Advair daily
Discharge Medications:
1. Aripiprazole 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
Disp:*180 Tablet(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take while using narcotics to prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*5*
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
gangrenous right colon
bipolar disease
depression
asthma
Discharge Condition:
good
Discharge Instructions:
Diet as tolerated. Resume your prehospitalization medications.
No bathing (showers are OK - pat wounds dry), no strenuous
activity, no driving while using narcotics. No lifting objects
heavier than a gallon of milk.
Contact your MD if you develop fevers>101, increasing redness or
drainage from your wounds, inability to tolerated oral diet, or
if you have any other questions or concerns.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in approximately 2 weeks.
Please call ([**Telephone/Fax (1) 2300**] to schedule an appointment.
ICD9 Codes: 0389, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5113
} | Medical Text: Admission Date: [**2124-12-24**] Discharge Date: [**2124-12-26**]
Date of Birth: [**2059-12-26**] Sex: M
Service: MEDICINE
Allergies:
Lithium / Erythromycin Base / Cogentin / Stelazine / Clozaril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer from [**Hospital **] Hospital for CVVH
Major Surgical or Invasive Procedure:
HD line placement L neck, CVVH
Intubation
History of Present Illness:
The patient is a 64-year-old male with multiple medical problems
including a history of chronic kidney disease (stage IV)
secondary to presumed lithium toxicity with renal tubular
acidosis, history of endocarditis in [**2110**] and presumed
endocarditis in [**2124-7-7**], schizoaffective disorder,
who was admitted to the [**Hospital **] Hospital on [**2124-8-31**]
for treatment of MSSA bacteremia and presumed endocarditis with
a six week course of nafcillin in the context of a hip fracture
with hardware in place in the left hip. The [**Hospital 228**] hospital
course at [**Hospital1 **] was complicated by 2 major gastrointestinal
bleeds secondary to multiple duodenal erosions and ulcerations,
severe malnutrition with anasarca and weakness. In the week
preceding [**2124-12-17**], the patient was noted to be less
alert by the chronic medical service
that was following him. He had been having continued diarrhea
with a recent history of Clostridium difficile colitis for which
he was treated with Flagyl and was again found to be Clostridium
difficile positive. The patient was also found to have a
urinary tract infection with urine culture growing enterobacter
cloacae. The patient's diarrhea and urinary tract infection were
accompanied with volume depletion and metabolic acidosis. On
[**2124-12-15**], the patient became hypotensive with blood
pressures in 80s/30s, nonresponsive to aggressive fluid
hydration. He was transferred to the ICU and started on
Levophed as well as increased antibiotic coverage.
.
In the ICU, he was started on po vanc and continued on IV flagyl
for treatment of cdiff. He had an episode of afib w/ rvr and is
s/p cardioversion for hypotension. He was treated with
Vanc/Zosyn for broad coverage in the setting of septic shock and
continued on cipro for treatment of an enterobacter UTI. He was
afebrile during his ICU course and has been off pressors for
several days however his blood pressure was thought to be too
low to tolerate HD so he was transferred to [**Hospital1 18**] for CVVH.
.
On arrival, he states he feels mildly SOB. He denies cough. He
endorses R testicular pain. No f/c/n/v. He feels hungry and
thirsty.
Past Medical History:
1. Bipolar disorder versus schizoaffective disorder with history
of suicide attempts and ECT tx (Followed in the past by PACT
team [**Telephone/Fax (1) 95230**]).
2. Enterococcal endocarditis in [**2110**].
3. Questionable MSSA endocarditis, [**2124-8-7**]: TEE at [**Hospital1 **] was
negative for vegetation and abscesses, so diagnosis of
endocarditis was not clear. However, given MSSA bacteremia at
the time, and presence of hardware in the left hip, a six week
course of nafcillin dating from first negative culture on [**7-30**], [**2123**] was recommended and completed on [**2124-9-11**].
4. Noninsulin dependent diabetes.
5. Hypertension.
6. Coronary artery disease status post myocardial infarction x2.
7. Echocardiogram performed [**2124-9-6**] showing ejection
fraction to 50%, focal thickening of the mitral and aortic
valves, and mild pulmonary hypertension.
8. Gastroesophageal reflux disease.
9. Benign prostatic hypertrophy.
10. Chronic kidney disease, stage 4 with nephrotic syndrome and
renal tubular acidosis secondary to presumed lithium toxicity
with a baseline creatinine of 2.5 while at the [**Hospital **]
Hospital.
11. DVT
12. Recent h/o afib w/ RVR.
13. Hyperlipidemia
14. s/p fall w/ occipital bleed
15. Duodenal ulcers w/ 3 recent GI bleeds
16. L hip femoral neck fracture s/p hemiarthroplasty in [**6-13**]
17. L radial fx [**6-13**]
Social History:
Prior to his hospitalization for hip surgery and then transfer
to the [**Hospital **] Hospital, the patient lived in an apartment by
himself with PACT team support for psychiatric issues. He was
at [**Hospital 671**] rehab from [**2124-7-5**] until [**Month (only) **]. The patient has a
girlfriend, [**Name (NI) **], who visits him occasionally. The patient has a
sister who is also his health care proxy who lives in [**Name (NI) 4565**]
but is very involved in his health care. The patient had a
smoking history of 1.5 packs a day x30-40 years. The patient has
a rare history of alcohol use. Denies illicit drug use.
Family History:
H/o bipolar disorder and depression in the family.
Physical Exam:
Vitals: T: 98 BP: 129/51 P: 89 R: 16 O2: 92% on 2L NC
General: Groggy and slow to answer but awake, oriented, no acute
distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, RIJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, but non-tender, hyperactive bs
Ext: anasarca, wwp, able to move all extremities
Pertinent Results:
[**2124-12-24**] 03:24PM TYPE-MIX
[**2124-12-24**] 03:24PM O2 SAT-74
[**2124-12-24**] 02:13PM TYPE-ART TEMP-37.8 PO2-87 PCO2-41 PH-7.26*
TOTAL CO2-19* BASE XS--8 COMMENTS-AXILLARY
[**2124-12-24**] 02:13PM LACTATE-1.7 NA+-137 K+-3.3*
[**2124-12-24**] 02:13PM freeCa-1.10*
[**2124-12-24**] 02:00PM URINE HOURS-RANDOM UREA N-280 CREAT-74
SODIUM-52
[**2124-12-24**] 02:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
[**2124-12-24**] 02:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2124-12-24**] 02:00PM URINE RBC-32* WBC->1000* BACTERIA-NONE
YEAST-MANY EPI-0
[**2124-12-24**] 02:00PM URINE WBCCLUMP-MANY
[**2124-12-24**] 01:16PM GLUCOSE-57* UREA N-95* CREAT-5.5*# SODIUM-142
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-19* ANION GAP-16
[**2124-12-24**] 01:16PM estGFR-Using this
[**2124-12-24**] 01:16PM ALT(SGPT)-4 AST(SGOT)-13 ALK PHOS-66 TOT
BILI-0.2
[**2124-12-24**] 01:16PM TOT PROT-3.1* ALBUMIN-1.3* GLOBULIN-1.8*
CALCIUM-7.3* PHOSPHATE-7.7*# MAGNESIUM-1.8
[**2124-12-24**] 01:16PM VIT B12-1222* FOLATE-16.8
[**2124-12-24**] 01:16PM VANCO-18.1
[**2124-12-24**] 01:16PM WBC-18.0*# RBC-2.62* HGB-8.3* HCT-26.1*
MCV-100*# MCH-31.8 MCHC-31.9 RDW-18.5*
[**2124-12-24**] 01:16PM NEUTS-77* BANDS-4 LYMPHS-12* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2124-12-24**] 01:16PM HYPOCHROM-OCCASIONAL ANISOCYT-2+
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
[**2124-12-24**] 01:16PM PLT SMR-NORMAL PLT COUNT-293
[**2124-12-24**] 01:16PM PT-15.6* PTT-83.1* INR(PT)-1.4*
Brief Hospital Course:
This is a 64 M w/ pmh of stage IV CK, 3 recent UGI bleeds in the
setting of duodenal ulcers, recent tx for MSSA endocarditis w/
3+ AR, recent cardioversion for afib w/ rvr, transferred to
[**Hospital1 18**] for consideration of CVVH in the setting of hypotension
and likely continuing septic physiology.
.
# Hypotension: Currently relatively hypotensive given h/o
hypertension. Vanc/Zosyn were started on [**12-16**] for empiric
broad-spectrum coverage for septic shock at OSH. Blood cx from
OSH on [**12-16**] w/ ngtd. Had been afebrile during his ICU stay at
OSH. WBC count 18 from 27 on the 14th. Given leukocytosis,
likely c/w continued sepsis.
Possibly from c diff colitis as seemed to improve with po
vancomycin. Patient was placed on continued PO vanc and IV
vanc/zosyn. His hypotension continued to progress. He was
intubated for airway protection after he became acutely less
responsive, diaphoretic and pale. His sister was called and she
decided to make him CMO. The tube was removed and the patients
blood pressure continued to drop until he passed at 855 PM.
.
# C. diff colitis: Currently being treated w/ po vanc (D1 = [**12-13**])
and IV flagyl (unknown time course). Has a history of chronic
diarrhea of unknown etiolgy.
- continue po vanc X 14 after last day of broad-spectrum
antibiotics ([**12-24**])
.
# Acute renal failure on chronic renal failure: His baseline cr
was 2.6 on admission to [**Hospital1 **]. Cr now 5.6 on transfer. ?
from ATN from hypotension. Has a h/o nephrotic syndrome w/
albumin of 0.7. Clearly has anasarca. Blood pressure on the
low side so unclear if he would tolerate HD.
- renal consult for possible CVVH-unable to place line on HD 2,
on HD 3 acutely hypotensive and L IJ line placed emergently.
CVVH never initiated as patient made CMO.
- renal diet
- nephrocaps
- phos binders given phos of 7.7
.
# Hypoxia: h/o smoking so likely has some underlying COPD.
Likely a component of volume overload/pulmonary edema given
renal failure.
- continue ipratropium nebs
- CXR
- CVVH vs HD as above
.
# Enterobacter clocae UTI: Per OSH, blood cx from [**12-16**] w/ NGTD.
- cipro started on [**12-13**] (no [**Last Name (un) 36**] data), will d/c as now s/p an
11-day course
- send UA/cx
.
# DVT: R superficial femoral vein thrombosis [**First Name8 (NamePattern2) **] [**Hospital1 **]
report. Is very high risk for recurrent GI bleed. The
risk/benefit ratio was discussed at [**Hospital1 **] and thought to
favor anticoagulation.
- heparin ggt-held given need for HD line, never re-initiated
.
# Afib: Currently in sinus. Status post cardioversion on [**12-20**]
in the setting of hypotension. Has been on heparin ggt and amio
was started to prevent recurrent afib. Likley afib occurred in
the seting of septic shock from ? cdiff.
- will discontinued amiodarone
.
# Anemia: Macrocytic. Had an upper GI bleed during his last
[**Hospital1 18**] hospitalization and 2 additional GI bleeds at [**Hospital1 **]
requiring 6 U PRBC. This may also be c/b B12 deficiency as it
appears that his B12 level was low in [**4-13**].
- guiac stools
- transfuse for hct < 21
.
# Decubitous ulcers: Stage 1 sacral decubitous ulcer.
- wound consult
.
# DM: BS well-controlled w/o insulin coverage at [**Hospital1 **].
- trend for now
- add insulin SS if needed
.
# Aortic regurgitation: 3+ on [**8-14**] ECHO thus although EF > 55%,
functionally his forward flow is not normal.
.
# Bipolar disorder/Schizophrenia: continue valproic acid,
wellbutrin, seroquel, lamictal
.
# GERD: continue pantoprazole 40 mg [**Hospital1 **] given h/o duodenal
ulcers and GI bleed during last [**Hospital1 18**] hospitalization
.
# Hyperlipidemia: continue simvastatin
.
# BPH: hold terazosin as has a foley in place
.
# FEN: No IVF, replete electrolytes, renal diet
.
# Prophylaxis: heparin ggt, VRE carrier, known cdiff +
.
# Access:
Lines:
1- Right IJ line (placed [**2124-12-16**]) - will order PICC and d/c
2- Right radial A-line (placed [**2123-12-21**]) - will d/c if not needed
.
# Code: FULL CODE
.
# Communication: Patient, sister ([**Telephone/Fax (1) 108572**]
.
# Disposition: pending above
Medications on Admission:
1. Ciprofloxacin 400 mg IV q. 24 hours.
2. Zosyn 2.25 grams IV q. 8 hours.
3. Vancomycin 1 gram IV daily (dose given daily depending on
daily a.m. vanco trough).
4. Vancomycin 250 mg p.o. t.i.d.
5. Flagyl 250 mg IV q. 8 hours.
6. Bicitra 10 mL p.o. b.i.d.
7. Valproic sodium 750 mg p.o. b.i.d.
8. Omeprazole 40 mg p.o. q. 12 hours.
9. Epogen 40,000 units subcu once weekly.
10.Lamictal 50 mg p.o. b.i.d.
11.Calcitriol 0.25 mcg p.o. daily.
12.Ipratropium bromide 0.5 mg 0.25% inhaled q. 4 hours p.r.n.
shortness of breath.
13.Tylenol 650 mg p.o. q. 6 hours p.r.n. temperature greater
than 101.
14.Atrovent inhaler q. 4 hours p.r.n. shortness of breath.
15.Folic acid 1 mg p.o. daily.
16.Cholecalciferol 400 units p.o. daily.
17.Oxycodone 5 mg p.o. q. 6 hours p.r.n. pain.
18.Wellbutrin SR 100 mg b.i.d.
19.Seroquel Extended Release 200 mg p.o. q. h.s.
20.Amiodarone 400 mg p.o. t.i.d.
21. Heparin gtt with q6 hours PTTs
22. NovaSource renal at 20 mL an hour around the clock with 250
mL normal saline flushes every 4 hours
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired secondary to cardiopulmonary compromise from sepsis
likely C.diff. Complicated by acute on chronic renal failure.
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2124-12-26**]
ICD9 Codes: 4241, 0389, 5845, 5990, 5856, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5114
} | Medical Text: Admission Date: [**2136-3-13**] Discharge Date: [**2136-3-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Lightheadeness, Gastrointestinal bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy
Blood transfusions
History of Present Illness:
Mr. [**Known lastname 14410**] is an 88 yo M with history of aortic aneursym status
post repair, MVR s/p porcine valve placement, atrial
fibrillation on coumadin, and diverticulosis who presented with
lightheadedness on [**2136-3-13**] and was found to have a GI bleed. He
admits to feeling weak one day prior and his wife reports he has
had increased fatigue throughout the week prior to presentation.
He notes he woke up early on morning of admission feeling very
dizzy and "woozy." His wife reports he has had bloody stools for
at least a week. He also has had relatively severe nosebleeds
and had excessive bleeding from a cut on his hand over the past
week. He denies any changes to his coumadin doses or other
changes in his medications recently.
In the ED, initial vs were: T 97.3, P 78, BP 122/60, R 16, O2
sat 98% on RA. A foley was placed and per report approximately
200 cc of urine drained. He was found to have a 12 point Hct
drop from his prevoius value taken last summer and INR greater
than assay as well as acute renal failure. Patient was given 1 L
of NS, vitamin K 5 mg PO x1, protonix 40 mg IV x1 and 2 units of
PRBCs and 4 units of FFP were ordered. Additionally, patient got
up in the ED to urinate and fell. He was possibly unresponsive
mom[**Name (NI) 11711**]. CT head was negative. He did sustain bilateral knee
hematomas at the time.
He denies any recent changes in his coumadin dose and has been
on coumadin for about two years. He reports taking some
supplements but mostly vitamins and melatonin. His last
colonoscopy was in [**11/2131**] and showed diverticulosis of the
sigmoid colon. EGD at that time showed a large hiatal hernia and
gastritis with normal biopsies.
In the MICU, the patient reports feeling well and denies ever
having chest pain, shortness of breath, abdominal pain, or
nausea and vomiting. His greatest concern on transfer to the
floor is that his urine appeared quite bloody.
Review of Systems: The patient denied any fevers, chills, weight
loss, or recent illnesses. No nausea, vomiting, abdominal pain,
or melena. He denied any chest pain, shortness of breath, or
palpitations. He did report some worsened urinary hesitancy and
feeling of being unable to void fully on the day prior to
presentation.
Past Medical History:
-Coronary Artery Disease s/p 2 vessel CABG in [**5-11**] (LIMA to LAD,
SVG to PDA)
-Ascending Aortic Aneurysm s/p repair in [**2134**]
-Mitral Regurgitation s/p MVR with bioprosthetic valve in [**2134**]
-Atrial fibrillation
-Diabetes Mellitus
-Hypertension
-Benign Prostatic Hypertrophy
-Obesity
-Hiatal hernia
-S/p pacemaker in [**2129**]
-S/p left knee surgery
-Splenic hypodensity
-Anti-K antibiodies (requies [**Doctor Last Name **] antigen neg blood)
Social History:
He is a retired optometrist and a veteran of WWII. He smoked
while he was in the Air Force and has not smoked since leaving
the army in the [**2067**]'s. Extremely rare alcohol use. He lives
at home with his wife.
Family History:
Non-contributory
Physical Exam:
Vitals: T:97.1 BP: 119/47 P: 60 R: 16 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
Ext: large hematoma on L knee
Pertinent Results:
LABORATORY RESULTS
===================
On Presentation:
WBC-10.6# RBC-3.23*# Hgb-9.2*# Hct-28.1*# MCV-87 RDW-15.8* Plt
Ct-182
----Neuts-85.9* Lymphs-9.0* Monos-4.7 Eos-0.2 Baso-0.1
PT->150* PTT-68.5* INR(PT)->21.8*
Glucose-271* UreaN-40* Creat-2.6*# Na-137 K-4.8 Cl-101 HCO3-23
Calcium-9.1 Phos-4.6* Mg-2.9*
On Discharge:
WBC-6.7 RBC-3.76* Hgb-11.2* Hct-32.4* MCV-86 RDW-16.3* Plt
Ct-192
PT-18.7* PTT-29.0 INR(PT)-1.7*
Glucose-86 UreaN-14 Creat-0.9 Na-140 K-3.7 Cl-106 HCO3-25
Cardiac Enzymes:
CK 258 -- 256 -- 276
CK-MB: 4-- 4 -- 4
TropT 0.03 -- 0.02 -- 0.03
OTHER STUDIES
===============
CT head [**2136-3-13**]:
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Possible remote infarct in the left cerebellar hemisphere.
3. Diffuse pagetoid changes of the calvarium. Clinical
correlation
recommended.
4. Maxillary and ethmoid sinus disease, likely chronic in
nature. Clinical correlation recommended.
Chest Radiograph [**2136-3-13**]:
IMPRESSION: Interval improvement in lung aeration with band-like
atelectasis at the left lung base. Hiatal hernia. Mildly
prominent small bowel loops in the upper abdomen. Recommend
correlation with abdominal radiographs if there is need for
further evaluation.
ECG [**2136-3-14**]:
Regular ventricular pacing with probable underlying atrial
fibrillation.
Compared to the previous tracing pacing is now more consistent.
Brief Hospital Course:
88 year old man with significant cardiac history admitted with
significant coagulopathy, acute renal failure and a GI bleed.
1) Gastrointestinal bleed: On presentation the patient had 12
point hematocrit drop from baseline and this was presumed to
have taken place over the previous week when he had been having
bleeding events. He never evidenced any signs of hemodynamic
instability though his tachycardic response could be blunted by
his beta blockade. At presentation he had guiac positive brown
stool but no hematochezia or melena. His coagulopathy was
corrected and he was transfused. Given overall he appeared
quite stable the decision was made to postpone endoscopy until
hematocrit was between 1.5 and 1.7. Given the patient's history
of divericulosis this was considered the most likely cause of
bleeding and gastritis or upper source was considered much less
likely given he had not had melena. Eventually, the patient
underwent upper and lower endoscopy of [**2136-3-16**], which showed no
active source of bleeding but erythema and congestion in the
lower part of the stomach with a small AVM. Presumed source of
bleeding was this gastritis in the context in his initial severe
coagulopathy. The patient was discharged on [**Hospital1 **] PPI therapy to
follow up with GI as an oupatient. At the time of discharge his
hematocrit had been stable around 32 for >48 hours.
2) Coagulopathy: The etiology of the patient's coagulopathy is
unclear. [**Name2 (NI) **] typically has had his INR checked monthly and
review of records by his [**Hospital3 **] reveals he has
been stable with INR's between 2 and 2.5 for a long time. No
antibiotics, illnesses, or diet change. On holding his coumadin
and reversal with vitamin K and FFP this quickly corrected. He
was discharged on half of his usual coumadin dose with close
follow up in his [**Hospital3 **]. They will also inspect
his most recent set of coumadin pills to make sure he had not
received pills of a different dosage in error. He was also
counseled to stop his supplements for the moment as these could
possibly interfere with his coumadin metabolism. The patient
was also restarted on his aspirin prior to discharge.
3) Acute Kidney Injury: On presentation the patient's Cr was
increased at 2.6. This quickly corrected with volume
resuscitation and transfusions, which suggests this was due to
pre-renal kidney injury due to his blood loss. At the time of
discharge Cr was less than one.
4) Bilateral knee hematomas: These occurred after traumatic fall
in the ED. He was seen by orthopedics who were confident that
this was superficial bleeding in the pre-patellar bursae with no
other major pathology. This was observed and no further
management was instituted.
5) Coronary Artery Disease: The patient never had chest pain or
signs of active ischemia though he did have TWI that resolved in
the ED. Three sets of cardiac enzymes remained stable
suggesting no demand infarction. He was continued on his statin
and restarted on ACEi and beta blocker prior to discharge.
6) Aortic aneurysm s/p repair: Given lack of significant
abdominal pain and the patient's rapid improvement with volume
replacement no particular management for his history of aneurysm
repair was considered necessary.
7) Benign Prostatic Hypertrophy: The patient was continued on
his home finasteride and terazosin in the hospital. Given
complaints of increased difficulty with urination he initially
had a foley catheter placed. This was discontinued after he
left the ICU without difficulties with urination. He did have
some hematuria while the catheter in place but this resolved
after removal and was thought most likely due to foley trauma in
the context of coagulopathy.
8) Diabetes Mellitus type 2: The patient was continued on his
home insulin regimen with some reduction in his standing doses
while NPO. Reasonable control of his blood pressures was
obtained with this regimen.
9) Hypertension: The patient was nevery hypotensive. Initially,
all of his home anti-hypertensives and diuretics were held.
Eventually his metoprolol, furosemide, and ACEi were restarted
but his calcium channel blocker continued to be held as he was
normotensive without it.
He received [**Hospital1 **] IV and then PO PPI for his GI bleed. He had
pneumoboots for DVT prophylaxis. He was full code. Prior to
discharge he was tolerating a full diet.
Medications on Admission:
Felodipine SR 10 mg daily
Finasteride 5 mg qam
Furosemide 20 mg daily
Insulin Asp Prt-Insulin Aspart [Novolog Mix 70-30] 5 units qam/8
units qpm
Lisinopril 2.5 mg daily
Metoprolol Tartrate 50 mg daily
Simvastatin 40 mg QHS
Terazosin 5 mg QHS
Aspirin 325 mg qam
Coumadin 5 mg 5 days, 10 mg 2 days
Benefiber
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: 5 in the
morning, 8 in the evening units Subcutaneous twice a day.
4. Simvastatin 40 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 once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please follow up with your primary care provider. [**Name10 (NameIs) 2172**] dose may
need to be adjusted according to your blood work.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*3 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
GI Bleed
Supratherapeutic INR
Hiatal hernia
Arterio-venous malformations
Discharge Condition:
Vital signs stable, HCT 33, INR 1.6
Discharge Instructions:
You were admitted because you were bleeding from your GI tract.
This was most likely due to your blood being much too thin from
your coumadin. The gastroenterologists looked and they only saw
some small foci of disordered vessels as a source of bleeding.
You seemed to stop bleeding once your blood was clotting
appropriately again but the gastroenterologists coagulated the
probable site of bleeding just in case. It is unclear why your
blood was so much thinner than it has been. It is possible you
got an incorrect prescription or somehow doses were confused.
You will need close monitoring of your coumadin over the next
weeks until your INR is stable once again.
Your medications have been changed. You have been started on
OMEPRAZOLE, a medication to help stop further bleeding from the
AVM. You should also stop taking the Warfarin you have and fill
a new prescription (you were given this). You will start taking
2.5 mg/day and follow up with the [**Hospital 2786**] clinic at
[**Location (un) 620**] early next week. Your FELODIPINE has been held as you
were not on this medication in the hospital and you had no high
blood pressure. You should discuss with your regular doctor,
Dr. [**Last Name (STitle) 2204**], whether you need this medication.
We have stopped 1 of your hypertension (high blood pressure)
medications. We have stopped your felodipine. You should
continue with your metoprolol, lasix, and lisinopril. Your
blood pressure has been fine while in the hospital. Please
follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] to see
if this medication needs to be re-added.
Please return to the hospital or call your doctor if you have
chest pain, shortness of breath, fevers or chills, or any other
concerning changes in your health.
Followup Instructions:
You have a follow up scheduled in [**Location (un) 620**] anticoagulation clinc
on Tuesday at 1:00 pm. They would like you to bring the
coumadin pills you were taking prior to this in order to make
sure these were the appropriate dose.
You also have a follow up appointment with stomach and colon
specialist Dr. [**Last Name (STitle) 1940**] on [**2136-5-11**] at 3PM. Please confirm this
with his clinic. The clinic number is [**Telephone/Fax (1) 463**].
Please follow-up with Dr. [**Last Name (STitle) 2204**] next week. His office number
is [**Telephone/Fax (1) 2205**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 5849, 2851, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5115
} | Medical Text: Admission Date: [**2143-6-9**] Discharge Date: [**2143-6-12**]
Date of Birth: [**2095-12-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
IPH, SAH s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47M intoxicated and fell down approx 15 steps. At OSH he was
found to have RR 8 intubated. ETOH 350. Was found to have R
frontoparietal SDH with traumatic SAH.
Past Medical History:
HTN, dyslipidemia
Social History:
unknown
Family History:
unknown
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT:L side parietal lac. Pupils:5->2 EOMs UTA
Neck: in c-collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated on propofol. Propofol held. Moves all
extremities spont. Appears to attempt to follow commands. Face
symmetric
Motor: UTA strength
Sensation: UTA
Toes mute
Coordination: UTA
Neuro Exam on Discharge:
Mental status: Alert and Oriented x 3. Appears to attempt to
follow commands.
Pupils: 5-->3 bilaterally
No pronator drift
Motor: Moves all extremities spont. Face symmetric, tongue
midline
Sensation: intact to light touch
Coordination: intact
Pertinent Results:
Labs on Admission:
[**2143-6-9**] 02:10AM BLOOD WBC-9.7 RBC-4.98 Hgb-15.9 Hct-45.7 MCV-92
MCH-32.0 MCHC-34.9 RDW-13.7 Plt Ct-323
[**2143-6-9**] 04:10AM BLOOD Neuts-76.4* Lymphs-18.7 Monos-3.6 Eos-0.8
Baso-0.5
[**2143-6-9**] 02:10AM BLOOD PT-14.2* PTT-21.6* INR(PT)-1.2*
[**2143-6-9**] 04:10AM BLOOD Glucose-187* UreaN-8 Creat-0.7 Na-145
K-4.0 Cl-107 HCO3-23 AnGap-19
[**2143-6-9**] 04:10AM BLOOD ALT-85* AST-45* LD(LDH)-283* AlkPhos-56
TotBili-0.7 DirBili-0.2 IndBili-0.5
[**2143-6-9**] 04:10AM BLOOD Albumin-5.1* Calcium-8.9 Phos-4.3 Mg-2.5
[**2143-6-9**] 02:10AM BLOOD Lipase-46
[**2143-6-9**] 04:10AM BLOOD Phenyto-15.4
[**2143-6-9**] 02:10AM BLOOD ASA-NEG Ethanol-311* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs on Discharge:
[**2143-6-11**] 06:00AM BLOOD WBC-8.4 RBC-4.54* Hgb-14.6 Hct-42.1
MCV-93 MCH-32.2* MCHC-34.7 RDW-13.3 Plt Ct-287
[**2143-6-11**] 06:00AM BLOOD Plt Ct-287
[**2143-6-11**] 06:00AM BLOOD PT-13.5* PTT-24.5 INR(PT)-1.2*
[**2143-6-11**] 06:00AM BLOOD Glucose-129* UreaN-11 Creat-0.8 Na-139
K-4.3 Cl-101 HCO3-27 AnGap-15
[**2143-6-9**] 04:10AM BLOOD ALT-85* AST-45* LD(LDH)-283* AlkPhos-56
TotBili-0.7 DirBili-0.2 IndBili-0.5
[**2143-6-11**] 06:00AM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.5 Mg-2.3
[**2143-6-11**] 06:00AM BLOOD Phenyto-3.8*
Imaging:
CT Head [**6-9**]:
FINDINGS: There are extensive foci of subarachnoid hemorrhage
throughout the right frontotemporal region with a thin right
hemispheric subdural hemorrhage measuring up to 4 mm. Subdural
hemorrhage also layers along the tentorium with a thin layer
along the falx cerebri. Multiple foci of right temporal
intraparenchymal hemorrhage measure up to 3.8 x 1.4 cm with
surrounding vasogenic edema. There is mild mass effect on the
right lateral ventricle with 3 mm of leftward shift of
normally-midline structures. The basilar cisterns appear grossly
patent. The calvaria appear intact. There is a moderate left
frontoparietal subgaleal hematoma, presumably, the site of
"coup." Moderate mucosal thickening involves the maxillary
sinuses and ethmoid air cells bilaterally, as well as the right
sphenoid and bifrontal air cells. There may be a few opacified
right
mastoid air cells.
IMPRESSION: Multiple foci of right temporal intraparenchymal
hemorrhage with multifocal right frontoparietal subarachnoid
hemorrhage. A small amount of subdural blood layer along the
right cerebral convexity, as well as along the tentorium and
falx cerebri. 3-mm of leftward shift of midline structures is
associated.
NOTE ADDED IN ATTENDING REVIEW: Comparison with the [**Hospital **]
Hospital NECT,
performed some 2.5 hrs earlier (and since uploaded into PACS)
demonstrates
significant interval evolution of, particularly, the multifocal
right temporal hemorrhagic contusions with surrounding edema, as
well as the multifocal SAH and slight generalized edema
involving the right hemisphere, which could reflect underlying
[**Doctor First Name **]. The slight shift of normally-midline structures is also new
over the short-interval.
CT Chest/Abd/Pelvis [**6-9**](OSH)
negative for acute traumatic injury
CT C-spine [**6-9**]:
No fracture or acute alignment abnormality. Prominent posterior
osteophyte at C6 could cause cord injury with the appropriate
traumatic mechanism, though evaluation of intrathecal details is
limited on CT.
Brief Hospital Course:
The patient was admitted to the hospital for eval of
intraparenchymal and diffuse right frontoparietal subarachnoid
hemorrhage. 47M intoxicated and fell down approx 15 steps. At
OSH he was found to have RR 8 intubated. ETOH 350. Was found to
have R
frontoparietal SDH with traumatic SAH. He receieved cerebrex
and transferred to [**Hospital1 18**] for further evaluation.
On hospital day number one, [**6-9**], the pt underwent a head CT w/o
contrast which demonstrated multifocal right temporal
hemorrhagic contusions, multifocal SAH
and slight generalized edema. He was admitted to the trauma ICU
and started on phenytoin. Later that day, a repeat CT was stable
and the patient was extubated and transferred to the
neurosurgery service.
On [**6-10**], the patient was transferred to the stepdown unit. The
patient was started on a CIWA scale.
On [**6-11**] and [**6-12**] the patient's neuro exam remained stable. He had
episodes of asymptomatic bradycardia into the 30's-40's. The
patient's cardiac medications were held. A cardiology consult
was obtained. The patient was cleared by cardiology to go home
with the recommendation that beta blockers are discontinued
until further outpatient evaluation.
The rest of his hospital stay was uneventful with his lab data
and vital signs within baseline values, and his pain controlled.
He is being discharged today in stable condition.
Medications on Admission:
Unknown
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): to start when 500 [**Hospital1 **] doses are complete .
Disp:*120 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily):
Medication should be held/reviewed secondary to bradycardia.
13. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO daily ().
14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right intraparenchymal and subarachnoid hemorrhages s/p fall
Discharge Condition:
Neurologically Stable
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 have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
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) 14074**], 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.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5116
} | Medical Text: Admission Date: [**2149-2-10**] Discharge Date: [**2121-1-27**]
Date of Birth: [**2149-2-10**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: A 1330 gm male infant, Triplet
#1, born to a 22 year old gravida 2, para 1 to 4, mother (2
pregnancies, 4 infants) with prenatal screens of A positive,
antibody negative, Group B Streptococcus unknown, hepatitis B
surface antigen negative, RPR nonreactive.
PAST MEDICAL HISTORY: Past medical history by report
remarkable for possible fetal alcohol syndrome, developmental
delay and depression in Mom. Antepartum history remarkable
for triplets, reportedly by spontaneous conception. Prior
admission to [**Last Name (un) 10076**] for preterm labor. Received magnesium
sulfate and Betamethasone. Admitted to [**Hospital6 649**] on [**1-31**], with premature rupture of
membranes, preterm labor and poor biophysical profile with
triplet #1, monitored with recovery of profile of concerning
triplet. No fever. On day of delivery had onset of labor
and decision was made to deliver by cesarean section. Infant
emerged with spontaneous cry, Apgars of 8 at one minute and 8
at five minutes.
PHYSICAL EXAMINATION: Examination on admission remarkable
for preterm infant in moderate respiratory distress with
stable vital signs. Skin pink. Anterior fontanelle soft.
Palate intact. Normal facies with mildly deformed nose.
Moderate retractions with fair air entry. Rales, no murmur.
Normal femoral pulses. Abdomen, soft, nondistended with no
hepatosplenomegaly. Normal male genitalia. Testes descended
bilaterally. Hips stable. Normal perfusion. Normal tone
and activity for gestational age.
HOSPITAL COURSE: (By systems) 1. Cardiovascular -
Cardiovascularly stable throughout admission with normal
blood pressures. The patient developed a murmur on day of
life #4 and echocardiogram was obtained which was negative
for patent ductus arteriosus. The murmur resolved. The
patient was again noted to have a murmur on day of life #14
which was clinically consistent with PPS, no further
cardiovascular issues.
2. Respiratory - The patient was intubated shortly after
birth and received Surfactant times one dose, weaned rapidly
on ventilator settings and was extubated on day of life #1 to
CPAP of 5. Weaned off of CPAP to room air on day of life #3,
however, placed back on CPAP for frequent spells. The
patient again weaned off of CPAP on day of life #10 to room
air. On day of life #15 was placed back on low-flow nasal
cannula again for spells. The patient was loaded with
caffeine prior to initial extubation, had frequent episodes
of apnea and bradycardia of prematurity. On day of life #7,
received a caffeine bolus and the caffeine dose was increased
with some improvement in spells. Again given a caffeine
bolus on day of life #15 for increased spells. The patient
continues to have spells from 0 to 10 per day, usually mild
but occasionally requiring some stimulation.
3. Fluids, electrolytes and nutrition - Initially NPO and on
intravenous fluids. A central PICC line was placed on day of
life #1. Parenteral nutrition was started on day of life #1.
Enteral feeds were initiated on day of life #2 and were
advanced as tolerated. Feeding advance was held around day
#4 when there was concern that the patient had developed a
patent ductus arteriosus when an echocardiogram was negative
for a patent ductus arteriosus, feeds continued to advance
and the patient tolerated this well. Reached full feeds on
day of life #8 and calories were then advanced, currently on
150 cc/kg/day of PE-26 with ProMod. Feeds every 3 hours
secondary to history of aspirates and spits. Feeds gavaged
over 45 minutes. The patient was started on Vitamin E and
Fer-In-[**Male First Name (un) **]. Birthweight was 1330 gm. Weight on [**2-26**] was
1410 gm. Patient with good weight gain on his current
feeding regimen.
4. Gastrointestinal - Bilirubin levels monitored, and
phototherapy initiated on day of life #2 for a bilirubin of
approximately 7/0.2. Peak bilirubin of 5.9/0.3.
Phototherapy was discontinued on day of life #6 for bilirubin
of 5.5/0.3, rebound bilirubin on day of life #7 was 5.7/0.2.
5. Infectious disease - Complete blood count and blood
culture sent on admission, white count of 9.9 with 34 polys
and 1 band. The patient was started on Ampicillin and
Gentamicin. Blood cultures showed no growth at 48 hours and
antibiotics were discontinued. Complete blood count and
blood culture were sent on day of life #15 secondary to
increased spells and revealed blood count of 12.5 with 40
polys and 4 bands. The patient was monitored off of
antibiotics and blood culture showed no growth at the time of
this dictation. Noted on day of life #14, and was treated
with warm soaks and monitored, left eye drainage was
improving.
6. Hematology - Initial hematocrit 34.1%, last hematocrit on
day of life #15 was 29.7% with a reticulocyte count of 2.0.
The patient has not required any blood products in the time
course covered by this dictation.
7. Neurology - Head ultrasound on day of life #8 was
negative.
8. Routine health care maintenance - Primary pediatrician is
Dr. [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) 33629**] of [**Hospital 3597**] Pediatrics. Newborn state screen
was sent on day of life #3 and had an indeterminate result
for the homocystinuria test. A repeat state screen was sent
and is pending at the time of this dictation. The patient
has not yet received any immunizations. The patient will
need a hearing screen and carseat test prior to discharge
home.
9. Ophthamology - The patient has not yet has his first eye
examination.
DISPOSITION: Plan is to transfer patient to [**Hospital **] Hospital
when ready for Level 2 nursery.
MEDICATIONS: Caffeine, Fer-In-[**Male First Name (un) **], Vitamin E.
DISCHARGE DIAGNOSIS:
1. Prematurity at 29 weeks gestational age.
2. Status post surfactant deficiency, respiratory distress
syndrome.
3. Feeding immaturity.
4. Status post hyperbilirubinemia.
5. Status post rule out sepsis.
6. Heart murmur probably PPS
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) 50027**]
MEDQUIST36
D: [**2149-3-3**] 06:19
T: [**2149-3-3**] 07:36
JOB#: [**Job Number 55324**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5117
} | Medical Text: Admission Date: [**2122-10-31**] Discharge Date: [**2122-11-2**]
Date of Birth: [**2061-9-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
-Central Venous Line Placement
-Dialysis Line Placement
History of Present Illness:
61M transferred from [**Hospital3 26615**] hospital with CAD s/p 3V CABG
and AVR @ [**Hospital3 2358**] [**4-/2121**] (90% distal left main extending to
LAD and ostium of LCX with 80% mid-RCA) for NSTEMI, s/p DDD
pacer implant for intermittent complete heart block @ [**Hospital1 3343**] [**9-/2122**] transferred from OSH for evaluation and
management of VT with HD instability requiring shocks x 1. He
was admitted to OSH after being started back on metoprolol which
caused him symptoms of light-headedness, lethargy, and mental
slowing (which he had previously experienced leading him to stop
taking metoprolol and lisinopril). He stopped the medication
himself and began to feel better but became extremely SOB when
walking up stairs and ended up lying on the floor due to his
inability to catch his breath which prompted him to call 911 and
present to OSH. He was assessed has possibly having ACS and
underwent ROMI with trops <0.03 -> 0.16 -> 0.12, negative MB's
throughout and EKG with pacer rhythm and 100% capture. He was
started on ASA 325, given lovenox 1mg/kg SQ.
.
Then rapid response was called at 3am today at OSH for VT with
HR to 280 with pt found to be diaphoretic and dyspneic but then
uresponsive for 5 seconds. VT self-teriminated after 2 minutes
and pt started on amiodarone drip @ 3:30AM, crit found to be 26
(stable from admission)and rec'd 1u pRBCs and trop drawn and
found to be 0.14. Later went into monomorphic VT with rate in
the 250's @ 11:45AM, shocked x 1 with return to paced rate of 88
and was apparently neurologically intact and AOx3 following. He
was transferred to the ICU and transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
On the floor he describes shaking chills occasionally over the
past 3 weeks after having his pacemaker placed although he
denies frank fevers. He also denies pain, redness, or drainage
from the site of his pacemaker. He also describes having a cough
over the past week but states it is non-productive.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools.
.
Cardiac review of systems is notable for dyspnea on exertion,
negative for paroxysmal nocturnal dyspnea, negative for
orthopnea, ankle edema, palpitations.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes type 2 +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY:
- CABG: Per report, CABG with AVR in [**4-/2121**] (90% distal left
main extending to LAD and ostium of LCX with 80% mid-RCA)
- PERCUTANEOUS CORONARY INTERVENTIONS: C. Cath [**9-/2122**] with
clean grafts per report at [**Hospital1 1774**]
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
HTN
HLD
DM2
R total hip replacement
Social History:
Married, works as carpenter. Denies drugs, alcohol, smoking.
Family History:
father with CAD, brother with carotid vascular disease, paternal
grandfather with CAD
Physical Exam:
ADMISSION EXAM:
VS: 100.9 98 127/62 14 98% on 2L
GENERAL: NAD, sleeping comfortably in bed
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP not appreciated
CHEST: pacemaker pocket-no erythema, no discharge, no tenderness
to palpation
CARDIAC: RRR, normal S1, S2, + mechanical click, no
murmurs/rubs/gallops appreciated
LUNGS: anterior lung fields clear to auscultation, patient
refused to sit up for posterior lung exam
ABDOMEN: soft, nontender, nondistended, +BS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+
PT 2+
Neuro: CN 2-12 grossly intact, normal strength and sensation
throughout
Pertinent Results:
ADMISSION LABS:
[**2122-10-31**] 05:56PM GLUCOSE-142* UREA N-11 CREAT-0.8 SODIUM-133
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13
[**2122-10-31**] 05:56PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2122-10-31**] 05:56PM WBC-15.0* RBC-3.35* HGB-9.8* HCT-28.1* MCV-84
MCH-29.3 MCHC-35.0 RDW-14.1
[**2122-10-31**] 05:56PM NEUTS-90.7* LYMPHS-5.0* MONOS-3.9 EOS-0.2
BASOS-0.1
[**2122-10-31**] 05:56PM PLT COUNT-429
[**2122-10-31**] 05:56PM PT-29.0* PTT-45.8* INR(PT)-2.8*
[**2122-10-31**] 05:56PM CRP-143.7*
[**2122-10-31**] 05:56PM SED RATE-62*
.
MICRO:
4/4 bottles positive for coagulase negative staph
.
ECHO [**2122-11-2**]
No atrial septal defect is seen by 2D or color Doppler. Two
pacemaker leads are seen entering the right atrium from the SVC,
without definite associated vegetations. Overall left
ventricular systolic function is normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. A mechanical
aortic valve prosthesis is present. The anterior attachment of
the prosthesis is normal. The posterior half of the prosthesis
appears hypermobile/partial dehiscence extending nearly [**12-14**] way
around the prosthesis (clip [**Clip Number (Radiology) **]). An echolucent space is seen
posteriorly with systolic flow into this space which is then
contiguous with the right atrium with continus flow (aorta to
right atrial fistula). There are mobile echodensities (clip [**Clip Number (Radiology) **],
84) seen at the posterior attachment site of the prosthesis c/w
tissue, sutures and/or vegetations. No aortic regurgitation is
seen through this area. There is trivial valvular aortic
regurgitation (normal for this prosthesis). The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen.
IMPRESSION: Partially posterior aortic valve prosthesis
dehiscence with flow from the aorta into the right atrium.
Vegetations vs. suture vs. tissue in the area.Moderate to severe
tricuspid regurgitation.
.
RUQ US [**2122-11-2**]
IMPRESSION:
1. Mildly coarsened hepatic echotexture. No frank biliary
dilatation.
2. A few peripheral echogenic foci in the liver likely represent
small portal branches; however, portal venous gas cannot be
entirely excluded. If there is clinical concern for ischemic
bowel, further assessment should be performed with CT.
3. Diffuse gallbladder wall thickening.
4. Splenomegaly to 15 cm.
.
KUB [**2122-11-1**]
FINDINGS: Two supine and one left lateral decubitus image show
no evidence of free air. There are air-filled loops of
nondilated small bowel. There is air and stool seen within the
colon extending into the sigmoid and rectum. There is no
evidence of obstruction or ileus. Patient is status post a total
left hip arthroplasty with no evidence of loosening. There are
degenerative changes of L4 and L5 in the right hip. The bases of
the lungs are clear. Sternotomy wires and pacemaker wires are
seen within the chest.
IMPRESSION: No evidence of obstruction or ileus.
.
KUB [**2122-11-2**]
FINDINGS: Three supine frontal images of the abdomen show newly
dilated loops of small bowel measuring up to 3.4 cm in the left
upper quadrant. Given history of recent arrest, the dilation may
be secondary to ischemia. Could also consider the possibility of
an early or partial small-bowel obstruction. There is no obvious
free air, although exam is somewhat limited due to supine
positioning. There has been interval placement of a femoral line
on the right groin. A catheter overlies the left upper quadrant,
and is likely external to the patient. Again noted is dense
calcification of the aorta and iliac vessels. A left total hip
arthroplasty is unchanged.
IMPRESSION:
Interval increasing dilation of air-filled loops of small bowel
loops raises concern for ischemia.
Brief Hospital Course:
Mr. [**Known lastname 91160**] is a 61M transferred from [**Hospital3 26615**] hospital with
CAD s/p 3V CABG and AVR in [**2120**], NSTEMI, s/p DDD pacer implant
for intermittent complete heart block in [**9-/2122**] transferred
from OSH for evaluation and management of VT with HD instability
requiring defibrillation.
.
# Septic shock/endocarditis with aortic valve dehiscence: The
patient underwent pacemaker placement [**2122-10-2**]. He was febrile
on admission with elevated wbc count and described weeks of
shaking chills. Blood cultures grew coag negative staph and he
was started on Vancomycin. His blood pressure decreased to the
SBPs in the 80-90s. He was started on cefepime in addition to
vancomycin. A TEE showed aortic valve dehiscence with flow from
the aorta to the right atrium and possible vegetations. He later
went into PEA briefly then his pulse returned but because of
hypotension and poor O2 saturation he was intubated and put on
pressors. His blood pressure continued to fall and he was
requiring 4 pressors and large volumes of IVF. A dialysis
catheter was placed to try to remove some volume and manage his
potassium. However, after this was placed his BP would not
tolerate dialysis. Shortly after he went into asystole and
passed away.
.
# VT/rhythm: In [**Month (only) 359**] he had a syncopal event thought to be
related to heart block so a pacemaker was placed. He was
transferred to [**Hospital1 18**] from an OSH after he had pulseless VT
requiring defibrillation. He was not in VT when he arrived at
[**Hospital1 18**]. He was planned to have an EP procedure and prior to the
procedure he was started on atenolol to prevent VT. However,
before he could undergo any procedure he developed septic shock
and aortic valve dehiscence and then expired as above.
.
Medications on Admission:
HOME MEDICATIONS:
ASA 81 mg daily
metformin 1000 mg qam
Vitamin D 1000 u daily
Coumadin
simvastatin 80 mg
lisinopril 10 mg daily (stopped taking)
metoprolol 50 mg daily (stopped taking)
.
Medications on transfer:
atenolol 25 mg daily
ASA 325 daily
atorvastatin 40 mg daily
NG
heparin drip
ISS
bisacodyl
docusate
milk of magnesia
Simethacone
guafenesin
acetaminophen
metformin 1000 mg
amiodarone infusion
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock
Presumed Endocarditis
Mechanical Disruption of aortic valve
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 2762, 4275, 4280, 2767, 2724, 4019, 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5118
} | Medical Text: Admission Date: [**2191-4-17**] Discharge Date: [**2191-6-29**]
Date of Birth: [**2191-4-17**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Known lastname 67149**] is a newborn, 865 g,
26 and 5/7 weeks' gestation twin, admitted to the NICU with
prematurity and respiratory distress. She was born at 1:01
a.m. on [**2191-4-17**]. She is an 856 g product of a 26 and
[**5-29**] week twin gestation to a 31-year-old, G3, P3-->5,
mother, with an [**Name (NI) 37516**] of [**2191-7-19**].
Previous obstetric history is notable for a term [**Doctor Last Name **]
and 36-week twin delivery. Prenatal labs included blood type
O+, antibody negative, RPR nonreactive, rubella immune,
hepatitis B surface antigen negative, GBS negative.
This pregnancy was notable for spontaneous di-di twin
gestation complicated by cervical shortening noted at 24
weeks. The mother was admitted at that time for bed rest and
monitoring and was given betamethasone [**3-28**] through [**3-29**]. Ultrasound showed estimated fetal weight at the 60th
percentile with normal amniotic fluid volumes and normal
biophysical profiles and vertex breech positioning.
The mother experienced spontaneous rupture of membranes on
[**4-13**], approximately 84 hours prior to delivery and was
begun on ampicillin and erythromycin. Later that evening, she was
noted to have progressive cervical dilation and was taken to the
OR for repeat cesarean section delivery. No fevers or other signs
of chorioamnionitis were noted.
At delivery, the infant emerged with moderate tone and
spontaneous cry requiring stimulation and blow-by oxygen for
resuscitation. Apgar scores were 8 and 8. The infant was
intubated in the delivery room for respiratory distress and
was later brought to the NICU.
PHYSICAL EXAMINATION:
On admission weight was 865g (25th to 50th percentile)
length 34 cm (25th to 50th)percentile
head circumference 25 cm (50th percentile)
Gen: well-developed, premature infant responsive to the
exam, intubated on the vent.
Vital signs: T96.5 HR169 RR50 BP 54/36 (MAP40)
HEENT: Fontanel soft and flat, Palate intact. Ears/nares normal.
Neck: Supple. No lesions.
Chest: Coarse, moderate aeration with PPV. Positive
retractions with spontaneous breath sounds.
Cardiac: Regular rate and rhythm. No murmur.
Abdomen: Soft. No hepatosplenomegaly.No mass. 3-vessel cord.
Quiet bowel sounds.
GU: Normal preterm female. Anus patent. Femoral pulses 2+.
Extremities: Back normal. No lesions.
Neurologic: Tone and activity appropriate for gestational age.
HOSPITAL COURSE: Respiratory: This patient was initially
intubated as previously stated in the delivery room and was
on conventional ventilator of SIMV for 2 days. The patient
did receive surfactant x 2. The patient was then extubated to
CPAP and was on CPAP x 1 week. She was then weaned to nasal
cannula and remained on nasal cannula x 4 days and was then
slowly weaned to room air. The patient has been on room air
for the past several weeks and has now completed a 5-day
spell count with no episodes of apnea or bradycardia.
Cardiovascular: The patient is status post diagnosis of
patent ductus arteriosus treated with 3 courses of Indocin.
The most recent echocardiogram on [**2191-5-10**] showed a trivial
PDA. The patient now has a soft systolic murmur.
Fluids, electrolytes and nutrition: Initially this patient
was maintained on PN and intralipids. The infant was slowly
advanced to full p.o. feeds of Enfamil AR ad lib. At this
time, the patient is tolerating approximately 140 cc/kg/day
minimum of Enfamil AR. On average, she takes in between 170-
200 cc of Enfamil AR p.o. ad lib. She is voiding and stooling
well. Her birth weight was 865 g. Discharge weight at this
time is 2495 g.
GI: The patient does have a remote history of
hyperbilirubinemia for which she was treated with
phototherapy x 3 days. Peak bilirubin was 3.9/0.3.
Phototherapy was discontinued after 3 days with rebound
bilirubin was 3.5/0.3.
Hematology: This patient was transfused once during this
hospitalization 20 cc/kg of packed red blood cells. She is
now maintained on iron with her most recent hematocrit of
26.5 and reticulocyte count of 6.4. She is also status post
ampicillin and gentamicin x 7 days for her initial rule out
sepsis evaluation at birth. All blood cultures
were negative to date. LP performed at that time also revealed
negative CSF culture.
Neurology: The infant's most recent head ultrasound was
performed on [**2191-6-24**], and revealed a small germinal
matrix cyst.
Sensory/audiology: Hearing screen was performed with
automated auditory brain stem responses. The infant passed
this examination on [**2191-6-27**].
Ophthalmology: Mature. Eyes were examined most recently on
[**2191-6-27**], revealing mature retinal vessels. A followup
exam is recommended in 6 months.
Psychosocial: [**Hospital6 256**] social
worker is involved with this family. The contact social
worker can be reached at [**Telephone/Fax (1) 8717**]. At the time of
discharge, the patient is in stable condition.
DISPOSITION: Home with mother.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 56424**] of [**Hospital1 8**], [**Hospital1 67150**] Health Center. Contact Office number [**Telephone/Fax (1) 47660**].
DISCHARGE MEDICATIONS: The patient is currently receiving
ferrous sulfate.
CAR SEAT POSITIONING SCREENING: The patient did pass her car
seat test on [**2191-6-27**].
IMMUNIZATIONS: This infant did receive her first hepatitis B
vaccine on [**2191-5-18**]. She has subsequently received her
Pediarix, DTaP and Prevnar on [**2191-6-22**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1) born at less than 32
weeks, 2) born between 32 and 35 weeks with 2 of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3) with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life),
immunization against influenza is recommended for all
household contacts and out-of-home caregivers.
FOLLOW UP: We recommend that this patient have a followup
appointment with her primary PMD within 1-2 days following
discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity.
2. Respiratory distress syndrome.
3. Sepsis evaluation.
4. Hyperbilirubinemia.
5. Apnea of prematurity.
6. Patent ductus arteriosus status post 3 courses of
Indocin.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 62404**]
MEDQUIST36
D: [**2191-6-28**] 14:51:06
T: [**2191-6-28**] 15:26:40
Job#: [**Job Number 67151**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5119
} | Medical Text: Admission Date: [**2162-9-18**] Discharge Date: [**2162-9-21**]
Date of Birth: [**2142-4-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
call out from ICU after admission for severe mononucleosis
Major Surgical or Invasive Procedure:
PICC line plcmt and PICC line removal
History of Present Illness:
20 yo W no PMHx who initially presented to [**Hospital6 **]
with > 1 week of fevers and vague symptoms including abdominal
pain. She was found to have a positive monospot and found to
have liver, pancreatic, pleural inflammation. Given her pleural
effusions she was transferred to [**Hospital1 18**] ICU. She did well for
the 1 day she was in the [**Hospital Unit Name 153**] and called out to the floor.
Fevers were ongoing up to 103F. She complained of abd pain in
the RUQ only during abd exams but no longer at rest. She had
no sore throat. Had pleuritic chest pain of the low mid chest /
epigastric region and inspiratory induced cough. She had no
hemoptysis or leg swelling. No diarrhea or constipation. Mild
chills. Very fatigued. All other systems are negative.
Past Medical History:
None
Social History:
Lives w/ mom, dad and 7 other siblings. Is nursing student at
[**Hospital1 **] [**Location (un) 86**]. No patient contact. [**Name (NI) **] been doing well.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
- Sexually active over the past 2 years, did not wish to
disclose partner number.
Family History:
Paternal aunt - "bone cancer" - died from PE.
Father - DVT, provoked
No AI, Inflammatory, connective tissue d/o. No other hx of
cancer.
Physical Exam:
VS: Tmax 102.6 at 9 p.m. [**9-18**] Tcurrent 99.0 BP 111/67 HR 88 RR
12 99% on 1L
GEN: NAD, AOX3
HEENT: MMM, OP CLEAR
CARD: RRR, no m/r/g
PULM: poor air movement, bilateral dullness at bases
ABD: patient currently refusing abdominal exam
EXT: WWP no c/c/e
NEURO: AOx3, CN2-12 normal, grossly normal
Pertinent Results:
[**2162-9-19**] 04:57AM BLOOD WBC-8.1 RBC-2.51* Hgb-8.7* Hct-24.6*
MCV-98# MCH-34.5* MCHC-35.3* RDW-21.8* Plt Ct-261
[**2162-9-18**] 07:49PM BLOOD WBC-11.0 RBC-2.88* Hgb-9.1* Hct-26.4*
MCV-91 MCH-31.6 MCHC-34.6 RDW-14.7 Plt Ct-238
[**2162-9-19**] 04:57AM BLOOD Neuts-39* Bands-0 Lymphs-38 Monos-5 Eos-2
Baso-0 Atyps-14* Metas-0 Myelos-2*
[**2162-9-18**] 07:49PM BLOOD Neuts-49* Bands-0 Lymphs-39 Monos-6 Eos-1
Baso-1 Atyps-4* Metas-0 Myelos-0
[**2162-9-18**] 07:49PM BLOOD PT-14.4* PTT-26.4 INR(PT)-1.2*
[**2162-9-18**] 07:49PM BLOOD Fibrino-321
[**2162-9-19**] 04:57AM BLOOD Parst S-PND
[**2162-9-19**] 04:57AM BLOOD Ret Aut-5.0*
[**2162-9-19**] 04:57AM BLOOD Glucose-86 UreaN-3* Creat-0.5 Na-139
K-3.5 Cl-104 HCO3-26 AnGap-13
[**2162-9-18**] 07:49PM BLOOD Glucose-98 UreaN-3* Creat-0.6 Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
[**2162-9-18**] 07:49PM BLOOD ALT-111* AST-170* LD(LDH)-1106*
AlkPhos-141* TotBili-1.3 DirBili-0.6* IndBili-0.7
[**2162-9-18**] 09:14PM BLOOD Lipase-112*
[**2162-9-19**] 04:57AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0 Iron-PND
[**2162-9-18**] 07:49PM BLOOD Albumin-3.0* Calcium-8.0* Phos-2.5*
Mg-2.0 Iron-120
[**2162-9-19**] 04:57AM BLOOD VitB12-PND Folate-PND Ferritn-PND TRF-PND
[**2162-9-18**] 07:49PM BLOOD calTIBC-254* Hapto-<5* TRF-195*
[**2162-9-18**] 07:49PM BLOOD Triglyc-245*
[**2162-9-18**] 07:49PM BLOOD HBsAg-PND HBsAb-PND HAV Ab-PND IgM
HBc-PND
[**2162-9-18**] 09:14PM BLOOD HIV Ab-PND
[**2162-9-18**] 07:49PM BLOOD HCV Ab-PND
[**2162-9-19**] 04:57AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-PND
[**2162-9-21**] 07:10AM BLOOD WBC-7.1 RBC-2.96* Hgb-9.3* Hct-27.2*
MCV-94 MCH-31.6 MCHC-34.3 RDW-15.7* Plt Ct-274
[**2162-9-21**] 07:10AM BLOOD Neuts-32* Bands-3 Lymphs-45* Monos-5
Eos-3 Baso-0 Atyps-9* Metas-3* Myelos-0
[**2162-9-20**] 06:10AM BLOOD Neuts-38* Bands-9* Lymphs-38 Monos-1*
Eos-1 Baso-0 Atyps-13* Metas-0 Myelos-0
[**2162-9-21**] 07:10AM BLOOD Glucose-81 UreaN-4* Creat-0.6 Na-141
K-3.2* Cl-105 HCO3-28 AnGap-11
[**2162-9-21**] 07:10AM BLOOD ALT-81* AST-102* LD(LDH)-785*
AlkPhos-273* TotBili-0.7
[**2162-9-19**] 04:57AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0 Iron-64
[**2162-9-19**] 04:57AM BLOOD calTIBC-247* VitB12-346 Folate-12.2
Ferritn-1393* TRF-190*
[**2162-9-18**] 07:49PM BLOOD HBsAg-PND HBsAb-POSITIVE HAV Ab-NEGATIVE
IgM HBc-NEGATIVE
[**2162-9-18**] 07:49PM BLOOD HCV Ab-NEGATIVE
[**2162-9-19**] CXR AP: The lung volumes are low. Borderline size of the
cardiac
silhouette. Moderate bilateral pleural effusions with subsequent
areas of
basal atelectasis. Minimal overhydration.
Time Taken Not Noted Log-In Date/Time: [**2162-9-19**] 11:29 am
SEROLOGY/BLOOD CHEM # 08445L.
LYME SEROLOGY (Pending):
[**2162-9-19**] 4:57 am Immunology (CMV)
CMV Viral Load (Pending):
[**2162-9-18**] 10:36 pm Immunology (CMV)
CMV Viral Load (Pending):
[**2162-9-18**] 7:49 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
MONOSPOT AT [**Hospital6 **]: POSITIVE
CT ABDOMEN AT [**Hospital6 **]:
[**2162-9-15**]
IMPRESSION:
bilateral lower lobe consolidations with bilateral small pleural
effusions
Appendix is top normal in size. Periappendiceal fluid may be
secondary to free fluid within the patient's pelvis. No
significant periappendiceal fat stranding or appendicolith
identified at this time. Recommend clinical correlation.
Geographic low attenuation region within the superomedial aspect
of the spleen which likely represents a focal area of infarction
in this patient with splenomegaly. Recommend clinical
correlation.
RADIOLOGY READ AT [**Hospital1 18**] [**2162-8-21**]: suggests possible organized
hematoma of the spleen which is small.
TRANSTHORACIC ECHO DONE AT [**Hospital6 **]: NORMAL LV
FUNCTION
Brief Hospital Course:
INFECTIOUS MONONUCLEOSIS: complicated by hemolytic anemia
realted to cold agglutinins. She also has evidence of multiorgan
involvement including liver inflammation, pancreatic
inflammation, serositits of pleura as well as the usual
inflammation of her upper respiratory tract. Her EBV IgM
returned positive (>5) on [**9-21**] from [**Hospital6 **] in
addition her monospot was positive. Multiple other tests had
been sent including hepatitis serologies, HIV, Lyme serologies,
CMV viral load which were all pending upon the time of discharge
and will need to be followed up by the patient's PCP. [**Name10 (NameIs) 87394**]
smear mainly looking for babesia was negative. Her hemolysis
stabilized, LFTs and LDH improved, fever curve trended downward
and the patient was discharged home with PCP follow up.
URINARY TRACT INFECTION, UNCOMPLICATED: Pyuria. No culture
data. Treated with cipro x 3 days.
POSSIBLE SPLENIC HEMATOMA: per [**Hospital6 **] this splenic
abnormality possibly represents a splenic infarct, per the
radiology team at [**Hospital1 18**] after images were uploaded it may
represent a organized hematoma. Given splenomegaly and mono a
organized hematoma was more clinically likely. Her HCT remained
stable after her hemolysis stablilized. She did not have any
LUQ pain. Given the small splenic bleed she was told to
strictly avoid driving or contact sports or vigorous exercise
for 6 weeks. In addition she was told the warning signs of
possible splenic rupture or bleed including syncope, presyncope,
diaphoresis or left upper quadrant pain.
Medications on Admission:
HOME MEDICATIONS:
NONE
TRANSFER MEDICATIONS:
Ciprofloxacin HCl 500 mg PO po bid x 3 days
Morphine Sulfate 2-4 mg IV Q4H:PRN pain
Guaifenesin-CODEINE Phosphate [**4-26**] mL PO/NG Q4H:PRN
Acetaminophen 650 mg PO/NG Q6H:PRN fever
Discharge Medications:
1. Outpatient Lab Work
Chem 7, CBC with differential, LDH, AST, ALT, Alk phos, total
bilirubin. Please have these labs drawn on [**9-27**] or [**9-28**]. Results to be faxed to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **]. Fax#
[**Telephone/Fax (1) 6808**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Infectious Mononucleosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers and found to have mono. This was
complicated by fluid around your lungs (pleural effusions),
liver and pancreas inflammation, break down of your red blood
cells causing anemia (called hemolysis) and a likely small bleed
in your spleen. You improved and are being discharged home to
follow up with your primary care physician. [**Name10 (NameIs) **] is very
important that you avoid any contact sports, vigorous exercise
or driving for 6 weeks as your spleen is at risk of bleeding
again if there is any trauma. There are many tests that are
still pending and unlikely to be positive. You can follow up
with these tests with your primary care physician.
NO MEDICATION CHANGES.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 34405**]
Appointment: Tuesday [**2162-9-28**] 10:40am
ICD9 Codes: 5990, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5120
} | Medical Text: Admission Date: [**2187-5-17**] Discharge Date: [**2187-6-4**]
Date of Birth: [**2187-5-17**] Sex: F
Service: Neonatology
TRANSFER DATE: [**2187-6-4**], to [**Hospital6 3872**].
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 43385**] is 32 6/7 weeks,
1740 gm female twin number 1 who was admitted to the Newborn
Intensive Care Unit for management of prematurity. This
II mother. Prenatal screens, blood type A+, antibody
negative, rapid plasmin reagin test non-reactive, hepatitis B
surface antigen negative, rubella immune.
This pregnancy was complicated by preterm labor with a cerclage
placed on [**2186-12-28**], at twelve weeks gestation. The mother
was admitted to [**Hospital1 69**] on [**3-5**],
membranes. Pregnancy also complicated by borderline
hypertension and insulin dependent gestational diabetes
mellitus. Mom received a full course of Betamethasone prior
to delivery.
On date of delivery with progressive spontaneous
labor to a vaginal delivery. Neonatology present at delivery.
The infant received DIM suction and facial CPAP. Apgar scores
were 7 at one minute and 8 at five minutes of age.
PHYSICAL EXAMINATION: Physical examination on admission,
weight 1740 gm, (50 percentile), length 42.5 cm, (25 to 50
percentile). Head circumference 31.5 cm, (50 to 75
percentile). General appearance, this is a premature infant
with decreased tone and respiratory distress. Skin, smooth
and pink, no rashes or birthmarks noted. Head and neck
examination, anterior fontanel open and flat, sutures
approximated. Eyes, positive red reflex bilaterally. Lips,
gums, palate intact. Thorax symmetrical. Lungs, positive
grunting, flaring and retracting with poor aeration
bilaterally. Heart, regular rate and rhythm, no murmur
auscultated, +2 pulses in upper and lower extremities.
Abdomen was soft, no hepatosplenomegaly, three vessel
umbilical cord. Genitalia consistent with preterm female,
patent anus, positive meconium shortly after delivery. Trunk
and spine, straight, no dimples or masses noted. Clavicles
intact. Hips stable. Tone consistent with gestational age.
HOSPITAL COURSE: Respiratory, the infant was admitted to the
Newborn Intensive Care Unit with significant grunting,
flaring and retracting, placed on nasal prong CPAP. Nasal
prong CPAP was weaned within a few hours and infant weaned to
room air with oxygen saturation greater then 95%, grunting,
flaring and retracting quickly resolved. The infant has
continued to be on room air for the remainder of her
hospitalization. The patient has occasional bradycardic
spells, no Methylxanthine have been required.
Cardiovascular, the patient's blood pressure has been stable
throughout her hospitalization. No saline boluses or pressor
support has been required. A soft intermittent murmur has
been noted during her hospitalization felt to be a PPS
murmur.
Fluids, electrolytes and nutrition, upon admission to the
Newborn Intensive Care Unit, the patient was started on
intravenous fluids of D10W at 80 cc per kg per day. D sticks
have been within normal range throughout her hospitalization.
Enteral feeds were initiated on day of life two and she
quickly advanced to full volume feeds by day of life five.
The patient is currently receiving feeds of premature Enfamil
enriched to 26 calories with ProMod. Feeds are partially by
bottle and partially by gavage. Last set of electrolytes on
day of life four, sodium of 147, potassium of 5.3, chloride
of 117 and a total carbon dioxide of 16. The patient is
voiding and stooling without difficulty. The patient's weight
at the time of transfer is [**2154**] gms (4 lbs 5.5 oz), length 45 cm,
head circumference 32.5 cm.
Gastrointestinal, peak bilirubin on day of life three was 8.2
with a direct bilirubin of 0.3. Phototherapy was started at
that time. Phototherapy was discontinued on day of life six
and rebound bilirubin on day of life seven was 5.2 with a
direct bilirubin of 0.2. There have been no issues with
feeding intolerance during her hospitalization.
Hematology. The infant has not received any blood products
during her hospitalization. Hematocrit at the time of
admission was 43.5.
Infectious Disease. A complete blood count and blood culture
were drawn upon admission to the Newborn Intensive Care Unit.
White blood cell count 10,000, platelet count of 284,000,
hematocrit of 43.5 with 19% neutrophils and 2% bands. The
patient received forty-eight hours of Ampicillin and
Gentamicin. The blood culture drawn on admission was
negative.
Neurology, head ultrasound was not indicated for this 32 6/7
weeks infant.
Sensory, a hearing screen was performed with automated,
auditory brain stem responses. The patient passed in both
ears.
Ophthalmology, eye examination was not indicated for this 32
6/7 weeks.
Psychosocial, a [**Hospital1 69**] social
worker has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) 43386**].
CONDITION AT TRANSFER: Infant stable on room air, tolerating
full feeds.
DISCHARGE DISPOSITION: Transfer to [**Hospital3 1280**] Hospital. Name
of primary pediatrician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital 6930**] Pediatrics,
phone number [**Telephone/Fax (1) 38703**].
CARE RECOMMENDATIONS: Feeds at transfer, premature Enfamil
enriched to 26 calories by concentration and MCT oil with
ProMod added.
MEDICATIONS: Iron supplements, a car seat position screening
has not yet been performed. State newborn screening status,
last newborn screen was sent on [**2187-6-1**], no abnormal
results have been reported. Immunizations received, the
patient has not received any immunizations at this time.
Immunizations recommended, RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria, 1) born at less then 32
weeks, 2) born between 32 and 35 weeks with plans for day
care during RSV season, with a smoker in the house or with
preschool siblings, 3) 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 immunizations against
influenza to protect the infant.
DISCHARGE DIAGNOSES: 1) Prematurity at 32 6/7 weeks. 2)
Transitional respiratory distress. 3) Rule out sepsis. 4)
Hyperbilirubinemia. 5) Mild apnea of prematurity.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Name8 (MD) 35942**]
MEDQUIST36
D: [**2187-6-3**] 14:32
T: [**2187-6-3**] 15:08
JOB#: [**Job Number 43387**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5121
} | Medical Text: Admission Date: [**2142-12-11**] Discharge Date: [**2142-12-14**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Peripheral vascular disease and left foot two toe gangrene
Major Surgical or Invasive Procedure:
1) Abdominal aortic unilateral extremity run off, angioplasty of
superficial femoral artery, popliteal tibioperoneal trunk and
peroneal arteries, stent of superficial femoral artery and
Cypher stent to tibioperoneal trunk and peroneal artery.
2) Amputation left 1st and 2nd toes
History of Present Illness:
84yF with known bilateral lower extremity vascular disease, seen
as an outpatient and scheduled for angiogram and angioplasty.
She was unable to make it into the hospital on her scheduled day
secondary to inclement weather. She was noted to have a fever
at her nursing home, and was sent to an outside hospital for
evaluation. They then transferred her from the outside hospital
to [**Hospital1 18**] for evaluation.
Social History:
Resident of [**Hospital6 59521**] Home
nonsmoker or drinker
Family History:
unknown
Physical Exam:
Vital signs: 97.6-100-24 97/46 oxygen saturation room air 97%
General: no acute distress
HEENT: no caroitd bruits
Lungs: clear to auscultation bilaterally
Heart: irregular irregular rythmn
ABd: begnin
PV: left ist and 2nd toe witrh ulcerations on dorasl aspect of
toes with erythema to mid leg.
Pulses: radial and femoral pulses 1+ bilaterally, distal [**Last Name (un) **]
monophasic dopperable signal only bilaterally.
Neuro: grossly intact
Pertinent Results:
[**2142-12-11**] 01:40PM WBC-9.3 RBC-4.23 HGB-12.0 HCT-35.9* MCV-85
MCH-28.3 MCHC-33.3 RDW-15.3
[**2142-12-11**] 01:40PM NEUTS-89.2* BANDS-0 LYMPHS-7.7* MONOS-2.6
EOS-0.4 BASOS-0
[**2142-12-11**] 01:40PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2142-12-11**] 01:40PM PLT COUNT-282
[**2142-12-11**] 01:40PM PT-15.4* PTT-30.4 INR(PT)-1.5
[**2142-12-11**] 01:40PM GLUCOSE-91 UREA N-20 CREAT-0.4 SODIUM-141
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11
[**2142-12-11**] 09:41PM WBC-6.2 RBC-3.78* HGB-10.4* HCT-31.4* MCV-83
MCH-27.4 MCHC-33.0 RDW-15.2
[**2142-12-11**] 09:41PM NEUTS-88.6* LYMPHS-7.1* MONOS-3.4 EOS-0.8
BASOS-0.1
[**2142-12-11**] 09:41PM MICROCYT-1+
[**2142-12-11**] 09:41PM PLT COUNT-268
[**2142-12-11**] 01:40PM GLUCOSE-91 UREA N-20 CREAT-0.4 SODIUM-141
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11
Brief Hospital Course:
[**2142-12-11**] Evaluated in the emergency room and admitted to
vascular surgical service for Iv antibiotics and wound care and
bed rest. Blood cultures were drawn results no growth but not
finallized. Wound culture gram positive cocci in pairs.Patient
give Vancomycin 1 GM, levofloxcin 500mgmnIV and flagyl 500mg IV
before admission.
She underwent a arteriogram with angioplasty to left distal SFA,
popliteal arteries and Tibial peroneal trunk , and peroneal
arteries.Stenting of SFA,[**Doctor Last Name **] and proximal AT
and peroneal arteries without complication and was transfered to
ICU for moniteringover night.
[**2142-12-12**] Podiatry consulted.Postoperative cadrdiac enzymes were
CK 236, MB 4 Troponin <0.01 No EKG changes. Patient underwent
radical debridment of bone and soft tissue of 1st and 2nd toe.
[**2142-12-13**]
[**2142-12-14**] continued to do well. wounds claen dry and intact with
no erythema, induration of tenderness. Coumadin restarted and
heparin discontinued. Patient transfered to Nursing home for
continued recovery. Will continue antibiotics of augmentin
500mgm tid x 7 days. Dressing dsd to amputation site qd. Keep
foot elevated when in chair or bed. Partial weight bearing left
heel when ambulating essential distances. Follwup as directed in
2 weeks.
Medications on Admission:
new: augmentin 500mgm tid x 7 days
percocet tab 5/325mgm [**12-15**] q4-6h prn
Discharge Medications:
1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Peripheral vascular disease and left foot two toe gangrene
blood loss anemia, transfused, corrected
HTN
hypercholesterolemia
osteoporosis
arthritis
h/o CVA
h/o Left leg sarcoma
Discharge Condition:
Stable
Discharge Instructions:
[**Name8 (MD) **] MD for temp >101.5, redness or drainage from groin puncture
site, redness or drainage from left toe amputation sites,
persistent pain, or any other questions. You may put partial
weight on your left heel, but do not bear weight on your left
toes.
moniter INR as needed to maintain goal of 2.0-3.0
Followup Instructions:
With Dr. [**Last Name (STitle) **] in 2 weeks. Please call for appt.
[**Telephone/Fax (1) 2625**]
With Dr. [**First Name (STitle) 3209**] [**Telephone/Fax (1) 543**]
Completed by:[**2142-12-14**]
ICD9 Codes: 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5122
} | Medical Text: Admission Date: [**2129-5-12**] Discharge Date: [**2129-5-17**]
Date of Birth: [**2107-10-30**] Sex: F
Service: GYNECOLOGY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 15942**] is a 21 year-old
G2 P1 who presented to [**Hospital1 69**]
on postpartum day/postoperative day number eight status post
primary low transverse cesarean section on [**2129-5-5**] (failed
IOL, complicated by preeclampsia) with dyspnea since the
evening prior to admission. She stated that the shortness of
breath began with gradual onset. She denies any chest pain,
palpitations, hemoptysis, cough, fever, or chills. She
states that the dyspnea is increased while she is in the
supine position.
OB HISTORY: G2 P1. [**2129-5-5**] primary low transverse cesarean
section for failed induction of labor for increased blood
pressures. The patient developed preeclampsia by increased
blood pressures, edema, headache, protein to creatinine ratio
of 0.7. Also of note is the fact that experienced an
intraoperative hemorrhage resulting in a hematocrit of 20%
and was not transfused at that time.
GYN HISTORY:
1. SAB times one.
2. History of OCP use in the past with no evidence of
thrombosis.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: Primary low transverse cesarean
section.
MEDICATIONS: An antihypertensive of which the patient could
not recall.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: There is a paternal history of cardiac
disease. No history of clotting disorders or deep venous
thrombosis and no history of acute myocardial infarction.
SOCIAL HISTORY: The patient denies tobacco, alcohol or drug
use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs blood
pressure 160/95. Heart rate 85 to 95. Respiratory rate 20
to 22. O2 sat was 89% on room air improving to 96% on face
mask O2. In general, the patient was in mild distress and
was tachypneic. Neck no JVD. Cardiovascular regular rate
and rhythm with 2 out of 6 systolic ejection murmur.
Pulmonary decreased breath sounds at bilateral bases along
with fine rales at bilateral bases. Abdomen was soft,
nontender, nondistended with the fundus firm 4 cm below the
umbilicus. Her incision was significant for blanching
erythema surrounding the incision with no fluctuance or no
drainage noted. Extremities 2+ pitting edema. Neurological
grossly intact. Deep tendon reflexes were 2+.
LABORATORIES ON ADMISSION: CBC white blood cell count 11.2,
hematocrit 19.4, platelets 517, fibrinogen 403, ALT 38, uric
acid 5.5. Chem 7 sodium 140, potassium 4.7, chloride 105,
bicarb 19, BUN 15, creatinine 0.5. Arterial blood gas
7.45/108/31/22 on 6 liters of O2. Portable chest x-ray was
performed and was pending at that time. Electrocardiogram
revealed sinus tachycardia at 98 beats per minute with normal
axis and no strain.
INITIAL IMPRESSION: The patient is a 21 year-old G2 P0 eight
days postoperative status post primary C section presents
with dyspnea, tachypnea, tachycardia, hypertension, and
peripheral edema. Also of note the patient has cellulitis
surrounding her incision. Differential diagnosis at that
time included congestive heart failure, peripartum
cardiomyopathy, or pulmonary embolism. The decision was made
to proceed with echocardiogram and CT angiogram at that time.
She was also begun on Kefzol intravenous for cellulitis.
HOSPITAL COURSE: 1. Cardiopulmonary: The patient was
admitted to the Medical Intensive Care Unit for more
comprehensive evaluation and further medical management.
Initially under gyn care the patient improved symptomatically
after initial dose of 10 mg intravenous Lasix. Chest x-ray
revealed cephalization of the pulmonary vasculature with
bilateral pleural effusions. Echocardiogram was normal. CT
angiogram revealed no evidence of pulmonary embolism and
confirmed bilateral pleural effusions. The patient received
10 mg intravenous Hydralazine times two, 10 mg Labetalol
intravenous times three, 10 mg intravenous of Lasix for a
total of two doses, all for elevated systolic blood pressures
in the 200s. She was begun on a nitroglycerin drip and
morphine prn. She also received intravenous Lasix as needed.
The patient's hypoxia was determined to be most likely
secondary to her hypertension and volume overload and
improved significantly with blood pressure control and
diuresis. On HD 2 she was transferred to gyn service. The
patient's antihypertensive regimen was
increased during her stay and the patient was discharged on
400 mg of Labetalol b.i.d. On discharge the patient had
blood pressures in the range of 120s to 160s/90s.
2. Infectious disease: Abdominal wound cellulitis was
significantly improved on intravenous Kefzol. Her T max on
[**2129-5-12**] was 103. She was afebrile for greater then 48 hours
prior to discharge. She was also found to have a urinary
tract infection during her stay, which was also treated with
Kefzol. This was changed over to po Keflex, which the
patient was discharged home on.
3. Hematology: The patient's hematocrit on admission was
19.4. The decision was made on the day of admission to give
the patient 2 units of packed red blood cells with
intravenous Lasix as needed. The patient's hematocrit
improved significantly initially to 24 and subsequently to 27
at the time of discharge.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern4) 10591**], M.D. [**MD Number(1) 47472**]
Dictated By:[**Last Name (NamePattern1) 38927**]
MEDQUIST36
D: [**2129-5-19**] 11:03
T: [**2129-5-19**] 13:55
JOB#: [**Job Number 47473**]
ICD9 Codes: 5990, 4280, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5123
} | Medical Text: Admission Date: [**2107-1-2**] Discharge Date: [**2107-1-22**]
Date of Birth: [**2081-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
fiberoptic intubation, IR-guided central line placement,
IR-guided PICC placement
History of Present Illness:
Patient is a 25 yo M with PMHx sig. for microcephaly/cerebral
palsy and is non-verbal and severely contracted at baseline who
presents with lethargy and was found to be in DKA at OSH. Per
his mother, he developed a fever to [**Age over 90 **] yesterday. His
grandmother, who also cares for him, recently had a cough
treated with 5 day course of antibiotics. However, the patient
never developed a cough; he may have looked a little more short
of breath today. Throughout the day today, he did became
increasingly lethargic, though he completed eating his breakfast
and lunch without problems. His mother felt that he was not
responding as well to her voice, ie smiling or looking at her.
His limbs were also more flaccid than at baseline. In addition,
she noticed that his eyes were twitching, which has occurred in
the past with fevers. They were also bloodshot. His mother
noticed that he has been urinating more and drooling less. She
denied any vomiting, diarrhea. He has had H1N1 already in
[**Month (only) **]. He also had a cough, treated with amoxicillin, in
[**Month (only) 1096**]. He usually gets over these episodes rather quickly.
.
He was taken to [**Hospital3 **], where VS were rectal temp of 100.5,
SBP 95, hyperglycemia to 1392, Na 162, and Cr 2.2. He was given
CTX there for UTI despite a U/A with neg nitrite, leuk est. He
was not given insulin. CT head at OSH reports no acute
pathology.
.
In the ED, vital signs were initially: 97.0, 98, 117/79, 18,
98%. Exam was sig. for slight rhonchi on the right. Labs were
sig. for glucose of 1208, Na 170, Cl 128, creatinine 2.6, HCT of
61, lactate 3.1. U/A showed ketones. CXR showed no infiltrate.
BCxs, UCx were obtained. He is receiving NS 100 cc/hr. He was
not started on insulin gtt. VS on transfer: 99, 117/87, 16, 100%
on 2L.
Past Medical History:
Microcephaly/Cerebral Palsy
Kyphosis s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47817**] rod
Social History:
Pt lives with his parents. He goes to a day program from 9AM
-3PM. His grandmother also cares for him. He is wheelchair
bound. He is fed pureed foods and Ensure once a day.
Family History:
Both parents are healthy. No history of heart disease, DM. Aunt
with epilepsy
Physical Exam:
Temp:97.0 HR:98 BP:117/79 Resp:18 O(2)Sat:98
GEN: The patient is in no distress and appears comfortable.
NECK: Supple. No lymphadenopathy in cervical, posterior, or
supraclavicular chains noted.
HEENT: L pupil 2 mm larger than R, both reactive. Erratic
nystagmus. MM dry.
CHEST: Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: Normoactive BS, soft, NT, ND.
EXTREMITIES: no peripheral edema, warm.
NEUROLOGIC: Alert. Wrists, elbows bilaterally flexed. Increased
tone in shoulder joint, less in elbow joint bilaterally.
SKIN: There is a maculopapular rash on the back, which the
mother states is his usual rash on dependent areas. Erythematous
rash on R groin.
Pertinent Results:
RIGHT UPPER QUADRANT ULTRASOUND [**1-3**]:
There is limited assessment, particularly in the midline, due to
overlying bowel gas. Where visualized, the liver demonstrates no
focal or echotexture architecture abnormality. Main portal vein
is patent with normal hepatopetal flow. No intra- or
extra-hepatic biliary ductal dilatation is noted, with the
common duct measuring 3 mm. The
gallbladder is filled with echogenic shadowing stones. No
evidence for
gallbladder wall thickening or pericholecystic fluid is seen to
suggest acute cholecystitis. The patient is nonresponsive,
therefore [**Doctor Last Name 515**] sign cannot be assessed. No ascites is seen
in the right upper quadrant.
IMPRESSION: Cholelithiasis, without findings of acute
cholecystitis.
CT CHEST/ABD/PELVIS [**1-5**]:
1. Bibasilar areas of consolidation and peribronchovascular
ground-glass
opacities, probably representing combination of atelectasis with
possible
aspiration, inflammation, and/or infection. Trace right pleural
effusion.
2. Patulous and edematous distal esophagus with circumferential
wall
thickening and intraluminal fluid, may represent esophagitis,
clinical
correlation recommended.
3. Nearly diffuse small and large bowel wall thickening and
hyperenhancement consistent with enteritis/colitis, such as
infectious/inflammatory, less likely ischemic. Appendix not
visualized. No bowel obstruction seen.
4. Area of hypoattenuation within the right hepatic lobe has
somewhat rounded appearance but has vessels coursing through it,
suggestive of perfusion heterogeneity or focal fatty
infiltration.
CT SINUS [**1-5**]:
1. Diffuse mild mucosal thickening with layering high-density
fluid seen
throughout the paranasal sinuses. Fungal colonization is not
excluded, nor is infection.
2. Area of demineralization along the superior aspect of the
medial right
maxillary sinus wall.
3. Opacification of the [**Last Name (un) **]- and oropharynx, with ET tube and
NG tube in
place.
4. Partial opacification of the visualized right mastoid air
cells.
5. Marked ventriculomegaly with very thin cerebral cortex,
incompletely
visualized on the current study.
ECHO [**1-10**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and 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. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. No masses or vegetations are seen on
the aortic valve. The mitral valve appears structurally normal
with trivial mitral regurgitation. No mass or vegetation is seen
on the mitral valve. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
CT CHEST/ABDOMEN/PELVIS [**1-12**]:
1. Extensive right lung and left lower lobe consolidations with
air
bronchograms are new compared to two days prior, with increased
left greater than right small pleural effusions.
2. Foley balloon catheter located within the urinary bladder.
There is new
diffuse anasarca with slight increase in small ascites. No
definite findings to account for increased abdominal pressure
otherwise.
3. While small bowel loops which are better distended today show
no wall
thickening, there is apparent persistent wall thickening along
the ascending and descending colon, representing non-specific
colitis.
4. Patulous esophagus with circumferential wall thickening,
again possibly
representing esophagitis. Intraluminal fluid extends to the
thoracic inlet, increasing risk for aspiration.
5. Rounded peripheral hypodense region in the right hepatic lobe
re-demonstrated on non-contrast study, probably representing
focal fatty
infiltration.
CXR [**1-22**]:
One supine view. Comparison with the previous study done
[**2107-1-21**]. Bilateral interstitial infiltrates consistent with
edema persist. Mediastinal structures are unchanged. These are
partially obscured by bilateral [**Location (un) 931**] rods. An endotracheal
tube, nasogastric tube and PICC line remain in place. All of
these are somewhat obscured by orthopedic hardware but appear
unchanged.
IMPRESSION: Limited study demonstrating persistent bilateral
interstitial
infiltrates consistent with edema.
MICRO:
All cultures from admission through [**1-12**] negative, including
flu, RSV, urine, stool and sputum. Sputum did grow yeast.
[**2107-1-13**] 8:18 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2107-1-15**]**
GRAM STAIN (Final [**2107-1-13**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2107-1-15**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
[**2107-1-17**] 2:35 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2107-1-17**]):
[**9-26**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2107-1-19**]):
Commensal Respiratory Flora Absent.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE
GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 86088**]
([**2107-1-15**]).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
FUNGAL CULTURE (Preliminary):
YEAST.
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 0.2 <0.5
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
>500 pg/mL * Negative Less than 60 pg/mL
Indeterminate 60 - 79 pg/mL
Positive Greater than or equal to 80
pg/mL
ADMISSION LABS:
[**2107-1-2**]
170 / 128 / 57
--------------< 1208
3.9 / 22 / 2.6
CK: 530 MB: 3 Trop-T: 0.04
Ca: 8.9 Mg: 3.1 P: 3.6
ALT: 86 AP: 321 Tbili: 1.0 Alb: 4.4
AST: 49 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 474
Osms:434
freeCa:1.26
Lactate:3.1
pH:7.10 (venous)
CBC:
5.7 > 17.4 / 61 < 122
N:80.7 L:15.6 M:2.8 E:0.1 Bas:0.7
URINE
Prot 25
Glu 1000
Ket 15
OTHER LABS
Hgb A1c: 9.7
ENZYMES & BILIRUBIN CK(CPK)
[**2107-1-13**] 03:39AM 291
[**2107-1-12**] 06:17AM 297
[**2107-1-11**] 05:30AM 790*
[**2107-1-10**] 02:19AM 2699*
[**2107-1-9**] 03:59AM 5212*
[**2107-1-8**] 01:59PM 8391*
[**2107-1-8**] 05:02AM [**Numeric Identifier 86089**]*
[**2107-1-7**] 08:59PM [**Numeric Identifier **]*
[**2107-1-7**] 01:04PM [**Numeric Identifier 86090**]*
[**2107-1-7**] 06:57AM [**Numeric Identifier 26950**]*
[**2107-1-7**] 03:31AM [**Numeric Identifier 57835**]*
[**2107-1-6**] 08:11PM [**Numeric Identifier **]*
[**2107-1-6**] 12:08PM 9652*
[**2107-1-6**] 04:17AM 6016*
[**2107-1-5**] 06:00AM 1322*
[**2107-1-3**] 09:59PM 1169*
[**2107-1-3**] 06:30PM 1185*
[**2107-1-3**] 02:20PM 1233*
[**2107-1-3**] 06:01AM 748*
[**2107-1-2**] 09:25PM 530*
RENAL & GLUCOSE Creat
[**2107-1-19**] 05:02PM 1.0
[**2107-1-18**] 05:23AM 1.2
[**2107-1-17**] 03:48AM 1.3*
[**2107-1-16**] 04:20PM 1.5*
[**2107-1-15**] 04:00PM 1.7*
[**2107-1-14**] 05:57PM 1.8*
[**2107-1-13**] 03:39AM 2.1*
[**2107-1-12**] 02:09PM 2.4*
[**2107-1-11**] 05:30AM 2.5*
[**2107-1-8**] 01:59PM 2.4*
[**2107-1-7**] 01:04PM 2.7*
[**2107-1-7**] 03:31AM 2.6*
[**2107-1-6**] 08:11PM 2.4*
[**2107-1-5**] 08:44PM 2.0*
[**2107-1-5**] 03:58AM 1.6*
[**2107-1-3**] 02:20PM 1.2
[**2107-1-2**] 09:25PM 2.6*
BLOOD GASES (all venous) pO2 / pCO2 / pH
[**2107-1-21**] 01:32PM 52* / 45 / 7.37
[**2107-1-19**] 12:40PM 43* / 50* / 7.42
[**2107-1-17**] 03:47PM 60* / 45 / 7.48*
[**2107-1-13**] 01:22AM 42* / 40 / 7.34*
[**2107-1-8**] 05:21AM 40* / 28* / 7.33*
[**2107-1-5**] 04:09PM 46* / 42 / 7.14*
[**2107-1-4**] 11:05PM 39* / 47* / 7.13*
[**2107-1-4**] 02:22PM 52* / 53* / 7.11*
DISCHARGE LABS:
[**2107-1-22**]
145 / 112 / 19
---------------< 124
3.7 / 21 / 0.8
Ca: 8.0 Mg: 2.0 P: 3.0
6.3 > 9.0 /27.3 < 523
Brief Hospital Course:
[**Known firstname **] is a 25 year-old with cerebral palsy who is non-verbal
at baseline. He was brought to the hospital by his family for
fever, lethargy and concern for dehydration. He was noted to be
in diabetic ketoacidosis/hyperosmolar hyperglycemic nonketotic
syndrome with profound hyperglycemia. His hopsital course was
complicated by aspiration pneumonia and respiratory failure/ARDS
requiring mechanical ventilation, septic shock requiring pressor
support and renal failure. He also developed a ventilatory
associated pneumonia with sputum growing pseudomonas and
stenoptrophomonas. He currently has improved significantly in
terms of hemodynamics and renal fuction which are both at
baseline and his persistant issue has been difficulty assessing
readiness for extubation.
ACTIVE PROBLEMS:
1. RESPIRATORY FAILURE
As above, initially in setting of aspiration with development of
ARDS. Improved over time and then subsequently developed
ventilator associated pneumonia as above. Now being treated with
antibiotics. Intubation was difficult even with use of fiber
optics. Extubation has been complicated by difficulty predicting
readiness. This is due to a combination of the following: a) 6mm
ETT which has non-trivial resistance. He actually appeared to
fatigue when kept on pressure support ventilation for more than
a couple hours. b) abnormal baseline respiratory mechanics
secondary to his body habitus and underdeveloped lungs and also
with chronic respiratory acidosis c) difficulty assessing mental
status d) concern about need for reintubation.
2. VENTILATOR ASSOCIATED PNEUMONIA
He developed new fevers on [**1-12**]. Sputum grew pseudomonas and
then stenotrophomonas. Day of transfer, [**2107-1-22**] is day [**7-16**] of
meropenem for pseudomonas and day [**3-16**] of bactrim for
stenotrophomonas.
3. ELEVATED B-GLUCAN
Isolated elevation in beta glucan x 3 with unclear significance.
Have been treating with micafungin as has been persistantly
febrile. This was changed to voriconazole on [**1-21**]. He should
have a repeat beta glucan.
4. DIABETES MELLITUS
Now on lantus 15 units and regular insulin sliding scale. When
taking meals, should have sliding scale changed to shorter
acting.
5. FEVERS
Likely secondary to VAP but persisted intermittently even with
treatment. Concern also for fungal infection given elevated beta
glucan. Central line removed and pan cultured as well. Other
possible source is sinus as has evidence of disease on CT.
6. CEREBRAL PALSY
Continued baclofen and valium for contractures.
7. ANEMIA
This has been stable. Unclear baseline. Initially with
gastrocult positive emesis. FOB negative. No evidence of
hemolysis.
RESOLVED PROBLEMS:
1. SEPTIC SHOCK:
Required phenylephrine from [**1-4**] - [**1-10**] with one day also
requiring vasopressin. Covered very broadly with antibiotics
including antifungals. No culture growth. Likely [**1-4**]
ARDS/distributive physiology.
2. ARDS
As above, no inciting organism identified. Likely [**1-4**] large
aspiration in setting of vomiting.
3. DIABETIC KETOACIDOSIS/Hyperosmolar hyperglycemic nonketotic
syndrome
Very hyperglycemic and with Hgb A1c 9.7 so more consistent with
DMII. Improved on insulin gtt and then transistioned to SQ.
Trigger may have been viral URI.
4. HYPERNATREMIA
Initially [**1-4**] profound dehydration. Resolution hindered by IVF
resusitation. Has improved with enteral free water.
5. ACUTE RENAL FAILURE
Became anuric in setting of sepsis. Also with elevated
intra-abdominal and bladder pressures which increased the MAPs
necessary for renal perfusion. Improved without need for
dialysis.
6. ELEVATED CK
This elevated after agressive fluid resusitation leading to
significant edema including scleral edema and likely resulted
from the anatomical limitations on fluid distribution
exacerbated by oligura. This improved with improving urine
output and resolution of edema.
7. ACCESS
Significant diffculty with IV access requiring IO access
intilliary and IR guided IJ line and then PICC. Unable to get
arterial blood gases.
8. Elevated lipase and transaminases:
RUQ US with cholelithiasis but not evidence of cholecystitis.
9. Thrombocytopenia
Initially low platelets which improved with resolution of
sepsis.
10. LLE edema
Asymmetric but multiple ultrasounds negative for DVT
Medications on Admission:
Fexofenadine 30 mg daily
Ranitidine 75 mg [**Hospital1 **]
Diazepam 6 mg/4 mg/6 mg
Baclofen 5 mg TID
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-4**]
Drops Ophthalmic Q2H (every 2 hours) as needed for eye
lubrication.
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
7. Diazepam 2 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
8. Diazepam 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
11. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous once a day.
12. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection four times a day.
13. Meropenem 500 mg IV Q8H
14. Pantoprazole 40 mg IV Q24H
15. Fentanyl Citrate (PF) 100 mcg/2 mL (50 mcg/mL) Syringe Sig:
25-50 mcg Intravenous every four (4) hours as needed for
agitation.
16. Voriconazole 200 mg IV Q12H
17. Sulfameth/Trimethoprim 185 mg IV Q8H
Day 1 = [**1-19**]
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
19. Midazolam 0.5-1 mg IV Q4H:PRN discomfort
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Primary:
Septic shock, respiratory failure, diabetic ketoacidosis,
Hyperosmolar hyperglycemic nonketotic syndrome, diabetes
mellitus, ventilator associated pneumonia, acute renal failure
Secondary:
cerebral palsy
Discharge Condition:
Mental Status: non-verbal, baseline
Level of Consciousness: Alert
Activity Status:Bedbound
Discharge Instructions:
Dear [**Doctor Last Name **],
You were admitted with high sugar and dehydration. You got very
sick and needed medicine to support your blood pressure and a
tube to help you breath. You are doing much better. You are
going to [**Hospital1 **] to have the tube removed in a setting where
they are more prepared to manage the potential complications in
people your size.
We will miss you.
Followup Instructions:
per [**Hospital1 **]
has been followed by [**Last Name (un) **] here
PCP
ICD9 Codes: 5849, 5070, 0389, 2760, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5124
} | Medical Text: Admission Date: [**2105-1-13**] Discharge Date: [**2105-1-16**]
Date of Birth: [**2034-7-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Intermittent claudication
Major Surgical or Invasive Procedure:
Right femoral to above-knee popliteal artery
bypass with an 8-mm PTFE graft
History of Present Illness:
This 70-year-old gentleman is status post an
aortobifemoral bypass in the distant past for aneurysm with
occlusive disease. He has developed bilateral superficial
femoral artery occlusions with severe disabling claudication.
The left side was treated with an angioplasty. The right side
is not amenable to catheter-based intervention. Arteriography
showed reconstitution of an above-knee popliteal artery with
3-vessel runoff below the knee.
Past Medical History:
AAA with illiac artery aneurysms treated with an aortobifemoral
graft [**2089**].
Bilat carotid endarterectomies
CAD - coronary angioplasty and stenting [**2103**]
CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential
SVG to AM/PDA)[**2089**]
Hyperlipidemia
HTN
AODM
Cerebral hemorrhage mid [**2085**]??????s
Prior CVA
Social History:
Patient is married with 8 children.
Lives with: Wife
Occupation: [**Name2 (NI) **] fitter - retired
ETOH: Rare
Tobacco: denies
Family History:
non contributory
Physical Exam:
Please See H&P
Pertinent Results:
[**2105-1-13**] 06:51PM GLUCOSE-153* UREA N-19 CREAT-1.1 SODIUM-137
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
[**2105-1-13**] 06:51PM estGFR-Using this
[**2105-1-13**] 06:51PM ALT(SGPT)-32 AST(SGOT)-50* ALK PHOS-40
[**2105-1-13**] 06:51PM CK-MB-2 cTropnT-<0.01
[**2105-1-13**] 06:51PM CALCIUM-8.6 PHOSPHATE-4.1 MAGNESIUM-1.9
[**2105-1-13**] 06:51PM HGB-11.9* HCT-35.4*
[**2105-1-13**] 06:51PM PLT SMR-VERY LOW PLT COUNT-50*
[**2105-1-13**] 06:51PM PT-14.3* PTT-30.9 INR(PT)-1.2*
[**2105-1-13**] 05:25PM TYPE-ART PO2-203* PCO2-43 PH-7.34* TOTAL
CO2-24 BASE XS--2
[**2105-1-13**] 05:25PM GLUCOSE-137* LACTATE-1.9 NA+-136 K+-4.1
CL--105
[**2105-1-13**] 05:25PM HGB-12.8* calcHCT-38
[**2105-1-13**] 05:25PM freeCa-1.15
[**2105-1-13**] 03:46PM TYPE-ART PO2-101 PCO2-32* PH-7.45 TOTAL
CO2-23 BASE XS-0
[**2105-1-13**] 03:46PM GLUCOSE-143* LACTATE-1.6 NA+-138 K+-3.9
CL--107
[**2105-1-13**] 03:46PM HGB-14.2 calcHCT-43
[**2105-1-13**] 03:46PM freeCa-1.23
Brief Hospital Course:
This 70-year-old gentleman is status post an aortobifemoral
bypass in the distant past for aneurysm with occlusive disease.
He has developed bilateral superficial
femoral artery occlusions with severe disabling claudication.
The left side was treated with an angioplasty. The right side is
not amenable to catheter-based intervention. Arteriography
showed reconstitution of an above-knee popliteal artery with
3-vessel runoff below the knee. Patient was admitted for Right
femoral to above-knee popliteal artery bypass with an 8-mm PTFE
graft.
Post-op patient was noted to be doing well with minimal pain and
stable hct.
POD1: Patient continued to do well had a small hematoma at his
groin site. DP and PT pulsed were dopplerable bilat.
POD 2: Foley was removed. Patient voided appropriately. Patient
was started on Plavix and tolerated a regular diet.
POD 3: Patient was seen by PT and cleared for home without
services.
Medications on Admission:
[**Last Name (un) 1724**]: Plavix 75', Folate-B6-B12, Gabapentin 1200', Glimepiride 1
mg', Lopressor 50', Simvastatin 80', Sitagliptin 100', ASA 81,
Niacin, Omega FA, Vit E 400'.
Discharge Medications:
1. Oxycodone 5 mg Capsule Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: otc - while on pain medication.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at
bedtime: home med.
6. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime): home med.
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
home med.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO at bedtime:
home med.
9. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day: home
med.
Discharge Disposition:
Home
Discharge Diagnosis:
Intermittent claudication with right
superficial femoral artery occlusion.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2105-1-29**] 12:40
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5125
} | Medical Text: Admission Date: [**2126-8-23**] Discharge Date: [**2126-9-19**]
Date of Birth: [**2048-6-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old female
involved in a motor vehicle accident. She was an unrestrained
driver with no loss of consciousness, but was hit by a dump
truck with significant intrusion into the car. She has
complaint of chest pain and systolic blood pressure of 88 and
heart rate of 100 in the field.
78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p
trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic
picture likely aspiration pneumonia secondary to dobhoff being
placed into lung.
Major Surgical or Invasive Procedure:
placement of G tube
History of Present Illness:
HISTORY OF PRESENT ILLNESS:78F re-admit (s/p MVC with c spine
fx/pulm contusions/rib fx s/p trach/spenic lac s/p
splenectomy/pelvic fx) - from rehab, septic picture likely
aspiration pneumonia secondary to dobhoff being placed into
lung. Seventy-eight-year-old female
involved in a motor vehicle accident. She was an unrestrained
driver with no loss of consciousness, but was hit by a dump
truck with significant intrusion into the car. She has
complaint of chest pain and systolic blood pressure of 88 and
heart rate of 100 in the field.admitted to [**Hospital1 18**] on [**7-29**] with C2
fracture, bilateral pleural
hematomas, L breast implant rupture, rib fractures, splenic
laceration s/p splenectomy and s/p nephrostomy tube placement,
who returned to [**Hospital1 18**] from rehab on [**8-23**] with hypoxia and
respiratory distress.
Past Medical History:
PMH:
Amyloidosis, depression, kidney stones, hx of tubal ligation, L
hip replacement
Social History:
SH: 2 cigs per day, 1-2 drinks per day
Family History:
FH: daughter [**Name (NI) 372**] is currently undergoing temporary
guardianship
Physical Exam:
Tc afebrile HR 96, BP 161/67, RR 34, 99% on PS
[**7-5**], 40% FI02
Gen: lying in bed, eyes open, minimal mvmt.
HEENT: trach in place, copious sputum out of trach opening,
coughing,mmm, OP benign
Neck: in C collar
CV: RRR, difficult to auscultate given breath sounds
Resp: coarse upper airway sounds bilaterally
Abd: multiple dressings covering postop incisions, ileostomy bag
c/d/i
Ext: warm, well perfused
Skin: ecchymoses on legs and arms.
MS: Awake, opens eyes to voice but not command and looks to
right
at calling of name, not consistently to left. Wiggles toes to
commands, will not squeeze hands to command, will not lift arms
to command.
CN: PERRLA, blinks to threat bilaterally. Full eye movements
horizontally but seems to have R gaze preference. No evidence of
nystagmus, no ptosis. Grimaces to stim on both sides of face.
Corneal reflex present. Face symmetric but difficult to assess
wtih collar. Hears voice. No speech. +cough.
Motor: Nl bulk, perhaps increased tone to passive motion in
bilateral upper extremities. Spontaneously wiggles toes R more
briskly than L, and spontaneously flexes R arm at elbow.
Otherwise, no spontaneous movements. ON passive flexion she does
resist my motion in both upper extremities. On painful
stimulation she grimaces but only withdraws in RUE and RLE.
Reflexes:
[**Hospital1 **] Tri BR Pat Ach Plantar
L 2 2 1 1 1 down
R 2 2 1 2 1 down
[**Last Name (un) **]: feels pain in all four extremities.
Pertinent Results:
[**2126-8-23**] 04:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
[**2126-8-23**] 04:10AM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2126-9-18**] 02:30AM BLOOD WBC-12.0* RBC-3.14* Hgb-9.6* Hct-28.1*
MCV-90 MCH-30.5 MCHC-34.0 RDW-15.3 Plt Ct-465*
[**2126-9-17**] 02:13AM BLOOD WBC-10.7 RBC-2.87* Hgb-9.0* Hct-26.0*
MCV-91 MCH-31.3 MCHC-34.5 RDW-15.3 Plt Ct-457*
Brief Hospital Course:
ID: Patient has been consistently febrile, initially started on
vancomycin and zosyn for presumed pneumonia, sputum cultures and
blood cultures positive for yeast. She was treated with
meropenam, vancomycin, flagyl, and then on [**8-31**] caspofungin
added. She continues to be febrile. Since [**8-30**] blood cultures
have been negative, sputum continues to grow yeast.
GI: On [**8-29**] she was noted to have rise in her LFT's and
abdominal
tenderness, she was taken to the OR for an exploratory
laparotomy
and found to have an ischemic colonic perforation. R colectomy
and ileostomy placement was performed at that time. She is still
not receiving feeds through the G tube.
Heme: Initially anemic, now hct has been stable in mid-20's.
Neuro: Pt when admitted on [**8-23**] was noted to follow commands and
express pain. She was on her home regimen of paxil for anxiety.
On day of admission she was started on propofol for agitation,
it
caused hypotension and it was weaned. She was at that time noted
to be sedated but still following commands. On [**8-24**] she was
switched to a versed drip. On [**8-26**] she was unarousable, versed
stopped and only given morphine PRN. She was noted on [**8-27**] to
follow commands and "awake and alert." [**8-29**] went to the OR, and
afterwards was treated with propofol and fentanyl. On [**8-30**] she
was noted to have minial movement of her LUE and none of her
RUE,
but moved both lower extremities in response to pain. On [**9-1**]
she
was reported to be "following commands" and responding to
painful
stimuli. She has been on a fentanyl drip until [**9-5**], when she
was
switched to a fentanyl patch. On [**9-7**] fentanyl patch was d/c'ed
and she has only been receiving fentanyl prn dressing changes.
Today, it was noted that despite being off sedation for several
days, she has not been awake or following commands initially
However this status has continues to improve and patient had
remained afebrile on trach trial up to 5 hours, she will need
continued wound care to incision with wet to dry dressing
Medications on Admission:
M
A
H
:
p
r
o
z
a
c
,
t
y
l
,
[**Initials (NamePattern5) 373**]
[**Last Name (NamePattern5) 374**],[**First Name3 (LF) **],dulcolax,diazepam,colace,lovenox,prevacid,lopressor,
oxycodone
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-2**]
Drops Ophthalmic Q2H (every 2 hours).
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN
(as needed) as needed for <2.0.
13. Caspofungin 50 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/p
trach/spenic lac s/p splenectomy/pelvic fx) - from rehab, septic
picture likely aspiration pneumonia secondary to dobhoff being
placed into lung.
ventilator dependent respiratoy failure, chronic anemia, sepsis,
poor nutritional status, tube feed dependence
Discharge Condition:
Stable
Discharge Instructions:
Please continue to ween ventilatory status (pt has been on trach
trial for 4-5 hr windows, continue local wound care, to midline
incicion, continue to monitor urine output via nephrostomy tube
and ostomy ourtput, please continue to ensure that she does not
become dehydrated.
Followup Instructions:
F/U recommended with interval CT scan [**1-3**] weeks to evaluate
fluid collection in right pelvis for catheter to be removed if
fluid is no longer draining as weel as be evaluated by Dr.
[**Last Name (STitle) 375**] please call regarding f/u and progress Trauma Clinic
Trauma W/LMOB 3a [**Hospital1 18**] ([**Telephone/Fax (1) 376**]. TRAUMA OUTREACH NURSE
TRAUMA OUTREACH W/LMOB 2G [**Hospital1 18**] ([**Telephone/Fax (1) 377**]
Completed by:[**2126-9-19**]
ICD9 Codes: 0389, 5070, 496, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5126
} | Medical Text: Admission Date: [**2119-10-11**] Discharge Date: [**2119-10-17**]
Date of Birth: [**2119-10-11**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**First Name9 (NamePattern2) 65644**] [**Known lastname 57455**] was born at 35
and 2/7 weeks gestation by stat cesarean section for a
nonreassuring fetal heart tracing. Her mother is a 35 year-
old gravida 7 para 5 now 6 woman. The mother's prenatal
screens are blood type 0 positive, antibody negative, rubella
equivocal, RPR nonreactive, hepatitis B surface antigen
negative and group B strep positive. By report there was late
prenatal care with only 2 prenatal visits before delivery.
This pregnancy was previously uncomplicated. Rupture of
membranes occurred spontaneously 7 and a half hours prior to
delivery. The mother did receive antepartum antibiotics. The
infant emerged with Apgars of 8 at 1 minute and 9 at 5
minutes. Hypoglycemia and hypothermia in L&D prompted NICU
admission.
PHYSICAL EXAMINATION: A vigorous preterm nondysmorphic
infant. Anterior fontanelle soft and flat. Comfortable
respirations. Lungs sounds clear and equal. Heart was regular
rate and rhythm. No murmur. Abdomen soft, nontender,
nondistended. No hepatosplenomegaly. Three vessel umbilical
cord. Normal female genitalia, patent anus and age
appropriate tone and reflexes.
The birth weight was 2225 grams. The birth length was 40.5 cm
birth head circumference is to follow.
NICU COURSE:
1. Respiratory status, the infant has remained in room air
throughout her NICU stay. She had only one episode of
desaturation with feeding on day of life number 1, but
had no further episodes of apnea, bradycardia or
desaturation. On examination respirations were
comfortable. Lung sounds clear and equal.
2. Cardiovascular status, she has remained normotensive
throughout her NICU stay. Heart was regular rate and
rhythm. No murmur. She has no cardiovascular issues.
3. Fluid, electrolyte and nutrition status, she initially
had some hypoglycemia on admission to the NICU, which was
resolved with feedings. Since then she has remained
euglycemic. She is eating 20 calorie per ounce formula on
an ad lib schedule taking approximately 160 to 180 ml per
kilo per day. Her weight at the time of discharge his
2140 grams.
4. Gastrointestinal status, her peak bilirubin occurred on
day of life number four and was total 10.8, direct 0.4.
On the day of discharge her total bili is 9.9, direct
0.4. She never received any phototherapy.
5. Hematology. Her hematocrit at the time of admission was
51.9. Platelets were 265,000. She has never received any
blood product transfusions.
6. Infectious disease status, a blood culture was done at
the time of admission. It remains negative to date. She
has never received any antibiotics.
7. Sensory, hearing screening was performed with automated
auditory brain stem responses and the infant passed in
both ears.
8. Other, she required isolette care secondary to
hypothermia. She weaned slowly and now has been stable in
a crib for more than 24 hours. Toxic screen was done
secondary to late and limited prenatal care. It was
negative. Mother is aware of testing.
9. Psycho/social, parents have been involved in the infant's
care throughout her NICU stay.
She is discharged home with her parents. She is discharged in
good condition. Her primary pediatric provider will be Dr.
[**First Name8 (NamePattern2) 51097**] [**Name (STitle) 12332**] at [**Hospital **] Community Health Center, [**Location (un) 669**],
[**State 350**]. Telephone number [**Telephone/Fax (1) 3581**].
RECOMMENDATIONS AFTER DISCHARGE: Formula feeding on ad lib
schedule. She is discharged on no medications. She has passed
a car seat position screening test. Her state newborn screen
was sent [**2119-10-14**]. She received her first hepatitis B vaccine
on [**2119-10-16**].
Recommended immunizations, Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infant's who meet
any of the following 3 criteria, born at less than 32 weeks,
born between 32 and 35 weeks with 2 of the following, day
care during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings or with chronic lung disease. Influenza immunization
is recommended annually in the fall for all infants once they
reach 6 months of age. Before this age and for the first 24
months of the child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
The infant will have a visiting nurse visit after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 35 and 2/7 weeks.
2. Hypoglycemia, resolved.
3. Hypothermia, resolved.
4. Sepsis ruled out.
5. Mild hyperbilirubinemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2119-10-17**] 06:16:40
T: [**2119-10-17**] 06:46:18
Job#: [**Job Number 65645**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5127
} | Medical Text: Admission Date: [**2155-2-9**] Discharge Date: [**2155-2-18**]
Date of Birth: [**2086-12-2**] Sex: M
Service: MEDICINE
Allergies:
Morphine Sulfate / Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
s/p CABGx3(LIMA->LAD, SVG->Ramus/OM, RCA)/AVR(21mm tissue)
[**2155-2-13**]
History of Present Illness:
68 y/o male with prior cardiac history and multiple risk factors
who presented who acute onset of shortness of breath and chest
pain. Was initially treated in the emergency room and eventually
underwent a cardiac catheterization. Cath revealed three vessel
coronary disease. Echo showed moderate to severe aortic stenosis
and moderate aortic regurgitation. He was then referred for
surgical revascularization and aortic valve replacement.
Past Medical History:
Coronary Artery Disease s/p MI x 2 s/p PTCA of LAD
Hypertension
Diabetes Mellitus
L4-L5 spondylolisthesis
h/o Congestive Heart Failure
s/p right Rotator Cuff Repair
s/p bilateral Ulnar nerve transposition
s/p post. and ant. cervical disk procedures and fusions
s/p iridectomy
s/p right total knee replacement
Physical Exam:
General: WD/WN male in NAD
HEENT: NC/AT, PERRLA, EOMI, OP benign
Neck: Supple, FROM, -lymphadenopathy, Carotid 2+ w/ Bilat.
radiation murmur
Lungs: CTAB -w/r/r
CV: RRR, +S1,S2 with SEM
Abd: Soft, NT/ND, +BS without masses
Ext: - C/C/E pulses 2+ throughout
Neuro: Non-focal, MAE, A&O x 3
Pertinent Results:
[**2155-2-9**] 05:30AM BLOOD WBC-13.4*# RBC-4.27* Hgb-12.5* Hct-37.0*
MCV-87 MCH-29.4 MCHC-33.9 RDW-14.3 Plt Ct-637*#
[**2155-2-15**] 05:00AM BLOOD WBC-11.5* RBC-3.36* Hgb-10.2* Hct-29.1*
MCV-87 MCH-30.4 MCHC-35.1* RDW-15.4 Plt Ct-155
[**2155-2-15**] 05:00AM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.0
[**2155-2-17**] 05:15AM BLOOD Glucose-35* UreaN-12 Creat-0.8 Na-136
K-4.5 Cl-97 HCO3-28 AnGap-16
[**2155-2-10**] 04:33PM BLOOD ALT-11 AST-14 AlkPhos-105 Amylase-61
TotBili-0.4
[**2155-2-17**] 05:15AM BLOOD Mg-2.3
[**2155-2-9**] 05:40AM BLOOD %HbA1c-7.3* [Hgb]-DONE [A1c]-DONE
[**2155-2-14**] 10:11AM BLOOD freeCa-1.12
[**2155-2-9**] 05:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
As mentioned in the HPI, pt was initially seen by cardiac
surgery following his cardiac cath. Patient was eventually
consented for surgery and on [**2155-2-13**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 3 and aortic valve replacement. Please see op note for
surgical details. Patient tolerated the procedure well and was
transferred to the CSRU in stable condition receiving
Neo-Synephrine, Dobutamine, and Levophed drips. Later on op day
sedation was weaned and patient awoke neurologically intact. He
was then weaned from mechanical ventilation and extubated. He
was weaned from all Inotropes/Pressors on post op day one and
was then transferred to the cardiac step-down unit. B Blockers
and Diuretics were initiated and patient was gently diuresed
towards his pre-op weight. Chest tubes and Foley catheter were
removed on post op day two. And epicardial pacing wires were
removed on post op day three. Pt was followed by physical
therapy during his entire post op course for strength and
mobility. Patient had a relatively uncomplicated post op course
and was at level 5 by post op day five. His exam and labs were
stable on post op day five and he was discharged home with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
Glyburide 5mg [**Hospital1 **]
Cimetidine 400mg [**Hospital1 **]
Indural LA 160mg qd
Indural XR 30mg
Advicor 500/20
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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO HS (at bedtime).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-8**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Tagamet 400 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary artery disease/Aortic regurgitation s/p Coronary Artery
Bypass Graft x 3 and Aortic Valve Replacement
Diabetes Mellitus
Hypertension
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1270**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2155-2-19**]
ICD9 Codes: 4241, 486, 4280, 4111, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5128
} | Medical Text: Admission Date: [**2114-11-18**] Discharge Date: [**2114-12-6**]
Date of Birth: [**2063-5-6**] Sex: M
Service: TRA
[**Hospital **] MEDICAL COMPLAINT: The patient in an MVC.
HISTORY OF PRESENT ILLNESS: This is a 51 year-old male who
had an MVC into a building. The patient was restrained, was
unresponsive except to painful stimuli upon presentation to the
emergency room. He required 2 units of blood transfused while in
the trauma bay. He had emesis. Patient is Portuguese speaking. At
the time of presentation to the emergency department the patient
had unknown allergies, unknown medical history, unknown family
history, unknown medications and unknown past surgical
history.
PHYSICAL EXAMINATION: His vitals on presentation was heart
rate in the 120s, blood pressure 100/palp. Breath sounds at
82. Patient was intubated. Bilateral chest tubes were placed.
He had altered mental status, GCS of 13. He had a scalp
laceration. He was intubated in the emergency room. Lungs
were clear. There were broken ribs on the right noted when
placing the chest tube in. His abdominal examination was
obtained which was negative. He had normal tone upon his
rectal examination, which was guaiac negative.
LABORATORY DATA: Upon presentation to the emergency
department, white count of 18.0, hematocrit 29.8 with a
platelet count of 220. His chem-10 was normal as well as his
coagulations. His alcohol level was 125 on presentation. Amylase
was 69 and fibrinogen 161. CT of chest was obtained upon
presentation to the emergency department. Trauma film was
obtained which showed widening mediastinum secondary to
rotational differences. An extremely limited pelvis due to the
fact that the patient was moving while the images were taking
place. The CT of cervical spine was also obtained which showed a
fracture of the right transverse process of C7 with questionable
extension to the right lamina. The fracture fragments were only
minimally displaced with mild narrowing of the neuroforamen at
that level. There was no extension of the vertebral artery canal.
Patient also was noted to have small apical right
pneumothorax and emphysematous changes of the lungs
bilaterally. A CT of head was also obtained in the emergency
department which was notable for no evidence of intracranial
hemorrhage. CT of pelvis was then obtained while in the
trauma bay. Patient was noted to have a right small apical
anterior inferior pneumothorax, status post chest tube
placement on the right. Atelectasis versus contusion of the
posterior right lung. Mild emphysematous changes along the
upper lobes bilaterally. An x-ray of the patient's right hand
was conclusively normal without any evidence of fracture.
HOSPITAL COURSE: Patient was then admitted to the trauma
service under Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He was admitted to the trauma
surgical Intensive Care Unit for evaluation. Follow up chest
x-ray was obtained on the [**2114-11-19**] for interval
changes of his pneumothorax and placement of the endotracheal
tube. There was relative [**Name (NI) 70433**] of the right upper
quadrant of the abdomen and sharp demarcation of the medial
right hemidiaphragm which would correspond to a basilar
pneumothorax on CT of torso. A neurosurgery consult was
obtained while the patient was in the trauma bay for his
cervical fracture. The patient was then placed on a cervical
collar and is to remain so for several weeks (6 to be exact)
in which case he is to follow up in the neurosurgery clinic.
Plastic surgery was also consulted for his right hand
laceration in which there was no evidence of fracture.
Plastic surgery service subsequently signed off. Patient
remained in the trauma and the neurosurgical Intensive Care
Unit for several days from [**11-18**] until [**2114-11-29**]. Patient did relatively well. His bilateral chest tubes
were removed without incident during his time in the trauma
Intensive Care Unit. There were no complications from such.
In addition an additional chest tube was placed in the
patient's anterior wall of the left lung due to the fact that
on placement of the chest tube in the emergency department it
was noted that the patient's lung was highly fibrotic to the
chest wall and we were concerned for noncommunication between
the placement of the original chest tube and the
pneumothorax. The patient tolerated this well without any
evidence of increased pneumothorax. He was placed on suction,
2 chest tubes to the left, 1 chest tube on the right for
several days. On the third day after placement of the third
chest tube all the chest tubes were subsequently removed, 1
each additional day while the patient was in the trauma SICU.
There was, however, noted to be a CT scan of the patient
chest which was accomplished on [**2114-11-28**] which
showed a small loculated pneumothorax, a small pig-tail tube
was placed in the patient's chest along the second
intercostal space on the left. The patient tolerated this
procedure well without any complaints. This pig-tail was then
subsequently placed to suction for a total of 5 days and was
removed. Chest x-ray following removal of this showed no
evidence of a pneumothorax. Patient had minimal output of
blood from the chest tube. The patient was also due to an
incident in the trauma bay in which a resident was lacerated
after removing glass from the patient's scalp. The resident
received a laceration and an HIV work up was obtained. The
patient was noted to be HIV positive with a viral load
greater than 100,000 and a CD4 count of less than 100. An ID
consult was then obtained on the [**11-29**] in which
case the patient was started on [**Doctor Last Name **] therapy for his HIV and
was begun on prophylaxis of PCP pneumonia which included
azithromycin and Bactrim. The patient was also started on
ciprofloxacin. It was noted with talking with the patient at
this time that a history of a pneumococcal empyema requiring
2 surgeries 2 years ago and 2 lymph node biopsies. The
patient was also noted to have a history of asthma,
alcoholism, depression, post herpetic neuralgia, steroid
dependence and questionable thrush and questionable adrenal
insufficiency. After several days in the trauma Intensive
Care Unit the patient was then moved to the floor for further
evaluation which was done on [**2114-11-30**]. The patient
obtained PT/OT evaluation in which it was noted that patient
had unstable gait. Started on [**Doctor Last Name **] therapy and had a pig-tail
to suction which was removed on the [**12-3**] on the
floor. Patient remained afebrile until the [**12-4**]
where it was noted that he had temperatures of 101.9.
Cultures were obtained. A urine culture was noted to have E
coli with greater than 100,000 per colony. Patient was then
started on ceftriaxone 1 gram q 24 for treatment of his
urinary tract infection empirically. On speaking with the
infectious disease consultation it was agreed upon to have
the patient on ceftriaxone for 3 days. On the [**12-6**] the patient passed his PT evaluation and is cleared
to go home.
Additional films of the patient's hands were also obtained in
this time which again showed no fractures of his wrist or his
humerus, his elbow or his shoulder. This was done due to the
fact that patient was complaining of pain on the right side
of his hand. The patient is being discharged home. His white
count is currently 6.7 with a hematocrit of 23.5 and a
platelet count of 538. The patient did not require any
transfusions during his hospitalization in this hospital. CD4
count was noted to be 66 with a CD8 count of 1465 with a
CD4/CD8 ratio of .1. The patient had no surgical intervention
during his hospital course here.
PHYSICAL EXAMINATION: He is afebrile today. Vital signs
stable. Lungs are clear. Heart rate showed regular rate and
rhythm. No murmurs, rubs or gallops. Abdomen is soft,
nontender, nondistended. Right hand is decreased swelling,
good range of motion. Patient is awake, alert and oriented
x3. He is ambulating and doing well.
He is being discharged on Tylenol, Colace, senna, Percocet,
Bactrim, ritonavir, atazanavir, azithromycin, __________,
abacavir, lamivudine, Colace and senna. He is told to follow
up with his PCP regarding his HIV status. He has been
scheduled to meet with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], on [**2114-12-13**] at 9:30 in the morning. He is also
told to follow up with his pulmonologist, Dr. [**Last Name (STitle) 70434**] at the
[**Hospital6 12736**] Center for evaluation of his
pulmonary status given the fact of his past empyemas. He is
also told to make an appointment in 1 to 2 weeks in the
trauma clinic and to call the trauma clinic office to
schedule an appointment with Dr. [**Last Name (STitle) **]. He has been
discharged with pain medications and told not to operate or
drive heavy machinery while on medications. He was also told
that he was going to be discharged on antibiotics and to take
his medications as prescribed. He was told to come to the
emergency department for the following reasons: Temperature
greater than 101.1, increased rest pain, abdominal
distention, any increased nausea or any shortness of breath.
DISCHARGE CONDITION: Good. Tolerating p.o., ambulating and
voiding.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 33889**]
Dictated By:[**Last Name (NamePattern1) 29268**]
MEDQUIST36
D: [**2114-12-6**] 12:47:59
T: [**2114-12-6**] 14:34:21
Job#: [**Job Number 70435**]
ICD9 Codes: 5185, 2851, 5990, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5129
} | Medical Text: Admission Date: [**2179-5-21**] Discharge Date: [**2179-6-1**]
Date of Birth: [**2104-2-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Abdominal pain and diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
PICC placement
History of Present Illness:
Mr. [**Known lastname 39861**] is a 75M with history notable for metastatic prostate
cancer, HTN, CAD s/p recent stenting, severe AS, dCHF, heart
block s/p pacemaker, prior gastric ulcers, pancytopenia, and
prior anemia felt secondary to GI bleed who presented to [**Hospital1 **]
[**Location (un) 620**] on [**2179-5-20**] with abdominal pain and diarrhea. For two
days prior to presentation, patient had constipation, but no
N/V. Saw his PCP [**5-19**], and had KUB which was c/w constipation.
Was started on bowel regimen with colace and mag citrate, and on
the morning of [**2179-5-20**], woke up with fecal urgency and had
multiple large semi formed bowel movements. After multiple
bowel movements, he was extremely fatigued prompting him to call
911. In addition to his fecal urgency, he also complained of
worsening diffuse abdominal pain, worse with
palpation/manipulation. He denied any melena, nausea or
vomiting.
He initially presented to [**Hospital1 **] [**Location (un) 620**], where per report he had
guaic positive stools. His labs were notable for Hct 28. plt
158, INR 1.1, Cr 1.3 (up from baseline 1), slightly elevated
Tbili 1.67. Lactate was 2.3. While at [**Hospital1 **] [**Location (un) 620**], the patient
was transferred to the ICU as his HCT decreased from 28 to 22
and he was oliguric. Rec'd transfusion. OF note, he remained
hemodynamcially stable He underwent a CT abd/pelvis which
showed a multifocal small bowel abnormality with acute on
chronic inflammation, and of note there were some intervening
loops of small bowel that appeared normal, raising the question
of possible Crohn's. He was also noted to have a large amount
of stranding in the left pelvic sidewall and left lower
retroperitoneum of the abdomen, indicating acute inflammation.
There was a distinct and abnormal portion of the sigmoid colon
suggestive of focal colitis, possibly ischemic. He has
extensive atherosclerotic disease with moderate-severe narrowing
of the SMA and possibly the celiac, but [**Female First Name (un) 899**] patent. Also of
note, he was found to have an isolated segment of peripheral
portal vein thrombus without more proximal thrombus. CT scan
also raised concern for left common femoral artery
pseudoaneurysm that was not seen on [**5-12**] ultrasound.
He was evaluated by GI and surgery, who did not feel there was a
need for acute surgical intervention. Plan was to proceed with
conservative measures including fluid resusictation and
antibiotics. Given rsk factors, GI didn not think he was a
cnadidate for an EGD or colonsocopy. Per family's request, he
was transfered to [**Hospital1 18**] for further management.
Of note, the patient recently had multiple cardiac procedures,
including a DES to LAD in mid [**Month (only) 958**] by Dr. [**Last Name (STitle) **], and a DES to
RCA in late [**Month (only) 958**] with a complication of a left groin hematoma
post procedure. Additionally, given bradycardia and Wenkebach
rhythm, had a pacemaker placed on [**2179-5-5**]. Plans at that time
were to continue ASA and Plavix for minimum of one year.
Regarding his aortic stenosis, he was deemed high risk and
decision was made for valvulplasty at a later date.
On arrival to the ICU, patient is lethargic requesting fluids.
Complaining of moderate abdominal pain worse with manipulation.
Otherwise no other complaints. States last bowel movement was
several hours ago.
Review of systems:
(+) Per HPI. Also endorses 10 lbs weight loss in last 3 weeks,
claiming general malaise for this period. Also c/o L/R shoulder
pain for last few days. Endorses chronic left lower extremity
swelling since lymph node removal in the [**2137**]'s.
(-) Denies recent travel, food aversion/abdominal angina. No
fever, chills, night sweats, recent weight gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations. Denies nausea, vomiting, changes
in bowel habits. Denies dysuria, frequency, or urgency. Denies
myalgias. Denies rashes or skin changes.
Past Medical History:
1. Severe aortic stenosis. Workup in process for valvuloplasty
with Dr. [**Last Name (STitle) **].
2. Diastolic congestive heart failure with an EF of 70%.
3. Hypertension.
4. Metastatic prostate cancer on Lupron.
5. Gastroesophageal reflux disease.
6. Gastric ulcer, details not very clear.
7. Mild ascending aortic dilation.
8. Lymphoma in [**2141**], lymphedema of his right lower extremity
status post lymph node removal in [**2141**].
9. He has a history of testicular cancer (?).
.
Other medical problems are:
1. CAD status post stent.
2. Left inguinal hernia.
3. Advanced heart block status post pacemaker recently placed in
[**2179-4-15**].
4. Anemia felt due to GI bleed.
5. Ulcers.
6. Lymphoma.
7. Pancytopenia; was supposed to have a bone marrow biopsy.
Social History:
The patient lives at home. No history of smoking. Drinks 1
glass of wine a night. No illicit drug use. Lives with wife
and 2 dogs. Works as insurance broker. 2 daughters that live
near by and 1 son who is a colorectal surgeon in [**State 108**]
Family History:
Mother passed away age [**Age over 90 **] from multiple comorbidities. Father
passed away in his 50's from heart disease. Brother passed away
age 69 from complications of diabetes. Sister passed away age 70
from MI and had a history of ETOH abuse. Denies history of
IBD/Celiacs/Liver disease.
Physical Exam:
Admission examination
Vitals: T:100 BP: 139/54 P: 77 R: 28 O2 94% on 2L
General: Alert but lethargic, oriented, no acute distress. Ashen
appearing.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: JVP not elevated, no LAD. Supple neck. No
supraclavicular LAD.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, loud crescendo decrescendo murmur,
late peaking with blurring of S2 with carotid radiations best
auscultated in aortic region. Otherwise no other adventitious
heart sounds appreciate. PMI slightly lateralized towards
axilla.
Abdomen: Ventral hernia appreciated in the midline. Tenderness
to moderate palpation, worst in the LLQ. soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: dark yellow urine
Ext: warm, well perfused, 2+ pulses, RLE with indurated
nonpitting edema 2-3x larger than LLE. No pain in calf.
Pertinent Results:
ADMISSION LABS:
[**2179-5-21**] 05:30PM BLOOD WBC-8.0# RBC-3.30* Hgb-10.0* Hct-29.5*
MCV-89 MCH-30.3 MCHC-34.0 RDW-15.2 Plt Ct-141*
[**2179-5-21**] 05:30PM BLOOD Neuts-95* Bands-1 Lymphs-0 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2179-5-21**] 05:30PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL
[**2179-5-21**] 05:30PM BLOOD PT-16.7* PTT-29.1 INR(PT)-1.6*
[**2179-5-21**] 05:30PM BLOOD Glucose-115* UreaN-41* Creat-1.2 Na-142
K-4.8 Cl-112* HCO3-21* AnGap-14
[**2179-5-21**] 05:30PM BLOOD ALT-18 AST-21 LD(LDH)-148 AlkPhos-105
TotBili-4.7* DirBili-1.1* IndBili-3.6
[**2179-5-21**] 05:30PM BLOOD Albumin-3.4* Calcium-8.0* Phos-4.1
Mg-2.7*
[**2179-5-21**] 05:30PM BLOOD Hapto-140
[**2179-5-21**] 05:57PM BLOOD Lactate-1.0
Micro:
Blood cultures [**5-20**], [**5-21**] ([**Location (un) 620**]): pending
Urine culture [**5-20**] ([**Location (un) 620**]): <10,000 org/ml GNRs
Images:
CXR [**2179-5-20**] ([**Location (un) 620**]): The lungs are clear. Heart size is within
normal limits. Pulse generator in the left chest with
electrodes in the right atrium and right ventricle has the
expected appearance. Aortic arch calcification indicates
atherosclerosis. Mediastinal contour is normal. No suspicious
bone findings or degenerative changes in the left AC joint.
CT Abd/Pelvis w/contrast [**2179-5-20**] ([**Location (un) 620**]):
1. MULTIFOCAL SMALL BOWEL ABNORMALITY SUGGESTING ACUTE ON
CHRONIC INFLAMMATION. AS THERE DO APPEAR TO BE NORMAL
INTERVENING LOOPS OF SMALL BOWEL, THIS RAISES THE QUESTION OF
CROHN'S DISEASE. THE ENTEROPATHY APPEARS TO BE LIMITED TO THE
WALL FOR THE MOST PART WITH ONLY MINIMAL AREAS OF INFLAMMATION
THAT [**Month (only) **] EXTEND INTO THE SEROSA BUT THERE IS NO MESENTERITIS OR
ABSCESS.
2. LARGE AMOUNT OF STRANDING IN THE LEFT PELVIC SIDEWALL AND
LEFT LOWER RETROPERITONEUM OF THE ABDOMEN, INDICATING ACUTE
INFLAMMATION. DISTINCT AND ABNORMAL PORTION OF THE SIGMOID
COLON WITHIN THE PELVIS SUGGESTS FOCAL COLITIS OF WHICH ISCHEMIC
COLITIS IS POSSIBLE. NO PERFORATION OR PNEUMATOSIS.
3. EXTENSIVE ATHEROSCLEROTIC DISEASE WITH MODERATE-SEVERE
NARROWING OF THE SMA AND POSSIBLY OF THE CELIAC ARTERY BUT
PATENT [**Female First Name (un) 899**]. THIS WOULD RAISE THE PATIENT'S RISK FOR ISCHEMIC
BOWEL DISEASE.
4. EXTENSIVE CORONARY ARTERY DISEASE AND AORTIC VALVE
CALCIFICATION,
LIKELY REFLECTING AORTIC STENOSIS, AS SUGGESTED ON CTA CHEST
FROM [**Hospital1 18**] [**Location (un) **] IN [**2179-3-17**].
5. BILATERAL RENAL INFARCTS SUBACUTE AND CHRONIC IN
APPEARANCE.
EXTENSIVE ATHEROSCLEROSIS BILATERAL RENAL ARTERIES AS WELL.
6. ISOLATED SEGMENT 5 PERIPHERAL PORTAL VEIN BRANCH THROMBUS
WITHOUT
MORE PROXIMAL THROMBUS. MARKEDLY ATROPHIC LEFT LOBE OF THE
LIVER.
7. CONCERN FOR LEFT COMMON FEMORAL ARTERY PSEUDOANEURYSM.
THIS WAS NOT SEEN AT [**2179-5-12**] ULTRASOUND AT [**Hospital1 18**] [**Location (un) **] AND
FINDINGS APPEAR TO HAVE EVOLVED SINCE THAT TIME AND THE LEFT
COMMON FEMORAL ARTERY APPEARS SLIGHTLY LARGER, THOUGH IT IS
DIFFICULT TO COMPARE BETWEEN THE MODALITIES.
8. LEFT PUBIS HETEROGENEOUS SCLEROSIS LIKELY REFLECTS PROSTATE
.
IMPRESSION:
CT abd/pelvis [**2179-5-31**]
1. No evidence of visceral perforation as questioned.
2. Interval increased segmental small bowel thickening and
dilatation up to 4-cm extending to the terminal ileum with
increased ascites and subtle
relative mucosal [**Name2 (NI) 39862**] of bowel loops in left upper
quadrant. No transition point identified. Persistent stable
sigmoid and descending
colitis. Overall, findings are compatible with known ischemic
colitis and
enteritis.
3. Persistent ascites and anasarca.
4. Unchanged moderate bilateral pleural effusions with
atelectasis.
5. Fluid layering in the lower esophagus, placing patient at
increased risk for aspiration.
6. Severe hepatosteatosis.
7. Bilateral cortical and parapelvic renal cysts. Left renal
cortical
thinning.
8. Severe diffuse atherosclerotic disease, without evidence of
frank vessel occlusion.
9. Left superior pubic ramus sclerosis may represent metastatic
disease in
the setting of known prostate cancer.
,
EKG ([**Location (un) 620**]): Sinus rhythm with rate of 76. LAD. Poor RWP.
TWI in AVL, V1, flattening in V2 (changed from prior, may be
lead placement).
PR interval 0.24 msec, normal QT. No evidence of
STE/Flattening.
.
ECHO [**4-/2179**] [**Hospital1 18**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 70%). 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
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.7 cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is
borderline/mild functional mitral stenosis (mean gradient 4
mmHg) due to mitral annular calcification. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Brief Hospital Course:
The patient is a 75 year old man with known severe aortic
stenosis, diastolic HF, hypertension, metastatic prostate
cancer, distant past lymphoma, s/p recent 2 stents several weeks
prior to presentation, now here with likely diffuse ischemic
injury to his small bowel and colon. The patient was initially
transferred from [**Hospital1 **] [**Location (un) 620**] with abdominal pain and diarrhea
after being diagnosed with colitis. Unclear cause, but some
concern for either embolic vs vascular insult, as atypical
distribution of areas of involvement. The patient intially
improved on bowel rest, but his pain worsened after a trial of
liquids and strict bowel rest was resumed. Increasing abdominal
pain in the setting of PO intake, but has not improved
significantly since transition back to NPO status. A PICC was
placed with plans for initation of TPN on [**5-26**]. Fever to 101F
on [**5-29**], without focal identifiable source beyond the potential
for translocation of bacteria from the ischemic bowel. We
continue to discuss with the patient and his family regarding
the severity of his illness and his wishes for his care.
#Abdominal Pain/Patchy colitis and bowel necrosis: Patient's
pain symptoms staretd after diarrhea. Radiographic imaging at
OSH confirmed patchy acute on chronic small intestin
inflammation with possible question of inflammatory disease.
Additionally, stranding on the left pelvic sidewall and lower
retroperitoneum suggestive of focal colitis to which ischemic
colitis was entertained. While theoretical the patient may
have had poor forward flow in the presence of diarrhea and
severe AS, the patient's presentation is not necessarily
consistent with ischemic etiology. While sigmoid involvement is
possible in the rectalsigmoid area (Sudeck's point),
distribution of inflammation of the small intestine with patchy
inflammation is not consistent with a vascular territory or
watershed area. Additionally, CT read showed a patent [**Female First Name (un) 899**] with
thrombosis downstream less likely. Lastly, lactate was
initially elevated above 2, but decreased with rehydration to
less than 1. Other possibilities included diverticulitis, but
would not explain small intestinal findings. IBD is possible
although less likely for initial occurrence to be in a patient
in his 70's. Infectious colitis possible, however stooling has
stopped with decreased PO intake and C.Diff negative at OSH.
Stool studies were negative for Cdiff and ova and parasites
while here. Bilirubin initially elevated but this was indirect
hyperbilirubinemia with benign ultrasound and resolved without
particular intervention. While gastritis is possible and his
history is unclear regarding PUD, this would not explain his CT
findings. Antibiotics were held (was given ertapenem at OSH) as
it was felt the patient was not actually experiencing bowel
necrosis. CBC was trended and no evidence for infection. IV PPI
was DCd as he had received 48 hours of IV PPI and no evidence of
further bleeding. Abdominal exam remained relatively benign
although he did have pain the night of admission. GI was
consulted and recommended flexible sigmoidoscopy, which showed
extensive bowel necrosis. Colorectal surgery felt the patient
was not an operative candidate due to the small and large bowel
distribution. After transfer to the floor pt was on tube feeds,
and abdominal pain progressed. Repeat abdominal CT [**5-31**] showed
worsening of bowel wall edema/necrosis. His prognosis appeared
quite limited, given the extent of the ischemic colitis and
necrosis, as well as his underlying medical conditions. Ongoing
discussion regarding the patient's wishes and hopes for his
treatment, especially in the setting of a poor prognosis.
Pallative care was consulted. See goals of care below.
# Hyoxia - day prior to death pt was developed acute onset
wheezing and subsequent hypoxia requiring transfer to the ICU.
Pt developed wheezing which was initially responsive to
albuterol, but subsequently became more hypoxic and dyspneic. In
the setting of severe AS, dCHF and several liters positive over
LOS, high likelihood that pulmonary edema/flash edema were a
component. Other possibilities included ischemic event vs
ossible albuterol induced tachycardia with subsequent flash. Pt
was given lasix 20mg IV x1, with significant improvement in
symptoms. Pt also became febrile to 101 peripherally with
shaking chills and new obscuration of L hemidiaphragm concerning
from evolving HAP (at that time was on vanc/cipro/flagyl),
though this doesn't exactly fit with the reportedly acute time
course. Further, pt with chronic RLE lymphedema appearing
enlarged, mildly erythematous and tender, in setting of no DVT
ppx, concern for VTE. Also of note, pt with persistent bilateral
pleural effusions. Abx coverage broadened to vanc/zosyn.
.
#GI Bleed: Guiac positive stools at OSH in presence of HCT drop
from 28 to 22. Reported history of gastritis/PUD. This was
also in the presence of fluid resuscitation. Per report,
patient did receive 2 U PRBC transfusiion. HCT appears to have
stabalized in house without further epsiodes of diarrhea or
suggestions of GIB. Was continued on omeprazole 20mg daily. HCT
was monitored closely without signs of further bleeding.
.
#AS/Diastolic CHF: Per reports severe AS 0.8-1.0 aortic valve
area. Future plans might include valuvloplasty if patient
continues to have CAD symptoms per Dr.[**Name (NI) 8664**] note in 3/[**2179**].
I's and Os carefully monitored with pt positive 1L over the
first 2 days of hospitalization but developed no signs of acute
on chronic diastolic CHF. Initially started on metoprolol then
switched to carvedilol for better blood pressure control to help
minimize afterload and strain on ventricle.
#CAD s/p recent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]: The patient had two DES placed in
the last month, one in the RCA and one in the LAD. On
presentation to the OSH had a mild troponin elevation but EKG
appeared improved from [**5-12**] with resolution of previous Q waves
and elevation likely due to procedure <10 days before given
troponin stays in system for two weeks. At initial Hct drop at
OSH ASA and clopidogrel were held but then restarted soon after
with stable Hct given high risks of stent rethrombosis. He
never had chest pain or clear signs of ACS.
#Normocytic Anemia with concurrent Pancytopenia: Per prior
reports has a history of pancytopenia. Prior Heme Onc notes
from [**4-/2179**] during patient's admission for
catherizations/pacemaker placement discuss likely marrow
suppression from Lupron use or MDS. Coupled with history of
radiation for metastatic prostate cancer, further marrow
dysfunction is possible. Coupled with low reticulocyte counts,
MDS high on differential. Interestingly, white count while in
normal limits, was elevated about 2x higher than baseline.
Haptoglobin/LDH did not suggest hemolysis, although he did have
an elevated bilirubin with the majority being indirect, but this
rapidly resolved as quickly as it presented. It was considered
that he may have an underlying Gilberts, but unclear.
.
#hypotension - on return to the [**Name (NI) 153**] pt was hypotensive
requiring 3 pressors. Dr. [**Last Name (STitle) 217**] had discussions with the
patient's son, who is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-rectal surgeon, by phone (son in
[**Name (NI) 108**]). Aggressive therapy was maintained until the son could
travel to [**Name (NI) 86**]. The following day his son came and family
decided to turn off pressors. Pt [**Name (NI) **] within the hour.
.
#Fever: Presumed related to ischemic bowel and progression of
necrosis. Started on cipro/metronidazole when abdominal pain
worsened, then added vancomycin with pending blood cultures.
.
#[**Last Name (un) **]: Likely prerenal. Improved with IVF. Pt was hydrated
judiciously and [**Last Name (un) **] resolved.
.
#Question pseudoaneursym on CT: no evidence on physical exam.
HCT drop may be related to aneursym pooling. Serial exams were
not concerning for further enlargement/bleed.
.
#1st degree AV blockade: s/p pacemaker DCCI recently.
.
#History of prostate cancer: Has been on Lupron previously.
Followed by Dr. [**Last Name (STitle) **].
.
PT [**Name (NI) 5485**] [**2179-6-1**].
Medications on Admission:
Home Medications:
-meclizine 12.5 q.8 hours (Listed in OMR, patient denies)
-omeprazole 20 mg p.o. daily
-ferrous sulfate 300 mg p.o. b.i.d.
-lisinopril 20 mg p.o. daily
-Plavix 75 mg p.o. daily
-multivitamin 1 tablet once daily
-aspirin 325 mg p.o. daily
.
Medications on Transfer:
Ertapenem 1 gram IV qday (day 1 [**2179-5-20**])
Aspirin 81 mg qday
Sennosides 2 tabs po qday prn
ondansetron 4 mg IV q8hrs prn
morphine sulfate 2 mg IV q4 hours prn
docusate sodium 100 mg [**Hospital1 **] prn
acetaminophen 1000 mg q6 hr prn pain
esomperzaole 40 mg IV bid
Clopidogrel 75 mg po qday
aspirin 324 mg po qday
Discharge Medications:
Pt [**Hospital1 **]
Discharge Disposition:
[**Hospital1 **]
Discharge Diagnosis:
Pt [**Hospital1 **]
Primary Diagnoses:
Regional Enteritis (ischemic bowel)
Anemia
Dehydration
Critical aortic stenosis
Coronary artery disease
Discharge Condition:
Pt [**Hospital1 **]
Discharge Instructions:
Pt [**Hospital1 **]
ICD9 Codes: 486, 4241, 4280, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5130
} | Medical Text: Admission Date: [**2133-9-18**] Discharge Date: [**2133-9-28**]
Date of Birth: [**2055-4-9**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 78-year-old woman with
a history of hypercholesterolemia and non-insulin-dependent
diabetes mellitus with a history of stable angina who was in
her usual state of health; however, she had sharp episodes of
chest pain. The patient did relate this information to her
primary care physician, [**Name10 (NameIs) **] the patient was told that it was
gastroesophageal reflux disease. She had these episodes
multiple times over the past year.
On the day of admission, she had worsening symptoms and
presented to the Emergency Department at the [**Hospital6 1760**] where she received
intravenous Lopressor, as well as Heparin, and she was
ultimately taken to the Cardiac Catheterization Lab on
[**2133-9-18**].
This revealed a left ventricular ejection fraction of 56%,
90% proximal right coronary artery lesion and 90% proximal
left anterior descending lesion as well. As a result of the
cardiac catheterization findings, the patient was taken to
the Operating Room the following day.
PAST MEDICAL HISTORY: Hypercholesterolemia. Type 2 diabetes
mellitus. Stable angina. Gastroesophageal reflux disease.
History of deep venous thrombosis with a PE in [**2131**], unclear
of the details. History of glaucoma.
MEDICATIONS ON ADMISSION: Metformin 850 mg p.o. b.i.d.,
Metoprolol 50 mg p.o. q.d., Zocor 20 mg p.o. q.d., Protonix
40 mg p.o. q.d., Glyburide 3 mg p.o. b.i.d., Quinine Sulfate
260 mg p.o. q.d., Cosopt eye drops, Travatam eye drops,
Multivitamin.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
HOSPITAL COURSE: The patient was subsequently taken to the
Operating Room on [**2133-9-19**], where she underwent
coronary artery bypass grafting times three with LIMA to the
left anterior descending, saphenous vein to the diagonal and
a saphenous vein to the posterior descending artery, as well
as closure of a PFO with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**].
Postoperatively the patient was taken from the Operating Room
to the Cardiac Surgery Recovery Unit on Neo-Synephrine and
Propofol drip. The patient was weaned from mechanical
ventilation and extubated on the night of surgery.
On postoperative day #1, the patient had some problems with
hypotension, remaining on Neo-Synephrine drip but had
otherwise progressed to satisfactory condition in her
postoperative course.
On postoperative day #2, the patient remained hypotensive,
requiring Neo-Synephrine drip, and for that reason, she
stayed in the Intensive Care Unit.
Over the next few days, the patient did have multiple
episodes of rapid atrial fibrillation which became difficult
to trace. She was started on Amiodarone intravenous drip,
and her oral course of beta-blocker was increased
subsequently over the next few days.
On [**9-24**], postoperative day #5, the patient remained
very difficult to rate control, in atrial fibrillation, and
an Electrophysiology consult was obtained at that time. It
was their recommendation to continue beta-blocker, as much as
her rate and blood pressure would tolerate, as well as to
continue the Amiodarone. It was also their recommendation to
check TSH, as well as to anticoagulate her.
An intravenous Heparin drip was started at that time, and she
has been transitioned to oral Coumadin dosing for
anticoagulation for postoperative atrial fibrillation.
Of note, the patient's TSH at that time was 13. She had an
Endocrinology consult the following day, and it was their
recommendation not to replace any thyroid hormone at that
time, yet their recommendation was to follow-up with her
primary care physician [**Last Name (NamePattern4) **] [**12-4**] weeks, and if her TSH was still
high at that time, they recommended thyroid replacements, but
due to the course of her being in the Intensive Care Unit due
to postoperative state, they did not feel that this was the
appropriate time to treat this elevation in TSH.
The patient remained hemodynamically stable over the next
couple of days, while we were initiating her Coumadin dosing.
She now has a therapeutic INR today of 2.2 and is ready to be
discharged home.
CONDITION ON DISCHARGE: The patient is afebrile.
Neurologically she is intact with no apparent deficits. Her
lungs are clear to auscultation. Her heart is regular, rate
and rhythm. She is in normal sinus rhythm with a rate in the
60s. Her blood pressure is in the 110s/50s for the most
part. Her respiratory rate is 18-20, and her room air oxygen
saturation is ranged between 95 and 97%. The patient's
sternal incision, as well as her endoscopic vein harvest leg
incisions are clean and dry with no erythema and no drainage
noted.
DISCHARGE MEDICATIONS: Simvastatin 20 mg p.o. q.d., Quinine
Sulfate 260 mg p.o. q.h.s., Timoptic eye drops 1 drop to the
right eye once a day, Travatam eye drops 1 drop as directed,
Glyburide 3 mg p.o. b.i.d., Lopressor 75 mg p.o. b.i.d.,
Lasix 20 mg p.o. b.i.d. x 5 days, Potassium Chloride 20 mEq
p.o. b.i.d. x 5 days, Colace 100 mg p.o. b.i.d., Zantac 150
mg p.o. b.i.d., Aspirin 81 mg p.o. q.d., Percocet 5/325 one
p.o. q.4-6 hours as needed for pain, Amiodarone 400 mg p.o.
q.d. x approximately 6 more weeks, this can be discontinued
at the discretion of the patient's cardiologist, Dr. [**First Name4 (NamePattern1) 1399**]
[**Last Name (NamePattern1) 17915**], she was placed on it for postoperative atrial
fibrillation, Metformin 500 mg p.o. b.i.d., Coumadin 2 mg
p.o. today, [**9-28**], and tomorrow [**9-29**].
FOLLOW-UP: She has an appointment to follow-up in Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 50159**] office, on Wednesday, [**9-30**], with his
physician assistant, [**Name9 (PRE) 8797**], 2:30 p.m. Dr.[**Name (NI) 50160**] office
will continue the Coumadin dosing from thereon, and her INR
levels will be followed through his office as well.
The patient should also follow-up with her primary care
physician regarding TSH level which was elevated at 13. Of
note, other thyroid function studies, which were checked,
include T4 of 7.0, free T4 of 1.2, T4 index of 6.6, and a
T-uptake of 0.94. A free T3 level was also sent, but the
results are still pending since those were handled at an
outside laboratory.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times three with a closure of a patent
foramen ovale.
2. Postoperative atrial fibrillation.
3. Diabetes mellitus type 2.
4. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2133-9-28**] 13:18
T: [**2133-9-28**] 13:24
JOB#: [**Job Number 50161**]
ICD9 Codes: 9971, 4111, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5131
} | Medical Text: Admission Date: [**2113-5-20**] Discharge Date: [**2113-5-22**]
Date of Birth: [**2054-5-1**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 59-year-old
male with chronic renal insufficiency and known coronary
artery disease status post inferior myocardial infarction in
[**2101**], status post CABG in [**2105**] [**Hospital1 **], hypertension,
hypercholesterolemia, and tobacco use, who presented to
[**Hospital3 3834**] with substernal chest pain. The patient
states that around 9:30 pm, he was lying down on the bed and
developed [**11-3**] substernal chest pressure. He felt it might
be from overeating, so he forced himself to vomit with no
relief. The pain continued with radiation to the back, arms,
bilateral jaw, nausea, vomiting, shortness of breath, or
palpitations, or diaphoresis.
He presented to [**Hospital3 3834**], where he was found to have
global ST depression, and was given a half of dose, TNK and
Aggrastat and Heparin drip, also borderline hypotension, SBP
in the 90s-100 which was sensitive to fluid. He received in
addition to above, aspirin 325 mg, IV Lopressor, Heparin, 6
mg of Morphine, and 1.2 liters of normal saline. The patient
was then transferred to [**Hospital1 69**]
for catheterization.
On arrival, he was evaluated by CCU and was found to be
stable and pain free, and was decided to transfer to unit and
in anticipation for catheterization in the am.
REVIEW OF SYSTEMS: No fever or chills, nausea, vomiting,
diaphoresis, normal bowel movements, no dysuria, no melena,
no bright red blood per rectum, no cough, no claudication, no
orthopnea, paroxysmal dyspnea, increased edema, increased
dyspnea on exertion.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post inferior myocardial
infarction in [**2101**]. CABG in [**2105**], several peripheral
vascular disease.
2. Hypertension.
3. High cholesterol.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER:
1. Heparin drip.
2. Aggrastat.
3. Aspirin.
4. Prinivil.
5. Lipitor.
6. Lopressor.
7. Zantac at home.
8. Aspirin.
9. Gemfibrozil.
10. Prinivil.
11. Lipitor.
12. Metoprolol.
13. Zantac.
SOCIAL HISTORY: Retired soldier. Positive tobacco.
Positive alcohol.
PHYSICAL EXAMINATION: Vital signs on admission: Atrial
fibrillation, heart rate 88, blood pressure 89/60, and 98% on
3 liters nasal cannula. Sleeping in bed, position in
Trendelenburg in no acute distress, and comfortable. HEENT:
Pupils are equal, round, and reactive to light and
accommodation. Extraocular muscles are intact. Oropharynx
is clear. Mucous membranes moist. Neck: Patient is flat,
no bruits. Chest was clear to auscultation bilaterally.
Regular, rate, and rhythm, no murmurs, rubs, or gallops, no
S3, normal S1, S2. Abdomen has positive bowel sounds,
nontender, and nondistended and no hepatosplenomegaly.
Extremities: No edema, warm, no clubbing or cyanosis. Skin:
No rash.
OUTPATIENT HOSPITAL LABORATORIES: White blood cells 12,
hematocrit 39.6, platelets 306. Sodium 138, potassium 4.8,
chloride 103, bicarb of 26, BUN 21, creatinine 1.0, glucose
of 164, INR of 1.0. CK of 166, MB 19, MB 111, troponin
greater than 25.
ELECTROCARDIOGRAM AT OUTSIDE HOSPITAL: Normal sinus rhythm
at 87, normal axis, normal intervals, ST depressions, in I,
II, greater than III, aVF, V2-V3, right sided V4, strain.
Electrocardiogram at [**Hospital1 **]: Normal sinus rhythm at 91, normal
axis and normal intervals, but significant ST depressions in
V4 through V6, significantly improved.
HOSPITAL COURSE: The patient was admitted to CCU service.
Had a bedside echocardiogram which was limited of optimal
with no obvious focal wall motion abnormalities through the
inferior wall, so the inferior wall may be more hypokinetic,
[**2-27**]+ mitral regurgitation, [**1-26**]+ tricuspid regurgitation.
Patient presented to initial CK 114, troponin 0.05 on
arrival, to [**Hospital3 **], CK 166, MB 19, troponin greater than
25 but pain free. Peak CK 571, MB 106, troponin greater than
50, stable and pain free on night of admission.
Catheterization the next morning. Coronary angiography of
this right dominant circulation revealed severe LMCA and
right coronary artery disease. The LMCA and RCA were both
totally occluded proximally without any filling of distal
vessels. Graft angiography demonstrated a patent LIMA to mid
left anterior descending artery that supplied a small distal
vessel and a small diagonal 2 that ran parralel as a "twin
left anterior descending artery" system. The LIMA also
supplied a small proximal vessel and a small bifurcating D1 0
via retrograde flow. The saphenous vein graft to PDA was
widely patent and also filled a small diffusely diseased PLV
via retrograde flow. The saphenous vein graft to OM-1
touchdown on the lower pole of the moderate bifurcating OM-1,
the small mid and distal left circumflex was also supplied
via retrograde flow. The saphenous vein graft to OM had an
85% distal stenosis just proximal to the anastomosis.
Resting hemodynamics revealed normal RV filling pressures
with a RV mean pressure of 7 mg Hg and RV end diastolic
pressure of 11. The mean PCW was 17. The cardiac output was
preserved at 5.5. Left ventriculography was not performed.
The stenosis in the saphenous vein graft OM near the distal
anastomosis was successfully treated by angioplasty and
stenting using a 2.5 x 18 mm velocity Hepakote stent with no
residual stenosis, no angiographic evidence of dissection,
and TIMI-3 flow.
The patient remained stable and was called out to the floor.
He was continued on aspirin, Plavix, and a statin, and was
started on low dose beta blocker. He remained normotensive.
On [**2113-5-22**], the patient had an echocardiogram which was
pending at the time of discharge. CKs were coming down. Left
femoral groin showed no evidence of hematoma or bruit.
The patient was counseled to quit smoking multiple times
throughout the hospital course, however refused. He was also
recommended to stay until receiving his echocardiogram
results so that he would be able to bring them to his primary
care doctor, however, he declined.
He was discharged to home to followup with his primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 3914**], whom he does not remember their name. He
had an echocardiogram performed on [**2113-5-22**] which was
pending at the time of discharge. However, it subsequently
returned showing ejection fraction of 40%, normal left
ventricular wall thickness, and cavity size, regional wall
motion abnormalities, including basal inferior akinesis with
basal and mid inferolateral mid inferior hypokinesis, right
ventricular chamber size, and free wall motion are normal.
The aortic valve is mildly thickened. No aortic
regurgitation is seen, moderate mitral regurgitation, and
borderline pulmonary artery systolic hypotension are also
visible.
DISCHARGE DIAGNOSIS:
1. Acute myocardial infarction status post catheterization
with stent.
2. Native three vessel coronary artery disease.
3. Moderate diastolic ventricular dysfunction.
4. Mild systolic dysfunction with ejection fraction of 40%.
5. Hypercholesterolemia.
RECOMMENDED FOLLOWUP: He must see doctor [**First Name (Titles) **] [**Last Name (Titles) 3914**] as soon
as possible.
DISCHARGE MEDICATIONS:
1. Atorvastatin 20 mg po q day.
2. Ranitidine 150 mg po bid.
3. Aspirin 325 mg po q day.
4. Plavix 75 mg po q day x9 months.
5. Lisinopril 5 mg po q day.
6. Metoprolol 25 mg po bid.
7. Nitroglycerin prn.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2113-5-24**] 10:57
T: [**2113-5-29**] 13:34
JOB#: [**Job Number 40148**]
ICD9 Codes: 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5132
} | Medical Text: Admission Date: [**2102-1-17**] Discharge Date: [**2102-3-5**]
Date of Birth: [**2039-4-20**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Consulted by ED for change in mental status, ?seizure
Major Surgical or Invasive Procedure:
brain biopsy
History of Present Illness:
Pt is a 62 year old man with a hx of diabetes, HTN, high
cholesterol, former cocaine use, and multiple strokes who
presents with altered mental status and question of seizure. He
was transferred from [**Hospital **] hospital for higher level of care.
On the day of admission, he was at rehab when he was found
minimally responsive with eyes open with leftward gaze and
bilateral UE and left LE "twitching". He was diaphoretic and
FSG = 89 (apparently low for him). 1mg glucagon given at
9:15AM. At 9:30, FSG 126 BP 200/110 HR 122. He was given
nitropaste at 10AM. EMS was called and he was brought to
[**Location (un) **] ED. In ER, he was found to be febrile and unresponsive.
His blood pressure was elevated 200's/100's and he
has another episode of "extremity shaking". He rec/d ativan 1mg
x2, lopressor, Levoflox, CTX (2g), and was put on a labetalol
drip. Neurology was consulted and felt that seizures may be due
to hypertensive urgency vs new stroke causing secondary HTN.
Recommended head CT (not done) and LP (Tube 1: 196 RBC 4 WBC,
Tube 4: 7RBC 3WBC, no diff, prot/gluc pending). He was
transferred here for ICU level of care. In our ED, he was
loaded with dilantin and given an additional ativan for another
episode of questionable seizure activity. He was intubated for
airway protection prior to imaging.
He has a history of multiple strokes in the past and has been
followed at multiple institutions. He was last seen here by Dr.
[**Last Name (STitle) **] for follow up in [**2101-1-25**] after his [**10-30**] admission for
multiple strokes thought to be secondary to small vessel
disease. At that time, he was found to be abulic, with left
hemiparesis and right leg plegia. Strength in the left leg was
noted to be
3+/5 at that time. He was hyperreflexic in and toes are upgoing
bilaterally. He was continued on Aggrenox for stroke prevention.
According to his family, he has had multiple other strokes since
this time and was transitioned from Aggrenox to Plavix at some
point. He was recently admitted to Caritas [**Hospital3 **] [**12-28**] for
acute
stroke (p/w decreased verbal output) and was found to have left
insular and and left aca/mca watershed infarcts. Aspirin was
added to Plavix and Norvasc was increased for HTN. Since that
time, he has been doing well at rehab. He walks with a walker
at baseline and is talkative and interactive with his family.
His family is not aware of any recent fevers, chills, headache,
cough, shortness of breath, N/V, or diarrhea. They say that
they last saw him yesterday and he appeared "fine". He has not
had a seizure before although his daughter noted that he had an
episode of whole body shaking from fever (?rigors) in the
setting of a UTI in the past.
Past Medical History:
-Hypertension
-Diabetes
-High cholesterol
-History of cocaine abuse
-Multiple strokes in the past attributed to drug use and
noncompliance with his medical regimen: [**11-16**] admitted for Right
leg weakness showed left parietal and right middle cerebral
peduncle infarcts. MR also showed basilar artery stenosis and
old right pontine and midbrain infarcts.
-s/p knee surgery
Social History:
From [**Country 3594**] originally. Currently lives in a nursing
home/rehab after his last admission to [**Hospital3 **] 2 weeks prior to
this admission. Former cocaine and MJ use. Denies tobacco use.
Quit ETOH last year. Former high school teacher, taught
automotive class.
Family History:
Mother had a stroke in her 40's; HTN; DM
Physical Exam:
Exam:
(prior to intubation)
T: 101.8 HR98-125 BP 150-185/80-109 RR16 O2 Sat 100% (on NRB)
Gen: Eyes closed, minimally responsive, spontaneously moving
left arm and leg semipurposefully.
HEENT: NC/AT, dry oral mucosa, +blood on lips, but cannot open
mouth as pt has jaw held shut.
Neck: rigid
CV: Tachy, Nl S1 and S2
Lung: Clear to auscultation anteriorly
Abd: +BS soft, non-distended
Ext: No edema
Neurologic examination:
Mental status: Unresponsive, does not open eyes to verbal or
tactile stimulation. Grimaces to noxious stim and moves his left
side to noxious stim. Doesn't follow commands.
.
Cranial Nerves:
No blink to threat bilaterally. Pupils: 3mm briskly reactive
bilaterally. Roving eye movements with left gaze preference, is
readily able to cross midline to right. +corneal bilaterally,
VOR intact, Grimaces to nasal tickle: face appears asymmetric,
with decreased movement of the left face. Unable to assess gag.
.
Motor:
Normal bulk bilaterally. Tone normal. Withdraws in all 4
extremities, but right leg is more sluggish than other
extremities.
.
Sensation: Grimaces in all 4 extremities.
.
Reflexes:
B T Br Pa Ach
Right 2 2 2 3 clonus
Left 3 3 3 3 clonus
.
Toes upgoing bilaterally
Coordination: unable to assess
Pertinent Results:
.
[**2102-1-17**] 05:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2102-1-17**] 06:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2102-1-17**] 06:10PM SED RATE-38*
[**2102-1-17**] 06:10PM CRP-3.1
.
[**2102-1-17**] 06:10PM PT-14.4* PTT-23.5 INR(PT)-1.3*
[**2102-1-17**] 06:10PM PLT SMR-NORMAL PLT COUNT-412
[**2102-1-17**] 06:10PM NEUTS-88.7* BANDS-0 LYMPHS-8.7* MONOS-2.1
EOS-0.1 BASOS-0.3
[**2102-1-17**] 06:10PM WBC-16.6*# RBC-3.96* HGB-11.6* HCT-33.2*
MCV-84 MCH-29.3 MCHC-34.9 RDW-15.2
.
[**2102-1-17**] 06:10PM cTropnT-<0.01
[**2102-1-17**] 06:10PM ALBUMIN-4.2 CALCIUM-9.5 PHOSPHATE-4.7*
MAGNESIUM-1.8
[**2102-1-17**] 06:10PM LIPASE-21
[**2102-1-17**] 06:10PM ALT(SGPT)-19 AST(SGOT)-26 CK(CPK)-172 ALK
PHOS-187* AMYLASE-136* TOT BILI-0.2
[**2102-1-17**] 06:12PM LACTATE-3.0*
[**2102-1-17**] 09:47PM LACTATE-5.7*
.
[**1-17**]: CXR: No radiographic evidence of pneumonia.
.
CT head [**1-17**]: No acute intracranial hemorrhage or mass effect.
Small wedge- shaped hypodensity in the left frontal lobe may
represent a chronic infarct but is new compared to [**2100-11-11**].
MRI/MRA head with and withou gad; [**1-18**]:
Exam compared to prior study of [**2100-11-11**].
FINDINGS: There is a focus of abnormal diffusion in the region
of the posterior limb of the internal capsule and thalamus on
the left side with abnormal signal on the T2-weighted sequence,
consistent with subacute infarction. There are abnormal signal
foci in the anterior insula on the left and in posterior frontal
sulci with contrast enhancement consistent with relatively
recent infarction. There is some increase in signal in this
posterior frontal cortical region on the nonenhanced T1-weighted
sequence consistent with laminar necrosis. There are multiple
abnormalities in the basal ganglia, periventricular white matter
and centrum semiovale unchanged from previous examination
consistent with remote lacunar infarction and microvascular
angiopathy. There is mild prominence of ventricles and sulci
consistent with mild brain atrophy. There is no evidence of a
focal extra- axial lesion or fluid collection. There is
increased signal in the right maxillary sinus consistent with
sinus disease unchanged from prior study. The appearance of the
left maxillary sinus has improved since previous exam.
IMPRESSION: Recent infarctions of varying age in the left basal
ganglia, thalamus, insula region and frontal cortex as
described.
MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES [**1-18**]:
Exam compared to prior study of [**2100-7-9**].
There is decreased visualization of the A1 portion of the right
anterior cerebral artery compared to the previous examination.
This may represent progressive atherosclerosis or could
represent a technical issue. The irregularity of the distal
basilar artery is not well visualized on the present examination
which again could be technical in nature. There is persistent
decreased visualization of the right posterior cerebral artery
unchanged from previous examination. There is persistent
irregularity of the M1 portion of the left middle cerebral
artery.
IMPRESSION: Findings consistent with atherosclerosis involving
in particular the left middle cerebral artery and the right
posterior cerebral artery. There may also be some progressive
disease involving the A1 portion of the right anterior cerebral
artery.
.
MRI brain with and without gad [**1-23**]:
Multiplanar T1- and T2-weighted images of the brain was obtained
without and with intravenous gadolinium administration.
Comparison is made to the prior recent MRI exam from [**1-17**], [**2101**]. There is persistent area of restricted diffusion
involving the posterior limb of the left internal capsule
abutting the left basal ganglia which is slightly larger in
size, most likely consistent with evolution of the previously
seen subacute infarct. There is moderate dilatation of the
lateral ventricles. Chronic periventricular T2 hyperintensities
are noted consistent with chronic microvascular ischemic or
gliotic changes.
There is an area of subtle enhancement involving the left
frontal lobe consistent with an area of recent infarction,
probably a few weeks old. An area of enhancement is also noted
in the left subinsular region which also represents the sequelae
of prior ischemic event or infarction. There is normal
enhancement seen along the superior sagittal sinus which appears
to be patent. Chronic mucosal thickening is noted within the
paranasal sinuses, unchanged in appearance since the previous
exam. There are old infarcts involving the brainstem and the
right aspect of the pons.
IMPRESSION: Evolving areas of infarction involving the left
frontal lobe and the left subinsular region. Progression of the
previously seen subacute infarct involving the posterior limb of
the left internal capsule.
MAGNETIC RESONANCE VENOGRAPHY: 2D time-of-flight magnetic
resonance venography was performed. There is normal signal seen
along the superior sagittal sinus which is patent. The
visualized internal cerebral veins, transverse and straight
sinuses are patent. There is no evidence for venous sinus
thrombosis.
IMPRESSION: Unremarkable magnetic resonance venography with
normal signal and patency seen involving the superior sagittal
sinus.
.
MRA OF THE CIRCLE OF [**Location (un) **] [**1-23**]: 3D time-of-flight MRA of the
circle of [**Location (un) 431**] was performed. Comparison is made to the prior
examination of [**2102-1-17**]. There has been further
reduction of signal involving the entire basilar circulation
suggestive of worsening thrombotic disease versus spasm of the
vessel itself. There is significantly decreased attenuation and
signal involving the middle cerebral circulation, left greater
than right with diminished signal along the M1 segment of the
left MCA. The findings could represent further embolic disease
versus further thrombosis of the middle cerebral circulation.
There is also attenuation of the proximal A2 portion of the
anterior cerebral artery.
IMPRESSION: Further reduction of signal involving the basilar
circulation and the middle cerebral arteries in comparison to
the previous exam of [**2102-1-17**], most likely indicating
worsening thrombotic disease and occlusion of these vessels.
There is near occlusion of the left MCA in comparison to the
previous exam. Further followup is suggested as clinically
indicated.
.
EEG [**1-18**]: This is an abnormal portable EEG due to the presence
of a
slow and disorganized background. This finding suggests an
encephalopathic pattern most likely due to medication effect.
There were no lateralizing or epileptiform abnormalities seen.
.
EEG [**1-22**]: This is an abnormal EEG due to the presence of diffuse
background slowing and generalized bursts of mixed frequency
delta and theta slowing. No focal or epileptiform features were
observed. This EEG is most common with encephalopathy. Common
causes of encephalopathy are medications, metabolic causes and
infectious processes. Encephalopathies can obscure focal
findings.
.
ECHO [**1-19**]: The left atrium is elongated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion. Compared with the prior
study (images reviewed) of [**2100-7-13**], there is no significant
change.
[**1-19**]: CSF:
NEGATIVE FOR MALIGNANT CELLS.
Rare lymphocytes and monocytes.
WBC RBC Polys Lymphs Monos Eos
21 187* 17 68 15
21 1890* 412 50 7 1
.
TotProt Glucose
42 94
.
PROTEIN ELECTROPHORESIS CSF-PEP
neg
.
HSV-PCR negative
BRAIN Bx RESULTS:
Acute ischemic encephalopathy. Scattered eosinophilic, crenated
cortical neurons. Perivascular hemosiderin and
arteriolosclerosis. No significant inflammation. No diagnostic
infectious process. No intravascular lymphoma or other
diagnostic neoplasia. #2, RIGHT FRONTAL DURA: Dense connective
tissue. No significant inflammation.
CT CHEST [**1-31**]- had requested to be performed with contrast to r/o
malignancy, but performed WITHOUT contrast.
IMPRESSION: Small bilateral effusions and bibasilar atelectasis.
No evidence of malignancy.
CT NECK [**2-6**] - performed for ?neck abscess
IMPRESSION: Confluent soft tissue density within the anterior
inferior neck, with posterolateral displacement of the thyroid
to the left. The confluent soft tissue density may represent
hematoma versus edema. No areas of active extravasation are
identified on this study. Underlying neoplasm cannot be entirely
excluded.
CTA abdomen/pelvis to look at kidneys [**2-7**]:
CONCLUSION:
1. Normal sized kidneys both supplied by a single renal artery,
which appears widely patent and normal in caliber. No evidence
of renal artery stenosis. Normal adrenal glands.
2. Moderate amount of intraabdominal and pelvic hematoma most
likely following recent PEG placement. The intraabdominal
component anteriorly included on the preceding non-contrast CT
of [**2102-2-6**] is no larger than on previous CT.
Repeated CT abdomen/pelvis [**2-14**]:
IMPRESSION:
1. No evidence of new intraperitoneal or retroperitoneal
hemorrhage.
2. Interval decrease in the amount of the high-density fluid
within the pelvis.
3. Bilateral small pleural effusions and associated atelectasis.
4. Mixed sclerotic and lytic changes within the left iliac bone
not typical for Paget's disease. Metastatic disease or chronic
infection cannot be completely excluded. Recommend correlation
with PSA and bone scan.
CT head [**2-13**] repeated for ?new infarcts:
NON-CONTRAST HEAD CT SCAN: Examination is slightly limited by
patient motion. The ventricles are unchanged in size and
appearance compared to the recent MR exam. There is no evidence
of acute intracranial hemorrhage or shift of the normally
midline structures. Multiple areas of infarction are again
noted, particularly in the left frontal lobe and subinsular
cortices bilaterally. An evolving (subacute-chronic) infarct is
again noted in the left putamen. No new areas of major vascular
territorial infarction are appreciated on today's exam. The
visualized paranasal sinuses are well aerated. There is partial
opacification of right mastoid air cells, which may be related
to fluid, mucosal thickening, or both. Post-surgical changes of
the right frontal calvarium are noted.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Multiple old infarcts noted, and evolving infarction of the
left putamen again appreciated. No new areas of major vascular
territorial infarction are appreciated on today's study.
CT ABDOMEN W/CONTRAST [**2102-3-3**] 4:24 PM
The lung bases demonstrate small bilateral pleural effusions
with associated atelectasis. The liver, pancreas, spleen,
adrenal glands are unremarkable. Right mid pole renal cyst,
measures simple fluid. There is a left mid pole low-attenuation
renal lesion which is too small to fully characterize. An NG
tube tip is seen in the distal pylorus. A PEG tube is seen in
place in the body of the stomach.
There is markedly dilated small bowel with a clear transition
point seen within the right lower quadrant in the distal small
bowel seen best on coronal images on series 4, image 16. Distal
to this transition point, there is collapse of the distal ileum
and entire colon. Contrast is seen in the ascending and
transverse colon, ending at the splenic flexure. However this
contrast is of high density and is likley residual contrast from
the prior feeding tube procedure of [**2-28**]. Contrast is seen in the
proximal small bowel loops but is not present in the distal
ileum at the the site of the focal transition. There is no free
intraperitoneal air.
Also seen in the midline in the site of previous hematoma, there
is a focal fluid collection with rim enhancement just below the
abdominal wall. Superinfection cannot be excluded. Within the
subcutaneous tissue of the abdominal wall, there are several
granulomas which may be secondary to prior injections.
CT PELVIS WITH IV CONTRAST: The urinary bladder is catheterized.
There is a foley catheter. The prostate and rectum are
unremarkable. There is no free fluid.
BONE WINDOWS: Again seen is a mixed sclerotic pattern seen
predominantly within the left iliac bone unchanged compared to
prior study, probably representing chronic fibrous dysplasia.
IMPRESSION:
1. High grade complete small-bowel obstruction of the distal
ileum with transition point in the right lower quadrant seen
best on coronal images (series 4, image 16). Contrast in the
colon is likely from prior exam as there is no contrast in the
distal small bowel at the site of the focal transition.
2. Well-demarcated fluid collection just below the anterior
abdominal wall in the site of previously seen hematoma.
Superinfection cannot be excluded.
3. Mixed sclerotic appearance of left iliac bone, unchanged most
consistent with chronic fibrous dysplasia.
Brief Hospital Course:
62 yo man with a hx of HTN, DM, high cholesterol, and multiple
strokes who presents with altered mental status and possible
seizure at his rehab in the setting of hypertension and fever.
Exam at admission was notable for minimal responsiveness, left
gaze preference, and decreased movement of his right LE (old).
.
1. Neuro/strokes:
-Neuro exam throughout much of admission remained stable as
follows: encephalopathic, not following commands, non-verbal,
not-tracking; PERL, often has a left gaze preference (does not
correlate with seizure on LTM), but can move eyes to either
side; right visual field cut; R-facial droop, R-hemiplegia,
limited spontaneous movement LUE and LLE, responding to noxious
RUE with grimace, triple flexion RLE. Tone increased in the
lower extremities. Bilateral upgoing toes.
-MRI/MRA with/without gado upon admission: L-int. capsule
infarct; multiple lesions on Flair (L>R) (see report in
"results" section).
-Workup performed to determine etiology - multiple past strokes
were often related cocaine use and vasospasm; this was in
differential, but tox screen was negative at admission.
-Patient noted to be very hypertensive throughout much of entire
admission - thought to be one possible etiology for new stroke
-Patient was kept on ASA; aggrenox changed to plavix as aggrenox
could not be crushed for NG tube; both were later held for
anemia, then restarted when HCT appeared more stable.
-MRV and MRI/MRA repeated [**1-23**]: MRV nl, MRI evolving infarct
L-int. capsule, evolving infarct L-insular region; MRA near
occlusion prox L-MCA, worsening basilar as well: restarted
plavix and started amlodipine for vasospasm: this rapid
detoriation also posed question of vasculitis
-Started solumedrol 1g q24 hrs iv on [**1-25**], which was switched to
Prednisone on [**1-28**] and eventually weaned off once brain bx neg
for vasculitis.
-Brain biopsy [**1-27**] (held plavix) to rule out vasculitis; post-op
CT head with no complications
-CT brain repeated [**2-13**] with evolution of left putamen infarct,
mult other old infarcts, nothing new on scan.
-Exam upon transfer to floor as follows: patient easily
awakened, looking around room, but often with left gaze
preference, spontaneously moving face but not following any
commands even with miming; no blink to threat on right, + on
left, perrlb 3->2, right facial droop, left arm and leg with
spontaneous movement, right arm plegic with no w/d to stim,
right leg with triple flexion to stim. Both toes upgoing.
-Aspirin 325 and Plavix were initially used to treat the patient
after his strokes, but they are being held as he is unable to
take PO; they should be restarted when GTube can be used once
again.
-Would recommend neuro consult to help manage stroke/seizure
issues.
2. Seizures:
-EEG after admission: slow and disorganized background, no
lateralizing or epileptiform abnormalities; repeat EEG [**1-21**]:
slowing right fronto-temporal>left.
-No seizures observed while in hospital for majority of hospital
course in ICU; patient continued on dilantin, with goal of 10,
but level very difficult to achieve, requiring frequent dilantin
boluses. As no seizure activity, this was eventually allowed to
trend down, with switch to [**Month/Year (2) 13401**] and wean of dilantin once
[**Month/Year (2) 13401**] therapeutic.
- Patient was transferred to floor on [**2-13**]. On day of transfer,
some tonic posturing of left arm noted (versus agitation -
associated with high blood pressure). For possibility that this
was seizure (unclear), [**Name (NI) 13401**] was increased from 1000bid to 1500
mg [**Hospital1 **].
- Patient started having more brief partial onset secondarily
generalized seizures consisting of turning of the head, face
contortion, followed by tonic flexion of left elbow and the
clonic jerking, all within less than 10 seconds per seizure.
He was monitored on LTM, and found to have both clinical and
subclinical events; furthermore, many events (ie "total body
shaking") were not consistent with seizure, but rather
agitation. Events that correlated with EEG activity involved
left arm flexion and tonic posturing and left gaze deviation
with tachycardia.
- Dilantin was added and the patient continued to have several
seizures in a day; therefore, depakote was added. Levels were
bolused to try to maintain levels near 20 and 80 respectively
but this was never achieved. Later free dilantin level was 2.0
with a total level of 10.8.
- When ileus developed 4 days after depakote load and kept
recurring, depakote was allowed to drift down, as it was felt to
be contributing to the ileus and the elevated LFTs. Depakote
was weaned to [**Telephone/Fax (3) 58581**] on the day of transfer, with plans to
wean this further.
-On the day of transfer to [**Hospital1 112**], seizure-like events were rare,
occurring once every few days; VPA level was 50, and PHT level
was 6.8, which was felt to be within goal based on a 20% free
dilantin:total dilantin ratio. He was also continued on IV
ativan for added seizure prophylaxis as he could not tolerate PO
meds.
-Seizures were thought to be related to ileus + sbo, and poor
absorption of PO [**Hospital1 13401**]; when he is able to take PO meds by
G-Tube, [**Hospital1 13401**] should be reconsidered.
3. GI/Small bowel obstruction
-TF and GI prophylaxis were initiated as an inpatient. LFTs
were normal.
-As he required tube feeds, a PEG tube was placed. For days
after the peg, the hematocrit dropped and the wbc count rose.
He had a gastrograffin test with no extravasation of contrast
per SICU team; they felt the site was not likely to be infected.
He did undergo CT abdomen and pelvis, which revealed moderate
hematoma (likely from PEG placement); this was felt to
potentially explain the drop in HCT. The scan was repeated
approximately one week later, and revealed no new hematoma,
interval decrease in the size fo the high-density fluid within
the pelvis (likely old hematoma), as well as bilateral small
pleural effusions and atelectasis.
-Several CTs of the torso had revealed: "Mixed sclerotic and
lytic changes within the left iliac bone not typical for Paget's
disease. Metastatic disease or chronic infection cannot be
completely excluded. Recommend correlation with PSA and bone
scan." This was not worked up.
-Ileus developed with KUB confirmed dilated loops of small bowel
on [**2-22**] and was treated with NGT to low wall suction. Surgery
was consulted. He maintained bowel movements and flatus and
ileus improved but recurred resulting in emesis on [**2-28**]. Repeat
KUB showed multiple dilated loops of small bowel. Surgery was
reconsulted and CT abdomen was done showing high grade small
bowel obstruction with transition point noted at the distal
ileum, with collapse of the ileum and colon distal to this
point. A small amount of contrast was seen but was felt to be
due to fluoroscopy 2 days earlier for NJ placement. Family was
presented options of surgery versus conservative management and
wished for transfer for surgical management of his bowel
obstruction.
-He has had G-tube to gravity and NGT to intermittent suction;
NGT output on the day of transfer to [**Hospital1 112**] was 600cc overnight.
All PO meds are being held for the time being.
3. Diabetes:
-The patient was placed on FS QID + RISS; remained on and off
insulin drip and sliding scale until his regimen was adjusted to
avoid the insulin drip further. He was started on metformin and
had better blood glucose control. When he was made NPO, he was
continued on the insulin sliding scale only.
.
4. HTN:
-Hypertension was a major issue throughout admission with BPs as
high as 280s systolic on occasion, (particularly with arousal
and pain).
-Goal SBP less than 180 via isosorbide mono, captopril
increased, metoprolol continued and increased, amlodipine for
vasospasm. He initially required a labetalol drip but was
finally able to tolerate meds by G-tube. He ruled out for MI
with serial enzymes. Echo [**1-19**] showed no change compared to
[**2099**] with no major valve abnormalities and EF 55%.
-Nephrology was consulted and recommended CTA kidneys which was
negative; other w/u for underlying d/o including urine
metanephrines, etc. negative. They also recommended continuing
propofol initially for BP control, but this had the side effect
of making him difficult to wean from the vent.
-BP eventually under better control once clonidine introduced -
propofol could be weaned to off, and eventually standing lasix
was implemented with better blood pressure control. BP range
decreased by [**2-17**] and only infrequently went as high as 200
systolic. Usual range was 140-180 systolic, on multiple
medications including clonidine patch. He was transferred to
the floor at this point.
-When he was unable to tolerate PO BP meds, he was changed to a
regimen of IV enalaprilat, lopressor, hydralazine, and lasix
(low-dose, for electrolyte and fluid imbalance earlier in
hospital course). He was previously on imdur 40 mg [**Hospital1 **],
captopril 100 mg tid, hydralazine 25 mg qid, metoprolol 150 mg
tid, and verapamil 80 mg tid, as well as lasix 20 mg [**Hospital1 **]. He
was hypertensive to 180s on the day of discharge/transfer to
[**Hospital1 112**]; we have been using lopressor and hydralazine prn in
addition to his current regimen to control transient increases
of blood pressure.
.
5. Pulmonary:
-The patient was initially intubated in ED for airway
protection. A chest xray was initially negative, and repeated
chest xrays showed mild congestion but no pneumonia. He was
extubated on [**1-20**] and reintubated [**1-27**] following brain biopsy.
He was difficult to wean because of his increased secretions, as
well as the inability to wean off propofol without his blood
pressure increasing above 200 systolic.
-CT of the chest was performed to r/o pulmonary malignancy as a
part of multiple repeat stroke workup - negative, but
unfortunately performed without contrast
-He had a trach placed, with the intention of weaning propofol.
He developed an infection at the site of the trach, treated with
vanco, and no surgical debridement.
-When BP was under better control, he was weaned to trachmask,
and transferred to the stepdown unit.
.
6. ID:
-He had developed fevers during the first month of his
admission. This was worked up with multiple sets of blood
cultures (all negative), and initial LP upon admission as
follows:
-Tube one: 4WBC (14 poly, 80L, 6 mono) RBC 196; tube 4: 3WBC(7
poly, 87L, 6 mono), RBC 7; prot 36; glc 81 (serum 120); gram
stain negative; tending towards viral infection
-He underwent repeat LP on [**1-19**]: OP 29cm; sent for cytology and
viral panel
Protein 42 Glucose 94 CSF-PEP: Pnd
WBC 2 RBC 187 Poly 17 Lymph 68 Mono 15 EOs
WBC 2 RBC 1890 Poly 41 Lymph 50 Mono 7 EOs 1
-ESR 38, CRP 3.1 (upon admission)
-initial CXR neg; UA negative/UCx negative; Blood Cx x3
negative
-CSF Cx: HSV-PCR negative (at [**Location (un) **]: [**Numeric Identifier 58582**]) and here.
-He was empirically treated with Ceftriaxone, Vanco and
Acyclovir until cultures, HSV PCR came back: d/c-ed [**1-21**].
-Initial CT abd/pelvis with contrast to r/o infection showed no
pathology
- By the beginning of [**Month (only) 958**], the WBC count was trending down and
sputum cultures showed only moderate growth oropharyngeal flora
-Inflammatory markers resent [**1-25**]: ESR 90, CRP 161.5, RPR, sent
cryptococcus Ab CSF [**1-24**] - all negative
-Developed elev wbc count on [**1-30**], which was monitored as he had
no current signs of infection.
-Following the PEG tube and Trach placement, WBC count went as
high as 20s, and he had recurrence of fevers. He was treated
with Levaquin and Flagyl for the possible source of infection
being the PEG. CT of the abdomen did not reveal infection, but
did show a retroperitoneal hematoma. After several days on this
antibiotic, his neck was noted to be edematous and erythematous
around the site of the trach, and trach site abscess or phlegmon
was felt to be the source of the infection. He was treated with
vancomycin for two weeks; this was discontinued before he was
transferred to the floor. The neck was not debrided.
-He had no further infectious issues while on the floor, and
remained afebrile with a normal white blood cell count on the
day of transfer.
.
7. Heme:
-He had periodic drops in hematocrit. He dropped to 22.4 on
[**1-23**]; he received 2uPRBC; plavix and ASA were on hold; guaiac'ed
stools (negative) and sent hemolysis labs, anemia labs.
Hematocrit became more stable at 28. Iron was started once
studies showed some iron deficiency anemia. B12 was normal.
Iron was discontinued when he could no longer tolerate PO meds
and NGt was to suction.
.
8. FEN:
-Renal consult was obtained for high blood pressure - see "CV"
above. No evidence of renal artery stenosis, pheochromocytoma,
or other neuroendocrine tumors by labs. Renal had recommended
propofol for BP management, but as this prevented weaning,
clonidine was eventually added with good effect. Lasix was also
added for further diuresis, as he was net positive >27 L since
admission and appeared edematous (though albumin and prealbumin
also lower since admission).
-PICC Line was placed for ease of access, and triple lumen was
d/c'ed
-Tube feeds were continued per nutrition recommendations; these
were later held when he developed SBO.
-TPN was started, and this should be continued after transfer to
[**Hospital1 112**].
9. Dispo:
-He was in the neuro ICU (with the SICU team comanaging) for
most of the admission
-Full code per discussions with Daughter: [**Doctor First Name **]
[**Telephone/Fax (1) 58583**]. However, family discussion was held later in the
admission and he was changed to DNR/DNI, which his daughter and
sister agreed upon. He was transferred to [**Hospital1 112**] for further
workup of his GI issues (above).
Medications on Admission:
ASA 81mg
Plavix 75mg qd
Lopressor 150mg [**Hospital1 **]
Zocor 40mg qd
Zoloft 100mg po qd
Lantus [**7-4**]
Detrol 2mg qd
Nexium 40mg qd
Norvasc 10mg qd
Capoten 50mg TID
Imdur 90mg qd
RISS
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed.
6. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous 4xd: SLIDING SCALE AS FOLLOWS:
if BG <70, give [**11-28**] d50; if BG 71-150, do nothing; if BG 151-200
give 2 units regular insulin; if bg 201-250 give 4 units; if bg
251-300 give 6 units; if bg 301-350 give 8 units; if bg 351-400
give 10 units; if bg>400 give 10 units and call HO.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
10. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed: for pain/fever.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Lorazepam 1-2 mg IV PRN seizure lasting more than 2 minutes,
more than 2 seizures in one hour
Please call HO if you need to give this.
14. Thiamine HCl 100 mg IV DAILY
15. Folic Acid 1 mg IV DAILY
16. Pantoprazole 40 mg IV Q24H
17. Phenytoin 150 mg IV Q8H
18. Metoprolol 10 mg IV Q4H
WHILE NPO
19. HydrALAZINE HCl 10 mg IV Q6H
WHILE NPO
20. Enalaprilat 2.5 mg IV Q6H
GIVE WHILE PT NPO
21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
22. Heparin Flush PICC (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.
23. Furosemide 20 mg IV DAILY
24. Lorazepam 1 mg IV QID
GIVE WHILE PT NPO
25. Valproate Sodium 500 mg IV Q12H
26. Valproate Sodium 250 mg IV UNDEFINED
in midday
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 13753**] - [**Location (un) 86**]
Discharge Diagnosis:
Strokes
Seizures
Small bowel obstruction
Ileus
S/p trach
trach site infection
S/p PEG
retroperitoneal hematoma
Malignant Hypertension
Akinetic mutism
Discharge Condition:
Stable exam - akinetic mute, hemiparetic - see discharge summary
for details.
Discharge Instructions:
Transferred to [**Hospital1 112**] for further workup of small bowel
obstruction.
Followup Instructions:
Please f/u with Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] - ([**Telephone/Fax (1) 7394**] - call
for appointment after discharge from hospital, or follow up with
[**Hospital1 112**] neurology if seen and family prefers.
Completed by:[**2102-3-5**]
ICD9 Codes: 5119, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5133
} | Medical Text: Admission Date: [**2117-6-7**] Discharge Date: [**2117-6-10**]
Date of Birth: [**2056-4-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
RUQ pain, jaundice
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy
History of Present Illness:
61 yo M with h/o cholecystectomy about 7 years ago p/w RUQ pain,
jaundice and fever. Saw his PCP prior to admission and was sent
to ED for uncontrollable shaking and fever. He has been having
intermittednt RUQ pain for the last few days, and jaundice for
the last few weeks. He was initially seen at [**Hospital 1562**] Hospital
for complaints of 2 days of rigors and fever and was noted to
have common bile duct dilation on RUQ u/s to 12 mm and fever to
102. Also with elevated AST, ALT, bilirubin. Amylase and lipase
wnl (47 and 47 at outside hospital). Also noted to have
leukocytosis. He was given a dose of zosyn and toradol for pain
control, as well as a 1L bolus of IVF for hypotension and
transferred here for further workup and ERCP
.
In the ED, initial vitals were 97.6 71 90/58 16 100% RA. RUQ u/s
done showing intra and extrahepatic biliary dilation with CBD
measuring 1.3 cm diameter with no obstructive cause seen.
Patient was given a dose of gentamicin 80 mg. He was also given
about 3L of IV normal saline for systolic BP in 80s-90s, R IJ
central line placed and levophed started as well with increase
in pressures to 120s. ERCP team consulted in ED and recommended
giving gentamicin and ERCP in AM. VS on transfer: 65 128/69 18
97%
.
On the floor, he has no complaints. Pain has resolved, no
nausea, vomiting, diarrhea, constipation, headache, or other
complaints. Has been having intermittent RUQ pain about once
every 2 weeks x 2-3 years, but acutely worsened over the the
past few days, with jaundice occuring over the past week.
Review of sytems:
(+) Per HPI
(-) Denies 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:
Cholecystectomy ([**2112**])
Appendectomy
Bipolar disorder
Social History:
live with wife, no [**Name2 (NI) **] contacts, smoked a pack per day x 30
years but doesn't smoke anymore, has not had EtOH in 18 years,
no h/o IVDU
Family History:
no h/o GI disease, malignancy
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress, jaundiced
HEENT: Sclera icteric, 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, ttp in RUQ and RUL, nondistended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs: [**2117-6-7**] 09:30PM
WBC-12.1* RBC-3.85* Hgb-11.6* Hct-33.3* Plt Ct-211
ALT-216* AST-157* LD(LDH)-182 AlkPhos-155* TotBili-5.7*
DirBili-4.7*
Glucose-107* UreaN-18 Creat-1.4* Na-142 K-4.2 Cl-111* HCO3-22
AnGap-13
Lactate-0.8
[**2117-6-8**] 05:18AM
WBC-6.4 RBC-3.46* Hgb-10.5* Hct-31.5* MCV-91 Plt Ct-188
PT-13.7* PTT-30.0 INR(PT)-1.2*
Glucose-86 UreaN-17 Creat-1.3* Na-145 K-4.1 Cl-116* HCO3-23
AnGap-10
ALT-172* AST-111* LD(LDH)-153 AlkPhos-138* DirBili-4.0*
[**2117-6-9**]
[**2117-6-9**] 05:35AM BLOOD WBC-5.4 RBC-3.82* Hgb-11.4* Hct-33.8*
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.9 Plt Ct-220
[**2117-6-10**] 06:10AM BLOOD Na-145 K-4.1 Cl-109*
[**2117-6-9**] 05:35AM BLOOD ALT-141* AST-67* TotBili-2.5*
MICRO:
Blood Cultures [**2117-6-7**] x 2 PENDING
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2117-6-7**]
9:41 PM
Intra- and extra-hepatic biliary dilation with the common bile
duct measuring up to 1.3 cm in diameter. The obstructing cause
is not seen; however, the pancreatic duct is also visualized
measuring at the upper limits of normal.
CHEST PORT. LINE PLACEMENT Study Date of [**2117-6-7**] 10:49 PM
Right internal jugular central venous catheter terminating in
the proximal-to-mid SVC without evidence of pneumothorax.
ERCP [**2117-6-8**]
Impression: Large peri-ampullary diverticula
Successful biliary cannulation
A moderate diffuse dilation was seen at the main duct with the
CBD measuring 13 mm.
The intrahepatics were also moderatley dilated.
Many round stones ranging in size from 7 mm to 12 mm were seen
at the main duct.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire. The sphincterotomy
was performed to facilitate extraction of the stones.
A CRE balloon was introduced for dilation and the diameter was
progressively increased from 8 to 10 mm to extend the
sphincterotomy.
Multiple rounds stones were extracted successfully using a 9
-12mm biliary balloon [**Last Name (un) **]. A repeat balloon cholangiogram
revealed no further filling defects in the bile duct.
Some pus was seen exiting the duct once the stones were all
cleared from the biliary tree.
Otherwise normal ercp to third part of the duodenum
Dx: Choledocholithiasis, cholangitis
Recommendations: NPO overnight and assess for pain in the am. If
no pain, advance diet as tolerated.
Watch for bleeding, perforation, and pancreatitis.
Continue IV antibiotics.
Complete a total of 14 days antibiotics due to cholangitis.
No need for repeat ERCP unless patient again develops
obstructing stones evidenced by increasing LFTs, jaundice, RUQ.
Please call Dr.[**Name (NI) 12202**] office at [**Telephone/Fax (1) 1983**] with any
further questions or concerns.
Please call the on call ERCP fellow at [**Telephone/Fax (1) 2756**] with any
immediate concerns such as fever, abdominal pain, bleeding,
following your procedure.
Return to the ICU for ongoing.
Brief Hospital Course:
CHOLANGITIS: related to CBD stones, given broad spectrum
antibiotics (vanc/zosyn) x 2 days and ERCP w/ sphincterotomy and
stone removal. His symptoms and LFTs improved, he was afebrile
on discharge and transitioned to PO cipro x an additional 12
days. Blood cultures were no growth to date at the time of
discharge.
DIABETES INSIPIDUS: Na of 146 when NPO in the setting of ERCP,
he likely has diabetes insipidus given prior lithium use. He
said that he thinks his nephrologist had discussed this with
him. No formal testing was done to diagnose this but it seems
to be the most likely cause, he will f/u with his nephrologist.
Medications on Admission:
Seroquel 25 mg [**1-19**] QHS
Klonopin 0.5 mg [**Hospital1 **]
Abilify 10 mg QHS
Imipramine 50 mg QHS
Lamictal 100 mg [**Hospital1 **]
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
2. quetiapine 25 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)) as needed for insomnia.
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. imipramine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with cholangitis (infection of your bile duct
system), you underwent an ERCP to remove a stone from the bile
ducts and will need to continue antibiotics for the next 12
days.
Please avoid any aspirin, ibuprofen / aleve / motrin / advil /
naproxen for the next 5 days.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge
from the hospital: [**Last Name (LF) **],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 14916**].
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5134
} | Medical Text: Admission Date: [**2171-2-4**] Discharge Date: [**2171-2-9**]
Date of Birth: [**2111-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tricor
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
crescendo angina
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram [**2171-2-4**]
insertion of intar aortic balloon pump [**2171-2-4**]
urgent coronary artery bypass grafts (LIMA-LAD,SVG-OM,SVG-RI)
[**2171-2-4**]
History of Present Illness:
This 59 year old white male has has several weeks of chest
discomfort while walking. He had worsening symptoms at less
exertion and underwentn catheterization to reveal double vessel
disease. He then had unstable, rest angina after cath and an
intra aortic balloon was placed with resolution of pain.
Past Medical History:
hypertension
hyperlipidemia
diverticulosis
gout
gastroesophageal reflux
h/o renal stones
Social History:
Last Dental Exam:
Lives with:Partner
Contact:[**Name (NI) **] [**Name (NI) 35996**] (partner): [**Telephone/Fax (1) 35997**]
Occupation:Works in upholstering
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-19**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Family History:Premature coronary artery disease- Father died of
sudden cardiac death secondary to massive MI at age 61
Race:Caucasian
Physical Exam:
Pulse:76 Resp:20 O2 sat:100/RA
B/P Right:118/67 Left:120/79
Height:5'7" Weight:210 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none appreciated Right: Left:
Pertinent Results:
[**2171-2-4**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant system
demonstrated severe multivessel and LMCA disease. The LMCA had a
50-60%
ostial lesion with dampening of the vatheter on engagement of
the artery
juts after the patient experience a vaso-vagal reaction. The LAD
had
severe diffuse disease proximally with a mid vessel occlusion
(after S1)
and reconsitution via right - left collaterals. The mid-distal
vessel
appeared reasonable for grafting. The ramus intermedius was a
small
diameter but long vessel with an 80% ostial lesion. The LCx was
atretic
in the AV groove with a major OM branch. The RCA had mild
diffuse
plaquing with a severe focal lesion in the ostium of a small
(upper
pole) PL.
2. Limited resting hemodynamics revealed normotension initially
with the
vaso-vagal reaction upon sheath insertion. This required
atropine and
dopamine but did eventually resolve.
3. At the end of the case the patient developed chest tightness.
ECG
showed no evidence of acute ischemia but because of significant
coronary
disease an intra-aortic balloon pump was placed. With insertion
of the
IABP sheath the patient had a second vaso-vagal reaction which
was
transient.
[**2171-2-4**] ECHO
PRE-CPB:
The study is limited as poor gastric windows are obtainable.
1. The left atrium is normal in size. No thrombus is seen in the
left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with apical hypokinesis.
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. The IABP
tip is seen 3 cm below the LSCA.
6. There are three aortic valve leaflets. They are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB:
Again the gastric windows are not accessible.
The patient is AV-Paced, on low dose phenylephrine.
Unchanged biventricular systolic fxn.
1+MR, no AI. Aorta intact.
Brief Hospital Course:
Mr. [**Known lastname 174**] was admitted to the [**Hospital1 18**] on [**2171-2-4**] for further
management of his chest pain. He underwent a cardiac
catheterization which revealed severe three vessel disease. As
he had chest pain during the procedure, an Intra-aortic balloon
pump (IABP) was placed. He continued to have chest discomfort
and thus the decision to bring him to surgery was made. He was
evaluated and worked-up in the usual preoperative manner by the
cardiac surgical service. He was taken to the operating room
where he underwent coronary artery bypass grafting to three
vessels. Please see operative note for details. Postoperatively
he was taken to the intensive care unit for monitoring. On
postoperative day one, his IABP was weaned and removed. He then
awoke neurologically intact and was extubated. On postoperative
day two he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service worked with him daily. He
continued to make steady progress and was discharged home on
postoperative four. Follow up appointments were given and
precautions, restrictions and medications were discussed.
Medications on Admission:
CHLORPHENIRAMINE-HYDROCODONE 10 mg-8 mg/5 mL Suspension,
Extended
Rel 12 hr -1 tsp by mouth twice a day as needed for cough
COLCHICINE 0.6 mg Tablet - 2 Tablets x1 for Gout attack Then 1
po
q 1-2 hr PRN. Max 8 tablets / day. Give until relief, N/V,
diarrhea or max dose reached; diarrhea likely will precede pain
relie
INDOMETHACIN Dosage uncertain
LISINOPRIL 40 mg daily
METOPROLOL SUCCINATE 25 mg Daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual - 1 Tablet sublingually
As needed as needed for chest pain Take one SL NTG for
exertional
chest pain. [**Month (only) 116**] take a second pull in 5 minutes if needed. call
911 if CP persists
OMEPRAZOLE 40 mg once a day PRN
ROSUVASTATIN 20 mg Daily
ASPIRIN 81 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:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: Take in morning with potassium.
Disp:*7 Tablet(s)* Refills:*0*
4. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain].
Disp:*40 Tablet(s)* Refills:*0*
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
coronary artery disease with unstable angina
hypertension
hyperlipidemia
diverticulosis
gout
gastroesophageal reflux
h/o renal stones
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
1+ Edema
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, will be discussed at follow up appointment with
surgeon when you will be able to drive
5) No lifting more than 10 pounds for 10 weeks
6) Take lasix and potassium in the morning for 1 week then stop.
7) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2171-3-14**] at 1pm
Cardiologist: Dr. [**Last Name (STitle) 35998**] on [**2171-3-1**] at 3:20pm
wound check on [**2171-2-14**] at 10:30 in [**Last Name (un) **] Office Building
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**] [**Telephone/Fax (1) 133**]) in [**4-18**] 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:[**2171-2-8**]
ICD9 Codes: 4111, 4019, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5135
} | Medical Text: Admission Date: [**2118-10-10**] Discharge Date: [**2118-10-25**]
Date of Birth: [**2070-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Altered mental status requiring intubation
Major Surgical or Invasive Procedure:
Intubation w/ mechanical ventilation
History of Present Illness:
The pt is a 48y/o M with PMH of Hepatitis C, inoperable HCC and
alcoholic cirrhosis admitted with encephalopathy after being
found unresponsive with an empty bottle of oxycontin nearby. Pt
has a longstanding history of alcohol-induced cirrhosis and
Hepatitis C with associated portal hypertension, varices,
ascites and encephalopathy, and hepatocellular carcinoma. His
most recent scans are notable for recurrence of his
hepatocellular carcinoma following his radiofrequency ablation
(5/[**2118**]). At his most recent oncology visit on [**2118-10-5**], he was
found to have a rapid deterioration in his liver function and
was felt not to be a candidate for further cancer-directed
therapies.
Per report, on the day of this admission, he was found to be
unresponsive by his family and was taken to [**Hospital3 **].
There he was intubated for airway protection in the setting of a
GCS of 8. CT A&P demonstrated an advanced tumor of the left lobe
of the liver and abdominal varices. RLL consolidation consistent
with PNA was also seen. CT Head negative for acute process. He
was sent to [**Hospital1 18**] for further managemnt. He was given zosyn and
clindamycin as treatment for his pneumonia. OG tube showed brown
aspirate and he was given zantac for GI protection.
On arrival to [**Hospital1 18**], T 95.9, HR 91, BP 136/96, RR 18. He was
given 1 L NS and transferred to MICU.
Past Medical History:
1. Cirrhosis Child's class C, complicated by varices,
encephalopathy, and ascites.
2. Hepatitis C secondary to IV drug use.
3. Hepatocellular carcinoma status post RFA in [**2118-5-5**].
4. Alcohol abuse, hx of DTs.
5. Polysubstance abuse with cocaine & heroin.
6. Nephrolithiasis.
7. Chronic back pain status post motor vehicle accident with
multiple rib fractures.
8. Depression.
Social History:
The patient is currently living in a trailer on his mother's
property in [**Location 23962**]. Social stressor is that his mother is
going to kick him out and he needs to find a new location for
his trailer. The patient is currently smoking 2 packs per week,
has significant tobacco history of 1 to 2 packs per day x 30
years. Alcohol use per HPI. No current IV, illicit or herbal
drug use. He is not currently sexually active. He is on
disability. Recently broke up with his girlfried, which is an
additoinal stressor and contributed to his increased drug and
alchohol use.
Family History:
He does not know of any liver disease or colon cancer. Father
with a history of alcoholism
Physical Exam:
VS - Temp 97.5, BP 140/85, HR 83, R 18, O2-sat 100% RA
GENERAL - Chronically ill appearing man, Comfortable
HEENT - Mild scleral icterus, No JVD, MMM, OP clear
LUNGS - CTA bilat
HEART - RRR, III/VI Systolic murmur at apex
ABDOMEN - Moderately distended, + shifting dullness, no HSM, NT,
no rebound/guarding
EXTREMITIES - WWP, 3+ pitting edema of LE's, 2+ peripheral
pulses (radials, DPs)
SKIN - multiple spider angiomas on chest
NEURO - No asterixis, A/OX3
Pertinent Results:
[**2118-10-10**] 06:15PM BLOOD WBC-10.7 RBC-3.00* Hgb-10.4* Hct-29.3*
MCV-98 MCH-34.6* MCHC-35.4* RDW-18.6* Plt Ct-223#
[**2118-10-11**] 05:05AM BLOOD WBC-10.3 RBC-2.48* Hgb-8.6* Hct-24.5*
MCV-99* MCH-34.7* MCHC-35.2* RDW-18.9* Plt Ct-192
[**2118-10-11**] 01:49AM BLOOD PT-26.8* PTT-39.1* INR(PT)-2.7*
[**2118-10-10**] 06:15PM BLOOD Glucose-128* UreaN-39* Creat-1.1 Na-126*
K-3.3 Cl-92* HCO3-26 AnGap-11
[**2118-10-11**] 05:05AM BLOOD Glucose-79 UreaN-41* Creat-1.3* Na-131*
K-3.3 Cl-100 HCO3-23 AnGap-11
[**2118-10-10**] 06:15PM BLOOD ALT-39 AST-154* AlkPhos-119*
TotBili-11.2*
[**2118-10-11**] 01:49AM BLOOD Ammonia-140*
[**2118-10-10**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2118-10-10**] 06:24PM BLOOD Lactate-1.9
[**2118-10-10**] 11:53PM BLOOD Lactate-1.7
[**2118-10-10**] CXR
The ET tube is seen in situ with its tip approximately 13 mm
from
the carina. The NG tube is seen traversing the gastroesophageal
junction and following a course towards the stomach. There are
bibasal effusions along with atelectasis/probable consolidation
at the lung bases. Follow up with AP and lateral chest
radiographs would be helpful to assess for atelectasis vs.
consolidation. There is apparent deformity of the left humeral
head which is not well visualized and if there is suspicion of
trauma to the left shoulder joint, dedicated views of the left
shoulder would be helpful.
[**2118-10-12**]
Abd U/S
1. Cirrhosis and large infiltrative mass in the left lobe of the
liver
consistent with patient's known hepatocellular carcinoma. There
is probable new tumor ingrowth into the left portal vein which
is non-occlusive. 2. Moderate ascites
[**2118-10-22**] 06:32AM BLOOD WBC-9.8 RBC-2.23* Hgb-8.3* Hct-24.4*
MCV-110* MCH-37.4* MCHC-34.1 RDW-21.3* Plt Ct-106*
[**2118-10-17**] 05:30AM BLOOD Neuts-76.6* Lymphs-15.4* Monos-6.1
Eos-1.6 Baso-0.4
[**2118-10-22**] 06:32AM BLOOD PT-24.8* PTT-42.4* INR(PT)-2.4*
[**2118-10-10**] 09:45PM BLOOD Fibrino-257
[**2118-10-24**] 05:20AM BLOOD Glucose-104 UreaN-8 Creat-0.7 Na-132*
K-2.7* Cl-103 HCO3-22 AnGap-10
[**2118-10-22**] 06:32AM BLOOD ALT-39 AST-102* LD(LDH)-402* AlkPhos-94
TotBili-7.8*
[**2118-10-24**] 05:20AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.3*
[**2118-10-17**] 05:30AM BLOOD %HbA1c-4.5*
[**2118-10-12**] 05:09AM BLOOD Ammonia-38
[**2118-10-10**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2118-10-10**] 11:53PM BLOOD Type-ART pO2-263* pCO2-39 pH-7.51*
calTCO2-32* Base XS-7
Brief Hospital Course:
The pt is a 48y/o M with PMH of Hepatitis C, HCC and alcoholic
cirrhosis admitted with altered mental status requiring
intubation for airway protection in the setting of suspected
opioid overdose.
Encephalopathy - The etiology of the patient's AMS was likely
multifactorial involving end stage liver disease,?anoxic-insult
given unknown down time, and opiate toxicity. Head CT negative
at OSH. Upon admission, the patient was sedated and intubated.
Pt began regimen of lactulose with >4BMs per day; with a
decrease in NH4 from 140-->38 during his MICU stay. The
patient's mentation improved during his admission, sedating
medications were weaned down before extubation, and upon
transfer out of MICU he was A&O to person and place and
following commands. Pt. was on CIWA on transfer to floor and
gradually cleared w/ less and less lorazepam. AT time of D/C he
was A/Ox3 for several days.
Respiratory failure/PNA ?????? Pt was intubated for unresponsiveness
and a GCS of 8 at an OSH. CT of chest demonstrated RLL
consolidation c/w possible aspiration PNA. Upon admission to
the MICU, the patient was still intubated and sedated with
propofol. Empiric zosyn was started for coverage of aspiration
PNA which was changed to Unasyn on [**10-11**]. Repeat CXR on [**10-12**]
showed improving lung fields with no signs of consolidation.
Sputum GS grew GPCs in pairs, chains, and clusters on [**10-12**]. The
pateitn was weaned off sedation on [**10-11**], extubated, and placed
on 2LNC O2 with adequate oxygen saturation. Upon transfer, the
patient was stable from a pulmonary standpoint. On the floor he
did not have any pulmonary distress, but did spike a fever to
102.5 while on unasyn, so he was switched to vanc/levo/zosyn.
His CXR was negative and he quickly defervesced so Abx were
stopped after a short course.
EtOH Cirrhosis/HepC/HCC ?????? Per recent history, the patient has a
h/o EtOH abuse, his HCC is rapidly progressing and his liver
function is rapidly declining. Upon admission, he had many
stigmata of liver disease, both on exam (encephalopathic,
scleral icterus, palpable mass in epigastric area c/w HCC mass
in left lobe, mild ascites, spider angioma, extensive
ecchymosis) and laboratory testing (elevated INR and abnormal
liver enzymes). Pt was given vit Kx1 without change in his INR.
The liver team was consulted and followed the patient during his
stay. An U/S of RUQ on [**10-12**] showed no signs of portal vein
thrombosis, cirrhosis and large infiltrative mass in the left
lobe of the liver c/w patient's known hepatocellular carcinoma;
there is probable new tumor ingrowth into the left portal vein
which is non-occlusive. Pt. was offered hospice house but could
not wait until this was available, he decided to leave AMA.
Hx of heavy EtOH abuse - The patient was maintained on CIWA
scale with 1mg of ativan per protocol in the MICU. The ativan
was weaned to 0.5mg on [**10-12**] and completely off two days later.
Pt. stated that he would continue to drink on d/c.
Hypotension: On [**10-11**], the patient developed hypotension to
80/40's. Likely secondary to physiology of hepatic failure and
possibly opioid toxicity. Given IVF boluses and bolus of albumin
with good response. Home BP medications were held. Pt remained
hemodynamically stable afterwards.
Guaiac + NGT aspirate - pt with history varices and significant
variceal bleeding, also EtOH abuse. Hct stable in mid-20's
during admission and hemodynamics not c/w acute bleed. The
patient was Type and Screened, adequate peripheral access was
achieved and he was placed on a PPI and Hct remained stable for
the duration of admission.
Medications on Admission:
CLONIDINE - 0.1 mg Tablet - 1 tablet twice a day
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 spray
inhaled apply to each nostril twice daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
LACTULOSE - 10 gram/15 mL Solutio- 30mls four times a day
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
patch daily wear 12 hours on then take off
MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime
NADOLOL - 40 mg Tablet - 1 Tablet(s) by mouth daily
NICOTINE - 14 mg/24 hour Patch 24hr - 1 patch daily
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 tablet
PO
twice a day
SPIRONOLACTONE [ALDACTONE] - 100 mg Tablet - 1.5 Tablet(s) by
mouth
once a day
Medications - OTC
FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth
daily
HEXAVITAMIN - Tablet - 1 tablet daily
THIAMINE HCL - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
8. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
11. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ML PO
every six (6) hours.
Disp:*3600 ML(s)* Refills:*2*
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
13. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Hepatic encephalopathy
Hepatocellular carcinoma
Secondary
alcohol abuse
Hepatitis C
Discharge Condition:
Against medical advice
Discharge Instructions:
YOU ARE LEAVING AGAINST MEDICAL ADVICE.
You have been diagnosed with hepatic encephalopathy and
hepatocellular carcinoma. You will need to take your lactulose
and Rifaximin exactly as prescribed so that you do not become
confused again. We stopped your clonidine and nadolol because
your blood pressure was low. We started you on a calcium
supplement because your nutrition was poor. We increased your
spironolactone to 200mg daily and your lasix (furosemide) to
80mg daily because your legs were swelling with fluid. We did
not change any of your other medications. We started you on
rifaximin to help stop you from getting confused.
Please take all of your medications exactly as prescribed.
If you have any confusion, fevers, chills, nightsweats, chest
pain, shortness of breath, abdominal pain, bleeding, black tarry
stools, vomiting blood or any other concerning symptoms call
your doctor immediately or go to the emergency department.
Followup Instructions:
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2118-10-26**] 4:10
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2118-11-2**] 3:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2118-11-7**] 11:30
Completed by:[**2118-10-29**]
ICD9 Codes: 5070, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5136
} | Medical Text: Admission Date: [**2138-10-6**] Discharge Date: [**2138-11-3**]
Date of Birth: [**2062-3-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Left Craniotomy for resection of brain mass
One CyberKnife treatment ([**2138-11-3**])
History of Present Illness:
This is a 76 year old Creole speaking man who was found
wondering around his senior center with new confusion. Family
saw him last week and he was his normal self. He was taken by
EMS to LMH and CT head showed a large Left frontal cystic lesion
and a small area of edema in the left cerebellum. CXR showed a 5
cm left peri-hilar mass. He was given 10 mg of Decadron and was
transferred to [**Hospital1 18**] for further management.
Past Medical History:
HTN, prostate CA s/p seed treatment and chemotherapy in [**2134**]
with a urologist at [**Hospital3 **], GERD
Social History:
He is a right handed Creole man. His family reports
that he was a marine and worked in metal welding. He has a long
history of Tobacco use 1ppd but now smoke about 10 cigarettes
daily.
Family History:
unknown
Physical Exam:
Upon Admission:
PHYSICAL EXAM:
O: T:99.7 102 137/79 18 99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:[**4-13**] EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam,
interpretation by family.
Orientation: Oriented to person, hospital, month and day
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4to3
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-15**] throughout. Mild right
pronator
drift
Coordination: normal on finger-nose-finger.
At transfer, he speaks French-Creole, is oriented to self,
follows commands readily, PERRL 4-2mm, Incision is
clean/dry/intact. No drift, no clonus, reflexes are 2+
throughout. tongue is at midline.
.
DISCHARGE EXAM:
VS: 98.6, 122/70, 90, 20, 95% RA, BG 103-241
General: Elderly man in NAD, comfortable, appropriate
HEENT: Longitudinal scar over the left frontal area. PERRL,
sclerae anicteric, MMM, OP clear
Neck: Supple.
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nml S1-S2, no MRG
Abdomen: +BS, soft/NT/ND, no palpable masses or HSM
Extrem: WWP, no c/c/e
Skin: no concerning rashes or lesions
Neuro: grossly non-focal
Pertinent Results:
[**2138-10-6**] 06:05PM URINE RBC-1 WBC-9* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2138-10-6**] 06:35PM PT-13.3 PTT-29.7 INR(PT)-1.1
[**2138-10-28**] LENIs - negative for DVT
DISCHARGE LABS:
[**2138-11-3**] 07:55AM BLOOD WBC-8.9 RBC-4.30* Hgb-12.2* Hct-37.1*
MCV-86 MCH-28.3 MCHC-32.8 RDW-15.9* Plt Ct-339
[**2138-11-3**] 07:55AM BLOOD Glucose-87 UreaN-15 Creat-0.7 Na-136
K-4.3 Cl-95* HCO3-32 AnGap-13
[**2138-11-3**] 07:55AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.0
MRI brain [**2138-10-8**]
1. Left frontal and left cerebellar hemispheric enhancing
lesions
demonstrating marked slow diffusion. In the setting of the
findings on the
recent chest CT, these intracranial lesions would be most
suggestive of
metastases from primary small cell carcinoma of the lung.
2. Additional round focus of slow diffusion and relatively
[**Name2 (NI) 15403**]
[**Name (NI) 90467**] in the medial left temporal lobe, without
convincing
enhancement. Although a focal infarct, particularly embolic, is
not entirely excluded, given the signal characteristics similar
to the other lesions, above, this is concerning for a third
metastatic deposit.
3. Relatively T1-hypointense regional bone marrow signal; while
this may
simply represent red marrow reconversion in response to anemia
or systemic
treatment, this finding should be correlated with clinical and
laboratory
data.
CT torso:[**2138-10-7**]
1. Large 4.4-cm left perihilar mass concerning for primary lung
cancer. There is associated left hilar and mediastinal
lymphadenopathy.
2. Severe right hydronephrosis with cortical atrophy and a 9-mm
calculus in the proximal right ureter. This represents a chronic
process, likely secondary to UPJ obstruction from a crossing
vessel.
3. No evidence of osseous metastatic disease
CT head [**10-10**]: expected postoperative changes, moderate
pneumocephalus. no hemorrhage
MRI Brain with and without contrast [**10-11**]: expected
postoperative changes with good resection of left frontal
lesion. No acute infarcts. stable left cerebellar lesion.
Lower Extremity Dopplers [**10-13**]:
No right- or left-sided lower extremity DVT.
Lower Extremity Dopplers [**10-20**]:
No DVT of the bilateral lower extremity.
[**2138-10-25**] Abd XR - Nonspecific air-fluid levels within
non-distended loops of small and large bowel. Although
nonspecific, this could potentially be related to
gastroenteritis, considering the provided clinical history.
18 mm and 3 mm diameter calcifications located in the right
abdomen may be
related to renal and ureteral calculi considering presence of
right ureteral calculus on CT of [**2138-10-7**].
Brief Hospital Course:
This is a 76 year old Croele-speaking man who was found confused
wandering around his Senior Center, and was taken to an OSH,
where CT showed multiple brain lesions including a large left
frontal lesion and a small area of edema in the left cerebellum.
# Brain Mets: Originally admitted to neurosurgery under the care
of Dr. [**Last Name (STitle) 65817**]. He was getting Q4 hr neuro checks on the floor.
MRI brain was ordered as was a CT torso. He was on Keppra.
Decadron was held for possible lymphoma. He was started on
Bactrim for a slightly positive UA. Neuro-onc and
neuro-radation services were consulted. MRI revealed a large
Left frontal tumor and a small cerebellar mass. He had an fMRI
and was taken to the OR with Dr. [**Last Name (STitle) **] on [**2138-10-10**]. The patient
was extubated in the OR. Immediately post-operative the patient
was opening his eyes to voice and moving all extremities. There
was some soft tissue edema noted above the left ear and an Ace
wrap was applied for 1 hour. The patient was started on Decadron
4 mg every 6 hours. Keppra was continued. Ancef was continued
post operativly for three doses. The patient was brought to the
SICU for recovery and a post operative Head Ct was performed
which was consistent with expected post-operative change with
some pneumocephalus. On [**2138-10-11**], a MRI with and without
constrast was performed which was consistent with expected
post-op changes. He was deemed fit for transfer to the floor and
PT and OT consults were ordered. The patient was then
transferred to the oncology service for cyberknife therapy.
# Lung Mass: CT chest showing 4.4cm left peri-hilar mass
concerning for primary lung cancer. Hematology-oncology
consulted and wanted to see him as an outpatient after final
pathology from brain lesion was confirmed. Discharged with
outpatient follow up.
# Right Renal Calculus: Urology consult was called for right
renal calculus. Imaging indicates that this is a longstanding
process for him and recommended nonurgent follow up as an
outpatient. Urinalysis and urine culture were sent [**10-7**] and
urine culture was negative. During his hospital stay he
completed a 7 day course of Bactrim for WBCs in urine and
altered mental status suspiscious for UTI. Discharged with
outpatient follow up with urology.
# Hyponatremia: On [**10-14**] the patient's serum Na was 130 and so he
was placed on a fluid restriction and started on salt tabs.
Patient was continued on fluid restriction on day of discharge,
and salt tabs were discontinued. Labs to be rechecked 1 week
post discharge.
# Physical Therapy and Placement: He was seen and evaluated by
physical therapy and occupational therapy who felt that he would
benefit from rehab. He remained afebrile and stable during his
course on the floor. Screening lenis continued to be done Q7
days and were negative as of [**10-20**].
# Goals of Care: Multiple family meetings occurred with social
work, case management and the neurosurgery team. The family
stated that they could not provide 24 hour supervision at home
and evaluation for placement was initiated. On [**10-28**] patient had
a LENIs for surveillance which was essentially negative. OMED
was consulted to management while receiving cyberknife
treatment. On [**10-30**] he underwent mapping for his cyberknife
treatment and was transferred to OMED in stable condition. He
completed 1 cycle of cyberknife on day of discharge and
tolerated the procedure well. He will have 4 more treatments.
TRANSITION OF CARE:
-continuation of Cyberknife treatment as an outpatient. To be
completed on [**2138-11-5**].
-continue 1L fluid restriction for treatment of hyponatremia.
Hyponatremia has been improving with fluid restriction. Would
re-evaluate the need for fluid restriction in the near future.
Re-check sodium within 1 week from discharge.
Medications on Admission:
Norvasc 2.5 QD, Flomax 0.4mg QD, HCTZ 25 QD, Vit D 1000 Units
QD,
Prilosec 20 QD, APAP
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily): Hold for SBP < 100.
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp/ha.
13. insulin regular human 100 unit/mL Solution Sig: Per insulin
sliding scale units Injection ASDIR (AS DIRECTED): Please see
the attached sheet for the patient's regular insulin sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Brain Tumor
Lung Mass
Large Kidney stone with hydronephrosis
Hyponatremia
Dysphagia
Malnutrition
hyperkalemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known firstname 90468**],
It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You presented to [**Hospital1 18**] for treatment of metastatic lung cancer
to your brain. You had brain surgery followed by 1 day of
CyberKnife therapy. You will continue to have CyberKnife therapy
for another 4 treatments while you are outside fo the hospital.
The following changes were made to your medication:
ADDED:
-Bisacodyl 10mg po daily
-docusate sodium 100mg by mouth daily
-Dexamethasone 2mg orally twice a day
-Insulin sliding scale
-Levetiracetam 750mg by mouth twice a day
-Ondansetron 4mg po every 8 hours as needed for nausea
-senna 1 tab by mouth daily
-Vitamin D 800units by mouth daily
-Trazadone 25mg by mouth as needed for insomnia
-acetaminophen 325-650mg every 6 hours as needed for pain
CHANGED:
- Increased your dose of norvasc from 2.5mg daily to 5mg daily
by mouth
STOPPED: none
We are in the process of arranging follow-up. The patient will
need to have follow-up in the following clinics:
1. Hematology-Oncology Thoracics Division- please call
([**2138**] to arrange an appointment for a new patient at the
next earliest available new patient appointment. The clinic is
located in [**Hospital Ward Name 23**] Clinical Center on the [**Location (un) 24**].
2. Brain [**Hospital 341**] Clinic- please call ([**Telephone/Fax (1) 27543**] to arrange an
appointment for 1-2 weeks after discharge. You will also need to
follow-up with the neurosurgeons during this appointment. The
clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**]
Building, [**Location (un) **].
3. The patient will also need to follow-up with Urology in [**1-12**]
weeks from discharge for hydronephrosis and right kidney stone.
To make an appointment, their number is [**Telephone/Fax (1) 164**].
Followup Instructions:
We are in the process of arranging follow-up. The patient will
need to have follow-up in the following clinics:
1. Hematology-Oncology Thoracics Division- please call
([**2138**] to arrange an appointment for a new patient at the
next earliest available new patient appointment. The clinic is
located in [**Hospital Ward Name 23**] Clinical Center on the [**Location (un) 24**].
2. Brain [**Hospital 341**] Clinic- You will be contact[**Name (NI) **] with this
appointment after you complete CyberKnife Treatment. Please
call ([**Telephone/Fax (1) 27543**] if you need to change this appointment date.
The clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the
[**Hospital Ward Name 23**] Building, [**Location (un) **].
3. The patient will also need to follow-up with Urology in [**1-12**]
weeks from discharge for hydronephrosis and right kidney stone.
To make an appointment, their number is [**Telephone/Fax (1) 164**].
.
Patient will need to have 3 more CyberKnife treatments for which
he will need to return to [**Hospital1 18**] ([**Location (un) **]. [**Location (un) 86**]) to
the [**Hospital Ward Name 332**] Basement ([**Hospital Ward Name 516**]) for treatment: Tuesday,
[**2138-11-4**] at 9:15, Wednesday [**2138-11-5**] at 9:15, and Thursday
[**2138-11-6**] at 10:15.
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5137
} | Medical Text: Admission Date: [**2169-8-25**] Discharge Date: [**2169-9-6**]
Date of Birth: [**2095-1-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
left hip fracture noted at [**Hospital1 **] s/p mechanical fall
Major Surgical or Invasive Procedure:
Left Hemiarthroplasty
History of Present Illness:
74 yo female with who presented to [**Hospital1 **] s/p fall, found to
have left subcapital fracture by CT of hip, transferred to [**Hospital1 18**]
for further management.
She initally was in an MVA last year when it was noted that she
had a AAA on CXR. She then had an elective Thoracoabdominal
aortic aneurysm resection/repair with hospital course c/b
post-op respiratory failure, recurrent Afib, multiple
bronchs, L sided lung collapse, trach on [**2169-1-26**] after failed
extubation of [**2169-1-23**]. Trach was removed at Rehab, however she
was readmitted in [**2-11**] with slight hyperfunction of false vocal
cords, bilateral vocal cord immobility with ~1mm glottic gap
requiring trach placement on [**2169-3-7**].
Pt was walking with her walker when she tripped on the carpet
and fell onto her left L hip hitting her head at home. Denies
LOC, HA, neck pain, CP, SOB, weakness, LH. Assisted to bed, able
to bear wt for 2 steps. Pain localized to medial thigh with
movement of LLE. Was brought to [**Hospital1 **], initially XRay
unrevealing, CT though showed fx of L hip. Ortho evaluated in
ED, plan to perform ORIF during this admit after risk
stratified; NWB on L, no traction indicated, anticoagulate.
Given extensive comorbidities, she was admitted to Medicine for
periop management.
Past Medical History:
1. Thoracic and abdominal aortic aneurysm, repair [**1-14**], c/b resp
failure and trach.
2. Bilateral vocal cord paralysis, s/p repeat trach [**3-14**].
3. Clostridium difficile positivity.
4. VRE positivity.
5. Postoperative atrial fibrillation requiring cardioversion.
6. Hypertension.
7. Type 2 diabetes.
8. Osteoarthritis.
9. Lower back pain.
10. Hypercholesterolemia.
11. Left Breast Cancer - s/p lumpectomy
12. Atrial fibrillation - this was first noted post op from the
AAA repair. She was started on a BB and amio at that time then
DCCV. She has not been on coumadin.
.
PAST SURGICAL HISTORY:
-Thoracic/abdominal aortic aneurysm repair, [**2169-1-10**].
Social History:
Retired RN, she was living at home at the time of the hip
fracture. Her husband and daughter involved in her care. No
tob, etoh, other drugs. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] Globe reporter has been
following her [**Last Name (un) 26796**] in [**Hospital1 18**] s/p her hip fracture
Family History:
DM, ? type - in mother
Physical Exam:
Vitals: T 98.4 HR 64 BP 130/61 RR 24 Sat 92% on mist O2
Gen: elderly caucasian woman with trach mask in place, breathing
comfortably, A+Ox3, NAD
HEENT: NCAT, no bruising or ecchymosis, PERRL, EOMI, MMM, OP
clear
Neck: supple, trach in place, no LAD
CV: RRR nl s1 s2 no m/g/r
Lungs: CTA b/l
Abd: soft, nt, nd, +bs
Ext: L medial thigh pain with external rotation
Neuro: no sensory deficit in affected limb
EKG: sinus, nl rate, nl axis, nl intervals, LAE, Q III, aVF;
flat T's throughout limb leads and V4-V6, TWI in V1-V3, no sig
change since prior EKG [**2169-3-7**]
Pertinent Results:
Admission labs:
GLUCOSE-132* UREA N-14 CREAT-0.9 SODIUM-139 POTASSIUM-3.6
CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
WBC-9.9 RBC-4.31 HGB-12.1 HCT-36.6 MCV-85 MCH-28.0 MCHC-32.9
RDW-16.5*
NEUTS-84.0* LYMPHS-11.9* MONOS-3.5 EOS-0.2 BASOS-0.4
ANISOCYT-1+ MICROCYT-1+
PLT COUNT-179
PT-14.7* PTT-25.5 INR(PT)-1.5
CXR [**8-25**]:
Cardiomegaly unchanged. The aorta is very tortuous and dilated
as seen previously. There are postoperative changes in the left
hemithorax with rib fractures/ressections, which is unchanged
when compared to prior study. There is again noted a left
retrocardiac opacity silhouetting the left hemidiaphragm, which
is improved when compared to the prior study likely representing
atelectasis or scarring. The right lung is grossly clear. The
patient is status post tracheostomy. Tracheostomy tube appears
to be in appropriate position. In the left upper quadrant, there
are metallic wires and surgical clips. There is mild S-shaped
scoliosis of the thoracolumbar spine with some mild dextroconvex
thoracic component and levoconvex lumbar component. No evidence
of pneumothorax. There is mild upper zone redistribution of the
pulmonary vascularity, which could represent mild CHF. There are
degenerative changes of the sternoclavicular joints bilaterally.
HIP UNILAT MIN 2 VIEWS LEFT [**8-25**]:
Unusual small lucency involving the medial cortex of the left
proximal femur without clear fracture line identified.
Knee film [**8-27**]:
The alignment appears normal. There are some mild degenerative
changes. No fracture is identified.
Echo [**8-28**]:
Normal regional with low normal left ventricular systolic
function. Dilated ascending aorta. Mild-moderate pulmonary
artery systolic hypertension. Compared with the prior study
(tape reviewed) of [**2169-1-12**], the ascending aorta is minimally more
dilated. Global left ventricular systolic function is similar.
Micro: [**8-31**] sputum grew PSEUDOMONAS AERUGINOSA and ESCHERICHIA
COLI, both pan-sensitive.
VRE and MRSA screens were negative here. Has had a h/o of this
in the past.
Discharge labs:
[**2169-9-5**] 05:32AM BLOOD WBC-9.3 RBC-3.82* Hgb-10.5* Hct-33.2*
MCV-87 MCH-27.5 MCHC-31.7 RDW-15.4 Plt Ct-260
[**2169-9-4**] 05:52AM BLOOD PT-14.6* PTT-26.3 INR(PT)-1.4
[**2169-9-5**] 05:32AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-137
K-4.0 Cl-102 HCO3-27 AnGap-12
[**2169-8-25**] 07:00PM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
74 yo F s/p fall, found to have left subcapital hip fracture by
CT, admitted to medical service for risk stratification prior to
ORIF. She then had resp failure following ORIF requiring MICU
stay for diuresis and suctioning. She was transferred to the
floor and has been recovering well.
#) Left Hip Fx. She was kept non weight bearing until Left
hemiarthroplasty on [**8-29**]. She has multiple cardiac risk factors
making her intermediate risk and could achieve at least 4 mets
prior to recent surgery. She had a normal perfusion on a
Persantine MIBI preop in [**1-14**] at [**Hospital 620**] Hosp. A pre-op echo was
preformed on [**8-28**] revealing normal regional wall motion with low
normal left ventricular systolic function and mild-moderate
pulmonary artery systolic hypertension. When compared with the
prior study of [**2169-1-12**], the ascending aorta is minimally more
dilated with similar global left ventricular systolic function.
She received aggressive pulmonary toilet (chest PT, incentive
spirometry, encourage coughing) prior to surgery to maximize her
lung function. Her pain was well controlled with acetaminophen
1000mg q6h and oxycodone 5mg Q4H PRN prior to surgery. The
cemented left unipolar hip hemiarthroplasty was done on [**8-29**]
without complications. She was transfused 2 units of blood for
post-op anemia. She received Lovenox SC BID for prophylaxis.
She should remain on this until she has adequate activity. On
discharge her wound was without evidence of infection and had
some serous drainage.
#) Post-op Hypoxemia - After the hip surgery, she was
persistently and progressively hypoxemic and was requiring
increasing suctioning. She was transferred to the MICU on [**8-30**].
Her MICU course was significant for low grade temps and
increased sputum production. She was started on empiric Zosyn
and Vanco for hospital-acquired PNA. Her O2 sats gradually
improved and she made less secretions. In rehab, she will
continue to need suctioning and incentive spirometry as well as
to continue Zosyn/Vanc for a total of 7 days, ending on [**9-9**].
Her sputum culture grew pseudomonas (pansensitive), e.coli
(pansensitive), and staph aureus (MRSA).
.
#) Pain management: She hallucinations with the IV Dilaudid
given to her for her post-op pain. Therefore, her post op pain
was controlled with Tylenol 1 gm q6 hrs and oxycodone 5 mg po
prn. She also has chronic abdominal pain from her AAA surgery
since [**Month (only) 956**]. The pain service was consulted who recommended
starting neurontin 600 mg qhs. This should be titrated as
tolerated. Neurontin is for chronic pain from thoracoabdominal
aneurysm repair. At discharge, the Neurontin was controlling her
pain somewhat.
.
#) CAD (no known CAD though multiple cardiac risk factors
including age, DM, HTN). She had a normal stress test at [**Location (un) 620**]
prior to aneurysm repair.
She was continued on ASA 81mg qd, Simvastatin 10mg daily, and
Metoprolol.
.
#) Mild dystolic disfunction. She was on lasix QOD prior to
admission. This was not restarted at present, but if she
continues to require large amounts of TM O2, then consider
restarting.
.
#) AFIB: h/o postoperative atrial fibrillation requiring
cardioversion in [**1-14**]. She was in NSR and well rate controlled
with Amiodarone 400 daily and Metoprolol. She will f/u with Dr.
[**Last Name (STitle) **] as an outpatient about this. She will likely need
coumadin once she is no longer on Lovenox.
.
#) Trach care: She takes Guaifenesin prn, Atrovent neb prn, and
needs aggressive pulm toilet. Scheduled outpt pulm f/u. She also
needs ENT f/u (?h/o laryngeal dysfunction)
.
#) Type 2 diabetes: She was on Avandia 4mg daily prior to the
surgery. However, she has bot been requiring insulin here on a
RISS. She also has not been eating much. She may need to start
the Avandia again in the future as she eats more.
#) GERD: She is on Protonix 40 daily.
#) Insomnia: We continued her on outpatient dose of Ativan 0.5mg
qhs:prn
#) Depression: Celexa 40mg qd. Her mood was hopeful on
discharge.
Medications on Admission:
-APAP prn
-Protonix 40 daily
-Avandia 4mg daily
-Amiodarone 400 daily
-Aspirin 81 daily
-Simva 10 daily
-Bisoprolol 5mg daily
-Senna prn
-Colace qd
-Celexa 40mg qd
-Citracal 2 tabs [**Hospital1 **]
-KCl 20 mEq qd
-Gaifenesin prn
-Vicodin prn
-Lasix 20mg qod
-Ativan 0.5mg qhs:prn
-Atrovent neb prn
Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous every twelve (12) hours for 7 days: Last dose is on
[**9-9**].
2. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 7 days: Last dose is
[**9-9**].
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours).
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
7. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): Continue this until that patient is ambulatory or
at least one month. Check weekly Cr and adjust the dose if
necessary.
8. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for sbp < 110, hr < 55 .
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): Max 4gm per day.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Give before washing or PT.
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for sbp < 110 .
16. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR
Injection ASDIR (AS DIRECTED).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
21. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
22. Heparin Flush PICC (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.
23. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day:
Hold if NPO.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Left Hip Fracture
Hypoxic respiratory failure
pneumonia
Secondary Diagnoses:
S/P Thoracoabdominal aortic aneurysm repair
Diabetes
Hypertension
Tracheostomy
Discharge Condition:
Good, O2 sat is 99% on 35% trach mask. All other vitals are
normal.
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience chest pain, shortness of breath,
worsening pain, or have any other concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] (PCP), [**Telephone/Fax (1) 8477**] in [**3-15**]
weeks.
Please follow-up the [**Hospital **] Clinic regarding your history of vocal
cord paralysis. ([**Telephone/Fax (1) 6213**]
Please follow-up in the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic. ([**Telephone/Fax (1) 46112**] in
[**3-15**] weeks.
You have the following appointments scheduled:
1. Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] (pulmonary) Where: [**Hospital 273**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-9-25**]
3:45
2. You have an appointment with Dr. [**Last Name (STitle) **] (cardiologist) on
[**10-11**] at 11:00AM at the [**Location (un) 620**] office. Call [**Telephone/Fax (1) 4105**] if you
are unable to make this.
3. You have an appointment with Dr. [**Last Name (STitle) **] (orthopedics) on [**10-12**]
at 2:20PM on the [**Location (un) **] of the [**Hospital Ward Name 23**] Center at [**Hospital1 771**]. Call [**Telephone/Fax (1) 9118**] if you are unable to
make this.
ICD9 Codes: 2851, 5180, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5138
} | Medical Text: Admission Date: [**2144-6-22**] Discharge Date: [**2144-7-7**]
Date of Birth: [**2085-7-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4975**]
Chief Complaint:
Hypoxia, tachypnea
Major Surgical or Invasive Procedure:
Pericardiocentesis [**2144-7-5**]
Fine needle aspiration of axillary node [**2144-6-30**]
History of Present Illness:
She is a 58-year-old [**Last Name (un) 18355**] resident with mental retardation,
COPD, and no reported past cardiac history who presents for
examination of distended belly, anemia and noted to have large
pericardial effusion. Given mental retardation, interview with
patient is extremely limited, and pt. minimally able to report
symptoms. Pt. was admitted to [**Hospital3 **] after ECHO for workup
of shortness of breath revealed moderate pericardial effusion
without tamponade. Repeat ECHO 24h later showed
stable-to-improved effusion and was discharged with plans for
f/u ECHO in 14d.
.
Today, she presented to ED from NH with short episode hypoxia
with recovered with albuterol and 02 and started on
levofloxacin. also had KUB given some abdominal distension which
reportedly was concerning for ileus. she was transferred to
[**Hospital1 18**] for evaluation of a distended belly in setting of previous
volvulus. In ED, she had a distended abd with minimal TTP,
normal LFTs, pancreatic enzymes, without leukocytosis. She was
guaiac negative with VSS and received Abdominal CT shich showed
large pericardial effusion and presacral, perihepatic fluid, but
no acute abdominal process. Given large pericardial effusion
without previous comparisons, pt. was admitted for planned f/u
ECHO in the AM.
.
Spoke with pt.'s brother and wife who report that 8 weeks ago,
she started to become pale, have increased shallow breathinig,
low grade temps to 100-101, with some abdominal distension that
has been ongoing. Concern for GERD, COPD, UTI, all diagnosed
within this time period. UTI tx. with levaquin.
she has had no bloody or black stools per family until she
starte Fe So4.
Past Medical History:
- Mental retardation of unknown etiology.
- DJD.
- Bilateral knock knees (talus valgus, pes planus).
- Neurodermatitis.
- Psoriasis.
- History of obesity.
- Status post volvulus and colonic resection.
- Status post left oophorectomy.
- Fe deficiency anemia 28.5 at [**Hospital3 **] 1 week ago
- GERD
Social History:
Social history is significant for the absence or EtoH use.
Patient is a resident at [**Last Name (un) 18355**] Center.
Family History:
Father died of prostate cancer, CABG, MIs; he also had colon CA.
maternal aunt with ovarian and breast cancer. MI and CAD
throughout family on both sides.
Physical Exam:
VS - T 99.8 137/65 HR 101, 95%RA, no pulsus
Gen: middle-aged woman, NAD, repititious and perseverative,
follows commands. Oriented x 1.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, no with sublingual pallor, MMM
Neck: unable to assess JVP as pt. will not allow herself to be
reclined. at 45 degrees, JVP flat.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, borederline tachycardic, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no wheezes or
rhonchi. mild, occ. crackles at Right base.
Abd: mildly distended, obese, with difficult abodminal exam as
pt. denies belly pain but seems to grimace on palpation of
RUQ>RLQ. No organomegaly noted in context of bodyhabitus and
difficulty participating in exam. No abdominial bruits.
Ext: 2+ pitting edema to knees (new per PA at bedside. No
femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. +
hirsutism
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ 2+ DP 2+ PT 2+
Neuro: CN II-XII grossly intact, moving all 4 ext.
spontaneously, follows commands.
Pertinent Results:
Echocardiogram [**2144-6-23**]
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. Right ventricular chamber size and free wall
motion are normal. Trivial mitral regurgitation is seen. There
is a moderate to large sized circumferential pericardial
effusion. Stranding is visualized within the pericardial space
c/w organization. There is substantial right atrial collapse and
brief diastolic invagination of the right ventricular outflow
tract (cine loops #15 and #28), consistent with low filling
pressures or early tamponade.
IMPRESSION: Moderate-to-large pericardial effusion with
echocardiographic findings of early tamponade.
.
CT chest, abdomen & pelvis W/CONTRAST [**2144-6-29**]
IMPRESSION:
1. Diffuse lymphadenopathy in the axillary, supraclavicular and
mediastinal regions. Pulmonary nodules in the left lung apex is
also noted. This is concerning for a neoplastic process.
Differential diagnosis includes primary lymphoma or lung
neoplasm.
2. Small pericardial effusion, decreased in size.
3. Bilateral small pleural effusions.
4. Splenic hypodensity.
5. Multiple hepatic subcentimeter hypodensities which are too
small to characterize.
6. Cholelithiasis without evidence of cholecystitis.
7. Diffuse colonic distention up to 12.2 cm. No evidence of
obstruction.
.
Pericardial fluid:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. CD45-bright, low-side scatter
lymphoid cells comprise 23% of total analyzed events. Of these,
B cells comprise approximately 15% of lymphoid-gated events and
do not express aberrant antigens. Surface immunoglobulin
expression is extremely dim-to-absent, precluding evaluation of
clonality. T cells comprise approximately 80% of lymphoid gated
events, express mature lineage antigens, and have a
helper-cytotoxic ratio of 5.0. Natural killer cells represent
approximately 3% of lymphoid gated events. No expansion of
CD34-immunoreactive events are identified in the "blast gate".
Monocytic cells comprise 6% of total analyzed events.
.
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a
lymphoproliferative disorder are not seen in specimen.
Correlation with clinical findings and morphology (see 08-[**Numeric Identifier 78642**])
is recommended. Flow cytometry immunophenotyping may not detect
all lymphomas due to topography, sampling or artifacts of sample
preparation.
.
L axillary lymph node FNA
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. B cells comprise approximately 9% of
lymphoid-gated events, are polyclonal, and do not express
aberrant antigens.T cells comprise approximately 89% of lymphoid
gated events and express mature lineage antigens (CD2,3,5,7).
.
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B-cell
lymphoma are not seen in specimen. Review of cytospin slide
(1096V-[**7-1**]) shows predominantly blood with admixed lymphocytes
and numerous degenerated cells precluding definitive morphologic
assessment. Correlation with clinical findings and morphology
is recommended. Flow cytometry immunophenotyping may not detect
all lymphomas due to topography, sampling or artifacts of sample
preparation.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2144-7-6**] 07:00AM 9.4 3.38* 8.2* 28.6* 85 24.3* 28.7* 16.3*
389
[**2144-7-5**] 07:00AM 9.8 3.21* 7.8* 26.8* 83 24.3* 29.2* 16.5*
381
[**2144-6-25**] 01:36AM 9.6 3.73* 9.0* 29.9* 80* 24.2* 30.1* 15.5
410
[**2144-6-24**] 06:00AM 7.1 3.27* 8.2* 27.0* 83 25.0* 30.2* 15.8*
355
[**2144-6-23**] 10:30AM 10.5 3.40* 8.2* 27.5* 81* 24.2* 29.9*
15.7* 385
[**2144-6-22**] 04:30PM 8.8 3.46* 8.5* 28.2* 82 24.5* 30.1* 15.7*
381
.
DIFFERENTIAL Neuts Lymphs Monos Eos Baso
[**2144-6-30**] 04:20AM 89.0* 5.5* 4.5 0.9 0.1
[**2144-6-25**] 01:36AM 89.3* 5.6* 4.8 0.2 0.1
[**2144-6-22**] 04:30PM 89.1* 4.7* 4.6 1.5 0.2
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2144-7-6**] 07:00AM 101 13 0.3* 144 3.8 109* 29
[**2144-7-5**] 07:00AM 103 12 0.3* 141 3.6 107 26
[**2144-6-25**] 01:36AM 155* 10 0.4 144 3.6 110* 26
[**2144-6-24**] 03:50PM 109* 8 0.3* 143 3.9 109* 25
[**2144-6-23**] 10:30AM 126* 9 0.4 138 3.9 103 28
[**2144-6-22**] 04:30PM 117* 13 0.4 140 4.1 105 29
.
ENZYMES & BILIRUBIN ALT AST LD(LDH) AlkPhos Amylase TotBili
[**2144-6-30**] 04:20AM 27 19 292 129* 14 0.5
[**2144-6-22**] 04:30PM 14 14 245 134* 0.5
.
OTHER ENZYMES & BILIRUBINS Lipase
[**2144-6-30**] 04:20AM 15
.
Brief Hospital Course:
58 yo F with mental retardation & h/o volvulus s/p colonic
resection admitted with hypoxia & abdominal distention, also
repeat echocardiogram given newly diagnosed pericardial
effusion.
.
# Pericardial Effusion: s/p pericardiocentesis when early signs
of tamponade seen on echocardiogram. Bloody pericardial effusion
~510cc's removed, ?malignancy. However no evidence of malignancy
cells seen on flow cytometry as well as cytology. W/u already
started at [**Hospital6 **] and so far studies negative
except for elevated ESR, CRP & CA 125. Required overnight CCU
stay after pericardial drain placed. Developed afib with RVR
during stay. No evidence of reaccumulation of fluid seen on
repeat echocardiogram or vital signs including nml pulsus.
.
# Atrial fibrillation with RVR: ?r/t pericardial effusion,
worsened after pericardiocentesis during which time she stayed
in the CCU given pericardial drain. She was treated with IV
metoprolol, diltiazem then finally started on an emsolol drip
for good control. This was weaned off with the onset of
Verapamil which was uptitrated during stay. Metoprolol was also
added for better rate control. The decision was made for no
anticoagulation given bloody pericardial effusion, pt was
continued on full strength aspirin.
.
# CT findings: Diffuse lymphadenopathy in the axillary,
supraclavicular and mediastinal regions with pulmonary nodules
in the left lung apex which were concering for neoplastic
process. Pt underwent L axillary lymph node biopsy for concern
of malignancy, ?Lung CA, lymphoma vs. other other cancers.
However, pathology was not diagnostic. Pt with no prior
colonoscopies or vaginal exams, however with nml mammograms &
per report, last [**3-/2144**] nml. Guaiac negative stools during
admission. Pt will need outpt evaluation for excisional lymph
node biopsy vs mediastinoscopy for tissue diagnosis, if desired
by the family.
.
# Abdominal distension: Appeared to be chronic, however worsened
acutely during admission. No evidence of volvulus, cholecystitis
or obstruction; imaging showed significant amounts of air with
colonic distention, likely colonic ileus. Surgery was consulted
and recommended endoscopic decompression per GI. However, GI
recommended rectal tube placement with was effective in
decompressing her abdomen. Pt initially made NPO, however
resumed regular diet gradually. had no episodes of nausea or
vomiting, however it was difficult to access abdominal pain. Per
GI, pt will require intermittent decompression with rectal tube
until ileus resolves. Also given possibility of malignancy, it's
recommended that pt under colonoscopy as part of further workup.
.
# Microcytic anemia: c/w anemia of chronic disease; low retic
count, however hematocrit stable. Guaiac negative stool x 1 in
the ED. We continued iron supplementation, ?other stools
guaiac'ed.
.
# Peripheral edema: Unclear if new, no evidence of chronic
venous stasis and no significant ascites seen on CT despite
abdominal distention. No evidence of proteinuria, however
sl.lower albumin. ?heart failure, however no other evidence on
PE. Liver function appears nml.
.
# Neurodermatitis: continued topicals
# DJD: continued celecoxib & tylenol.
.
DNR/DNI
Medications on Admission:
- Multivitamin 1 tab
- CaCo3 1250mg qdaily
- Celebrex 100 mg twice a day
- artifical tears PRN
- Eucerin cream topical every day,
- Vitamin E and Vitamin D ointments
- Chlorhexidine topical
- FeSo4 325 mg [**Hospital1 **]
- started on levaquin 500mg at NH today given transient hypoxia
.
ALLERGIES: NKDA
Discharge Medications:
1. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO once a day.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Celecoxib 100 mg Capsule Sig: One (1) Capsule PO bid ().
4. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QID (4 times a day) as needed for dry eyes.
5. Eucerin Cream Sig: One (1) application Topical once a
day.
6. Glucosamine-Chondroitin Complx 500-400 mg Capsule Sig: Two
(2) Capsule PO twice a day.
7. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO twice a day.
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 2.5
Tablet Sustained Release 24 hrs PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebs Inhalation Q6H (every 6 hours) as needed for
wheezing, SOB.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath, wheezing.
12. Verapamil 120 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] center
Discharge Diagnosis:
Pericardial tamponade s/p pericardiocentesis
Atrial fibrillation with RVR
Colonic ileus with abdominal distension s/p rectal decompression
Mental retardation
Degenerative joint disease
s/p volvulus with colonic resection
Discharge Condition:
stable
Discharge Instructions:
You were admitted with pericardial tamponade and you underwent
draining of the fluid around your heart. Laboratory analysis of
the fluid did not reveal a cause. You were also found to have
multiple enlarged lymph nodes in your chest. You had a biopsy of
one of these nodes that was not diagnostic. You should speak
with your doctor about having an excisional biopsy of one of
your lymph nodes.
During your hospitalization, you had abdominal distention from
an ileus that resolved with rectal tube decompression which
should be continued intermittently as needed.
.
MEDICATION CHANGES:
- start Toprol XL 125mg po daily, Verapamil 180mg po q8h
- Aspirin 325mg po daily
Continue to take your other medications as prescribed.
.
Please call your PCP or come to the ED if you develop chestpain,
shortness of breath or any other worrisome symptoms.
Followup Instructions:
Please f/u with PCP at the residence within 1 week of discharge.
You should discuss whether you should have a mediastinoscopy or
excisional biopsy of one of your lymph nodes.
Completed by:[**2144-7-7**]
ICD9 Codes: 2760, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5139
} | Medical Text: Admission Date: [**2143-1-1**] Discharge Date: [**2143-1-8**]
Date of Birth: [**2069-10-1**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old
male with known coronary artery disease status post
percutaneous transluminal coronary angioplasty to the left
anterior descending coronary artery in [**2130**] and [**2131**] status
post non Q wave myocardial infarction in 10/89, presented
with a two year history of increasing dyspnea on exertion,
chest pressure. Persantine thallium was performed that
showed anterior wall ischemia. He had a catheterization done
on [**2143-1-1**] at an outside hospital that revealed three
vessel disease with a normal EF.
PAST MEDICAL HISTORY: Significant for type 2 diabetes,
hypertension, coronary artery disease status post
percutaneous transluminal coronary angioplasty to the left
anterior descending coronary artery in [**2130**] and [**2131**]. He has
had a history of chronic obstructive pulmonary disease. He
is a former smoker. He quit two years ago. Bright red blood
per rectum in [**10/2142**] transfused one unit. Had an ultimately
negative esophagogastroduodenoscopy and colonoscopy. He is
status post a _______ lens implant for contacts in his right
eye and has a dilated right pupil.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: [**Year (4 digits) 37612**] 2.5 500 b.i.d.
SOCIAL HISTORY: He is widowed and lives with his brother.
REVIEW OF SYSTEMS: Revealed positive shortness of breath and
dyspnea on exertion. Denies any claudication, history of
gastrointestinal bleed, history of diabetes.
PHYSICAL EXAMINATION: Temperature 98.6. Pulse 76. Blood
pressure 146/76. O2 sat on 2 liters is 95 and 96% on room
air with 88 and in no acute distress. Alert and oriented
times three. Heart was regular rate and rhythm. 2+ radial
pulses. Extremities warm and dry. Abdomen was benign.
Respiratory was decreased breath sounds throughout with no
wheezes or rhonchi. Gastrointestinal, abdomen was large,
obese with positive bowel sounds, soft, nontender,
nondistended. His lower extremities were notable for
varicosities. Carotids without audible bruits. He was
edentulous.
ASSESSMENT/PLAN: The patient is a 73 year-old male with
three vessel coronary artery disease who presented to Dr.
[**Last Name (STitle) **] in need of coronary artery bypass grafting. He was
therefore admitted and went to the Operating Room on [**2143-1-3**]. Preoperative laboratories were notable for a white
count of 9000, hematocrit 35, platelets 307. Chemistries
were unremarkable. BUN and creatinine of 18 and 1.2. Chest
x-ray was negative except for changes consistent with chronic
obstructive pulmonary disease. Urinalysis was negative. On
the [**1-3**] the patient underwent a four vessel
coronary artery bypass graft, left internal mammary coronary
artery to left anterior descending coronary artery, saphenous
vein graft to obtuse marginal one, saphenous vein graft to
obtuse marginal two and saphenous vein graft to the posterior
descending coronary artery with Dr. [**Last Name (STitle) **] and Tavaf. He was
transferred to the Cardiac Surgery Recovery Unit. He was
alert and oriented and extubated on the night of the
operation. His Swan was removed. His Lopressor and Lasix
and aspirin were started on postoperative day number one.
His diet was advanced. He was transferred to the floor.
While on the floor the patient began aggressive physical
therapy and was noted to have high O2 requirements secondary
to poor pulmonary toilet as well as the patient's prior
chronic obstructive pulmonary disease. Physical therapy
worked with the patient aggressively. He was able to get to
a level 3 or 4 by postoperative day number 3. Postop
laboratories were notable for a hematocrit of 24 down from 35
preop. He had BUN and creatinine of 27 and 1.4 up from 1.0.
The remainder of his electrolytes were within normal limits.
He continued incentive spirometry and his ambulatory
assistance with physical therapy as well as his diuresis.
His diuresis was, however, changed to q day Lasix instead of
the standard b.i.d. for the postoperative coronary artery
bypass graft. The patient ultimately by postop day four the
patient's hematocrit was 24 and stable. BUN and creatinine
were normalized to 1.2. He was started on his [**Last Name (STitle) 37612**] and
began to have more normal glycemia since his Lopresor was
titrated to bring his heart rate down into the 70s.
On discharge his examination was noted for a temperature of
99.0, pulse 72, regular in sinus, 107/65, 22 respiratory
rate, 92% on 1 liter. Room air sats were 90%. He was in no
acute distress. He had decreased breath sounds throughout.
His sternum was stable with no erythema or exudate. He had
staples intact. Chest tube wires were all removed. The
patient had no drains. The remainder of his examination was
unremarkable. The saphenous vein harvest on the right lower
extremity was clean, dry and intact with no drainage as well.
The patient was therefore deemed appropriate and stable for
discharge to Pawtuckets near where his daughter lives. [**Name2 (NI) **] is
a resident of [**Location **].
His follow up will include to see Dr. [**Last Name (STitle) **] one month from
the time of discharge. He should have a wound check in one
week.
DISCHARGE MEDICATIONS: Lopressor 50 mg po b.i..d, Lasix 20
mg po q.a.m., Colace 100 mg po b.i.d., Zantac 150 mg po
b.i.d., Percocet as needed for pain as well as Glucotrol
Glucophage combination, which the trade name is [**Name (NI) 37612**]
2.5/500 b.i.d.
DISCHARGE STATUS: Stable.
DISPOSITION: To rehab.
DISCHARGE DIAGNOSIS:
Three vessel coronary artery disease status post coronary
artery bypass grafting.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2143-1-8**] 08:46
T: [**2143-1-8**] 08:59
JOB#: [**Job Number 29838**]
ICD9 Codes: 4111, 496, 412, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5140
} | Medical Text: Admission Date: [**2118-1-28**] Discharge Date: [**2118-2-2**]
Date of Birth: [**2056-1-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
transfer for ERCP
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stent
History of Present Illness:
62 yo female w/ PMH sig for metastatic ovarian cancer diagnosed
10 years ago, s/p TAH and BSO, adjuvant chemo (last treated
[**9-24**]), and peritoneal stripping in [**2110**], HTN, hyperlipidemia,
who presented initially to [**Hospital6 33**] with malasie and
transferred to [**Hospital1 18**] for ERCP. History is taken from chart
review and sister. She initially presented to [**Hospital3 **] beginning of [**1-26**] and was diagnosed w/ an SBO and
chronic cholecystitis discharged home on cipro. She represented
[**1-25**] to the OSH with left flank pain, poor appetite, nausea and
emesis. Per sister, + constipation, infrequent on/off emesis
one episode bloody, no fevers/chills, ~100lb weight loss over
one year. No shortness of breath/chest pain.
.
An abdominal US was sig for contracted gallbladder w/ wall
thickening, sludge concerning for acute cholecystitis
superimposed on chronic inflammatory changes, with mildly
dilated CBD 9mm, and loculated ascites. MRCP was notable for
dilatation of intrahepatic bile ducts and proximal CBD, with
midportion of the CMB narrowed by extrinsic mass. She was guaic
neg. Labs [**1-25**] sig for wbc 11, h/h 13.4/40.7, ast 306, alt 144, t
bili 3.8, ap 776, lipase 215. Urine cx grew enterococcus
faecium (prior urine cx [**1-21**] sig for enteroccocus R to
amp/vanc/macrobid, S linezolid/gent) and she was started on
linezolid. She was transferred to [**Hospital1 18**] for ERCP. Labs on
transfer sig for down trending ast/alt 127/94, ap 585, but
persistently elevated t bili 3.9.
.
ERCP was notable stricture at the common hepatic duct and
bifurcation of main biliary duct w/ mild post-obstructive
dilation compatible w/ extrinsic compression. A sphincterotomy
was performed and biliary stent placed. She had brief episode
of sbp in 90s, received 100mcg of neo. During procedure,
patient had retained food in the stomach and with worry for
aspiration in setting of possible SBO, she remained intubated.
.
Currently, patient is intubated and sedated.
.
Review of sytems: Unable to assess
Past Medical History:
-- Metastatic ovarian cancer: s/p TAH/BSO, peritoneal stripping
-- Hypertension
-- Hyperlipidemia
Social History:
Lives with her mother, in [**Location (un) 686**]. Self ambulates. Retired,
worked for state in public relations. No ETOH/cig/illicits
Family History:
No family hx of breast or ovarian cancer. Cousin with lymphoma.
Father AMI at 47yo. Sister w/ HTN.
Physical Exam:
General: Sedated, intubated, no jaundice
HEENT: Sclera mildly icteric, dry MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Anterior breath sounds clear to auscultation bilaterally,
no wheezes, rales, ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Obese, non-tender, non-distended, bowel sounds
present, areas of firmness along lower quadrants, no rebound
tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2118-1-28**] 09:23PM URINE COMMENT-DUE TO ABNORMAL URINE COLOR
INTREPRET DIPSTICK WITH CAUTION
[**2118-1-28**] 09:23PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-2
[**2118-1-28**] 09:23PM URINE COLOR-Brown APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2118-1-28**] 11:11PM PT-14.1* PTT-30.8 INR(PT)-1.2*
[**2118-1-28**] 11:11PM PLT COUNT-248
[**2118-1-28**] 11:11PM WBC-9.4 RBC-4.70 HGB-12.1 HCT-38.7 MCV-82
MCH-25.8* MCHC-31.3 RDW-17.2*
[**2118-1-28**] 11:11PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.4*
[**2118-1-28**] 11:11PM ALT(SGPT)-80* AST(SGOT)-77* LD(LDH)-307* ALK
PHOS-592* TOT BILI-2.8*
[**2118-1-28**] 11:11PM estGFR-Using this
[**2118-1-28**] 11:11PM GLUCOSE-165* UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-12
.
ERCP [**2118-1-28**]:
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
Biliary Tree: A single stricture of malignant appearance that
was 40 mm long was seen at the common hepatic duct and
bifurcation of the main biliary duct. There was mild
post-obstructive dilation. These findings are compatible with
extrinsic compression.Likely large mass at porta hepatis causing
Bismuth III type stricture. Unable to access left system. Right
system appears moderately dilated
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
A 6cm by 80mm Uncovered Wallflex biliary stent biliary stent was
placed successfully. Area of stricture bridged successfully.
Distal end of stent within CBD.
Impression: Cannulation of the biliary duct was successful.
A single stricture of malignant appearance that was 40 mm long
was seen at the common hepatic duct and bifurcation of the main
biliary duct.
There was mild post-obstructive dilation.
These findings are compatible with extrinsic compression.
Likely large mass at porta hepatis causing Bismuth III type
stricture.
Unable to access left system.
Right system appears moderately dilated
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A 6cm by 80mm Uncovered Wallflex biliary stent biliary stent was
placed successfully.
Area of stricture bridged successfully.
Distal end of stent within CBD.
.
CXR [**2118-1-31**]
In comparison with study of [**1-30**], allowing for differences in
patient position, there is little change. Left basilar
opacification
persists, consistent with volume loss and pleural effusion.
Diffuse pulmonary metastases are again seen.
CT Torso w/contrast:
1. Mid-small bowel obstruction, likely due to omental and
anterior abdominal wall mass.
2. Necrotic left pelvic side-wall mass, possibly nodal.
3. Enlarged celiac axis, paraaortic, and right external illiac
lymph nodes.
4. Innumerable bilateral pulmonary nodules compatible with
metastatic
disease.
5. Bilateral pleural effusions, left greater than right with
compressive
atelectasis on the left side.
6. Stent within the CBD, but the distal tip does not difinitely
enter into
the duodenum. There is periportal edema and mild biliary ductal
dilation.
.
Microbiolgy:
C diff neg X 3, most recent from [**1-30**].
Sputum culture GRAM STAIN (Final [**2118-1-30**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
Blood culture [**1-29**] NGTD
.
Discharge labs:
[**2118-2-2**] 04:04AM wBC 6.5 Hgb 9.4* HCt 27.7* MCV 80* Plts
210
INR 1.3
Glucose 132* BUN 5* Cr 0.4 Na 131* K 3.8 Cl 97 CO2 30
Mg 2.0, Ca 7.9, Phos 3.2
ALT 15, AST 15, Alk phos 200, T bili1.0
Brief Hospital Course:
Cholecystitis: MRCP notable for extrinsic mass w/ dilatation of
CBD and hepatic duct. No evidence for cholangitis. Patient is
currently s/p ERCP that was notable for stricture at the common
hepatic duct and biliary duct. Sphincterotomy and stenting was
performed. Her LFTs continued to improve and she remained
hemodynamically stable.
.
SBO: Suspected SBO, given high grade emesis, abdominal pain and
distension and from residual food seen in stomach during
procedure. Likely secondary to presumed extensive peritoneal
involvement of her ovarian cancer. CT torso was done which
confirmed incomplete partial small bowel obstruction of small
and large intestines without definite transition point
identified. Pt was kept NPO and NG tube was placed to
low-intermittent suction with improvement in patient's emesis
and pain. Dilaudid and fentanyl patch also improved patient's
pain. Pt's emesis resolved completely. Pt developed diarrhea as
well, this was C diff negative x3. By discharge, her emesis had
stopped, and she was started on clear liquid diet with mild
nausea. The NG tube was left in place in the event of recurrent
emesis.
.
Metastatic Ovarian Cancer: Extensive pulmonary mets as well as
abdominal disease seen on CT torso, pt and family was made aware
of this metastasis. [**Month (only) 116**] benefit from systemic chemotherapy. She
requested transfer back to [**Hospital1 34**] for management per her primary
oncologist.
.
Aspiration PNA: Concern for aspiration PNA given aspiration
event, leukocytosis, and tachycardia. Cefepime and
Metronidazole were added to linezolid and pt improved
significantly. Sputum cx nondiagnostic and blood cx remained
negative. She will need an 8 day course of linezolid, flagyl
and cefepime (last dose [**2118-2-5**])
UTI: per OSH results, sig for 100,000 Vanc resistent
enterococcus (VRE). Continued linezolid. Urine culture here was
negative.
.
Diarhea: She developed significant diarrhea, requiring rectal
tube. Stool was negative for C diff X 3.
.
NSVT: Pt developed significant NSVT, probably [**1-18**] beta blocker
withdrawal and hypokalemia [**1-18**] diarrhea/emesis. Repleted K and
started metoprolol 5mg IV Q4H to good effect. She was
transitioned to po metoprolol 25 mg po tid on the day of
discharge, which can be titrated up as necessary.
HTN: Restarted betablocker as above
.
Hyperlipidemia: Holding statin
.
FEN: on clear liquid diets as of today, replete electrolytes,
regular diet
-- If cannot start tolerating POs soon will need nutrition
consult for possible TPN
.
Prophylaxis: Subutaneous heparin
.
Access: peripherals
.
Code: Full
.
Communication: Patient
.
Disposition: transfer back to [**Hospital **] hospital today [**2118-2-2**]
Medications on Admission:
Transfer medications:
linezolid 600mg [**Hospital1 **]
lopressor 50mg daily
pantoprazole 40mg [**Hospital1 **]
paxil 20mg daily
simethicone 80mg tid
simvastatin 40mg daily
sucralfate 1gm
letrozole 2.5g daily
lovenox 40mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Linezolid 600 mg IV Q12H
5. Pantoprazole 40 mg IV Q12H
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Prochlorperazine 10 mg IV Q6H:PRN nausea
8. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
9. CefePIME 1 g IV Q12H
10. HYDROmorphone (Dilaudid) 0.5 mg IV Q2H:PRN Pain
Hold for sedation or RR<12
11. Potassium Chloride 40 mEq / 100 ml SW IV ONCE Duration: 1
Doses
12. Calcium Gluconate 2 g IV ONCE Duration: 1 Doses
13. Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses
14. Metoprolol Tartrate 5 mg IV Q4H
hold for SBP <100, HR <55
15. 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.
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Cholecystitis
Small Bowel Obstruction
Aspiration pneumonia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair.
NG tube in place, not to suction.
Foley catheter in place.
VRE precautions.
PICC in place.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for ERCP. We found a mass
compressing the biliary tree. You had a stent placed to relieve
obstruction. You were also vomiting, because of a small bowel
obstruction. We treated you for an aspiration pneumonia and
placed an nasogastric tube for your obstruction. We are
transferring you to [**Hospital6 33**] for further managment
based on your request.
Followup Instructions:
You are being transfered to [**Hospital6 33**] for further
management.
.
Follow up with your primary oncologist and primary care doctor
after discharge.
ICD9 Codes: 5070, 5990, 4019, 2724, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5141
} | Medical Text: Admission Date: [**2103-10-13**] Discharge Date: [**2103-10-16**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
CC: SOB
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures.
History of Present Illness:
HPI: 64 yo male with Hx of CAD s/p NSTEMI, severe COPD with
multiple intubations on chronic steroids, who p/w onset of SOB
over several hours. One day prior to admission, pt reports that
he had been sitting in bed and noted the gradual progression of
SOB over several hours. Denies sudden onset SOB, CP, pleuritic
pain, orthopnea, pnd, inc le edema. States that it feels like
a COPD flare. +occ cough, unchanged from chronic pattern.
+yellow sputum, unchanged in frequency or character. Took
ipratroprium/albuterol nebs x10, without improvement and decided
to come to the ED.
.
In ED, 108, 140/90, 23, 88% ra. Durintg time in room, bp dropped
to 97/69, rec'd 1.5L NS w/ subsequent improvement in BP. Rec'd
cipro 250 mg. Also rec'd solumdrol 125, and underwent bipap
while in ED.
Past Medical History:
PMH:
1. COPD on 4 L O2 at home and s/p multiple admissions and
intubations for flares-FEV1 .47(19%) FEV1/FVC 36% on 4L home 02,
and BiPap QHS.
2. Hypertension
3. Hyperlipidemia
4. CAD s/p NSTEMI ([**2101**]) [**4-10**] with cath normal
5. Chronic low back pain L1-2 laminectomy from accident at work
6. Steroid induced hyperglycemia
7. Left shoulder pain for several months
8. Cataract
9. GERD
10. Chronic indwelling urethral catheter.
Social History:
Married with six children. Lives at home in [**Location (un) 16174**] with
wife. Retired [**Company 19015**] mechanic. Exposed to a lot of spray
paint.
Former smoker. Quit 25 years ago. 20 pack year history.
Occassional EtOH Quit marijuana 3 years ago. Denies IV drug
use.
Activity limited due to prior spine and current shoulder
problems.
Family History:
Mother with asthma and [**Name (NI) 2481**]
Father with [**Name2 (NI) 499**] cancer
Physical Exam:
PE:
97.1, bp 123/43, 92, 18, 99% 4L NC
Well appearing male, not utilizing acc mm, breathing comfortably
in NAD.
PERRL.
OP clr, MMM
6cm JVP
Regular S1,S2. No m/r/g.
LCA b/l. +inc expiratory time.
+bs. soft. nt. nd.
no le edema.
Pertinent Results:
EKG: 85bpm, nl axis, nl interval, non-specific IVCD, unchanged.
.
CXR [**2103-10-13**]
AP UPRIGHT PORTABLE CHEST X-RAY: The study is limited secondary
to patient's positioning. The right costophrenic angle is not
seen. The cardiac silhouette is normal in size. The aorta is
tortuous. There is stable overinflation of bilateral lung
fields, with flattening of the cardiac silhouette, and bilateral
hemidiaphragms. Hyperlucency bilaterally and symmetrically is
consistent with diffuse emphysema. The imaged lung fields are
otherwise clear, with slight stable scarring at the left lung
base. There is no pneumothorax, and the pulmonary vasculature is
normal.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Underlying diffuse bilateral emphysema.
.
[**2103-10-15**] 5:09 pm URINE
**FINAL REPORT [**2103-10-16**]**
URINE CULTURE (Final [**2103-10-16**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
[**2103-10-13**] 1:05 pm URINE Site: CATHETER
**FINAL REPORT [**2103-10-14**]**
URINE CULTURE (Final [**2103-10-14**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
[**2103-10-13**] BLOOD CX: NEGATIVE
.
[**2103-10-13**] 02:35PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016,
BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD; RBC-[**11-25**]* WBC->50
BACTERIA-MANY YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2103-10-13**] GLUCOSE-114* UREA N-16 CREAT-0.8 SODIUM-141
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15,
CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-1.7, WBC-14.0* RBC-4.52*
HGB-12.2* HCT-37.8* MCV-84 MCH-27.1 MCHC-32.3 RDW-15.4,
NEUTS-67.9 LYMPHS-24.3 MONOS-4.3 EOS-3.2 BASOS-0.4, PLT
COUNT-333
Brief Hospital Course:
A/P: 64 yo male with HTN, severe COPD with FEV1 20%, on home
oxygen 4L and chronic steroids, with multiple prior intubations,
admitted with COPD flare and hypotension.
.
1) Shortness of breath: The patient's presentation was
consistent with a COPD flare. There was no new infiltrate on
Chest X-ray, and there was no change in the
consistency/amount/frequency of his sputum production.
Pulmonary embolism is highly unlikely. It was felt there was no
indication for antibiotics. We continued his steroids at
prednisone 60mg po qd, and discharged the patient on a taper
over 10 days. We continued albuterol and ipratropium bromide
nebulizer treatments, scheduled. The pt was started on
fluticasone and salmeterol inhalers, and he will use these as an
outpatient. He did not have to go on Bipap. At discharge, he
was able to walk around the ICU five times. He reports this is
his baseline. He will follow up with Dr. [**Last Name (STitle) 575**], his
pulmonologist in the next 2 weeks.
.
2) [**Name (NI) **] The pt had one episode of SBP in the 90s in the
ED. He was asymptomatic. We considered a normal variation in
BP, and could not r/o mild volume depletion given insensible
losses vs adrenal insufficiency as pt is on steroid taper.
We recommend cortstim on the pt as an outpatient. We continued
steroids for COPD flare. Our goal was for MAP<60 and
UOP<30cc/hour, supported with fluid boluses if need be, however
he did not require this. He was with stable VS throughout his
[**Hospital Unit Name 153**] stay. No more episodes of hypotension. He was placed on
his high blood pressure medications while in the [**Hospital Unit Name 153**].
.
3) [**Name (NI) 20182**] The pt's urine cultures came back positive for
>3 colony types, consistent with fecal contamination. Urology
felt that this was likely colonization, given he has a chronic
indwelling catheter. The catheter was changed on [**2103-10-15**], and
urology recommended Macrodantin for 3 day course given the cath
change. The pt is to follow up with Dr.[**Name (NI) 20183**] at [**Hospital1 112**] for
potential transurethral needle ablation of the prostate for
benign prostatic hyperplasia.
.
4) [**Name (NI) 3674**] Pt has history of anemia in past, unclear when his
last colonoscopy was. Will have pt follow up with PCP as
outpatient to schedule colonoscopy. Stools were guiaic
negative.
.
5) Coronary Artery Disease- No current evidence of angina. We
continued his ACE inhibitor/[**Name (NI) **]/statin.
.
6) Code status- FULL.
Medications on Admission:
Meds:
1.Aspirin 325 mg qd
2.Atorvastatin Calcium 10 mg qd
3.Calcium Carbonate 500 mg qd
4.Cholecalciferol (Vitamin D3) 400 unit qd
5.Senna 8.8 mg/5 mL [**Hospital1 **]
6.Sertraline 50 mg qd
7.Albuterol Sulfate 0.083 % Neb q4hours
8.Ipratropium Bromide Nebq4hours
9.Multivitamin qd
10.Lisinopril 5 mg qd
11.Prednisone 30mg qd on taper(down from 40mg on [**7-25**])
12.Percocet
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*4*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*3*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: Please see your primary
care physician for refills of this medication. .
[**Date Range **]:*30 Tablet(s)* Refills:*0*
5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
[**Date Range **]:*1 Disk with Device(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
7. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
[**Date Range **]:*30 Lozenge(s)* Refills:*0*
8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
[**Date Range **]:*30 Tablet Sustained Release(s)* Refills:*2*
9. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) for 2 days: To Complete a 3 day
course. .
[**Date Range **]:*8 Capsule(s)* Refills:*0*
10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Date Range **]:*30 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours.
[**Date Range **]:*120 nebulizer* Refills:*2*
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours).
[**Date Range **]:*120 nebulizer treatment* Refills:*2*
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*qs MDI* Refills:*2*
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): for constipation.
[**Hospital1 **]:*60 Capsule(s)* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: for constipation.
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
17. Prednisone 10 mg Tablet Sig: see instructions Tablet PO once
a day for 7 days: Take 4 tab po qd for 1 day, then 3 tab po qd
for 2 days, then 2 tab po qd for 2 days, then 1 tab po qd for 2
days. .
[**Hospital1 **]:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 20184**] medical services
Discharge Diagnosis:
1. Chronic Obstructive Pulmonary Disease flare/exacerbation
2. Chronic indwelling urethral catheter
3. Benign Prostatic Hypertrophy
4. Hypertension
5. Hyperlipidemia
6. Coronary artery disease
7. Chronic lumbago
8. Gastroesophageal Reflux Disease
Discharge Condition:
Stable
Discharge Instructions:
If you experience worsening shortness of breath, coughing and
sputum production increased in quantity or quality, please
report to the emergency room immediately. If you notice that
you are requiring more inhalers or oxygen than normal, please
come to the ER.
Please follow up with your physicians (see information below).
Please take all of your medications.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 612**].
Date/Time: You will be called by [**Name8 (MD) 20185**], RN from Dr. [**Name (NI) 20186**] office regarding a time in the next two weeks for
you to come in.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2103-11-6**] 9:30 AM.
3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2103-11-26**] 11:30
4. Please follow up with Dr.[**Name (NI) 20183**] at [**Hospital6 13185**], Urology, for evaluation for your transurethral needle
ablation of the prostate.
5. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2104-4-7**] 11:00
Completed by:[**2103-10-17**]
ICD9 Codes: 4019, 2724, 412, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5142
} | Medical Text: Admission Date: [**2199-2-19**] Discharge Date: [**2199-2-25**]
Date of Birth: [**2158-11-18**] Sex: F
Service: Medicine
CHIEF COMPLAINT: Lethargy, hyperglycemia.
HISTORY OF PRESENT ILLNESS: This is a 40 year-old woman with
history of type I diabetes with nephropathy, hypertension,
and chronic headaches who presents with lethargy and
increased blood sugars over the past week.
The patient was recently admitted on [**2-11**] for
worsening headaches. Extensive work up in the past has shown
these headaches to be sometimes correlated to anemia, as was
the case on the previous admission. She was transfused two
units of packed red blood cells with resolution of her
headache. She was noted at that time to be hyperglycemic
secondary to missed insulin doses and hypertensive. She was
discharged on Catapres with appropriate follow up. Since
discharge, the patient had been doing well with occasional
chronic typical headache relieved by Percocet. Her blood
sugars were running slightly high in the 300's over the
course of the week. In addition her blood sugars were high
at night, causing her to add additional insulin. Over the
three days prior to admission, blood sugars were increased.
She wet to he [**Female First Name (un) 3408**] for her scheduled appointment and was
told to come to the emergency department for hyperglycemia.
On further review, patient was noted to have increased
lethargy, decreased strength, decreased p.o. intake, nausea,
emesis, polyuria and polydipsia. The patient denies any
fevers, chills, new headaches, vision changes, chest pain,
palpitations, shortness of breath, cough, abdominal pain,
dizziness, or light headedness.
PAST MEDICAL HISTORY: 1) Insulin dependent diabetes mellitus
with nephropathy, retinopathy, and neuropathy. Two previous
admissions for diabetic ketoacidosis. 2) Gastroparesis. 3)
Chronic headache. 4) Hypertension. 5) Anemia secondary to
renal disease. 6) Barrett's esophagitis. 7) Status post
left cephalic vein clot secondary to PIC line in [**2198-4-30**].
8) History of sepsis and endocarditis. 9) History of
depression. 10) History of amenorrhea with increased
prolactin. 11) Hypercholesterolemia. 12) Previous
echocardiogram from [**2198-3-31**] showed ejection fraction of 45
to 50 percent with mild mitral regurgitation.
MEDICATIONS: 1) Catapres patch .1 mg change q. week, patient
not using. 2) Lasix 40 mg p.o. q.d, 3) Reglan 15 mg p.o.
q.d., 4) Protonics 40 mg p.o. q.d., 5) Percocet p.r.n.
headache. 6) NPH insulin 25 q. A.M., 4 q. P.M., 7) Sliding
scale Humulog insulin. 8) Allergies: no known drug
allergies. Notes vomiting with Erythromycin.
SOCIAL HISTORY: Patient is divorced, works as an accountant,
currently living with her parents because of her increased
care requirements secondary to her numerous illnesses.
Denies tobacco or alcohol.
FAMILY HISTORY: No history of early coronary artery disease,
diabetes, hypertension, hypercholesterolemia.
ADMISSION PHYSICAL EXAMINATION: Temperature 97 degrees,
heart rate 81, blood pressure 103/36, 99 percent on room air.
General: this is a drowsy middle aged woman who is easily
arousable. She sluggishly is able to answer questions,
otherwise in no apparent distress. Pupils were reactive,
extraocular movements were intact, sclerae are anicteric.
There was no photophobia. Oropharynx was clear. Neck is
supple without bruits. There is no jugular venous
distention. There is bilateral shotty cervical
lymphadenopathy, tender. Chest is clear to auscultation
bilaterally. The heart is regular, tachycardic, S1, S2, with
a II/VI systolic murmur at the left upper sternal border.
Abdomen was soft, nontender, nondistended, with normal active
bowel sounds. Extremities showed no clubbing, cyanosis or
edema. Pulses are thin, palpable bilaterally.
ADMISSION LABORATORIES: CBC showed white count of 8.5,
hematocrit of 33, platelets of 264. Chem-7 is significant
for sodium of 126 which corrects to 135, potassium of 6.6,
chloride of 99, bicarb of 5, BUN is 74, creatinine 4.9,
glucose of 702. Urinalysis significant for greater than 300
protein, greater than 1,000 glucose, 40 ketones, specific
gravity 1.021, count 5.5. Electrocardiogram shows normal
sinus rhythm at 83 beats per minute, T wave flattening in
[**Last Name (LF) 1105**], [**First Name3 (LF) **]. ST elevations in V1 through V3. ST depressions in
V4 through V6, I, AVL. This shows no change from previous
electrocardiogram from [**2199-1-14**]. Chest x-ray is
clear.
HOSPITAL COURSE: The patient received a total of 20 units of
insulin in the emergency room with improvement in her sugars.
She was then admitted to the Intensive Care Unit for close
observation and during correction of her hyperglycemia. She
was then called out to the regular medicine service on [**2-20**],
when it was noted that her cardiac enzymes were significantly
elevated, most notably for a troponin of 21.2, which later
went up to as high as 29.1. The patient was medically
managed for non-Q wave myocardial infarction, and it was
decided to try to avoid cardiac catheterization secondary to
the potential and likely damage that the dye load would cause
to her kidneys. Therefore, she underwent echocardiogram
which showed no focal wall motion abnormalities but did
demonstrate global hypokinesis of the ventricular wall. She
then underwent Persantine Thallium, which demonstrated a
small fixed anterior filling defect. The patient was placed
on beta blocker, heparin, aspirin, and Lipitor for her post
myocardial infarction regimen. ACE inhibitors were avoided
secondary to her renal function.
During her course, the patient's cardiac enzymes gradually
improved, and she had no symptoms or further
electrocardiogram changes or cardiac enzyme elevations. Her
course, however, was complicated by labile hypertension, with
surges into the 220s/110s. She was given increasing doses of
Lopressor, with eventual stabilization of blood pressure in
the 130s to 150s/80s. By [**2-25**], the patient's
hypertension was fairly stable, blood sugars were stable in
the high 100s, and she was having no cardiac symptoms and had
normal CKs. She was discharged to home with services, with
plans for follow up with Dr. [**Last Name (STitle) 19512**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharged to home with [**Hospital6 1587**].
DISCHARGE DIAGNOSES:
1. Non-Q wave myocardial infarction.
2. Diabetic ketoacidosis.
3. Hypertension.
4. Diabetes mellitus.
5. Hypercholesterolemia.
6. Chronic renal insufficiency.
DISCHARGE MEDICATIONS: 1) NPH 25 units q. A.M., 5 units q.
P.M., 2) Humulog sliding scale. 3) Lasix 40 mg p.o. q.d., 4)
Reglan 15 mg p.o. q. day, 5) Protonics 40 mg p.o. q.d., 6)
Lopressor 100 mg p.o. b.i.d., 7) Norvasc 10 mg p.o. q.d., 8)
Lipitor 10 mg p.o. q.d., 9) Epogen 3,000 units subcutaneous
injections three times a week. 10) Kayexalate 30 grams p.o.
q.d.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 19513**]
Dictated By:[**Last Name (NamePattern1) 19919**]
MEDQUIST36
D: [**2199-2-25**] 12:21
T: [**2199-2-26**] 20:47
JOB#: [**Job Number 19921**]
ICD9 Codes: 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5143
} | Medical Text: Admission Date: [**2131-12-31**] Discharge Date: [**2132-1-4**]
Date of Birth: [**2060-3-7**] Sex: M
Service: NEUROLOGY
Allergies:
Procardia / Aliskiren
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Altered Mental Status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known firstname 95455**] [**Known lastname 95456**] is a 71-year-old man with a history of
diastolic CHF, CAD, type II diabetes mellitus, and most recently
a insular glioblastoma diagnosed in [**2131-9-16**] now status post
radiotherapy and temzolomide currently being managed by Dr. [**First Name11 (Name Pattern1) **]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]. Mr. [**Known lastname 95456**] presents from his [**Hospital1 1501**] after having
acute onset of lethargy at 06:00 p.m. this evening. He was
monitored closely and his vital signs remained stable. At
around 11:30 pm he was noted to have increased left sided
weakness and new left sided facial droop. He was brought to
[**Hospital1 18**] Emergency Department by EMS for further evaluation of his
altered mental status.
In the Emergency Department initial vital signs were:
Temperature 97.3 F, pulse 70, blood pressure 137/79, repsiration
16, and oxygen saturation 97% on 2 liters via nasal cannula.
Patient was found to be lethargic but arousable. CT head was
performed showing interval increase in hemorrhage around the
mass, now with acute area of hemorrhage 2.6 cm x 1.4 cm.
Neurology was consulted urgently for left sided facial droop and
weakness. Given evidence of bleed they recommended holding home
aspirin and maintaining blood pressure control. Per ED team, Dr.
[**First Name8 (NamePattern2) 1151**] [**Last Name (NamePattern1) **] from the Neuro-Oncology Service reviewed the imaging
and did not recommend any changes to current antiepilectic and
steroid regimen at this time. He recommended further imaging
only if significant change in neurologic examination.
Laboratory findings were notable for troponin 0.11, Hct 35
(baseline), creatinine 1.2 (baseline), INR 1.0, PTT 20.8.
Patient's EKG was unchanged compared to prior. Chest X-ray was
without evidence of an acute cardiopulmonary process. Patient
received no medications or IV fluids prior to transfer to the
Medicine ICU for serial neurologic examinations.
On arrival to the ICU the patient appears comfortable. He
attempts to follow simple commands but is too lethargic to
follow any complex commands or to speak in full sentences.
ROS: Difficult to obtain given lethargy. Patient does deny any
headache, chest pain, shortness of breath, abdominal pain. Per
OMR he has urinary incontinence.
Past Medical History:
-Right frontotemporal glioblastoma multiforme WHO Grade IV,
status post biopsy on [**2131-9-27**], on protocol using
hypofractionated involved-field radiotherapy with temozolomide
followed by Cyberknife boost
-Ischemic stroke
-Malignant HTN
-CAD s/p IMI
-Chronic diastolic CHF
-PAF (ED visit [**7-25**])
-Type II diabetes mellitus
-Anxiety/Depression
Social History:
He is a resident of [**First Name5 (NamePattern1) 4542**] [**Last Name (NamePattern1) 19207**] & Nursing Center in
[**Location (un) 38**], MA. He is a retired rocket scientist from [**Country 532**].
He worked for USSR space program and NASA. A former pipe
smoker, he quit in [**2097**]. He is a social drinker and he does not
abuse illicit drugs.
Family History:
Father: Type [**Name (NI) **] diabetes and hypertension. Mother: [**Name (NI) **] [**Name (NI) 3730**].
Brother: Type [**Name (NI) **] Diabetes.
Physical Exam:
VITAL SIGNS: Tempperature 96.3 F, blood pressure 160/88, pulse
65, respiration 18, and oxygen saturation 96% in room air.
GENERAL: Lethargic, opens right eye to loud verbal stimuli
SKIN: No rasheS, jaundice, or splinters
HEENT: Left eye s/p cataract surgery, left pupil appears
chronically dilated, right eye pupil 3 --> 2 mm, EOMI,
anicteric, dry MM, no supraclavicular or cervical
lymphadenopathy, no JVD, no thyromegaly or thyroid nodules
CARDIOVASCULAR: Irregular, bradycardic S1 and S2 wnl, no m/r/g
PULMONARY: Irregular respirations concerning for sleep apnea
versus [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations, rhonchorus breath sounds at
bilateral bases
ABDOMEN: Non-distended, positive bowel sounds, soft,
non-tender, and without masses
EXTREMITIES: No clubbing, cyanosis, or edema
DRAINS: Portacath in place, Foley catheter in place.
NEUROLOGICAL EXAMINATION: Awake, alert, and oriented x 1 only.
He is lethargic, keeps eyes open for only seconds, answers
questions appropriately, cooperative while awake, and has mild
left-sided facial droop. Tongue at midline. Strength and
sensation difficult to assess given lethargy. Left arm appears
weaker than right. Patient able to wiggle fingers and toes in
both hands and feet symmetrically.
Pertinent Results:
Imaging:
[**2131-12-30**] Head CT:
1. Large mass in the right frontal lobe with adjacent new
hemorrhage at the right putamen.
2. Subacute infarcts in the right occipital lobe and right
posterior corona radiata.
3. No subfalcine herniation or uncal herniation.
4. No hydrocephalus.
[**2131-12-31**] Chest X-Ray:
1. No focal lung consolidation.
2. Right Port-A-Catheter with tip at the mid SVC in similar
position compared to prior.
3. Upper mediastinal silhouette widened could be due to goiter.
Correlate
with physical exam.
Microbiology:
[**2132-1-2**] URINE CULTURE-PRELIM {PROTEUS MIRABILIS} >100,000
ORGANISMS/ML
[**2132-1-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEGATIVE
[**2131-12-31**] URINE CULTURE-FINAL {PROTEUS MIRABILIS}
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2131-12-31**] MRSA SCREEN MRSA SCREEN-NEGATIVE
Labs on admission:
[**2131-12-31**] 05:05AM BLOOD WBC-10.0 RBC-4.03* Hgb-12.0* Hct-36.0*
MCV-89 MCH-29.8 MCHC-33.4 RDW-17.0* Plt Ct-255
[**2131-12-30**] 11:38PM BLOOD Neuts-86.9* Lymphs-8.8* Monos-3.8 Eos-0.2
Baso-0.3
[**2131-12-31**] 05:05AM BLOOD PT-11.7 PTT-21.6* INR(PT)-1.0
[**2131-12-31**] 05:05AM BLOOD Glucose-160* UreaN-43* Creat-1.0 Na-143
K-3.8 Cl-101 HCO3-34* AnGap-12
[**2131-12-31**] 05:05AM BLOOD ALT-21 AST-17 CK(CPK)-50 AlkPhos-89
TotBili-0.5
[**2131-12-31**] 05:05AM BLOOD CK-MB-4 cTropnT-0.09*
[**2131-12-31**] 05:05AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.2
[**2131-12-31**] 04:51AM BLOOD Type-ART pO2-76* pCO2-42 pH-7.50*
calTCO2-34* Base XS-7
[**2131-12-31**] 04:51AM BLOOD Lactate-1.3
[**2131-12-31**] 04:51AM BLOOD freeCa-1.14
Labs on discharge:
[**2132-1-4**] 04:30AM BLOOD WBC-10.7 RBC-3.42* Hgb-10.3* Hct-29.9*
MCV-88 MCH-30.3 MCHC-34.5 RDW-16.6* Plt Ct-238
[**2132-1-4**] 04:30AM BLOOD Glucose-160* UreaN-49* Creat-1.0 Na-142
K-3.6 Cl-106 HCO3-27 AnGap-13
[**2132-1-4**] 04:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2
Finger stick glucose on day of discharge: 331 <-- 143 <-- 220
<-- 298
Brief Hospital Course:
Patient with acute mental status change found to have
intraparenchymal hemorrhage at site of glioblastoma multiforme
on CT scan. Initially admitted to the ICU, and then transferred
to the floor in stable condition.
(1) Altered Mental Status: His head CT shows increased
hemorrhage around known glioblastoma multiforme. It is not
clear whether his symptoms on presentation are secondary to this
hemorrhage, increased edema from his tumor, possibly a new
ischemic stroke, or the UTI. Patient's known intracranial
lesion also raises concern for seizure activity though this is
less likely given his seizure prophylaxis and clinical history.
There was no evidence of intoxication or other metabolic
etiologies to explain his lethargy. His daughter does report
that the rehab facility had wanted to start a trial of
additional antidepressants in the last week, however, this would
not support the acute change in mental status evening prior to
admission. Throughout the day of admission, the patient's
mental status improved without intervention. He has baseline
confusion and at times seems that he did not fully comprehend
certain questions despite being A&O x3. His mental status has
stabilized and there is no concern at this time that he is
unable to protect his airway.
(2) Intraparenchymal Hemorrhage: Patient with acute mental
status change found to have intraparenchymal hemorrhage at site
of glioblastoma multiforme on CT scan. There was no history of
recent head trauma or use of anticoagulation, except for aspirin
325 mg daily. His last XRT and chemotherapy was in [**Month (only) **]
[**2131**]. Platelets and coags within normal limits. Serial
neurological exams were done and there was clinical improvement.
It is believed that the intracranial hemorrhage has stabilized
and the patient was transferred from the intensive care unit to
the floor. Goal BP was systolic blood pressure in the
140's-160's. We held his antihypertensive medications during
his time in the ICU in order to meet this goal. Patient is being
discharged on reduced dose of labetalol 800 mg [**Hospital1 **] to 400 mg
[**Hospital1 **]. We will stop his aspirin on discharge.
(3) Diabetes: This was poorly controlled on presentation with
fingerstick blood glucose >350 and remained >400 upon transfer
to floor. Home oral hypoglycemics were held during admission.
He continued fingerstick blood glucose and home insulin regimen
(75 units of Glargine qhs). Also, we placed the patient on an
Humalog ISS during his admission. Of note, patient was eating
constantly throughout the day during admission, making glucose
control difficult. We discharged patient on his home regimen
of oral and subcut insulin.
(4) Urinary Tract Infection: This was found on admission,
initially treated with bactrim. Culture grew Proteus, resistent
to Bactrim, discharging patient on cefazolin to complete a 7 day
course (Day 1 is [**2132-1-2**]).
(5) Elevated Cardiac Enzymes: Patient has known history of CAD
s/p IMI. EKG unchanged compared to prior on presentation.
Patient denies symptoms of chest pain or shortness of breath.
His elevated cardiac may be due to demand in the setting of
hypertension as patient has a history of poorly controlled blood
pressures and atrial fibrillation. Patient cardiac enzymes were
stable at 0.09 and CK-MB was flat at 4. He was not started on
treatment for ACS as it was not believed that this was the cause
of his elevated troponins. In addition, given recent bleed
heparin and aspirin would be contraindicated in this patient
given recent cranial bleed. Patient denied chest pain,
shortness of breath, nausea or diaphoresis during his admission
on the floor.
(6) Atrial Fibrillation: Patient currently in sinus rhythm.
Labetolol was decreased during ICU stay due to persistent sinus
bradycardia; pressures remained in the 140s-160s.
(7) Chronic Diastolic Heart Failure: Patient with significant
history of multiple intubations for dCHF exacerbations. Held
many of his BP meds initially. BP stabilized on modified home
regimen. He was discharged with decreased labetalol dose as
stated above. Patient denied SOB during admission after
receiving several gentle IV fluid boluses. His lower extremity
edema was stable during admission.
(8) Anemia: Patient's Hct was at a baseline, remained stable
throughout his admission.
(9) Anxiety/Depression: Home clonazepam and buspirone was held
initially for accurate neuro exam. He was restart upon
discharge as patient's mental status is back at baseline.
Medications on Admission:
- AMLODIPINE- 10 mg daily, last received [**12-30**] @ 2PM
- DIOVAN 160 mg [**Hospital1 **], last received [**12-30**] @ 6AM
- BUSPIRONE- 5 mg [**Hospital1 **], last received [**12-30**] @ 8PM
- CLONAZEPAM- 0.5 mg Tablet qHS, last received [**12-29**]
- CLONIDINE- 0.2 mg/24 hour 2 Patches Weekly on Saturdays, last
received [**12-29**]
- DEXAMETHASONE- 3 mg [**Hospital1 **], last received [**12-30**] @ 8PM
- EPLERENONE- 50 mg daily, last received [**12-30**] @ 8AM
- GLYBURIDE- 5 mg [**Hospital1 **]
- Lantus 75 units at bed time, last received [**12-30**]
- LABETALOL- 200 mg tab, 4 tablets [**Hospital1 **], last received [**12-30**] @
8PM
- LEVETIRACETAM- 500 mg tab, 1 tab, TID, last received [**12-30**] @
10PM
- OMEPRAZOLE- 20 mg Capsule, 1 tab, daily, last received [**12-30**] @
8AM
- SIMVASTATIN- 40 mg Tablet, 1 tab, daily, last received [**12-30**] @
5PM
- TIMOLOL [BETIMOL]- 0.5 % Drops- 1 gtt(s) OU twice a day
- TORSEMIDE- 10 mg tab, 3 tabs, daily, last received on [**12-30**] @
8AM
- ACETAMINOPHEN- 325 mg, 2 tabs, q4h PRN for pain
- ASPIRIN- 325 mg Tablet, 1 tab, daily, last received [**12-30**] @
8AM
- DOCUSATE SODIUM- 100 mg, 1 tab, [**Hospital1 **], last received on [**12-30**]
- SENNA- 8.6 mg tab, 1 tab, [**Hospital1 **] PRN (received none in [**Month (only) **])
- Nitroglycerin 0.4 mg SL tab PRN for chest pain, last received
on [**12-25**] once with chest pain resolved
- Milk of Mag, 30 ml by mouth if no BM in 48 hours prn
- Bisacodyl 10 mg supp, insert 1 PR if no BM in 12 hours after
MOM
- [**Name (NI) 20342**] enema, insert 1 PR if no BM in 12 hours after
suppository
- Magnesium citrate, 1 bottle PO if no BM in 12 hours after
[**Name (NI) **] enema PRN unless contraindicated
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Buspirone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Transdermal
once a week: on Saturdays.
6. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO twice a
day.
7. Eplerenone 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Lantus 100 unit/mL Cartridge Sig: 75 units Subcutaneous at
bedtime.
10. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Timolol 0.5 % Drops Sig: One (1) drop Ophthalmic twice a
day.
15. Torsemide 10 mg Tablet Sig: Three (3) Tablet PO once a day.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
four (4) hours as needed for pain/fever.
17. Docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: Please give up
to 3 x q 5 minutes.
20. Milk of Magnesia 400 mg/5 mL Suspension Sig: 30mL PO once a
day as needed for constipation: Please give if no BM in 48H.
21. Bisacodyl 10 mg Suppository Sig: One (1) PR Rectal once a
day as needed for constipation: if no BM in 12H.
22. [**Name (NI) 20342**] Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once
a day as needed for constipation: if no BM after suppository.
23. Magnesium citrate Solution Sig: One (1) bottle PO once a day
as needed for constipation: if no BM in 12 hrs after [**Name (NI) **] enema
prn, unless contraindicated.
24. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
25. cefazolin 1 gram Recon Soln Sig: One (1) gram Intravenous
twice a day for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Glioblastoma mulitiforme
Urinary tract infection
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:
It was a pleasure to take care of you during your admission. You
were admitted for confusion; your confusion improved, and you
were treated for an urinary tract infection.
Please make the following changes to your medications:
-START cefazolin 1g intravenously twice daily for 4 days for
your urinary tract infection
-REDUCE Labetolol to 400mg daily for your blood pressure
- STOP aspirin 325mg once daily
Please continue all other medications as prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: NEUROLOGY
When: FRIDAY [**2132-1-25**] at 11:00 AM
With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2132-5-21**] at 10:30 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 431, 5990, 2760, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5144
} | Medical Text: Admission Date: [**2161-4-20**] Discharge Date: [**2161-4-24**]
Date of Birth: [**2101-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2161-4-21**] Mitral valve repair (28mm Annuloplasty band)
Past Medical History:
Mitral regurgitation, Coronary artery disease/myocardial
infarction tatus post coronary stent, Congestive heart failure,
Hypertension, Hypercholesterolemia, h/o skin cancer status post
removal, Hemorrhoids, remote fracture of fingers and toes, skin
cancer status post removal, status post hernia repair x 2,
status post repair of facial laceration, status post cyst
removal from his scrotum, status post vasectomy, status post
left arm surgery
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse or IVDU. Patient
smokes marijuana daily. Works as a motorcycle repairmen and
carpenter. Active in his job, but does not exercise regularly.
Family History:
non-contributory. There is no family history of premature
coronary artery disease or sudden death.
Physical Exam:
On physical examination, his heart rate is 64. Blood pressure
is 118/68. His height is 65" and he weighs approximately 175
lbs. In general, he appeared to be in no acute distress. His
skin is mostly unremarkable with multiple healed scars
throughout his body. HEENT examination revealed extraocular
movements are intact. Pupils are equal, round, and reactive to
light. Oropharynx is benign. His neck is supple, full range of
motion without any JVD. His lungs are clear to auscultation
bilaterally. Cardiac examination revealed regular rate and
rhythm with a soft murmur of mitral regurgitation. His abdomen
is soft, nontender, and nondistended with positive bowel sounds.
Extremities are warm and well perfused with no edema.
Neurologically, he is grossly intact, alert, and oriented x3,
moving all extremities.
Pertinent Results:
[**2161-4-20**] Echo: 1. No atrial septal defect is seen by 2D or color
Doppler. 2. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %)with hypokinesia of the mid
and apical portions of the inferior, inferolateral and
inferoseptal walls. There is moderate global RV free wall
hypokinesis. 3. The ascending, transverse and descending
thoracic aorta are normal in diameter. There are simple atheroma
in the aortic arch and descending thoracic aorta. 4. There are
three aortic valve leaflets. Trace aortic regurgitation is seen.
There is no aortic stenosis. 5. The mitral valve leaflets are
mildly thickened. There is moderate/severe mitral valve prolapse
of the A2 and A3 scallops. The P2 portion is mildly restricted
in movement. Severe (4+) mitral regurgitation is seen. The
mitral valve annulus measures 3.7 cms with the anterior leaftlet
measuring 3.47 cm and the posterior leaflet measuring 1.35 cm.
The Csept distance is 3.57 cm. 6. There is no pericardial
effusion. 7. Dr. [**Last Name (STitle) **] was notified in person of the results
during the procedure on [**2161-4-20**] at 820 am. POSTBYPASS: 1. The
patient is on phenylephrine, epinephrine, milrinone infusions
and AV paced. 2. RV function is improved compared to the
prebypass study. 3. LV function is worse than prebypass, now
with EF of 30%. Inferior, inferoseptal, and inferolateral walls
are akinetic. 4. An annuloplasty ring is noted in the mitral
postion. It appears well seated. There is trivial mitral
regurgitation. Peak gradient is 6 mm Hg and the mean gradient is
3 mmHg across the mitral valve. 5. Aortic contour is smooth
after decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit and on [**4-20**] he was brought to
the operating room where he underwent a mitral valve repair.
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. Pacing
wires and chest tubes were removed per Cardiac surgery protocol.
CXR without pneumothorax. Patient transferred from the ICU to
the floor. Patient experienced post op afib and was started on
Amiodarone and betablockade was increased and converted back to
sinus rhythm.
Patient was evaluated by physical therapy and cleared for d/c to
home.
Medications on Admission:
ASA 325', Plavix 75', Lisinopril 15', Lasix 20', Simvastatin
80', Metoprolol 25', Sertraline 75',
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for recent stent .
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): dose decreased while on amiodarone.
Disp:*30 Tablet(s)* Refills:*2*
5. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 2 tabs daily for 6 days then one tab daily there after.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral regurgitation status post Mitral Valve repair
Secondary: Coronary artery disease/myocardial infarction tatus
post coronary stent, Congestive heart failure, Hypertension,
Hypercholesterolemia, h/o skin cancer status post removal,
Hemorrhoids, remote fracture of fingers and toes, skin cancer
status post removal, status post hernia repair x 2, status post
repair of facial laceration, status post cyst removal from his
scrotum, status post vasectomy, status post left arm surgery
Discharge Condition:
good
Discharge Instructions:
Adhere to 2 gm sodium diet
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks([**Telephone/Fax (1) 62**])
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**2-13**] weeks ([**Telephone/Fax (1) 250**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Please call for [**Hospital Ward Name 4314**]
Completed by:[**2161-4-24**]
ICD9 Codes: 4240, 9971, 4280, 2875, 412, 2859, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5145
} | Medical Text: Admission Date: [**2198-2-11**] Discharge Date: [**2198-2-18**]
Date of Birth: [**2132-2-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 65 year old female
with a past medical history notable for diabetes mellitus,
hypertension, coronary artery disease status post myocardial
infarction and coronary artery bypass graft, right lower
lobectomy, asthma and congestive heart failure, who presents
complaining of cough times one week, malaise and fatigue.
The patient had a low grade temperature of 99.6 F., at home.
The patient denied any lower extremity edema or weight gain.
The patient's peak flows at home were in the 150 range.
The patient was recently admitted to the hospital [**1-28**]
until [**2-5**] for similar complaints of shortness of
breath and cough. At that time, she was treated with
steroids, Azithromycin and nebulizers for a presumed
bronchitis exacerbation.
In the Emergency Room, the patient was treated with a
Combivent nebulizer, Solu-Medrol intravenously, Levaquin and
Lasix.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Neuropathy.
3. Hypertension.
4. Coronary artery disease status post inferior myocardial
infarction in [**2182**]; status post coronary artery bypass graft
in [**2190**]; most recent catheterization in [**2196-8-1**] with an
ejection fraction of 40%; left internal mammary artery with
40% disease and right coronary artery with 90% disease.
5. Status post right lower lobectomy for question of
tuberculosis disease at age 16.
6. Asthma.
7. Congestive heart failure.
8. Fibromyalgia.
9. Osteoarthritis.
10. Low back pain secondary to spinal stenosis.
ALLERGIES: Penicillin and tetracycline.
MEDICATIONS AT TIME OF ADMISSION:
1. Aspirin 325 mg a day.
2. Prednisone taper.
3. Protonix 40 mg a day.
4. Trandolapril 2 mg a day.
5. NPH 34 units in the morning and 26 units at night.
6. Subcutaneous insulin.
7. Albuterol inhaler.
8. Fluticasone inhaler.
9. Valium p.r.n.
10. Sotalol 80 mg twice a day.
11. Nystatin swish and swallow.
SOCIAL HISTORY: The patient lives at home independently.
She has around 12 siblings. She has a 30 pack history of
tobacco but quit in [**2182**]. She does not use any alcohol.
PHYSICAL EXAMINATION: Temperature 99.5 F.; pulse 96; blood
pressure 110/60; respiratory rate 24; pulse oximetry 95% on
two liters. In general, a sad tearful female with a flat
affect. HEENT: Pupils are equal, round and reactive to
light. Mucous membranes were moist. Neck is supple without
any jugular venous distention. Chest: Crackles at the lung
bases about [**2-3**] of the way up. Cardiovascular: Regular
rate, no murmurs. Abdomen is soft. Extremities are warm
without edema with good pulses. Neurological is alert and
oriented times three.
LABORATORY: Data at the time of admission is white blood
cell count of 10.3 with 70% neutrophils, hematocrit of 39.7,
platelets of 226. Sodium 134, potassium 4.4 hemolyzed,
chloride 95, bicarbonate 29, BUN 24, creatinine 1.4 with
baseline of 1.0, and glucose of 120.
Chest x-ray shows blunting of the left costophrenic angle,
right middle and lower lobe pneumonia.
EKG with normal sinus rhythm at a rate of 95, old Q waves in
the inferior leads with no acute ST changes.
HOSPITAL COURSE:
1. Hypoxic hypercarbic respiratory failure: The patient was
initially admitted to the Medical Floor for treatment of her
multi-lobar pneumonia. She initially maintained an oxygen
saturation of greater than 95% on three liters of nasal
cannula, however, developed hypoxia to 80% with saturation of
90% on non-rebreather, in the setting of a narrow complex
tachycardia while she was on the floor. However, the patient
remained hypoxic at about 96% on a nonrebreather; therefore
she was transferred to the Fenard Intensive Care Unit.
In the Intensive Care Unit her arterial blood gas revealed a
pH of 7.16, a pCO2 of 74 and pO2 of 94 with abnormal mental
status. The patient's culture data revealed a Methicillin
resistant Staphylococcus aureus pneumonia and the patient's
antibiotic regimen was changed to Vancomycin. There was also
a question of aspiration.
The patient was initially tried on a trial of Bi-PAP,
however, she did not tolerate this very well and her mental
status decreased to the point of requiring intubation.
Initially there was significant confusion regarding her code
status, as on a previous admission it was documented that she
wanted to be resuscitated but did not want to be intubated.
So, after discussion with various of her attendings and given
her clinical status, the decision was made to intubate the
patient as she was in acute respiratory distress.
The patient continued to require high ventilatory support and
had adult respiratory distress syndrome physiology.
2. Tachycardia: The patient, just prior to her transfer to
the Intensive Care Unit, had a tachycardia that was presumed
to be either an atrial tachycardia versus an NRT. She
decreased her rate from the mid 200s to 100 after receiving
diltiazem 20 mg intravenously and was followed closely in the
Intensive Care Unit. She had multiple episodes of
tachycardia and the Electrophysiology Service was consulted
as well as the Electrophysiology physician, [**Name10 (NameIs) **],
occasionally her rhythm would break with Idenosine and
occasionally with Diltiazem and eventually she was on a
diltiazem drip. There was a question of amiodarone loading
as well.
Of note, her Sotalol, which she had been maintained on as an
outpatient, had been discontinued during her hospital course
as she had started to develop renal failure.
3. Hypotension: The patient remained hypotensive after she
was intubated and was not fluid responsive. Her MAPs were
around 50. She was started on norepinephrine and vasopressin
and the etiology was thought to be sepsis although it then
also became cardiogenic later in her hospital course.
4. Acid Base: The patient had a mixed respiratory and
metabolic acidosis. She was given intravenous fluids and her
respiratory status was maintained with a ventilator, although
it was very difficult to correct her acid base status given
her overwhelming sepsis as well as her worsening renal
failure.
5. Acute Renal Failure: The patient had worsening renal
failure likely secondary to acute tubular necrosis with
anuria. CVH was debated upon, however, ultimately a change
in the patient's code status did not require use of this node
of volume removal.
DISPOSITION: After extensive discussion with the family,
initially the patient was clearly full code as she was
intubated, ventilated and on pressors, however, after two to
three family meetings and multi-system organ failure
including cardiovascular, pulmonary, renal with overwhelming
sepsis, Methicillin resistant Staphylococcus aureus pneumonia
and progressive overall worsening, it was decided that goal
for care would change from "Do Not Resuscitate" "Do Not
Intubate" followed by COMFORT MEASURES ONLY status. The
patient had multiple family members who came to see her prior
to her demise.
The patient expired at 03:55 a.m. on [**2198-2-18**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2198-4-5**] 13:13
T: [**2198-4-6**] 22:25
JOB#: [**Job Number 9246**]
ICD9 Codes: 4280, 5845, 4275, 0389, 2761, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5146
} | Medical Text: Admission Date: [**2124-10-6**] Discharge Date: [**2124-10-12**]
Date of Birth: [**2068-11-10**] Sex: F
Service: MED
Allergies:
Azmacort / Clindamycin / Versed / Fentanyl / Morphine
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: 55-year-old female with MMP
including demyelinating syndrome, neurogenic bladder, adrenal
insufficiency, and recent admission for exacerbation of
asthma/COPD with elevated WBC who was found on that admission to
have L renal infarct with associated arterial thrombosis,
hepatic artery tortuosity/aneurysm, secundum ASD and a negative
hypercoag work-up although warfarin anticoagulation has been
continued with INR goal [**1-18**] maintained.
.
On [**2124-10-5**], 1 d. PTA, the patient noted to Dr. [**First Name (STitle) **], her
primary care provider that she has been having gross urinary
bleeding when voiding; she notes passing a bolus of blood "the
size of a softball." In order to determine if the bleeding was
vaginal or urinary in nature, she straight-cathed herself and
note that there was blood and clots in the urine. Her INR on
that day was therapeutic at 2.6 on warfarin 7 mg po qhs. She was
then directed to the [**Hospital1 18**] ED.
.
On presentation, she notes that she previously has had
hematuria, but can't remember the details due to memory problems
she attributes to her demyelinating syndrome. She also admits
to a craming pain in the abdomen which she cannot quantify, but
is loated at the left abdomen and radiates downward and to the
back. She denies nausea, but does admit to one episode of
mildly bloody, mildly bilious emesis, although she cannot
remember the details. She denies diarrhea, melena, or BRBPR.
She denies fevers and night sweats. She admits to epistaxis
occuring over the last number of days and says that she had
cauterization of the nose performed to stop the bleeding but
does not recall where or by whom.
Past Medical History:
Left renal infarct with arterial thrombosis.
ASD, secundum
? hepatic artery aneurysm
?h/o eosinophilia
Asthma.
Restrictive lung disease.
Unknown demyelinating syndrome (L leg paresis, bilateral arm
weakness, demyelination on brain MRI, neurogenic bladder)
Adrenal insufficiency.
Osteoporosis.
Hypothyroidism.
History of chest nodules.
Dyslipidemia.
History of K breast papilloma with nipple discharge.
Anxiety.
Labile hypertension.
History of right IJ thrombus in [**2112**].
IgG deficiency.
Anemia.
Status post cholecystectomy in [**2112**].
Dysfunctional uterine bleeding by history.
Atypical pap smears.
Common bile duct stenosis s/p sphincterotomy.
Gastritis and prepyloric ulcers per EGD.
Bilateral hearing loss.
G-tube and self-catheterization
Social History:
The patient states she lives with her husband. Over 50 pack
year smoking hx; quit in [**2109**]. Denies any recent alcohol or IV
drug abuse.
Family History:
Family history is notable for coronary artery disease. Father
had [**Name2 (NI) 499**] cancer, her mother had breast cancer, and her sister
had brain cancer.
Physical Exam:
Physical Exam:
Vital signs
Temp: 99.6 F Pulse: 90 bpm BP:132/86
RR: 17/min O2Sat: 86%,RA
.
Gen: Drowsy, pleasant 55y/o female in no respiratory distress.
Derm: skin normal coloration, no rash.
HEENT: Eyes: no scleral icterus. PERRLA, EOM full but jerky with
occasional dipping movements.
Ears: normal shape and external auditory canals. Reduced hearing
in R ear on finger rub test.
Nose: septum midline: + epistaxis.
Throat: Oropharynx clear. Mucous membranes tacky. Top and
bottom dentures. No LAD. No thyromegaly.
Pulm: Reduced movement of air. No dullness to percussion. No
audible wheezing, rhonchi, or bronchial breath sounds.
CV: S1, S2 normal, RRR. III/VI systolic harsh murmur loudest at
base with some radiation to RUSB.
Abd: Nonobese, vertical well-healed scar right of midline. Bowel
sounds present but not hyper/hypoactive. No aorta/renal artery
bruits. Voluntary +/- involuntary guarding, severe tenderness
left lower quadrant, no detectable masses. No
hepatosplenomegaly.
CVA: Tender to percussion on the left CVA and only slightly on
the right CVA.
Ext: Pedal and radial pulses [**1-18**]+, somewhat bounding. No edema.
Neuro: Muscle tone decreased in both LEs, L less tone than R;
rigidity in both LEs, L>R. Hip flexors symmetric and [**4-19**]. Knees,
ankles and toes [**3-20**] left, [**4-19**] right. Light touch sensation
intact in upper and lower extremities and face.
Pertinent Results:
On previous admission:
HCV Ab, HepBsAg, HBsAb, GHcAb all negative
[**Doctor First Name **] negative
B2microglob, ATIII, protC, protS, V leiden, LAC, aCL all
negative
C3 118, C4 20
*
ANCA ([**Hospital1 **]) borderline positive by indirect IF, pANCA pattern
*
On this admission:
[**2124-10-5**] 11:15PM WBC-10.3# HCT-37.4 PLT COUNT-530* MCV-99*
RDW-14.6
[**2124-10-5**] 11:15PM NEUTS-72.8* LYMPHS-20.3 MONOS-4.9 EOS-1.4
BASOS-0.6
[**2124-10-5**] 11:15PM MACROCYT-1+
[**2124-10-5**] 12:17PM PT-20.3* INR(PT)-2.6
[**2124-10-5**] 11:15PM SODIUM-140 POTASSIUM-3.7
CHLORIDE-101 BICARB-28
UREA N-12 CREAT-0.9 GLUCOSE-88
*
[**2124-10-5**] 12:17PM CHOLEST-232*
*
[**2124-10-6**] 09:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2124-10-6**] 09:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2124-10-6**] 09:50AM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
CT Abd/Pelvis w&w/o contrast ([**2124-10-6**], 01:49a):
1) Mild to moderate hydronephrosis of the left kidney which
extends down to the mid ureter with perinephric stranding. There
is hyperattenuating fluid within the left renal collecting
system consistent with an obstructing clot.
2) Peripheral, wedge-shaped areas of hypoenhancement within the
left kidney are improved when compared to previous study without
evidence of cortical scarring. This may indicate that these
areas of hypoattenuation represented infection or inflammation
rather than infarcts.
3) 2 cm soft tissue nodule in the left anterior abdominal wall
which is new since the previous study and may represent a small
hematoma.
PA AND LATERAL CHEST ([**2124-10-6**]): The heart size is at the upper
limits of normal. The
mediastinum is not widened. There is minimal left basilar
atelectasis. There is no evidence of pneumonia or failure. The
previously visualized right middle lobe opacity has resolved.
Brief Hospital Course:
## Hematuria. The patient has left renal infarction and right
renal vein thrombosis. TEE has documented the presence of a
secundum ASD, raising the possibility of paradoxical embolus.
Pyelonephritis is also a consideration, considering the findings
on CT, but bleeding is out of proportion to other findings. The
patient has been anticoagulated on warfarin and perhaps has been
supratherapeutic, causing hemorrhage of the infarcted kidney.
Because the infarcted kidney may have a higher propensity to
bleeding, we will hold anticoagulation and institute a lower
dose of warfarin when appropriate aiming for a target INR of
2.0. Once patient transfered to the floor patient had one
episode of passing clots and after produced clear urine.
Patient was kept on heparin for anticoagulation and started on
lower dose of coumadin for goal INR of 2.0. Urology stated that
the patient would most likely continue to pass clots but no
further intervention was needed at this time since patient with
normal urine output. Upon discharge patient sent home with
coumadin and bridged with lovenox.
## Klebsiella urosepsis - Patient found to be septic and
transfered to the MICU. Patient hypotension responded well to
fluids and given Zosyn for coverage. Patient urine culture and
blood culture came back positive for KLEBSIELLA PNEUMONIAE.
After 1 day in the MICU patient was transferred back to the
floor and continued on Zosyn. When the sensitivities came back
it was found that the Klebsialla was only intermediate sensitive
to Zosyn and patient was switched to meropenum. Patient was
continued on meropenum upon discharge.
## Epistaxis: Likely also secondary to supratherapeutic
anticoagulation. Recently received cautery to limit epistaxis.
.
## Rheumatologic Disease: The patient's hematuria, epistaxis,
and hemoptysis, coupled with her history of thrombosis, history
of "demyelinating disease," and the presence of hepatic artery
irregularity suggest the possibility of a unifying rheumatologic
diagnosis of vasculitis. pANCA was borderline positive and and
an extensive hypercoagulability work-up was negative.
Nevertheless, the hematuria may be explained by renal
infarction, and epistaxis may be underlying the hemoptysis.
.
## ?Hypercoaguability: Renal vein thrombosis may be caused by a
thrombophilia but an hypercoagulability work-up was negative.
Cancer screening with colonoscopy and mammogram is up to date
and negative for malignancy. The patient does have a family
history of malignancy, but has no other stymptoms to suggest a
specific malignancy and has been imaged thoroughly. A chest
nodule is stable on follow-up. The patient is due for a pap
smear.
.
## Adrenal insufficiency - Patient given stress dose steroids in
the MICU when she was found to have urosepsis. Upon transfer to
the floor patient put on PO prednisone and slowly tapered.
.
Medications on Admission:
ADVAIR DISKUS 500-50MCG--Use one puff by mouth twice a day
ALBUTEROL --Take 2 puffs four times a day
ALBUTEROL SO4 0.083 %--One neb q 4-6 hrs as needed
[**Doctor First Name **] 60MG--Take one by mouth twice a day
BACLOFEN 10 MG--Two tabs three times a day
BECLOMETHASONE (NASAL) --Take 2 sprays each nostril twice a day
CALCIUM CARBONATE 500MG--Take one by mouth three times a day
with meals
CLONAZEPAM 1 MG--Two tabs three times a day
COLACE 100MG--Take one by mouth three times a day while on
narcotics to soften stool
COUMADIN 7MG QHS to maintain inr [**1-18**]
CYCLOBENZAPRINE 10 MG--Take one pilll up to three times a day as
needed
IPRATROPIUM BROMIDE 14 GM--2-3 puffs inh four times a day
LEVOXYL 50MCG--Take one pill every day
LIPITOR 10MG--Take one pill every day
LORAZEPAM 1MG--One by mouth three times a day as needed
NUTREN 1.0/FIBER --One can three times a day as needed
PREDNISONE 5MG--As directed, discontinued [**2124-9-23**]
RANITIDINE 150 MG--One by mouth twice a day
ROXICET 5 MG/325 MG--[**12-17**] by mouth every 4-6 hours as needed for
pain
ULTRAM 50MG--One to two every 6 hours as needed
VITAMIN D 400U--Take one by mouth every day
[**Month/Day (2) **] 4MG--Two every 6 hours as needed for spasms
Discharge Medications:
1. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD ().
3. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD
().
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD ().
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD ().
9. Buspirone HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO qd () for 3
days: Please take 40mg tab (two 20mg tabs ) once a day for 3
days starting on [**2124-10-13**] .
Disp:*6 Tablet(s)* Refills:*0*
11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO qd () for
3 days: Please take 30mg prednisone (three 10mg tabs) once a day
for 3 days after finishing course of 40mg prednisone.
Disp:*9 Tablet(s)* Refills:*0*
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO qd () for 3
days: Please take 20mg prednisone once a day for three days (one
20mg tab) after finishing three day course of 30mg prednisone.
Disp:*3 Tablet(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO qd () for 3
days: Please take 10mg prednisone (one 10mg tab) once a day for
three days after finishing 3 day course of 20mg prednisone.
Disp:*3 Tablet(s)* Refills:*0*
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qd () for 3
days: Please take 5mg prednisone once a day for three days after
finishing 3 day course of 10mg prednisone.
Disp:*3 Tablet(s)* Refills:*0*
15. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
16. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
17. Tizanidine HCl 4 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
18. Meropenem 1000 mg IV Q8H
19. Lovenox 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous twice
a day for 7 days.
Disp:*14 ml* Refills:*3*
20. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
21. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day for 6
months.
Disp:*180 Tablet(s)* Refills:*3*
22. Outpatient Lab Work
Patient should have her INR checked on Saturday, [**2124-10-14**] and Monday, [**2124-10-16**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Hematuria
Klebsiella urosepsis
Discharge Condition:
Patient is tolerating PO, urinating and having bowel movements
without difficulty.
Discharge Instructions:
Please continue to lovenox until INR level becomes therapeutic.
You will have to have your blood work (INR) checked every [**1-18**]
days to determine if the level therapeutic. INR goal is 2. If
INR < 2 continue to take lovenox along with the coumadin. If
the INR is >2.5, please hold your coumadin dose.
Please follow up with your primary care doctor, Dr. [**First Name (STitle) **] next
Thursday [**10-19**] to have INR checked and coumadin adjusted if
need be.
Please finish prednisone taper as prescribed, 40mg for 3 days
first, then 30mg for three days, then 20mg for three days, then
10mg for three days, and finally 5mg for three days.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2124-10-18**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3031**], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-10-19**] 11:20
Patient needs her INR checked on Saturday, [**10-14**] as well
as on [**10-16**]. Scripts are included for this lab work and
patient should call her PCP later that day to get the results
and titrate her doses of lovenox/coumadin as recommended above.
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5147
} | Medical Text: Admission Date: [**2126-9-22**] Discharge Date: [**2126-10-7**]
Date of Birth: [**2062-8-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Tetracycline Analogues / Keflex /
Propofol Analogues / Vancomycin / Nuts / Pepper / Eggs / Coconut
/ Bleach / Aztreonam / Carbapenem / Erythromycin Base
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Mechanical Fall w vertebral fracture
Major Surgical or Invasive Procedure:
orthopedic surgery fixation of thoracic spine
intubation
mecanical ventilation
[**First Name3 (LF) **] transfusion
History of Present Illness:
This is a 64 yo F with PMHx of OSA on CPAP, DMII, CKD baseline
2.5, HTN, dCHF (LVEF >55%), peripheral neuropathy, morbid
obesity, asthma, hypothyroidism and anxiety who was transferred
to [**Hospital1 18**] s/p mechanical fall from OSH ED ([**Hospital 36837**] Healthcare.
The patient fell down 10 stairs at her son's house. Per report
there was possible LOC and head strike, CT head in OSH ED
negative for ICH or fracture, but positive for subgaleal
hematoma at the vertex. CT spine showed T10 vertebral body fx,
T8-10 spinous process fx and R tranvsverse fx of T11-12. She was
briefly hypotensive in the ED, SBP nadir 80s with improvement to
133 after 1L NS and was transferred to [**Hospital1 18**] for further
management. At OSH ED she also got Zofran, Tylenol, Lidoderm
patch.
In the [**Hospital1 18**] ED, VS 109/38 64 20 98% 2L. Admission labs notable
for K 6.2 (not hemolyzed), Cr 3.3 (baseline 2.0-2.5), HCT 29
(baseline 32-35), INR 1.0, CK 2056. There were no EKG changes
and she received 10U Regular Insulin, 1 amp D50 and Kayexalate
x1, with improvement in her K to 5.8, but worsening renal
failure (Cr 4.2) and rising CK (3045). She was seen by ACS and
Ortho Spine and was neuro intact, no urinary retention or
incontinence of bowel or bladder. She is being transferred to
medicine for [**Last Name (un) **] and hyperkalemia, plan for OR tonight with
Ortho-Spine for stabilization of transverse T11-12 fractures.
Consulting services are ACS, Ortho-Spine and Neurosurgery.
Documented UOP 300cc in past 12 hours. She was seen by ACS and
Ortho Spine and was neuro intact, no urinary retention or
incontinence of bowel or bladder.
ROS: The patient says she has had increased muscle/joint aches
recently which she attributes to OA. She has felt increasingly
disoriented and dizzy recently. She says her vision has seemed
cloudier recently.
Past Medical History:
- OSA on CPAP
- DMII, peripheral neuropathy
- CKD baseline 2-2.5
- HTN
- dCHF (LVEF >55%)
- morbid obesity
- asthma
- hypothyroidism
- anxiety
Social History:
Lives with her husband, [**Name (NI) 9102**], in [**Name (NI) 5871**]. She
has a son who lives in [**Name (NI) 36838**].
Former smoker, denies alcohol or illicit drug use.
Family History:
Mother- MVP, hypothyroid. Father- lung CA, smoker, mets to
brain. Brother- healthy, lives in [**Name (NI) 4565**], 3 sons, all
healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 99.1 120-145/41-60 70-82 20 96% 2L NC
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
lying flat on her back.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - obese, no elevation in JVP appreciated.
LUNGS - CTA anteriorly, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use. Uncomfortable lying all the
way flat, more comfortable with head of the bed raised 10
degrees.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-18**] in LEs, sensation grossly intact throughout.
DISCHARGE PHYSICAL EXAM
VS - 98.2 Tmax 100.3 136/82 72 20 99%RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
lying flat on her back.
HEENT - + mild TTP over frontal and maxillary sinuses, improved
from prior, NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP
clear
NECK - obese, no elevation in JVP appreciated.
LUNGS - CTABL, no r/rh/wh, good air movement anteriorly, resp
unlabored, no accessory muscle use. Breath sounds distant [**2-14**]
obesity
HEART - PMI non-displaced, RRR, + 3/6 systolic murmur heard best
at LUSB, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS
[**2126-9-22**] 08:23PM URINE HOURS-RANDOM UREA N-425 CREAT-209
SODIUM-13 POTASSIUM-85 CHLORIDE-12
[**2126-9-22**] 08:23PM URINE OSMOLAL-383
[**2126-9-22**] 07:30PM GLUCOSE-217* UREA N-73* CREAT-4.3*
SODIUM-131* POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-24 ANION GAP-15
[**2126-9-22**] 07:30PM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-2.0
[**2126-9-22**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2126-9-22**] 06:00PM URINE [**Month/Day/Year 3143**]-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-SM
[**2126-9-22**] 06:00PM URINE RBC-32* WBC-9* BACTERIA-NONE YEAST-NONE
EPI-0
[**2126-9-22**] 06:00PM URINE MUCOUS-RARE
[**2126-9-22**] 06:00PM URINE EOS-NEGATIVE
[**2126-9-22**] 01:00PM GLUCOSE-257* UREA N-68* CREAT-4.2* SODIUM-133
POTASSIUM-5.8* CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
[**2126-9-22**] 01:00PM CK(CPK)-3045*
[**2126-9-22**] 01:00PM cTropnT-0.04*
[**2126-9-22**] 01:00PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.9
[**2126-9-22**] 06:20AM GLUCOSE-223* UREA N-62* CREAT-3.5* SODIUM-133
POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-22 ANION GAP-19
[**2126-9-22**] 06:20AM CALCIUM-8.6 PHOSPHATE-4.2 MAGNESIUM-1.9
[**2126-9-22**] 01:20AM GLUCOSE-234* UREA N-62* CREAT-3.3*
SODIUM-131* POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-23 ANION GAP-16
[**2126-9-22**] 01:20AM estGFR-Using this
[**2126-9-22**] 01:20AM CK(CPK)-2056*
[**2126-9-22**] 01:20AM COMMENTS-GREEN TOP
[**2126-9-22**] 01:20AM K+-5.9*
[**2126-9-22**] 01:20AM WBC-7.2 RBC-3.14* HGB-9.5* HCT-29.0* MCV-92
MCH-30.1 MCHC-32.6 RDW-13.0
[**2126-9-22**] 01:20AM NEUTS-84.7* LYMPHS-10.5* MONOS-4.3 EOS-0.3
BASOS-0.2
[**2126-9-22**] 01:20AM PLT COUNT-218
[**2126-9-22**] 01:20AM PT-11.0 PTT-30.1 INR(PT)-1.0
K 6.2-->5.8-->5.3-->5.3
Cr 3.3-->3.5-->4.2-->4.3-->4.1-->3.9-->4.1
MICROBIOLOGY
BCx [**9-25**] x2: No Growth
BCx [**10-2**]: pending
URINE CULTURE (Final [**2126-9-25**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
[**2126-9-25**] 4:43 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2126-9-29**]**
GRAM STAIN (Final [**2126-9-25**]):
[**11-7**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2126-9-29**]):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Sensitivity testing performed by Sensititre.
[**2126-10-4**] 9:24 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2126-10-4**]):
[**11-7**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
[**2126-10-2**] 10:20 am [**Month/Day/Year 3143**] CULTURE
**FINAL REPORT [**2126-10-5**]**
[**Month/Day/Year **] Culture, Routine (Final [**2126-10-5**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>2 R
ERYTHROMYCIN---------- =>4 R
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING
OSH IMAGING
CT Abd Pelvis w/o contrast:
- Rt 11th posterior rib fracture, appears acute
- T10 Vertebral body fracture (s7:52), t8, 9, 10 spinous process
fractures. Rt trv process fracture pf T11, T12
- Right buttock and low back hematoma
- 12 x 19 x 12 cm mass in pelvis - peripheral calcification,
central areas of fat and soft tissue - likely represents a large
dermoid.
- gallstones. atrophic kidneys.
CT Head w/o contrast: subglaleal hematoma at the vertex
CT C-spine: Congenital unfused anterior and posterior arch of
C1. Congentital fusion of C2 and C3 vertebral bodies. No
fracture. Degenerative disease C5-7.
L hip and AP pelvix 3 views: No acute fracture or dislocation
L spine, 2 views: Degenerative changes in the lumbar spine, no
acute fracture
Thoracic spine, 2 views: Diffuse degenerative changes with
overhanging osyeophyte formation. Possible ankylosing
spondylitis.
[**Hospital1 18**] IMAGING
MRI Entire spine [**2126-9-22**]
1. There are 11 thoracic vertbral bodies. This results in a
discrepancy
between the CT and MRI vertebral level labeling. Utilizing 11
vertebral bodies with this report's numbering system, the T9
vertebral body is fractured. T9 vertebral body fracture without
retropulsion or compromise of the spinal canal. The anterior
longitudinal ligament is disrupted at this level. If there is to
be surgical intervention, consider correlation at time of
surgery with plain radiographs.
2. Increased fluid signal in the L4-L5 and L5-S1 intervertebral
discs may reflect disc injury or alternatively may reflect
normal signal which appears higher than expected due to
degenerative loss of normal high signal in the adjacent
intervertebral discs.
3. Spinous process and transverse process fractures in the lower
thoracic
spine are better appreciated on the prior CT.
DISCHARGE LABS
[**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] WBC-5.3 RBC-2.57* Hgb-7.8* Hct-24.4*
MCV-95 MCH-30.2 MCHC-31.7 RDW-14.3 Plt Ct-486*
[**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] Glucose-80 UreaN-63* Creat-2.5* Na-142
K-4.0 Cl-108 HCO3-24 AnGap-14
[**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] ALT-56* AST-48* AlkPhos-104 TotBili-1.7*
Brief Hospital Course:
This is a 64 yo F with PMHx of OSA on CPAP, DMII, CKD baseline
2.5, HTN, dCHF (LVEF >55%), peripheral neuropathy, morbid
obesity, asthma, hypothyroidism and anxiety who was transferred
to [**Hospital1 18**] s/p fall down stairs, found to have thoracic vertebral
fractures.
# Traumatic thoracic spine vertebral body fractures: S/P fall
down 10 stairs. No signs and symptoms of cord impingement,
rectal tone intact. The patient was planned for urgent
orthopedic fixation procedure but CPK and Cr found to be rising
with decreasing urine output, so transfered to medicine for
stabilization before surgery (see below). Patient was optimized
medication and underwent open reduction of T
fracture/dislocation, and T8-T12 posterior fusion and
instrumentation on [**9-24**], with estimated [**Month/Year (2) **] loss of 1300 mL.
PT saw patient and recommended rehab. Post surgical pain well
controlled with medication at time of DC.
# Respiratory Failure/Shortness of breath: Post operatively,
extubation was difficult [**2-14**] increased fluid balance. Patient
was optimized and was subsequently extubated after diuresis. Of
note, in the ICU Sputum Cx were sent emperically and grew MSSA.
When the patient was extubated she was afebrile without cough or
prominent pulmonary sx, so the decision was made not to treat.
Patient has paroxsyms of breathlessness without hypoxia. CXR and
CT torso was otherwise unremarkable.
- Patient will need to continue CPAP while at rehab and would
benefit from outpatient pulmonary follow-up.
# Acute on chronic renal failure: The patient was oliguric at
presentation, urine output improved with gentle fluids (fluid
recussitation limited by h/o CHF and limitation that patient
must lie flat). All meds renally dosed, and nephrotoxic meds
held until Cr improved. [**Last Name (un) **] thought likely [**2-14**] pre-renal. After
IVF, PRBC, and diuresis in the ICU, the patient's Cr normalized
to baseline (2.0-2.5).
# S/P Fall: Unclear history of loss of consciousness leading to
fall with Thoracic fractures, and the patient endorses several
months of feeling dizzy. CPK ~3000 at peak, thought to represent
mild rhabdo. The patient was thought to be volume depleted on
presentation, given elevated Cr, low UOP, and good response to
IVF and PRBC. Fall could have been [**2-14**] orthostasis, so HCTZ was
Discontinued. Alternatively, fall may have been [**2-14**] dizziness
and confusion from medication effect, as she was on Topamax 100
HS at the time of the fall. Topamax was DCed. TSH was within
normal limites, tele showed no events, felt unlikely to be
cardiac in origin. The patient no longer felt dizzy at
discharge, but had mobilized very little given post surgical
pain.
# Anemia: During admission the patient had several episodes of
anemia requireing multiple PRBC transfusions. It was felt that
[**Last Name (un) **] had led to transient low EPO state. The patient was not felt
to be actively bleeding either at her trama/sugical sites or
elsewhere. Hct bumped appropriately after PRBC given, and [**Last Name (un) **]
improved by time of DC.
- recheck Hct in 4 days after admitted to rehab to make sure Hb
remains stable.
# Sinus infection: The patient complained of sinus pressure and
nasal discharge after being extubated, which improved without
specific therapy. Thought to be related to a viral etiology.
# Diarrhea: The patient was initially constipated having some
gassy abdominal pain, so a bowel regimin was started. After that
she began having loose stools. Since she had been exposed to
Cipro and Levofloxacin, C diff was sent, though suspicion was
not high b/c BMx were 1/day and soft not profusely wattery.
- C diff pending at time of discharge
# LFTs elevated: LFTs were found to be mildly elevated, unclear
etiology, not related to acute presentation.
- F/U w outpatient PCP to monitor for resolution or pursue
futher work up
# Blurry vision: The patient says that her R eye had blurry
vision since the fall, and improved during admisison. Denies
floaters or flashes of light or other worrisome signs of retinal
detachment. No other neurological signs. She says she has blurry
vision at baseline, and since this acute worsening the vision in
her R eye has been getting better since she has been in the
hospital. Possible etiologies include dry eyes (has a h/o this),
acute hyperglycemic episode (glucose had been 200s-300s), or
worsening of known cataracts.
# UTI: E. coli grew in urine in the setting of normal UA but
[**Last Name (un) **]. UTI may have contributed to [**Last Name (un) **] presentation, so warrents
treatment for complicated UTI given DMII.
- continue Cipro for a total of 14 day course, last day of
therapy is [**2126-10-8**]
# MSSA in sputum: The patient had difficulty with extubation
after procedure, so sputum cultures were sent and grew MSSA. The
patient says she continues to have some SOB, no cough. Has had
several low grade temps but has never spiked. Repeat Sputum
culture grew the same organism, may represent colonization.
- continue to monitor fever curve, if spikes consider treating
with linezolid (the patient is Vanc allergic)
# Coag negative staph in [**Month/Day/Year **] Cx: No growth from other
cultures. Likely contaminent.
# DM: The patien was placed on ISS. Dose was decreased for NPO
for procedure and while intubated in the ICU. When the patient
started eating again she was transiently hyperglycemic with FS
200s-300s, her insulin was titrated back to her home dose and FS
improved to well controlled.
# Asthma
- albuterol prn
# OSA
- CPAP at night
- monitor on continuous O2 monitoring
# HTN, HLD, CV risk factors, dCHF: Fluid recussitation was
gentle given dCHF. Cont home meds except HCTZ was discontinued.
# Hypothyroidism
- cont Levothyroxine Sodium 50 mcg PO/NG DAILY
# Anxiety
- cont Bupropion, hold Topamax because of side effect of
dizziness
# Pelvic mass: incidentally found on CT abd. Likely dermoid, 12
cm in size. Unlikely to be related to current presentation. The
mass was discussed w the patient, and F/U w gynecology was
obtained.
# L renal cystic lesions: Also incidentally found on CT abd.
Unlear if it is a cyst, may need US follow up per PCP.
# PPX: pneumoboots and heparin sq (held for surgery, then
restarted several days after per ortho recs)
TRANSITIONAL ISSUES
- Large pelvic mass seen on CT scan, likely dermoid. F/U with
PCP and Gyn to further eval and possibly remove mass
- L renal cystic lesions, may need US F/U per PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] cultures pending at discharge, will communicate with
rehab if positive cultures
- Recheck Hct 4 days after admission to rehab to check that Hct
is stable.
- F/U w outpatient PCP to monitor for resolution of LFT
elevations or pursue futher work up
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. BuPROPion 150 mg PO DAILY
2. Gabapentin 100 mg PO HS
3. Lisinopril 2.5 mg PO DAILY
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Topiramate (Topamax) 100 mg PO HS
6. Simvastatin 10 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO BID
8. Glargine 44 Units Breakfast
Glargine 44 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Albuterol Inhaler [**1-14**] PUFF IH Q4H:PRN wheezing
11. Symbicort *NF* (budesonide-formoterol) unknown units
Inhalation unknown
12. Carvedilol 25 mg PO BID
13. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Fall
thoracic spinal fractures
acute on chronic renal failure
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted after a fall where you
sustained spinal fractures, and you were found to have worsening
kidney function. You underwent orthopedic surgery for your
spinal fractures, and required care in the intensive care unit
as well as several transfusions of [**Hospital1 **]. After several days the
breathing tube was removing and transfered to the floor. Your
kidney function improved with IV fluids. You were discharged to
rehab to regain your strength.
It is important that you keep all follow up appointments, and
take all medications as prescribed. Your CT scan showed a pelvic
mass, which you should follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 36839**]t for further evaluation.
You will also need follow up with a lung doctor after you leave
a rehab.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5849, 2851, 5990, 2762, 3572, 2767, 2449, 311, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5148
} | Medical Text: Admission Date: [**2145-7-15**] Discharge Date: [**2145-7-20**]
Date of Birth: [**2069-3-8**] Sex: F
Service: NEUROLOGY
Allergies:
Coumadin
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
right sided weakness and confusion
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
Pt. is 76 yr old woman with PMH as below called in as code
stroke. Last known well at 5:15, then a few minutes later at [**Hospital1 1501**]
when she was due to get her meds she was noted to have right
sided weakness and confused. EMS called. [**Hospital1 2025**] was on divert, and
pt. brought here. Neurology called 5:59 PM. On initial
evaluation, she had a NIHSS stroke scale of [**9-22**]. She was not
aphasic. She was taken to CT scanner which was negative for any
signs of new infarction. STAT labs drawn, no recent surgeries.
Contrast allergy to dye, no CTA.
Past Medical History:
2 heart attacks
b/l CEAs, on coumadin which has been d/c'ed
bypass of left carotid
htn
mild dementia
high chol
AAA surgery
Social History:
lives in nursing home/[**Hospital3 **] facility, daughter very
involved. remote history of tobacco.
Family History:
noncontributory
Physical Exam:
T-not recorded BP-143/94 HR-70 RR-24, 99% RA
Gen: lying in bed in mild apparent distress
Heent: NCAT, oropharynx clear
Neck: supple, no carotid bruits
Chest: clear to auscultation b/l
CV:regular rate, normal s1s2, no m/r/g
Ext: no c/c/e, 2+ dorsalis pedis
Neurologic Exam:
MS:
Oriented to person, place and time.
Alert.
Able to say months of year backwards.
Fluent speech, repetition, naming intact.
Memory [**4-15**] registration, recall 0/3 at 5 minutes.
No apraxia, neglect, frontal signs.
CN:
Visual fields intact to confrontation
R surgical pupil , L pupil reactive 3->2mm. R eye amblyopia.
Eomi
without nystagmus.
Normal facial sensation
R facial droop with [**Month (only) **]. NLF on R side.
Hearing intact to finger rub.
Palate rises symmetrically. Tongue midline.
Motor:
Normal tone and bulk. No tremors or fasciculations.
The pt. is full strength on left side and antigravity on R
hemibody which can easily be overcome.
Reflexes:
There are [**3-19**]
Plantar reflexes
Sensory:
Intact to pinprick, vibration, proprioception and temperature
throughout.
Coordination:
Intact FTN b/l.
Intact [**Doctor First Name **].
Gait:
Romberg sign
narrow based, stable, good arm swing. Tandem intact.
Pertinent Results:
[**2145-7-15**]
7:36p
Na:145 K:4.8 Cl:105 Glu:146
Comments: Green Top Tube
[**2145-7-15**]
7:20p
CK: 31 MB: Notdone Trop-*T*: <0.01
Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
142 105 26
--------------< 150
3.9 24 1.0
93
6.0 \ 14.5 / 182
/ 42.4 \
PT: 12.2 PTT: 23.4 INR: 0.98
Comments: Note New Normal Range As Of 12 Am [**2145-6-12**]
Fibrinogen: 339
Cardiology Report ECG Study Date of [**2145-7-15**] 7:13:42 PM
Normal sinus rhythm. Left atrial abnormality. Left axis
deviation. Probable
left anterior fascicular block. T wave inversions in leads VI-V2
- cannot
exclude anteroseptal ischemia. No previous tracing available for
comparison.
CT HEAD W/O CONTRAST [**2145-7-15**] 7:16 PM
Streak artifact limits evaluation of the left temporal lobe. It
also limits evaluation of the posterior fossa. There is no
evidence of intra or extraaxial hemorrhage. The ventricles and
sulci are prominent, probably secondary to age related
involutional changes. There is no hydrocephalus, mass effect, or
shift of the normally midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is preserved and the middle cerebral arteries
appear symmetric bilaterally. There is some probable
calcification of the cavernous carotids bilaterally. Multiple
bilateral hypodensities consistent with some lacunar infarcts
are seen. The visualized paranasal sinuses and mastoid air cells
are clear and the osseous structures are unremarkable.
IMPRESSION: No evidence of intracranial hemorrhage, or other
acute abnormality. Multiple hypodensities bilaterally consistent
with lacunar infarcts.
CAROTID SERIES COMPLETE [**2145-7-16**] 1:51 PM
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaque was identified.
On the right, peak systolic velocities are 73, 53, 107 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.4.
This is consistent with no stenosis.
On the left, peak systolic velocities are 60, 39, 150 in the ICA
and CCA, ECA respectively. The ICA to CCA ratio is 1.5. This is
consistent with no stenosis.
There is antegrade flow in the right vertebral artery. The left
vertebral artery is not visualized.
IMPRESSION: No evidence of stenosis in either carotid artery
status post endarterectomy.
Cardiology Report ECHO Study Date of [**2145-7-16**]
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity size and systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded.
3. The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. There is
moderate
thickening of the mitral valve chordae. Trivial mitral
regurgitation is seen.
MR HEAD W/O CONTRAST [**2145-7-17**] 11:43 AM
FINDINGS: On the diffusion images increased signal is seen in
the left side of the pons. Additionally, a small area of
increased signal is seen in the left corona radiata. In absence
of ADC map, it is unclear whether this is due to subacute
infarcts or T2 shine through. Mild changes of small vessel
disease are seen in the periventricular white matter. A chronic
right frontal cortical infarct is identified. An area of chronic
blood products is also seen in the left frontal subcortical
region which could be secondary to prior trauma or ischemia.
Moderate changes of some brain atrophy are noted. On coronal
images, no evidence of increased signal is seen within the
hippocampal region.
IMPRESSION: Increased signal on the diffusion images with
corresponding T2 abnormalities involving the left side of the
pons and left corona radiata could be due to subacute infarcts
or due to T2 shine through. In absence of ADC map, this could
not be distinguished. Chronic right frontal cortical infarct.
Moderate changes of brain atrophy.
Brief Hospital Course:
1) Stroke: The patient presented with a right sided paralysis.
She was evaluated in the ED and head CT showed no bleed, so she
received TPA starting at 8:07 pm. While pushing the TPA, she was
thought to develop a right third nerve palsy with pupil sparing,
but this resolved. The TPA was stopped, but repeat CT with no
bleed, so the remaining dose of TPA was given. She had
improvement in the symptoms post-tpa, and the etiology of this
was unclear. MRI showed a left pons area of signal intensity on
diffusion weighting that corresponded to her weakness, which
suggested she had an ischemic stroke. She was continued on
aspirin and aggrenox 24 hours after TPA, and her atenolol was
held. She was ruled out for MI with two sets of troponins and
telemetry showed no events. Echo showed no source of embolism.
Carotid ultrasound showed no significant stenosis. She slowly
regained function and by the time of discharge back to her
[**Hospital3 **] facility she only had mild R sided weakness. PT
and OT evaluated her and felt her functioning to be adequate to
not require acute rehab or skilled nursing. For secondary stroke
prevention she was continued on her aggrenox and was started on
a baby aspirin that she should take for two weeks post stroke.
2) Hyperglycemia: Her fasting sugars were initially elevated on
presentation. She was kept on an insulin sliding scale and her
sugars were less than 150 during admission. If elevated in the
future, a hemoglobin A1C should be checked.
3) Hypertension - Her atenolol was initially held and can be
restarted approximately 1 week after the ischemic event.
4) Hypercholesterol - she was kept on Niaspan. She was started
on Zetia due to an LDL of 212, since her PCP reported that
statins had previously been ineffective for her. A statin could
be added to synergize with Zetia if her LDL is still not at goal
in [**3-18**] months. She should stay on a low cholesterol diet.
5) Peripheral vascular disease - Her trental was continued.
6) Dementia - Her reminyl was continued. The daughter expressed
concerns that this medication was not working and she was
instructed to discuss the continuation of this medication with
her mother's PCP.
Medications on Admission:
aggrenox
niaspan 500
atenolol
trental
reminyl
meclizine
tylelol
Discharge Medications:
1. Niacin 100 mg Tablet Sig: Five (5) Tablet PO qhs () as needed
for inc lipids.
Disp:*150 Tablet(s)* Refills:*3*
2. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q 24H (Every 24 Hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
3. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Dipyridamole-Aspirin 200-25 mg Capsule, Multiphasic Release
Sig: One (1) Cap PO BID (2 times a day).
Disp:*60 Cap(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) for 7 days.
Disp:*7 Tablet, Chewable(s)* Refills:*0*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
RESTART ATENOLOL 1 week after discharge.
Discharge Disposition:
Home With Service
Facility:
Halmark Health
Discharge Diagnosis:
Subacute infarct in L pons and corona radiata, chronic right
frontal cortical infarct.
Discharge Condition:
improved, with very mild R hand weakness.
Discharge Instructions:
please call Dr.[**Name (NI) 5255**] office at [**Telephone/Fax (1) 1694**] to make a follow
up appointment.
Can restart your atenolol in 1 week.
Continue aspirin for 1 more week, then can d/c.
Followup Instructions:
please call [**Telephone/Fax (1) 1694**] for follow up with Dr. [**Last Name (STitle) 1693**]. You need
to give your registration information to his scheduler.
ICD9 Codes: 2720, 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5149
} | Medical Text: Admission Date: [**2135-8-22**] Discharge Date: [**2135-8-28**]
Date of Birth: [**2087-5-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2135-8-24**] Coronary artery bypass grafting x4 with a left internal
mammary artery graft to the left anterior descending and reverse
saphenous vein graft to the ramus intermedius branch, first
diagonal branch, and left ventricular branch.
History of Present Illness:
This is a 48 year old male with a 4 week history of intermittent
chest pain. His anginal episodes would last approximately 20
minutes and resolve spontaneously. On the day of admission, he
experienced rest pain associated with left arm numbness. He
denied SOB, syncope, presyncope, nausea, vomiting and
diaphoresis. He sought medical attention at the [**Hospital1 18**]. While in
the EW, his chest pain was relieved with sublingual Nitro and
Morphine. His first set of cardiac enzymes were negative. He was
subsequently admitted for further evaluation and treatment.
Past Medical History:
Active smoker - 1ppd for 20 years
Hypercholesterolemia
History of spontaneous bilateral pneumothoraces - s/p
pleurodesis
Hemorrhoids
Polypectomy - [**2134-12-11**]
Social History:
Active smoker, 20 pack year history. Admits to several alcoholic
drinks per day. He works as a consultant. He lives with a male
partner.
Family History:
Unknown, patient adopted
Physical Exam:
Vitals: BP 110-130/70-90, HR 64-78, RR 18, SAT 98% RA
General: Well developed male in no acute distress
HEENT: Oropharynx benign
Neck: Supple, no JVD
Heart: REgular rate, normal s1s2, no murmur
LUngs: Clear bilaterally
Abd: Soft, nontender
Ext: Warm, no edema
Pulses: 2+ distally, no carotid/femoral bruits
Neuro: Nonfocal
Pertinent Results:
[**2135-8-28**] 04:55AM BLOOD Hct-28.4*
[**2135-8-27**] 05:24AM BLOOD WBC-12.5* RBC-2.79* Hgb-9.2* Hct-26.5*
MCV-95 MCH-33.0* MCHC-34.8 RDW-14.0 Plt Ct-187
[**2135-8-27**] 05:24AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-135
K-3.9 Cl-100 HCO3-26 AnGap-13
[**2135-8-27**] 05:24AM BLOOD Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 26581**] was admitted and ruled out for a myocardial
infarction. The following day, he underwent stress testing which
was notable for ischemic ECG changes with angina. Nuclear
imaging revealed severe and reversible anterior wall defects
extending from the apex to the mid chamber; and a moderate,
reversible defect in the inferior wall, most notable in the mid
chamber. There was global hypokinesis with apical akinesis.
There was ischemic dilatation with an end-diastolic volume of
177 ml. The left ventricular ejection fraction was 33%.
Subsequent cardiac catheterization showed a right dominant
system with severe three vessel disease. Left venriculography
showed a preserved ejection fraction of >60% with mild
anterolateral hypokinesis. Angiography showed that the LAD had a
long 90-99% stenosis after the first septal extending to the
origin of D2; the Ramus
had an ulcerated 60-70% plaque in its proximal segment; the
circumflex had an
ulcerated stenosis and was totally occluded after a large
collateral to
the RCA; the OMs were small and occluded; and the RCA was
occluded proximally and filled with L->R collaterals. Based on
the above results, cardiac surgery was consulted and further
evaluation was peroformed. Workup was essentially unremarkable
and he was cleared for surgery.
On [**2135-8-24**], Dr. [**Last Name (STitle) **] performed four vessel coronary artery
bypass grafting. Within 24 hours, he awoke neurologically intact
and was extubated without incident. He weaned from inotropic
support without difficulty. He was transfused with PRBC to
maintain hematocrit near 30%. He maintained stable hemodynamics
and transferred to the SDU on postoperative day two. Over
several days, medical therapy was optimized. He responded well
to Lasix and by discharge, was near his preoperative weight with
oxygen saturations over 90% on room air. He remained in a normal
sinus rhythm. The rest of his postoperative course was routine
and he was discharged to home on postopertive day four.
Medications on Admission:
None
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
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. 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*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Hypercholesterolemia
hemorrhoids
h/o spontaneous bilateral pneumothorax s/p pleurodiesis
Coronary artery disease - s/p CABG
Discharge Condition:
Stable
Discharge Instructions:
Shower, wash incision with soap and water and pat dry. No
lotions, creams, powders, or baths. Call with fever, redness or
drainage from incisions, or wieght gain more than 2 pounds in
one day ro five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks.
Dr. [**Last Name (STitle) 5781**] in 2 weeks.
Completed by:[**2135-9-28**]
ICD9 Codes: 4111, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5150
} | Medical Text: Admission Date: [**2187-3-26**] Discharge Date: [**2187-4-5**]
Date of Birth: [**2105-12-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
LLQ Pain and BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 y/o M w/ h/o AAA s/p repair, colon ca s/p sigmoidectomy,
diverticulitis, prostate cancer, and non-small cell lung cancer
p/w 4 days of LLQ pain. Patient states that for the past four
days he has had a band like abdominal pain across his lower
abdomen. On day of admission his home health aide noted bright
red blood in his stools and so patient referred to the ED.
.
In the ED, initial vs were: VS 97.8 106 129/83 18 100%. Patient
with BRB on DRE and mild LLQ pain (intermittent). HR improved
with 1L NS. CT A/P done in ED showed no acute abdominal
pathology c/w patient's symptoms. Patient was observed and had
one further episode of BRBPR in the ED prior to ICU transfer.
Repeat Hgb went from 10.9 on arrival to 8.2 (baseline Hgb
[**11-19**]).
.
On arrival to the ICU, patient comfortable with stable VS. On
further questioning, denies any recent f/c/n/v/ns/diarrhea/
constipation/weight gain or weight loss/chest pain/syncope or
other complaints. Denies melena.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Past Medical History:
1) Non Small Cell Lung Cancer: found during [**5-13**]
hospitalization, s/p LUL lobectomy [**2183-7-28**], complicated by left
recurrent laryngeal nerve palsy.
2) Abdominal Aorta Aneurysm: s/p repair [**5-13**]
3) Colon Carcinoma: s/p sigmoid colectomy [**2171**]
4) Prostate cancer: s/p radical prostatectomy [**2169**]
5) 3 vessel CAD w/ hx remote MI in [**2164**] - no stents
6) Hypercholestermia
7) h/o recurrent small bowel obstructions
8) Diverticulitis
9) HTN
10) Hypercholesterolemia
11) Squamous cell cancer of face surgically resected and getting
XRT.
Social History:
Lives alone but has a HHA/VNA. Son is nearby.
He has two children and seven grandchildren.
Previously he worked for the electric company as a street lamp
worker. Habits: 20 pack year smoking history, quit 20 years
ago. Quit alcohol 50 years ago, drank scotch "for a long time."
Denies any
other drug use. Not currently sexually active.
Family History:
His son is a diabetic. Brother died of myocardial infarction in
his 70s. He had a brother with a myocardial infarction in his
80s. His mother died of cardiogenic shock in her 80s. His father
also died from "heart problems."
Physical Exam:
On admission:
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:
Labs on Admission:
[**2187-3-26**] 06:25PM BLOOD WBC-8.2 RBC-3.30* Hgb-9.7* Hct-27.9*
MCV-84 MCH-29.2 MCHC-34.6 RDW-16.1* Plt Ct-203
[**2187-3-26**] 06:25PM BLOOD PT-13.1 PTT-22.8 INR(PT)-1.1
[**2187-3-27**] 12:29AM BLOOD WBC-7.0 RBC-3.34* Hgb-9.9* Hct-28.2*
MCV-84 MCH-29.6 MCHC-35.1* RDW-16.0* Plt Ct-145*
[**2187-3-27**] 12:40AM BLOOD Hct-26.2*
[**2187-3-27**] 09:41AM BLOOD Hct-27.9*
[**2187-3-26**] 06:25PM BLOOD Glucose-135* UreaN-28* Creat-1.2 Na-137
K-4.8 Cl-103 HCO3-21* AnGap-18
.
Imaging:
[**2187-3-26**] CT Abdomen/Pelvis
Impression:
1. Status post sigmoid colectomy and prostatectomy. No
small-bowel
obstruction. Moderate fecal load, limiting the evaluation of
intraluminal
colonic mass but no obstructing mass is noted. No colonic wall
thickening. No acute diverticulitis.
2. Right inguinal hernia with a loop of non-obstructed small
bowel.
Fat-containing left inguinal hernia.
3. Interval progression of T12 compression fracture since [**2183**]
with now
almost complete loss of vertebral height, but minimal
retropulsion into the spinal canal.
4. Stable left adrenal nodule. Cholelithiasis without acute
cholecystitis. Unchanged increased lung base interstitial
marking suggestive of pulmonary fibrosis.
5. Status post AAA repair with persistent thrombosed [**Female First Name (un) 899**].
6. If clinical concern remains high for colonic mass, recommend
followup with colonoscopy.
.
[**2187-3-27**] CXR
Cardiac size is top normal. There is no change in diffuse
emphysema and
peripheral reticular abnormality, left greater than right,
consistent with
pulmonary fibrosis. There is evidence of loss of volume in the
left lung
consistent with left upper lobe wedge resection. Mild increase
opacity of the left lower lobe is likely atelectasis. There is
no pneumothorax or pleural effusion. There are no new lung
abnormalities suggestive of pneumonia.
.
[**2187-3-28**]: colonoscopy: Diverticulosis of the whole colon. Large
amount of old blood and clots were seen throughout the colon,
but not in the terminal ileum. This is likely a right-sided
diverticular bleed. No active, ongoing bleeding at present.
Limited view of mucosa given extensive old blood.
Brief Hospital Course:
Acute blood loss anemia [**1-9**] GIB: The patient was initially
admitted to the MICU for a GI bleed. Serial hematocrits were
stable after receiving 2 units of PRBCs from [**3-26**]
(admission)-[**3-27**] and he was transitioned to the regular medical
floor. Pt was maintained with 2 large bore IVs, active type and
screen, consented and crossmatched. His home aspirin and
antihypertensives were held. GI was consulted and recommended
colonoscopy for the morning on [**2187-3-28**]. Colonoscopy showed
multiple diverticuli and bleeding (see above). Overnight on
[**5-3**] pt had 2 episodes large volume BRBPR with HR in 110s.
Pt recieved 2U of PRBCs and did not have further bleeding until
[**3-30**] when he started to have melanotic stools. His hematocrit
was trending down and he was transfused to a hematocrit of >28.
His melana resolved and GI felt an EGD would not be necessary at
this time. It was felt his melana was residual blood from his
previous bleed. In total pt recieved 6 [**Location 2984**] throughout
hospitalization.
# Dementia: continued namenda
# Hypertension: lisinopril and metoprolol were held. They were
held upon discharge as well and based on patient's outpatient
blood work and blood pressure readings, the decision should be
made in the outpatient to restart these medications.
# CAD: aspirin was held
# SC nodule: pt was noted to have a small subcutaneous nodule
very low in LLQ. Pt stated that it had been present for many
years (though pt is variable historian). Management deferred to
primary care provider.
# Prostate/Lung/Colon/Skin cancer: management deferred to outpt
providers.
# HLD: continued lipitor
Medications on Admission:
Lipitor 10mg daily
lisinopril 5mg daily
metoprolol 25mg [**Hospital1 **]
namenda 10mg [**Hospital1 **]
aspirin 81mg daily (started in last 3-4 weeks)
Discharge Medications:
1. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Outpatient Lab Work
Please check Hematocrit [**Last Name (LF) 2974**], [**4-6**] and send results to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**0-0-**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
primary: rectal bleeding
secondary: htn, hypercholesterolemia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted for bleeding for bloody bowel movements. You
had a colonoscopy which showed out-pouchings of your colon
(called diverticulosis) without active bleeding or polyps. The
bleeding initially probably came from one of those outpouchings
but we could not tell which one. After your colonoscopy, you
started having bleeding in your stool again. This time the
bleeding slowed down considerably. Your blood levels remained
stable. It was felt the minimal blood in your stool was residual
blood from your previous bleed. You should follow up with your
outpatient doctor for a re-check of your blood level.
You also had some difficulty with shortness of breath. A CT scan
was performed that did not show any acute concerning causes of
shortness of breath. This may be due to underlying lung disease.
Your oxygen levels were normal while walking. You should follow
up with your doctor for further managment.
When you go home please continue your home medications with the
following changes:
1. HOLD Lisinopril 5 daily
2. HOLD Metoprolol 25 mg [**Hospital1 **]
3. HOLD Aspirin 81 mg daily
****These two medications should be re-adjusted at your follow
up visit on [**Hospital1 766**]. Your blood pressure was not elevated and
with concern for bleeding, these were not re-started.***
4. START Protonix 40 mg twice a day. This will help decrease the
acid in your stomach.
It is important that you keep all of your doctor's appointments.
Followup Instructions:
You have the following appointment arranged for you:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Appointment: [**Last Name (LF) 766**], [**4-9**], at 3:00 PM at Location: CARDIOLOGY
ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
The GI doctors [**Name5 (PTitle) 2985**] they did not need to follow up with you. If
you ever need to see them in the future the number to call
Phone: [**Telephone/Fax (1) 2986**] . The doctor you saw in the hospital was
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**], MD.
ICD9 Codes: 2851, 4019, 412, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5151
} | Medical Text: Admission Date: [**2153-8-2**] Discharge Date: [**2153-8-22**]
Date of Birth: [**2095-10-27**] Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
male with no significant past medical history. He presented
with a three-day history of right upper quadrant and
intermittent at first and made better by food; however, he
had decreased appetite by the time of admission. He had
nausea with one episode of non-bloody vomiting after drinking
one cup of soup. He also complained of chest pain, but he
did not have any shortness of breath. He reported symptoms
of nausea and vomiting one month prior to admission; however,
at that time no intervention was taken. He has a primary
week.
He denied any orthopnea, paroxysmal nocturnal dyspnea, lower
extremity edema. He denied fevers or chills.
He denied melena, bright red blood per rectum, hematochezia,
or [**Doctor Last Name 352**] stool. He did report have report having dark urine.
He has decreased appetite.
He was initially sent to [**Hospital 8**] Hospital, but he was
transferred over here with an Amylase of 2660, total
bilirubin of 11, with a direct bilirubin of 7.7. Right upper
quadrant ultrasound showed two stones at the common bile duct
at 11 mm.
PAST MEDICAL HISTORY: He has no past significant medical
history or surgical history.
MEDICATIONS: Ranitidine 150 mg p.o. q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He is married with a daughter. [**Name (NI) **] works in
the trucking business. He reported smoking. Occasional
alcohol use. He denied any drug abuse.
PHYSICAL EXAMINATION: Vital signs: On admission temperature
was 98.8??????, blood pressure 143/77, heart rate 113,
respirations 35, oxygen saturation 97% on room air. General:
He was alert, awake, and oriented times three. He was in no
apparent distress. HEENT: He had icteric sclerae. Pupils
equal, round and reactive to light and accommodation. He had
no jugular venous distention. Pulmonary: Lungs had
decreased breath sounds at the bases. Cardiovascular: He
was tachycardiac. No murmurs, rubs or gallops. Abdomen:
Nondistended but tender to palpation diffusely, especially at
the midepigastric and right upper quadrant area. He had no
[**Doctor Last Name 515**] sign. Extremities: He had no clubbing, cyanosis or
edema. Neurological: The patient was alert, awake, and
oriented times three. Cranial nerves II-XII intact. No
motor or sensory deficits.
LABORATORY DATA: On admission white blood cell count 7.1,
hematocrit 42.5, platelet count 114,000; sodium 137,
potassium 4.3, chloride 99, bicarb 22, BUN 32, creatinine
1.9, glucose 115; neutrophils 37, lymphocytes 8, monocytes,
9, 6 bands; ALT 129, AST 77, alkaline phosphatase 191, total
bilirubin 6.7, amylase 858, lipase 937.
Chest x-ray was with poor inspiratory effort with left
hemidiaphragm, elevated and large amount of dilated loops of
bowel with gas. He had a right pleural effusion which was
moderate to large. Right upper quadrant ultrasound showed a
common bile duct of 7.3 mm, thickened gallbladder walls, no
fluid, two stones in the gallbladder, non-obstructing, with
an echogenic liver.
HOSPITAL COURSE: The patient was thought to have acute
pancreatitis possibly due to gallstones.
1. GI: The patient was thought to acute pancreatitis
possibly secondary to gallstones. He had an ERCP done in
which a large stone was found impacted in the distal common
bile duct. It was removed with along with a sphincterotomy.
His cystic duct was patent though. The biliary tree had
mild, diffuse dilatation. Before the procedure and after, he
was started on Ampicillin, Ciprofloxacin, and Metronidazole
for empiric coverage of possible cholangeitis. He was
continued NPO. He did have some postresidual distention of
his abdomen. KUB was consistent with ileus, but no
obstructions were visualized. He continued to have right
upper quadrant pain. He was given Demerol IM 50-75 mg. He
reported great relief with the Demerol.
Because of his ileus, and orogastric tube was inserted;
however, the patient had denied a nasogastric tube because of
previous deviated septum. He felt very uncomfortable
accepting a nasogastric tube. He was placed on Protonix. He
had not been able to tolerate clear sips. He was started on
TPN which continued until [**8-21**].
During this time, his LFTs had resolved to essentially
normal. He continued to have somewhat elevated amylase and
lipase but overall had a general decline. On discharge, his
amylase and lipase were still elevated. On [**8-14**], the
patient's white blood count increased from the mid teens to
19. His hematocrit was in the low 30s, so a CT was
performed. The CT did not show any evidence of bleeding. It
did show subphrenic collection of fluid. It also showed
bilateral pleural effusion. Radiology aspirated the
subphrenic collection draining approximately 30 ml. The
abdominal fluid did not grow any bacteria. During this time,
he was also started on Ampicillin, Levaquin, and
Metronidazole.
Past cultures returned back negative, and the antibiotics were
discontinued. He had one other event of
decreased hematocrit. It came back as 25, so a gastric
lavage was performed which was negative. Repeat hematocrit
was 29.6. The 25 hematocrit may have been a spurious value.
Repeat CT was again performed which showed similar subphrenic
fluid collection with bilateral pleural effusions. A repeat
CT was done because of increased pain after the aspiration of
his subphrenic collection. The CT was done to rule out any
source of bleed.
Surgery consult was also requested. Surgery did not feel
that surgical intervention was needed at this time; however,
they felt that after this episode had resolved, the patient
should be followed up in the Surgery Clinic for future
cholecystectomy. The patient was able to tolerate some clear
sips. His diet was advanced, and TPN was stopped. He now
leaves with an abdomen that is less distended, soft, with
normal bowel sounds. He has had bowel movements with the
encouragement of suppositories. He has not really had any
nausea or vomiting for much of his admission. His amylase
and lipase are still somewhat elevated. His ALT and AST are
within normal limits; however, his alkaline phosphatase,
amylase, and lipase remained somewhat elevated.
2. Pulmonary: The patient came in with a moderate to large
right pleural effusion. He also had left-sided pleural
effusions. He been intubated during the ERCP and was easily
extubated; however, he had increased oxygen requirements. He
had required face mask. He was given Lasix a few times. He
responded well to 10 mg IV Lasix. However, not much fluid
was taken off based on repeat chest x-rays. He had
complained of some chest pain but had no electrocardiogram
changes. After the thoracentesis procedure, he had some
right-sided chest pain and right flank pain. He became
tachypneic greater than usual at a rate in the 50s. An ABG
was done which showed respiratory alkalosis. No
electrocardiogram changes were noted. He was given Lasix and
had improved respirations. The patient has had right lateral
wall chest pain, particularly on movement, respirations,
coughing, or sneezing. Chest x-ray did not show any
pneumothorax. He is not in any respiratory distress and has
no shortness of breath. This was considered to be
postprocedural from reexpansion of the right lower lung.
Throughout the whole time, the patient never really
complained of any shortness of breath; however, he was always
somewhat tachypneic in the low 30s. He was also started on
Combivent and Albuterol/Atrovent nebulizers which had some
moderate affect. The tachypnea was thought to be due to 1)
atelectasis, 2) pleural effusions, 3) splinting from the
right upper quadrant abdominal pain after the CT, and he had
a subphrenic fluid collection which was thought to have
increase his abdominal pain and subsequently his shallow,
rapid respirations. He was eventually switched to nasal
cannula, and now he is on room air with oxygen saturations of
94%.
He has received one diagnostic thoracentesis and two attempts
at therapeutic thoracentesis; the second one removing a large
amount of fluid from the right lung. Chest x-rays after the
procedure did not reveal any pneumothorax. After the third
and final thoracentesis, the patient had a much more aerated
right lung. Repeat chest x-ray did show some right lower
lobe and possibly right middle lobe atelectasis.
3. Cardiovascular: The patient never really had an ischemic
event. He had an echocardiogram done which showed an
ejection fraction of 40%, and within the echocardiogram, he
had no gross evidence of abdominal cardiac function.
4. Renal: The patient had an elevated creatinine after the
ERCP which increased to 2.9; however, with hydration, the
patient's creatinine had decreased gradually. On discharge
it is 1.4, slightly increased from his 1.2 low. On admission
his creatinine had been 1.9.
5. Heme: The patient had a slowly drifting hematocrit. He
was transfused with 1 U of red blood cells once the
hematocrit had been recorded as 25, and he responded to the 1
U.
6. Pain: The patient had been controlled with Demerol
initially 50-75 mg IM; however, it was switched to 100 mg
Demerol and then finally converted to a PCA. When he was on
PCA, the patient required less pain medication. He was
converted to oral Dilaudid on [**8-21**] because of some right
flank pain. He required Dilaudid 4 mg almost every 6 hours;
however, he has decreased pain.
FOLLOW-UP: The patient will be seen by Surgery in two week,
[**9-11**], at 10:15 with Dr. [**Last Name (STitle) 34985**], at the [**Hospital6 1760**]. He will be considered for a
possible cholecystectomy. He will also be followed up with
his primary care physician either in [**Name9 (PRE) 8**] or with the
[**Hospital3 **] at [**Hospital6 256**]
where he will be assessed for his pleural effusions and
subphrenic fluid collection, pulmonary status, and resolution
of the gallstones, and pancreatitis.
DISCHARGE MEDICATIONS: Dilaudid 2-4 mg p.o. q.4 hours
p.r.n., Heparin 5000 U subcue b.i.d., Protonix 40 mg p.o.
q.d., Dulcolax 10 per rectum q.8 hours p.r.n., Combivent 2
puffs q.4 hours.
CONDITION ON DISCHARGE: The patient will be discharged to
[**Hospital **] [**Hospital **] Hospital.
DISCHARGE DIAGNOSIS: Gallstone pancreatitis.
DISCHARGE STATUS: The patient is stable.
[**Last Name (LF) **], [**Name8 (MD) **] M.D. [**MD Number(1) 9783**]
Dictated By:[**Name8 (MD) 4877**]
MEDQUIST36
D: [**2153-8-22**] 10:09
T: [**2153-8-22**] 11:41
JOB#: [**Job Number **]
[**Hospital3 **], [**Hospital1 34986**], [**Hospital1 8**], [**Numeric Identifier 34987**], phone
[**Telephone/Fax (1) 34988**](cclist)
ICD9 Codes: 5849, 5119, 5180, 2765, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5152
} | Medical Text: Admission Date: [**2160-1-28**] Discharge Date: [**2160-1-29**]
Date of Birth: Sex: F
Service: General Cardiology
NOTE: This dictation will cover the period from the point
that the patient was admitted to the point that the patient
was transferred to the Intensive Care Unit. Hence, it will
serve as a dictation from [**2160-1-28**] to [**2160-1-29**]. The rest will be dictated by the Medical Intensive
Care Unit house staff.
CHIEF COMPLAINT: The patient's chief complaint is chest pain
and shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female with a history of coronary artery disease, status post
coronary artery bypass graft (saphenous vein graft to left
anterior descending artery, saphenous vein graft to diagonal,
and second obtuse marginal to posterior descending artery) in
[**2152**], with a history of an abnormal MIBI studies times two,
status post abnormal MIBI in [**2159-9-3**] with moderate
reversible defect at the apex, septum, inferolateral wall.
She deferred catheterization on last admission in the setting
of flat enzymes and positive MIBI.
The patient now presents with shortness of breath that awoke
her this morning which has progressively worsened through the
morning. The patient has no chest pain. No fevers. No
chills. No nausea. No vomiting. No abdominal pain. No
dysuria. No melena. No swelling in the lower extremities.
At 6:45 a.m., she developed 8/10 chest pain which decreased
to [**6-12**] with three sublingual nitroglycerin and then [**3-12**]
status post 2 mg of morphine sulfate. She was started on
nitroglycerin drip in the Emergency Room. She was
guaiac-negative. She was started on a heparin drip. The
patient was then chest pain free. She states that otherwise
she has not had chest pain or shortness of breath since her
last admission. She states that she is able to do all of her
activities of daily living without difficulty.
On [**2159-9-24**], the patient had a Persantine MIBI with
a moderate reversible perfusion defect in the apex, septum,
inferolateral walls, and an ejection fraction at that time of
59%. She had apical hypokinesis new since MIBI in [**2157-9-3**]. An echocardiogram in [**2158-11-3**] revealed an
ejection fraction of 60%, nonobstructive focal hypertrophy of
the basal septum. No aortic stenosis. No aortic
regurgitation. Trivial mitral regurgitation. There was 1+
tricuspid regurgitation.
PAST MEDICAL HISTORY: (Otherwise, the patient's past medical
history is significant for)
1. Coronary artery disease; status post coronary artery
bypass graft with saphenous vein graft to left anterior
descending artery, saphenous vein graft to diagonal, and
second obtuse marginal to posterior descending artery in [**2142**]
with a recent abnormal stress MIBI (as mentioned above). The
patient is status post four catheterizations.
2. History of emphysema.
3. History of hypertension.
4. History of hyperlipidemia.
5. History of type 2 diabetes.
6. Status post corneal transplant.
7. History of diverticulosis.
8. Status post appendectomy.
9. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
10. Status post right lung lobe puncture in the setting of
catheterization (per patient).
MEDICATIONS ON ADMISSION:
1. Tylenol 325-mg tablets one tablet by mouth at hour of
sleep.
2. Isosorbide mononitrate 90 mg by mouth once per day.
3. Aspirin 325 mg by mouth once per day.
4. Lipitor 10 mg by mouth once per day.
5. Docusate 100 mg by mouth twice per day.
6. Metformin 500 mg by mouth twice per day.
7. Protonix 40 mg by mouth once per day.
8. Valium 5 mg by mouth as needed.
9. Ranitidine 150 mg by mouth twice per day.
10. Albuterol as needed.
11. Nasacort.
12. Plavix 75 mg by mouth once per day.
ALLERGIES: The patient's allergies are to SULFA.
FAMILY HISTORY: The patient's family history is significant
for diabetes, coronary artery disease, and myocardial
infarction in father.
SOCIAL HISTORY: Her social history is significant for the
fact that she lives alone in [**Location (un) **] housing. She is
divorced. She does all of her activities of daily living.
No ethanol. No tobacco.
CODE STATUS: She is a full code.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
her temperature was 96.3 degrees Fahrenheit, her heart rate
was 57, her blood pressure was 110/48, her respiratory rate
was 20, and her oxygen saturation was 97% on room air.
Generally, a very pleasant female in no acute distress. She
was alert and oriented times three. Head, eyes, ears, nose,
and throat examination revealed normocephalic and atraumatic.
The extraocular movements were intact. The oropharynx was
clear. The mucous membranes were moist. The neck was supple
with no jugular venous distention. There was no
lymphadenopathy. Cardiovascular examination revealed a
regular rhythm, bradycardic. No murmurs, rubs, or gallops
were noted. The lung examination revealed there were
bilateral bibasilar crackles. No wheezes or rales.
Otherwise, the lungs were clear. The abdomen was flat, soft,
nontender, and nondistended. Guaiac-negative. There were
good bowel sounds. Extremity examination revealed the
extremities were clear of any clubbing, cyanosis, or edema.
There were 2+ dorsalis pedis pulses. Bilaterally, the
patient groin was free of any bruits. Neurologic examination
revealed cranial nerves II through XII were intact. Strength
was [**5-7**] and symmetric. The toes were downgoing. The skin
was clean, dry, and intact. There were no lesions or rashes
were noted.
PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
admission laboratory data included a white blood cell count
of 4.8, her hematocrit was 40.5, and her platelet count was
91 (baseline 82 to 150). Differential revealed neutrophils
of 61 and lymphocytes of 26. Sodium was 138, potassium was
4.3, chloride was 100, bicarbonate was 30, blood urea
nitrogen was 26, creatinine was 1, and her blood glucose was
156. Her calcium was 9, her magnesium was 1, and her
phosphate was 4. Creatine kinase was 44. Troponin was less
than 0.01.
RADIOLOGY/IMAGING FINDINGS: A chest x-ray was significant
for mild tortuosity. The lungs were clear. Chronic scarring
of the right lung base. Scoliosis, status post median
sternotomy.
Electrocardiogram revealed a right bundle-branch block.
There was a sinus rhythm. There were ST depressions in V4
through V6. There was a normal axis.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
[**Hospital 228**] hospital course by issue/system was as follows.
1. CHEST PAIN ISSUES: The patient's first set of cardiac
enzymes were negative. She was continued on nitroglycerin as
well as heparin drip. The plan was that the patient would be
ruled out for a myocardial infarction.
Initially, the patient was resistant to have cardiac
catheterization. Hence, it was decided that the patient
would be medically managed. The patient did rule out for a
myocardial infarction.
On day two of admission, the patient agreed to a cardiac
catheterization which revealed the following. Left
ventriculography revealed no mitral regurgitation with an
left ventricular ejection fraction of 55%. Coronary
angiography revealed a right-dominant system. The left main
coronary artery with mild diffuse disease. The left
circumflex with serial 70% stenosis before grafted obtuse
marginal. The right coronary artery to mid PL filled by
left-to-right collaterals. The saphenous vein graft diagonal
to obtuse marginal was patent with 70% focal stenosis in
obtuse marginal limb. The saphenous vein graft to left
anterior descending artery had a 3-mm X 13-mm cypher stent
delivered to obtuse marginal.
Status post procedure, the patient was maintained on
Integrilin. Status post procedure, the patient was noted to
be hypotensive to 96/57. The patient underwent a computed
tomography scan to rule out a retroperitoneal bleed due to a
6-point hematocrit drop from 40 to 33. This computed
tomography scan revealed no retroperitoneal bleed. However,
the patient became agitated again and became hypotensive to
90/60 and then dropped to 70/50. The patient was transiently
placed on a dopamine drip. A second femoral line was placed.
The patient was taken to the Medical Intensive Care Unit.
2. CORONARY ARTERY DISEASE ISSUES: While on the Cardiology
floor, the patient was continued on aspirin, atenolol,
Lipitor, as well as a nitroglycerin drip.
3. GASTROINTESTINAL ISSUES: The patient was on a bowel
regimen and proton pump inhibitor.
4. EMPHYSEMA ISSUES: The patient was on albuterol and
Atrovent.
5. ANXIETY ISSUES: The patient was on Valium at hour of
sleep as needed.
6. DIABETES ISSUES: For diabetes, her metformin was held
and she was continued on a regular insulin sliding-scale and
four times per day fingerstick blood glucose checks. The
patient was nothing by mouth while she ruled out and was on
intravenous fluids.
7. CODE STATUS ISSUES: Her code status was full.
NOTE: For the rest of the [**Hospital 228**] hospital course by
system, please refer to the Medical Intensive Care Unit
discharge note.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**]
Dictated By:[**Last Name (NamePattern1) 5843**]
MEDQUIST36
D: [**2160-2-28**] 15:50
T: [**2160-3-1**] 07:09
JOB#: [**Job Number 98661**]
ICD9 Codes: 4111, 4280, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5153
} | Medical Text: Admission Date: [**2188-8-9**] Discharge Date: [**2188-8-21**]
Date of Birth: [**2119-10-6**] Sex: F
Service: SURGERY
Allergies:
PEPPERS
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2188-8-13**]
1. Diagnostic laparoscopy.
2. Lysis of adhesions.
3. Drainage of abscess.
History of Present Illness:
Pt is 68 y/o F with h/o atrial fibrillation who presents
with worsening lower abdominal pain for past week and a half.
Pt
did have diarrhea earlier in the week, but currently is feeling
constipated. No nausea/vomiting. Pt also denies fevers but is
having chills. Pt presented to [**Hospital1 18**]-[**Location (un) 620**] where she was
noted
to be hypotensive with BP in 80s and in atrial fibrillation. Pt
was resuscitated with 7L crystalloid prior to being transferred
to [**Hospital1 18**] ED. Last colonoscopy was more than 10 years ago. Pt
did have right breast lumpectomy for DCIS earlier in the week.
Past Medical History:
PMH:
- Chronic atrial fibrillation
- Hypertension.
PSH:
- Tonsillectomy.
- Appendectomy.
- D&C.
- Fibroid ablation.
-S/P Right breast lumpectomy for DCIS
-S/P Reexploration R breast for more tissue sampling
Social History:
No alcohol or tobacco.
lives with husband
Family History:
Aunt with breast cancer. Father with lung cancer. Brother with
prostate cancer.
Physical Exam:
Temp 97.8 P 120 BP 98/60 R 16 SaO2 98% RA
Gen: no acute distress
Heent: no scleral icterus
neck: supple
Lungs: clear
Heart: irregular rate and rhythm
abd: soft, nondistended, moderately tender in lower abdomen
rectal: no masses, guaiac negative
Extrem: no edema
Pertinent Results:
[**2188-8-9**] 03:35AM WBC-7.3 RBC-3.14*# HGB-8.7*# HCT-26.2*#
MCV-84 MCH-27.7 MCHC-33.2 RDW-14.5
[**2188-8-9**] 03:35AM NEUTS-79.7* BANDS-0 LYMPHS-15.2* MONOS-4.3
EOS-0.7 BASOS-0.2
[**2188-8-9**] 03:35AM PLT COUNT-279
[**2188-8-9**] 03:35AM GLUCOSE-128* UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12
[**2188-8-9**] CT Abd/pelvis :There is an irregular fluid collection in
the pelvis with fluid surrounding the sigmoid colon. The
findings are likely due to
perforated diverticulitis and abscess formation. The abscess
appears
multilocular about 7 cm in diameter.
[**2188-8-11**] CT Abd/pelvis :
1. Bilateral pleural effusions with associated compressive
atelectasis.
2. Some decrease in size of the main multiloculated pelvic fluid
collection secondary to perforated sigmoid diverticulum.Smaller
pockets of air and gas are seen surrounding the sigmoid colon.
Again, the collection is not amenable to transcutaneous
drainage.
Brief Hospital Course:
Mrs. [**Known lastname 97450**] was evaluated by the Acute Care team in the
Emergency Room and subsequently admitted to the SICU for further
management od her perfforated sigmoid diverticulitis as she was
hypotensive and in rapid atrial fibrillation. As she was fluid
resuscitated her heart rate and blood pressure returned to
[**Location 213**]. She maintained NPO, bowel rest and IV antibiotics as a
conservative treatment. Her WBC was rising and her pain was
controlled with narcotics.
Interventional Radiology was then consulted about drainage of
her pelvic abscess but felt the area was too difficult to reach.
A deciision was made to continue conservative treatment another
day to see if she improved. Unfortunately her WBC continued to
rise and her abdominal pain persisted. She was taken to the
Operating Room on [**2188-8-13**] and underwent an exploratory
laparotomy with lysis of adhesions and drainage of pelvic
abscess. She tolerated the procedure well and returned to the
SICU in stable condition. She did require reintubation after
arriving in the SICU as she was hypoventilating but was easily
extubated the following day.
Following transfer to the surgical floor on [**2188-8-15**] she
continued to make steady progress. She remained afebrile and
her WBC was normal. Her antibiotics were changed from IV Zosyn
and Vancomycin to oral Cipro and Flagyl on [**2188-8-18**].
Her creatinine was noted to be elevated to 1.4, she was given IV
fluid bolus and labs were re-checked. Her other electrolytes
were repleted as indicated. A renal ultrasound on [**2188-8-21**] showed
no obstruction. Her repeat Cr was 1.3 on [**8-21**] pm. She wished to
go home at this time and she was ready for discharge on [**8-21**],
with follow-up at [**Location (un) 620**]. Patient was ambulating, tolerating
diet at this time.
It was noted that her TSH was elevated (7.2) during her hospital
stay which she will need repeated as an outpatient during her
follow up with her PCP.
Medications on Admission:
aspirin 325 mg daily
Plavix 75 mg daily
albuterol 90 mcg 2 puffs q4h prn sob
fluticasone 220 mcg 2 puffs daily
hctz 25 mg daily
metoprolol 100 mg [**Hospital1 **]
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. metronidazole 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours): thru [**2188-8-27**].
Disp:*27 Tablet(s)* Refills:*0*
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): thru [**2188-8-27**].
Disp:*18 Tablet(s)* Refills:*0*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**2-3**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
5. metoprolol tartrate 50 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 DAILY (Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
1. Complicated diverticulitis with abscess
2. Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with abdominal pain due to a
small hole on your colon. You eventually required operative
drainage as bowel rest and antibiotics alone were ineffective.
* Currently you have improved and are able to tolerate a regular
diet and stay well hydrated.
* Your right abdominal drain remains in place and should be
emptied daily, noting the amount, color and consistency of the
drainage. Write the amounts down daily and bring this with you
to your next appointment.
* You also need to follow up with Dr. [**Last Name (STitle) **] from radiation
oncology. The treatments won't start right away but you will
meet with him on Friday and discuss a plan.
* If you develop any increased redness or drainage from your
abdominal drain OR if you have fevers > 101, more abdominal pain
or any new concerns please call your doctor or return to the
Emergency Room.
Followup Instructions:
Follow up with your primary care doctor within the next [**2-3**]
weeks for a general physcial and for re-checking your thyroid
function labs as your TSH was elevated during your hospital stay
along with your kidney function. You will need to call for an
appointment.
Dr. [**Last Name (STitle) **], radiation oncology [**Telephone/Fax (1) 9710**] Appointment Friday
[**2188-8-22**] at 9AM. [**Hospital Ward Name 516**], [**Hospital Ward Name 332**] basement
Wednesday, [**2188-8-27**] Radiology at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name8 (NamePattern2) **] [**Location (un) 33570**]
CT scan of abdomen and pelvis. Call them for a time.
Continue discharge antibiotics for 2 weeks. Follow-up at [**Hospital1 **] in
[**Location (un) 620**] for labs on Monday. Call to schedule time.
Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2188-9-1**] 11:45
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2188-8-21**]
ICD9 Codes: 5119, 5180, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5154
} | Medical Text: Admission Date: [**2194-12-8**] Discharge Date: [**2194-12-14**]
Date of Birth: [**2125-12-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2194-12-9**] Aortic valve replacement ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] Epic Porcine),
reduction aortoplasty
[**2194-12-8**] Cardiac Cath
History of Present Illness:
68 year old female with coronary artery disease status post
myocardial infraction with angioplasty in [**2175**] and known aortic
stenosis who has been followed by serial echocardiograms. Over
the past year, she has noted progressive dyspnea on exertion,
fatigue and mild peripheral edema. He most recent echocardiogram
revealed severe aortic stenosis with a mean gradient of 36mmHg.
Given the progression of her symptoms and the severity of her
aortic stenosis, she had been referred for surgical management.
Admitted today s/p cardiac catherization as preop for AVR with
Dr [**Last Name (STitle) **] in the morning.
Past Medical History:
Aortic stenosis
Coronary artery disease s/p angioplasty
Myocardial infarction [**2176-9-30**]
Hypertension
Dyslipidemia
Diabetes mellitus type 2
Pancreatitis [**2179**] developiong diabetes after
GERD
Anemia
Bilateral shoulder fractures (Left [**2191**], Right [**2192**])
Past Surgical History:
Cholecystectomy with drainage of pancreatic cyst
Incisional hernia repair [**2188**]
Ganglionic cyst of wrist surgical excised
Social History:
Race: Caucasian
Last Dental Exam: 6 months ago - clearance obtained.
Lives with: Alone, son and [**Name2 (NI) **] in law live upstairs in 2
family house (Husband recently passed away from pancreatic
cancer).
Occupation: Retired
Tobacco: Quit [**9-/2176**]. 48 year pack history
ETOH: Denies
Family History:
Sister with CABG at age 70. Uncle died of MI at age 21. Mother
with angina. Father with fatal MI at age 74.
Physical Exam:
Pulse: Resp:20 O2 sat: 97% RA
B/P Right:91/58 Left:
Height: 4'[**93**]" Weight: 181
General: AAO x 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] Distant breath sounds
Heart: RRR [x] Irregular [] Murmur III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Obese
Extremities: Warm [x], well-perfused [x] Edema - trace
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: Transmitted murmur vs bruit B/L
Pertinent Results:
[**2194-12-8**] Cardiac cath: 1. No angiographically-apparent
flow-limiting CAD. 2. Normal pulmonary capillary wedge pressure.
3. Mild pulmonary arterial hypertension. 4. Low normal systemic
systolic arterial pressure with occasional hypotension. 5.
Sheaths to be removed. 6. Additional plans per Dr. [**Last Name (STitle) **].
Admit to CSurg. 7. Reinforce primary preventative measures
against CAD. 8. Follow-up with Dr. [**Last Name (STitle) 39486**].
[**2194-12-8**] Carotid U/s: 1. No evidence of internal carotid artery
stenosis on either side. 2. Reversal of flow in the right
vertebral artery, which is usually associated with subclavian
steal.
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname 18654**] was admitted following her
cardiac cath and underwent pre-operative work-up. On [**2194-12-9**] she
was brought to the operating room where she underwent an aortic
valve replacement. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one beta blockers and diuretics were started and
she was diuresed towards her pre-op weight. Later on this day
she was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. During her post-op course she worked with physical
therapy. On post-op day five she appeared ready for discharge
home with VNA services and the appropriate medications and
follow-up appointments. She will take lasix for 2 weeks and then
resume her spirinolactone if instructed by Dr. [**Last Name (STitle) 39487**].
Medications on Admission:
Aspirin 81mg daily
Cardizem CD 240mg daily
Cozaar 50mg twice daily
Spirinolactone 25mg daily
Zocor 40mg daily
Zetia 10mg daily
Glucophage 1000mg twice daily
Humalog sliding scale 10-15 units TID
Lantus 50units daily
Amitriptyline 10mg daily
Calcium 600mg daily
Vitamin D 2000units daily
Multivitamins
Mobic 15mg daily
Omeprazole 20mg daily
Ativan 0.5 mg po QHS
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Mobic 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
13. insulin glargine 100 unit/mL Cartridge Sig: Please refer to
provided instruction sheet for daily dose and sliding scale
Subcutaneous As Instructed.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Past medical history:
Coronary artery disease s/p angioplasty
Myocardial infarction [**2176-9-30**]
Hypertension
Dyslipidemia
Diabetes mellitus type 2
Pancreatitis [**2179**] developiong diabetes after
Gastresophageal reflux disease
Anemia
Bilateral shoulder fractures (Left [**2191**], Right [**2192**])
Past Surgical History:
Cholecystectomy with drainage of pancreatic cyst
Incisional hernia repair [**2188**]
Ganglionic cyst of wrist surgical excised
Angioplasty [**2175**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: trace
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. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
6) No lifting more than 10 pounds for 10 weeks
7) Take lasix and potassium daily in the morning for 14 days
then stop. You may then resume your spirinolactone if instructed
by Dr. [**Last Name (STitle) 39488**].
8) You may resume your insulin sliding scale and night time
lantus 20 units. Please refer to dosage sheet provided.
9) 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
10_ You may resume your at home vitamins.
**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) **] [**1-8**] at 1:15pm
Cardiologist: Dr. [**First Name (STitle) 39489**] [**Name (STitle) 39488**] on [**1-9**] at 10:45am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**3-3**] 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:[**2194-12-14**]
ICD9 Codes: 4241, 5119, 4019, 2724, 4168, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5155
} | Medical Text: Admission Date: [**2138-3-15**] Discharge Date: [**2138-3-25**]
Date of Birth: [**2079-8-12**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Cryptogenic cirrhosis awaiting liver
transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
male with cryptogenic cirrhosis who presents to FAR10 which
is the 3rd time for preoperative evaluation for liver
transplant. He denies any fevers, cough, chills, nausea,
vomiting, diarrhea, headache, or urinary symptoms. He
finished his recent course of Valcyte.
PAST MEDICAL HISTORY: History of cirrhosis. History of
ascites encephalopathy. History of varices. Noninsulin
dependent diabetes. Hypertension. Sleep apnea. Lumbar disk
problems. History of left ankle fusion. Erectile dysfunction.
Undescended testicle on the right side. Esophageal varices
status post banding in [**2137-8-26**] and subsequent banding in
[**2137-11-26**]. History of chronic lower extremity edema,
right greater than left. Shortness of breath, baseline with 2-
3 L on nasal cannula at home, [**2-28**] pillow orthopnea.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Lactulose, losartan 50 mg daily,
Protonix 40 mg daily, Lantus 20 units, regular insulin
sliding scale, Lasix 80 mg b.i.d., Aldactone 100 mg daily,
Neoral 10 mg daily, Valcyte.
PHYSICAL EXAMINATION: Vital signs: The patient is afebrile,
vital signs stable. Weight 109 kg, 95% on 3 L. General:
Awake, alert and oriented x3. No acute distress. Fingersticks
are 121. Lungs: Decreased breath sounds at bases.
Cardiovascular: Regular rate and rhythm. Abdomen: Soft,
obese, nontender, nondistended, no ascites, guaiac negative.
Extremities: Bilateral venous stasis changes.
LABORATORY DATA: On admission WBC was 4.8, hematocrit 39.1,
platelet count 41; INR 1.5, PTT 37; sodium 134, 2.7, 105, 20,
15, 1.2, 111.
Chest x-ray from [**2138-3-8**], demonstrated no acute CP
processes. EKG from [**2138-3-8**], was normal sinus
rhythm at 65, no ST/T wave changes. Echocardiogram
demonstrated an ejection fraction of 60%. CT of the abdomen
and pelvis demonstrated cirrhosis, positive splenomegaly.
HOSPITAL COURSE: On [**2138-3-15**], the patient was
admitted for possible liver transplant surgery. The patient
was prepped preoperatively with routine medications prior to
admission for liver transplant surgery.
The patient went to the OR on [**2138-3-15**], where an
orthotopic liver transplant with a duct-a-duct biliary
reconstruction was performed by Drs. [**First Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 816**].
Two drains were placed; 1 drain was placed in the portal
space and another behind the liver. The abdomen was closed.
The skin was closed with staples. The patient was stable and
went to the ICU postoperatively. Please see the operative
note from [**2138-3-15**], for more details.
On postoperative day 1, the patient had a liver ultrasound
demonstrating patent portal and hepatic veins, main hepatic
artery was seen. The left and right branches were not
visualized on this technically limited study. A short
interval followup is recommended.
Labs on [**2138-3-16**], revealed a WBC of 10.3, hematocrit
29.4, platelets 119; sodium 145, 3.8, 102, 16, BUN and
creatinine of 19 and 1.1, glucose 217; LFTs included an ALT
of 786, AST 2072, alkaline phosphatase 88, amylase 59, total
bilirubin 5.3.
The patient was intubated and was receiving morphine for pain
management. He was weaned off the ventilator. He received
Unasyn, Bactrim, fluconazole and ganciclovir.
A bronchoscopy was performed on [**2138-3-17**], due to a
slow wean off the ventilator. The bronchoscopy revealed that
the patient had right lower lobe pneumonia. Cultures were
sent, and cultures reported that the patient Pseudomonas
aeruginosa from the bronchioalveolar lavage.
The patient received Lasix for continued diuresis. The
patient was placed on Bactrim, Zosyn, vancomycin and
fluconazole. The Zosyn and vancomycin was for the pneumonia.
Ultrasound was performed on [**2138-3-18**], to the liver
demonstrating the patent hepatic vasculature. On [**2138-3-18**], the patient was still intubated on assist-control. The
patient received diuresis. He was continued on antibiotics.
He was afebrile and bradycardiac.
The ET tube was changed over a catheter for incompetent
balloon. The patient was given multiple units of blood
products.
On [**2138-3-19**], tube feeds were started. Antibiotics
were changed, and levofloxacin was added for Pseudomonas. The
patient was intubated and sedate. Pupils were equal, round
and reactive to light. Lungs were coarse bilaterally. Abdomen
was soft. There was 1+ edema of the lower extremities. The
dressing was clean, dry and intact.
On [**2138-3-19**], his weight was slowly dropping. Labs
that day demonstrated a WBC of 2.7, hematocrit 31.5, platelet
count 36, sodium 142, 4.2, 102, 31, BUN and creatinine of 43
and 1.3, glucose 115. His AST decreased significantly to 800,
ALT 1603, alkaline phosphatase 82. Total bilirubin was 8.2.
INR was 1.8.
FK was started on [**2138-3-17**], and was slowly increased
in dose. On [**2138-3-19**], the patient had chest x-ray to
evaluate his pneumonia and ET tube manipulation demonstrating
that the right perihilar consolidation or edema is clearing
with lung essentially clear. No pleural effusions. Heart
normal size. Mediastinum is midline.
The patient was extubated and doing well. He was transferred
to the floor on [**2138-3-20**]. There the patient was
afebrile, vital signs stable, good input and output. Two JPs
with good output. The patient received physical therapy. Diet
was advanced.
On [**2138-3-22**], the patient had another chest x-ray
since the patient needed increase O2 requirement. The
impression stated that there was continued improvement of the
right infrahilar opacity. There were no signs of pleural
effusion, focal infiltrates or evidence of overt pulmonary
edema.
Since being on the floor, the patient has required from 2-4 L
of oxygen to keep an O2 saturation of 94%, but no exertional
shortness of breath witnessed.
The patient continued with physical therapy, Lasix, pulmonary
toilet and incentive spirometer. He was doing well. He was
walking around. He was voiding. He was eating well.
On [**2138-3-23**], on postoperative day 7, the patient
continued on fluconazole and Levaquin. The second JP drain
was removed. The patient continued on MMF, prednisone and FK.
Central line was removed on the 26th.
The patient was screened for rehab. On postoperative day 9,
the patient required a little bit more pain medication.
Dilaudid was increased to every q.3-4 hours. He was afebrile
with vital signs stable. Fingersticks have been relatively
high in the 200-300s. The patient has been on 2 L at 95% O2.
He had good input/output. He had bibasilar rales but non-
labored.
The patient otherwise is doing well status post liver
transplant complicated by Pseudomonal pneumonia, but the
patient is receiving pulmonary toilet. He is to have
levofloxacin x 10 days. The patient did receive chest x-ray
on [**2138-3-25**], demonstrating no significant interval
change in the lung parenchyma, no signs of pleural effusion
or overt pulmonary edema.
Physical therapy felt that the patient should go to rehab. A
bed is available on [**2138-3-25**]. The patient may be
going to rehab soon.
DISCHARGE MEDICATIONS: Fluconazole 400 mg q.24, Bactrim SS 1
tablet daily, Protonix 40 mg 1 tablet q.24 hours, Colace 100
mg b.i.d., Dilaudid 2 mg q.4-6 hours p.r.n., levofloxacin 500
mg tablet 1 q.24 hours discontinue after [**2138-3-30**],
prednisone 20 mg daily, Valcyte 900 daily, Lasix 20 mg
b.i.d., MMF 500 p.o. q.i.d., the patient will go on insulin
sliding scale, the patient will possibly be placed on
tacrolimus 3 mg b.i.d.
FOLLOW UP: The patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] on
[**2138-4-3**], at 10 a.m., also on [**2138-4-10**], at 8:40
a.m., and [**2138-4-17**], at 9 a.m.; please call [**Telephone/Fax (1) 673**]
if any changes need to be made for the appointment. He will
also be seeing Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], [**Telephone/Fax (1) 2422**], on [**2138-4-22**]. He will also be meeting with a GI group on [**2138-4-22**], at 10 a.m. The patient needs to call [**Telephone/Fax (1) 673**] for
any fevers, chills, nausea, vomiting, inability to take
medications, any redness, bleeding, pus from incision or
capped bile drain. The patient will labs every Monday and
Thursday for CBC, CHEM10, AST, ALT, alkaline phosphatase,
total bilirubin, albumin and Prograf trough level. Fax the
results to the transplant office.
Pathology results from [**2138-3-15**], demonstrated 1)
liver parenchyma with mild micro-macrovesicular status which
involves 10% of the liver parenchyma, 2) mild portal
mononuclear cell inflammation, nonspecific, 3) iron stain
demonstrated no increased stainable iron, 4) there was no
significant fibrosis seen on the trichrome stain, 5) on the
native liver, hepatectomy with established cirrhosis, 3
reactive lymph nodes, negative vascular biliary margins, no
fatty changes seen, chronic cholecystitis and cholelithiasis
and mild septal mononuclear cell inflammation.
Labs from [**2138-3-25**], demonstrated a WBC of 5.9,
hematocrit 37.2, platelets 52; UA from [**2138-3-24**], is
unremarkable; sodium 136, 3.5, 100, bicarb 31, BUN and
creatinine 16 and 1.0, glucose 123; ALT 162, AST 27, alkaline
phosphatase 173, total bilirubin 3.3; FK on [**2138-3-25**], was 12.8.
The patient may be able to go to rehab today depending on Dr.[**Name (NI) 42792**] decision.
FINAL DIAGNOSIS: End-stage liver disease with cryptogenic
cirrhosis, Type 2 diabetes, hypertension, OSA, and
Pseudomonas pneumonia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2138-3-25**] 14:24:34
T: [**2138-3-25**] 15:21:22
Job#: [**Job Number 57683**]
ICD9 Codes: 5185, 5715, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5156
} | Medical Text: Admission Date: [**2121-6-11**] Discharge Date: [**2121-6-17**]
Date of Birth: [**2065-1-9**] Sex: M
Service: Cardiothoracic
CHIEF COMPLAINT: This patient is a postoperative admit. He
was directly admitted to the operating room where he
underwent coronary artery bypass grafting.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1968**] is a 56-year-old
gentleman with known coronary artery disease and insulin
dependent diabetes mellitus, who had been previously admitted
in [**2121-5-11**] with chest pain, congestive heart failure and
ruled out for myocardial infarction at that time, but had a
positive exercise tolerance test and was brought to cardiac
catheterization during that admission. At that time his
catheterization showed normal left main, left anterior
descending coronary artery 95% occluded, circumflex coronary
artery 70% occluded, obtuse marginal #1 70% occluded, right
coronary artery 70% occluded, no left ventriculogram was done
at that time due to an elevated creatinine, however his
ejection fraction by echocardiogram at that time was 40-45%.
PAST MEDICAL HISTORY: 1. Diabetes mellitus with associated
neuropathy. 2. Hypertension. 3. Hypercholesterolemia. 4.
Chronic renal insufficiency with a baseline creatinine of 2.1
to 2.5. 5. Congestive heart failure. 6. Anemia. 7.
Bilateral claudication. 8. Peripheral vascular disease.
PAST SURGICAL HISTORY: 1. Right fifth metatarsal resection.
2. Tonsillectomy. 3. Left eye vitrectomy. 4. Bilateral
laser surgery to both eyes.
ALLERGIES: Sulfa, ampicillin and codeine, all of which make
him nauseated.
MEDICATIONS DURING LAST ADMISSION: 1. Zestril 40 mg q.d. 2.
Lasix 40 mg q.d. 3. Norvasc 10 mg q.d. 4. Coreg 6.25 mg
b.i.d. 5. Glipizide 10 mg b.i.d. 6. Digoxin 0.125 mg q.d.
7. Lipitor 40 mg q.d. 8. Aspirin 81 mg q.d. 9. Pepcid AC no
dose or frequency provided. 10. Insulin 70/30, 21 units in
the AM and Lente 19 units in the PM. 11. IV Natrecor. 12.
Epoetin 5,000 units subcutaneous q. Saturday. 13. Vitamin
B12 1,000 mcg q. day.
LABORATORY DATA: On his last admission white count was 7.9,
hematocrit 34.4, platelet count 211, sodium 140, potassium
4.4, chloride 104, CO2 25, BUN 41, creatinine 2.3, glucose
191. EKG was sinus rhythm with a rate of 88, ST wave changes
laterally.
PHYSICAL EXAMINATION: Heart rate 80 and sinus rhythm, blood
pressure 168/69, respiratory rate 18, oxygen saturation 97%
on room air. Lungs: Clear to auscultation bilaterally.
Cardiac: Regular rate and rhythm, S1 and S2 with a 2/6
systolic ejection murmur. Abdomen: Soft, nontender,
nondistended, no hepatosplenomegaly, positive bowel sounds.
Pulses: Radial 2+ on the right, 1+ on the left; femoral 2+
bilaterally; dorsalis pedis 1+ bilaterally; posterior tibial
2+ bilaterally. Extremities: Well perfused, no clubbing,
cyanosis or edema, no varicosities. Neurological: Pupils
equally round and reactive to light. Extraocular movements
intact. Cranial nerves II-XII were grossly intact.
HOSPITAL COURSE: As stated previously, on [**6-11**] the patient
was a direct admission to the operating room at which time he
underwent coronary artery bypass grafting. Please see the
operating room report for full details. In summary, the
patient had a coronary artery bypass grafting x 4 with a left
internal mammary artery to the left anterior descending
coronary artery, saphenous vein graft to the posterior
descending coronary artery, saphenous vein graft to obtuse
marginal #1 and obtuse marginal #2 sequentially. His bypass
time was 127 minutes with a cross-clamp time of 112 minutes.
He tolerated the operation well and was transferred from the
operating room to the cardiothoracic intensive care unit. At
the time of transfer the patient's mean arterial pressure was
76. He was in sinus rhythm at 95 beats per minute. He had
dobutamine at 5 mcg per kg per minute, Neo-Synephrine at 0.3
mcg per kg per minute and propofol at 10 mcg per kg per
minute.
The patient did well in the immediate postoperative period.
He was noted however to have a mixed metabolic respiratory
acidosis. His ventilator was manipulated until the acidosis
corrected itself. Once the acidosis corrected itself the
patient's anesthesia was reversed and he was successfully
weaned from the ventilator and extubated. On the first
postoperative day the patient remained hemodynamically
stable. He was weaned from his dobutamine drip and was
scheduled to be transferred to the floor, however check of
his electrolytes prior to transfer revealed a rising
creatinine as well as some hyperkalemia. The patient was
treated with Kayexalate and was kept in the intensive care
unit to monitor his renal status. Additionally a renal
consultation was called on the patient. Given his tenuous
renal status the patient stayed in the intensive care unit
for an additional three days waiting for his creatinine to
plateau.
On postoperative day four the patient's creatinine was back
down to his baseline, and on postoperative day five he was
transferred to [**4-11**] for continuing postoperative care and
cardiac rehabilitation.
Over the next two days the patient's activity level was
increased with the assistance of the nursing staff and
physical therapy. On postoperative day six it was decided
that the patient was stable and ready to be discharged to
home.
At the time of discharge the patient's physical examination
was as follows: Vital signs were temperature 98.2, heart
rate 75 and sinus rhythm, blood pressure 122/76, respiratory
rate 18, oxygen saturation 95% on room air. Weight
preoperatively was 107.9 kg, at discharge 113.6 kg.
Laboratory data was white count 8.0, hematocrit 27.4,
platelet count 248, sodium 140, potassium 3.8, chloride 102,
CO2 26, BUN 50, creatinine 2.3, glucose 117. Physical
examination was alert and oriented x 3, moving all
extremities, followed commands. Lungs had diminished distant
breath sounds, no rales appreciated. Cardiac was regular
rate and rhythm, S1 and S2. Sternum was stable. The
incision with Steri-Strips was open to air, clean and dry.
The abdomen was soft, nontender, nondistended with normal
active bowel sounds. Extremities were warm, well perfused,
[**12-12**]+ edema bilaterally.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Atorvastatin 40 mg q.d.
3. Glipizide 10 mg b.i.d.
4. Protonix 40 mg q.d.
5. Furosemide 40 mg q.d.
6. Norvasc 10 mg q.d.
7. Multivitamin 1 q.d.
8. Metoprolol 50 mg b.i.d.
9. Insulin 70/30, 10 units q.a.m. and Lente 10 units q.p.m.
10. Dilaudid 2-4 mg q. 4-6 hours p.r.n.
11. Regular Insulin sliding scale q. 6 hours as needed.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting x 4 with left internal mammary artery to the left
anterior descending coronary artery, saphenous vein graft to
posterior descending coronary artery, saphenous vein graft to
obtuse marginal #1 and obtuse marginal #2 sequentially.
2. Hypertension.
3. Hypercholesterolemia.
4. Chronic renal insufficiency.
5. Congestive heart failure.
6. Anemia.
7. Diabetes mellitus with associated neuropathy.
8. Status post right fifth metatarsal resection.
9. Status post tonsillectomy.
10. Status post left eye vitrectomy.
11. Status post bilateral laser surgery of the eye.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Discharged to home with services.
FOLLOW UP: He is to be seen in the wound clinic in two
weeks; to be seen in Dr.[**Name (NI) 18056**] office in three to four
weeks; and to be seen by his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2121-6-17**] 11:47
T: [**2121-6-17**] 12:01
JOB#: [**Job Number 18057**]
ICD9 Codes: 5849, 4280, 2767, 2762, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5157
} | Medical Text: Admission Date: [**2163-7-20**] Discharge Date: [**2163-8-9**]
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 89-year-old
female, with a history of atrial fibrillation, coronary
artery disease, who underwent colonoscopy on [**2163-5-10**]
which showed a large cecal mass. Biopsies revealed well-
differentiated adenocarcinoma for which she was admitted on
[**2163-7-20**] for right hemicolectomy.
PAST MEDICAL HISTORY: Sick sinus syndrome.
Coronary artery disease.
Atrial fibrillation.
Hypertension.
Osteoporosis.
PREADMISSION MEDICATIONS:
1. Fosamax.
2. Lasix.
3. Lisinopril.
4. Lopressor.
5. Digoxin.
6. Prozac.
7. Amiodarone.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient has never smoked cigarettes.
She lives in the [**Hospital3 **] Center secondary to an
inability to take care of herself. She is retired. She has
a large family. She is Russian speaking.
HOSPITAL COURSE: The patient was admitted on [**2163-7-20**].
She was taken directly to the operating room where an
epidural was placed in an attempt to avoid general
anesthesia, secondary to the patient's high respiratory and
cardiac risk. The patient tolerated the procedure with
minimal blood loss.
Postoperatively, the patient was eventually mildly
hypotensive secondary to hypovolemia and was bolused fluid.
She was also given a unit of packed red blood cells due to
postoperative anemia complicating preexisting anemia. She
was also treated for hypokalemia. She received serial Crit's
to insure that the patient was not bleeding significantly.
The patient was monitored cautiously during the resuscitative
period, and evaluated for congestive heart failure, despite
the fact that her EF was greater than 55 percent,
particularly because of O2 saturations in the low-90's,
although this was not an initial finding on chest x-ray. The
patient received aggressive chest physical therapy, as well
as received a rule out for myocardial infarction, which was
confirmed negative by enzymes.
On the night of postoperative day 4, the patient experienced
a decrease in O2 saturation, satting only in the 70 percent
range on a nonrebreather after nebulizer treatments. The
patient received a chest x-ray which showed bilateral
pulmonary edema. She had bilateral wheezes and rales, right
side greater than left. Her ABG showed both a respiratory,
as well as metabolic acidosis.
The patient was transferred to the ICU for closer monitoring
and treatment. The patient had a triple-lumen subclavian
catheter inserted while in the unit. The patient was
intubated and placed on a ventilation system, was given Lasix
as needed, and received serial ABG's. She was made NPO, and
a G-tube was placed. A right A-line was also placed for
closer monitoring. The patient spiked a temperature to
103.8, which prompted a fever work-up including UA, urine
culture, sputum culture, and blood culture. The patient was
placed on Zosyn for a question of pneumonia. While in the
unit, despite the fact that the patient had pulmonary edema,
as well as a question of pneumonia, it was also decided that
the patient had a component of acute respiratory distress
syndrome.
The patient also experienced issues with atrial fibrillation
which required an increase in Lopressor treatment. She
eventually had a feeding tube placed to initiate tube feeds.
Over time, cultures came back with coag-negative staph in 1
blood culture, and E. coli in the urine. The patient was
continued on Zosyn, but also placed on vancomycin.
The patient was finally successfully extubated on the [**7-31**]. Her diuresis was continued aggressively to pull
fluid off. After extensive treatment with Lasix, the patient
developed a metabolic alkalosis, and for that reason was
placed on Diamox, both to aid with diuresis and with
correction of her metabolic alkalosis.
On the 3, the patient underwent a speech and swallow study
which she failed, and for that reason was left NPO, and left
on aggressive tube feed treatment. On the 3, it was
confirmed that one of the patient's blood cultures was
confirmed with Enterococcus, and the patient was started on
linezolid. She had experienced another decrease in oxygen
saturation, requiring nonrebreather mask and increased
pulmonary toilet. The patient also experienced increase in
confusion at that time. She received Haldol, as well as
continued persistence with fever/infection work-up.
On the 5, the patient had a beside swallow reattempted which
she failed. On the night of the 8, the patient was
transferred to the Vascular ICU to continue a closer eye on
her, but because she did not need the super close attention
of the regular ICU. While in the VICU, the patient continued
to flourish, and her respiratory status improving. She
reached her baseline preoperative weight, and her Lasix was
stopped. She did not require persistent replacement of
potassium and magnesium for hypokalemia and hypomagnesemia.
The patient continued to tolerate her tube feeds well. It is
now [**2163-8-9**], and the patient will be discharged as soon as
a bed is available at [**Hospital 100**] Rehab. The patient is in good
condition. She will be discharged with a Dobbhoff in place
and on tube feeds at 40 cc/h, and in 1 week will require a
swallow study. If, at that time, she is able to swallow, the
tube feeds can be DC'd, and the patient placed on a diet.
She does require physical therapy, for which the patient was
started on in house, but will need continued therapy as the
days go on.
DISCHARGE MEDICATIONS:
1. All the patient's antibiotics are being DC'd with the
exception of linezolid which she will be required to
complete a 10-day course of.
2. She will be discharged on Tylenol prn for pain.
3. Albuterol nebs 1 neb q 4 h.
4. Amiodarone 400 mg po bid.
5. Heparin 5,000 U subcu tid.
6. Insulin sliding scale.
7. Atrovent 1 neb q 6 h.
8. Lopressor 50 mg po tid.
9. Miconazole powder 1 application tid prn.
10.Nystatin oral suspension 5 ml po qid prn.
11.Prevacid 30 mg per Dobbhoff qd.
FOLLOW UP: She is to follow-up with Dr. [**Last Name (STitle) **] in [**12-31**]
weeks. She is to have her speech and swallow in
approximately 1 week. She should follow-up with her primary
care physician in approximately 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2163-8-9**] 10:24:38
T: [**2163-8-9**] 11:11:26
Job#: [**Job Number 94628**]
ICD9 Codes: 2851, 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5158
} | Medical Text: Admission Date: [**2155-11-14**] Discharge Date: [**2155-11-27**]
Date of Birth: [**2102-5-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
acute alcoholic hepatitis
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
This is a 53 year old female with a hx of alcoholism and binge
drinking since her teenage years who presents with liver
failure. She initially presented to [**Hospital1 34**] from [**10-31**] to [**11-4**] with
jaundice, and found to have a Bili of 30 and an INR of 2.3.
During that admission she also developed mild ARF, Cr. to 1.4,
but it improved to 1.1 at the time of discharge. She was also
noted to have a leukocytosis of 16.7 but only small ascites on
ultrasound, not tapped. She was evaluated for other forms of
liver disease which was negative, including negative hepatitis
viral serologies, negative [**Doctor First Name **], and a ceruloplasmin of 29. It
was thought to be alcoholic hepatitis and she was started on
40mg PO steroids starting [**11-1**]. She was seen in follow up by
Dr. [**Last Name (STitle) 31823**], GI, and she was feeling "miserable" with decreased
PO intake. On labs drawn then, her bili had worsened to 41 and
her creatinine was 2.2 with a BUN of 47. She also had a worsened
WBC count to 29K. She was readmitted to [**Hospital1 34**], given IVF with no
improvement in her renal function and poor UOP. She is
transferred to [**Hospital1 18**] for further evaluation and treatment of
hepatorenal syndrome. She underwent an abdominal ultrasound
prior to transfer with marking for paracentesis but did not get
a paracentesis.
.
The patient states that her last drink was 4 weeks ago. On
admission she had c/o mild abdominal discomfort and fullness.
She has also experienced dypnea on exertion while moving to the
bathroom. Patient had emotional breakdown on the floor. She
wanted to go home. She was found to be sinus tachycardia to
110s. Her oxygen saturation dropped to 88% in RA from 92-93%
and came upto 92% on 3LNC. Liver team wanted her to be
monitored closely and requested ICU transfer.
.
On arrival to the MICU her vitals were T 99.4 Hr 110 BP 101/53
RR 24 92% 3LNC. She states that she feels calmer. Deneis any
chest pain, shorntess of breath, palpitations, HA, visual
changes, cough, diarrhea, constipations, f/c, rash, focal
weakness or numbness. No other complaints.
Past Medical History:
Alcoholism
Liver disease
Prolapsed bladder
Depression
Social History:
Married with children. Very heavy drinker until recently but has
trouble quantifying currently. Denies IVDU
Family History:
NC
Physical Exam:
VS: T 99.4 Hr 110 BP 101/53 RR 24 92% 3LNC.
Gen: NAD, icteric
HEENT: NCAT, EOMI, PERRL. Icteric sclera. OP clear, MMM.
Neck: difficult to assess JVP given prominent carotids, no LAD
Heart: tachycardic, regular rhythm, no m/r/g
Lungs: Bibasilar crackles right greater than left
Abd: soft +BS, distended, +fluid wave, non-tender
Extrem: 1+ BLE edema, DP 2+
Skin: very jaundiced
Neuro: CN II-XII in tact bilaterally. Strength is [**4-7**] in upper
and lower extremities and sensation is intact bilaterally. No
tremor/asterixis.
Pertinent Results:
[**2155-11-15**] 10:05AM BLOOD WBC-11.4* RBC-2.74* Hgb-9.9* Hct-27.7*
MCV-101* MCH-36.2* MCHC-35.9* RDW-18.1* Plt Ct-54*
[**2155-11-15**] 10:05AM BLOOD Neuts-94.8* Lymphs-2.8* Monos-2.0 Eos-0.4
Baso-0
[**2155-11-15**] 10:05AM BLOOD PT-23.6* PTT-55.5* INR(PT)-2.3*
[**2155-11-15**] 10:05AM BLOOD Glucose-75 UreaN-60* Creat-2.4* Na-135
K-3.7 Cl-105 HCO3-13* AnGap-21*
[**2155-11-15**] 10:05AM BLOOD ALT-134* AST-198* LD(LDH)-290*
AlkPhos-117 Amylase-104* TotBili-40.6*
[**2155-11-26**] 04:05AM BLOOD ALT-85* AST-122* LD(LDH)-201 AlkPhos-91
TotBili-32.6*
[**2155-11-15**] 10:05AM BLOOD Albumin-3.6 Calcium-7.4* Phos-4.8*
Mg-2.7* Iron-48 Cholest-56
[**2155-11-15**] 10:05AM BLOOD calTIBC-47* Ferritn-1446* TRF-36*
[**2155-11-15**] 10:05AM BLOOD Triglyc-144 HDL-11 CHOL/HD-5.1 LDLcalc-16
[**2155-11-15**] 10:05AM BLOOD CEA-5.8* AFP-1.8
[**2155-11-15**] 10:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2155-11-15**] 10:05AM BLOOD AMA-NEGATIVE
[**2155-11-15**] 10:05AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2155-11-15**] 10:05AM BLOOD IgG-979 IgA-316 IgM-188
[**2155-11-15**] 10:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-11-15**] 10:05AM BLOOD HCV Ab-NEGATIVE
[**2155-11-18**] 04:47PM BLOOD Lactate-2.4* K-2.9*
[**2155-11-15**] 10:05AM BLOOD CA [**65**]-9 -Test
[**2155-11-15**] 10:05AM BLOOD CERULOPLASMIN-Test
[**2155-11-20**] 05:10AM BLOOD HEREDITARY HEMOCHROMATOSIS MUTATION
ANALYSIS-Test
.
Brief Hospital Course:
53 year old female with hx of alcoholism admitted to MICU with
hepatic and renal failure.
.
# Hepatic failure: Her hepatic failure was secondary to
alcoholic hepatitis/cirrhosis. She was followed by liver team.
Patient was treated for spontaneous bacterial peritonitis and
hospital acquired pneumonia with vancomycin and zosyn. She also
received albumin, octreotide and midodrine for hepatorenal
syndrome. During her course of hospital stay, her mental status
progressively worsened and required intubation in order to give
her lactulose and other necessary medications. Patient also
developed pneumonia most likely secondary to aspiration. Goals
of care were discussed with the family as her clinical condition
worsened. Decision was made to make the patient's status
comfort measures only as she was not a transplant candidate
currently due to recent alcholol intake. Patient passed away on
[**2155-11-27**].
.
# Respiratory Failure: Tachypnea on admission. [**2155-11-17**] V/Q scan
not suspecious for pulmonary emboli. Lower extremity non
invasive sutidies did not show evidence of deep venous
thrombosis. Intubated on [**11-21**] for worsening mental status,
underlying multifocal pneumonia and tachypnea, with large amount
of aspirate surrounding vocal cords. She had worsening metabolic
acidosis which also played a role in her ventilation, as is
apparent on her ABGs. Sputum samples only showed oropharyngeal
flora. Antibiotics and goals of care as above.
.
# Acute renal failure: Renal function worsened during admission,
likely secondary to hepatorenal syndrome. Lasix initially then
pressors did not improved her urine output, and hemodialysis was
not an option that would have improved her outcome in the
long-term. Her electrolytes were repleated carefully given her
renal failure.
.
# Metabolic acidosis: Secondary to renal failure.
.
#Mental Status ?????? Patient initialy with evidence of waxing/[**Doctor Last Name 688**]
levels of consciousness with clear confusion in presence of
liver failure suggestive of hepatic encephalopathy. Subsequently
she was intubated and sedated. When sedation was decreased, she
was increasingly confused and agitated as her condition
worsened.
.
# Anemia: Had been Stable 24-26. Stool brown, guaiac negative.
Patient had no prior endoscopies to document varices. She was
not actively bleeding during the hospital stay.
.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
ICD9 Codes: 5849, 5070, 2762, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5159
} | Medical Text: Admission Date: [**2182-8-29**] Discharge Date: [**2182-9-20**]
Date of Birth: [**2124-3-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine / Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
s/p Mitral Valve Replacement(#27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical)[**9-5**]
s/p Cardiac [**Month/Year (2) **] [**8-30**]
History of Present Illness:
58 yo F with PMH of CAD s/p PCI x3 presents with chest and left
arm discomfort, along with SOB, for the past 1 week.
Past Medical History:
Coronary Artery Disease s/p Multiple PCI's (stent LAD [**2171**], [**Year (4 digits) **]
[**2179**], [**2182**])
Congestive Heart Failure
Hypertension
Hypercholesterolemia
Fibromyalgia
Chronic Obstructive Pulmonary Disease
Asthma
Chronic Renal Insufficiency(1.3)
Lower back pain
Hiatal hernia
PSH:
Ectopicx2 in [**2155**],79
Social History:
50 pack year h/o smoking (quit in [**2179**])
does not drink alcohol
Family History:
not contributory
Physical Exam:
Afebrile, HR 80, BP 140/52 RR 22 5'3" 126kg
Gen: Sleepy but arousable, AAOx3
HEENT: no lymphadenopathy, no carotid bruits
Neck: JVP around [**8-21**] cms
Heart: S1 S2, RRR, 3/6 SEM
Lungs: BS w/ rales 1/2 up
Abd: soft/NT/ND, BS+
Ext: 1+ edema, warm, well-perfused
Neuro: no focal deficits, MAE
Pertinent Results:
TTE [**8-30**]: Severe mitral regurgitation with probably rheumatic
mitral valve disease. Moderate to severe pulmonary artery
systolic hypertension. Left ventricular cavity enlargement with
regional dysfunction c/w CAD
[**Month/Year (2) **] [**8-30**]: 1. One vessel coronary artery disease.2. Severe
diastolic ventricular dysfunction.3. Moderate precapilary
pulmonary hypertension.4. Successful deployment of a Cypher
drug-eluting stent in the distal RCA
Carotid U/S [**9-4**]: Moderate plaque with bilateral 40-59% carotid
stenosis. Of note, both of the stenoses will fall into the lower
end of the range.
[**2182-8-29**] 04:30PM BLOOD WBC-13.2* RBC-4.62 Hgb-11.8* Hct-36.5
MCV-79* MCH-25.5* MCHC-32.2 RDW-16.4* Plt Ct-390
[**2182-9-4**] 07:50AM BLOOD WBC-12.3* RBC-4.52 Hgb-11.8* Hct-36.4
MCV-81* MCH-26.1* MCHC-32.4 RDW-17.3* Plt Ct-352
[**2182-9-12**] 01:23AM BLOOD WBC-19.0* RBC-3.78* Hgb-10.0* Hct-30.8*
MCV-82 MCH-26.4* MCHC-32.4 RDW-18.6* Plt Ct-354
[**2182-9-19**] 06:21AM BLOOD WBC-12.8* RBC-3.11* Hgb-8.4* Hct-26.9*
MCV-87 MCH-27.0 MCHC-31.2 RDW-20.6* Plt Ct-508*
[**2182-8-30**] 01:00AM BLOOD PT-13.9* PTT-45.1* INR(PT)-1.3
[**2182-9-13**] 02:24AM BLOOD PT-27.6* PTT-39.4* INR(PT)-5.0
[**2182-9-20**] 12:30AM BLOOD PT-17.3* PTT-54.8* INR(PT)-2.0
[**2182-8-29**] 04:30PM BLOOD Glucose-120* UreaN-26* Creat-1.3* Na-141
K-4.1 Cl-100 HCO3-27 AnGap-18
[**2182-9-19**] 06:21AM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-138
K-3.7 Cl-100 HCO3-29 AnGap-13
[**2182-9-14**] 08:49AM BLOOD ALT-178* AST-96* LD(LDH)-516*
AlkPhos-127* Amylase-66 TotBili-1.7*
[**2182-9-18**] 05:37PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018
[**2182-9-18**] 05:37PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2182-9-18**] 05:37PM URINE RBC-[**12-1**]* WBC-[**3-16**] Bacteri-MOD Yeast-NONE
Epi-[**6-21**]
Brief Hospital Course:
Pt. was admitted on [**8-29**] and then underwent both a Cardiac Echo
and [**Month/Year (2) **] on [**8-30**]. The Echo revealed severe MR [**First Name (Titles) **] [**Last Name (Titles) **] showed 1
vessel CAD and a stent was placed in the distal RCA. Cardiac
surgery was consulted following these procedures for
replacement/repair of her mitral valve. But pt needed to be
aggressively diuresed before surgery d/t CHF (pt was SOB and
fluid overloaded-Edema & bilat pleural effusions). Please see
medical records for CXR reports. She continued to be followed by
us along with medicine and cardiology (see notes in medical
records). PT. underwent a carotid u/s on [**9-4**] along with a
dental consult and was cleared for surgery pending her WBC(12).
On [**9-5**] pt was brought to the operating room where she underwent
a mitral valve replacement with a mechanical valve. She
tolerated the procedure well with no complications. Please see
op note for surgical details. She was transferred to CSRU in
stable condition on a Propofol gtt. Later on op day pt was
weaned from mechanical ventilation and propofol and was
extubated. She was MAE, following commandes, and A&O. On POD #1
pt appeared somewhat hypoxic w/ CXR showing CHF. Albuterol MDI,
along with Diuresis, Oxygen via face tent and NC was started.
Heparin was being given and Coumadin would be started later that
night until target INR/PT/PTT was reached. POD #2 pt was stable
and being diuresed with increased pulmonary toilet. Chest tubes
and Swan-Ganz catheter were removed. On POD #3 Levofolx was
started for increased WBC and yellow sputum. Sputum was
cultered. She also received a blood transfusion b/c HCT was 24.
Pt. remained in the CSRU until POD #12 and was then transferred
to step-down unit. During that time (POD #[**4-23**]) she continued to
have pulm symptoms and required aggressive pulm toilet w/ high
flow oxygen. Pt. was encouraged to get OOB and ambulate.
Pulmonary eventually was consulted. Also during this time pt's
heart rhythm went into atrial flutter (EP followed pt).
Amiodarone and Verapamil were started. Pt. also experienced a
rise in her WBC while in the CSRU, multiple cultures were
performed and appropriate antibiotics coverage was given. From
POD #13 to 15 her oxygen was slowly weaned down. Also during
here entire post-op period her Coumadin and Heparin were
adjusted to reach a goal INR of 2.5 to 3 d/t her mechanical
valve. Physical therapy followed pt during post-op period as
well. She was transferred to rehab on POD #15 in stable
condition and will have her INR followed and coumadin adjusted
until goal is reached. She will also make appropriate f/u's with
physicians.
Medications on Admission:
1. Atenolol 50mg qd
2. Plavix 75mg qd
3. Protonix 40mg qd
4. Lasix 40mg [**Hospital1 **]
5. ASA 325mg qd
6. Folic Acid
7. KCL
8. Lipitor 40mg qd
9. Nitro
10. Atrovent
11. Flovent
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks: Then 200mg qd for 1 month.
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2)
Inhalation twice a day.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Warfarin Sodium 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): to maintain target INR 2.5-3.
15. Lasix 40 mg Tablet Sig: 1.5 Tablets PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Mitral Regurgitation S/P Mitral Valve Replacement(#27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
mechanical)[**9-5**]
PMH:Coronary Artery Disease s/p Multiple PCI's
Congestive Heart Failure
Hypertension
Hypercholesterolemia
Fibromyalgia
Chronic Obstructive Pulmonary Disease
Asthma
Chronic Renal Insufficiency(1.3)
Lower back pain
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
Take all of your medications as directed.
Please seek medical attention immediately if you feel any chest
pain, shortness of breath, or any otehr concerning symptoms.
Do not lift more than 10 pounds for 2 months.
Do not drive for 1 month.
Can take shower. Wash incision with warm water and gentle soap.
Gently pat dry. Do not take bath or go swimming.
Do not apply lotions, creams, ointments or powders to incision.
Followup Instructions:
Dr. [**Last Name (STitle) 48108**] 2-3 weeks.
Dr. [**Last Name (STitle) **] in 4 weeks.
Completed by:[**2182-9-20**]
ICD9 Codes: 4111, 9971, 4019, 2724, 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5160
} | Medical Text: Admission Date: [**2145-12-20**] Discharge Date: [**2145-12-24**]
Date of Birth: [**2087-12-9**] Sex: F
Service: MEDICINE
Allergies:
Zanaflex
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Chief complaint: Hypotension post-TIPS revision, after transfer
from OSH ([**Hospital3 17162**]) with shortness of breath, refractory
ascites
Major Surgical or Invasive Procedure:
TIPS revision, paracentesis x 2
History of Present Illness:
History of Present Illness
Ms. [**Known lastname **] is a 58 yo woman with a history of HCV cirrhosis s/p
TIPS [**3-5**] who presents with increased abdominal distension.
.
She previously had refractory ascites in early [**2145**], and
underwent placement of TIPS for this reason. She was then doing
well and was without significant ascites on aldactone. Lasix was
added [**11-4**] for some edema. Subsequently her ascites continued to
worsen. She was getting therapeutic paracentesis with removal of
[**7-4**] L each time every two weeks. US [**11-18**] showed increased
velocity in the TIPS.
.
She was recently admitted to [**Hospital3 **] [**Date range (1) 40579**] with
increasing SOB, received 60 mg lasix underwent removal of 10 L
of ascitic fluid, with resolution of SOB. Creatinine at that
time on admission was 1.8. She had an ultrasound with Doppler
[**12-12**] showing increased flow in the TIPS.
.
She was doing well until [**12-18**] when she presented for routine
labs and was found to have renal failure beyond her baseline
(creatinine 2.0 elevated from recent b/l 1.5) and hyperkalemia
to 5.4 with peaked T waves. She received kayexalate, insulin,
bicarb, D50 and was admitted. Diuretics were held. Because of
concern for TIPS occlusion, she was transferred to [**Hospital1 18**] for
possible revision.
.
On acceptance to the medicine team, she complains of epigastric
pain, worse with lying and accompanied by a sour taste. She
denies fevers, chills, change in bowel movements or blood in BM
(baseline 4 BM/day on lactulose). Also no chest pain or
shortness of breath. No urinary symptoms.
.
Upon admission to [**Hospital1 18**], plan was to proceed with TIPS revision.
The day of admission to the MICU, she underwent TIPS revision
and had a 6L paracentesis. Intraoperatively you way hypotensive
to SBP 70s, treated with 1L 5% albumin and neo gtt without
complication. [**Name (NI) **], pt again became hypotensive to
the 70s, asymmptomatic and resolve with 50g 25% albumin and
500cc NS. In total in [**Name (NI) 13042**], pt received 1400cc NS, 800cc
Bicarb/D5W and 200cc of 25% albumin. EBL 147ml.
.
Upon transfer to MICU, patient confirms story as above. States
she's had some mild abdominal pain.
.
Past Medical History:
PAST MEDICAL HISTORY:
# ESLD secondary to HCV cirrhosis
- Hep C dxed [**2126**], unknown exposure: no hx transfusion, IVDU,
tatoo placed after hep C diagnosis
- genotype IA, treated with multiple courses of interferon
unsuccessfully
- bx [**2140**] stage 3-4 fibrosis
- hx encephalopathy,
- grade 3 varices banded [**3-5**]. No history of variceal bleeding.
+ history of hemorrhoidal bleeding.
- hx refractory ascites, s/p TIPS [**2145-3-19**], revised [**8-3**] after
presenting with recurrent ascites
- on transplant list
# Renal insufficiency, baseline creatinine 1.5 per OSH records
but previously has bumped to >2
# Diastolic CHF
# Asthma
# Depression
# Anxiety
# GERD
# IDDM
# Seizure disorder
# Hypertension
# OSA
# Refractory nausea - controlled with reglan - ? gastroparesis
# s/p CCY
# h/o Asthma - stable
# Pancytopenia - related to ESLD
.
Social History:
From [**Male First Name (un) **] and visited recently. ? past h/o IVDU. Denies
tobacco, EtOH, or current recreational drug use.
Family History:
Family History: no family history of liver disease
Physical Exam:
Admission PE:
T 96.1 89, 100/58, 23, 99/RA
Gen: no apparent distress, appears well
HEENT/NECK: could not visualize JVP, supple, oropharynx clear,
sclera anicteric
Cor: regular, 2/6 systolic murmur heard best at the left upper
sternal border
Pulm: lungs clear bilaterally except fine bibasilar crackles
posteriorly
Abd: Distended, soft, nontender. + shifting dullness. No
rebound, no guarding.
Ext: trace pitting edema bilaterally, warm
Neuro: A&O x 3, appropriate, coherent historian, no asterixis.
Pertinent Results:
EKG [**12-20**]: Normal sinus rhythm at 87 bpm. Normal axis, normal
intervals. No evidence of ischemia.
.
Admission Labs:
[**2145-12-21**] 03:40AM BLOOD WBC-4.3 RBC-2.91* Hgb-10.3* Hct-28.5*
MCV-98 MCH-35.6* MCHC-36.2* RDW-14.1 Plt Ct-88*
[**2145-12-21**] 03:40AM BLOOD Neuts-72.3* Lymphs-15.6* Monos-8.4
Eos-3.2 Baso-0.6
[**2145-12-21**] 03:40AM BLOOD PT-14.6* PTT-32.8 INR(PT)-1.3*
[**2145-12-21**] 03:40AM BLOOD Plt Ct-88*
[**2145-12-21**] 03:40AM BLOOD Glucose-173* UreaN-35* Creat-1.7* Na-126*
K-4.2 Cl-95* HCO3-25 AnGap-10
[**2145-12-21**] 03:40AM BLOOD ALT-24 AST-39 LD(LDH)-246 AlkPhos-393*
TotBili-4.9*
[**2145-12-21**] 03:40AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.8 Mg-2.1
.
Labs prior to discharge:
[**2145-12-24**] 06:15AM BLOOD WBC-2.7* RBC-2.43* Hgb-9.1* Hct-23.8*
MCV-98 MCH-37.3* MCHC-38.0* RDW-14.5 Plt Ct-66*
[**2145-12-24**] 06:15AM BLOOD Glucose-125* UreaN-35* Creat-1.5* Na-129*
K-4.1 Cl-97 HCO3-25 AnGap-11
[**2145-12-24**] 06:15AM BLOOD ALT-17 AST-33 AlkPhos-229* TotBili-5.4*
.
Micro:
[**2145-12-21**] URINE CULTURE (Final [**2145-12-22**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
Radographic studies:
.
LIVER OR GALLBLADDER US [**12-21**] (to evaluate TIPs)
IMPRESSION:
1. Patent TIPS with velocities of 100 to 180 cm/s.
2. There is a lack of wall-to-wall flow in the mid to distal
TIPS, suggestive
of neo-intimal hyperplasia.
3. Interval increase in the amount of ascites since the prior
exam.
4. Splenomegaly.
Brief Hospital Course:
A 57 yo woman with HCV cirrhosis s/p TIPS is transferred from
OSH with refractory ascites for consideration of TIPS revision.
.
# Ascites: The patient had large ascites on exam but was not
uncomfortable. Last therapeutic tap had been [**12-13**]. Ultrasound
showed lack of wall-to-wall flow in the mid to distal TIPS,
suggestive of neo-intimal hyperplasia. Given the history of
apparent improvement in ascites after placement and subsequently
after revision of TIPS, she underwent TIPS revision with 10 mm
balloon and improved flow. Follow-up US two days later showed
patent tips. Paracentesis of 6 L was done at the time of
revision, and an additional 11.25 liters were taken off two days
later, with albumin replacement each time. Diuretics were held
for elevated creatinine. PPI was continued for reflux symptoms
likely secondary to ascites.
.
# Hypotension: Intraoperatively while under general anesthesia,
patient was hypotensive with SBP 70s. This continued in the
[**Month/Year (2) 13042**] post-operatively. Initial hypotension likely related to
anesthesia and fluid shift from large volume paracentesis. She
was transferred briefly to the MICU, where blood pressure
returned to baseline SBP 90s with IVF and albumin.
.
# Acute renal failure: Creatinine at OSH was increased from
baseline 1.5 to 2.0. On admission, creatinine was 1.7. Diuretics
were held. Urinary sodium was <10, consistent with prerenal vs
HRS. She was given albumin at the time of paracentesis, and
creatinine trended down to 1.5 prior to discharge. She was
discharged off all diuretics with plans for lab tests in 3 days
to monitor kidney function given that she had large volume
paracentesis on the day of discharge.
.
# UTI: She had had a recent E Coli treated with Bactrim at an
outside hospital. UA and cultures here were negative.
.
# Hyponatremia: Sodium was near baseline. She was asymptomatic.
.
# DM: Lantus was continued at home dose; she was given regular
insulin as needed.
.
# Pancytopenia: Hematocrit and platelets were at baseline.
.
# Depression/Anxiety. Mirtazapine and trazadone were continued.
.
# Seizure disorder: Carbamazepine was continued.
.
Medications on Admission:
- Potassium 20mEq PO daily
- Spironolactone 200mg PO daily
- Lactulose 30ml PO QID, titrated to [**2-28**] BM daily
- Rifaximin 400 mg PO TID
- Metoclopramide 10mg QACHS
- Lasix 40mg daily
- Clotrimazole
- Levaquin 250mg daily (for E. coli UTI, subseq R to levoflox)
- Protonix 40mg daily
- Mirtazapine 15mg PO HS
- Lantus 26 units SubQ
- Carbamazepine 200 mg QAM, 400 mg QPM
- Ibuprofen PRN pain
- Folic acid 1mg daily
- Dulcolax 1 tablet PO Q12H
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Lantus
26 units qhs
7. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
8. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day) as needed.
11. Outpatient Lab Work
Please do chemistry panel including creatinine, CBC, and LFTs.
Please fax results to: [**Telephone/Fax (1) 697**] ATTN: Dr. [**Last Name (STitle) 497**].
Discharge Disposition:
Home
Discharge Diagnosis:
primary: cirrhosis
secondary: renal insufficiency, diastolic congestive heart
failure, type 2 diabetes
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you needed to have
your TIPS revised. You had the TIPS revised and fluid taken out
of your abdomen.
The following medications were changed in the hospital:
spironolactone, lasix, levaquin, and potassium were stopped
.
Please have your labs checked next Monday, [**12-27**] with the
attached prescription.
.
Please call your doctor or return to the hospital if you have
chest pain or shortnes of breath, increasing abdominal girth,
fevers and chills, or other symptoms that are concerning to you.
Followup Instructions:
Please have your labs checked on Monday, [**12-27**] with the
attached prescription.
.
You will need to have follow-up TIPS surveillance in [**7-4**] weeks.
Dr. [**Last Name (STitle) 497**] can arrange this.
.
You have an appointment for an ultrasound and then at the
[**Hospital 20871**] clinic:
ULTRASOUND Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-1-12**] 1:45
TRANSPLANT [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-1-12**] 3:20
Completed by:[**2145-12-25**]
ICD9 Codes: 5849, 5990, 2761, 5715, 4280, 5859, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5161
} | Medical Text: Unit No: [**Numeric Identifier 69025**]
Admission Date: [**2168-10-25**]
Discharge Date: [**2168-10-27**]
Date of Birth: [**2168-10-25**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 69026**] is a 4.175
kg product of a term gestation, born to a 38 year-old,
Gravida III, Para II woman. Prenatal screens 0 positive,
antibody negative, hepatitis surface antigen negative. RPR
nonreactive. Rubella immune. GBS negative. Pregnancy
history: Reportedly benign. Mother presented in spontaneous
labor. No maternal fever, no prolonged rupture of membranes.
Clear amniotic fluid. Maternal anesthesia by epidural.
Vaginal delivery. Loose nuchal cord x1. Apgars were 9 and 9.
NICU called to inspect infant at 30 minutes of life for
grunting, flaring and retracting. On initial exam, decreased
breath sounds on the right chest. Taken to NICU for further
management.
PHYSICAL EXAMINATION: On admission, birth weight was 4.175
kg. Length was 53.3 cm. Head circumference was 34 cm. Radiant
warmer, under oxygen [**Doctor Last Name **] for N2 wash-out. Pink, remarkably
comfortable appearing. No grunting, flaring and retracting
noted. Non dysmorphic. Anterior fontanel soft and flat. Red
reflex deferred. Ears: Normal set without anomalies. Intact
palate. Neck supple with intact clavicles. Cardiovascular:
Regular rate and rhythm. No murmur, non displaced PMI, good
peripheral pulses. Lungs clear to apex with audible breath
sounds now bilaterally. Abdomen soft. Positive bowel sounds.
Normal male. Testes down bilaterally. Patent anus. No sacral
anomalies. Extremities pink and well perfused.
HOSPITAL COURSE: Respiratory: X-ray on admission
demonstrated bilateral pneumothoraces. Infant placed on
oxygen [**Doctor Last Name **] for nitrogen wash-out of 100%. Blood gas on oxy-
[**Doctor Last Name **] was pH of 7.37, PC02 of 42, P02 of 125. Infant weaned
out of oxygen [**Doctor Last Name **] by midnight on [**10-25**] and is currently
stable in room air. Most recent CXR shows resolution of air
leaks. Persistent increased opacity most likely represents
unresolved atelectasis although congenital malformation is
possible.
Cardiovascular: Has been cardiovascularly stable throughout
hospital course with typical rates 120 to 160s.
Fluids, electrolytes and nutrition: Birth weight was 4.175
kg. Discharge weight is . Infant was initially feeding 50 cc
per kg per day of D-10-W. Enteral feedings were initiated on
day of life 1 and infant is currently ad lib feeding, taking
in adequate amounts. Infant has been euglycemic throughout
hospital course.
Gastrointestinal: No issues.
Hematology: Hematocrit on admission was 48.4. Infant did not
require any blood transfusions.
Infectious disease: CBC and blood culture obtained on
admission. CBC was benign. White blood cell count of 19.7;
platelet count of 244. 72 polys, 0 bands. Infant received 48
hours of Ampicillin and Gentamycin, at which time they were
discontinued and blood cultures remained negative. Neuro:
Infant has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated
auditory brain stem responses and the infant.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 2270**] [**Last Name (NamePattern1) 59017**], MD, telephone
number [**Telephone/Fax (1) 51263**].
RECOMMENDATIONS: Feeds at discharge: Continue ad lib breast
feeding.
Medications: Non applicable.
Car seat position screening test: Not applicable.
State newborn screens were sent as per protocol and have been
within normal limits.
Immunizations received:
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES:
1. Moderate respiratory distress.
2. Rule out sepsis with antibiotics.
3. Bilateral Pneumothoraces/pneumediastinum.
4. Would repeat CXR in [**1-11**] months to verify normality of lung
fields in order to rulle ourt congenital lung malformation.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 60288**]
MEDQUIST36
D: [**2168-10-26**] 22:09:33
T: [**2168-10-27**] 05:09:44
Job#: [**Job Number 69027**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5162
} | Medical Text: Admission Date: [**2200-4-6**] Discharge Date: [**2200-4-19**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
male with history of diabetes, hypertension,
hypercholesterolemia, CAD, ventricular tachycardia, status
post implantable defibrillator with newly diagnosed right
upper lobe [**Hospital **] transferred from [**Hospital6 2561**] for
right main stem bronchus stent for recurrent ex vacuo
effusion, status post thoracentesis times three. The patient
was admitted to [**Hospital3 **] on [**2200-2-17**], with
ventricular tachycardia following a motor vehicle accident.
An implantable defibrillator was placed at that time. He was
then readmitted on [**2200-3-26**], for a recurrent pleural
effusion, for which he received a pigtail catheter and
consideration of possible pleurodesis. However, he was not a
candidate for pleurodesis secondary to the pleural effusion
ex vacuo. Thus CT surgery placed a chest tube, which was
accidentally pulled out by the patient during movement on
[**2200-3-30**]. On [**2200-4-4**], the patient became
acutely short of breath with drop in sense requiring non-
rebreather. Further decompensation occurred while the
patient was transferred to the CCU and he ultimately required
emergent intubation. Pre-intubation gas 7.42/41/79. The
patient's blood pressure decreased following intubation
requiring IV fluids and Neo-Synephrine. The patient was
transferred to [**Hospital1 18**] for a right main stem bronchus shunt to
hopefully resolve his pleural effusion ex vacuo, which was
thought to be secondary to right lobar collapse secondary to
his obstruction.
PAST MEDICAL HISTORY: Diabetes, hypertension, CAD status
post MI in [**2197**], status post LAD stent, catheterization in
[**2194**] showed three-vessel disease with 50 percent narrowing of
the LAD, 30 percent narrowing of the proximal SARC and 60
percent narrowing of the marginal branch. Echo in [**2198-11-18**], showed an EF of 50 percent, mild MR [**First Name (Titles) **] [**Last Name (Titles) **]; and a
normal pulmonary artery pressure, history of ventricular
tachycardia status post implantable defibrillator, right
upper lobe mass diagnosed as squamous cell carcinoma, no
endobronchial disease on bronchoscopy done at [**Hospital1 336**] (status
post pleuracentesis, fluid was non malignant, MRI revealed
mediastinal involvement, thus the patient was considered non-
resectable; status post 12 radiation treatments in addition
to a course of Paxil and carboplatin), hypercholesterolemia,
and history of atrial fibrillation, taken off Coumadin four
weeks ago.
MEDICATIONS:
1. Avandia 4 mg p.o. q.p.m.
2. Lipitor 20 mg p.o. q.p.m.
3. Trazodone 50 mg p.o. q.h.s.
4. Megace 100 mg p.o. q.d.
5. Amiodarone 200 mg p.o. q.d.
6. Lopressor 25 mg p.o. b.i.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Brother was deceased in his 50s secondary to
lung cancer with positive history of tobacco, multiple
members with early CAD.
SOCIAL HISTORY: The patient is positive tobacco, 0.5 packs
per day times 50 years, no alcohol, and worked as a fish
cutter in the past.
PHYSICAL EXAMINATION: Temperature is 97.2, blood pressure
72/25 with a CVP of four, and heart rate of 65. The patient
is on AC with a tidal volume of 600 and respiratory rate of
14, with a PIP of 5, FIO2 of 60 percent, with an O2
saturation of 95 percent. ABG was 7.43/31/75. In general,
the patient is intubated, sedated in no apparent distress.
Skin, no rash. HEENT, pupils are equally round and reactive
to light and accommodation. Sclerae anicteric.
Cardiovascular, bradycardia with regular rhythm, no murmurs,
rubs, or gallops. Pulmonary, coarse breath sounds on the
left, poor air movement on the right. Abdomen, normoactive
bowel sounds, soft, nontender, nondistended, no masses or
hepatosplenomegaly. Extremities, 1 to 2 plus pitting edema
in the upper extremities, left greater than the right, no
clubbing or cyanosis. Neurologically, alert, follows
commands, strength 4/4 bilaterally in the upper and lower
extremities, 1 plus reflexes bilaterally.
LABORATORY DATA AND DIAGNOSTICS: White count is 3.9,
hematocrit 32.2, platelets 88 with 86 percent neutrophils, 12
percents lymphocytes, and 2 percent monocytes. Sodium is
136, potassium 4.5, bicarbonate 20, BUN 59, creatinine 1.7,
and lactate 1.2. EKG, paced at 66 beats per minute, left
bundle branch block, questionable new T-wave inversion in V5-
V6. Chest x-ray, right upper lobe collapse, positive
atelectasis/wide-out of the remainder of the right lung.
HOSPITAL COURSE: This is a 75-year-old male with a history
of diabetes, hypertension, hypercholesterolemia, CAD status
post MI and LAD stent, ventricular tachycardia status post
defibrillator, transferred from [**Hospital6 2561**] for
right main stem bronchus stent for obstructing right lung
mass, diagnosed as squamous cell carcinoma complicated by an
ex vacuo pleural effusion.
Right lung mass. The patient presents with a diagnosis of
non-small cell lung cancer identified as stage 3B squamous
carcinoma with mediastinal involvement by MRI with a non-
malignant ex vacuo pleural effusion and associated lung
collapse, status post 12 radiation treatments and a course of
Paxil and carboplatin. Plan for an initial right main stem
bronchus stent, however, bronchoscopy revealed multiple
endobronchial lesions, thus be more appropriate treatment was
thought to be photodynamic therapy. The patient was
activated with photodynamic therapy on [**2200-4-10**]. He
required three subsequent bronchoscopies for removal of
debridement from the right main stem bronchus.
Unfortunately, his lung did not re-expand following this
intervention and the patient passed before any significant
recovery could occur. During his hospital stay, hematology-
oncology was consulted to discuss further management as
daughter looking to shift care to [**Hospital1 18**]. Discussion
initially was made of further chemotherapy. Radiation
oncology was consulted and felt no further radiation was
indicated as the patient has progressed through 12 treatments
of radiation. However, the patient, as stated earlier,
passed before recovery from his immediate ailment.
Right pleural effusion ex vacuo. The patient presented with
a right chest tube in place. The chest tube remained water
sealed. Our hope was that this chest tube could be removed
following the re-expansion of his lungs after intervention to
open up his right main stem bronchus. Unfortunately, his
lung did not re-expand and the chest tube remained in place
at the time of his death.
Respiratory failure. Due to the patient's obstructing mass
leading to a pleural effusion ex vacuo, the patient suffered
hypoxic respiratory failure. At the outside hospital, a
chest tube was placed. It was accidentally dislodged, but
ultimately required replacement as the patient had
respiratory decompensation. He was transferred, intubated on
assist control. He was tried on pressor-support during the
course of his ICU stay. However, he was unable to be weaned
from the ventilator.
Hypotension. The patient presented with blood pressure of
72/25 with a CVP of four on peripheral Neo-Synephrine. His
hypotension was initially thought to be due to decreased pre-
loads secondary to increased inter-chest pressures from his
pleural effusion ex vacuo and positive pressure ventilation.
His cortisol was found to be within normal limits. His blood
pressure did respond to p.r.n. fluid boluses. He was
maintained on Neo-Synephrine. During the course of his stay
Vasopressin was added to further support his blood pressures.
The patient's condition began to decompensate. During this
hospital stay, the patient became septic from likely
pulmonary source and required increasing amounts of pressors
for support. He ceased to respond to IV fluid boluses and
pressor-support was thought to be maximized. The patient was
maintained on all these medications till the time of his
death.
Cardiovascular.
Ischemia. The patient's beta-blocker was held due to his
hypotension. Troponins were slightly elevated at level of
0.05; however, CK MB remained negative, and EKG unchanged.
Rhythm. The patient has a history of atrial fibrillation and
ventricular tachycardia, but was paced at a rate of 66 on
presentation and remained in sinus.
Pump. The patient had significant amount of third spacing;
however, no evidence of obvious heart failure. His EF was
noted to be 35 to 40 percent.
Upper extremity edema. The patient presented with bilateral
upper extremity edema, left greater than right; bilateral
Dopplers were negative for DVT. This was thought to be
secondary to third spacing from aggressive fluid
resuscitation.
Neutropenic fever. The patient with low-grade fever in the
setting of neutropenia. Thus, he was started on empiric
ceftazidime. Vancomycin was later added for persistent
hypotension, but was subsequently discontinued when the
patient was able to be weaned off all pressors. The patient
was administered GCSF in hopes of recovering his white blood
count and this medication was discontinued when he was no
longer neutropenic. Unfortunately, the patient developed
worsening functions. Sputum culture grew Gram-negative rods
with moderate Haemophilus. He was thus continued on his
ceftazidime and vancomycin was restarted in addition to Cipro
for double-pseudomonas coverage. Unfortunately, the patient
subsequently developed a copious amounts of diarrhea, and was
empirically treated for C. Diff. colitis, subsequent toxins
were positive. He was continued on Flagyl and his diarrhea
subsided. KUB was assessed during the course of his ICU stay
and was negative for toxic megacolon. The patient continued
to deteriorate. His coagulase were increased. He was
administered vitamin K and DIC panel was negative. An ID
consult was obtained and on [**2200-4-13**], mucolytic
cultures were then growing yeast. The patient was thus
started on AmBisome, which was changed to IV fluconazole upon
the identification of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] leukopenia in the patient's
blood. Ultimately, the patient's ceftazidime was
discontinued secondary to drop in platelets and eminent death
as this medication was thought to be doing more harm than
good.
Acute renal failure. The patient presented with elevated
creatinine. His renal function worsened in the first few
days of his ICU admission. A FENA at the time was 0.3
percent. His creatinine came down with IV fluids and his
urine output responded to fluid boluses. However, later in
his ICU stay, his creatinine again rose. Urine eos were
negative. Protein to creatinine was 1.0; FENA at that time
was 0.9 percent with urine output of 423. The patient's
progressive worsening renal failure was thought to be due to
HEN and secondary to hypotension and sepsis. His creatinine
reached as high as 4.2.
Diabetes. The patient was initially on a sliding scale
insulin, however, he was quickly changed to an insulin drug
for improved blood sugar control.
Prophylaxis. The patient maintained on PPI, subcutaneous
Heparin, and neutropenic precautions.
FEN. The patient's nutritional status maintained with tube
feeds. Nutrition followed and provided guidance along the
way.
Code status. As the patient rapidly declined near the end of
his stay, despite attempted intervention and photodynamic
therapy to improve his overall outcome, a number of family
meetings were organized to discuss the patient's wishes
regarding further intervention. His daughter had significant
difficulties with the decision making. Ethics was consulted
to aid and supporting her and making these difficult
decisions. Multiple staff were uncomfortable with perceived
discomfort on the part of the patient. It was the opinion of
ethics that we would continue to support the daughter's
wishes as likely this gentleman would desire that, and the
daughter did come to a point at which she began to withdraw
care. Please see death certificate for the date and time of
this patient's death. Dictation on the patient's date of
death to be done by the intern covering at that time.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 19957**]
MEDQUIST36
D: [**2200-7-30**] 07:00:54
T: [**2200-7-30**] 11:27:41
Job#: [**Job Number **]
ICD9 Codes: 5119, 5180, 486, 5845, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5163
} | Medical Text: Admission Date: [**2130-6-13**] Discharge Date: [**2130-6-16**]
Date of Birth: [**2068-8-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Ciprofloxacin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:[**CC Contact Info 3582**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:61yo female from OSH who was found at the bottom of a
staircase approximately 2.5hrs ago. EMS called and pt
transported to [**Hospital3 3583**]. At scene pt noted to be awake
and alert. GCS at [**Hospital3 3583**] 6. Intubated at approx. 18:40
Past Medical History:
PMHx: Seizure disorder, "frontal lobe syndrome", Ulcerative
colitis, Recurrent UTI's(fungal),Neurogenic bladder with chronic
suprapubic tube, Peptic ulcer disease, Perforated duodenal
ulcer,
depression, COPD, Respiratory failure, DVT, Pulmonary embolism,
s/p right hemicholectomy, hysterectomy, IVC filter placement,
venous access device placement, s/p surgical repair of ankle
fracture
Social History:
Social Hx: single with sig. other, 2 adult
daughters,stepchildren
Family History:
unknown
Physical Exam:
PHYSICAL EXAM:Propofol off during initial exam @7:55pm
O: T:97 BP: 130/ p HR:80-85 R 15 O2Sats 100% Vent
Gen: Intubated, sedated en route from [**Hospital3 **]. NAD.
HEENT: Pupils: 4.0mm NR
Neck: Thin, No bruits
Lungs: ETT present, audible airleak.
Cardiac: RRR. S1/S2.
Abd: Flat, Soft, Suprapubic tube present, BS+
Extrem: Cold, poor skin turgur
Neuro:
Mental status:Cranial Nerves:
I: Not tested
II: Pupils NR 4.0mm bil.
III, IV, VI: Does not track or follow examiner
V, VII: Facial symmetry even.
VIII: Does not respond to voice.
IX, X: UTA.
[**Doctor First Name 81**]: UTA.
XII: UTA.
Motor: Decreased bulk, No abnormal movements,tremors or seizure
like activity.Does not move upper extremities with noxious
stimuli. Widraws both lower extremities with noxious stimuli.
+Babinski.
Pertinent Results:
CT Head: [**6-13**] from OSH: Left frontotemporal SDH 1.5 CM Left to
right Midline shift, partial effacement of the basilar cisterns.
There is mass effect present which encroaches the left lateral
ventricle. The subdural measures 1.9CM at the widest point.
Discussed with ED radiologist as well.
Repeat CT Head: [**6-13**] [**Hospital1 18**]: Final read not available at this
time.
Noted to have worsening interval changes with Midbrain
hemorrhage
and Uncal herniation.
[**2130-6-13**] 07:50PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2130-6-13**] 07:50PM WBC-23.5* RBC-3.81* HGB-10.3* HCT-32.0*
MCV-84 MCH-26.9* MCHC-32.1 RDW-17.8*
[**2130-6-13**] 07:50PM PT-13.3 PTT-21.1* INR(PT)-1.1
[**2130-6-13**] 07:50PM PLT COUNT-643*
[**2130-6-13**] 07:50PM FIBRINOGE-382
[**2130-6-13**] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2130-6-13**] 07:50PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM
[**2130-6-13**] 07:50PM URINE RBC-[**6-21**]* WBC-[**12-1**]* BACTERIA-MOD
YEAST-FEW EPI-[**3-16**]
Brief Hospital Course:
Pt was admitted to ICU for monitoring. Her neurologic exam
remained poor. Discussion was had with family regarding poor
prognosis. After discussion it was decided to make her comfort
measures only. She expired.
Medications on Admission:
Medications prior to admission: Advair 250/50, 1puff [**Hospital1 **],
ASA81mg po daily, Tegretol 200mg [**Hospital1 **], Tegretol 100mg po
@12noon,Cymbalta 30mg po Daily, Isosorbide mononitrate 30mg po
Daily,Asacol 800 mg po TID, Mirtazapine 15mgpo Qhs, Protonix
40mg po daily, Dilantin 200mg TID, Potassium chloride 20meq po
BID,Topamax 100mg po BID, Plavix 75mg po daily, Xanax 0.5mg po
TID,Percocet 5/325 1-2 tabs p.o. Q6hrs prn pain
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
subdural hematoma
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2130-9-29**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5164
} | Medical Text: Admission Date: [**2196-2-11**] Discharge Date: [**2196-2-17**]
Date of Birth: [**2134-12-21**] Sex: F
Service: C-MED
Admitting physician: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
ADMISSION DIAGNOSIS: Chest pain
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft x4 vessels.
2. Coronary artery disease.
3. Borderline diabetes mellitus.
REFERRALS: Cardiology, cardiac surgery and physical therapy
PROCEDURES:
1. Coronary artery catheterization.
2. Coronary artery bypass graft x4 vessels.
ADMISSION H&P: Mrs. [**Known firstname **] [**Known lastname 101729**] is a 61-year-old female with a
past medical history of hypercholesterolemia, positive
Persantine thallium study, arthritis and occult guaiac
positive rectal exam who presented with a complaint of
shortness of breath for over the duration of one month with
progressive dyspnea on exertion. She denied any history of
chest pain, reflex dysphasia or odynophagia and presented for
coronary catheterization on [**2196-2-11**]. The findings of
catheterization were that she had an ejection fraction of 36%
in anterior basal and posterior basal normal function and
her anterior lateral, apical and inferior margins were
hypokinetic. Her right coronary artery had a discrete
proximal stenosis of 60% to 70%. Her mid obtuse marginal
distal RCA and posterior descending arteries were all normal.
Her left main had a stenosis of approximately 40% with
diagonal stenosis of 90%. The proximal LAD was 80%,
intermediate LAD was 90% and the middle LAD was approximately
60%. The distal LAD was 40%. The circumflex was normal and
the obtuse marginal was normal. Her right sided heart
pressures were a mean of approximately 12 mmHg. Her PAP was
38, 20 and 26 and her left ventricular end diastolic pressure
was 20. She had moderate systolic and diastolic dysfunction.
PAST MEDICAL HISTORY:
1. Degenerative joint disease.
2. Pneumonia in [**2189**].
3. Occult blood one time on a recent screening exam.
ALLERGIES: She has no allergies to any known drugs.
PREVIOUS MEDICATIONS:
1. Aspirin 325 mg po qd.
2. Prempro 0.625/2.5 mg po qd.
3. Elavil 20 mg po q p.m.
4. Naprosyn 500 mg po bid.
PAST SURGICAL HISTORY:
1. Tubal ligation.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: She was 5 foot 1.5 inches tall with a weight of
171 pounds. Her blood pressure was 142/82 on the left. On
the right it was 135/80. Her pulse was 68.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Without murmurs, rubs or gallops. She had a normal
S1 and S2. She had palpable DP and PT arteries bilaterally.
After her catheterization, cardiothoracic surgery was
consulted and plans were made to perform coronary artery
bypass graft on [**2196-2-12**] on hospital day #2. On hospital day
#2, she went to the Operating Room, where she underwent
coronary artery bypass graft x4 vessels with a left internal
mammary artery to LAD and vein to diagonal ramus and the
right coronary artery. The patient was then transferred to
the Cardiothoracic Intensive Care Unit where she was
extubated shortly thereafter and out of bed on postoperative
day #1. Her chest tube was maintained until postoperative
day #2; it was discontinued.
On postoperative day #2, she was evaluated by physical
therapy and her dressing on postoperative day #3 while taken
down, revealed some serosanguinous drainage. Her midline
sternotomy was then painted with Betadine and dressed with a
dry sterile dressing twice daily over the next couple of
days. She was ambulating and able to take care of herself
with clear lungs and extremely minimal drainage from her
midline incision, therefore plans were made to discharge her
on postoperative day #5. That morning, it was noted that she
had a run of a questionable ventricular tachycardia on her
telemetry monitoring. However, the
electrophysiology/cardiology service was contact[**Name (NI) **] and the
impression was that this was an artifact with a QRS wave and
the patient would not require any further evaluation.
Therefore, plans were made to discharge the patient home.
DISPOSITION: Discharge to home
DISCHARGE CONDITION: Good
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg po bid.
2. K-Dur 20 milliequivalents po q day x7 days.
3. Lasix 20 mg po qd x7 days.
4. Lipitor 10 mg po q hs.
5. ASA 81 mg po qd.
6. Elavil 20 mg po q p.m.
7. Percocet 1 to 2 tablets po q 3 to 4 hours.
8. Colace 100 mg po bid.
DISCHARGE INSTRUCTIONS: The patient is to follow up with the
nurses on Far Six for a wound check in approximately one
week, to follow up with her primary care physician in one to
two weeks and to follow up with Dr. [**Last Name (STitle) **] in four weeks.
She can continue Betadine painting and dressings with dry
sterile gauze twice daily until her midline sternotomy heals.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 13391**]
MEDQUIST36
D: [**2196-2-18**] 13:14
T: [**2196-2-18**] 13:13
JOB#: [**Job Number **]
ICD9 Codes: 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5165
} | Medical Text: Admission Date: [**2133-3-28**] Discharge Date: [**2133-4-2**]
Date of Birth: [**2072-12-20**] Sex: M
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 60-year-old man with
CAD, PVD who had difficulty speaking after left carotid
endarterectomy in [**2133-2-16**]. The patient has had bilateral
carotid stenosis. On [**2-21**] while he was sitting in a chair he
developed sudden onset of right arm and leg numbness,
followed by right arm and leg weakness. He also had
difficulty speaking. He was admitted to [**Hospital3 **]
and underwent a left carotid endarterectomy on [**2-26**] and
afterwards began having severe left sided headache behind his
left eye that lasted for hours and was constant.
Nevertheless, he visited [**Hospital3 **] for continued
headaches and nausea and vomiting. During one of those
visits he had a contortion of his right face and bilateral
arm jerking and was started on Dilantin with presumptive
diagnosis of seizures. He has recovered from that event when
was again discharged home. On [**3-13**] he again presented with
persistent headaches, confusion and inability to talk. He
had difficulty getting his words out. He had a head CT at
[**Hospital3 **] which showed a linear hyperintense region
in the left central temporal lobe but also other lesions in
the left posterior parietal lobes. At that time he was
transferred to the [**Hospital1 69**]. MRI
of his head showed left MCA/ACA and left MCA/PCA watershed
strokes with acute and subacute hemorrhage conversions. It
was thought at that time that he had extended his watershed
infarcts after carotid endarterectomy leading to a carotid
hyperperfusion syndrome. The patient was discharged from the
neurologic Intensive Care Unit to a rehab facility. On
Thursday, [**2133-3-26**], patient's wife noticed erythema on
patient's face. On [**3-27**] the visiting nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 11282**] of
a rash on his arms as well. The patient was noted to be
febrile and was admitted to the [**Company 191**] Firm. In the EW,
patient's Dilantin was discontinued and he was given Tegretol
instead.
PAST MEDICAL HISTORY: 1) Left CEA in [**2133-2-16**]. 2) CVA in
[**2133-2-16**]. 3) Paroxysmal atrial fibrillation. 4) CAD. 5)
PVD. 6) Hypercholesterolemia. 7) History of amaurosis
fugax. 8) Status post lymph node removal.
MEDICATIONS: On admission, Lopressor 25 mg po bid, Dilantin
200 mg po tid, Prilosec 40 mg po q day, Lipitor, Ambien.
ALLERGIES: Iodine.
SOCIAL HISTORY: The patient lives in [**Location 3146**], tobacco since
[**2126**], one pint of alcohol per day. The patient works as a
carpenter.
FAMILY MEDICAL HISTORY: CAD.
PHYSICAL EXAMINATION: On admission, temperature 98.3, pulse
86, blood pressure 94/65, respiratory rate 18, saturations
96% on room air. In general, alert, oriented times three, no
apparent distress. HEENT: Pupils are equal, round, and
reactive to light, mucus membranes moist, oropharynx clear.
No lymphadenopathy. Cardiovascular, regular rate and rhythm,
no murmurs. Lungs clear to auscultation bilaterally.
Abdomen soft, nontender, non distended, positive bowel
sounds. Extremities, no cyanosis, erythema, edema. Neuro,
cranial nerves II through XII intact. Skin red maculopapular
blanching erythema on face, torso and extremities, sparing
the soles. Bilateral lower extremity petechiae, no
significant oral lesions noted.
HOSPITAL COURSE:
1. Derm: Over the course of patient's stay on [**Company 191**] Firm,
patient had rigors and fevers of up to 101 degree. The
patient was initially continued on Tegretol. The patient had
worsening rash throughout his torso with lip swelling and
tongue swelling. The patient did not experience any
respiratory difficulties throughout the course of his stay on
the [**Company 191**] service. A derm consult was obtained. The
dermatology team recommended discontinuing Tegretol. Their
thought was that the patient's symptoms were secondary to his
hypersensitivity to Dilantin. The patient was treated
symptomatically with IV fluids, Zantac, Benadryl and Synalar
cream. The patient was transferred to the Medical Intensive
Care Unit overnight for observation given risk of respiratory
distress. [**Hospital **] Medical Intensive Care Unit stay was
uneventful. Skin biopsy was also consistent with
hypersensitivity reaction. Over the course of patient's stay
in the hospital, patient's rash started to improve with
decreasing erythema and edema.
2. Neuro: Patient was seen by neurology service. They
recommended stopping all anti-epileptic medications since
they thought that his symptoms were likely secondary to
carotid reperfusion syndrome and anti-seizure medications are
not necessarily beneficial under these circumstances.
3. GI: Patient's LFTs were slightly elevated during his
admission. The patient's Lipitor was held due to increased
LFTs. His increased LFTs were likely secondary to Dilantin.
Patient to follow-up with his PCP to make sure LFTs are
trending down and before restarting Lipitor.
DISCHARGE DIAGNOSIS:
1. Dilantin hypersensitivity reaction.
DISCHARGE MEDICATIONS: [**Doctor First Name **] 60 mg po bid, Zantac 150 mg
po bid, Synalar ointment, Eucerin cream. Discharged to home.
patient to follow-up with PCP next week as well as with
dermatology. Patient's PCP to assess blood pressure before
restarting Atenolol.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2133-4-21**] 16:51
T: [**2133-4-21**] 16:57
JOB#: [**Job Number 11284**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5166
} | Medical Text: Admission Date: [**2164-9-7**] Discharge Date: [**2164-9-12**]
Date of Birth: [**2086-10-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old
gentleman with a history of AFib and hypertension, who is
status post a bicycle accident, where he suffered a
concussion over two months ago. He reports problems from the
accident including headaches, diplopia, and vertigo have
improved other than fatigue. He and the son have noticed
that he has become slow and more fatigued. The patient's
voice has become softer. His gait is starting to shuffle.
The son noticed that he is slower in initiating or changing
motor movements. The patient denies any resting tremor or
urinary incontinence, although he is urinating much more
frequently recently. He had a single fall while walking the
[**Doctor Last Name 6641**] when he slipped on a wet log with no other falls. He
denies feeling depressed. Denies any changes in appetite or
sleep pattern.
PHYSICAL EXAMINATION: On physical exam, he is an elderly man
in no acute distress. He is alert and oriented with normal
language and memory. EOMs are full. Pupils are equal,
round, and reactive to light. He has no ptosis. His face is
symmetric. His tongue is midline. He has no drift, no
resting tremor, some mild paratonia in the arms and legs, but
no cogwheeling even with distractions. However, his give-way
and effort dependent throughout. He has no specific pattern
with impairment, although weakest muscles are iliopsoas at
4-/5. Fine finger movements are rapid and precise. His deep
tendon reflexes are 1+ in the arms and 1+ at the knees.
Trace ankles and toes are downgoing. Gait has difficulty
initiating movements. Needs arms to get up out of a chair.
Head CT initially after the accident showed small bilateral
frontal hygromas and a slight subarachnoid hemorrhage. On
the 19th, he has got a large hygroma with subdural hemorrhage
located within the subfalcine, subfalcine herniation .
The patient was taken to the operating room for evacuation of
the subdural hematoma, which he tolerated without
complication. His vital signs remained stable.
Postoperative, he is awake, alert, and oriented times three,
moving all extremities with good strength with a subtle left
drift, subtle left sided weakness. His vital signs remained
stable. He did have a right frontal-parietal crani for
evacuation of the subdural.
He was monitored in the ICU postoperatively, and transferred
to the regular floor on postoperative day one. He was seen
by Physical Therapy and Occupational Therapy, and found to be
safe for discharge to rehab.
MEDICATIONS AT TIME OF DISCHARGE:
1. Milk of magnesia 30 cc p.o. q.6h. prn.
2. Atenolol 25 mg p.o. q.d.
3. Percocet 1-2 tablets p.o. q.4-6h. prn.
4. .................... 7.5 mg p.o. q.d.
5. Zantac 150 mg p.o. b.i.d.
6. Fluoxetine 10 mg p.o. q.d.
7. Senna one tablet p.o. b.i.d. prn.
8. .................... bromide inhaler two puffs q.i.d.
9. Colace 100 mg p.o. b.i.d.
CONDITION ON DISCHARGE: The patient's condition was stable
at the time of discharge.
FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**First Name (STitle) **] in one
month with a repeat CT. Staples should be removed on
postoperative day #10. Surgery was on [**2164-9-8**].
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2164-9-12**] 11:26
T: [**2164-9-12**] 11:36
JOB#: [**Job Number 93362**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5167
} | Medical Text: Admission Date: [**2114-8-23**] Discharge Date: [**2114-9-7**]
Date of Birth: [**2075-5-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
Right IJ Central line placement [**2114-8-24**] at [**Hospital1 18**] with removal of
(L) subclavian placed at OSH; intubation at OSH [**8-14**] and [**8-16**];
extubated [**2114-8-29**].
History of Present Illness:
Mr. [**Known lastname 82971**] is a 39 year old man with diabetes,
hypertriglyceridemia, and alcoholism who presented to an OSH on
[**8-11**] with abdominal pain in the setting of increased EtOH use
over the last month.
.
There, admission labs were notable for lipase 1687, WBC 11 with
24% bands, Hct 50, AST 125, ALT 99, Na 125, gap of 17.
Cholesterol was approximately 3000. CT scan on admission showed
evidence of pancreatitis, pancreatic edema with free fluid in
the pelvis. He was admitted to the ICU for close monitoring and
fluid resuscitation.
.
At the OSH ICU, he became progressively confused despite
treatment with lorazepam per CIWA. He developed respiratory
distress on [**8-14**] and was intubated. He self extubated on [**8-16**] and
did well initially, though had to be reintubated later that day
for respiratory distress and altered mental status. He has
undergone multiple attempts at weaning from the vent apparently
complicated by increased hypercapnia and hypoxia.
.
He remained febrile throughout his hospital course. He was
started on ceftriaxone and vancomycin empirically on [**8-14**]. Flagyl
was added subsequently, and then ceftrixone was changed to
levofloxacin. Oral vancomycin was added on [**8-19**]. His antibiotics
were again modified to doripenem on [**8-20**] with improvement of his
WBC from 25 to 12k by [**8-21**]. A RIJ had been placed on [**8-14**] and was
removed on [**8-21**]. Cultures of blood, urine, and lines have been
negative as have C diff toxin assays.
.
On evaluation in the [**Hospital Unit Name 153**], he is intubated and unable to provide
any history.
Past Medical History:
Familial hypertriglyceridemia, Alcohol abuse, HTN, Anxiety, DM,
Gout, MVA s/p ankle fracture
Social History:
Married. Daily drinker 6 beers/day. Uses marijuana and cocaine.
No tobacco.
Family History:
Other family members with Diabetes
Physical Exam:
On [**Hospital Unit Name 153**] admission:
Vitals 102.2 112 139/81 23 100% on AC
General Young man intubated and sedated
HEENT Sclera anicteric, conjunctiva slightly injected on right
Neck Supple
Pulm Diminished at right base
CV Tachycardic regular S1 S2 no m/r/g
Abd Mildly distended, diminished bowel sounds, grimaces with
palpation
Extrem Warm no edema palpable distal pulses. legs symmetric
Neuro Opens eyes to voice, squeezes hands and wiggles toes to
command
Derm No rash or jaundice
Lines/tubes/drains foley yellow urine left subclavian
.
On [**Hospital Unit Name 153**] transfer:
Vitals: T98.6 P97 BP 144/93 RR19 SaO2 96% RA
General: Calm, asks appropriate questions, oriented to person,
hospital
Pulm Decreased breath sounds L base, otherwise CTA
CV Tachycardic, nl S1 S2, no m/r/g
Abd: s/nt, mildly distended, active bowel sounds
Extrem Warm, 2+ distal pulses. legs symmetric, no /c/c/e
.
At Discharge:
VS: 98.9 PO, 92, 144/82, 20, 94% RA
GEN: In NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: CTA(B).
COR: RRR
ABD: BSx4. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
Pertinent Results:
On [**Hospital Unit Name 153**] admission [**2114-8-23**]:
WBC-14.0* RBC-2.48* Hgb-8.1* Hct-24.0* MCV-97 MCH-32.5*
MCHC-33.6 RDW-13.7 Plt Ct-690*
Neuts-71* Bands-1 Lymphs-14* Monos-7 Eos-3 Baso-1 Atyps-0
Metas-0 Myelos-2* Plasma-1*
PT-12.6 PTT-24.7 INR(PT)-1.1
Glucose-95 UreaN-19 Creat-0.6 Na-149* K-4.1 Cl-111* HCO3-29
AnGap-13
ALT-18 AST-46* LD(LDH)-474* AlkPhos-67 Amylase-13 TotBili-0.5
Lipase-94* Hapto-613* Triglyc-259* Lactate-0.8
Albumin-2.8* Calcium-8.4 Phos-3.9 Mg-2.1
.
Labs at transfer [**2114-9-2**]:
WBC-18.3* RBC-2.82* Hgb-8.7* Hct-25.2* MCV-89 MCH-30.9 MCHC-34.6
RDW-14.2 Plt Ct-762*
PT-15.2* PTT-67.7* INR(PT)-1.3*
Glucose-94 UreaN-11 Creat-0.5 Na-138 K-3.0* Cl-101 HCO3-24
AnGap-16
Calcium-8.7 Phos-3.8 Mg-1.8
.
VitB12-633
Folate-14.0
.
OSH Imaging:
[**8-11**] CT abd/pelvis:
severe pancreatitis no necrosis, pseudocyst, or organized fluid
collection. fatty liver.
.
[**8-17**] CT abd/pelvis:
increased ascites and RP effusions, no organized collection
bilateral pleural effusions
.
[**Hospital1 18**] Imaging:
[**8-23**] EKG: Sinus rhythm. Early R wave progression. No previous
tracing available for comparison.
.
[**8-23**] CT head: Normal study.
.
[**8-23**] CT Abd/pelvis:
1. Extensive peripancreatic fluid collections extending from the
greater
curvature of the stomach into the deep pelvis in the presacral
area. Areas of hypoenhancement within the pancreas, particularly
within the body and neck are identified and concerning for
possible necrosis, although artifact from interdigitating fluid
cannot be excluded.
2. Small bilateral pleural effusions with associated
atelectasis.
3. Air within the bladder likely due to recent Foley
catheterization.
Clinical correlation is recommended.
4. Diffuse anasarca.
.
[**2114-8-28**] CT Abdomen/pelvis:
1. No CT evidence of pancreatic necrosis.
2. Grossly unchanged appearance of very large peripancreatic
fluid
collections, with largest collection adjacent to the greater
curvature of the stomach slightly more organized and increased
in size than seen previously.
3. Increased bilateral pleural effusions and bibasilar
atelectasis
.
[**8-30**] Lower extremity doppler ultrasound:
1. Deep venous thrombosis involving the calf veins, including
both peroneal veins and one of the paired right posterior tibial
veins.
.
[**8-30**] CTA Chest:
1)Left Lower lobe subsegmental pulmonary embolism.
2)Large left pleural effusion with near-complete collapse of the
left lower lobe and right lower lobe atelectasis and small
pleural effusion.
3)Large pseudocyst has slightly decreased in size since the
previous abdominal study and now measures 6.9 x 10 cm.
.
[**9-2**] CXR:
Compared to [**8-30**], the general haziness of the left hemithorax is
substantially less, suggesting improvement in the pleural
effusion. The right central catheter has been removed and the
nasogastric tube remains coiled in the upper stomach. No
evidence of acute pneumonia or vascular congestion.
.
[**2114-9-5**] Gallbladder U/S:
1. No gallstones identified within the gallbladder.
2. Mild right hydronephrosis possibly related to right ureter
passing through post-pancreatitis phlegmonous change from prior
recent CT scan.
3. Pseudocyst/inflammatory change incompletely evaluated in the
region of the distal pancreatic body and tail as noted on CT
scan from [**2114-8-11**].
.
Micro
[**8-23**], [**8-24**], [**8-25**], [**8-26**] BCx - no growth
[**8-30**], [**8-31**] Bx- pending
[**8-29**] BCx - STAPHYLOCOCCUS, COAGULASE NEGATIVE from central and
peripheral sites
[**8-25**], [**8-26**], [**8-29**], [**8-30**] UCx - negative
[**8-28**] Sputum Cx- sparse growth oropharyngeal flora
[**8-31**] IJ catheter tip cx- no significant growth
[**8-31**] Blood Cx - No Growth
[**8-31**] Stool C.diff - negative
Brief Hospital Course:
[**Hospital Unit Name 153**] Course [**2114-8-23**] - [**2114-9-2**]:
Mr. [**Known lastname 82971**] is a 39M with h/o DM and alcoholism and pancreatitis
who is transferred to [**Hospital1 18**] for a higher level of care.
.
* Pancreatitis - Based on admission labs, pt with pancreatitis
on presentation. No evidence of necrosis on OSH imaging and
[**Hospital1 18**] imaging. Most likely precipitated by drinking binge. HCTZ
can also be associated with pancreatitis though less likely.
Triglycerides 259 here but approx 3000 per report at OSH,
suggesting there may also be some component of hyperlipidemia as
cause. Surgery was consulted who recommended supportive care
with fluids and fever management. Pt's increased abdominal
pressure may have contributed to his respiratory failure by
increasing bibasilar atelectasis and pain leading to spliting.
Bladder pressure 11 at transfer and abdomen soft. Once stable,
pt was transferred to surgery for further management and
evaluation given possible need for resection of pseudocyst.
.
* Respiratory distress: Pt was intubated at OSH on [**8-14**] for
respiratory distress. He has no h/o lung disease. Respiratory
distress attributed to increased abdominal pressure exerting
pressure on lungs and increasing atelectasis with bilateral
pleural effusions as well as pulmonary edema. Also some
component of spliting due to pain/pancreatitis. Esophageal
balloon demonstrated pressure of 8, suggesting that large
plateau pressures were most likely due to non-compliant chest
wall rather than intrinsic lung disease. Pt was diuresed without
problems and was extubated [**2114-8-29**] without complications. Given
that small left PE was on same side as pleural effusion, there
was concern that thoracentesis may increase VQ mismatch vs
continued effusion leading to lung trapping. IP evaluated
pleural effusion and determined thoracentesis could be performed
after pt stable 1-2 weeks on anticoagulation regimen; however,
pleural effusion on CXR [**2114-9-2**] had significantly decreased. Pt
was saturating 96% RA at transfer.
.
* Pulmonary embolus: Bilateral deep vein thrombi were found on
doppler ultrasound on [**8-30**] and a small PE was found chest CTA.
A heparin drip was started without bolus for concern about
precipitating hemorrhagic transformation of his pancreatitis. No
transition to coumadin given need for possible procedures.
.
* Fever and leukocytosis - Pt spiked intermittent fevers up to
103-104 during acute phase of illness. Tm on transfer was 100.2.
This was attributed to pancreatitis. Due to concern for necrosis
as cause of fever, pt had repeat CT abdomen/pelvis [**8-28**] with
results above. Cultures remained negative and empiric
antibiotics were stopped. However, blood cultures from [**8-29**]
demonstrated coagulase negative Staph aureus, pan sensitive.
Vancomycin (started [**2114-8-30**]) was changed to nafcillin on
[**2114-9-1**]. WBC continues to be elevated (18.3 at transfer),
possibly due to pancreatitis vs PE vs bacteremia. C. diff
negative x2.
.
* Agitation - Patient 10+ days out from last drink, therefore
delirium tremens less likely. [**Month (only) 116**] be delirious from acute
illness, medications, prolongued ICU stay. Head CT here
negative. His neurontin (on med list from OSH transfer) was
held. Also concern for benzo withdrawal as he required heavy
sedation with midazolam during intubation. Agitation responded
well to ativan PRN and patient was calm and appropriate on
transfer.
.
* Anemia - Hct was very concentrated at initial presentation to
OSH (Hct 50) likely [**2-12**] third spacing. Hct on presentation here
was 24. Pt was transfused 1 unit cells for Hct 23 -> 28.
Haptoglobin 613 making hemolysis unlikely. B12 and folate were
normal. There was concern for hemorrhagic pancreatitis given Hct
has been slowly decreasing throughout hospital stay with Hct
25.2 at transfer.
.
* Alcohol and substance abuse - Patient received thiamine,
folate and multivitamin. Social work was consulted.
.
* DM - patient intially on insulin drip given pancreatitis,
which was transitioned to ISS.
.
* HTN - Patient remained hypertensive (SBP 130s-160s) even after
home meds of cozaar and HCTZ were restarted. Continued HTN
attributed to pain, agitation.
.
FEN - Patient restarted on tube feeds via NGT prior to transfer.
Following transfer to the Surgical floor, his nasogastric tube
was removed and he was started on a clear liquid diet, which was
gradually advanced to regular. Coumadin was started for his
DVT/PE to maintain an INR 2.5-3.0 with background heparin. His
foley was discontinued as well; he was able to void without
problem.
He was evaluated by Physical Therapy due to his prolonged
hospitalization and deconditioned state, but after working with
him for a few days he was steady on his feet and walking short
distances without difficulty.
Blood cultures were negative from [**2114-8-30**] and [**2114-8-31**], and
Nafcillin was discontinued on [**2114-9-7**]. He remained afebrile and
his WBC 10K.
On [**2114-9-7**], the Heparin infusion was discontinued. As the
patient's INR was 1.7 that morning and close to therapeutic goal
of [**2-13**], it was determined that a Lovenox-Coumadin bridge was not
indicated. INR goal is 2.5; therapeutic range 2-3.
At the time of discharge on [**2114-9-7**], 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. He was discharged home without services,
and will follow-up with his new PCP on [**Name9 (PRE) 766**], [**2114-9-10**] for
further management of Coumadin. Generally, it is recommended
that anticoagulation therapy with Coumadin be continued for
6months for an initial PE. Follow-up with a Pancreatologist was
also recommended. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Medications at home:
Cozaar 100mg PO daily
Lipitor 80mg PO daily
HCTZ 25mg Po QAM
Allopurinol 100mg PO Daily
.
Medications on transfer from outside hospital:
Versed @ 6/hr
Fentanyl @ 150/hr
Doripenem 500mg IV q8h
Clonidine patch 0.3mg q7d
Neurontin 400mg q8h
Zyprexa SL 10mg q8h
Afrin [**Hospital1 **]
Lovenox 40mg SQ daily
Protonix 40mg IV daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
5. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QAM.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Warfarin 4 mg Tablet Sig: One (1) Tablet PO QDAY in the
evening: Please take this medication the same time each day.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatitis
2. Alcohol Abuse
3. Lower lobe subsegmental pulmonary embolism
4. HTN
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-20**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
DO NOT DRINK ANY ALCOHOL WHATSOEVER
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Your new PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82972**] ([**Telephone/Fax (1) 82973**]). You have an
appointment with him on [**Last Name (LF) 766**], [**2114-9-10**] at 1PM. You will
need your PT/INR checked on that day, and Dr. [**Last Name (STitle) 82972**] will tell
you how much Coumadin to take.
It is recommended that you follow-up with a Gastroenterologist
specializing in Pancreatitis. Your new PCP can refer you to a
local Gastroenterologist. If you prefer to see a
Gastroenterologist at [**Hospital1 18**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] is recommended.
Phone: ([**Telephone/Fax (1) 82974**]. Location: [**Hospital Ward Name 452**] Rose 101, [**Hospital Ward Name 516**].
Completed by:[**2114-9-7**]
ICD9 Codes: 5180, 2930, 5119, 7907, 2749, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5168
} | Medical Text: Admission Date: [**2135-4-13**] Discharge Date: [**2135-4-18**]
Date of Birth: [**2085-8-16**] Sex: M
Service: CARDIAC SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 49 year-old gentelman
who has a many year history of a heart murmur who was found
to have mitral valve disease by echocardiogram with a recent
onset of chest discomfort and diaphoresis with exertion.
Echocardiogram in [**2134-12-6**] showed a moderately
dilated left atria, mildly dilated left ventricle, ejection
fraction of 60 to 70%, mildly thickened mitral valve
leaflets, mild mitral valve prolapse, partial mitral leaflet
flail with 3+ mitral regurgitation, 1+ tricuspid
regurgitation and mild pulmonary hypertension. The patient
underwent cardiac catheterization on [**2135-3-7**], which showed
an ejection fraction of 60% with 2+ mitral regurgitation and
no coronary disease. The patient was referred to Dr. [**Last Name (Prefixes) 411**] for mitral valve repair.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Mitral valve prolapse.
4. Depression.
5. Psoriasis.
6. Status post tonsillectomy.
7. Status post right knee arthroscopy.
8. Multiple orthopedic injuries.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Enteric coated aspirin 325 mg po q day.
2. Zestril 40 mg po q day.
3. Prozac 60 mg po q day.
4. Hydrochlorothiazide 25 mg po q day.
5. Multivitamins.
HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room
on [**2135-4-13**] with Dr. [**Last Name (Prefixes) **] for a minimally
invasive mitral valve repair. Please see operative note for
further details. The patient was transported to the
Intensive Care Unit in stable condition on neo-synephrine and
Propofol infusions. The patient was weaned and extubated
from mechanical ventilation on his first postoperative night
requiring low dose neo-synephrine. On the evening of
postoperative day number one the patient was noted to have a
moderate amount of chest tube drainage and a drop in
hematocrit. Chest x-ray showed a right sided pleural
effusion. A chest tube was inserted into the right pleural
space with immediate drainage of about 500 cc of bloody fluid
with fair resolution by chest x-ray. The patient continued
to have a drop in hematocrit and a thoracic surgery consult
was obtained. Thoracic surgery felt that the postoperative
bleeding was self limiting. By postoperative day number two
the patient's hematocrit had stabilized and there was no
drainage of the chest tube, however, the patient continued to
be anemic. The patient was again transfused packed red blood
cells and given Lasix and the patient's hematocrit over the
next several days began to climb. The patient was started on
Lopressor. Repeat chest x-ray showed elevated right
hemidiaphragm with little change between inspiratory and
expiratory films, right middle and right lower lobe
atelectasis. Coughing and deep breathing was encouraged as
well as incentive spirometry. Postoperative day number four
one of the patient's chest tubes were removed and the other
was placed to water seal. Chest x-ray after this was done
showed a small right apical pneumothorax unchanged from the
previous films.
On postoperative day number four the patient was transferred
from the Intensive Care Unit to the regular part of the
hospital where he began working with physical therapy. On
postoperative day number five the patient's last remaining
right pleural chest tube was removed and post removal chest
x-ray showed unchanged from previous chest x-rays, which was
small bilateral effusions right greater then left, elevated
right hemidiaphragm, right middle and right lower lobe
atelectasis and a small right apical pneumothorax. The
patient ambulated with physical therapy and was able to climb
one flight of stairs and walk 500 feet while remaining
hemodynamically stable and without requiring oxygen and the
patient was cleared for discharge to home.
CONDITION ON DISCHARGE: Temperature max 100.1. Pulse 65 in
sinus rhythm. Blood pressure 111/68. Respiratory rate 15.
Room air oxygen saturation 95%. The patient's weight on
[**4-18**] is 95.3 kilograms. Preoperatively the patient
weighed 93 kilograms. Laboratory data, white blood cell
count 7.9, hematocrit 27.3, platelet count 237, sodium 138,
potassium 4.4, chloride 102, bicarb 30, BUN 14, creatinine
0.6, glucose 90, PT 12.4, INR 1.0, PTT 23.8. Neurologically
the patient is awake, alert, and oriented times three,
nonfocal. Heart is regular rate and rhythm without rub or
murmur. Breath sounds are clear, decreased right. There is
no rhonchi or rales. Abdomen positive bowel sounds, soft,
nontender, nondistended. The patient is tolerating a regular
diet. Right incisions are clean, dry and intact. There is
no erythema. The chest tube site is covered with a dry
sterile dressing, which is to be removed on [**4-19**].
Extremities are without edema.
DISCHARGE DIAGNOSES:
1. Mitral regurgitation.
2. Status post minimally invasive mitral valve repair.
3. Postoperative right hemothorax.
4. Postoperative elevated right hemidiaphragm.
5. Postoperative anemia.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 one to two po q 4 to 6 hours prn.
2. Enteric coated aspirin 325 mg po q day.
3. Zantac 150 mg po b.i.d.
4. Colace 100 mg po b.i.d.
5. Lasix 20 mg po q day times seven days.
6. Potassium chloride 20 milliequivalents po q day times
seven days.
7. Niferex 150 mg po q day.
8. Vitamin C 500 mg po b.i.d.
9. Multivitamin one po q day.
10. Lopressor 50 mg po b.i.d.
DISCHARGE CONDITION: The patient is to be discharged to home
in good condition.
DI[**Last Name (STitle) 408**]E FOLLOW UP: The patient is to follow up with Dr.
[**First Name (STitle) **] in one to two weeks. The patient is to follow up
with Dr. [**First Name (STitle) 216**] in one to two weeks and the patient is to
follow up with Dr. [**Last Name (Prefixes) **] in three to four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2135-4-18**] 12:13
T: [**2135-4-18**] 12:47
JOB#: [**Job Number 100959**]
ICD9 Codes: 4240, 5180, 2851, 4019, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5169
} | Medical Text: Admission Date: [**2181-1-12**] Discharge Date: [**2181-1-26**]
Date of Birth: [**2133-8-30**] Sex: F
Service: [**Doctor Last Name 1181**]
ID: The patient is a 47 year-old female with chronic obstructive
pulmonary disease flare/aspiration pneumonia status post
extubation in the Operating Room transferred from MICU to [**Doctor Last Name **]
Medicine Service.
female with a past medical history significant for juvenile
rheumatoid arthritis, type 1 diabetes mellitus, hypothyroidism,
asthma/chronic obstructive pulmonary disease, encephalitis with
intubation leading to vocal cord paralysis, multiple pneumonias
each year, who initially presented on [**1-7**]
Hospital in [**Location (un) 8973**], [**State 350**]. At that time she reported
a one day history of fever, nausea and vomiting and was diagnosed
with viral gastroenteritis. While hospitalized she became
dyspneic with wheezing and was started on Levofloxacin on [**1-9**] for a positive infiltrate on chest x-ray for possible
aspiration pneumonia, and then on Timentin on [**1-11**] when
there was no improvement. Her condition worsened on [**1-12**]
with shortness of breath and the patient was bronched revealing
edematous vocal cords. During her bronchoscopy the patient had
to be intubated for airway protection due to loss of airway. The
patient was noted to have a "difficult airway."
The patient was then transferred to the [**Hospital Unit Name 153**] at [**Hospital1 346**] for further airway management. She
was then transferred to the MICU on [**1-18**]. While in the
Intensive Care Unit at [**Hospital1 18**] she was treated for aspiration
pneumonia as well as asthma, chronic obstructive pulmonary
disease exacerbation with Solu-Medrol 80 mg intravenous q 8
hours, Levofloxacin and Clindamycin. Cultures were negative.
Legionella antigen was negative. She was also treated with
Albuterol and Atrovent nebulizers. Tube feeds were started
on [**1-13**] due to aspiration risk. Aggressive pulmonary
toilet was continued on [**1-18**]. High risk extubation was
done in the Operating Room and the patient was moved to the
PACU in stable pulmonary status. The patient was then
transferred to the medical floor.
PAST MEDICAL HISTORY: 1. Encephalitis in [**2164**] requiring
intubation. 2. Status post intubation in [**2164**] from
encephalitis. Vocal cord paralysis injury. 3. Asthma/chronic
obstructive pulmonary disease. 4. Pneumonia each year. 5. Type
1 diabetes mellitus. 6. Juvenile rheumatoid arthritis. 7.
Hypothyroidism for twenty years. 8. Depression.
In [**2164**] she presented to St. [**Hospital **] Hospital in [**Location (un) 8973**],
[**State 350**] in [**Month (only) **] with a three week history of headache,
swollen legs and extreme fatigue. She was admitted to the
hospital with diagnosis of meningitis and treated with
antibiotics. Apparently she got worse and went in to a coma
and was then transferred to [**Hospital3 2576**] [**Hospital3 **] with diagnosis
of encephalitis apparently from a mosquito bite. Her hospital
stay was approximately months while in a coma for about three
weeks as per the patient. She was intubated at that time, which
then resulted in a vocal cord paralysis. Since then she reports
having pneumonia each year requiring admission to the hospital at
St. [**Doctor First Name **] for approximately one week stays without intubation.
She reports her history of type 1 diabetes mellitus starting
when she was four years old. At four years old she was also
diagnosed with malaria at the time she was living in [**Country 480**]
and [**Country 37027**]. The patient was born in [**Country 6257**].
Her history of juvenile rheumatoid arthritis started with
hand deformities as well as deformities of the feet at 11
years old. Her chronic obstructive pulmonary disease was
diagnosed approximately three years ago. Her asthma was
diagnosed around the time she had encephalitis in [**2164**].
ALLERGIES: Sulfa drugs, which she reports having a rash
reaction.
SOCIAL HISTORY: She quit smoking fifteen years ago. At that
time she had been smoking one pack per day. She reports no
alcohol use or intravenous drug use. Her mother's phone
number is [**Telephone/Fax (1) 37028**].
MEDICATIONS (ON TRANSFER): NPH, Riss Dulcolax, heparin subQ,
Prozac, Tylenol, intravenous fluids, Ativan, Fleets enema,
Prednisone, Colace, Levofloxacin, Clindamycin, Synthroid,
Albuterol and Atrovent nebulizers and Zantac.
PHYSICAL EXAMINATION (ON ADMISSION): Vital signs, T equals
98.2. Heart rate 68. Respiratory rate 18. Blood pressure
115/59. Oxygen saturation equals 99% on 3 liters nasal
cannula. General appearance no acute distress. HEENT mucous
membranes are moist. Normocephalic, atraumatic. Pupils are
equal, round and reactive to light and accommodation.
Extraocular movements intact. Cardiovascular regular rate
and rhythm. Normal S1 and S2. Sounds, 2 out of 6 systolic
ejection murmur at the left upper sternal border. Lungs,
coarse inspiratory breath sounds throughout upper airway
sounds and slight rales at the bases bilaterally. Abdomen
soft, slight distention, nontender, normoactive bowel sounds.
Extremities rheumatoid arthritis findings of the hands
bilaterally. No edema, cyanosis or clubbing present.
LABORATORY DATA: White blood cell equals 20.9, HCT equals
31.8, platelets 496. SMA 7 with sodium of 135, potassium
4.1, chloride 94, bicarb 34, BUN 16, creatinine .6, glucose
181, calcium 8.3, phos 4.1, magnesium 2.1. TSH .06, free T4
1.1, Legionella antigen negative, INR 1.1, PT 12.6, PTT 27.7.
Chest x-ray on [**2181-1-12**] was diffuse reticulonodular opacities
becoming confluent and air space disease in the right upper
lobe. On [**2181-1-15**] significant resolution of ill defined air
space opacities with persistent opacity at the right lung
base. On [**2181-1-21**] atelectasis at the right lung base with no
consolidation, effusion or pneumothorax.
HOSPITAL COURSE: The patient is a 47 year-old with asthma
and chronic obstructive pulmonary disease exacerbation,
aspiration pneumonia status post extubation in the Operating
Room one day prior to transfer to the Medical Service, in stable
respiratory status. While in the hospital the patient was
continued on her steroid taper for asthma/chronic obstructive
pulmonary disease exacerbation. She was treated with a fourteen
day course of po Levofloxacin and intravenous Clindamycin for
aspiration pneumonia. A neck airway CT was obtained, which
revealed severe tracheomalacia near clasp of the trachea and
bronchomalacia as well as multifocal ground glass lung opacities,
small bilateral pleural effusions and bibasilar atelectasis.
The pulmonary team of Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] followed the
patient throughout the hospital stay. A video swallow study was
obtained, which revealed no evidence of aspiration pneumonia,
but the patient was maintained on a nasogastric tube with tube
feeds during hospital stay for fear of loss of airway or
aspiration. A bronchoscopy was attempted, which revealed
supraglottic edema with tissue redundancy, which was thought to
be secondary to gastroesophageal reflux disease. The patient
then had a pH probe placed without manometry (which she refused),
which revealed evidence of reflux disease. Dr. [**Last Name (STitle) **] of
ENT evaluated the patient. A video probe was done, which
revealed swelling of the glottic area. It was decided that no
esophagogastroduodenoscopy or bronchoscopy would be performed
until the upper airway was cleared. The patient will wait for
two to three weeks for the swelling to decrease in the glottic
area. A high dose proton pump inhibitor of Prilosec at 40 mg po
b.i.d. was prescribed to the patient prior to discharge. While
in the hospital the patient was maintained on intravenous Zantac.
The patient will follow up with ENT in the next two to three
weeks as well as with pulmonary and her primary care physician.
[**Name10 (NameIs) **] procedure will be done until her case is reevaluated. A T
tube tracheostomy as well as a Y stent in her airway was
considered by the pulmonary team while in the hospital, but will
be held off until upper airway swelling decreases.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Asthma/chronic obstructive pulmonary disease
exacerbation.
2. Aspiration pneumonia.
3. Tracheomalacia/bronchomalacia.
4. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS: The patient will continue on her
regular medications at home. Her only new medications are
Prilosec 40 mg po b.i.d. and Prednisone steroid taper 10 mg
po q.d. times two days and 5 mg po q.d. times three days.
The patient will have close follow up with ENT, pulmonary and
her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 37029**] [**Name (STitle) 34792**] [**Telephone/Fax (1) 37030**].
[**Doctor Last Name **] [**Doctor Last Name **] 12.AAD
Dictated By:[**Last Name (NamePattern1) 1183**]
MEDQUIST36
D: [**2181-1-26**] 10:23
T: [**2181-1-29**] 07:37
JOB#: [**Job Number 37031**]
ICD9 Codes: 5070, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5170
} | Medical Text: Admission Date: [**2157-1-14**] Discharge Date: [**2157-1-18**]
Service: MEDICINE
Allergies:
Lidocaine (Anest)
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89-yo M w/extensive hx including HTN, MI, CABG X 2, carotid
stenosis s/p bilat CEA, afib, CRI, and non-Hodgkins lymphoma in
remission. Presents w/hx of SOB since shortly before noon today
until arrival in ED in evening. Hx limited due to patient being
taken for VQ study. Basically, pt. notes that he began to feel
SOB around lunch time with no precipitant that he can recall. It
persisted until he came to ED at which point it began to
resolve. Only recent problems pt. can note are difficulty eating
since his L CEA as well as recent diarrhea and very little
urination. Per pt., nursing home told him diarrhea had a little
bit of blood in it. Pt. reports some recent nausea w/o vomiting.
No fevers, weight change, sweats, chills. Found to have INR of
10 on arrival at ED. Was given 5 mg SC vit K and 1 unit FFP.
Past Medical History:
-hypertension
-carotid stenosis s/p Rt. CEA'[**52**] and now s/p L CEA with patch
angioplasty on [**2156-12-21**]
-hypercholestremia
-CAD with chronic angina-stable, s/p MI, s/p CABG's x2
-chronic Atrial fibrillation
-CHF, EF 50%, O2 dependant --> more recent ECHO [**12-17**] showed EF
of 20-30% and 3+ MR [**First Name (Titles) **] [**Last Name (Titles) **]
-chronic renal insuffiency ( 1.2-1.6)
-on-Hodgkins lymphoma
-Major depression with sucidal ideation
-macrcytic anemia
-chronic low back pain
-cervical dissc disease s/p cervical laminectomy
-bilateral catracts s/p surgery
Social History:
Retired educator, wife with [**Name2 (NI) 8483**] in nursing home. Patient
lives alone. Former smoker
Family History:
unknown
Physical Exam:
99.9,89,156/71,20,94% on 3.5L
GEN: Thin, lying in bed NAD.
HEENT: Not assessed; bandages s/p CEA noted
CVS: Irregular rhythm, no m/r/g
PULM: Coarse inspiratory/expiratory breath sounds bilat in all
lung fields but w/good air movement.
ABD/GU: No palpable inguinal LAD.
NEURO: Grossly normal.
SKIN: Multiple ecchymoses bilat in UE's. Otherwise no cyanosis,
rashes or other obvious lesions.
EXT: trace bilateral LE edema
Pertinent Results:
.CBC: 9.1 27.8* 149 Diff: N 88.5* L 9.1* M 2.3 Eo 0 Bas 0.1
.PT,PTT,INR: 80.9,45.0,10.7
.Chem-7: 134,4.8,96,19,104,2.8,139
.ALT,AST,ALK,TBILI,ALB - 33,44,144,0.6,3.8
.D-dimer:979
.LDH:414
.CK, MB, Trp: Pend,4,0.20
.CXR: CHEST, ONE VIEW: Comparison with [**2156-12-24**]. The
patient is status post CABG. The cardiac and mediastinal
contours are stable. There are no consolidations, effusions,
pneumothorax, or pulmonary vascular congestion. IMPRESSION: No
acute cardiopulmonary process.
Brief Hospital Course:
A/P: 89-yo M w/extensive comorbidities who present with sudden
onset SOB while at his nursing home, likely to have UGIB given
his melena
...
# SOB: His shortness of breath was thought to be secondary to
his aspiration as he had been complaining of difficulty
swallowing after his recent CEA. He also did show increased
risk of aspiration on a bedside swallow examination during his
hospitalization. His chest xray on admission was negative for
signs of volume overload, although his oxygen saturation and
comfort improved with some diuresis. He was continued on
albuterol and ipratropium nebulizers with good relief. A V/Q
scan done on admission was low probability for pulmonary
embolism. He required 4L of oxygen at time of discharge to
maintain his oygen saturation.
...
# GIB. This was likely an UGIB due to supratherapeutic INR. He
had no history of NSAID use or EtOH use, his colonoscopy 3
years ago was negative per patient while at [**Hospital3 **].
He received 3 units of PRBC, although his hematocirt slowly
trended down with occasional melena. He was started on protonix
and his INR was reversed with FFP and vitamin K, but secondary
to his respiratory status, he was felt to be a poor candidate
for egd and colonoscopy.
....
# ARF: His initial presentation of acute renal failure was
likely secondary to dehydration as his FeNa was 1% in the
setting of home diuretics, rare urine eosinophils, but no
peripheral eosinophils were found. He responded well to
hydration, but then his creatinine worsened with likely
overdiuresis. Laboratory monitoring was held after the patient
became comfort measures.
...
#Elevated WBC: The patient was without a clear source of
infection, he was afebrile although with a WBC up to 14.2 with
78%PMN. His chest xray was clear, blood, urine, stool cultures
were negative.
.
#Elevated Lactate: His lactate peaked at 2.9 but trended down.
The etiology was unclear, he was monitored with serial abdominal
exams for possible bowel ischemia, given his leukocytosis,
although unlikely given his elevated INR
.
# ANEMIA
He received 3 units of PRBC, he anemia was likely secondary to
GI blood loss
-
...
# RECENT L CEA. His surgeons were contact[**Name (NI) **] in regards to
holding his plavix given his recent CEA and now acute GI blood
loss. He was to continue plavix, but as the patient was changed
to comfort measures, plavix was held.
..
# HTN/AFIB/CAD
His home lasix, and antihypertensive were held in the setting of
comfort measures only
...
# DEPRESSION
His home medications were held in the setting of comfort
measures only
...
# PPx
- Activity as tolerated
...
# FEN: He was evaluated to have aspiration risk, but given his
comfort measures status, he was continued on a regular diet as
tolerated
Code CMO
Disp: Home with Hospice
...
Medications on Admission:
Bactrim DS x 7 dd for UTI
Trazodone 25 mg
Sertraline 25 mg Tablet
Aspirin 81 mg Tablet, Delayed Release
Cyanocobalamin 500 mcg
Folic Acid 1 mg
Docusate Sodium 100 mg
Atorvastatin 80 mg
Coumadin 1 mg
Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO
Q4-6H:prn
Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-13**]
Puffs q4h:PRN
Acetaminophen 160 mg/5 mL Solution Sig: 650mgm PO Q4-6H:PRN
Albuterol Sulfate 0.083 % Solution One Inhalation
Q6H:PRN
Isosorbide Dinitrate 10 mg Tablet Sig
Clopidogrel 75 mg
Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Hydralazine 10 mg PO Q6H
Isosorbide Dinitrate 10 mg TID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: 1-20 mg PO q1hr
as needed for pain.
Disp:*100 mls* Refills:*0*
4. Ativan 0.5 mg Tablet Sig: 1-4 Tablets PO every four (4)
hours.
Disp:*180 Tablet(s)* Refills:*0*
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 417**] Hospice
Discharge Diagnosis:
GI Bleed
Discharge Condition:
Stable
Discharge Instructions:
If you experience increased pain, shortness of breath or other
concerning symptoms please contact your doctor
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2157-2-15**] 4:00
ICD9 Codes: 5789, 4280, 5859, 5849, 2851, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5171
} | Medical Text: Admission Date: [**2171-5-6**] Discharge Date: [**2171-6-8**]
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fever, hypoxia, hypotension
Major Surgical or Invasive Procedure:
1. Tracheostomy
2. PICC line
3. Mechanical ventilation/intubation
History of Present Illness:
[**Age over 90 **] yo F with h/o dementia, CVA with residual left sided
paralysis who presents from a NH with fevers and hypoxia. Per NH
records and family report, pt was found to be febrile to 103F,
hypoxic to 88% on RA today and was noted to have a cough.
Daughter believes that pt has been "sick" for at least a week as
she has been less conversant and responsive. She has also
noticed shallow, rapid breathing that occasionally improves
after neb treatments. A CXR was reportedly done at the NH on
Monday that was negative. However, she had increasing mouth
secretions and by Wednesday the daughter believes the [**Name (NI) **] started
the pt on an antibiotic for PNA, although this is not listed on
the transfer paperwork. Yesterday evening, the patient was noted
to have a fever and hypoxia and was transported to ED for eval.
.
In the ED, initial vitals T 102, HR 111, BP 120/63, RR 20s, O2
sat 100% NRB -> 90% RA -> 99% 6L NC. Labs notable for WBC 8.1
with 77.3%N, lactate 1.7, Na 150, BUN 36, Cr 0.9, UA negative.
CXR with small to moderate right pleural effusion with
underlying infection that could not be excluded. Given 4L IVFs
with improvement in HR to 80s; however, BP trended down as low
as 86/38. RIJ TLC placed and started on levophed gtt at 0.04
mcg/kg/min with BPs to 116/66. Also given vancomycin 1 gm IV X
1, zosyn 4.5 gm IV X 1, tylenol 1 gm PR, albuterol nebs and
admitted to [**Hospital Unit Name 153**] for further care. Per ED discussion with
family, pt is DNR but ok to intubate for now if necessary.
.
ROS could not be performed with patient as not responding to
questions or commands in Mandarin.
Past Medical History:
h/o CVA with L sided paralysis but contractures in all 4
extremities, PEG
Dementia
HTN
CHF, unclear if systolic or diastolic
Spinal stenosis
Sciatica
h/o peptic ulcer
Hypothyroidism
Osteoporosis
Rheumatoid Arthritis
h/o PNA, UTIs
MRSA carrier
Social History:
Widowed. Mandarin speaking. Per family, has resided in NH since
CVA 3-4 years ago. Speaks occasionally in very short sentences
to daughter but per [**Name (NI) **] and [**Name (NI) **] notes, pt mostly aphasic and
non-verbal. No h/o tobacco but significant second hand smoke
exposure. No illicits, EtOH.
Family History:
non-contributory
Physical Exam:
Admission physical exam:
T 98.2 BP 94/40 HR 87 RR 22-27 O2 sat 97% 4L NC
Gen - elderly female in no apparent distress, not responsive to
commands in Mandarin. Briefly opens eyes to sternal rub. Lying
on left side
HEENT - sclerae anicteric, difficult to assess MM as pt not
cooperative with opening mouth. Cannot assess JVP due to RIJ
TLC.
CV - RRR, no m/r/g appreciated
Lungs - Decreased BS at right base without clear crackles
appreciated, exam is limited by pt not taking deep breaths
Abd - Soft, mod distended, + BS, PEG in place with surrounding
denuded area with macerated tissue. PEG dressing c/d/i.
Ext - no LE edema but edema noted in UEs with L > R. WWP with 1+
pulses distally.
Neuro - lethargic, briefly opens eyes to sternal rub. No
spontaneous movement of any 4 extremities. All 4 extremities
with contractures. Increased tone of RUE. LUE flaccid. [**12-25**]+ DTRs
b/l. Upgoing toe on left, equivocal on right. Unable to assess
remaining neurologic exam due to MS.
Skin - no rashes appreciated
Pertinent Results:
LABS ON ADMISSION:
[**2171-5-6**] 12:20AM BLOOD WBC-8.1 RBC-3.19* Hgb-9.6* Hct-30.5*
MCV-96 MCH-30.1 MCHC-31.5 RDW-15.0 Plt Ct-287
[**2171-5-6**] 12:20AM BLOOD Neuts-77.3* Lymphs-17.6* Monos-2.5
Eos-1.8 Baso-0.6
[**2171-5-5**] 10:30PM BLOOD PT-11.9 PTT-21.0* INR(PT)-1.0
[**2171-5-5**] 10:30PM BLOOD Glucose-103 UreaN-36* Creat-0.9 Na-150*
K-3.9 Cl-114* HCO3-29 AnGap-11
[**2171-5-6**] 03:46AM BLOOD Albumin-2.5* Calcium-6.3* Phos-3.0 Mg-2.1
Iron-49
.
.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2171-6-5**] 04:51AM 12.8* 2.89* 8.7* 26.7* 92 30.0 32.4 16.5*
994*
Source: Line-PICC
[**2171-6-4**] 04:32AM 13.1* 2.80* 8.3* 26.4* 94 29.7 31.5 16.5*
1002*
Source: Line-picc
[**2171-6-3**] 03:16AM 12.6* 2.83* 8.4* 26.9* 95 29.5 31.1 16.3*
1019*1
Source: Line-PICC
[**2171-6-2**] 02:08AM 8.9 2.84* 8.4* 26.8* 94 29.7 31.5 16.1*
967*
Source: Line-PICC
[**2171-6-1**] 04:03AM 10.2 2.81* 8.4* 26.8* 96 30.0 31.3 16.4*
993*
Source: Line-PICC
[**2171-5-31**] 04:24AM 8.0 2.67* 7.9* 25.6* 96 29.5 30.8* 16.4*
919*
Source: Line-PICC
[**2171-5-30**] 04:15AM 11.4* 2.84* 8.4* 26.9* 95 29.4 31.1 16.8*
971*
.
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-6-5**] 04:51AM 95 14 0.7 138 3.1* 96 33* 12
Source: Line-PICC
[**2171-6-4**] 12:42PM 3.9
Source: Line-pic
[**2171-6-4**] 04:32AM 105 13 0.6 139 3.8 99 32 12
Source: Line-picc
[**2171-6-3**] 03:16AM 102 12 0.7 134 3.7 98
Source: Line-PICC
[**2171-6-2**] 02:08AM 118* 10 0.7 137 3.6 101 28 12
Source: Line-PICC
[**2171-6-1**] 08:02AM 3.8
Source: Line-left picc
[**2171-6-1**] 04:50AM GREATER TH1
Source: Line-PICC
[**2171-6-1**] 04:03AM 112* 9 1.1 132* 7.6*2 101 25 14
Source: Line-PICC
[**2171-5-31**] 04:30PM 9 1.1 138 3.7 100 30 12
Source: Line-PICC
[**2171-5-31**] 04:24AM 116* 8 1.1 141 3.8 100 29 16
Source: Line-PICC
[**2171-5-30**] 04:50PM 115* 8 1.3* 138 3.6 99 32 11
Source: Line-PICC
[**2171-5-30**] 04:15AM 100 9 1.2* 138 3.7 97 32 13
.
.
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2171-5-30**] 04:15AM 4 22 100 0.2
Source: Line-PICC
[**2171-5-29**] 03:54AM 8 22 98 0.2
.
.
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2171-6-5**] 04:51AM 8.2* 2.4* 2.0
Source: Line-PICC
[**2171-6-4**] 04:32AM 8.1* 2.3* 2.0
Source: Line-picc
[**2171-6-3**] 03:16AM 8.0* 2.2* 2.0
Source: Line-PICC
[**2171-6-2**] 02:08AM 8.1* 2.5* 2.2
Source: Line-PICC
[**2171-6-1**] 04:03AM 7.8* 3.4 2.3
.
.
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent Comment
[**2171-6-4**] 01:09PM [**Last Name (un) **] 32*1 53* 7.45 38* 10
NOT INTUBA2
[**2171-6-3**] 01:09PM MIX 32*1 51* 7.43 35* 7
[**2171-6-2**] 11:18AM [**Last Name (un) **] 37.23 /19 40 PND PND PND PND
PND TRACH MASK
[**2171-6-1**] 01:47AM [**Last Name (un) **] 54*1 44 7.45 32* 5
[**2171-5-31**] 10:17PM [**Last Name (un) **]
GREEN-TOP/4
[**2171-5-31**] 11:01AM [**Last Name (un) **] 37*1 53* 7.41 35* 6
[**2171-5-30**] 02:15PM ART 37.75 /24 [**Telephone/Fax (2) 83491**] 7.51* 36*
9 INTUBATED
[**2171-5-30**] 02:06PM [**Last Name (un) **] 37.76 /24 [**Telephone/Fax (2) 83492**] 7.59*7 35*
11 INTUBATED SPONTANEOU8 GREEN TOP
[**2171-5-28**] 05:52PM ART 88 44 7.47* 33* 7
[**2171-5-15**] 09:19PM CENTRAL VE9 39*1 56* 7.31* 30
0
[**2171-5-11**] 04:58PM ART 98 38 7.39 24 -1
[**2171-5-9**] 12:42PM CENTRAL VE9
[**2171-5-8**] 08:07PM ART 37.710 14/0 [**Telephone/Fax (2) 83493**]* 39 7.35
22 -3 431 73 INTUBATED CONTROLLED
[**2171-5-8**] 05:58PM ART 127* 55* 7.22*11 24 -5
[**2171-5-6**] 04:12AM MIX
[**2171-5-6**] 02:54AM ART 36.8 /23 89 46* 7.38 28 0
NOT INTUBA2
.
.
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2171-5-11**] 04:58PM 2.5*
[**2171-5-9**] 12:42PM 1.8
[**2171-5-9**] 04:25AM 3.0*
[**2171-5-8**] 08:07PM 1.8
[**2171-5-8**] 05:58PM 5.1*1
[**2171-5-6**] 02:54AM 1.2
[**2171-5-5**] 10:52PM 1.7
.
.
PLEURAL
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos
[**2171-5-8**] 10:59AM 72* [**Numeric Identifier **]* 88*1 4* 8*
25 CELL DIFFERENTIAL
PLEURAL CHEMISTRY TotProt Glucose LD(LDH)
[**2171-5-8**] 10:59AM 0.0 75 40
ASCITES
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Macroph Other
[**2171-5-28**] 03:09PM 218* 39* 11* 26* 0 62*1 1*2
PIGMENT LADEN CELLS PRESENT
ATYPICAL CELLS,REFER TO CYTOLOGY
REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21496**],MD ON [**2171-5-29**]
ASCITES CHEMISTRY TotPro Glucose Creat LD(LDH) Amylase TotBili
Albumin
[**2171-5-28**] 03:09PM 3.0 94 1.0 160 13 0.2 1.3
.
.
Date 6 Specimen Tests Ordered By
All [**2171-5-5**] [**2171-5-6**] [**2171-5-8**] [**2171-5-9**] [**2171-5-14**]
[**2171-5-24**] [**2171-5-28**] [**2171-6-1**] [**2171-6-2**] [**2171-6-3**] All
BLOOD CULTURE BLOOD CULTURE NOT PROCESSED Influenza A/B by DFA
MRSA SCREEN PERITONEAL FLUID PLEURAL FLUID SPUTUM STOOL URINE
All EMERGENCY [**Hospital1 **] INPATIENT
[**2171-6-3**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-6-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2171-6-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +, GRAM NEGATIVE ROD(S), GRAM NEGATIVE ROD
#2, YEAST} INPATIENT
[**2171-6-1**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-6-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-6-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-28**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2171-5-24**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2171-5-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-14**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2171-5-9**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-5-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-9**] BLOOD CULTURE NOT PROCESSED INPATIENT
[**2171-5-8**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL INPATIENT
[**2171-5-6**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT
[**2171-5-6**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2171-5-6**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2171-5-5**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2171-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
[**2171-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
OTHER:
[**2171-5-6**] 03:46AM BLOOD calTIBC-189* VitB12-852 Folate-GREATER TH
Ferritn-177* TRF-145*
[**2171-5-6**] 03:46AM BLOOD TSH-2.2
[**2171-5-6**] 03:46AM BLOOD Free T4-1.1
.
URINE:
[**2171-5-5**] 10:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2171-5-5**] 10:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
MICRO:
Bl cx - no growth to date
Urine legionella - negative
Influenza DFA - negative
Sputum culture ([**2171-6-1**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**5-/2468**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
YEAST. SPARSE GROWTH.
Urine culture ([**2171-6-1**]): YEAST. 10,000-100,000 ORGANISMS/ML
C. diff toxin: negative
.
CARDIOLOGY:
TTE ([**5-6**]):
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
global biventricular systolic function. Mild aortic
regurgitation. No significant pericardial effusion. Increased
PCWP.
CLINICAL IMPLICATIONS:
Based on [**2168**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
RADIOLOGY:
CXR:
The heart is moderately enlarged and the aortic contour is
tortuous. Vascular calcifications are seen along the aorta and
in
the right neck. Additionally, rounded calcification along the
right
mediastinal contour is atypical for lymph node calcification and
may also represent vascular calcification. There is small to
moderate right pleural effusion with adjacent atelectasis,
although right lower lung infection cannot be excluded. There
may also be tiny left pleural effusion with some atelectasis.
The upper lungs are grossly clear, without evidence of pulmonary
edema. Degenerative changes are noted along the thoracic spine.
IMPRESSION:
1. Marked cardiomegaly, without evidence of pulmonary edema.
2. Right pleural effusion with atelectasis, although right
basilar infection cannot be excluded.
.
Port CXR post line - RIJ terminating in appropriate position, no
PTX
.
Final Report
REASON FOR EXAM: Pulmonary edema. Acquired pneumonia.
Comparison is made with prior study performed [**2171-6-3**].
Tracheostomy tube is in standard position. Large right and small
to moderate
left pleural effusion are unchanged. Cardiomediastinal contours
are partially
visualized and unchanged. Mild interstitial edema seen in the
left lung is
stable. There is no pneumothorax. Opacity in the left base is
unchanged
likely atelectasis.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: WED [**2171-6-5**] 12:02 PM
.
.
CT Abdomen
HISTORY: [**Age over 90 **]-year-old woman with history of CVA, dementia,
hospital-acquired
pneumonia, status post tracheostomy, now with emesis for four
days. A GJ
tube. Distended abdomen on exam. The patient underwent exchange
of the GJ
catheter earlier today.
COMPARISON: None.
TECHNIQUE: MDCT axial images were obtained from the lung bases
to the pubic
symphysis following administration of 50 mL of Optiray
intravenous contrast
that was hand injected via the left upper extremity PICC line.
Multiplanar
coronal and sagittal reformatted images were generated.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is a moderate right
and small
left pleural effusion, with underlying atelectasis. There is
fluid within the
distal esophagus. The gastrostomy balloon is located within the
stomach, and
the jejunostomy catheter terminates in the jejunum.
The liver is normal. The gallbladder is decompressed. The spleen
is not
enlarged. The pancreas, adrenals and kidneys are unremarkable.
There are dilated proximal small bowel loops and decompressed
diatal lops
are seen, however contrast progresses into the decompressed
loops consistent
with a partial obstruction.
There is a moderate amount of ascites within the abdomen and
pelvis. The
greater omentum is abnormal, with nonspecific soft tissue
infiltration. This
may be related to recent procedure/tube placement and reactive,
but in the
absence of recent instrumentation could be seen with neoplasm.
The abdominal aorta is normal in caliber, with dense vascular
atherosclerotic
calcifications.
CT PELVIS WITH INTRAVENOUS CONTRAST: The uterus is not
identified. Two low-
density ovoid soft tissue foci measuring up to 2.3 cm in
diameter (2:66) in
the left hemipelvis, one represents the ovary which contains a
cystic mass.
There is a Foley catheter in the urinary bladder, which is
decompressed. The
rectum and sigmoid colon are unremarkable.
There is diffuse soft tissue stranding consistent with anasarca.
BONE WINDOWS: There are severe compression deformities of L2,
T11 and T9,
with resultant narrowing of the spinal canal, most severely at
T9 and T11.
Heterotopic ossification arises from the anterior aspect of the
intertrochanteric region of the left femur is likely
post-traumatic in
etiology.
IMPRESSION:
1. Partial small bowel obstruction with transition point in the
right lower
quadrant.
2. Left ovarian cystic mass with thickening of the omentum and
ascites is
concerning for ovarian carcinoma, The ovarian mass could be
further evaluated
with ultrasound. Alternatively, diagnostic paracentesis could be
performed
3. Moderate right and small left pleural effusions.
4. Fluid in the distal esophagus.
5. G-tube balloon in the stomach, and jejunostomy catheter
terminating in the
jejunum.
6. Compression deformities of T9, T11 and L2 with resultant
narrowing of the
spinal canal, significantly at T9 and T11.
Revised report was discussed with Dr. [**Last Name (STitle) **] at 9:30AM on [**2171-5-28**]
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: TUE [**2171-5-28**] 9:32 AM
.
.
Brief Hospital Course:
[**Age over 90 **] female with h/o CVA, dementia, RA who presented with fever
and hypoxia to the ICU [**2171-5-6**]. She was started on Vanc, Zosyn
and Levofloxacin for Health Care associated pneumonia vs.
aspiration PNA. Hemodynamically she was stable and transferred
to the general medicine floor [**2171-5-7**]. On the general medicine
floor patient was continued for treatment of HAP, had G tube
replaced to a GJ tube and thoracentesis to eval effusion.
Patient received lasix for diuresis. On the floor patient's
blood pressure ranged from 92-141/56-87, was re-started on
outpatient B-blocker and started on lasix diuresis. She was
afebrile, pulse 97-118, 94-99 on 2 L. At 1830 [**2171-5-8**] patient
was found to be tachypneic (RR 40s) and ABG demonstrated CO2 55,
pH 7.22 and lactate of 5.1. Patient was consequently intubated,
required phyenlepineprine for pressor support and transferred to
the [**Hospital Unit Name 153**]. [**Hospital 153**] hospital course according to problem list as
below. The patient was ultimately discharged with comfort
measures.
Respiratory distress: Patient known HAP PNA, large effusion and
diastolic CHF. Acute episode requiring intubation most likely
related to aspiration. Patient with poor urine output, did not
respond to lasix and dopamine drip support. Continued Zosyn and
Vancomycin for total 8 days treatment ([**Date range (1) 83494**]) of HAP.
Scopolamine patch to decrease oral secreations. Continued
albuterol, ipratropium nebs prn for wheezing. From [**Date range (1) 11734**],
patient was stable on ventilator, however experienced some
apneic events due to oversedation and was responsive to narcan.
On [**5-22**], after much discussion with HCP and family, Mrs. [**Known lastname **],
recieved a tracheostomy by thoracic surgery. On [**5-23**] crepitus
was noted around the trach site, thoracic surgery consulted,
resolved without intervention. Mrs. [**Known lastname **] was gradually weaned off
the vent from [**5-22**] to [**5-31**] using MMV overnight due to apnea and
PS during most of the day. On [**5-28**], she had a possible
aspiration event after GJ tube replacement, however, she was
monitored for infection/fever, which did not develop. A sputum
culture from the trach revealed MRSA, however, the trach is
likely colonized. Before discharge, Mrs. [**Known lastname **] was tolerating her
tracheostomy mask well with no signs of respiratory distress or
infection. However, upon discharge after repeated lengthy
discussions with her family, it was determined that Ms. [**Known lastname **] was
to be treated with comfort measures, so her trach was capped,
and started on morphine, ativan, and continued on albuterol nebs
while breathing on room air. She was discharged comfortable and
breathing room air in the high 80 percents.
Abdominal Distension: Patient noted to have abdominal distension
on admission to [**Hospital Unit Name 153**]. KUB on [**5-9**] with no obstruction, bowel
regimen increased. Pt noted to have increasingly decreased
bowel sounds over next week, however portable supine on [**5-24**]
showed no obstruction. GJ tube replaced by IR on [**5-27**], with
subsequent emesis and drainage of gastric contents out of tract.
CT scan abdomen showed properly placed GJ tube, ascites and
ovarian mass. Diagnostic paracentesis cytology consistent with
adenocarcinoma. G tube placed to suction and J tube to gravity.
She was started on tube feeds until she started to drain dark
brown mildly heme-positive material from her gastric tube. It
was unclear if the drainage was either coffee ground emesis or
feculent material from obstruction. She remained NPO at
discharge due to comfort measures. Her G-tube was to gravity and
J tube clamped.
Allergic Reaction: On [**5-13**], day 7 of Zosyn treatment, Mrs. [**Known lastname **]
developed a rash on her torso that was maculopapular and
erythematous. The rash ultimately spread to her upper and lower
extremities, sparing her feet, palms and face. Froom [**Date range (1) **],
the rash progressed to blister/bullae-like lesions, then began
weepy before crusting and desquamating. Zosyn and Vancomycin
were stopped due to concern of allergy and it is thought that
the reaction most likely from Zosyn and not Vancomycin. The
rash was treated with supportive care and sulfadine creme to
prevent super-infection. Due to insensible losses, fluids were
repleated as needed. At time of discharge, rash resolved with
minimal desquamation.
Hypotension: Most likely combination of septic shock (related to
HAP) and cardiac failure (see below). Lactate elevated on
admission, trended downward. Patient was slowly weaned off
pressor support. No aggressive fluid resucitation due to
overload on exam and CXR. Over course of ICU stay, Mrs. [**Known lastname **] had
intermittent hypotension, usually related to over-sedation.
When sedation weaned, blood pressure returned to her normal.
Mrs. [**Known lastname **] ultimately tolerated Lasix gtt started on [**5-28**] later
transition to Q8 boluses, to diurese excess fluid off with a
goal of negative 1 liter/day. Upon discharge she was not on any
diuretics with the aim of comfort measures.
Cardiac Failure: EF demonstrated new regional wall abnormality
and worsened MR, troponin and CK negative. EKG no ST elevation.
Most likely suffered strain related to acute respiratory event.
Held outpatient BB and CCB due to low blood pressure and due to
comfort measures at discharge it is not recommended that any of
her outpatient medications be restarted.
Anemia: Decreased to 24 from 29. Drop most likely related to IVF
and possible suppression for sepsis. Iron studies consistent
with anemia of chronic disease. Patient required no
transfusions.
UTI: Urine with yeast on [**5-9**], foley was changed. On [**5-24**], pt
became hypotensive and tachycardic, remained afebrile. Urine
grew E. Coli, completed course of Bactrim.
Rheumatoid arthritis: Held azathioprine in setting of acute
infection and due to comfort measures at discharge it is not
recommended that any of her outpatient medications be restarted.
Osteoporosis: Continued outpatient calcium and vitamin D and due
to comfort measures at discharge it is not recommended that any
of her outpatient medications be restarted.
Goals of care: Ongoing discussion with family goals of care and
patient's quality of life. After trying many interventions for
her multiple medical problems, the patient seemed unlikely to
recover. Her daughter decided to switch from DNR to DNR/DNI with
no escalating care including pressors. After more repeated
conversations, it was determined that Ms. [**Known lastname **] goal of care
would be to maximize comfort measures. The ICU team then
withdrew invasive measures such as ventilation through
tracheostomy, and plans for any future G tube use. She was
started on morphine, ativan, and continued on albuterol nebs for
comfort. The remainder of her home medicines and medicines in
the hospital were discontinued.
Medications on Admission:
Fleet enema daily prn
Natural tears 1 ddrop q4h prn
Lacrilube ointemnt qhs
Levothyroxine 125 mcg daily
Calcium carbonate 500 mg [**Hospital1 **]
Vitamin D 400 units daily
Prevacid 15 mg tab daily
Aricept 10 mg daily
Multi-delyn liquid 5 ml daily
KCL 10 meq qMon,Wed,Fri
Metoprolol tartrate 25 mg daily
Vitamin C 500 mg (5ml) [**Hospital1 **]
Reglan 5 mg/5ML 10 ML tid
Scopolamine patch 1.5 mg/72hr behind ear q72h
Amlodipine 5 mg daily
Lasix 20 mg tab qod
Azathioprine 25 mg daily
Duoneb qid and q2h prn
Tylenol 650 mg prn
Docusate 100 mg [**Hospital1 **] prn
Milk of Magnesia 30 ml prn
Dulcolax 10 mg PR prn
Tube feeds: Jevity 1.2 at 60 ml/hr for 15 hrs off at 8am and on
at 5pm. 30 ml H2O flush before and after medss via G tube. 300
ml H20 flushes q4h
Discharge Medications:
1. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO
Q2H:PRN as needed for Pain or dyspnea.
Disp:*15 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary:
pneumonia
small bowel obstruction secondary to ovarian cancer
acute renal failure secondary to hypovolemia now resolved
.
Secondary:
-asthma
-dementia /Alzheimers type
-gait disorder
-dysphagia
Discharge Condition:
comfortable, afebrile, stable vitals, extubated, NPO,
nonambulatory
Discharge Instructions:
You were admitted to the ICU for respiratory distress, probable
pneumonia, and small bowel obstruction secondary to ovarian
cancer. You were treated with antibiotics and you were intubated
due to difficulty breathing. You eventually had to have a tube
placed in your trachea since you were intubated for such a long
time. After several repeated discussions with your family it was
decided that you would be provided with measures to maximize
your level of comfot, but that we would discontinue attempts for
invasive care and escalation of care. We also discontinued use
of your feeding tube due to the small bowel obstruction.
.
You should not take any of your usual home medicines since you
are now being medicated only for your own comfort. The only
medicine that we will prescribe you is liquid morphine that you
should take as needed for pain or until you have achieved
comfort.
.
Please take all medications as prescribed.
Please do not hesitate to return to the hospital if you have any
concerning symptoms.
Followup Instructions:
none
ICD9 Codes: 0389, 5849, 2760, 5070, 5119, 2762, 5990, 4280, 4019, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5172
} | Medical Text: Admission Date: [**2145-12-6**] Discharge Date: [**2145-12-23**]
Date of Birth: [**2078-11-23**] Sex: M
Service: SURGERY
Allergies:
Ephedrine / Adhesive Tape / Oxycodone / Augmentin / Bactrim Ds
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
[**2145-12-17**]: Angiogram with coiling
History of Present Illness:
67M with history of metastatic renal cell cancer presented
to an outside hospital [**2145-11-28**] with BRBPR. He was
anticoagulated with coumadin for a mechanical valve and his INR
was 3.9, his hematocrit on admission was 24. He was transfused
roughly 2 units pRBC, 4U FFP and given vitamin K. He underwent
an upper endoscopy [**2145-11-30**] which demonstrated gastritis,
duodenitis and an actively bleeding duodenal ulcer which was
clipped. He was discharged home on [**2145-12-2**] and returned on
the same day with abdominal pain and bright red blood per
rectum.
He underwent another EGD [**12-3**] which did not show evidence of
bleeding, but he did undergo a colonoscopy which demonstrated a
splenic flexure mass which is hypervascular, consistent with a
hypernephroma. His hematocrit on discharge to [**Hospital1 18**] is 27.4.
He
is transferred to [**Hospital1 18**] for further management.
Past Medical History:
RCC [**2140**]; MI [**2136**]; DM- diet controlled
PSH: CABGx5 and AVR [**2136**]; Nephrectomy [**2140**]; ERCP x 3 with
multiple stent placements
[**2144-2-11**]: CBD excision with cholecystectomy, Roux-en-Y and segment
III, IV, V, VI and VII mass resections
[**2144-9-18**]: Wound revision and closure of incisional hernia with
Prolene mesh
Supratherapeutic INR
Bacteremia, VRE/E.coli
[**2145-12-17**] Coil and Gelfoam embolization of the 3rd to 4th order
inferior branch off the replaced right hepatic artery
Social History:
N/[**Doctor First Name **] has no history of alcohol use. He has a smoking history
but quit eight years ago. He has no history of IV drug use,
marijuana use, tattoos, hepatitis, or piercing. He did have
blood transfusions in [**2136**] and [**2140**]. He has one year of college.
He has been married for 36 years.
Family History:
N/C
Physical Exam:
Vitals: Temp 97.9, HR 92, BP 140/70, RR 16, 92% RA
Gen: alert and oriented, somewhat somnolent
CVS: RRR, systolic murmur present
Pulm: CTA b/l
Abd: soft / non distended / min tenderness epigastrium
Rectal: giuiac positive, no obvious masses
Pertinent Results:
On Admission: [**2145-12-7**]
WBC-4.0 RBC-3.01*# Hgb-8.2*# Hct-24.9*# MCV-83 MCH-27.2
MCHC-32.9 RDW-17.7* Plt Ct-117*
PT-15.0* PTT-30.3 INR(PT)-1.3*
Glucose-93 UreaN-12 Creat-0.8 Na-139 K-3.6 Cl-102 HCO3-29
AnGap-12
ALT-15 AST-25 AlkPhos-147* TotBili-1.0
Calcium-8.7 Phos-2.8 Mg-1.7 Albumin-3.0*
On Discharge: [**2145-12-23**]
WBC-3.6* RBC-3.67* Hgb-10.7* Hct-31.2* MCV-85 MCH-29.2 MCHC-34.4
RDW-18.1* Plt Ct-79*
PT-20.2* INR(PT)-1.9*
Glucose-104 UreaN-12 Creat-1.1 Na-135 K-4.2 Cl-98 HCO3-32
AnGap-9
***HEPARIN DEPENDENT ANTIBODIES-PND
Brief Hospital Course:
67 y/o male admitted from OSH with recent GI bleeding.
Outpatient scope and reports were reviewed and an abdominal CT
was showing:
- Invasion into the hepatic flexure colonic wall by a tumor
closely associated with and possibly arising from the large
segment V-VI hepatic mass.
Colonic wall thickening from the cecum to the proximal
transverse colon, proximal and distal to this mass.
- Increase in size of multiple perihepatic masses adjacent to
the inferior
aspect of the liver in comparison to the prior study.
Due to concern for thrombus risk in his prosthetic aortic heart
valve, heparin was started and then bridged back to coumadin
when it appeared he was not having large amounts of bleeding.
He was receiving blood transfusions almost daily to maintain his
hematocrit 26-30%
Sutent 50 mg was started on [**12-11**], which was the dosage
recommended by his Oncologist Dr [**Last Name (STitle) 76148**]. His records had been
reviewed by oncology at this institution and it was determined
that this was the most appropriate medication given the type of
tumor although there was a risk for bleeding.
On [**12-16**] he was ordered for bowel prep to attempt a colonoscopy
on [**12-17**] and on the morning of [**12-17**] he had multiple large
volume bowel movements that were very bloody. He was transfused
4 units pRBCs on [**12-17**] units on [**12-18**], FFP and platelets x 1.
His Hct was as low as 9.4% and was restabilized at 30%.
On the evening of [**12-17**] an arteriogram was performed. Please see
the report for details. He had Coil and Gelfoam embolization of
the 3rd to 4th order inferior branch off the replaced right
hepatic artery resulting in occlusion of one of the
arteries supplying hepatic/hepatic flexure mass.
Following the procedure his hematocrit has remained 28-33%. He
received an additional 2 units on [**12-22**]. Bowel movements since
the time of the procedure have been brown with no evidence of
bleeding.
His coumadin was only held on the 11th and he has otherwise
received 8 mg daily with goal INR 1.5-2 (has aortic valve).
Platelet count trended down over the past few days since [**12-17**]
when he was 196. Platelet count decreased to 69-79 range.
He was started on methadone for pain management as he was
requiring frequent dosing of dilaudid. Dilaudid usage has
decreased.
All other home medications were maintained.
He is going home today on coumadin 8mg daily and sutent 50mg
daily. He will get daily cbc and inr with results called to Dr. [**Last Name (STitle) 76149**] office [**Telephone/Fax (1) 19102**] (fax [**Telephone/Fax (1) 76150**]).
At time of discharge, vital signs were stable. He was ambulatory
and tolerating a regular diet.
Medications on Admission:
Prilosec 20", lasix 40", duoneb QID, advair diskus 250/50 [**Hospital1 **],
lactulose, amitriptyline, coumadin 12', colace 100", dilaudid 2
q
4 prn, vicodin 1 tab q 4 prn, zenate 5 qday, iron 325 [**Hospital1 **]
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for > 2 stools daily.
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
6. Methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):
Prescribed for pain relief.
Disp:*30 Tablet(s)* Refills:*2*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): Hold for > 2 BMs daily.
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Hydromorphone 4 mg Tablet Sig: [**1-8**] Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Sutent 50 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
11. Outpatient Lab Work
Daily stat cbc, inr with results called first to Dr.[**Last Name (STitle) 76151**]
office [**Telephone/Fax (1) 19102**] and fax'd to Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 697**]
12. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Renal Cell carcinoma with liver metastases now with colonic mass
Lower GI bleeding
Discharge Condition:
Stable, Hct 31.2 upon discharge
Ambulatory
Alert and Oriented. Caution use of too many narcotics
Discharge Instructions:
Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, bleeding from rectum, weakness, dizziness,
increased abdominal pain.
Contact [**Name2 (NI) 76152**] office at [**Telephone/Fax (1) 19102**] for further
medication adjustments and continued plan for oncology
daily labs for INR and CBC with results called to Dr.[**Last Name (STitle) 76153**]
office and fax'd to Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 697**]
Followup Instructions:
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-2-22**] 1:00
Please schedule follow up with Dr. [**Last Name (STitle) **]. [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] will call
you with date/time
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2145-12-23**]
ICD9 Codes: 5789, 4019, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5173
} | Medical Text: Admission Date: [**2134-2-12**] Discharge Date: [**2134-3-5**]
Date of Birth: [**2134-2-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 8840**] is the former
1.78 kg product of a 31 and [**5-24**] week gestation pregnancy,
born to a 34 year old, Gravida I, Para 0 now I woman.
PRENATAL SCREENS: Blood type AB positive, antibody negative,
Rubella immune. RPR nonreactive. Hepatitis B surface
antigen negative. Group beta strep status unknown.
PAST MEDICAL HISTORY: Notable for a temporal lobe seizure,
epilepsy disorder since [**2128**]. Episodes of epigastric pain
and chronic vomiting. There was no definitive diagnosis but
suspicion for porphyria was thought to perhaps be the
etiology. She was treated with Dilantin, Neurontin, Zofran
and Celexa. During the pregnancy, the patient had multiple
evaluations for pregnancy induced hypertension. On the day
of delivery, the mother had a severe headache followed by a
tonic/clonic seizure. She was admitted for evaluation, where
increased blood pressure, increased uric acid and persistent
headache and epigastric pain raised grave concern for
pregnancy induced hypertension. She was taken to elective
cesarean section due to transverse lie.
The infant emerged with good tone and cry. He subsequently
developed mild grunting, flaring and retracting. Apgars were
seven at one minute and seven at five minutes. He was
admitted to the Neonatal Intensive Care Unit for treatment of
prematurity.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight was 1.78 kg; length 44 cm; head
circumference 30 cm. General: Preterm infant in moderate
respiratory distress. HEAD, EYES, EARS, NOSE AND THROAT:
Slightly broad nasal bridge. Anterior fontanel flat.
Positive red reflex bilaterally. Palate intact. Skin
without rashes or lesions. Chest: Inspiratory crackles;
positive grunting, flaring and retracting; symmetric chest
movement. Cardiovascular: Normal S1 and S2 without murmur.
Pulses 2+ and equal. Abdomen soft, no hepatosplenomegaly or
masses. Genitourinary: Normal male; testes descended
bilaterally. Anus patent. Trunk and spine intact. Normal
sacrum. Extremities: Hips stable. Clavicles intact.
Neurologic: Moving all extremities. Slightly decreased
tone. Reflexes consistent with gestational age.
HOSPITAL COURSE: Hospital course by system, including
pertinent laboratory data:
1. Respiratory: [**Known lastname **] was intubated shortly after admission
to the Neonatal Intensive Care Unit. He was treated with
three doses of Surfactant. His maximum ventilator settings
were a peak inspiratory pressure of 22 over a positive end
expiratory pressure of 5; intermittent mandatory ventilatory
rate of 30, 45% oxygen. He weaned gradually over the next 36
hours and was extubated to nasopharyngeal C Pap on day of
life #2. He transitioned to room air on day of life #4 and
continued in room air through the rest of his neonatal
Intensive Care Unit admission. He has had episodes of apnea
and bradycardia intermittently during admission. He usually
has two to four episodes per day. He has not received any
medication for his apnea of prematurity.
At the time of discharge, he is breathing comfortably in room
air with a respiratory rate between 30 and 60.
2. Cardiovascular: [**Known lastname **] has maintained normal heart rate
and blood pressure. A murmur was noted on day of life #9 and
continues through the time of discharge. The murmur is soft
and consistent with peripheral pulmonic stenosis.
3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially
n.p.o. and treated with intravenous fluids. Enteral feedings
were started on day of life #3 and gradually advanced to full
volume. At the time of discharge, he is taking 150 cc per kg
of Preemie Enfamil 24 calorie per ounce p.o. p.g. He takes
about half of his feedings p.o. Serum electrolytes were
checked twice in the first week of life and were within
normal limits. Discharge weight is 2.22 kg with a length of
44 cm and a head circumference of 30.5 cm.
4. Infectious disease: Due to the unknown etiology of the
respiratory distress and unknown group B beta strep status,
[**Known lastname **] was evaluated for sepsis. A white blood cell count
was 6,500 with an initial differential of 10%
polymorphonuclear cells, 0% bands. A repeat on day of life
#2 had a white count of 13,500 with 72% polymorphonuclear and
1% band. A blood culture was obtained prior to starting
antibiotics. The blood culture was no growth at 48 hours and
the antibiotics were discontinued.
5. Hematology: Hematocrit at birth is 45.9%. [**Known lastname **] did
not receive any transfusions of blood products during
admission.
6. Gastrointestinal: [**Known lastname **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life three with a total of
7.7 over 0.4 direct mg/dl. Phototherapy was continued for
approximately 72 hours. A rebound bilirubin on day of life
six was 5.4 total over 0.3 direct.
7. Neurology: A head ultrasound was performed on [**2134-2-19**] and
was within normal limits. A follow-up head ultrasound at one
month of age is recommended. There are no neurologic
concerns at the time of discharge.
8. Audiology: Hearing screening has not yet been performed.
9. Ophthalmology: Initial eye examination was performed on
[**2134-3-1**] showing immature retina to zone three; recommended
follow-up in three weeks.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to level II care at [**Hospital3 418**] Hospital in [**Location (un) 701**], MA.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital 7740**]
Pediatrics, [**Location 53083**], [**Location 942**], [**Numeric Identifier 53084**].
Phone number [**Telephone/Fax (1) 53085**].
CARE AND RECOMMENDATIONS:
1. Feeding: Preemie Enfamil 24 calorie per ounce, 150 cc
per kg per day po/pg.
2. Medications:
Ferrous sulfate 25 mg per ml dilution, 0.2 ml p.o. q. day.
3. Car seat position screening is recommended but has not
yet been performed.
4. State newborn screens were sent on [**2-15**] and [**2134-2-26**] with
no notification of abnormal results to date.
5. Hepatitis B vaccine was administered on [**2134-3-2**].
6. Immunizations recommended:
Synagis-RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria:
1.) Born at less than 32 weeks.
2.) Born between 32 and 35 weeks with two of three of the
following: Day care during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
school age siblings.
3.) With chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW-UP:
1. Pediatric ophthalmology screening for retinopathy of
prematurity the week of [**2134-3-22**].
2. Primary pediatrician within three to five days of
discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 31 and 6/7 weeks gestation.
2. Respiratory distress syndrome.
3. Suspicion for sepsis ruled out.
4. Apnea of prematurity.
5. Unconjugated hyperbilirubinemia.
6. Cardiac murmur, consistent with peripheral pulmonic
stenosis.
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (Titles) 53086**]
MEDQUIST36
D: [**2134-3-5**] 12:26
T: [**2134-3-5**] 05:29
JOB#: [**Job Number 53087**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5174
} | Medical Text: Admission Date: [**2187-8-22**] Discharge Date: [**2187-8-27**]
Date of Birth: [**2149-6-25**] Sex: M
Service: Medicine and Medical Intensive Care Unit
HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old
male who presented with a 3-day history of nausea, vomiting,
coffee-grounds emesis, and dark stools.
Of note, the patient has a history of ethanol abuse and
presented with similar symptoms approximately one month prior
in [**2187-5-21**]. An upper gastrointestinal series at that
time revealed 2+ esophageal varices and 4+ gastric varices.
The patient presented to an outside hospital in Excitor, [**Location (un) 7498**] on [**2187-8-21**]. Upon presentation the patient
was noted to be orthostatic with a hematocrit of 27.4. He
required 4 units of packed red blood cells as well as fresh
frozen plasma. An urgent endoscopy was performed which
showed findings of gastric varices in the stigmata of a
recent hemorrhage. At that time, he was banded five times.
The patient was transferred to [**Hospital1 188**] for evaluation of a transjugular intrahepatic
portosystemic shunt procedure.
Also of note, the patient has a history of ethanol abuse. He
quit approximately two months ago (in [**Month (only) 205**]). He has a
previous 20-year history of ethanol abuse. He started
drinking vodka again (approximately four to five drinks per
day) about two weeks prior to admission. Also of note, prior
to admission the patient had a 4-day history of a toothache
as well as left jaw swelling. He started ibuprofen for this.
He was noted to have fevers to approximately 102 with
associated chills prior to admission.
PAST MEDICAL HISTORY:
1. Ethanol abuse.
2. History of upper gastrointestinal bleed; the first was in
[**2187-5-21**].
3. History of gout.
4. History of psoriasis.
5. History of [**Location (un) 931**] rod placed in [**2166**] for scoliosis.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father has a history of colonic polys,
alcohol abuse, and seizures associated with withdrawal, and
cirrhosis. Mother has a history of ethanol abuse.
SOCIAL HISTORY: The patient is married with no children. He
works as a self-employed computer consultant. He is a
nonsmoker and denies intravenous drug abuse. He has a
history of cocaine abuse in the distant past. He has a
history of alcohol abuse as noted above. He has
approximately a 20-year drinking history and recently quit
two months ago, but restarted within the past two to three
weeks prior to admission drinking about four to five drinks
on routine.
PHYSICAL EXAMINATION ON PRESENTATION: In general, on
admission to [**Hospital1 69**], the
patient was in no acute distress. Temperature was 99.6,
pulse was 64, blood pressure was 154/74, breathing at a rate
of 21, saturating 99% on room air. Head, eyes, ears, nose,
and throat revealed pupils were equally round and reactive to
light. Extraocular muscles were intact. The oropharynx was
notable for extremely poor dentition. Sclerae were
anicteric. The neck was supple with no appreciable jugular
venous distention. The patient had a spider angiomata on the
nose. The lungs were without crackles. The heart was
regular in rate and rhythm. The abdomen was soft and
nontender with slight distention. There was no clubbing,
cyanosis, or edema. On neurologic examination, the patient
was alert and oriented times three. No appreciable asterixis
was seen on examination.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 8.2, hematocrit
was 31.7, platelets were 128. Chemistry-7 revealed sodium
was 138, potassium was 3.7, chloride was 101, bicarbonate
was 23, blood urea nitrogen was 8, creatinine was 0.7, and
blood glucose was 90. AST was 61, ALT was 31, amylase
was 60, lipase was 27, total bilirubin was 1.6, alkaline
phosphatase was 101. PTT was 35.3 and INR was 1.5.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient presented with a history
of upper gastrointestinal bleed in [**2187-5-21**] and repeat
upper gastrointestinal bleed upon this admission in [**2187-8-21**]. At the outside hospital, he had received banding
times five, and an Octreotide drip was started.
The patient received a transjugular intrahepatic
portosystemic shunt procedure on [**2187-8-24**] and
tolerated the procedure well. The ultrasound showed that the
transjugular intrahepatic portosystemic shunt was patent.
The velocity within the transjugular intrahepatic
portosystemic shunt ranged from 80 cm/sec to 140 cm/sec. The
velocity within the portal vein was 32 cm/sec. The left and
right portal veins were patent.
In addition, the patient was started on ciprofloxacin for a
10-day course for spontaneous bacterial peritonitis
prophylaxis. A liver biopsy was also sent during the
transjugular intrahepatic portosystemic shunt procedure; the
results of which was still pending at the time of discharge.
Also, for the esophageal and gastric varices, the Octreotide
drip started at the outside hospital was continued. In
addition, Protonix was continued as well.
After the transjugular intrahepatic portosystemic shunt
procedure, lactulose was started, and the patient was
instructed to titrate the lactulose to approximately three
bowel movements per day to avoid increased encephalopathy
which could be associated with the transjugular intrahepatic
portosystemic shunt procedure.
Hepatitis serologies were also sent which showed hepatitis A
antibody positive, hepatitis B surface antigen negative,
hepatitis B surface antibody positive, and hepatitis C virus
antibody negative.
The patient's hematocrit was stable during the hospital
course, and he did not require further transfusions.
Alpha-fetoprotein levels were sent, and the alpha-fetoprotein
level was 5.4.
2. DENTAL: During this hospitalization, the patient was
seen by the Dental Service given his history of poor
dentition. A Panorex film was performed which showed on
tooth #21 there was very apical pathology and multiple caries
on multiple teeth including #4, #6, #7, #8, #9, #10, #11,
#13, #15, #28, #30, #31, and #32. The assessment at this
time was the #21 tooth showed residual signs of a recent
acute infection. The patient was started on clindamycin
given these findings for the infection.
3. PSYCHIATRY: The patient has a history of ethanol abuse.
During this hospital course, the patient was hemodynamically
stable and did not show any signs or symptoms of ethanol
withdrawal. He was placed on a CIWA scale but did not
require any Valium for a CIWA scale.
DISCHARGE FOLLOWUP:
1. The patient was to follow up with Dentistry. The patient
was given the name of a dentist at the [**Hospital6 1130**] Emergency Clinic. If he were to choose to follow up
there, he could follow up telephone number [**Telephone/Fax (1) 45690**]. In
addition, the patient has arranged to follow up with a
dentist closer to his house two days after discharge for
further evaluation of his teeth.
2. He was also to follow up with [**Hospital 3585**] Clinic as well.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed; status post transjugular
intrahepatic portosystemic shunt procedure.
2. History of ethanol abuse.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. q.d.
2. Iron 325 mg p.o. q.d.
3. Nadolol 40 mg p.o. q.d.
4. Clindamycin 600 mg p.o. q.8h.
5. Ciprofloxacin 500 mg p.o. b.i.d. (times six days).
6. Lactulose 30 mL to 45 mL p.o. q.6-8h. (to titrate to two
to three bowel movements per day).
DR.[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 12.697
Dictated By:[**Last Name (NamePattern1) 45691**]
MEDQUIST36
D: [**2187-8-27**] 16:43
T: [**2187-8-30**] 14:33
JOB#: [**Job Number 45692**]
ICD9 Codes: 2851, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5175
} | Medical Text: Admission Date: [**2119-8-18**] Discharge Date: [**2119-8-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Irregular Heart Rate
Major Surgical or Invasive Procedure:
TEE
Intubation
Cardioversion
Temporary pacing wire placement
Electrophysiology study
Dual device pacemaker placement
History of Present Illness:
history limited by patient sedation/intubation.
EVENTS / HISTORY OF PRESENTING ILLNESS: 84 year old male with
atrial fibrillation on coumadin, HTN, history of angina who
presented to [**Hospital **] Hospital complaining on light headedness,
diaphoresis and presyncope and dizziness on the day of
admission. No reports of chest pain. Had seen his PCP one week
prior for low HR, unknown details. Stopped taking all of his
medications a week ago for a few days because he wasn't feeling
well per his son but then restarted.
At OSH, his EKG showed wide complex tachycardia with right
bundle branch block. His systolic blood pressures were
hypotensive to systolic blood pressures in the 70's. He was
given approximately 4L of iv fluids. He was intubated for
unclear reasons although likely airway protection, sedated with
versed drip and started on dopamine. He was given 10mg iv
vitamin K and aspirin 325mg po x 1. He was then transferred to
[**Hospital1 18**] ED.
In [**Hospital1 18**] ED, he was continued on versed drip and Cardiology was
consulted. Electrophysiology looked at patient's EKG:
Irregular, HR 60's-140's, varying between right and left bundle
branch block. At baseline, EKG with right bundle branch block.
On review of symptoms, he was intubated and sedated and unable
to answer questions. All of the other review of systems were
negative.
*** Cardiac review of systems was unable to be obtained
secondary to intubation/sedation.
Past Medical History:
AFib on coumadin
HTN
Question of CAD with angina (20 years ago)
Social History:
Widowed, Lives with his son in a 2 family house (different
floors), No tobacco, occasional EtOH.
Family History:
Non-contributory
Physical Exam:
VS: T 98.2F HR 68-150, BP 107/63, RR 20 , ?O2 % on
ABG: pH 7.28 pCO2 39 pO2 170 on AC 500x14/FiO2%:100 ?PEEP
ABG pH 7.37/32/112 on AC 500x14/60/5
.
Gen: Well developed and well nourished elderly male, intubated,
sedated, and responsive to stimuli moving all 4 extremitites
HEENT: Normalcephalic/atraumatic. Sclera anicteric. PERRL, EOMI.
MMM, intubated.
CV: PMI located in 5th intercostal space, midclavicular line.
Irreg irrgeular, occasional pauses and ectopy
Chest: Coarse breath sounds bilaterally, faint bibasilar
crackles.
Abd: Obese, soft, non-tender and non-distended, No
hepatosplenomegally or tenderness. No abdominal bruits.
Ext: Trace bilateral lower extermity edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: 2+ DP
Left: 2+ DP
Pertinent Results:
[**2119-8-18**] TEE
IMPRESSION: No intracardiac thrombus identified. Moderate
regional LV systolic dysfunction, c/w CAD. Moderate MR. Mild AS.
Mild AR.
.
[**2119-8-18**] TTE
IMPRESSION: Global and regional LV systolic dysfunction c/w
diffuse process (multivessel CAD). Moderate mitral
regurgitation. Pulmonary artery systolic hypertension. Mild
aortic regurgitation.
.
[**2119-8-18**] CXR - moderate CHF, Small bilateral pleural effusion,
left greater than right, Endotracheal tube in satisfactory
position.
.
[**2119-8-23**] PA and Lateral CXR: Pacemaker lead placement in the
right atrium and the right ventricle.
.
[**2119-8-18**] WBC-14.4* RBC-5.24 Hgb-15.8 Hct-48.3 MCV-92 MCH-30.1
MCHC-32.7 RDW-16.0* Plt Ct-190 Neuts-86.4* Bands-0 Lymphs-8.0*
Monos-4.5 Eos-0.3 Baso-0.9
[**2119-8-23**] WBC-8.2 RBC-4.42* Hgb-13.7* Hct-38.7* MCV-87 MCH-30.9
MCHC-35.4* RDW-16.1* Plt Ct-139*
.
[**2119-8-18**] PT-22.8* PTT-28.8 INR(PT)-2.3*
[**2119-8-23**] PT-15.3* PTT-26.4 INR(PT)-1.4*
.
[**2119-8-18**] Glucose-118* UreaN-19 Creat-1.0 Na-132* K-5.2* Cl-103
HCO3-12* Calcium-8.3* Phos-2.0* Mg-2.5
[**2119-8-23**] Glucose-105 UreaN-14 Creat-0.7 Na-142 K-3.9 Cl-108
HCO3-27 AnGap-11
.
[**2119-8-18**] CK(CPK)-114 CK-MB-6 cTropnT-<0.01
[**2119-8-18**] CK(CPK)-122 CK-MB-19* MB Indx-15.6* cTropnT-0.18*
[**2119-8-19**] CK(CPK)-20* CK-MB-NotDone cTropnT-0.18*
.
[**2119-8-18**] ALT-49* AST-48* LD(LDH)-273* AlkPhos-67 Amylase-41
TotBili-1.9*
TSH-1.3 Free T4-1.4 Lactate-1.4 BTriglyc-54 HDL-38 CHOL/HD-3.3
LDLcalc-78
Brief Hospital Course:
In summary, Mr. [**Known lastname 74063**] is an 84 year old male with AFib on
coumadin, HTN who presnted to OSH with lightheadedness,
presyncope and tachy-brady episodes.
# Rhythm - On admission, the patient's rhythm was as follows:
tachy-brady, occasional pauses 1.5 sec, underlying right bundle
with intermittent left bundle and bigeminy with runs of VTach.
The patient arrived to the unit intubated and while the patient
was still sedated, a transesophegal echocardiogram was performed
to evaluate for thrombus in the setting of chronic afib and
rhythm abnormalities. No thrombus was appreciated and the
patient then underwent synchronized cardioversion with 200J in
syn mode. The patient was converted into normal sinus rhthymn.
However, the patient continued to have runs of ventricular
tachycardia that were mildly symptomatic. These episodes
responded to a lidocaine drip and a temporary pacing wire was
placed on [**2119-8-18**]. The patient was also loaded with a
beta-blocker in an attempt to control the tachyarrythmia.
However, the patient not only had episodes of ventricular
tachycardia but also had episodes of bradycardia which made the
dosing of the beta blocker difficult. Electrophysiology testing
was performed on [**2119-8-21**] but revealed a trigger fascicular
ventricular tachycardia which is not amenable to VT ablation.
Therefore, on [**2119-8-22**], a dual device pacemaker was placed with
leads in the right atrium and right ventricle. It is hoped that
the pacemaker will control the patient's bradycardia so that a
theraputic dose of beta blocker can be given. On [**2119-8-23**], the
patient's metorolol was titrated up to 37.5mg PO TID. The
pacemaker was interogated on [**2119-8-23**] and found to be working
properly. PA and lateral chest films confirmed the pacemaker's
lead placement in the right atrium and right venticle. The
patient continued on 48 hours of antibiotics due to the
pacemakder placement and will be followed in the device clinic
on [**2119-9-1**] at 10:30am.
# Pump - On admission, the patient appeared volume overloaded
with bibasilar crackles and bilateral infiltrates and pleural
effusions on chest x-ray. The patient was diuresed with prn
lasix. An echocardiogram done on [**2119-8-18**] showed: EF 35% Global
and regional LV systolic dysfunction c/w diffuse process. There
was moderate mitral regurgitation. The patient was discharged
on standing lasix due to poor left ventricular systolic
function.
#)CAD-Cardiac enzymes were cycled and an acute coronary process
was ruled out. The patient does report a past history of chest
pain and the echocardiogram did show regional left ventricular
wall motion abnormalities suggestive of a past infarct.
Therefore, the patient was started on an ACEinhibitor. The beta
blocker was also continued. Additionally, it is recommended
that the patient recieve a chemical stress test to evaluate for
CAD as an outpatient.
#)Anticoagulation: Heparin drip was initially started because
patient received Vitamin K at the OSH. Additionally, the
coumadin was held due to the temparary pacing wire placement,
electrophysiology study, and pacemaker placement. The patient
was anticoagulated with a heparin drip, and Coumadin restarted.
On [**2119-8-23**], the patient was on coumadin 5mg PO Dialy with an INR
of 1.4. The patient will follow up with Dr. [**Last Name (STitle) **] to have the
INR checked.
# HTN - Initially, the patient was hypotensive. The B-blocker
and ACE inhibitor titrated to blood pressure. It is recommended
that these continue to be titrated up as tolerated as an
outpatient.
# Metabolic Acidosis: On admission, a Gap acidosis was suggested
by labs and ABG. However, the acidosis resolved. Lactate was
found to be within normal limits. The patient is not diabetic
or in renal failure. There was no know history of ingestions.
The patient will be discharged home with services. The patient
will follow up with Dr. [**Last Name (STitle) **] (PCP) on Monday [**2119-9-4**] at 2:45pm.
Dr. [**Last Name (STitle) **] will check the INR. Additionally, the patient is
scheduled with the device clinic ([**Telephone/Fax (1) 59**]) on [**2119-9-1**] at
10:30am. Finally, the paitient is scheduled with Dr.
[**Last Name (STitle) **](cardiologist) on [**2119-9-14**] at 2:30pm at his office at
[**Hospital1 18**]-[**Location (un) 620**].
Medications on Admission:
coumadin
isosorbide
atenolol
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Warfarin 1 mg Tablet Sig: 2-3 Tablets PO at bedtime: please
resume your old dose of 3mg mon/wed/fri, and 2mg
Tues/Thurs/Sat/Sun. Please have your INR checked frequently and
adjust your dose accordingly.
Disp:*180 Tablet(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Keflex 500 mg Capsule Sig: One (1) Capsule PO every eight (8)
hours for 3 doses.
Disp:*3 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
1.) Tachy/Brady syndrome
2.) Bifascicular ventricular tachycardia
3.) Sick sinus syndrome
4.) Atrial fibrillation
5.) Hypertension
Discharge Condition:
good, hemodynamically stable, chest pain free
Discharge Instructions:
You were admitted to the hospital because of an irregular heart
beat. During your hospitalization you were placed on
medications that help prevent your heart from beating too fast
(metoprolol), and also had a pacemaker placed to prevent a very
low heart rate.
Please take all medications as instructed, and continue to keep
all health care appointments. Please resume your coumadin as
before and follow up with Dr. [**Last Name (STitle) **] to have your INR checked.
You have also been placed on a water pill (lasix) to keep fluid
off.
.
If you experience, chest pain, worsening shortness of breath,
lightheadedness, dizziness, or loss of consciousness, or your
condition worsens in any way, seek immediate medical attention.
Followup Instructions:
The visiting nurse will check your coumadin level on [**2119-8-25**] and
fax the results to Dr.[**Name (NI) 74064**] office.
.
Please follow-up with Dr. [**Last Name (STitle) **] on Monday [**2119-9-4**] at 2:45. Dr.
[**Last Name (STitle) **] will check your INR (coumadin blood test.)
.
Please follow up with Dr. [**Last Name (STitle) **] on [**2119-9-14**] at 2:30PM
at [**Hospital1 18**]-[**Location (un) 620**] ([**Telephone/Fax (1) 4105**]). Please check-in at patient
registration at 2:15 on the ground floor of the hospital, and
then proced to the [**Location (un) 453**] to Dr.[**Name (NI) 40168**] office. Your
in-patient cardiologist recommended that you get a nuclear
stress test. Please discuss this with Dr. [**Last Name (STitle) **].
.
Please follow up in the device clinic to ensure that your
pacemaker is functioning properly:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2119-9-1**]
10:30
ICD9 Codes: 4280, 4271, 2762, 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5176
} | Medical Text: Admission Date: [**2121-3-27**] Discharge Date: [**2121-4-2**]
Date of Birth: [**2042-6-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Hematocrit drop, presumed GIB
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
2 units of packed red blood cells
History of Present Illness:
78 yo M w/ prior MWT, PVD (s/p SFA stending on [**2-16**] admission
started on [**Month/Year (2) 4532**]), DM, HTN, HCV/EtOH abuse, urinary retention
who presents to the ED from PCP's office in setting of
confusion, weakness and hypotension.
.
Of note, the patient had partial amputation of his right great
toe, caused by vasulopathy. The patient was recently admitted to
[**Hospital1 18**] for right SFA and popliteal stenting at which time he was
started on [**Hospital1 **] and pletal. In addition, course was
complicated by UTI (Klebsiella) and monitored for EtOH
withdrawal. The patient has been at [**Hospital3 **] until
this Monday when he returned home. He is unsure of his current
medications. He denies any drinking since before [**3-3**]
when he was initially hospitalized. The patient thinks he may
have had some dark stools earlier in the week. The patient
further mentions taking two Aleve per night for back pain. Mr.
[**Known lastname 23050**] has an abrasion on his upper lip but cannot remember
any trauma. He denies any recent incidents of nausea, vomiting.
He denies pain, chest pain, dyspnea, hematemesis of known
history of liver disease, but states that he has been drinking
since he was 16 years old. He does not remember his earlier
endoscopy or any diagnosis of [**Doctor First Name **]-[**Doctor Last Name **] tears.
In the ED, initial VS were 98.3F 94 81/44 100% on unknown amount
of O2. He received 1.2L of NS, with SBPs to low 100s. Labs
revealed an HCT of 21 (baseline 30), thrombocytosis, BUN/Cr
18/1.1, Lactate of 2.4 and normal coags. WBC was wnl. Given
these findings, was started on PPI gtt and admitted for further
evaluation to MICU. CXR was negative for acute process and CT
head revealed no .
.
On arrival to the MICU, the patient was resting comfortably and
had no complaints. He was being prepared for endscopy
Past Medical History:
-Peripheral arterial disease
-Diabetes
-Hypertension
-Hep C
-Urinary retention requiring straight cath at home{has refused
TURP}
-hx of GI bleed with resolving [**Doctor First Name 329**] [**Doctor Last Name **] tear
-ETOH abuse(active)
-Dyslipidemia
-Right superficial femoral artery and tibioperoneal trunk
stenting for nonhealing hallux ulcer. sp right partial hallux
amputation [**2120**]
Social History:
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
alcohol:hx of drinking regularly since he was 16 and has
desribed himself as a recovering alcoholic for the last 20 yrs
and attends AA but does have relapses and last night he said
that he drank a [**1-6**] pt of whiskey and a beer, denies w/d sz of
blackouts
drugs: denies
tob:smoked 4ppd until 15 yrs ago
caffeine: [**2-7**] cups of coffee a day
Grew up in the [**Location (un) 86**] area. Entered National Guard in [**2055**] and
ultimately sent to [**Country 2784**]. Returned in the early 50s and
started working as a court officer. He was married once. He and
his ex-wife divorced about 25 years ago but still are in close
contact. She is remarried. He has a son who owns a local paper
company who recently got married. Currently lives alone in a
senior living facility in JamaicaPlain but was recently
discharged from [**Hospital 100**] Rehab following vascular surgery.
Family History:
Noncontributory
Physical Exam:
Admission Exam:
SBP 80s --> 110s, HR high 90s
General: Alert, oriented x 3, no acute distress, can state the
days of the week forward and backward
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD
CV: Heart sounds quiet, but S1, S2 no murmurs auscultated
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, midline scar, bowel
sounds present
GU: No foley
Ext: Warm and without edema, patient has had amputation of right
great toe
Skin: Hyperkeratosis and sloughing of dead skin on feet
Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
guiac + w dark stool
Discharge Exam:
VS: 97.5 110/60 65 18 100%RA
General: Alert, A&Ox3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD, No JVD
CV: Heart sounds quiet, reg rate and rhythm, nl S1/S2, no
murmurs auscultated
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, midline scar, bowel
sounds present
GU: No foley
Ext: Warm extremities bilaterally, no edema, patient has had
amputation of right great toe, 1+ DP b/l
Skin: Hyperkeratosis and sloughing of dead skin on feet,
melanotic lesion and dual colored dark lesion with irregular
borders in midline of back. superficial abrasion over right
knee.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
normal sensation of feet bilaterally
Pertinent Results:
Admission Labs:
[**2121-3-27**] 01:00PM BLOOD WBC-7.6 RBC-2.60*# Hgb-6.2*# Hct-21.6*#
MCV-83 MCH-23.9* MCHC-28.7*# RDW-16.4* Plt Ct-603*#
[**2121-3-27**] 01:00PM BLOOD Neuts-84.5* Lymphs-12.2* Monos-2.8
Eos-0.1 Baso-0.3
[**2121-3-27**] 01:00PM BLOOD PT-11.0 PTT-24.8* INR(PT)-1.0
[**2121-3-27**] 01:00PM BLOOD Glucose-183* UreaN-18 Creat-1.1 Na-135
K-4.5 Cl-103 HCO3-22 AnGap-15
[**2121-3-27**] 01:00PM BLOOD ALT-35 AST-48* LD(LDH)-200 AlkPhos-41
TotBili-0.3
[**2121-3-27**] 01:00PM BLOOD Lipase-60
[**2121-3-27**] 01:00PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1
[**2121-3-27**] 01:00PM BLOOD Hapto-60
[**2121-3-27**] 01:00PM BLOOD TSH-2.1
[**2121-3-27**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-3-27**] 01:34PM BLOOD Lactate-2.4*
[**2121-3-27**] 08:57PM BLOOD Lactate-1.1
[**2121-3-27**] 08:47PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2121-3-27**] 08:47PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2121-3-27**] 08:47PM URINE RBC-3* WBC->182* Bacteri-FEW Yeast-NONE
Epi-1
[**2121-3-27**] 08:47PM URINE CastHy-4*
Hct trend (received 2 units PRBCs on [**3-28**] in AM):
[**2121-3-27**] 01:00PM BLOOD WBC-7.6 RBC-2.60*# Hgb-6.2*# Hct-21.6*#
MCV-83 MCH-23.9* MCHC-28.7*# RDW-16.4* Plt Ct-603*#
[**2121-3-27**] 06:36PM BLOOD Hct-18.5*
[**2121-3-28**] 01:02AM BLOOD Hct-23.2*#
[**2121-3-28**] 05:16AM BLOOD WBC-7.2 RBC-3.02* Hgb-7.4* Hct-23.9*
MCV-79* MCH-24.4* MCHC-30.8* RDW-17.0* Plt Ct-479*
[**2121-3-28**] 03:13PM BLOOD Hct-25.7*
[**2121-3-28**] 11:38PM BLOOD WBC-9.1 RBC-3.44* Hgb-8.2* Hct-27.9*
MCV-81* MCH-23.9* MCHC-29.5* RDW-17.1* Plt Ct-577*
[**2121-3-29**] 08:34AM BLOOD WBC-8.4 RBC-3.57* Hgb-8.6* Hct-28.7*
MCV-81* MCH-24.1* MCHC-30.0* RDW-17.4* Plt Ct-523*
Micro:
[**3-27**] Blood culture
[**3-27**] MRSA screen
[**3-27**] Urine Culture negative
[**3-27**] HELICOBACTER PYLORI ANTIBODY TEST positive
Imaging:
CXR [**2121-3-27**]: 1. No evidence of acute disease.
2. Newly apparent nodular focus projecting along the right lower
lung, probably a nipple shadow, although a pulmonary nodule
should be considered. When clinically appropriate, repeat PA
view with nipple markers is recommended.
.
CT head w/o contrast [**2121-3-27**]:
1. No evidence of acute intracranial process.
2. Age-related atrophy.
3. Chronic small vessel ischemic disease.
.
CT abdomen/pelvis w/o contrast [**2121-3-27**]:
IMPRESSION:
1. No evidence of retroperitoneal or intramuscular hematoma.
2. Left adrenal hypoattenuating mass is likely an adenoma.
3. Multiple bladder diverticula.
4. Extensive atherosclerotic disease and coronary artery
disease.
5. Old right posterior rib fractures and anterior wedge
compression of L2 and
multilevel lumbar degenerative disease.
6. Multiple tiny renal cysts, too small to characterize but
without
concerning features.
7. Right femoral stent is noted, patency cannot be assessed.
.
EGD [**2121-3-27**]:
Impression: Small hiatal hernia
Mild erythema and friability in the antrum compatible with mild
gastritis
Normal mucosa in the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: The findings do not account for the symptoms
Serial hcts, monitor stool output; consider extraluminal blood
losses given recent femoral puncture. Would consider non-urgent
colonoscopy prior to d/c if within patient wishes and no
extraluminal bleeding site localized. Would discuss
[**Month/Day/Year 4532**]/aspirin with vascular surgery. Given overall well
appearance of the patient, would seem in favor of continuing if
stent high risk for occlusion.
.
[**2121-3-29**] CXR: PA and lateral upright chest radiographs were
reviewed in comparison to [**2121-3-27**].
Heart size and mediastinum are unremarkable. Lungs are
essentially clear. No pleural effusion or pneumothorax is
demonstrated. Hyperinflation of the upper lungs most likely
reflects emphysema.
No nodular opacity along the right lower lung is currently
demonstrated, most likely reflecting nipple shadow on the prior
examination.
.
Colonoscopy [**2121-3-31**]:
Polyp in the proximal ascending colon (polypectomy)
Polyp in the distal ascending colon (polypectomy)
Polyp in the hepatic flexure (polypectomy, endoclip)
Otherwise normal colonoscopy to terminal ileum
Brief Hospital Course:
The patient is a 78-year-old man with a history of alcohol
abuse, Mallroy [**Doctor Last Name **] tear, peripheral vascular disease, and
diabetes who presents with confusion, weakness and hypotension,
susequently found to a large hematocrit drop.
.
# Anemia, probable GI bleed: The patient has a history of
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear and gastritis. His anemia and episode of
hypotension was thought to be secondary to hypovolemia from a GI
bleed. The patient received a bolus of normal saline and two
units of packed red blood cells. His hematocrit responded by
improving from 18 to 23. GI performed an endoscopy which showed
gastric erythema and friability, but no obvious source of GI
bleed. Because he had recently undergone stenting of peripheral
artery, a retroperitoneal bleed remained on the differential. CT
of abdomen and pelvis showed no evidence of RP bleed. His
hematocrit remained stable and steadily increasing, so he was
transferred to the Medicine service with plans to perform
colonoscopy after appropriate preparation. His aspirin and
[**Last Name (NamePattern1) **] were held. After contacting his vascular surgeon, his
[**Name (NI) **] continued to be held in the setting of a likely lower GI
bleed. ASA was restarted. Colonoscopy showed 3 polyps but no
active bleeding. The polyps were biopsied. The patient's
hematocrit remained stable and he had no more bloody stools.
Discharged with plans for close outpatient follow-up and repeat
hematocrit on [**2121-4-3**]. Crit on discharge was 30.2.
.
# Presumed urinary tract infection: The patient has a history of
urinary retention requiring straight catheterization. His
urinalysis in the ICU was suggestive of infection so he was
started on ceftriaxone therapy. Urine culture showed mixed
bacteria growth, without evidence of UTI. Ceftriaxone was
stopped and a repeat Ucx was unremarkable. Antibiotics not
restated.
.
# Alcohol abuse: Patient has history of alcohol abuse, according
to old records. It appears he has been at home the last few
days, which means he may have started drinking again, though the
patient denies it. He was placed on CIWA, though he never
triggered and did not require benzodiazepines. He was provided
thiamine and folate. Social work was consulted. The patient was
discharged on thiamine and folate.
.
# Diabetes: Provided insulin sliding scale while in hospital.
.
# Urinary retention: Continued home tamsulosin.
.
# Incidentalomas:
Left adrenal adenoma.
Multiple bladder diverticula
Old right posterior rib fxs.
Anterior wedge compression of L2
.
Transitional Issues:
- Repeat hematocrit on [**4-3**]. Hematocrit on dischare was 30.2. If
drifting downwards, GI would recommend capsule study.
- Patient should have dermatology follow up for two skin lesions
noted on his upper back
- F/u GI biopsies. Patient is concerned about these and would
like to be contact[**Name (NI) **] about results
- F/u H. Pylori stool antigen
Medications on Admission:
-cilostazol 100 mg Tablet 1 Tablet(s) by mouth twice a day
-clopidogrel [[**Name (NI) **]] 75 mg Tablet 1 Tablet(s) by mouth once a
day
-metformin 500 mg Tablet 1 Tablet(s) by mouth twice a day
-pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet
Qday
-tamsulosin 0.4 mg Capsule, Ext Release 24 hr 1 Capsule Qhs
-aspirin 81 mg Tablet, Delayed Release (E.C.) daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 100**] Senior Life for Home Care
Discharge Diagnosis:
Primary Diagnosis: Gastrointestinal bleed
Secondary Diagnosis:
Peripheral Vascular Disease s/p stent placement
Alcohol Abuse
Diabetes
Skin lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 23050**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because you were feeling weak
and were found to have very low blood levels. It was presumed
that you were bleeding from your intestines. You had a scope of
your upper and and lower intestinal tract which showed polyps
but no active bleeding. You did not have any further episodes of
bleeding and your blood counts improved during your time in the
hospital. You are safe for discharge home. Your primary care
doctor should follow up on the results of the biopsies of the
polyps. You should have your blood counts rechecked on Friday
[**2121-4-4**] and the results faxed to your primary doctor. Please
also discuss with your primary care doctor getting a referral to
dermatology to look at the skin lesions on your back.
Please continue all your home medications with the exception of
the following, which have been changed:
1) Please START Thiamine 100mg daily
2) Please Start Folic acid 1mg daily
3) Please START Simethicone 40mg four times daily as needed for
gas
4) START mupirocin cream; apply this on the rash under your nose
twice a day
Followup Instructions:
Department: BIDHC [**Location (un) **]
With: [**First Name11 (Name Pattern1) 3295**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3296**] [**Last Name (NamePattern1) 3297**], MD
Phone # [**Telephone/Fax (1) 608**]
Specialty: Primary Care
When: TUESDAY [**2121-4-8**] at 1 PM
Building: 545A Centre St. ([**Location (un) 538**], MA) None
Campus: OFF CAMPUS
Department: VASCULAR SURGERY
When: THURSDAY [**2121-5-15**] at 1:30 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2121-4-2**]
ICD9 Codes: 5789, 2851, 4589, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5177
} | Medical Text: Admission Date: [**2200-4-1**] Discharge Date: [**2200-4-6**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
man with past medical history of coronary artery disease,
status post stent to the left circumflex artery as well as
history of chronic left bundle branch block. The patient was
admitted to [**Hospital1 69**] on [**4-1**] with complaint of [**3-16**] weeks of epigastric pain. The
patient describes the pain as [**7-20**] and nonradiating. The
patient states that the pain was not associated with
shortness of breath, nausea, vomiting, lightheadedness, or
palpitations.
The patient reports that on [**3-31**], he awoke from a nap
with severe pain. This prompted him to seek treatment in the
Emergency Department.
The patient also reports increasing dyspnea on exertion.
Several years ago the patient noted dyspnea on exertion with
a two block walk. ETT MIBI in [**2194**] disclosed no
electrocardiogram changes or perfusion defects. Over the
past few months the patient has become short of breath over
only a half a block walk. He experiences dyspnea on exertion
occasionally accompanied by a nonradiating epigastric pain,
though the pain is only 1.5/10.
Patient was admitted to Medicine Service on [**3-31**] for
evaluation of his epigastric pain. Initial CKs were within
normal limits. He was continued on the proton-pump inhibitor
and the GI service was consulted. He underwent MRI/MRA for
workup for possible mesenteric ischemia. This study was
negative. It did disclose intra and extrahepatic ductal
dilatation.
On 06:30 pm on [**4-1**], the patient noted onset of
epigastric pain. The am troponins from that day was elevated
at 6.7. The patient was given aspirin, beta blocker, and was
started on Heparin. He eventually became pain free. The
patient was sent to the SICU for closer observation. At
catheterization the patient was found to have three vessel
coronary artery disease, left anterior descending artery had
95% calcified stenosis before D1. There is an 80% focal
stenosis after D1. The left circumflex had 40% stenosis of
OM-2, 40% of the ramus was occluded. Right coronary artery
was heavily calcified with 50% stenosis in the mid vessel and
90% stenosis in the branching PL.
Furthermore, during the catheterization patient had episode
of asystole requiring temporary pacing. Nevertheless, the
patient underwent successful stenting of the left anterior
descending artery and diagonal. He was admitted to the CCU
for further management.
PAST MEDICAL HISTORY:
1. Esophagitis/GERD.
2. Coronary artery disease, last catheterization in [**2191-3-11**] disclosed two vessel disease. The patient had PTCA and
stent to the left circumflex lesion with 20% residual
stenosis. The calculated ejection fraction was 60%. There
were no wall motion abnormalities. There was mild mitral
regurgitation. Chronic left bundle branch block.
3. Transient ischemic attack.
4. Chronic renal insufficiency.
OUTPATIENT MEDICATIONS:
1. Ditropan 5 mg po q day.
2. Nexium 40 mg [**Hospital1 **].
3. Vicodin 1-2 tablets prn.
4. Vioxx 25 mg po q day.
5. Reglan 5-10 mg po q day.
6. Dyazide 37.5/25 q day.
7. Atenolol 25 mg po q day.
8. Plavix 75 mg po q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home and spends [**Doctor Last Name 6165**]
in [**State 108**], former smoker. Drinks 2-3 alcoholic beverages
per week. No IV drug use.
PHYSICAL EXAMINATION: Pleasant elderly male in no apparent
distress. Blood pressure 160/86, heart rate 80s, respiratory
rate 21, and O2 saturation is 96% on room air. HEENT:
Pupils are equal, round, and reactive to light. Extraocular
movements are intact. Mucous membranes moist. Oropharynx is
clear. Neck is supple, jugular venous distention 2 cm below
mandible. Heart: Regular, rate, and rhythm, distant heart
sounds. Lungs are clear to auscultation anteriorly. Abdomen
is obese, nontender, positive bowel sounds. Extremities:
Trace lower extremity edema, right knee scar, right femoral
line in place. Neurologic is alert and oriented times three.
Cranial nerves II through XII are grossly intact.
Examination is otherwise nonfocal.
LABORATORY DATA: White count was 5.1, hematocrit 34.3,
platelets 128. Chemistries are a significant for a BUN and
creatinine of 126 and 1.7. Magnesium 2.6.
IMAGING: MRI/MRA of the abdomen disclosed celiac and SMA
widely patent, severe intrahepatic and extrahepatic bile duct
dilatation, no common bile duct stone, or ampullary mass
identified.
ELECTROCARDIOGRAM: Sinus bradycardia at 48 beats per minute,
prolonged P-R interval, left bundle branch block, no
significant ST segment elevation.
HOSPITAL COURSE: The patient is admitted to CCU for further
management.
1. Cardiovascular: A. Ischemia: Following patient's
catheterization results noted above, the patient was
continued on aspirin and Plavix during the remainder of his
hospital stay. He was administered beta blocker, ACE
inhibitor, and a statin as well. Patient will likely undergo
intervention to the right coronary artery in approximately
two weeks.
B. Pump: Echocardiogram was checked during the patient's
admission. Patient had an ejection fraction of 55%, regional
left ventricular wall motion is normal, trivial MR is seen,
moderate 2+ TR is seen. Pulmonary artery systolic
hypertension is noted.
C. Rhythm: The patient is noted to have bradycardia during
catheterization. The patient developed asystole in
catheterization laboratory and required stent placement, a
temporary pacer wire. EP consult was obtained. EP service
recommended starting a low dose beta blocker, and monitoring
the heart rate for his signs and symptoms of chronotropic
insufficiency. Etiology of bradycardia/asystole event
thought to be related to catheter used during cardiac
catheterization. Furthermore, the patient has no history of
syncope/presyncope.
2. GI: MRI/MRA results noted above. The patient will
require ERCP for further evaluation.
3. Heme: Patient required transfusion 2 units of blood
during his hospital stay.
4. Nutrition: Patient maintained on a clear liquid diet
initially. His diet was advanced as he tolerated.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Home.
FOLLOW-UP INSTRUCTIONS: The patient will follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Flyer. The patient will
also followup with his cardiologist, Dr. [**Last Name (STitle) 120**]. The
patient will follow up with Dr. [**Last Name (STitle) **] from Gastroenterology
in four weeks.
DISCHARGE DIAGNOSES:
1. Three vessel coronary artery disease.
2. NonST elevation myocardial infarction.
3. Severe left ventricular diastolic dysfunction.
4. Pulmonary hypertension.
5. Asystole requiring temporary pacing.
6. Successful stenting of the left anterior descending artery
and diagonal.
7. Esophagitis.
8. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS:
1. Zestril 5 mg po q day.
2. Dyazide 37.5/25 mg po q day.
3. Plavix 75 mg po q day.
4. Lipitor 10 mg po q day.
5. Enteric coated aspirin 325 mg po q day.
6. Nitroglycerin sublingual prn chest pain.
7. Toprol XL 25 mg po q day.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**MD Number(1) 4062**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2200-4-6**] 22:59
T: [**2200-4-11**] 07:56
JOB#: [**Job Number 96496**]
ICD9 Codes: 9971, 4275, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5178
} | Medical Text: Admission Date: [**2181-11-23**] Discharge Date: [**2181-11-28**]
Date of Birth: [**2146-4-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
# Seizure
# Respiratory distress
# L parietal ICH
Major Surgical or Invasive Procedure:
Intubation
Central line
Arterial line
History of Present Illness:
35F h/o C-section, 2 wks post-partum, admitted to MICU s/p
seizure and respiratory distress. Pt had experienced new-onset
nighttime snoring and severe evening headaches x 1 week waking
her from sleep. At 2 am on day of admission, pt awoke with a
severe headache and had a witnessed 45 sec tonic clonic seizure.
CT head at [**Location (un) **] demonstrated 2-3 cm L parietal ICH. Patient
subsequently had a second seizure, after which she felt "dizzy
and not herself." Pt subsequently was intubated for airway
protection, and received phenytoin, mannitol, and decadron
before transfer to [**Hospital1 18**] for further evaluation.
.
While in the ambulance, patient became hypoxic (SaO2 40% ) and
was producing frothy, pink sputum. On arrival to [**Hospital1 18**], ET was
noted to be dislodged. Patient was extubated and then
reintubated with SaO2 83-84%. Pt received etomidate,
succinylcholine and vecuronium. SaO2 further improved with
paralysis, but was difficult to vent (ABG 7.14/71/61 on 480x20,
PEEP 15, FiO2% 82). Repeat CT head demonstrated 2-3 cm ICH with
surrounding edema, also with ? air-fluid level; CTA chest was
completed and demonstrated extensive bilateral opacities.
.
In transit to MRI, pt became hypotensive with SBP 50-60; MRI was
aborted and patient was directed to the MICU. On arrival to
MICU, SBP had increased to 180s without additional fluids or
pressors.
Past Medical History:
# C-section ([**2181-11-8**])
# Gestation diabetes during most recent pregnancy
# Tonsillectomy
Social History:
# Personal: Lives with husband and children.
# Alcohol: None.
# Tobacco: None.
# Recreational drugs: None.
Family History:
Noncontributory
Physical Exam:
VS: T 99, BP 120/70, HR 120, RR 27 (vented), SaO2 90s
Gen: Lying in bed intubated, sedated and paralyzed
HEENT: NC/AT, moist oral mucosa
Neck: Supple, no carotid or vertebral bruit
CV: Tachycardic, 2/6 SEM heard over pre-cordium
Lung: Crackles to auscultation bilaterally
Abd: +BS soft, nontender
Ext: No edema
Brief Hospital Course:
35F h/o C-section two weeks prior to admission, admitted with
intracranial hemorrhage and subsequent seizures, as well as
respiratory distress.
.
# L parietal ICH: Initially, differential diagnosis included
postpartum hypertension, although OB/GYN later confirmed that
patient had not had preeclampsia or eclampsia during her
pregnancy. Other considerations included possible metastatic
choriocarcinoma, sinus thrombosis, mass lesion, or aneurysm.
Serum bHCG was negative. MRI demonstrated L parietoccipital
lobe hemorrhage with associated infarct, as well as associated
subarachnoid hemorrhage in the region, although MRA/MRV were
normal. TTE demonstrated [**2-13**]+ MR with no PFO or septal defect,
and no hypokinesis. Per neurology, patient was started on
verapamil to control SBP (MAP<130) as well as possible vasospasm
at the left MCA. Patient was kept on minimal fluids and during
her MICU stay, was net even. Patient was also started on
phenytoin as well as levetiracetam, with pending discussions
with her OB/GYN about this antiseizure regimen as patient would
like to breast-feed. ICH was most likely due to venouse
thrombosis, for which pt will continue taking aspirin dailyy and
follow up with neurology.
.
# Respiratory failure [**3-16**] ARDS: Patient was initially intubated
at OSH, with the endotracheal dislodged during her EMS transit.
Patient was also suspected to have aspirated leading to likely
ARDS. Patient was ultimately extubated after empiric
antibiotics were begun; sputum cultures were negative for PNA.
Patient experienced normal postpartum diuresis with large volume
urine output, and had a net even fluid status for her MICU stay.
.
# H/o gestational diabetes: Patient was hyperglycemic on
admission, but had not been on insulin therapy as outpatient.
In the MICU, patient was continued on regular insulin sliding
scale PRN, with goal of FS<150.
.
# Post-partum care: Pt has been using breast pump in the ICU.
.
# Anemia: Pt was anemic on admission, with no clear sources of
bleeding this was suspected to be dilutional.
Medications on Admission:
None
Discharge Medications:
1. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
3. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO at bedtime for 1 doses: please take evening of [**11-28**] two
capsules.
Disp:*2 Capsule(s)* Refills:*0*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO three times a day for 2 days: for the dates : [**11-29**] and
[**11-30**].
Disp:*6 Capsule(s)* Refills:*0*
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO twice a day for 2 days: for the dates [**12-1**] and [**12-2**].
Disp:*4 Capsule(s)* Refills:*0*
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO once a day for 2 days: for the days [**12-3**] and [**12-4**].
Disp:*2 Capsule(s)* Refills:*0*
8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime: start [**11-28**].
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Cortical vein thrombosis c/b left occipital lobe hemorrhage.
2. Generalized seizure.
3. Accelerated hypertension.
4. Acute respiratory distress syndrome.
5. Mild to moderate ([**2-13**]+) mitral regurgitation.
Secondary:
1. G2P2.
2. C-section x 2
3. Gestational diabetes mellitus
Discharge Condition:
Good
Discharge Instructions:
Please follow carefully the instructions regarding your
medications (see below)
.
Please follow up with your follow up appointments.
.
Please call your doctor or 911 if you have headache, nausea,
vomiting, dizzyness or any other concerning symptoms.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 23**] at 12:15 PM on
[**2181-12-5**].
.
And Dr. [**First Name (STitle) **] from neurology: Tel [**Telephone/Fax (1) 3767**] on [**12-4**]
at 9:30
ICD9 Codes: 431, 5070, 2859, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5179
} | Medical Text: Admission Date: [**2198-8-31**] Discharge Date: [**2198-9-6**]
Date of Birth: [**2171-1-25**] Sex: F
Service: [**Last Name (un) **]
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
None
History of Present Illness:
27 y/o female who was in high speed MVA. Positive LOC. Positive
ejection from vehicle. Transfered from OSH. En route GCS 15 and
hemodynamically stable. The patient was complaining of RUQ and
RLE tenderness.
Past Medical History:
Tonsilectomy
L arm ORIF
Recent teeth surgery
Social History:
Smokes 1 ppd
Family History:
Non-contributory
Physical Exam:
97.6 P 87 123/63 RR 18 100% RA
Gen: NAD. Lying flat in bed.
HEENT: PERRL. NC/AT
CV: RRR, no MGR
Lungs/Back: CTAB, non-tender spine, no step offs
Abd: soft, flat, tender to palp RUQ, normal bowel sounds
Ext: warm, 2+ DP/PT bilaterally, no edema
Neuro: non-focal
Pertinent Results:
Abdominal CT (from OSH): grade IV liver laceration, ? R
posterior-lateral 6th rib fracture
Chest/Pelvis X-ray: Unremarkable chest and pelvis, no evidence
of rib fracture
Brief Hospital Course:
27 y/o female w/ grade IV liver laceration s/p high speed MVA.
Chest x-ray, pelvis, T spine, L spine, and right tib-fib films
w/ no evidence of injury. Patient was admitted to the Trauma
SICU for close observation of her HCT which remained stable
around 30. On HD 3 the patient was transfered to the floor
where her HCT continued to remain stable. At this time she was
noted to have cellulitis of her left antecub at the site of an
old IV. She was started on clindimycin given her history of PCN
allergy. However after one day of therapy her cellulitis
remained about the same. The antibiotic regimen was changed to
vanc and over the course of the next three days, the cellulitis
essentially resolved. The patient was discharged home on HD 7.
At discharge she still had minimal tenderness to palpation in
the RUQ. She was tender to palpation around her right upper
chest. This is most likely secondary to chest contusion/?rib
fracture. There was no rib fracture noted on chest x-ray.
However, on review of the OSH abd ct which films part of the
chest, there appears to be a possible 6th rib postero-lateral
rib fracture. The patient will be discharged on a 4 day course
of clindimycin and percocets for pain control. She will follow
up in the trauma clinic next week.
Medications on Admission:
None
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. liver laceration, grade IV
2. right upper chest wall pain likely secondary to rib fx/chest
wall contusion
3. left antecub cellulitis at IV site
4. s/p mvc
Discharge Condition:
Good
Discharge Instructions:
Please call your primary care doctor or go to the Emergency
Department if you have fevers, chills, nausea, vomiting,
worsening abdominal pain, lightheadedness or for other concerns.
Followup Instructions:
Please follow up in the trauma clinic next week. [**Telephone/Fax (1) **]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5180
} | Medical Text: Admission Date: [**2121-10-27**] Discharge Date: [**2121-11-6**]
Date of Birth: [**2073-9-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Shortness of breath (initial CC)
Transfer from OSH for NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with thrombectomy and PTCA of left
circumflex artery
History of Present Illness:
49 year old male with a history of diabetes mellitus, coronary
artery disease with ?PCI and stents, presenting from [**Location (un) **]
with shortness of breath and respiratory distress. Initially,
the patient presented called EMS with a hx of shortness of
breath x 2 hours. He told EMS that he was unable to lie flat and
he was thought to be pale and diaphoretic. The patient denied
any chest pain or chest pressure; he was tachycardic to the
130s, HTN to 245/128 and oxygen saturations of 75-85% on 2 L NC.
He was started on nitropaste, SL NTG in the field. Lopressor,
ativan, solumedrol, lasix, levoquin and CTX, vanco were given,
and was then bag ventilated given poor saturations and
eventually placed on mechanical ventilation and transferred to
[**Hospital1 18**] for further management. Upon arrival to [**Hospital1 18**] on transfer
from Nashobe, BP still in 150s, slowly trended down to SBP
90s-110s, on a propofol drip for sedation. He received 4L NS
with 3L uop.
Past Medical History:
PAST MEDICAL HISTORY (incomplete, awaiting PCP [**Name Initial (PRE) 14453**]):
1. CARDIAC RISK FACTORS: DM 2
2. CARDIAC HISTORY:
- CAD s/p PCI with stent x2 to LCx (~2 years ago)
3. OTHER PAST MEDICAL HISTORY: Unknown
Social History:
SOCIAL HISTORY: On review of MICU admission note, +EtOH.
Family History:
Unknown
Physical Exam:
On admission:
98.6 108 120/71 24 100% on 100% Fi02 AC, Tv 550 RR 18 RR 15
Gen: Appropriately responsive on sedation
HEENT: PERRL, MMM
Heart: RRR, nl S1/2, no murmurs
Lungs: Diminished at bases, upper lungs clear
Abd: Benign
Extrem: No edema
Pertinent Results:
[**2121-10-27**] 11:35AM cTropnT-0.27*
[**2121-10-27**] 11:35AM CK-MB-42* MB INDX-3.5 proBNP-869*
[**2121-10-27**] 03:40PM CK-MB-95* MB INDX-5.1 cTropnT-0.63*
[**2121-10-27**] 03:40PM CK(CPK)-1860*
[**2121-10-27**] 05:34PM LACTATE-3.4*
[**2121-10-27**] 11:11PM CK-MB-117* MB INDX-5.4 cTropnT-1.07*
[**2121-10-27**] 11:11PM CK(CPK)-2156*
[**2121-10-27**] 11:35AM WBC-27.2* RBC-5.00 HGB-15.6 HCT-46.4 MCV-93
MCH-31.1 MCHC-33.5 RDW-13.4
[**2121-10-27**] 11:35AM NEUTS-87* BANDS-0 LYMPHS-9* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-1*
[**2121-10-27**] 11:35AM PT-12.8 PTT-24.1 INR(PT)-1.1
[**2121-10-27**] 11:35AM GLUCOSE-466* UREA N-20 CREAT-1.3* SODIUM-142
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-18* ANION GAP-27*
[**2121-10-27**] 11:47AM LACTATE-5.7*
[**2121-10-27**] 11:35AM ALT(SGPT)-72* AST(SGOT)-106* CK(CPK)-1208*
ALK PHOS-116 TOT BILI-0.2
[**2121-10-27**] 11:35AM LIPASE-28
[**2121-10-27**] 03:40PM ETHANOL-NEG
Chest CT [**10-27**]
1. No evidence of pulmonary embolism.
2. Sequelae of massive aspiration with bilateral lower lobe
consolidation and scattered centrilobular ground-glass
opacities.
3. ET and NG tubes positioned appropriately.
TTE [**10-28**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with near akinesis of the
basal inferolateral wall and mild global hypokinesis of the
remaining segments (LVEF = 40 %). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (?#)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Suboptimal image quality. Mild regional and mild
global left ventricular systolic function. No pathologic
valvular flow identified.
Cardiac Cath [**10-28**]:
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate diastolic ventricular dysfunction.
3. Moderate systolic ventricular dysfunction.
4. Moderate primary pulmonary hypertension.
5. Acute posterior myocardial infarction, managed by acute ptca.
6. Manual aspiration thrombectomy and PTCA of the late stent
thrombosis
of the LCX.
CT Head [**11-3**]
IMPRESSION:
1. Technically limited study secondary to motion artifact
without evidence of acute intracranial hemorrhage or mass
effect. Consider MR if there is concern for PRES as [**First Name9 (NamePattern2) 12287**] [**Male First Name (un) **]
the requisition.
2. Layering secretions in the [**Last Name (un) **]- and oropharynx.
CT Abdomen/Pelvis [**11-3**]
IMPRESSION:
1. Bibasilar consolidations, right more than left.
2. No evidence of intra-abdominal source of fever.
3. Fatty liver
Brief Hospital Course:
49 yo man with presumed CAD, DM who presents w/ resp distress
found to be profoundly hypertensive, evidence of aspiration on
CT chest and rising CEs.
.
1) NSTEMI: Pt presented with shortness of breath, rising
troponins, and LBBB (unknown baseline), overall suspicious for
ACS, possibly in the setting of hypertensive emergency and flash
pulmonary edema. Troponin, CKs rising since presentation to OSH.
Pt denied any history of pain. He was started on IV heparin.
He was continued on ASA, Plavix which he was taking his coronary
stent. Troponins were cycled X 3 with elevation in CK-MB and
troponins. ECHO showed akinesis of the basal inferolateral wall
and mild global hypokinesis of the remaining segments (LVEF = 40
%). Cardiology was consulted, and cath patient underwent cardiac
cath, which showed in-stent restenosis of patient's prior LCx
stent, and underwent thrombectomy and re-stenting. Patient was
also found to have moderate systolic and diastolic dysfunction,
moderate pulmonary hypertension.
.
2) Acute on chronic Heart Failure: Patient was found to have
moderate systolic and diastolic dysfunction (EF 40%), and
required Lasix diuresis for fluid overload and pulmonary edema.
He responded well to a Lasix drip, with no supplemental O2
requirement on discharge.
.
2) Aspiration PNA - Febrile with WBC count elevated at 27 on
initial labs, now trending down likely after fluid
resuscitation. Aspiration PNA vs pneumonitis read based on
appearance on CT Chest. He was started on vancomycin, cefepime,
and ciprofloxacin. Sputum and blood cultures were obtained, but
were negative. Patient finished a course of treatment for
aspiration PNA and antibiotics were subsequently d/c'ed.
.
3) Persistent Fevers - Patient continued to be febrile despite
broad antibiotic coverage, and was believed to be febrile [**2-24**]
DTs vs. drug fever, as all cultures and infectious w/u was
negative following the initial imaging of aspiration PNA vs.
pneumonitis. Following the resolution of DTs and d/c of CIWA,
patient's antibiotics were discontinued after a full course of
treatment for possible aspiration pneumonia. Patient's fevers
resolved shortly thereafter with all cultures negative. Likely
fevers [**2-24**] DTs or from antibiotics which were started to treat
aspiration PNA on intial presentation, and had completely
resolved prior to discharge.
.
4) Acute renal failure - Pt was admitted with elevated
creatinine, which improved upon receiving IVF. Likely [**2-24**] poor
perfusion in the setting of NSTEMI.
.
5) Mental Status - Patient was initially sedated on a vent, but
was weaned off vent and sedation following cardiac
catheterization. Once off sedation, the patient went into DTs
from alcohol withdrawal, and CIWA scale was promptly initiated
and patient was re-intubated with re-initiation of sedation.
Patient was gradually weaned off sedation and extubated, and
CIWA scale was continued until patient's DTs resolved. Mental
status returned to baseline prior to discharge. Patient was
seen by social work re: quitting alcohol use and was interested
in quitting alcohol use on discharge.
.
6) DM: Patient required sliding scale insulin while in-house,
and was discharged on insulin with f/u.
Medications on Admission:
Home Medications:
ASA 325
Spironolactone 25 daily
Plavix 75 daily
Niaspan 500
Glyburide 5
Lisinopril 10 daily
Metoprolol 25 daily
Simvastatin 40
Metformin 1000 [**Hospital1 **]
Medications On Transfer:
Aspirin 325 mg PO DAILY
CefePIME 2 g IV Q12H
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Ciprofloxacin 400 mg IV Q12H
Clopidogrel 75 mg PO DAILY
Famotidine 20 mg IV Q12H
Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
Heparin IV per Weight-Based Dosing
Insulin SC (per Insulin Flowsheet)Sliding Scale & Fixed Dose
Midazolam 1-10 mg/hr IV DRIP TITRATE TO sedation
Propofol 5-20 mcg/kg/min IV DRIP TITRATE
Simvastatin 80 mg PO DAILY
Spironolactone 25 mg PO DAILY
Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Decrease to 162 mg (2 baby aspirin) in 1 month.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. insulin 75/25 Sig: Forty Five (45) units Injection twice a
day.
Disp:*1 bottle* Refills:*2*
7. One Touch Ultra Test Strip Sig: One (1) bottle In [**Last Name (un) 5153**]
four times a day.
Disp:*1 bottle* Refills:*2*
8. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO at bedtime.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Decrease to 75mg, one pill, after 1 month.
Disp:*60 Tablet(s)* Refills:*2*
12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-3 tablets
Sublingual take 1 tablet under tongue every 5 minutes for total
3 doses as needed for chest pain.
Disp:*1 bottle* Refills:*0*
13. Lancets Misc Sig: One (1) lancet Miscellaneous four
times a day: Please check your blood sugar at breakfast, lunch,
dinner, and before bedtime.
Disp:*120 lancets* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Non ST elevation myocardial Infarction
Delerium Tremens
Acute Renal Failure
Diabetes Mellitus Type 2
Acute Respiratory Failure
Discharge Condition:
stable.
Discharge Instructions:
You had a heart attack because a stent in your heart artery
clotted off. This was opened by a balloon angioplasty and the
blood flow was restored. You will need to take Plavix and
aspirin every day for at least one year and possibly
indefinitely. for the next month, please take PLavix twice
daily. Your kidneys had trouble working while you were so sick,
they are now normal. You also had DT's from not drinking and was
on Valium that is now off. Do not drink any more alcohol, you
should seek intensive day therapy and AA after you go home. Your
diabetes medicine was also changed to insulin only to be taken
before breakfast and dinner. check your fingersticks before
meals and at bedtime, write down the results so you can show
them to the NP[**MD Number(3) **] [**Hospital **] Clinic at [**Location (un) **].
.
Medication changes
1. Stop taking Metformin and Glyburide
2. Start Insulin 75/25 45 units twice daily before breakfast and
dinner. Eat lunch about 5 hours after your insulin shot and eat
a snack at bedtime.
3. Decrease your Lisinopril to 5 mg daily
5. Increase your Atorvastatin to 80 mg daily
6. Increase your Metoprolol to 150 mg daily
.
Please call Dr. [**First Name (STitle) **] if you have any recurrent chest pain,
nausea, fevers, trouble breathing, or any other concerning
symptoms.
Followup Instructions:
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**], [**MD Number(3) 1240**]: [**Telephone/Fax (1) 62842**] Date/time: Wed [**11-12**] at
11:30am.
Diabetes:
Nurse [**First Name8 (NamePattern2) 30484**] [**Last Name (Titles) **] Phone: [**Telephone/Fax (1) 27738**] Date/Time: [**2121-11-18**] at
11:00am. [**Hospital6 27369**], [**Location (un) 78692**].
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 28959**] Date/time: Tuesday [**11-25**]
at 10:00am.
ICD9 Codes: 5849, 5070, 2762, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5181
} | Medical Text: Admission Date: [**2122-5-12**] Discharge Date: [**2122-6-24**]
Date of Birth: [**2059-6-12**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
female status post subarachnoid hemorrhage on [**5-11**],
complicated by hydrocephalus. The patient was transferred
from [**Hospital 1562**] Hospital to [**Hospital3 **] Hospital where she was
was brought to the Intensive Care Unit and treated according
to subarachnoid hemorrhage protocol with control of her blood
pressure, Dilantin and Nimdipine. The patient was intubated
and sedated at [**Hospital1 69**] on
arrival.
PAST MEDICAL HISTORY:
2. Gastroesophageal reflux disease.
3. Hypercholesterolemia.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is widowed and lives in
[**Hospital1 1562**]. No tobacco history; social alcohol use.
PHYSICAL EXAMINATION: On admission, the patient is afebrile,
heart rate of 69; blood pressure 120/74; breathing at 10; O2
saturation is 100% on assist control, total volume 750;
respiratory rate of 10; PEEP of 5, FIO2 of 40%. Her ICP is
10. The patient is intubated and sedated, grimacing and
withdrawing to painful stimuli in all four extremities.
Pupils equal, round and reactive to light; 3 to 2
bilaterally. Clear to auscultation bilaterally. Regular
rate and rhythm, soft, nontender, nondistended. No
cyanosis, clubbing or edema.
LABORATORY: Labs from outside hospital were sodium 145,
potassium 3.0, chloride 109, bicarbonate 24, BUN 14,
creatinine 0.7, glucose 105, white blood cell count 7.2,
hematocrit 36, platelets 287. PT 12.3, INR 0.9, PTT 22.9.
Arterial blood gas is pH 7.59, pCO2 20, pO2 200. CT scan
shows subarachnoid hemorrhage with hydrocephalus.
Chest x-ray shows no infiltrates, no effusions. EKG shows
normal sinus rhythm.
HOSPITAL COURSE: The patient was initially admitted to the
[**Hospital1 69**] Intensive Care Unit
followed by the Angio Suite. Her initial therapy consisted
of keeping her systolic blood pressure less than 140 with
Nipride, elevating the head of her bed to greater than 30
degrees, Dilantin 100 mg three times a day; Amlodipine 60 mg
q. four hours; vent drain at 20 to 25 cm.
The patient had a diagnostic four-vessel cerebral angiogram
on [**5-12**]. The left A1, A2, aneurysm was embolized at that
time by Dr. [**Last Name (STitle) 1132**]. The aneurysm was noted to be 3 mm and the
result of the embolization was good. The patient,
postoperatively, moved all extremities well, opened eyes.
Amlodipine was then decreased to 30 q. four hours to avoid
hypotension.
The patient's HHH therapy was slowly weaned over the course
of the next several days. The patient was taken off
anti-hypertensives. Her blood pressure was in the 110 to
120's following her embolization. The patient was started on
Kefzol postoperatively; she had temperatures in the 103.0 F.,
range on [**5-16**] and [**5-17**]. The patient was noted to have
a right pronator drift on [**5-17**]. She was taken back to the
Angio Suite where bilateral middle cerebral artery and ACA
distal vasospasm was noted. Superselective papaverine infusion
was performed for treatment with good success.
The patient was managed by controlling the blood pressure to
a range of 190 to 200 with a CVP of 10 to 12, and a pCO2 of
35 to 45. The vent drain was set at 10 cm after the
procedure.
On [**2122-5-19**], the patient became hypoxemic, requiring
intubation. Chest x-ray demonstrated right greater than left
pulmonary infiltrates. A Cardiology consultation was
requested. EKG did not show any ST or T wave changes.
Echocardiogram showed an ejection fraction of 30%, anterior
septal lateral, severe mitral regurgitation and aortic
regurgitation with two plus mitral regurgitation. Mitral
valve prolapse, one to two plus tricuspid regurgitation.
Cardiology consultation recommended pulmonary capillary wedge
pressure in the range of 12 to 18, heparin intravenously,
discontinuation of Diltiazem and paralytics. An intraaortic
balloon pump was placed to support the low cardiac output.
The patient had another diagnostic angiogram on [**5-19**];
Papaverine was instituted in the left ICA. Systolic blood
pressure goals were established at 150 to 160, and the drain
was changed to 10 cm. The patient was placed on an
intra-arterial balloon pump to support her cardiac function.
The patient was also placed on Amiodarone to slow down her
supraventricular tachycardia.
The patient was noted to have platelets decreased to 100;
this was felt secondary to heparin-induced thrombocytopenia.
The patient should no longer receive heparin and she has
demonstrated this reaction. The patient continued to spike
fevers and was placed on Vancomycin and Levofloxacin. The
patient had another diagnostic angiogram to rule out
vasospasm on [**2122-5-23**]. Papaverine was instituted in the
left internal carotid artery, the A1 and the MM1.
The patient had an IVC, [**Location (un) 260**] filter placed on [**2122-5-24**]. The patient's Levaquin was changed to Ceftazidime
shortly thereafter for a sputum culture. The patient had a
PEG and tracheostomy on [**6-5**].
On a follow-up CT the patient was noted to have new
intracentricular blood and subarachnoid blood around the
AComm complex which prompted an engiogram which showed the
presence of two new aneurysms not previously visualized on
angiogaphy. The patient underwent surgical clipping of these new
aneurysms and did well post-op. She subsequently underwent an
angiogram which showed that these new aneurysms had been isolated
from the circulation. The patient now has a PEG and
tracheostomy. She has undergone a VP shunt which was successful,
on [**2122-6-22**]. The patient has been afebrile and is now off
antibiotics. Her current medications at the time of this
dictation are:
1. Tylenol 650 mg p.o. q. four to six hours p.r.n.
2. Insulin sliding scale.
3. Miconazole Powder 2%, one application twice a day.
4. Artificial Tears 1 to 2 drops o.u. p.r.n.
5. Albuterol.
6. Atrovent one to two puffs inhaled q. six hours.
7. Calcium carbonate 1000 mg p.o. p.r.n.
8. Magnesium oxide 400 mg p.o. p.r.n.
9. Potassium chloride p.r.n.
10. Guaifenesin, p.r.n.
11. Nystatin p.r.n.
12. Albuterol nebulizers p.r.n.
13. Dulcolax 10 mg p.o. q. day p.r.n.
14. Reglan 10 mg p.o. or intravenously twice a day p.r.n.
15. Sodium chloride one gram p.o. four times a day.
16. Morphine sulfate 2 mg intravenously q. two hours p.r.n.
17. Zantac 150 mg via NG tube twice a day.
18. Lopressor 25 mg p.o. twice a day.
19. Diperodon nasal ointment, 2%, one application to each
nostril twice a day. Methicillin resistant Staphylococcus
aureus duration five days beginning on [**6-22**].
20. Captopril 12.5 mg p.o. three times a day.
DISCHARGE DIAGNOSES:
1. Subarachnoid hemorrhage.
2. Five cerebral angiograms.
3. Ventriculoperitoneal shunt.
4. Supraventricular tachycardia.
5. Pneumonia.
6. Denovo formation of aneurysms at the base of the coiled
aneurysm.
7. Craniotomy for the clipping of these new aneurysms.
CONDITION AT DISCHARGE: The patient will require extensive
rehabilitation. She has a PEG and tracheostomy at this
point. She will require neurologic rehabilitation. On her
current neurological examination, she opens eyes to commands,
smiles, does not follow commands other than opening eyes.
The patient is being discharged in stable condition.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2122-6-24**] 11:03
T: [**2122-6-24**] 11:45
JOB#: [**Job Number 42595**]
ICD9 Codes: 4271, 2875, 4240, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5182
} | Medical Text: Admission Date: [**2186-7-20**] Discharge Date: [**2186-8-3**]
Date of Birth: [**2116-11-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Penicillins / Sulfamethoxazole
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
Bronchoscopy w/ BAL, intubation for tunneled dialysis line
placement
History of Present Illness:
Ms. [**Known lastname 81668**] is a 69 year-old female with h/o insulin-dependent
diabetes, chornic kidney disease and complete heart block s/p
PPM who was in her usual state of health until 5-6 days ago at
which time she
developed progressive fatigue, malaise and weakness. She also
notes
diffuse body aches in hips, back, legs. Yesterday she notes the
development of significant shortness of breath with exertion.
She has noted shaking chills on occasion without fevers. She had
a diffuse
headache yesterday but denies dizziness or blurred vision. No
mouth
sores, bleeding from gums or nose. She denies nausea, vomiting,
abdominal pain. No diarrhea, constipation, dysuria. No
hematuria, bright red blood per rectum, or dark tarry stools.
She notes her blood sugars have been in the 400's for the past
week despite eating
very little. She denies weight loss.
She presented to [**Hospital6 33**] yesterday where labs
were
notable for WBC count of 95.2K with mostly blasts, smear
reviewed
by Dr. [**Last Name (STitle) 94913**] of Hematology-Oncology. Hct 34.5, plts 55K. Cr
2.6
from baseline 1.5, uric acid 16.7. LD 1600. Pt received
allopurinol and cefepime. Vital signs were stable apart from
transient desaturation to 80's on RA with rapid improvement to
97% on 2L. BNP was 5085, she was started on heparin gtt given
concern for
PE. She was transferred to our ICU given concern for leukostasis
with consideration for pheresis.
Past Medical History:
- Type 2 diabetes: Diagnosed 25 years, insulin-dependent,
complicated by peripheral neuropathy
- Chronic renal insufficiency (baseline Cr 1.5)
- Complete heart block c/b syncope, s/p PPM placement [**2185-9-29**]
- Legal blindness
- Hypertension
- Hyperlipidemia
- Morbid obesity
- Lymphedema
Social History:
Pt lives in [**Hospital1 392**], MA with her husband. She previously worked
at [**Last Name (NamePattern1) 74733**]in counseling. She denies tobacco, alcohol,
illicits. They have 5 children, 9 grandchildren.
Family History:
Both parents with diabetes, no family history of leukemia, other
malignancy.
Physical Exam:
Physical Exam on admission:
VS: 99.3 130/64 80 22 97% 3L; 0/10 pain
General- Overweight female lying in hospital bed, appears
uncomfortable but in no acute distress
HEENT-NC/AT, PERRL, EOMI, no icterus/injection. (+) thrush
Lymph- no palpable cervical, submandibular, supraclavicular
adenopathy
CV- regular, no murmurs, rubs, gallops
Resp- Clear to auscultation anteriorly, no crackles/wheezes
Abd- rotund, soft, NT/ND, no palpable hepatosplenomegaly
Ext- (+) lymphedema changes in LE bilaterally.
Skin- few ecchymoses on UE bilaterally
Neuro- AAOx3, CN2-12 intact/symmetric, strength grossly
intact/non-focal
Pertinent Results:
ADMISSION LABS:
[**2186-7-20**] 12:20AM BLOOD WBC-110.1* RBC-4.26 Hgb-11.8* Hct-35.5*
MCV-84 MCH-27.6 MCHC-33.1 RDW-17.6* Plt Ct-73*
[**2186-7-20**] 12:20AM BLOOD Neuts-14* Bands-0 Lymphs-2* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-82*
[**2186-7-20**] 12:20AM BLOOD PT-14.0* PTT-27.6 INR(PT)-1.3*
[**2186-7-20**] 12:20AM BLOOD Fibrino-752*
[**2186-7-20**] 12:20AM BLOOD Glucose-239* UreaN-86* Creat-2.6* Na-138
K-2.6* Cl-99 HCO3-26 AnGap-16
[**2186-7-20**] 12:20AM BLOOD ALT-17 AST-39 LD(LDH)-1662* AlkPhos-84
TotBili-0.2
[**2186-7-20**] 12:20AM BLOOD Albumin-3.1* Calcium-8.8 Phos-2.9 Mg-2.3
UricAcd-16.8
Urine studies
[**2186-7-20**] 05:57AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2186-7-20**] 05:57AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2186-7-20**] 05:57AM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE Epi-3
TransE-<1
Peripheral smear:
numerous large immature white blood cells with
large nucleoli, some with indented/folded nuclei, few granules
in
cytoplasm, no auer rods seen. Few lymphocytes, eosinophils. RBC
with few burr cells, tear drops. Platelets decreased in number.
IMMAGING:
CXR [**2186-7-20**]:
There is moderate cardiomegaly. Pacemaker leads are in the
standard position in the right atrium and right ventricle. The
lungs are grossly clear. There is no pneumonia, pneumothorax or
pleural effusion. There is mild vascular congestion.
TTE [**2186-7-20**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
[Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation. Moderate tricuspid regurgitation
around a pacer wire. Normal estimated pulmonary artery systolic
pressure.
CXR [**7-21**]:
FINDINGS: In comparison with study of [**7-20**], there is little
change.
Monitoring and support devices remain in place. Enlargement of
the cardiac silhouette persists, though there is no evidence of
pulmonary vascular congestion or acute pneumonia.
CT Chest w/o contrast
1. Endotracheal tube tip at the carina coursing towards the
orifice of the
right main stem bronchus. Retraction is recommended.
2. Multifocal diffusely distributed bilateral pulmonary nodular
and
ground-glass opacities, consistent with infection.
3. Coronary artery calcifications.
4. Catheter in the inferior vena cava, incompletely imaged.
MICROBIOLOGY
[**2186-7-30**] 2:05 pm BRONCHOALVEOLAR LAVAGE Site: LINGULA
GRAM STAIN (Final [**2186-7-30**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2186-8-1**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2186-7-30**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2186-7-31**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2186-7-31**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2186-7-31**]):
SPECIMEN COMBINED WITH [**Numeric Identifier 112363**].
Reported to and read back by DR [**First Name (STitle) **] [**2186-7-31**] 8:05AM.
PATIENT CREDITED.
Blood Culture, Routine (Final [**2186-7-29**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2186-7-24**]):
Reported to and read back by [**Doctor Last Name **] EL-OKDI @ 2207 ON
[**7-24**] - [**Numeric Identifier 23447**].
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
All other blood cultures negative, the above culture was thought
to be a contaminent
Brief Hospital Course:
Ms. [**Known lastname 81668**] is a 69 yo F with h/o insulin-dependent diabetes
mellitus, chronic kidney disease (baseline Cr of 1.4) and
complete-heart block s/p PMM who presented to [**Hospital3 **] with one week with malaise, chills, diffuse
arthralgias/myalgias and shortness of breath, found to have WBC
of 95K with increased peripheral blasts, elevated creatinine to
2.4, uric acid of 16.5, transferred to [**Hospital1 18**] for further
treatment of acute leukemia.
# Acute leukemia: Peripheral blood smear showed many
myeloid-appearing blasts, most likely c/w acute myeloid
leukemia. No auer rods were appreciated, no evidence of DIC
clinically or in lab testing, making APL less likely. Bone
marrow biopsy was performed. She received two doses of
rasburicase and was started on allopurinol with a decrease in
uric acid from 16.8 to 0.1. She also received hydroxyurea [**Hospital1 **]
to acutely lower her WBC. Echo and line were placed on [**7-20**].
Her urine output was decreased on [**7-21**] and creatinine remained
elevated at 2.7 depite continuous IVF with a 1L NS [**Last Name (LF) 1868**], [**First Name3 (LF) **]
renal was consulted. She was also started on cefepime for
neutropenic prophylaxis. Chemotherapy was administered and she
was inducted. She developed Tumor Lysis syndrome and Renal
failure, requiring dialysis.
# TLS: Recieved rasburicase and allopurinol. Elevated BUN/Cr and
other toxins were felt to be contributing to her AMS.
# Renal failure: Was felt to be [**3-2**] tumor lysis syndrome.
Required dialysis. A temporary port was placed for a while, then
removed in anticipation of placement of a tunneled catheter.
Tunneled cath was placed, but she was unable to be extubated
after the procedure.
# AMS:She developed AMS, but was responsive and interactive,
giving several word answers to questions. However, after she
failed the trial of extubation, she remained sedated and
un-interactive
# Pneumonia: She developed PNA seen on CT scan in the setting of
neutropenia. She was treated with Vanc/vori/cefepime. This was
felt to be a large contributor to her failure to extubate.
#Decision to withdraw care was made by the family members after
she had been on a ventilator for a week, since she had a very
poor prognosis and had previously articulated that she did not
want to be kept alive by a ventilator for a prolonged period of
time. The team held multiple meetings with the patient's husband
and children (most of whom attended work rounds on a daily
basis) to discuss her medical problems and her wishes. Comfort
measures were initiated and the patient expired.
Medications on Admission:
Insulin Lispro 6-15 units with meals
Humulin: 35 units SQ QPM
Aspirin 325 mg PO daily
Rosuvastatin 40 mg PO QHS
Enalapril 20 mg PO daily
Hydralazine 50 mg PO TID
Amlodipine 10 mg PO daily
Torsemide 20mg PO daily
Cefepime
Allopurinol 100 mg daily
Zofran
Tylenol
Hydralzine 50 mg TID
Amlodipine 10 mg daily
Morphine 2mg Q4h
NG 1 tab every 5 minutes
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute leukemia, respiratory failure, renal failure
Discharge Condition:
Patient expired during hospitalization
Discharge Instructions:
Dear Ms. [**Known lastname 81668**],
It was sincere pleasure taking care of you during your
hospitalization at [**Hospital1 69**]. You
were tranferred for further treatment of your fatigue and
shortness of breath. A bone marrow biopsy confirmed that you
had acute leukemia.
Followup Instructions:
patient expired
ICD9 Codes: 486, 5856, 5849, 2762, 7907, 2724, 3572, 2767, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5183
} | Medical Text: Admission Date: [**2182-4-10**] Discharge Date: [**2182-4-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89yM with CAD, systolic CHF EF 25-30%, moderate AS, on aspirin
and [**First Name3 (LF) **] presenting with severe anemia and melena. 3-4 days of
melena, [**3-21**] stools per day. Stool foul smelling, sticky, black.
No red blood. No abdominal pain, no nausea or vomiting. No EtOH
or NSAIDs, just ASA and [**Month/Day (3) **]. No additional ASA. No history of
GI bleeding and no EGD in th epast. Has NYHA class III CHF
symptoms at baseline, no angina at baseline. He gets short of
breath while walking in the part, does okay around the house. No
orthopnea, PND, or pedal edema. Weighed 177lbs on admission, 175
baseline. No other symptoms. No fevers/chills. In ED, had 2 PIV,
got 1L IVF, 40mg IV Protonix, and 1 unit pRBC's.
Past Medical History:
Diabetes
Dyslipidemia
CAD s/p PCA in [**1-/2182**]
Moderate Aortic Stenosis
Anemia
CKD (baseline creatinine 2.1)
Gout
CHF, EF 25-30%
Social History:
Lives in [**Location 1268**] with wife. [**Name (NI) **] 2 daughters and a son.
[**Name (NI) **] was born in [**Country 4754**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3
children and 9 grandchildren.
-Tobacco history: Denies
-ETOH: Occasional
-Illicit drugs: Denies
Family History:
No know FH of cardiac disease, diabetes, no colon/proste/breast
cancer. Parents lived to 70s to 80s with no known medical
problems. Children in good health. Brother had heart disease.
Physical Exam:
Vitals 97,0F, BP 98/51, HR 77, RR 14, O2 sat 97%RA
General: NAD, A&O x 3
HEENT: MM slightly dry, JVP 8cm
Cardiac: RRR, [**2-23**] mid peaking systolic crescendo decrescendo
murmur at the USB with radiation to the precordium and the
carotids, good carotid pulsations
Lung: CTAB
Abdomen: Soft, NT, ND, no masses or organomegaly
Rectal: minimal melnea in rectal vault, no red blood, no rectal
masses
Neuro: A&O x3, grossly normal
DISCHARGE EXAM:
98.2F, BP 102/64, 862, 96%RA
No JVD
RRR, 2/6 systolic murmur
Lungs clear to auscultation bilaterally
Abdomen benign
No peripheral edema
A&O x 3
Pertinent Results:
[**2182-4-9**] 11:30PM PT-12.8 PTT-29.3 INR(PT)-1.1
[**2182-4-9**] 11:30PM PLT COUNT-233
[**2182-4-9**] 11:30PM NEUTS-68.5 LYMPHS-17.4* MONOS-6.1 EOS-7.3*
BASOS-0.6
[**2182-4-9**] 11:30PM WBC-5.0 RBC-2.32*# HGB-7.5*# HCT-22.1*#
MCV-96 MCH-32.2* MCHC-33.7 RDW-13.6
[**2182-4-9**] 11:30PM cTropnT-0.05*
[**2182-4-9**] 11:30PM CK(CPK)-81
[**2182-4-9**] 11:30PM GLUCOSE-195* UREA N-163* CREAT-2.9*
SODIUM-132* POTASSIUM-6.3* CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
[**2182-4-10**] 04:32AM PT-12.9 PTT-29.3 INR(PT)-1.1
[**2182-4-10**] 04:32AM HCT-22.4*
[**2182-4-10**] 04:32AM ALBUMIN-3.4* CALCIUM-8.3* PHOSPHATE-4.0
MAGNESIUM-2.8*
[**2182-4-10**] 04:32AM ALT(SGPT)-79* AST(SGOT)-36 LD(LDH)-177 ALK
PHOS-57 TOT BILI-0.6
[**2182-4-10**] 04:32AM GLUCOSE-55* UREA N-158* CREAT-2.7* SODIUM-136
POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
[**2182-4-10**] 12:40PM HCT-24.8*
[**2182-4-10**] 12:40PM POTASSIUM-5.2*
[**2182-4-10**] 03:39PM HCT-25.8*
[**2182-4-10**] 06:07PM MAGNESIUM-2.4
[**2182-4-10**] 06:07PM estGFR-Using this
[**2182-4-10**] 06:07PM UREA N-134* CREAT-2.3* POTASSIUM-5.3*
Echo [**2182-4-10**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal for the patient's body size. There is
moderate global left ventricular hypokinesis (LVEF = 35-40 %).
The aortic valve leaflets are severely thickened/deformed. There
is moderate to severe aortic valve stenosis (valve area
1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2182-3-16**],
the heart fate is higher and left ventricular systolic function
is slightly more vigorous. The left ventricular ejection
fraction may have been slightly underestimated in the prior
report. . Estimated valve area is slightly higher in the current
report.
Chest X-ray [**2182-4-10**]: IMPRESSION: No evidence for pulmonary
edema. Suspected tiny or small pleural effusion on the left.
Chest X-ray [**2182-4-16**]: IMPRESSION: Unchanged mild cardiomegaly
and small bilateral effusions.
Brief Hospital Course:
89yM with CAD and systolic CHF, moderate AS, on aspirin and
[**Year (4 digits) **], admitted with severe anemia and melena.
# GI Bleeding. Hct on admission 22; baseline 30-32. Thought
secondary to UGIB (gastritis, PUD). ASA/[**Year (4 digits) **] stopped on
admission. Seen by GI; given multiple cardiac problems, any
procedure would need to be done by [**Last Name (LF) **], [**First Name3 (LF) **] deferred. Hematocrit
stabilized off ASA/[**First Name3 (LF) **]; GI bleeding thought secondary to
[**Last Name (LF) **], [**First Name3 (LF) **] this should be permanently discontinued. Metoprolol,
lisinopril, and torsemide held in setting of GI bleeding.
Hematocrit after [**4-12**] was stable, ranging from 25-30%. Received
a total of 5 units pRBC's during admission (last on [**4-16**]);
hematocrit at discharge 28%. No bowel movement in 3 days at time
of discharge. Discharged on pantoprazole [**Hospital1 **].
# Acute on chronic renal failure. Creatinine 2.7 at time of
admission (baseline 2.0-2.2). Creatinine was as low as 1.7
during the admission. Bumped from 1.7 to 2.2 when lisinopril
initially restarted; this medication was discontinued again and
should be restarted as an outpatient. Torsemide to be restarted
on discharge.
# Coronary artery disease. [**Hospital1 **] discontinued. Aspirin
restarted three days prior to discharge with subsequent stable
hematocrit. Statin continued. Metoprolol restarted two days
prior to discharge, and lisinopril to be restarted as
outpatient.
# Chronic systolic heart failure. Well-compensated throughout
the admission. Change in x-ray demonstrated accumulation of mild
bilateral pulmonary effusions (diuresis was held during the
admission). I's/O's closely monitored, and he remained euvolemic
throughout the admission. Beta blocker restarted during
admission, torsemide to start as outpatient, and lisinopril to
be restarted within one week of discharge.
# Delirium. Noted to have reversed sleep/wake cycles during the
admission, with subsequent confusion. Improved with trazodone,
to be continued on discharge.
# Gout flare. On [**5-6**], patient had low-grade fever and
bilateral great toe pain. Given one dose of colchicine with
resolution of fever and pain.
# Hyperlipidemia. Continued statin.
# Hypernatremia. Did develop hypernatremia during
hospitalization. Resolved with increased PO fluid intake.
# Full Code, confirmed with patient.
Medications on Admission:
Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Lisinopril 10mg daily
[**Date Range **] 75mg daily
Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
Torsemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for pain.
Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day
Zantac 75mg [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for pain.
9. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1) GI bleed
2) Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent, with cane/walker
Discharge Instructions:
You were admitted with bleeding in your GI tract. This was most
likely due to your medication, [**Hospital **], that you recently started
taking. Please do not take your [**Hospital **]. Your aspirin was
restarted, and you had no further bleeding; you should continue
to take this medication.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Please take all of your medications as prescribed
and keep all follow up appointments.
The following changes are made to your medication list:
- [**Name8 (MD) **]: DO NOT TAKE THIS MEDICATION, as it likely contributed
to your episode of bleeding from your GI tract
- Pantoprazole: this is an anti-acid medication that you are
prescribed to help prevent bleeding from your GI tract
- Lisinopril: This medication will likely be restarted by Dr.
[**Last Name (STitle) 131**]; please discuss this medication with him when you see him
on [**2182-4-24**]
- Trazodone: This is a medication for sleep.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2182-4-24**] 10:30am
Location: [**Street Address(2) 3375**] [**Location (un) 858**], [**Location (un) **] MA
Phone number: [**Telephone/Fax (1) 133**]
Special instructions for patient:
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7965**]
Specialty: Cardiology
Date/ Time:
Location:
Phone number: [**Telephone/Fax (1) 62**]
Special instructions for patient: The office will call you with
an appointment. If you do not hear or have any questions please
call the office. Thanks.
ICD9 Codes: 5789, 5849, 2930, 2760, 2851, 5859, 4280, 4241, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5184
} | Medical Text: Admission Date: [**2161-8-13**] Discharge Date: [**2161-8-24**]
Date of Birth: [**2125-1-11**] Sex: F
Service: Neurology
HISTORY OF PRESENT ILLNESS: The patient is a 36 year old
right handed woman who works as a secretary, with no history
of hypertension, heart disease, lung disease, liver disease,
renal disease or diabetes mellitus. She has some
intermittent sinus problems. She is also being followed for
ovarian cysts which do not seem to have bothered her.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2161-8-24**] 11:38
T: [**2161-8-24**] 11:52
JOB#: [**Job Number 35420**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5185
} | Medical Text: Unit No: [**Numeric Identifier 75904**]
Admission Date: [**2155-12-3**]
Discharge Date: [**2156-2-12**]
Date of Birth: [**2155-12-3**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: 1380 gram, baby boy, twin #2
[**Name2 (NI) **] to a 29 year-old, G2, P0 now 2 mother. Diamniotic
dichorionic twin gestation at 28 and 5/7 weeks. Cesarean
section secondary to breech presentation of this twin. The
mother was just discharged from the hospital on the [**10-29**] for prolonged admission with shortened cervix and
was readmitted on the [**11-1**] with rupture of
membranes. The reason for delivery was secondary to
progression of labor. There was no maternal fever. The infant
emerged with a good spontaneous cry and was doing well with
facial CPAP. In preparation for transfer to the NICU, the
infant had more apnea and did not tolerate being off the
CPAP. He was intubated with a 3.0 ET tube and admitted to
the NICU for further care. The Apgars were 7 and 9 at 1 and 5
minutes respectively.
PRENATAL LABS: Mom B positive, antibody negative, hepatitis
B antigen negative. Rubella immune. RPR nonreactive. Group
beta strep status unknown.
PREGNANCY HISTORY: Complicated by emergent cerclage at 18
weeks gestation and prolonged admission at [**Hospital1 18**] antepartum
floor from the [**10-28**] to the [**10-29**] with
preterm contractions and shortened cervix. The patient was
beta complete from that time. Di/di IUE assisted pregnancy.
Mother with gestational diabetes on insulin, TCOS.
SOCIAL HISTORY: Loss of previous IUE assisted pregnancy.
Father is a dentist.
PHYSICAL EXAMINATION: On admission, weight was 1380 grams
(75th percentile). Length 38.5 cm (50th
percentile). Head circumference 28.5 cm (75th-90th
percentile).
Examination on discharge: Weight 3615g (75th-90th%ile), length 51
cm (75th-90th%ile) HC 36 cm (>90th %ile)
The patient is alert and awake, very well
perfused. Chest: Clear breath sounds bilaterally. Heart:
Regular rate. No cardiac
murmur. Abdomen: Soft, nontender, nondistended. Bowel
sounds within normal limits. Liver at costal margin.
Genitourinary: Normal male, cicumcised. Testes descended
bilaterally.
Neuro: Soft fontanel. Moves all 4 extremities. Tone
appropriate for corrected age. Normal reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
patient was intubated in the delivery room because of apnea.
He received one dose of Surfactant and was extubated on the
[**11-2**] and put on CPAP on room air. He was
transitioned to room air on the [**10-8**]. He needed
the nasal cannula again transiently on the [**10-22**]
and then again from the 30 to the [**11-5**]. He was
presenting with apnea and was started on caffeine. Caffeine
was finally discontinued on the [**11-3**], at 33 weeks
and [**1-12**] post menstrual age. His last desaturation was [**2-7**] while
feeding. He had no apnea or bradycardia during the last 2 weeks
of his NICU stay.
Cardiovascular: The patient remained hemodynamically stable
during this hospitalization.
Fluids, electrolytes and nutrition: The patient was made
initially n.p.o. and put on 100 ml by kg per day of PN. The
feed was begun on the [**11-4**] and was well tolerated
and increased progressively. He reached full volume enteral
feedings on the [**10-12**]. The calories were increased to 22 on the [**10-14**] to 24 on the [**10-15**] to 26 on the [**10-16**] and were again decreased to 24 on the [**10-7**]. The patient was transitioned to Enfacare 24 on the
[**10-20**]. He was taking all feeds by mouth at discharge
with evidence of good weight gain. His discharge weight was 3615
g.
Gastrointestinal: The patient received phototherapy from the
[**11-2**] to the [**10-11**]. The maximum
bilirubin was 7.9 and 0.4 on the second of [**Month (only) 1096**].
Hematology: The initial hematocrit was 50.6 and on the last
check on the [**10-27**] was 30%. He received iron and
vitamin E supplementation until he was transitioned to enfacre 24
kcal/oz.
Infectious disease: The mom had rupture of membranes since
the [**11-1**]. Blood culture and CBC with differential
were obtained on admission. Initial white blood cell count was
6.5 with no left shift. The blood culture remained negative.
Antibiotics of ampicillin and gentamicin were begun at birth
and were stopped after 48 hours. On the [**11-4**], the
patient began to present with desaturations and required
again the nasal cannula. A blood culture from the [**11-4**] came back positive for E. Coli. A urine culture
from the [**11-5**] came back with E. Coli. The
diagnosis was made of urosepsis with E. Coli. The lumbar
puncture from the [**11-5**] remained negative and a
renal ultrasound on the [**10-7**] was normal. The
patient was begun on ampicillin and gentamycin on the [**11-5**]. These antibiotics were changed to Cefotaxime on
the [**10-7**] and the patient was treated for a total of
7 days until the [**10-11**]. He has been on amoxicillin
prophylaxis for urinary tract infections. To note, the
urine culture on the [**10-11**] was negative. He had a VCUG
on [**1-29**] that demostrated grade II vesicoureteral reflux
bilaterally. He had a normal renal ultrasound at that time. The
plan is to remain on amoxicillin and have these studies repeated
concurrent with a visit to urology (Dr. [**Last Name (STitle) 3060**] at CH [**Location (un) **]
office [**3-9**] at 1:30 pm.
Neurology: Head ultrasound on the [**11-4**] and the
[**10-11**] and these were normal. His 2 month cranial
ultrasound revealed a small right-sided IVH as well as a small
left sided cerebellar cyst. Upon consultation with neurology an
MRI of his head was obtained on [**2-3**] and this showed a likely
subependymal cyst on the posterior aspect of the 4th ventricle
(lesion seen on cranial u/s), as well as a 6mm cyst along the
right lateral ventricle and a 2 mm cyst along the body of the
left ventricle, which are also thought to be subependymal in
nature. He also has a 4 mm cyst adjacent to the pineal gland.
Neurology examined the patient, reviewed these findings, and met
with the family. Their impression is that these areas are
unlikely to lead to any clinical effect, but that [**Known lastname **] should be
followed in their clinic with a plan for repeat MRI at one year
of age. He is scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**3-24**] at
4:30 pm.
Audiology: Hearing screening was performed with automated
auditory brain stem responses. [**Known lastname **] passed his hearing screen on
[**2-9**].
Ophthalmology: The patient's eyes were examined by ophthalmoogy
and his retinas were mature without evidence of ROP on [**1-26**]. He
needs repeat examination in 6 months.
Psychosocial: [**Hospital1 69**] social
work was involved with the family. The contact social worker
can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72876**], [**Location (un) 15749**], MA.
([**Telephone/Fax (1) 75905**], fax ([**Telephone/Fax (1) 75906**].
CARE AND RECOMMENDATIONS:
MEDICATIONS: [**Known lastname **] is on prophylactic amoxicillin 20 mg by kg
by day each day by mouth.
Iron supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All infants
fed predominantly breast milk should receive Vitamin D
supplementation at 200 i.u. (may be provided as a multi-
vitamin preparation) daily until 12 months corrected age.
He passed his car seat position screening on [**2-11**].
State newborn screening has been sent per protocol on the [**10-6**] and also on the [**10-14**]
and results are pending.
Immunizations received: The infant has received hepatitis B
vaccine on the [**11-2**]. He received his 2 months
immunizations on [**2156-2-2**]. He received synagis on [**2156-2-9**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following four criteria: (1) [**Month (only) **] at less than 32
weeks; (2) [**Month (only) **] between 32 weeks and 35 weeks with two of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease or (4)
hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
Follow-up recommended: Pediatrician appointment scheduled for
[**2-16**]. VNA on [**2156-2-13**].
Plan for renal ultrasound and VCUG in 6 weeks after the
urinary tract infection.
Neonatal [**Hospital 878**] clinic [**3-24**].
DISCHARGE DIAGNOSES:
1. Prematurity at 28 and 5/7 weeks, twin pregnancy, this
twin being twin #2.
2. Footling breech presentation.
3. Respiratory distress syndrome.
4. Apnea of prematurity.
5. Rule out sepsis.
6. E. Coli urinary tract infection.
7. Hyperbilirubinemia.
8. Bilateral grade II vesicoureteral reflux.
9. Pineal, bilateral ventricular subepndymal, and 4th ventricle
(subependymal) cysts.
[**Name6 (MD) 11709**] [**Last Name (NamePattern4) 75907**], MD [**MD Number(2) **]
Dictated By:[**Doctor Last Name 75307**]
MEDQUIST36
D: [**2156-1-16**] 16:14:43
T: [**2156-1-16**] 17:37:14
Job#: [**Job Number 75908**]
ICD9 Codes: 769, 7742, 5990, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5186
} | Medical Text: Admission Date: [**2163-3-21**] Discharge Date: [**2163-3-25**]
Date of Birth: [**2101-9-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
[**2163-3-21**] Coronary artery bypass graft x 3 (left internal mammary
artery to left anterior descending, saphenous vein graft to
obtuse marginal, saphenous vein graft to posterior descending
artery)
History of Present Illness:
61 yo man with hypertension, hyperlipidemia and a known bicuspid
aortic valve who went to see his PCP [**1-12**] with symptoms of right
calf pain, expressing his concerns for DVT. A routine EKG showed
ST elevations that were thought to be an ischemic process versus
left ventricular hypertrophy versus left axis deviation. He was
sent to the ER for further evaluation. Troponins were positive
to .21. However, the presence of EKG Q-waves were thought to
suggest that this was a remote event. An echo demonstrated new
anterior lateral hypokinesis, compared to previous studies,
overall LV systolic function was decreased (LVEF 45%) and
demonstrated new wall motion abnormalities. A cardiac
catheterization revealed three vessel coronary artery disease.
He has now been referred for surgery.
Past Medical History:
- Anteroseptal myocardial infarction in [**2162-12-13**]
- Dyslipidemia
- Hypertension
- Bicuspid aortic valve
- DVT right leg [**2153**]
- Sciatica
- Ischemic cardiomyopathy (LVEF 45%)
- Obesity
- Tobacco and ETOH abuse
- Right lower extremity DVT
- ?Soft palate lesion
Past Surgical History:
- s/p Testicular repair
Social History:
Race: Caucasian
Last Dental Exam: 1 yr ago
Lives with: Partner in [**Name2 (NI) 3494**]
Occupation: Works as a bus driver for Holiday Inn, MSM.
Tobacco: 0.5-1ppd x 35 years. -quit [**2163-3-6**]- on Chantix
ETOH: 6 drinks/day
Family History:
Father died at 48 from lung cancer/MI
Physical Exam:
Pulse: 90 Resp: 16 O2 sat: 100%
B/P Right: 125/86 Left: 127/78
Height: 5'8" Weight: 198lbs
General: Well-developed male in no acute distress
Skin: Warm[X] Dry [X] intact [X]
dry, erythematous bilateral infra-mammary eruption
HEENT: NCAT[X] PERRLA [X] EOMI [X] anicteric sclera, OP benign,
no lesion seen
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 2/6 SEM
Abdomen: Obese, Soft [X] non-distended [X] non-tender [X] bowel
sounds + [X]
Extremities: Warm [X], well-perfused [X] Edema none
Varicosities: None [X]
Neuro: Grossly intact [X], MAE, [**6-16**] strengths, non-focal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2163-3-21**] Echo: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A patent foramen ovale is
present. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Overall left ventricular systolic
function is mildly depressed (LVEF=45 %). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is moderately dilated. The aortic valve is bicuspid. There
is mild aortic valve stenosis (valve area 1.8cm2) with Cardiac
output 4.0L/min.. Mild to moderate ([**2-13**]+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**Known firstname **] [**Known lastname 100303**]. POST-BYPASS: Preserved RV
systolic function. LVEF 45%. The mid anterior and anteroseptal
walls are hypokinetic compared to pre CABG. Surgeon informed of
these findings. With epinephrin only 0.02 mcg/kg/min they
improved signficantly later on. Intact thoracic aorta. Same
valvular findings as before. All wall motions similar to
prebypass after chest closure.
Brief Hospital Course:
Mr. [**Known lastname 100303**] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**2163-3-21**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 3. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated. Beta-blockers and
diuretics were started and he was gently diuresed towards his
pre-op weight. On post-op day one he was transferred to the
step-down floor for further care. Chest tubes and epicardial
pacing wires were removed per protocol. He continued to make
good progress while working with physical therapy for strength
and mobility. On post-op day four he was discharged home with
VNA services and the appropriate medications and follow-up
appointments.
Medications on Admission:
Aspirin 325 mg p.o. daily
Plavix 75 mg p.o. daily,
Metoprolol 50 mg p.o. b.i.d.
Lisinopril 10 mg p.o. daily
simvastatin 80 mg p.o. daily
Chantix
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
Disp:*90 Tablet(s)* Refills:*2*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO BID (2 times a day) for
7 days.
Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*0*
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day:
this is [**2-13**] of your home dose.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft
Past medical history:
- Anteroseptal myocardial infarction in [**2162-12-13**]
- Dyslipidemia
- Hypertension
- Bicuspid aortic valve
- DVT right leg [**2153**]
- Sciatica
- Ischemic cardiomyopathy (LVEF 45%)
- Obesity
- Tobacco and ETOH abuse
- Right lower extremity DVT
- ?Soft palate lesion
Past Surgical History:
- s/p Testicular repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: trace upper and lower extremity
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:
Please come to [**Hospital Ward Name 121**] 6 next Thursday, [**3-31**] at 10AM for wound
check.
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**4-14**] at 1:15PM [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) **] on [**4-26**] at 2PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**5-17**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2163-3-25**]
ICD9 Codes: 4111, 412, 2720, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5187
} | Medical Text: Admission Date: [**2170-7-12**] Discharge Date: [**2170-7-14**]
Date of Birth: [**2136-9-29**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
Fever and back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 1004**] originally presented to her PCP [**Last Name (NamePattern4) **] [**2170-7-11**] with a 4
day history of four days of fevers, chills, myalgias, headache,
and generalized malaise. On exam, vitals were 102.8, 120 ->
102, 110/70, 18. She had R CVA tenderness, suprapubic
tenderness, urine dip + for leukocytes (LG), blood (LG), and
nitrites. She was started on a 10d course of ciprofloxacin
(500mg PO BID) and ibuprofen (600mg PO PRN fevers and myalgias).
Urine cultures from this visit have since grown out >100,000 E
coli with sensitivity to ciprofloxacin.
She presented to the [**Hospital1 18**] ED on [**2170-7-12**] with increased back
pain and persistent fever, where her vitals were 103.2 144
100/55 20 100%/RA. She developed tachycardia and hypotension,
resolved on 3L of IVF. She was started on ceftriaxone 2g IV and
acetaminophen and transferred to the MICU with nl HR and BP.
She was given an additional 3L of IVF, and remained RRR and
normotensive for the length of her stay. She had 3 breakthrough
fevers (101s-102s) on [**7-13**] controlled with acetaminophen
500-1000mg PO Q6H PRN fever/pain. Follow-up blood and urine
cultures were sent but have shown no growth to date. Her
hematocrit trended from 32.5->22.0->27.6, likely [**1-2**]
hemodilution and menstruation, with autoregulation. Renal U/S
showed no stones, masses, hydronephrosis or perinephric fluid
collections.
She was transferred to the medicine floor late [**7-13**], where her
vitals have been stable and normal, and she reports feeling much
improved, with reduced back pain, no fevers or myalgias, no
dysuria or hematuria, no nausea or vomiting and no headache.
While on the floor, she was noted to be having an oral herpes
outbreak, which was treated with valacyclovir 2g PO BID x1 day.
Past Medical History:
- Ulnar fracture s/p open reduction and internal fixation
([**1-/2170**])
- Laparoscopic cholecystectomy s/p recurrent choleclithiasis
([**3-/2170**])
- Recurrent UTIs (once per year), last in [**2168**]
- Recurrent oral herpes
Social History:
Ms. [**Known lastname 1004**] came to the US from [**Country 21363**] nine years ago. She
lives with her husband and 2 sons (ags 5 and 1 years old). She
works as a cashier in a restaurant and studies English. She does
not smoke or drink ETOH.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
VS - Temp 97.3 80 94/P 16 98/RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, some mild suprapubic tenderness, R>L, otherwise
soft/NT/ND, no masses or HSM, no rebound/guarding. Mild right
CVA tenderness .
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radial and PT
SKIN - Abundant perioral herpetic lesions; otherwise no skin
lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, sensation
grossly intact throughout
Pertinent Results:
[**2170-7-11**] 04:00PM NEUTS-82.2* LYMPHS-12.4* MONOS-4.9 EOS-0.3
BASOS-0.2
[**2170-7-11**] 04:00PM WBC-9.9# RBC-3.97* HGB-11.3* HCT-32.7* MCV-82
MCH-28.6 MCHC-34.7 RDW-14.6
[**2170-7-12**] 05:35PM WBC-10.7 RBC-3.99* HGB-11.3* HCT-32.5* MCV-82
MCH-28.2 MCHC-34.6 RDW-14.6
[**2170-7-12**] 05:35PM calTIBC-230* FERRITIN-247* TRF-177*
[**2170-7-12**] 05:35PM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-2.0
IRON-10*
[**2170-7-12**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2170-7-12**] 07:00PM URINE RBC-0-2 WBC-[**2-2**] BACTERIA-OCC YEAST-OCC
EPI-0-2
Renal U/S from [**2170-7-13**]:
IMPRESSION: No evidence of perinephric abscess.
[**2170-7-11**] Urine Culture:
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Bloood cultures [**Date range (1) 52084**]/[**2169**]: negative and pending as of day
of discharge
Brief Hospital Course:
33F history of recurrent UTIs who was admitted to [**Hospital1 18**] with 4
days hx of fever, urinary frequency, foul-smelling urine and
right-sided back pain found to have sepsis secondary to
pyelonephritis. Initialy sent to the unit and then transfered to
the medical floor.
# Pyelonephritis: Pt initially presented with symptoms
consistant with pyelonephritis: fever, chills, right flank pain.
Pt found to have sepsis with hypotension and was given 3L IVF.
Urine cultures returned positive for E. Coli. Blood cultures
were negative up to day of discharge. She was started on empiric
Ceftriaxone 2g IV and was sent home on 2 weeks of Cipro after
sensitivities returned. Renal ultrasound performed and was
negative for abscess, stones or hydronephrosis. Pts symptoms
improved during hospitalizaiton and on day of discharge she was
asymptomatic with stable vitals, afebrile. Repeat UA and Urine
culture were negative.
#Microcytic anemia: Hct dropped from 32->22 then back up to 27.
This acute drop was likely combination of dilution and
menstruation. Iron studies: low iron of 10, low TBIC, and
increase in ferritin with Fe/TIBC< 4% (<15%). Findings
consistant with iron deficiency anemia in combination with
increase in ferritin due to acute infection. HCT was trended. Pt
should follow up with her Primary care doctor to start iron
therapy given her very low iron levels.
#Oral Herpes: Pt found to have herpes vessicles on her upper and
lower lips. Was given 2 doses of valacyclovir for treatment of
acute episode. Pt told to follow up with her primary care doctor
to discuss prophylactic continuous therapy, depending on the
number of herpes outbreaks she gets each year.
**FOLLOW UP:
1)Low Iron: pt has very low iron, likely needs iron supplements
and monitoring of HCT.
2)Oral Herpes: Depending on the number of episodes pt gets a
year, she might be a candidate for daily prophylactic
medicatins.
3)Pyelo: patient will complete 2 week course of Cipro for
complicated pyelonephritis.
Medications on Admission:
1. Ciprofloxacin 500 mg PO BID for 10 days
2. Ibuprofren 600 mg PO Q6H PRN fever, pain
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1)Pyelonephritis- complicated
2)Sepsis
Secondary
1)Oral Herpes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you during your hospitalization at
the [**Hospital1 69**].
You were admitted for an infection of your urinary tract that
involved your kindeys. The infection made you so sick that it
lowered your blood presure and caused fevers. You were intially
sent to the Intensive Care Unit until you stabalized. Bacteria
was found in your urine. You were treated with fluids through
your veins and antibiotics and your symptoms improved. On the
day you left the hospital, you had no fevers and your blood
pressure was normal. You must complete an entire 2 week course
of antibiotics. It is very important to take every pill.
You were also found to have a viral infection of your lips,
called herpes. We gave you Valacyclovir, a medicine that will
get rid of the lip infection. You were given 2 pills which will
resolve this episode. However, to prevent future herpes
outbreaks, it is important to follow up with your primary
doctor, Dr. [**Last Name (STitle) **], who can give you medicine that you take
every day to prevent outbreaks.
You were found to have anemia, low red blood cells. It is likely
from menstruation and low iron. It is important to follow up
your anemia with Dr. [**Last Name (STitle) **].
The following changes were made to your medications:
Ciprofloxacin: You must take 1 pill in the morning, 1 pill in
the evening for 2 weeks. You will finish on [**7-27**].
Valacyclovir: you were given 1 day of pills. You do not need to
continue this medicine.
You came into the hospital on no other medications.
Please follow up with Dr. [**Last Name (STitle) **] within 1 week. You must call
his office to schedule the appointment. [**Telephone/Fax (1) 9556**].
Followup Instructions:
You MUST call Dr.[**Name (NI) 11689**] office to schedule an appointment to
see him within 1 week. This is very important. Call #[**Telephone/Fax (1) 86784**].
Department: ORTHOPEDICS
When: MONDAY [**2170-7-30**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 25538**], NP [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: WEDNESDAY [**2170-10-3**] at 4:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5188
} | Medical Text: Admission Date: [**2117-3-31**] Discharge Date: [**2117-4-2**]
Date of Birth: [**2070-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
MICU call out, initial admit for Hematemesis
Major Surgical or Invasive Procedure:
EGD x2
History of Present Illness:
46 y.o. male with history of alcoholism and Hep. C, complicated
by varices, ascites and encephalopathy who presented with
hematemesis.
.
Patient reported continued alcohol use, but less compared to his
routine. He notes two recent stressors - pain and a break-up
with his girlfriend, which caused him to rely more heavily on
alcohol and in doing so, he noticed "dark" emesis evening of
admisison around 10 PM, which was persistent, prompting him to
call EMS. He denies fevers, chest pain, SOB, but does report
some lightheadedness. He denied any BRBPR, but did not
increasing dark to black stools.
.
In the ED, patient was reported to have 700 ccs of coffee ground
and bright red blood emesis. However, he remained
hemodynamically stable with SBPs ranging from 123-130 and no
tachycardia. A hepatology consult was placed and the patient was
started on Ceftriaxone and received 3 L of NS before coming to
the floor.
.
Of note, pt. was hospitalized at [**Hospital1 18**] from [**2-24**] - [**3-10**] for
encephalopathy and had an EGD revealing 2 cords of grade I - II
esophageal varices, which were banded. He was also found to have
portal hypertensive gastropathy at this time.
.
Patient was initially admited to the MICU and underwent EGD
which showed varices. Received 1 unit PRBC with originally with
no improvement in hct. Had EGD the following day. Banding was
not performed during either EGD. In total received 3 units PRBC,
2U FFP. Last transfusion [**3-31**] at 5PM.
.
At time of transfer pt has no complaints. Denies any recent
vomiting. Continues to have some dark stools. Denies
lightheadedness, dizziness, chest pain.
Past Medical History:
- Etoh cirrhosis, actively drinking, MELD 18
- HCV viral load is 436,000 international units. The patient
has not had a liver biopsy nor has the patient had any treatment
to date for his hepatitis C followed by Dr. [**Last Name (STitle) 497**] (last seen
[**12-9**]).
- EGD [**2115-12-23**] revealing varices at the lower third of the
esophagus, with two bands placed, and portal gastropathy.
- Grade 3 esophageal varices with multiple admissions for GIB,
banding in past
- Ethanol abuse with history of DTs.
- h/o Nephrolithiasis.
- MVA [**2113-5-4**] with two fractured lumbar vertebrae, torn
rotator cuff, and humeral head fracture.
- h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia
- foot surgery
- facial reconstruction as a child
- leg cramps
- asthma
Social History:
The patient is single. Moved to cape and is living with friends.
Currently moving. He is actively drinking. Has long hx of etoh
abuse (since high school, with 1 6 month period of sobriety) and
withdrawl. He smokes 1 pack every 3 days, x 30+ years. He is not
working. He used to work as a carpenter. He denies IVDA x last
15 years, has used intranasal drugs within the past year or so,
+cocaine/heroin use in past; hx of incarceration in the past.
Family History:
He does not know much about his family history. He does not
know
of any liver disease or colon cancer.
Physical Exam:
Tmax 99 Tc 98.6 BP 131/93 (130-140/80-92) HR 80 RR 14 O2 96%RA
I/O (24 hr)3216/1455
.
Gen: Young male lying in bad in nad
HEENT: PERRL, EOMI, OP clear, poor dentition
Neck: Supple, no LAD
Lungs: CTAB, no carckles.
Heart: S1, S2 nl, no m/r/g appreciated
Abd: Soft, nontender, nd
Ext: No lower ext edema.
Neuro: CN II - XII intact, moves all extremities equally
Pertinent Results:
EGD [**3-31**]
Varices at the lower third of the esophagus
Medium hiatal hernia
Blood in the stomach body
Erythema, congestion, nodularity and friability in the stomach
body and fundus compatible with portal hypertensive gastropathy
Blood in the first part of the duodenum and second part of the
duodenum
There were no gastric varices.
Otherwise normal EGD to second part of the duodenum
.
EGD [**4-1**]
Impression:
Esophageal varices
Erythema, congestion, nodularity and friability in the stomach
body and fundus compatible with portal hypertensive gastropathy
Blood in the stomach
Otherwise normal EGD to second part of the duodenum
Recommendations:
Continue once daily PPI.
Brief Hospital Course:
Pt is a 46 yo M with history of ETOH/HCV cirrhosis with known
varices and portal gastropathy admitted with hematemesis. Now
being called out of the ICU.
.
# Hematemesis: Baseline hct 26-30 and patient presented with
hct of 22 which then dropped to 19. EGD was performed x2 which
showed esophageal varices as likely source of bleed, but no
active bleeding from site. He had variceal banding performed
recently on [**3-8**]. EGD this admission also showed gastritis. He
received a total of 3U prbcs and 2U FFP and hct at time of
discharge was 30 and he was without evidence of any further
active bleeding. Nadolol and diuretics were originally held in
the setting of unstable blood volume, but were restarted upon
his discharge.
.
# Cirrhosis: Secondary to ETOH and HCV. Multiple complications
including variceal bleeding, ascites, encephalopathy,
coagulopathy, thrombocytopenia. As above, nadolol, lasix, and
spironolactone were originally held, but were restarted for
discharge. He was taking pentoxyfilline on admission, but this
was discontinued per liver team.
.
# Alcohol abuse: He continues to actively drink with last drink
1 night PTA. He has history of withdrawal, no seizures. He was
placed on CIWA scale with prn valium and was continued on MVI,
thiamine and folate. Although addressed with social work and
case management, he currently refuses rehab as he states that he
has been "detoxed" here.
.
# Hepatic encephalopathy: He was not encephalopathic during
this admission. He was continued on lactulose titrated for goal
[**4-8**] bowel movements daily.
.
# Ascites: Fluid from previous paracenteses showed SAAG c/w
portal HTN. No paracentesis performed during this admission.
He was restarted on spironolactone and lasix prior to his
discharge.
.
# Coagulopathy/thrombocytopenia: Secondary to cirrhosis. In
the setting of his GI bleed, he received vitamin K and 2U FFP.
.
# Asthma: During this admission, he had no active pulmonary
issues. He was continued on prn albuteral and ipratropium.
Medications on Admission:
Meds at home: Has not been taking his meds for 5 days.
Meds from last d/c summary:
1. Thiamine HCl 100 mg Qday
2. Hexavitamin Qday
3. Gabapentin 300 mg TID
4. Nadolol 40 mg qday
5. Pentoxifylline 400 mg TID
6. Folic Acid 1 mg Qday
7. Furosemide 80 mg [**Hospital1 **]
8. Spironolactone 150 mg [**Hospital1 **]
9. Lactulose 10 g/15 mL QID
10. Clonidine 0.1 mg [**Hospital1 **]
11. Albuterol 90 mcg prn
12. Sucralfate 1 g QID
13. Atrovent prn
14. Omeprazole 20 mg [**Hospital1 **]
15. Nicotine 21 mg/24 hr Patch
16. Hydromorphone 2 mg Q8hrs:prn
.
MEds at transfer:
Ciprofloxacin 400 mg IV Q12H Duration: 5 Days
Multivitamins 1 CAP PO DAILY
Diazepam 10 mg IV Q2H:PRN CIWA>10
Nicotine Patch 21 mg TD DAILY
Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea
Pantoprazole 40 mg IV Q12H
Gabapentin 300 mg PO Q8H
HYDROmorphone (Dilaudid) 0.5-2 mg IV Q6H:PRN
Lactulose 30 ml PO QID Goal [**4-8**] BM's per day
Thiamine HCl 100 mg PO DAILY
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*qs * Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*0*
4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
7. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*0*
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): Titrate to [**4-8**] BMs daily.
Disp:*qs * Refills:*0*
9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-5**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*qs * Refills:*0*
11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*0*
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
13. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Disp:*qs 1 month supply* Refills:*2*
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
15. Atrovent Inhalation
16. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for pain.
Disp:*15 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper GI bleed
Esophageal varices
Cirrhosis
Alcohol abuse/dependence
.
Asthma
Recent Left humeral surgical neck fracture
Discharge Condition:
Stable with stable hematocrit and hemodynamics.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
develop blood in your vomit or stool, fevers/chills,
nausea/vomiting, inability to tolerate food/fluid, heavy alcohol
consumption, or alcohol withdrawal.
.
Please avoid alcohol consumption.
.
Please follow up with your appointments as scheduled below.
Please take your medications as prescribed and be sure to
complete an addional 2 days of your antibiotics.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 497**] on [**4-30**] at 2:40pm.
.
Appointments scheduled prior to this admission:
1. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2117-4-16**] 9:40am
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2117-4-29**] 8:20am
3. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2117-4-30**] 1:30pm
ICD9 Codes: 2761, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5189
} | Medical Text: Admission Date: [**2126-12-4**] Discharge Date: [**2127-1-12**]
Date of Birth: [**2080-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
R basilic vein thrombosis
Major Surgical or Invasive Procedure:
R heart catheterization
L internal jugular central venous line
L radial arterial line
History of Present Illness:
Ms. [**Known lastname 28331**] is a 46 year old woman with history of AML s/p
allogeneic stem
cell transplant from an unrelated donor in [**2124-10-24**], with
TBI and Cytoxan for conditioning regimen. Her course was
complicated by graft versus host disease of the skin and lungs,
hypertension and numerous steroid-related complications such as
diabetes, steroid myopathy, and increased peripheral edema.
.
She presents today from clinic with right arm swelling (she had
a PICC in the arm) and was found to have a completely occluded
right basilic vein. She has some pain in the right arm,
especially with movement. The PICC line was pulled and she was
admitted for anticoagulation.
.
Of note, she was recently discharged after she was admitted with
Enterococcal bacteremia (vanco sensitive); she finished her
course of ampicillin yesterday. She has otherwise been doing
well at rehab-- she has been slowly diuresed and is making some
progress with PT.
Past Medical History:
PMH/PSH:
1) Acute Myelogenous Leukemia type M2 s/p matched unrelated
donor stem cell transplant [**10-29**]; complicated by GVHD of the
liver, skin and lungs.
2) Bronchiolitis Obliterans
- PFTs [**2126-6-6**] showed FEV1 0.47 L/17% of predicted, FEV1/FVC 41%
- developed due to GVHD [**6-29**]
- at End Stage Lung Disease - severely limited functional status
40 (on prior admission)
3) Right lung abscess, s/p resection
4) Pulmonary nodules with geotrichum
5) Diabetes Mellitus, [**1-25**] steroid treatment
6) Hypertension
Social History:
Patient lives with mother, but has been at rehab since her [**Hospital1 18**]
discharge one week ago. Currently unemployed. Previously
worked as stock clerk. Quit smoking 2 years ago. Occasional EtOH
use.
Family History:
No history of oncologic diseases.
Physical Exam:
Vitals on arrival to the floor: 97.7, 60, 120/92, 100% 3L NC
Gen: Obese cushingoid female pleasant, sitting up in bed. Wearin
oxygen
HEENT: + mucous on eyelashes and injected conjunctivae b/l- old
per patient [**1-25**] GVHD. No scleral icterus.
Neck: No cervical LAD. JVP could not be appreciated.
CV: nml S1, S2, no m/r/g
Lungs: occ wheeze, but overall CTA b/l
Extremities: 4+ pitting edema of the legs, L + R, to the thigh.
No areas of cellulitis on legs or arms. Some weeping of clear
fluid from anterior left leg and right arm (at sites where she
has scabs and scratches). Extremities somewhat cool to touch,
but 2+ DPP b/l and radial pulse.
Neuro: CN II- XII grossly intact. Gait deferred.
Upper extremities: No increases tone. 2+ DTRs. 4/5 strength
throughout.
Lower extremities: 2/5 strength present in proximal muscles with
[**3-29**] in distal muscles s/l. No reflexes elicited.
Pertinent Results:
ADMISSION LABS:
[**2126-12-4**] 11:20AM BLOOD WBC-6.4 RBC-2.67* Hgb-9.9* Hct-30.7*
MCV-115* MCH-37.3* MCHC-32.4 RDW-15.8* Plt Ct-131*
[**2126-12-4**] 11:20AM BLOOD Neuts-86.2* Lymphs-7.6* Monos-5.3 Eos-0.7
Baso-0.1
[**2126-12-4**] 11:20AM BLOOD Plt Ct-131*
[**2126-12-4**] 11:20AM BLOOD UreaN-37* Creat-1.3* Na-142 K-3.6 Cl-96
HCO3-40* AnGap-10
[**2126-12-4**] 11:20AM BLOOD ALT-15 AST-16 LD(LDH)-255* AlkPhos-669*
TotBili-0.3 DirBili-0.2 IndBili-0.1
[**2126-12-4**] 11:20AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.8
UricAcd-10.1* Cholest-156
DISCHARGE LABS:
RADIOLOGY:
[**2126-12-4**] RUE US: Basilic vein thrombosis
[**2126-12-4**] Bilateral LE US: No evidence of DVT
[**2126-12-11**] Renal US: Unremarkable renal ultrasound without
evidence of vascular abnormality.
Brief Hospital Course:
1. Anasarca: The patient appeared to be total body overloaded by
intravascularly dry at admission. She [**Month/Day/Year 1834**] right heart
catheterization on [**2126-12-6**] that showed pulmonary hypertension
(systolic BP 45, diastolic BP 20, mean BP 28). She was therefore
started on sildenafil. The nephrology service was consulted, and
she diuresed well on a regimen on albumin, lasix, and
chlorthiazide (then metolazone). Her diuresis was discontinued
on [**1-8**] because of development of hypotension occuring in the
setting of a urinary tract infection. Subsequently, she was
transferred to the [**Hospital Unit Name 153**] for hypotension (see below) where
sildenafil was d/c'd as the patient was unlikely benefiting from
it in the setting of relatively mild to moderate pulmonary HTN
and overall systemic hypotension.
2. UTI: She developed a urinary tract infection with Pseudomonas
on [**12-15**] and was treated with a two week course of levofloxacin
then ciprofloxacin. A repeat urine culture was obtained for
followup on [**1-2**] although she was afebrile and had no urinary
complaints. This culture again grew out Pseudomonas, this time
quinolone resistant. Her foley catheter was changed, as she
refused to have it removed. She subsequently developed a fever
to 101.3 on [**1-7**] and was started on cefepime, with addition of
vancomycin and flagyl on [**1-8**]. Upon transfer to the [**Hospital Unit Name 153**] for
hypotension and tachycardia (see below), she was continued on
vancomycin, cefepime, and flagyl. A central venous line and
arterial line were placed under sterile conditions. After 24
hours in the ICU, the patient was on 3 pressors with the
differential diagnosis including septic vs. cardiogenic shock.
Meropenem was added as for double gram-negative and Psuedomonas
coverage. In spite of maximal medical therapy, the patient
remained maxed out on 3 pressors. A repeat family meeting was
held with the pt's HCP and mother, who agreed to make the
patient CMO. She expired shortly thereafter. An autospy was
offered, but declined.
3. Hypotension and tachycardia: She developed hypotension to the
70's sytolic on [**1-8**] which responded initially to fluid boluses.
Her hypotension was thought to reflect both aggressive diuresis
and possible urosepsis. She developed tachycardia to the 120's
on [**1-9**] with a new RBBB. She was transferred to the [**Hospital Unit Name 153**] where
she was given adenosine 6 mg X 2 with conversion to sinus
tachycaria after the second dose of adenosine. However, she went
back into a wide complex tachycardia with a RBBB pattern soon
thereafter. The cardiology team evaluated her and felt that this
rhythm was most likely an SVT with rate related aberancy;
however the following day, after reviewing the EKG strips with
the EP attending, the patient was determined to have a fasicular
ventricular tachycardia in the setting of no known prior CAD or
ischemic scar. The treatment of choice in this setting would
have been verapimil; however this was not feasible as the
patient was already on 3 pressors (neo, levophed, and
vasopressin). The following day, a dose of verapimil was tried
given concern for possibly worsening cardiogenic shock (however
the patient's extremities remained warm to palpation, which
suggested likely septic shock) with conversion back to sinus
tachycardia. She was not cardioverted secondary to the patient's
wishes to remain DNR/DNI. Given the patient's lack of
improvement in spite of maximal medical care, the patient was
made CMO after another family meeting and expired shortly
thereafter.
3. C. diff colitis: She experienced loose stools after admission
and a stool sample was positive for C. diff toxin on [**12-8**]; she
was subsequently treated with a 14 day course of flagyl. This
was restarted on [**1-8**] as noted above in the context of recurrent
fever and increased stooling.
4. Right basilic vein thrombosis: The patient's PICC line was
removed and she was started on IV heparin and then coumadin. Her
anticoagulation was discontinued in the setting of heme positive
stools and widely varying INR (thought likely to be due to
interactions with her many medications). A repeat ultrasound of
the upper extremity showed no evidence of persistent thrombus
therefore she was not continued on further anticoagulation.
5. AML with history of GVHD: She was continued on cyclosporine,
Cellcept, and her prednisone was titrated down per BMT
recommendations.
6. Elevated LFTs: Her transaminases, alkaline phosphatase, and
bilirubin were moderately elevated and thought to be secondary
to GVHD of the liver after review of her medication list and
right upper quadrant ultrasound revealed no other clear causes
of these findings. Her alkaline phosphatase elevation was
probably due at least in part to her bony disease as the bone
specific fraction was elevated as well.
7. Acute renal failure: The patient's creatinine was 1.3 at
admission peaking at 1.9. She was thought to be intravascularly
dry with prerenal failure. Her creatinine improved with addition
of albumin to her diuretic regimen consistent with this.
8. Pulmonary hypertension: Ms. [**Known lastname 28331**] [**Last Name (Titles) 1834**] right heart
catheterization on [**12-7**] to assess whether pulmonary
hypertension might be contributing to her significant edema.
This study showed mean pulmonary pressures of 28 and she was
subsequently started on sildenafil, which was subsequently d/c'd
upon transfer to the [**Hospital Unit Name 153**] (see above).
9. Heme positive stools: As noted above, she had heme positive
stools in the setting of anticoagulation with IV heparin and
warfarin and recent C. difficile colitis infectoin. In addition,
she had a prior history of gastritis on endoscopy and was
receiving steroids for her GVHD. She was started on a PPI and
her Hct was followed closely.
10. Hyperparathyroidism and vitamin D deficiency: The patient's
PTH was rechecked as the differential for her bone changes noted
on plain films included osteitis fibrosa. She was evaluated by
the endocrinology consult service who felt that her
hyperparathyroidism was likely secondary, perhaps due to renal
failure or steroid use. Her vitamin D levels were rechecked and
found to be low. She was started on weekly vitamin D and daily
calcium. She will need repeat vitamin D studies and should
follow up with endocrinology for further management. She was
started on a bisphosphonate per endocrine recs.
11. Pulmonary osteoarthropathy: She complained of diffuse body
pains and aches. Imaging of her extremities was notable for
diffuse periosteal reaction. The endocrinology service reviewed
the films and felt the history and imaging were most consistent
with pulmonary osteoarthropathy. Her pain was treated with oral
dilaudid as needed for pain control.
12. Eye pains: Ms. [**Known lastname 28331**] complained of eye soreness. This was
thought to be secondary to GVHD. She was started on cyclosporin
eye drops and artificial tears. She was evaluated by the
opthalmology consult service who recommended addition of Refresh
eye drops which she continued with relief of her symptoms.
Medications on Admission:
Atenolol 100 mg qd
Cell cept [**Pager number **] mg qam
Cellcept [**Pager number **] mg qpm
Hydralazine 25 mg q 6 hrs
Neoral 50 mg qam
Neoral 25 mg qhs
Prednisone 15 mg [**Hospital1 **]
Valtrex 500 mg [**Hospital1 **]
VFEND 200 mg [**Hospital1 **]
Benzonatate
Azithromycin 250 mg qod
Bactrim DS MWF
Lantus 12 U qd
HSSI
Zolpidem 10 mg qd
Oxycodone 5 mg prn
Odansetron 4 mg q 8 hrs prn
Albuterol prn
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiorespiratory Arrest
Septic vs. cardiogenic shock
Psuedomonas UTI
Fasciular Ventricular Tachycardia
AML c/b GVHD
R basilic DVT
Acute renal failure
Anasarca
Pulmonary Hypertension
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2127-1-13**]
ICD9 Codes: 5849, 0389, 5990, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5190
} | Medical Text: Admission Date: [**2110-6-14**] Discharge Date: [**2110-7-1**]
Date of Birth: [**2026-12-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2108-6-13**] EGD
[**2110-6-27**] Esophagogastroduodenoscopy, laparoscopic giant
paraesophageal hernia repair and gastrostomy tube
History of Present Illness:
83 yo who presented with atypical chest pain and
backache,particularly when swallowing. Admitted with a question
of esophagealperforation. On endoscopy she had a partial tear
just above the GE junction but more notably she had a nearly
complete intrathoracic stomach with a giant paraesophageal
hernia. We
treated her conservatively for several days and a subsequent
barium swallow revealed no evidence of leak.
Past Medical History:
COPD
HTN
HLP
GERD
PMR (Steroids)
Social History:
Cigarettes:[X ] ex-smoker quit: 20 yrs ago
ETOH: [X ] Yes drinks/day: [**11-29**]
Lives:[X ] Alone
Family History:
Non-contributory
Pertinent Results:
[**2110-6-20**] 05:31AM BLOOD WBC-7.8 RBC-2.91* Hgb-8.4* Hct-26.7*
MCV-92 MCH-28.9 MCHC-31.5 RDW-13.3 Plt Ct-352
[**2110-6-18**] 03:49AM BLOOD WBC-6.9 RBC-2.97* Hgb-8.8* Hct-26.7*
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.5 Plt Ct-317
[**2110-6-15**] 04:51AM BLOOD WBC-9.7 RBC-3.09* Hgb-9.4* Hct-28.3*
MCV-92 MCH-30.2 MCHC-33.0 RDW-13.1 Plt Ct-289
[**2110-6-22**] 12:58PM BLOOD Glucose-132* UreaN-44* Creat-1.0 Na-140
K-3.7 Cl-103 HCO3-27 AnGap-14
[**2110-6-19**] 02:14PM BLOOD Glucose-232* UreaN-36* Creat-0.9 Na-141
K-3.8 Cl-103 HCO3-29 AnGap-13
[**2110-6-18**] 02:54PM BLOOD Glucose-125* UreaN-25* Creat-0.8 Na-143
K-4.4 Cl-104 HCO3-29 AnGap-14
[**2110-6-15**] 08:42PM BLOOD Glucose-122* UreaN-33* Creat-1.2* Na-136
K-3.5 Cl-103 HCO3-26 AnGap-11
[**2110-6-14**] 10:55PM BLOOD Glucose-150* UreaN-44* Creat-1.4* Na-133
K-3.2* Cl-99 HCO3-25 AnGap-12
[**2110-6-17**] 05:15AM BLOOD ALT-11 AST-16 AlkPhos-43 TotBili-0.3
[**2110-6-22**] 12:58PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.9
[**2110-6-16**] 04:30AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8
[**2110-6-17**] 05:15AM BLOOD calTIBC-195* TRF-150*
[**2110-6-17**] 05:15AM BLOOD Triglyc-221* HDL-47 CHOL/HD-3.1
LDLcalc-56
[**2110-6-18**] 10:59AM BLOOD Type-ART pO2-66* pCO2-37 pH-7.46*
calTCO2-27 Base XS-2
[**2110-6-17**] 08:59AM BLOOD Type-ART pO2-72* pCO2-43 pH-7.47*
calTCO2-32* Base XS-6
[**2110-6-14**] 09:49PM BLOOD pO2-81* pCO2-42 pH-7.43 calTCO2-29 Base
XS-2 Intubat-INTUBATED Vent-CONTROLLED
[**2110-6-17**] 06:05AM BLOOD freeCa-1.13
[**2110-6-28**] 04:51AM BLOOD WBC-11.4*# RBC-2.95* Hgb-8.9* Hct-27.1*
MCV-92 MCH-30.1 MCHC-32.7 RDW-13.8 Plt Ct-332
[**2110-6-29**] 03:52AM BLOOD WBC-7.7 RBC-2.76* Hgb-8.3* Hct-25.7*
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.0 Plt Ct-297
[**2110-6-30**] 04:51AM BLOOD WBC-7.1 RBC-3.24* Hgb-9.4* Hct-29.7*
MCV-91 MCH-29.0 MCHC-31.7 RDW-14.2 Plt Ct-290
[**2110-6-27**] 07:52AM BLOOD Glucose-119* UreaN-30* Creat-0.7 Na-139
K-3.6 Cl-113* HCO3-17* AnGap-13
[**2110-6-29**] 03:52AM BLOOD Glucose-131* UreaN-25* Creat-0.7 Na-140
K-3.8 Cl-107 HCO3-25 AnGap-12
[**2110-6-30**] 04:51AM BLOOD Glucose-122* UreaN-24* Creat-0.7 Na-138
K-4.2 Cl-104 HCO3-28 AnGap-10
[**2110-6-30**] 04:51AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.5*
[**2110-7-1**] 04:18AM BLOOD WBC-7.1 RBC-3.01* Hgb-9.0* Hct-27.6*
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.5 Plt Ct-297
[**2110-7-1**] 04:18AM BLOOD Glucose-136* UreaN-22* Creat-0.7 Na-136
K-4.2 Cl-103 HCO3-26 AnGap-11
[**2110-7-1**] 04:18AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9
Brief Hospital Course:
83 yof pt transferred from Caritas [**Hospital6 **] where
she was admitted on [**2110-6-12**] with an atypical chest pain and
backache, particularly when swallowing.
CXR showed large Hiatal hernia. While waiting for UGI in the
Radiology dept she developed respiratory distress and was
admitted to the ICU rxed with nebs and IV hydrocortisone.Later,
She had a CT scan without contrast since her Cr. was 2.1 which
revealed R parenchymal infilterates and markedly distended
esophagus. No free air was evident. GI was consulted for EGD,as
a safe measure pt was intubated pre EGD. During intubation pt
developed hypotension and ST elevation and loss of p waves with
junctional rhythm, which was very transient and troponins were
0.02, this was improved as soon as the pt was started on
pressors/ neosnephrine. Soon after, EGD was done that showed a
perforation just prox to GE junction , clipping attempted ,
failed to close the perforation. She was started on Levaquin
Clinda and Zosyn. Pt was transferred to [**Hospital1 **] for evaluation and
definitive management of esophageal perforation.
[**2110-6-14**] EGD performed on arrival to [**Hospital1 **] : At 30 cm we could see
the GE junction. Right there, there were several metallic clips
which had been placed by the outside gastroenterologist
presumably. At the site of these clips we could see perforation
which measured approximately 1 cm across. This was oriented
posteriorly in the esophagus. I went ahead and entered the
stomach and noted that it was extremely tortuous consistent with
the possible gastric volvulus suggested by the noncontrast CT
scan. I was not able to traverse the entirety of the stomach
down to the pylorus due to this tortuosity. There is no other
site of bleeding or perforation in the stomach. We went back and
visualized the replacement of the NG tube to make sure that it
went back into the stomach. The perforation itself looked
subacute but it was unclear exactly how old it was. Patient was
admitted to ICU intubated and treated with antibiotics (Vanco,
cipro, flagyl, fluc). Extubated [**2110-6-16**] TPN started for
nutrition patient NPO. CXR RLL -? aspiration pneumonia. [**2110-6-19**]
transfered to [**Hospital Ward Name 121**] 9 with NPO w/TPN/PICC line and continued on
antibiotics. On [**2110-6-27**] Patient taken for surgery for:
Esophagogastroduodenoscopy, laparoscopic giant paraesophageal
hernia repair and gastrostomy tube. Patient did well transfered
back to [**Hospital Ward Name 121**] 9 Continued on TPN and Antibiotics advancing diet
to full liquids. Continued TPN adjusting as pos increased.
Daily Calorie Count and Crush all meds.
Transfered to rehab with TPN-wean on Full liquid diet only for
deconditioning and tx.
Medications on Admission:
Metoprolol 12.5 '' HCTZ 25 ' Levalbuterol inh '''' Lipitor 20 '
Prednisone 10' Bupropion 150'
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4H (every 4 hours) as needed for Pain.
10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig: One
(1) Recon Soln Injection DAILY (Daily).
14. insulin sliding scale achs
Insulin SC Sliding Scale AC and HS
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice
51-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 4 Units 4 Units 4 Units 4 Units
201-250 mg/dL 8 Units 8 Units 8 Units 8 Units
251-300 mg/dL 12 Units 12 Units 12 Units 12 Units
301-350 mg/dL 16 Units 16 Units 16 Units 16 Units
351-400 mg/dL 20 Units 20 Units 20 Units 20 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
giant paraesophageal hernia
Discharge Condition:
good
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] with any questins or concerns
[**Telephone/Fax (1) 2348**].
Call with Fevers greater than 101.5
Call with increased Shortness of Breath
Call with increased Cough
Call with difficult swallowing,vomiting problems eating.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2110-7-15**]
at 10:30 am on the [**Hospital Ward Name 517**] [**Location (un) 453**] in the chest disease
clinic. You need to report to x/ray (radiology) on the [**Location (un) **] for your chest x/ray.
Completed by:[**2110-7-1**]
ICD9 Codes: 5990, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5191
} | Medical Text: Admission Date: [**2134-5-6**] Discharge Date: [**2134-5-8**]
Date of Birth: [**2062-2-16**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
ASA desensitization
Major Surgical or Invasive Procedure:
Cardiac catherization with placement of drug-eluting stent to
Right Coronary Artery
Aspirin desensitization
History of Present Illness:
72 y/o M with hypertension and asthma referred for aspirin
desensitization prior to cardiac catheterization [**5-7**]. He
describes taking aspirin many years ago in the hospital and
having throat swelling and shortness of breath. He gets similar
symptoms with ibuprofen. He does not get hives or itching.
He has had recent intermittent episodes of
substernal/midepigastric discomfort described as gas pain,
lasting ~3 hrs., associated with belching, and relieved by TUMS.
No associated dizziness, lightheadedness, diaphoresis,
palpitations, shortness of breath, or vomiting. No component of
exertion or position. No orthopnea, PND, or edema. Symptoms
evaluated with ETT-MIBI [**5-5**] during which he exercised for 4:37
reaching 7 METS and 91% of max predicted HR. At peak exercise he
had chest discomfort with 2-[**Street Address(2) 82585**] depressions
inferiolaterally and ventricular ectopic activity with couplets
- chest pain resolved with NTG. Initial images showed inferior
defect. Also had asymptomatic 4-beat run of VT in immediate
post-recovery period. TTE [**5-6**] showed normal LV size and
systolic function (LVEF 65%), 2+ MR, 1+ TR, and trace AR.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or
rigors. He denies exertional buttock or calf pain. All of the
other review of systems were negative except as noted above.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Hypertension
Prostate Cancer s/p prostatectomy [**2125**]
Nasal polyps
Asthma
s/p removal nasal polyps
s/p tonsillectomy
CRI - Cr 1.5 on [**2134-5-5**]
Social History:
One glass of wine daily. Quit smoking in [**2085**]. o tobacco or
IVDU. Lives with wife in [**Name2 (NI) **]. retired truck driver
Family History:
No h/o premature CAD or SCD. Mother died of breast CA at 52.
Father died of lung CA at 72.
Physical Exam:
V/S: T 98.4 HR 95 BP 111/69
Gen: Well-appearing gentleman in NAD
HEENT: NC/AT. Sclera anicteric. Conjunctiva pink, no
xanthalesma.
Neck: Supple with JVP of 6 cm @ HOB 45 deg. No carotid bruit.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. II/VI holosystolic murmur at apex, no
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs:
[**2134-5-6**] 02:19PM BLOOD WBC-8.6 RBC-4.72 Hgb-14.5 Hct-41.9 MCV-89
MCH-30.6 MCHC-34.5 RDW-12.9 Plt Ct-307
[**2134-5-6**] 02:19PM BLOOD Neuts-65.4 Lymphs-24.8 Monos-7.1 Eos-2.2
Baso-0.6
[**2134-5-6**] 02:19PM BLOOD PT-13.6* PTT-24.6 INR(PT)-1.2*
[**2134-5-6**] 02:19PM BLOOD Glucose-122* UreaN-27* Creat-1.3* Na-138
K-3.9 Cl-104 HCO3-24 AnGap-14
[**2134-5-6**] 02:19PM BLOOD Calcium-9.5 Phos-2.8 Mg-1.9
[**2134-5-7**] 05:25AM BLOOD Triglyc-119 HDL-45 CHOL/HD-3.6 LDLcalc-91
.
.
Chest X-ray: Normal heart, lungs, hila, mediastinum and pleural
surfaces aside from a descending thoracic aorta, which is at
least tortuous and may be mildly dilated. Conventional
radiographs recommended for initial assessment
Cardiac cath:(Prelim report)
Initial angiography showed 80% mid RAC and 50% distal RCA at
crux. We
planned to treat the mid RCA lesion with PTCA and stenting.
Bivaliruding
provided adequate support. The patient also received ASA and
Plavix
prior to the procedure. A 6 French JR4 guide provided adequate
suport.
Choice Floppy wire crossed the lesion without dufficulty and was
positioned in the distal RPDA. A 3.0x12 mm Quantum Maverick RX
predilated the lesion at 18 ATM. We then deployed a 3.0x15 mm
Endeavor
stent RX at 16 ATM. Final angiography showed 0% residual
stenosis with
TIMI 3 flow and no dissection or distal emboli. We then
successfully deployed a 6 French Angioseal closure device into
the RCFA.
The patient left the carth lab free from angina and in stable
condition.
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated two-vessel coronary artery disease. The LMCA had
no
significant stenoses. The LAD had sequential 50% stenoses in
the mid-
and distal-vessel. The LCX had mild insignificant plaque. The
RCA had
an 80% mid-vessel stenosis and a 50% stenosis at the PDA/PLV
bifurcation.
2. Resting hemodynamics demonstrated high-normal biventricular
filling
pressures and mild pulmonary arterial hypertension as above.
3. Successful PTCA and stening of the mid RAC with 3.0x15 mm
Endeavor
DES. Final angiography showed 0% residual stenosis with TIMI 3
flow and
no dssection or distal emboli.
4. Successful deployment of a 6 French Angioseal closure device
to the
RCFA.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PTCA and stenting of the mid RCA with Endeavor
DES.
3. Successful deployment of 6 French Angoseal device to the
RCFA.
.
Discharge labs:
[**2134-5-8**] 02:56AM BLOOD WBC-10.0 RBC-4.01* Hgb-12.4* Hct-36.4*
MCV-91 MCH-31.1 MCHC-34.2 RDW-13.0 Plt Ct-288
[**2134-5-8**] 02:56AM BLOOD Glucose-87 UreaN-20 Creat-1.3* Na-140
K-4.4 Cl-106 HCO3-27 AnGap-11
[**2134-5-8**] 02:56AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
[**2134-5-7**] 05:25AM BLOOD Triglyc-119 HDL-45 CHOL/HD-3.6 LDLcalc-91
Brief Hospital Course:
A/P: 72 M w/ HTN, CRI, asthma, and nasal polyps referred prior
to cardiac catheterization for ASA desensitization following a
positive ETT. He has Samter's syndrome given h/o asthma, nasal
polyp's and aspirin allergy. He underwent aspirin
desensitization per protocol and tolerated this well. It was
emphasized he will need to consistently and reliably take an
aspirin daily and that if he misses a dose, he could potentially
have an adverse reaction such as anaphylaxis to aspirin or
NSAID's.
.
Regarding his CAD, inferolateral EKG changes with exercise and
preliminary MIBI images, isolated inferior Q on ECG suggest LCx
vs. RCA disease. He was hydrated for cardiac catherization and
pre=treated with mucomyst for renal protection given his history
of chronic renal insufficiency. He then underwent cardiac cath
which showed 50% stenoses in the mid and distal LAD, LCX with
mild insignificant plaque and RCA with an 80% mid-vessel
stenosis and a 50% stenosis at the PDA/PLV bifurcation. He
underwent placement of a drug eluting stent in his RCA. No
complications form the catheterization procedure. He was started
on full dose aspirin and plavix and was continued on these
medications at time of discharge.
Medications on Admission:
toprol XL 50mg qhs
monopril 40mg daily
diazide 37.5/25 (triamterene/HCTZ)
fosamax 70mg daily
advair 250/50 1 puff daily
albuterol INH prn
nasonex 1 sprah in am
prednisone 2.5mg qod
oscal +d 600 [**Hospital1 **]
tylenol 1gram qAM/qPM
aleve 440mg aAM/aPM
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime).
3. Monopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation DAILY (Daily).
5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
7. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease
Aspirin allergy
Hypertension
Chronic Renal Insufficency
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for aspirin desensitization
procedure prior to cardiac catheterization. This procedure was
successful. Cardiac catheterization showed a partial blockage in
one of your coronary arteries that supplies blood to your heart
and a stent was placed to help open this blood vessel.
The following changes were made to your medications:
1) STARTED plavix 75mg daily - this should be continued for at
least 1 year
2) STARTED aspirin 325mg daily. Because of your allergy, you
need to make sure to take this EVERY DAY. If you miss more than
a few days of aspirin your allergy might return.
Followup Instructions:
Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) 8797**] [**Last Name (NamePattern1) 23246**]
in 1 month. An appointment has been made for you on [**5-28**] at
1:15pm. Please call [**Telephone/Fax (1) 82345**] with questions.
Please follow up with your PCP as needed.
Completed by:[**2134-5-10**]
ICD9 Codes: 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5192
} | Medical Text: Admission Date: [**2168-9-2**] Discharge Date: [**2168-9-10**]
Date of Birth: [**2113-9-19**] Sex: M
Service: Cardiothoracic Surgery
ADMITTING DIAGNOSIS:
Coronary artery disease, requiring revascularization.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
man, transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
cardiac catheterization after a positive exercise tolerance
test. The patient reports overall good health and was active
in sports until about six months prior to admission, when his
activity was curtailed secondary to a knee injury and he
began to exercise again two weeks prior to admission.
Initially, he felt short of breath and attributed this to
deconditioning, but has noted progressive dyspnea over the
past several weeks, with chest pressure and heaviness with
activity. An exercise tolerance test was requested by his
primary care physician, [**Name10 (NameIs) 6643**] came back positive for
reversible wall motion defect, with a left ventricular
ejection fraction of 54%.
PAST MEDICAL HISTORY: Gastroesophageal reflux disease.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o.q.d., Lopressor
25 mg p.o.b.i.d., and heparin 5,000 units s.c.
SOCIAL HISTORY: The patient does not use tobacco or alcohol.
REVIEW OF SYSTEMS: Noncontributory except as per history of
present illness.
PHYSICAL EXAMINATION: Neck: Supple without jugular venous
distention or bruits. Chest: Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm, S1
and S2, no murmur, rub or gallop. Abdomen: Soft, nontender,
nondistended. Extremities: Without edema. Neurologic:
Intact, nonfocal.
HOSPITAL COURSE: The patient was admitted to [**First Name4 (NamePattern1) 3867**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2168-9-2**] and underwent
cardiac catheterization, which demonstrated severe three
vessel disease in the left main with an ulcerated 80%
stenosing plaque, 50% stenosis of the circumflex discreetly
and 80% stenosis of the right coronary system.
The patient was referred to Dr. [**Last Name (STitle) 70**] for coronary artery
bypass grafting. The patient was subsequently taken to the
Operating Room on [**2168-9-5**], where coronary artery
bypass grafting times four was performed as follows: Left
internal mammary artery to left anterior descending artery,
right internal mammary artery to right coronary artery,
saphenous vein graft to obtuse marginal one and saphenous
vein graft to diagonal.
Postoperatively, the patient did well. He was on
Neo-Synephrine, as he was transferred to the Cardiac Surgery
Recovery Unit, which was slowly weaned overnight. The
patient was transferred to the floor on postoperative day
number two and had an unremarkable postoperative course. He
was placed on Lopressor, aspirin and Lasix as well as
potassium supplementation.
By postoperative day number five, the patient was afebrile
with a heart rate in the 70s and blood pressure in the
120s/70s. His lungs were clear to auscultation. His
sternotomy looked well healed without any erythema, edema,
induration or drainage. His abdomen was soft. His
extremities were warm and well perfused without any edema.
There was no drainage from the saphenectomy sites. Given
this, the patient was deemed stable for discharge.
DISCHARGE DIAGNOSIS:
Coronary artery disease, status post coronary artery bypass
grafting.
Gastroesophageal reflux disease.
Hypertension.
DISCHARGE MEDICATIONS:
Lopressor 25 mg p.o.b.i.d.
Colace 100 mg p.o.b.i.d.
Zantac 150 mg p.o.b.i.d.
Aspirin 81 mg p.o.q.d.
Celebrex 100 mg p.o.b.i.d.
Percocet one to two tablets p.o.q.3-4h.p.r.n. pain.
Compazine 10 mg p.o.q.4-6h.p.r.n. nausea/vomiting 30 minutes
prior to the administration of Percocet.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2168-9-10**] 12:27
T: [**2168-9-10**] 09:53
JOB#: [**Job Number 36616**]
ICD9 Codes: 4111, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5193
} | Medical Text: Admission Date: [**2107-2-25**] Discharge Date: [**2107-3-9**]
Date of Birth: [**2059-5-15**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 47 y/o man with PMH HTN and alcohol/substance
abuse, who initially presented to OSH on [**2107-2-24**] ([**Hospital 47**]
[**Hospital 1281**] Hospital) unresponsive and who was transferred to [**Hospital1 18**]
after diagnosed with locked in syndrome. According to the
record,
as his girlfriend is unaware of the events surrounding his
admission, he went to a party and woke up the following morning
at 10 AM, at which point he said he wanted to go back to sleep,
but his friend noted some slurred speech and drooling. When he
woke up again around noon, his friend noted he was unresponsive;
just staring at her. EMS called and found him with gurgling
respirations amd BP 210/110. He arrived in ED nonverbal and with
snoring respirations; so he was intubated. Initially believed to
be substance or seizure related activity; but then CTA obtained
and official read noted large infarct involving brainstem,
primarily pons; he was diagnosed with locked in syndrome and
transfered to [**Hospital1 18**] for further management.
Past Medical History:
-HTN
-substance abuse (alcohol, cocaine)
Social History:
Currently resided in half-way house. He has 2
daughters- ages 19 and 17. Not employed. His longtime girlfriend
says that as far as she is aware, he has not used any substances
since [**Month (only) **]. He is a current 1 ppd smoker and has smoked for
30 years.
Family History:
Unknown/unable to obtain
Physical Exam:
general: laying in bed, NAD
chest: anterior lung fields cta b/l
CVS: RRR, S1S2, no murmurs
abd: soft, nondistended, +BS
ext: warm, no edema
Neuro: awake, alert, eyes open to vocie, can respond to
questions
appropriately (he blinks his eyes to yes and no questions). He
was able to correctly identify the president. On cranial nerve
exam, his pupils are 4-->3 b/l. Corneal reflex intact. EOMI (he
is able to track when asked). He blinks to command. Face
symmetric. Motor exam: flaccid tone of all 4 extremities. Unable
to move extremities spontaneously or in response to noxious
stimuli. Unable to elicit any reflexes and toes are mute.
Pertinent Results:
[**2107-2-25**] 10:17PM GLUCOSE-103* UREA N-14 SODIUM-141
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2107-2-25**] 10:17PM CK(CPK)-347*
[**2107-2-25**] 10:17PM CK-MB-1 cTropnT-LESS THAN
[**2107-2-25**] 10:17PM CALCIUM-9.1 PHOSPHATE-4.2 MAGNESIUM-2.3
[**2107-2-25**] 10:17PM WBC-13.3* RBC-4.95 HGB-13.6* HCT-40.8 MCV-82
MCH-27.5 MCHC-33.4 RDW-12.9
[**2107-2-25**] 10:17PM PLT COUNT-158
[**2107-2-25**] 10:17PM PT-12.7 INR(PT)-1.1
[**2107-2-25**] 10:17PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]->1.050
[**2107-2-25**] 10:17PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-150 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG
[**2107-2-25**] 10:17PM URINE RBC-[**7-8**]* WBC-[**7-8**]* BACTERIA-FEW
YEAST-NONE EPI-1
REASON FOR EXAMINATION: Evaluation of tracheostomy position.
Portable AP chest radiograph was reviewed in comparison to
[**2107-3-5**].
The tracheostomy tube is at the midline with its tip being
approximately 4.5
cm above the carina. There is also placement of the percutaneous
gastrostomy
with pneumoperitoneum demonstrated most likely due to surgery,
should be
further followed. Lungs are clear and cardiomediastinal
silhouette is stable.
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No LV thrombus seen. Normal global biventricular
systolic function. No pulmonary hypertension or
clinically-significant valvular disease seen.
CTA IMPRESSION:
Findings compatible with basilar artery thrombosis with acute
infarctions in the midbrain and left cerebellum and possibly in
the pons. The right distal V2 and V3 segment of the hypoplastic
vertebral artery is irregular and thread-like with prominent
venous plexus surrounding it. Recommend MRA with fat saturated
T1-weighted images to exclude the possibility of dissection in
this segment.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mr. [**Known lastname **] was transferred from [**Hospital1 **] after it was
discovered on CT brain that he had a acute infarctions in the
midbrain and left cerebellum and possibly in the pons with
occlusion at the basilar artery. He was well beyond the time in
which intervention could be performed when he arrived at [**Hospital1 18**].
He was first brought into the outside hospital on [**2107-2-24**] after
his girlfriend discovered him that morning unable to move around
11 AM. She let him sleep another 3 hours when she realized that
he still had not moved and he needed to go to the hospital.
During his course at [**Hospital1 **] he was intubated and pontinbe
stroke was then discovered. He arrived at [**Hospital1 18**] on [**2107-2-25**] at 10
pm (35 hours after first being found not moving). CTA brain and
neck showed occlusion of the mid basilar artery. It showed that
the right vertebral artery was hypoplastic. The right vertebral
artery was irregular and threadlike in the right V3 segment.
This raised concern for a dissection. MRA neck with T1 fat sats
was not performed because it would not have changed management.
He was started on aspirin 325mg daily. He had a TTE performed
that showed no intracardiac source. He refused a TEE for further
evaluation. On HD 4 he was noted to have some movement of his
right hand. This was not observed for several days, but was
again witnessed at the end of his hospital course. After
discussions with ethics, social work, and his girlfriend - a
family meeting was held in which Mr. [**Known lastname **] elected (by use of
his eyes) to have a trach and PEG placed.
Mr. [**Known lastname **] had a BAL that grew S. Aureus on [**2107-2-26**]. He was
started on antibiotics Vancomycine and Zosyn that were scaled
down to Nafcillin when sensitivities returned.
Antibiotic course
Nafcillin until [**3-13**] For MSSA
Cipro, Cefepime, Flagyl - until [**3-21**]
The Cipro and Cefepime are double coverage for VAP
the Flagyl is for Aspiration
Active Issues By System At Discharge
Gastrointestinal / Abdomen:
- TF's via PEG
Nutrition:
- PEG in place
- Replete w/ fiber 80 mL/hr (goal)
Renal:
- Adequate urine output
Hematology:
- no acute issues
Endocrine:
- RISS, adequate BG control.
Infectious disease:
- Purulent sputum, leukocytosis; Nafcillin restarted [**3-5**] for PNA
(stop [**3-13**]), cefepime, cipro, flagyl added [**3-7**] (stop [**3-21**]),
mini-BAL growing pseudomonas & Hflu, abx x 14d
Events by day
[**3-5**] CXR: No consolidation. Mild left basal atelectasis
[**3-7**] CXR: PEG in place w/pneumoperitoneum, lungs are clear and
cardiomediastinal silhouette is stable.
EVENTS:
[**2-25**]: Admitted to Neuro-ICU with pontine stroke.
[**2-26**]: CTA head/neck showing 12mm complete occlusion of the
basilar artery. CXR showing worsening opacification of both
bases ?aspiration PNA. Bronch'd/BAL showing 2+ GNRs, 2+GPC pairs
and febrile to 101.3, vanc/zosyn started. TF started during the
day.
[**2-27**]: Cont vanc/zosyn, tf cont'd. Decr'd oxygen sats, CXR
unchanged, incr PEEP.
[**3-1**]: Legal team c/s re consent for trach/peg. Echo -> no LV
thrombus seen. d/c abx
[**3-2**]: TF held and pt extubated. RPR pending. Able to move mouth,
nod, squeezed R hand, w/d BLE to pain
[**3-3**]: Patient reintubated and dobhoff placed / enteral feeds were
restarted. Prop gtt + fent gtt for sedation.
[**3-4**]: Purulent sputum, elevated wbc. mini BAL, CXR, vanc/zosyn
started. Meeting held and pt agrees to trach & PEG
[**3-5**]: Plan for t/p on [**3-6**]. Contiued thick secretions. D/C'd vanc.
Added nafcillin for MSSA in sputum
[**3-6**]: s/p trach/PEG. Mini BAL: pseudomonas & GNR#2
[**3-7**]: TFs started. Cefepime, cipro, flagyl added for pseud pna.
[**3-8**]: H2B d/c'd. plan d/c ltac [**3-9**].
[**3-9**]: speech and swallow c/s. will remove a-line before transfer
to rehab.
Medications on Admission:
none
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 13 days.
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 13 days.
10. CefePIME 2 g IV Q12H Duration: 13 Days
11. Nafcillin 2 g IV Q6H Duration: 10 Days
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you. You were transferred from
[**Hospital1 **] after it was discovered on CT imaging that he had a
acute infarctions in the midbrain and left cerebellum and
possibly in the pons with occlusion at the basilar artery.
While at [**Hospital1 **] you had a breathing tube placed.
You elected (by use of your eyes) to have a trach and PEG placed
(To aide in your breathing and eating).
You also had a few infections while in the hospital which are
treated with antibiotics. You are to leave with the following.
Nafcillin until [**3-13**] For MSSA
Cipro, Cefepime, Flagyl - until [**3-21**]
The Cipro and Cefepime are double coverage for VAP
the Flagyl is for Aspiration (anerobe coverage).
Followup Instructions:
establish and Outside PCP.
Neurology Follow-up
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2107-4-20**] 1:30
Completed by:[**2107-3-9**]
ICD9 Codes: 5070, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5194
} | Medical Text: Admission Date: [**2183-9-3**] Discharge Date: [**2183-9-19**]
Date of Birth: [**2125-7-5**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
odynophagia
Major Surgical or Invasive Procedure:
flex and rigid bronchoscopy x 2
radiation therapy to esophagus
lumbar puncture
EEG
History of Present Illness:
.
58F with a history of metastatic RCC complicated by extensive
mediastinal mets requiring placement of bronchial stent who was
recently admitted for near syncope where she had a work up
including head CT, which was without changes, a CTA of the
chest which was negative for PE and showed stable masses and an
Echo which showed mild hypokinesis and an 40-45%.
She noted yesterday she had a low grade temp 100.4 that she
states went up to 102 so she contact[**Name (NI) **] her oncologists Dr [**Name (NI) **]
and Dr [**First Name (STitle) **] who told her to come to the hospital if it
continued above 100.4. She has also been experiencing a
significant amount of throat pain from her esphagitis and was
encouraged to use lidocaine/ benedryl for this. She has been
unable to swallow and her PO intake is down. She has also noted
flu like symptoms over the past few days such as myalgias cough
with yello sputum, body aches. She just recieved radiation
therapy yesterday.
She was started on palliative chest XRT ([**2183-8-19**]) and
chemotherapy with sunitinib.
In the ED she was tachycardiac on presentation to 123 and
improved with fluids. She had a T Max of 101.4 for which she was
given rectal tylenol. She had nausea and was give 8mg Zofran.
Blood and urine cultures were drawn, she was flu swabbed and she
was started on Levofloxasin. Her WCC was 1.4 and ANC 1275.
lactate 1.1
Past Medical History:
PAST ONCOLOGIC HISTORY:
The patient was in USOH until winter of [**2181**] when she developed
cold symptoms which did not clear with antibiotics. She
developed hemoptysis, which was evaluated in [**2182-2-9**] with
x-rays of the chest. Lung mediastinal mass was detected on CXR,
which was followed by a CT scan, which confirmed a mass in the
mediastinum. Scanning also indicated a mass in the left kidney.
This was further evaluated with imaging studies of the abdomen,
which showed a large left renal mass measuring 15 x 11 cm. Lytic
lesion was also detected in the right acetabulum. She was
further evaluated with MRI which showed a left renal mass with
no evidence of involvement of the left renal vein. MRI scan
showed a mass in the vertex of the skull measuring 5 cm in
greatest dimension. She underwent a bronchoscopy to evaluate the
hemoptysis symptoms and biopsy the lung mass. However, pathology
from this study was inconclusive. She underwent a biopsy of the
left kidney mass, which showed renal cell carcinoma [**Last Name (un) 19076**]
nuclear grade 1. These slides have been reviewed and showed
renal cell carcinoma, clear cell type, and nuclear grade 1. With
these findings, she underwent radiation therapy to the right hip
and leg receiving 10 treatments at the [**Hospital6 5016**].
Following these treatments, she was evaluated by the Biologics
group and the Urology group for definitive treatment of renal
cell carcinoma. Recommendation was for dendritic cell vaccine
therapy. For this therapy, she will require a tumor sample. She
is now s/p left debulking nephrectomy [**2183-4-11**].
======================
PAST MEDICAL HISTORY:
- Renal CA metastatic to skull, R hip, lungs, medistiastinum as
above
- Airway compression, s/p y-stent
- sciatica
====================
Social History:
Married. Occ Etoh, 30-40pkyr Hx of smoking, no illicits
Family History:
Non-contributing oncologic history
Physical Exam:
Vitals: stable HR 100 BP 121/65 O2 98% 2L T 98.1
GENERAL: Laying on the bed with discomfort in her neck
[**Name (NI) 4459**] Pt not allowing palpation of neck due to pain
CVD tachy
Lungs: scattered rhonchi all lung fields
Abdomen soft non distended diffuse tenderness
Ext WWP
Back No CVA tenderness
LN No axillary or femoral LN palpated
Exam on discharge:
97.6 110/70 100 18 96% RA
590+2260/3750
GENERAL: Laying on the bed, NAD, communicative, A and O x 3 and
appropriate
[**Name (NI) 4459**]- PERRLa, EOMi, clear oropharynx
CV- regular rhythm, tachycardic, no m, r, g
Lungs: left lung has improved breath sounds s/p bronchoscopy,
clear on right
Abdomen soft, non distended, non-tender to palpation, no
guarding/rebound, active BS
Ext WWP
No CVA tenderness
LN No axillary or femoral LN palpated
Pertinent Results:
TTE:
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. There is severe global left
ventricular hypokinesis (LVEF = 20 %). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
.
Compared with the prior study (images reviewed) of [**2183-8-28**],
the LVEF has significantly decreased. There is now a small
pericardial effusion.
.
CT abdomen/pelvis
1. Distended gallbladder, with no definite CT evidence of
cholecystitis. If clinical concern, this can be further
evaluated with HIDA scan.
2. Interval free fluid in the abdomen, mostly at the perihepatic
and
perisplenic distribution and tracking along the right paracolic
gutter into the pelvis. Bilateral pleural effusions.
3. Questionable wall thickenning of the colon at the splenic
flexture, could be due to collapsed colon; however this finding
can be seen in colitis, if there is clinical concern.
4. Stable right acetabular lesion with pathologic fracture at
the right
inferior acetabulum, unchanged. Multiple lesions within the
spine consistent with metastatic disease, with possible
hemangioma at L1.
5. Status post left nephrectomy with no definite evidence of
recurrence at
the surgical bed.
.
EEG [**9-15**]: This is a normal video EEG study. Interictal
background activity was normal. There were no epileptiform
discharges or electrographic seizures. Compared to recording
from 24 hours prior, this study contains fewer electrographic
seizures
.
EEG [**9-13**]
This is an abnormal portable EEG due to continuous generalized
rhythmic spike and slow wave activity at a frequency of 2.5 Hz
for the first half of this record consistent with non-convulsive
status epilepticus. EEG markedly improved after administration
of I.V. Ativan with resolution of non-convulsive status and only
brief short bursts of generalized spike slow wave discharges in
the latter half of the study. No focal lateralizing features
were noted. An irregularly irregular rhythm was seen on cardiac
monitor. Based on these findings, we would recommend long-term
monitoring for this patient
.
MR head:
Compared to the previous MRI from [**2183-2-18**], the soft tissue
component
associated with the vertex frontal bone calvarial lesion has
markedly
decreased in size likely reflecting interval treatment. The bony
component
appears relatively stable. This may represent treated neoplasm
in bone.
.
Left frontal scalp lesion is unchanged compared to the most
recent study.
.
There is no evidence for intracranial metastatic disease.
.
There is diffuse pachymeningeal enhancement, which may be
related to prior
radiation/LP or infectious/inflammatory sequela. Appearance is
not suggestive of dural mets. There is a tiny 5- mm left frontal
subdural focal thickening or collection which does not cause
mass effect.
.
[**9-19**] CXR (post-bronch): Atelectasis in the left base has
minimally improved. Cardiomediastinal contours are unchanged.
Patient has known mediastinal and hilar lymphadenopathy and
right rib metastatic lesion. There is no evident pneumothorax or
enlarging pleural effusion. The left hemidiaphragm is elevated.
Stent is seen in the left main bronchus
.
[**9-15**] CXR: Complete white out of the left hemithorax and
shifting of the
cardiomediastinum towards the left is unchanged due to collapse
of the left lung. Assessment of the left pleural effusion is
limited. The right lung is grossly clear. Destructive lesion in
the lateral aspect of right mid rib is again noted.
.
Labs on discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
1.6* 2.90* 8.5* 24.6* 85 29.2 34.3 21.3* 200
.
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos
68 2 14* 14* 0 0 0 2* 0
.
PT 11.5 PTT 26.4 INR 1.0
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
108* 17 0.6 136 4.4 101 25 14
.
ALT AST AlkPhos TotBili
11 15 78 0.2
.
Calcium Phos Mg
8.7 3.4 2.2
Brief Hospital Course:
58 year old female with metastatic renal cell carcinoma to
skull, mediastinum, lungs, s/p Y stent placement presented with
an episode of fever, nausea and worsening dysphagia/odynophagia.
.
# Fever/odynophagia/dysphagia- Initial differential diagnosis of
this constellation of symptoms included esophagitis from
radiation, thrush, or mucositis. Flu swab was negative. The
patient was initially given levofloxacin in the ED, but this was
discontinued. The patient also received supportive care,
including magic mouthwash, sucralfate, PPI, H2 blocker,
morphine, and reglan. Fluconazole was given for oral/esophageal
candidiasis.
.
# Renal cell carcinoma- Patient recently completed course of
radiation therapy to skull and espophagus. Sutent had been
started and was initially continued upon admission with good
response. Sutent was then discontinued in the setting of
developing pancytopenia, which improved following cessation of
the drug.
.
# Mental status- The patient had an episode of altered mental
status on [**2183-9-7**] that was attribued to hyponatremia. She
required a brief course in the ICU, received IVF and hypertonic
saline with improvment in both her mental status and
hyponatremia (thought to be due to mild hypovolemia and SIADH).
The patient was hypotensive thought to be due to hypovolemia,
which improved with IVF. An echocardiogram was obtained, and
her LVEF was depressed at 20%. The patient did not have any
other signs or symptoms of CHF, and was started on metoprolol
and lisinopril. Her depressed EF was non-ischemic in etiology
and was thought to be due to either radiation or sutent.
.
The patient then developed second episode of AMS on [**2183-9-12**]-
patient was non-verbal/non-communicative, not somlonent. An LP
was performed, which showed a normal opening pressure, with no
evidence of infection. The patient received empiric
ceftriaxone, vancomycin, and acyclovir which were all
discontinued after cultures were negative. An EEG on [**2183-9-13**]
showed that the patient was in non-convulsive status
epilepticus. She was loaded with ativen and fosphenytoin with
near-immediate improvement in her mental status. She again
required a brief stay in the ICU to monitor her airway after
receiving anti-epileptic therapy. Her airway was never
compromised. She initially received phenytoin, but developed a
leukopenia thought to be secondary to phenytoin. She is now
being bridged to keppra and doing well. She will continue
taking phenytoin 100 mg TID for six days. She will continue
taking keppra 500 mg [**Hospital1 **] for three days, then keppra 750 mg [**Hospital1 **]
for three days, then keppra 1000 mg [**Hospital1 **] ongoing.
.
# Bronchial stents- The patient underwent a flex bronchoscopy on
[**2183-9-11**] which showed increasing tumor burden in the left main
stem bronchus. Post-bronchoscopy, the patient was noted to have
decreased breath sounds on the left, and a chest film showed a
white out of her left lung. The patient never dveloped an
oxygen requirement. A scheduled rigid bronchoscopy on [**2183-9-18**]
was performed which showed an occluded left main stem with
granulation tissue, dilation was performed and a stent was
replaced in the left main stem with good effect and significant
improvement in her chest film. The patient has scheduled follow
up with her outpatient pulmonologist on [**2183-10-6**].
.
#
PROPHY: mobilization (patient will need continued physical
therapy, ppi, bowel regimen)
Nutrition: the patient was tolerating some PO intake at
discharge, and was also receiving PPN. please cont transition
to full regular diet
ACCESS: PIV
CODE: FULL
Medications on Admission:
Docusate Sodium 100 mg Capsule PO BID
Folic Acid 1 mg Tablet PO DAILY
Senna 8.6 mg Tablet Sig: One Tablet PO BID
Morphine 30 mg Tablet Sustained Release i tab PO q12
Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H
Tessalon Perle 100 mg Capsule Sig: One Capsule PO TID prn
Levalbuterol HCl 0.63 mg/3 mL 1 neb q4 hours prn
Ipratropium Bromide 0.02 % Solution One (1) neb q6h prn
Lactulose(30) ML PO Q8H as needed for constipation.
Reglan 10 mg One (1) Tablet PO every 6-8 hours prn nausea
Ferrous Sulfate 325 mgOne (1) Tablet PO once a day.
Ativan
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 days.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 6 days.
6. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
7. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO every
six (6) hours as needed for pain with swallowing.
9. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
10. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for pain.
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
16. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety/seizure.
17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gm PO DAILY (Daily) as needed for constipation.
19. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) Neb
Miscellaneous TID PRN () as needed for wheezing/cough.
20. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
21. Guaifenesin AC 10-100 mg/5 mL Syrup Sig: [**4-20**] ml PO four
times a day as needed for cough.
22. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnosis:
renal cell cancer with mediastinal/bronchial metastases
Secondary Diagnoses:
systolic CHF
sciatica
Chronic sinusitis
benign breast cyst
C-section
seasonal allergies
Discharge Condition:
stable and improved
Discharge Instructions:
You were admitted to the hospital with difficulty swallowing and
fever. You finished radiation to your esophagus, and your
discomfort was thought to be due to a possible infection in your
esophagus or from the radiation itself. You then developed some
confusion, which was thought to be due to a low sodium level.
You improved somewhat after your sodium was increased and you
received IVF. However, you developed increased confusion and an
inability to speak, which was due to a seizure. This improved
dramatically after you received treatment for your seizure. You
will need to continue taking a medication to prevent future
seizures. You also had an ultrasound of your heart which showed
decreased function (EF of 20%), but luckily you did not have
symptoms from this. You also had 2 bronchoscopies to help clean
out your airways. You will need rehabilitation.
.
Medications:
Most of your medications have changed. Please see the list
provided to your rehabilitation center.
- You will be transitioned from phenytoin to Keppra as indicated
on your medication list and on the discharge summary.
.
Please call your doctor or return to the ER if you have
increasing pain, confusion, fevers/chills, nausea/vomiting,
diarrhea, chest pain or other concerns.
Followup Instructions:
You should call the neurology clinic ([**Telephone/Fax (1) 2528**] for an
appoinment in the next 2-4 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-9-30**]
2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2183-9-30**] 2:00
[**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2183-10-6**] 10:00
ICD9 Codes: 486, 0389, 5180, 5119, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5195
} | Medical Text: Admission Date: [**2122-12-23**] Discharge Date: [**2123-1-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Nausea, vomiting and chills
Major Surgical or Invasive Procedure:
Central Line placement
Midline IV placement
History of Present Illness:
82 y/o M w/CAD, CHF, HTN, who was in his USOH until 2 days prior
to admission when he awoke at 5AM with shaking chills. He then
began to have nausea with vomiting and later on profuse
diarrhea. Apparently the patient had been having decreased PO
intake for a couple of days prior to this episode. Patient
states that he had some minor abdominal pain, epigastric in
location. He says that the chills he experienced lasted for one
hour and then resolved. Patient denies any hematemesis or BRBPR.
No sick contacts although patient has 9 grandchildren who visit.
The night before he ate take out chicken, however other family
members ate the same food and did not have similar symptoms.
.
ROS: Positive for chronic joint pain, walks with a cane. Denies
any chest pain, occasionally has palpitations, has anxiety at
times. His ET is limited by joint pain but can walk to end of
room without SOB. He says that his legs are always slightly
swollen, not worse at present, sleeps in hospital bed at home
with raised hed, denies PND, gets up fequently to urinate at
night. Denies headache. +fatigue, decreased energy.
Past Medical History:
1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
2. CHF, TTE [**3-6**] w/depressed EF
3. Hypertension, per daughter pt's bp usually 90s-100s on meds
4. Severe Lumbar Spinal stenosis, mild cervical stenosis
5. Sleep apnea, on 2L home O2 at night
6. Afib, s/p DCCV which failed, now rate controlled, not
anticoagulated secondary to fall risk
7. Arthritis
8. Gout
9. COPD? No PFTs
Social History:
Lives with 2 daughter who look after him, wife deceased, has 9
grandchildren, moved to the US from [**Country 4754**] in [**2064**]. Worked at
Sears [**Last Name (un) 40191**] as a firefighter for 41 years, now retired. Has 5
children who all live in the Northeast, lives in [**Location (un) 538**].
Widowed. No tobacco or alcohol x 50 years.
Family History:
HTN, CAD, CVA
Physical Exam:
VS: T: 97.6 P: 61 BP: 100/60 R: 18 O2 sat 97% on 2L FS 183
Gen: Elderly man, lying in bed, NAD
HEENT: EOM full, anicteric, L facial droop (old) moist, OP clear
Neck: supple, JVP flat
Chest: Diffuse scattered wheezines, crackles at lower bases b/l
CV: nl S1 S2, regular, no m/r/g
Abd: obese, soft, nt/nd. +bs. no palpable hepatosplenomegaly.
Ext: 2+ pedal edema to upper calf, warm and dry, 2+ dp pulses
b/l
Pertinent Results:
On Admission:
[**2122-12-23**] 12:40AM PLT COUNT-167
[**2122-12-23**] 12:40AM NEUTS-82* BANDS-14* LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2122-12-23**] 12:40AM WBC-19.0*# RBC-4.83 HGB-15.8 HCT-44.5 MCV-92
MCH-32.7* MCHC-35.5* RDW-13.8
[**2122-12-23**] 12:40AM DIGOXIN-0.5*
[**2122-12-23**] 12:40AM CORTISOL-36.5*
[**2122-12-23**] 12:40AM GLUCOSE-178* UREA N-29* CREAT-1.9* SODIUM-136
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-21* ANION GAP-23*
[**2122-12-23**] 12:51AM LACTATE-3.7*
[**2122-12-23**] 12:51AM COMMENTS-GREEN TOP
[**2122-12-23**] 02:45AM PT-14.5* PTT-31.4 INR(PT)-1.4
[**2122-12-23**] 02:45AM PLT COUNT-159
[**2122-12-23**] 02:45AM NEUTS-83* BANDS-12* LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2122-12-23**] 02:45AM WBC-18.9* RBC-4.55* HGB-14.7 HCT-41.6 MCV-92
MCH-32.3* MCHC-35.3* RDW-13.8
[**2122-12-23**] 02:45AM CRP-189.1*
[**2122-12-23**] 02:45AM CORTISOL-218.9*
[**2122-12-23**] 02:45AM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-2.3*#
MAGNESIUM-1.4*
[**2122-12-23**] 02:45AM CK-MB-2 cTropnT-0.03* proBNP-2335*
[**2122-12-23**] 02:45AM LIPASE-19
[**2122-12-23**] 02:45AM ALT(SGPT)-30 AST(SGOT)-25 CK(CPK)-265* ALK
PHOS-73 TOT BILI-1.2
[**2122-12-23**] 02:45AM GLUCOSE-212* UREA N-30* CREAT-1.8* SODIUM-133
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-20* ANION GAP-20
[**2122-12-23**] 02:54AM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2122-12-23**] 02:54AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2122-12-23**] 02:54AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2122-12-23**] 03:02AM LACTATE-2.7*
[**2122-12-23**] 03:02AM COMMENTS-GREEN TOP
[**2122-12-23**] 05:26AM LACTATE-2.2*
[**2122-12-23**] 05:26AM COMMENTS-GREEN TOP
[**2122-12-23**] 08:00AM CK-MB-3 cTropnT-0.02*
[**2122-12-23**] 08:00AM CK(CPK)-246*
[**2122-12-23**] 02:26PM CK-MB-4
[**2122-12-23**] 02:26PM CK(CPK)-300*
[**2122-12-23**] 02:26PM GLUCOSE-278* UREA N-27* CREAT-1.6* SODIUM-136
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-20* ANION GAP-17
[**2122-12-23**] 02:37PM cTropnT-0.01
.
Upon discharge/other relevant labs:
[**2123-1-1**] 06:18AM BLOOD WBC-23.0* RBC-4.01* Hgb-13.1* Hct-36.9*
MCV-92 MCH-32.5* MCHC-35.4* RDW-13.5 Plt Ct-254
[**2123-1-1**] 06:18AM BLOOD Plt Ct-254
[**2122-12-31**] 06:08AM BLOOD Glucose-79 UreaN-30* Creat-1.2 Na-137
K-4.0 Cl-98 HCO3-26 AnGap-17
[**2122-12-24**] 04:24AM BLOOD LD(LDH)-195
[**2122-12-23**] 02:26PM BLOOD CK(CPK)-300*
[**2122-12-23**] 08:00AM BLOOD CK(CPK)-246*
[**2122-12-23**] 02:45AM BLOOD ALT-30 AST-25 CK(CPK)-265* AlkPhos-73
TotBili-1.2
[**2122-12-23**] 02:45AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-2335*
[**2122-12-23**] 02:37PM BLOOD cTropnT-0.01
[**2122-12-23**] 08:00AM BLOOD CK-MB-3 cTropnT-0.02*
[**2122-12-30**] 06:25AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8 UricAcd-9.5*
[**2122-12-23**] 02:45AM BLOOD CRP-189.1*
[**2122-12-23**] 12:40AM BLOOD Digoxin-0.5*
[**2122-12-25**] 01:47AM BLOOD Type-ART Temp-38.6 pO2-71* pCO2-32*
pH-7.46* calHCO3-23 Base XS-0 Intubat-NOT INTUBA
[**2122-12-25**] 01:47AM BLOOD Lactate-1.9
.
Microbiology:
Imaging:
[**12-23**] CXR: Portable supine AP radiograph of the chest is
reviewed, and compared to previous study at 1:09 a.m. The right
subclavian IV catheter terminates in the right atrium. No
pneumothorax is identified. The lung volume is small with
continued slight elevation of the right hemidiaphragm. The heart
is normal in size. Again, note is made of tortuosity of the
thoracic aorta. IMPRESSION: No pneumothorax.
.
[**12-23**] KUB: No evidence for small-bowel obstruction. Limited
study, which cannot rule out the presence of free air. If of
clinical concern, would repeat examination.
.
[**12-23**] CT Abdomen: 1. Distended gallbladder likely containing
gallstones or sludge without evidence for cholecystitis. 2. No
evidence for intra-abdominal or intrapelvic bowel abnormality
including colitis or diverticulitis. 3. Diverticulosis without
evidence for diverticulitis.
4. Low-density lesions within the liver and bilateral kidneys
likely representing cysts. These foci could be definitively
characterized with ultrasound if clinically indicated.
.
[**12-23**] EGK: Atrial fibrillation with a mean ventricular response,
rate approximately 115. Inferior myocardial infarction.
Non-diagnostic T wave flattening in the lateral leads. Compared
to the previous tracing of [**2121-3-24**] cardiac now atrial
fibrillation.
[**12-25**] EKG: Atrial fibrillation Old inferior infarct Low QRS
voltages in precordial leads Since last ECG, ventricular
response slower
.
CXR [**12-25**]: The exam is unchanged. Lung volumes are small. Right
subclavian IV catheter tip overlies the SVC. Pneumothoraces
present. Patchy atelectasis unchanged, no infiltrates. Heart
size and mediastinal contour within normal.
.
Renal Ultrasound [**12-29**]: The left kidney measures 13.7 cm. The
right kidney measures 14.7 cm. There is no evidence of
perinephric fluid or abscess. In the right kidney there are four
cysts identified, as seen on prior CT exam from [**2122-12-23**]. The
simple cysts range in size from approximately 4 cm to 7 cm in
diameter. In the left kidney there are multiple subcentimeter
simple cysts along with a large 3.5 x 3.7 x 4.2 cm simple cyst
seen in the mid to lower pole. The bladder is full and
unremarkable
Brief Hospital Course:
Mr. [**Known lastname **] is an 82 yo gentleman with CAD, CHF, ?COPD, A.
Fib/flutter admitted with E.coli sepsis and rapid atrial
fibrillation. The patient was initially managed in the MICU for
24 hrs with central line placement and IVF resuscitation. He was
then transferred to the regular medical floor once stabilized.
Initially the patient was doing very well on the floor, sitting
in chair [**Location (un) 1131**], heart rate well controlled on digoxin only
(sotalol held in setting of relative hypotension on admission).
Blood cultures returned positive for gram negative rods
resistant to quinolones and therefore his antibiotics were
changed from Levofloxacin/Flagyl/Ampicillin antibiotics to
Ceftriaxone mid afternoon. Patient also noted to be
intermittently wheezing, started on Albuterol/Atrovent nebs and
given 2x 40 IV lasix for fluid overload on exam. Overnight,
patient spiked temp to 101.6 and went into rapid A. fib with
rates in 140s, BP 100/67, given IV diltiazem 10 mg x 2 then 30
mg PO with persistent elevation in HR ranging 120-130s. The
patient was transferred back to the MICU for management of his
rapid A.fib and sepsis.
.
In the MICU, patient treated with Ceftriaxone initially. Blood
cultures came back positive for E.coli. Patient remained his
blood pressures, no evidence of septic shock. Eventually
antibiotics were tailored further and he was transferred to the
medical floor once again, this time on IV Cefazolin (Ancef). His
central line d/ced prior to transfer.
.
Rapid A. Fib: Patient was taking Sotalol/Dig at home, not on any
anticoagulation. He required IV diltiazem in ED for rapid rate.
Upon transfer to the floor, patient was initially maintained on
Digoxin w/out restarting sotalol for concerns of borderline low
BP. His HR was well controlled in the 80s. Dig level 0.5 on
admission. Patient later went into rapid afib the same evening
in setting of fever spike requiring IV diltiazem. He was started
on IV diltiazem->PO with improvement in HR control while in the
MICU. Patient also restarted on sotalol which was eventually
increased to 80 mg daily for optimal control. His current
regimen for HR control includes Sotalol 80 mg [**Hospital1 **] and Diltiazem
300 mg daily sustained release, Digoxin is discontinued. Patient
was also started on anticoagulation for A.fib with coumadin. He
is currently on 3 mg of coumadin daily. His INR must be checked
and reported to his PCP (as outlined in the discharge plan) in
case adjustments must be made. Patient was monitored on
telemetry throughout his stay in hospital.
.
E. Coli Sepsis: Blood cx growing E.coli sensitive to
Cephalosporins, resistant to quinolones, likely source is GI
given hx of N/V/D although unclear. [**Name2 (NI) **] clear source on abdominal
CT such as cholecystitis, diverticulitis. Patient was initially
treated with broad coverage with Ampicillin/Flagyl/Levofloxacin.
He was changed to IV Ceftriaxone and then Cefazolin once the
sensitivities were available. Patient is now afebrile x several
days, WBC was generally trending down from admission 18->12 but
later increased to >20 in setting of gouty flare and in setting
of increases steroids. He is discharge with negative urine/blood
cultures, afebrile, HR well controlled and generally feeling
much better. He should continue narrow spectrum antibiotic
coverage with Cefazolin IV to complete a 14 day course.
Infectious disease felt that the patient should be treated with
IV antibiotics for 14 days since PO antibiotics will likely not
be adequate for this type of infection. Renal son[**Name (NI) **] was also
performed to r/out any other potential source such as a
perinephric abscess, this was negative. Of note, patient
developed one episode of diarrhea on [**12-30**] which resolved
spontaneously. His stool is negative for C.diff and he has not
had any abdominal pain/discomfort to date.
.
?COPD. Patient noted to be wheezing upon transfer to the floor.
He does not have a documented diagnosis of COPD, no PFTs on
record. It was unclear whether this was a COPD flare vs. cardiac
wheezing given that the patient required aggressive fluid
hydration in the MICU. The patient as treated with
Albuterol/Atrovent nebulizers with improvement. He was also
diuresed with IV lasix 40 mg [**Hospital1 **] and then put on lasix PO 80 QOD
then daily. He is discharged on 80 mg of lasix daily. He
diureses well with this dose. Of note, the patient was also
started on prednisone for presumed COPD and due to ongoing
wheezing. He is discharged on 20 mg of prednisone for COPD and
concomitant gouty flare. Steroids should be tapered over the
next 12 days. Patient also received a 5 day course of
Azithromycin for presumed COPD exacerbation.
.
Acute Renal Insufficiency: Patient has a baseline creatinine of
1.3-1.5 on prior visits in [**2121**]. On admission his Cr was 1.9
which has trended down to 1.2 on discharge. Likely prerenal
secondary to volume depletion from vomiting/diarrhea, was fluid
resuscitated in MICU and later diuresed on the floor. Currently
patient appears euvolemic with trace pedal edema. His
medications were renally dosed throughout this admission.
.
CAD/CHF: Patient has a depressed EF on echo in [**2121**], %EF not
reported. Upon initial transfer to floor the patient appeared
fluid overloaded s/p fluid resuscitation in MICU. Patient had
elevated JVP, 2+ pitting edema, wheezing with crackles. Cardiac
enzymes were negative x 3 on admission. Question of
subendocardial ischemia in setting of hypotension based on
subtle EKG changes in ST-T segments. BNP elevated on admission
as well. Patient required diuresis with IV lasix initially and
is not maintained on PO lasix. He is currently euvolemic per
exam and stabilized on his current regimen. He should be
continued on ASA, Statin. He is currently not on an ACEI (defer
to Dr. [**Last Name (STitle) **] his PCP and cardiologist), likely because he does not
have a depressed EF.
.
Gout. Patient has a history of gout in the past. He developed a
gouty attack in his right foot on [**12-29**] and then in his left
elbow on [**12-31**]. He was treated with Ibuprofen 600 mg x 2
intially and then placed on Indomethacin 25 mg TID with some
relief. His steroids were also increased to 20 mg daily. He was
not treated with Colchicine which he has taken in the past due
to one episode of diarrhea and the potential to cause stomach
upset with this medication. This medication can be restarted in
the future as per the PCP. [**Name10 (NameIs) **] should also be on prophylaxis with
Allopurinol in the future once he is over this acute flare.
.
Diabetes: Patient is usually managed on oral medication as an
outpatient. He requires coverage with regular insulin sliding
scale while on steroids. The regular insulin sliding scale can
be discontinued once he is off steroids. He is also discharged
on Glipizide which he was taking prior to admission. This
medication was discontinued while in hospital and he was
maintained on a sliding scale regimen with good control.
.
FEN: Cardiac/diabetic diet; No standing IVF; electrolytes were
monitored and replaced as needed.
.
Prophylaxis: SQ heparin, bowel regimen, PPI (only while on
steroids, can be d/ced afterwards)
.
Code: Full. Confirmed with patient.
Medications on Admission:
Crestor 5 mg daily
Niaspan 500 mg daily
Colchicine 0.6 mg daily
Sonata 5 mg daily
Digitek 125 mcg daily
Carbidopa 25/100 3x/day
Aspirin 81 mg daily
Glipizide 5 mg [**Hospital1 **]
Lisinopril 5 mg daily
Sotalol 80 mg qam, 40 mg qpm
Potassium 20 meq daily
[**Doctor First Name **] 180 mg daily
Lasix 80 mg qod
Doxepin 25 mg prn itching
Discharge Medications:
1. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous
Q12H (every 12 hours) for 10 days.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 5 days.
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days: Please give 20 mg daily x 4 days then 10 mg daily
for 4 days then 5 mg for 4 days.
8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Sonata 5 mg Capsule Sig: One (1) Capsule PO at bedtime.
14. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection as directed on flow sheet for 12 days.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
17. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
22. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
1. E. coli sepsis
2. Rapid atrial fibrillation
Discharge Condition:
Good - breathing comfortably, afebrile, heart rate well
controlled
Discharge Instructions:
Please take all medications as directed
Please ensure that you follow up with your primary care doctor
(see below) as indicated by his PCP.
Please check INR on Saturday [**2123-1-2**] and Monday [**2123-1-4**] and
then weekly INR - patient recently started on coumadin, please
forward results to PCP listed below who will make adjustments to
his medication if necessary:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
One [**Location (un) **] Place, [**Apartment Address(1) 19746**]
([**Telephone/Fax (1) 5455**] ext:[**Numeric Identifier 40192**]
Pager: [**Pager number 40193**]
[**University/College 40194**]
.
Please follow up with other appointments as listed below.
.
Please return to the hospital if you have any fevers, chills,
nausea/vomiting, elevated heart rate or any other complaints
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Date/Time:[**2123-2-18**] 10:00
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
One [**Location (un) **] Place, [**Apartment Address(1) 19746**]
([**Telephone/Fax (1) 5455**] ext:[**Numeric Identifier 40192**]
Pager: [**Pager number 40193**]
[**University/College 40194**]
Completed by:[**2123-1-1**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5196
} | Medical Text: Admission Date: [**2120-6-18**] Discharge Date: [**2120-6-26**]
Service: Green Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
female with a 24-hour history of abdominal pain that started
the day prior to admission. The patient also complained of
urgency to defecate and nausea. The patient had emesis x 2
the night prior to admission. She felt lightheaded and had
increasing abdominal pain. She was taken to [**Hospital **] Hospital
where she was hypotensive at the time. She was admitted to
the unit. A femoral line was placed and volume resuscitation
was initiated. She continued to have worsening abdominal
pain this morning.
PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Atrial
pacer. 3. Primary pulmonary hypertension. 4. Ischemic heart
disease. 5. Atrial fibrillation. 6. Hypertension. 7. Gout.
8. Myocardial infarction.
PAST SURGICAL HISTORY: Open cholecystectomy.
MEDICATIONS AT HOME: 1. Amiodarone 200 b.i.d. 2. Lopressor
25 b.i.d. 3. Protonix 40 q.d. 4. Nitroglycerin patch 0.2
p.r.n. 5. Plavix 75 q.d. 6. Aspirin q.d. 7. Digoxin 0.125
q.o.d.
ALLERGIES: Codeine causes hallucinations.
PHYSICAL EXAMINATION: Vital signs were temperature 95.3,
heart rate 79, blood pressure 94/41, respiratory rate 18, 96%
on two liters nasal cannula. She was on a Neo-Synephrine
drip. Her cardiovascular examination showed a paced rhythm
with no murmurs, gallops, or rubs. Her lung examination was
clear to auscultation bilaterally. On abdominal examination
the patient was distended with decreased bowel sounds. She
was tender in the lower left lateral abdomen with mild tenderness
in the right lower and left upper quadrants. She exhibited
voluntary guarding of the left lower quadrant. There was no
rebound tenderness. On rectal examination there were no
masses and she was guaiac positive. Her extremity
examination showed no evidence of cyanosis, clubbing or
edema.
LABORATORY DATA: White blood cell count was 15 with 34%
bands, creatinine 1.6, amylase in the 600s, lipase 15. CAT
scan from yesterday showed a contained perforation and mild
thickening of the descending colon with stranding of the
mesentery.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2120-6-18**] emergently with a preoperative diagnosis of
ischemic left colon. While in the operating room the patient
had a left hemicolectomy, a Hartmann pouch and end ileostomy.
Details of the procedure can be found in the operative note. She
had complete transmural necrosis of the proximal left decending
colon with obvious perforation or peritonitis. The SMA pulse was
strong. The presumed etiology was an embolis with ischemia vs.
a low flow state (less likely given strong SMA pulse).
While in the operating room the patient's blood pressure
dropped initially. The patient was treated with increasing
IV fluids, Neo-Synephrine drip and was transfused two units
of packed red blood cells. In addition, the calcium and
bicarbonate were repleted for lactic acidosis. The patient
was transferred to the surgical intensive care unit
postoperatively intubated and on a Neo-Synephrine drip.
Vital signs were stable when transferred to the surgical
intensive care unit.
While the patient was in the surgical intensive care unit,
the patient was heparinized for presumed embolic event. A
transesophageal echocardiogram was performed to evaluate for
cardiac source of embolus. No thrombus was seen, however the
echocardiogram was positive for a right-to-left shunt at rest
with the bubble study, consistent with a stretched patent
foramen ovale. While in the surgical intensive care unit the
patient continued to be intubated until mobilizing her
fluids.
On postoperative day number three in the surgical intensive
care unit, it was attempted to extubate the patient, but the
patient started to desaturate to the 80s and so the patient
was placed back on the ventilator. She was given Lasix with
good diuresis and staff was able to extubate the patient in
the afternoon post diuresis. The patient was weaned to O2 by
nasal cannula at four liters when her oxygen saturations were
greater than 95% with no shortness of breath and her arterial
blood gas was within normal limits.
On postoperative day five the patient was tolerating clear
liquids without any nausea or vomiting. Her intake was
greater than 400 cc p.o. that day. Her colostomy stoma was
pink with small round brown ischemic areas on the outer
aspect. Her ostomy was producing stool and the ostomy nurse
replaced the appliance. The patient continued to be
monitored in the surgical intensive care unit. Her heparin
drip was titrated accordingly. The patient continued to be
hemodynamically stable and on postoperative day six the
patient was transferred to the floor.
While on the floor the patient continued to tolerate p.o.
without difficulty. Her ostomy stoma was pink, viable and
showed good output. Her abdominal examination continued to
be soft and nontender. Anticoagulation was continued as the
patient was started on Coumadin. Heparin was discontinued
when the INR was greater than 2.0. The patient's diet was
advanced. She would continue to tolerate a regular diet
without difficulty. Physical therapy was consulted and
recommended aggressive physical therapy and rehabilitation
placement. The patient was discharged on postoperative day
11 with an INR of 2.0 and her last dose of Coumadin prior to
discharge was 0.5 mg on that day. The patient's pain was
well controlled and the patient had been out of bed with
physical therapy help.
Arrangements were made by the case manager for the patient to
go to rehabilitation at [**Hospital6 25759**] and
Rehabilitation Center in [**Location (un) **].
CONDITION ON DISCHARGE: Good, stable.
DISCHARGE STATUS: To rehabilitation at [**Hospital6 25759**]
and Rehabilitation Center in [**Location (un) **], [**State 350**].
DISCHARGE DIAGNOSES:
1. Ischemic left colon probable cause thromboembolism, status
post exploratory laparotomy, left hemicolectomy, Hartmann
pouch, and end ileostomy.
2. Coronary artery disease.
3. Atrial pacing.
4. Primary pulmonary hypertension.
5. Ischemic heart disease.
6. Atrial fibrillation.
7. Hypertension.
8. Gout.
9. Myocardial infarction.
DISCHARGE MEDICATIONS:
1. Ostomy care.
2. Amiodarone 200 mg q.d.
3. Famotidine 20 mg b.i.d.
4. Metoprolol tartrate 50 mg b.i.d.
5. Digoxin 125 mcg q.d.
6. Coumadin 0.5 mg q.d.
7. Outpatient laboratory work for Coumadin dosing.
DISPOSITION: The patient is to go to rehabilitation and then
to follow up with Dr. [**Last Name (STitle) **] in one to two weeks for staple
removal and follow up. Dr.[**Name (NI) 6218**] number is included in
the discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28129**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 28130**]
MEDQUIST36
D: [**2120-6-27**] 10:01
T: [**2120-6-27**] 10:24
JOB#: [**Job Number 28131**]
ICD9 Codes: 2762, 4019, 412, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5197
} | Medical Text: Admission Date: [**2117-7-5**] Discharge Date: [**2117-7-15**]
Date of Birth: [**2040-3-14**] Sex: M
Service: MEDICINE
Allergies:
Angiotensin Receptor Antagonist / Ace Inhibitors
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
dyspnea, IVIG-mediated ATN
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 77 year-old r handed male with PMHx significant for CAD
s/p MI x3 w/ stent, HTN, afib admitted for IVIG therapy related
to recently diagnosed motor neuropathy.
.
- Following history adapted from neuromuscular fellow note of
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] -
.
Pt states that for a couple of years, he has had some difficulty
reaching things on high shelves. He began to have to use both
his
hands to lift anything as heavy as a plate from a high shelf. He
did not notice any other problems at that time. In [**Month (only) 1096**]
[**2115**],
he was diagnosed with atrial fibrillation. In [**Month (only) 404**] of this
year, he began to notice some dyspnea on exertion while lifting
his paraplegic wife. At the end of [**Month (only) 404**] he noticed he could
no
longer breathe while lying flat. He went to [**State 108**] in [**Month (only) 956**]
and shortly afterward developed severe shortness of breath and
lower extremity edema. He was hospitalized in [**State 108**] and given
a
diagnosis of a left lower lobe infiltrate and started on
diuretics and antibiotics.
.
After discharge his symptoms did not improve. He returned to
[**Location 86**] and was admitted to [**Hospital1 18**] with worsening orthopnea,
pitting edema and shortness of breath. He was given a diagnosis
of diastolic heart failure with an elevated BNP. There was no
evidence of MI. He was cardioverted during admission and
aggressively diuresed in the CCU. Amiodarone was added. He
continued to be hypoxic and require supplemental oxygen. TTE
showed EF 50%.
.
He was discharged to rehabilitation. Since then, he has
continued
to need supplemental oxygen. He has continued orthopnea and
dyspnea on exertion and always sleeps in a chair. He walks with
a
walker now to carry his oxygen tank and provide a chair if he
needs to rest. He can walk around his house without the walker,
and admits he often dosen't use the nasal cannula at home. He
has
been unable to get a chest CT due to the inability to lay flat.
.
In addition to the breathing problems, a couple of months ago he
also developed paresthesias and numbness in the fourth and fifth
digits of his left hand. This included the palm and the dorsal
surface of the fourth and fifth digits. He also notes weakness
of
the left hand, particulary his grip. His fourth and fifth
fingers
"feel big," and when touched feel as though something is between
his fingers and the stimulus. He denies neck, wrist and elbow
pain.
.
He denies weakness in the lower extremities. He also denies
numbness and paresthesias in the lower extremities. He has not
noticed any rippling muscles or twitching. He has had chronic
lower extremity cramps at night for years, but this is
unchanged.
He denies trouble speaking or swallowing, and denies double
vision or increased weakness at the end of the day.
.
A few weeks ago, he had PFTs, which showed an FVC 29% predicted,
FEV1 32% predicted. The FEV1/FVC ratio was 111% predicted, which
is elevated. The test was consistent with a restrictive lung
process. He also had a moderately reduced DLCO.
.
There is no history of fevers, chills, chest pain, rashes
abdominal pain, nausea, vomiting, incoordination, change in
vision, change in speech and swallowing.
Past Medical History:
CAD, s/p stenting of RCA in [**2113**]
TTE at OSH: EF=60% as above
Atrial fibrillation, diagnosed [**11-14**] s/p cardioversion, on
coumadin
HTN
Hypercholesterolemia
Gout
s/p Spinal fusion
Benign tumor of Left breatst 6 yrs ago
Left knee replacement
Benign tumor of spine
Appendectomy
OSA
carpal tunnel release bilaterally, [**2089**]
rib removal for ? thoracic outlet syndrome bilaterally
car accident [**2075**] with head trauma
Social History:
He has a ninth grade education. He was in the military, then
he worked in a machine shop. In the shop, he says the air was
constantly thick with smoke from the materials they were using.
He lives with his wife. She was paralyzed from the waist down by
a spinal cord infacrtion about 15 years ago. He is her primary
caretaker.
Family History:
His father died at age 72 from heart disease. His mother
died at age [**Age over 90 **] from heart disease. He has a living brother and a
living sister. His other sister died from breast cancer at age
45. There is no history of neurological problems in the family.
Physical Exam:
GEN: Sitting in chair, NAD
HEENT: NC/AT, MMM, o/p clear, neck supple, no carotid bruits,
CV:RRR S1/S2 no m/r/g
RESP:CTA b/l
ABD: soft NT ND + BS
EXT: no c/c/e
.
NEURO EXAM: oriented to person, place and time, patient
repeating intact, naming intact, language fluent with normal
comprehension. Able to spell WORLD backwards. [**Location (un) **] inact.
[**2-11**] registration. [**12-14**] recall after 3 minutes, [**2-11**] with
prompting.
.
CN: PERRL, EOMI, face symmetric, normal sensation, no hearing on
left ear, sternocleidomastoid intact, palate symmetric, tongue
midline.
.
MOTOR: He has full strength of neck flexion and extension. There
is no pronator drift. Tone is normal. Right deltoid [**4-15**], Left
deltoid 4+/5.
Right biceps strength is [**4-15**]; left biceps strength is 4+/5.
Right triceps [**4-15**], left triceps 4+/5. Wrist extension strength
is 4+/5 bilaterally. Wrist flexion is full strength bilaterally.
Right finger flexion [**4-15**]. Left 1st, 2nd, and rd digit finger
flexion [**3-16**]. Left 4th and 5th digit flexion 4-/5. There is
mild 4+/5 weakness of the iliopsoas muscles bilaterally.
Dorsiflexion and plantar flexion are also full strength
bilaterally. There was mild weakness of toe extension
bilaterally.
.
SENSATION: Decreased sensation to cold temperature from hands to
elbows bilaterally. Decreased vibration on toes bilaterally.
.
DTR: absent throughout. Toes dowgoing bilaterally.
.
COORDINATION: Finger nose finger without dysmetria, [**Doctor First Name **] normal
.
GAIT: normal stride and arm swing
Pertinent Results:
[**Doctor First Name 2841**] - electrophysiologic findigs most c/w multifocal motor
neuropathy w/ conduction block, affecting bilateral median
nerves and ulnar nerve.
Brief Hospital Course:
This is a 77 yo man with multifocal motor neuropathy, CAD, HTN,
OSA, s/p PCI, hyperlipidemia, restrictive lung disease
(diagnosed [**2117-6-25**] with FVC of 34% predicted)who initially
presented with slowly progressive dyspnea and orthopnea over six
months. The patient also reported weakness of his left hand
over the last year. On exam the patient was found to have
proximal muscle weakness in his upper and lower extremities. He
was also noted to have a numbness from his elbows to his finger
tips bilaterally with weakness of his left 4th and 5th digits.
He also had largely absent reflexes. The patient's [**Month/Day/Year 2841**] study
from [**2117-6-15**] suggested his defecits are from a multifocal motor
neuropathy with conduction block. He also seems to have an
ulnar neuropathy. The pt was admitted for an elective 5 day
course of IVIG for this motor neuropathy. After administration
of the IVIG, the pts creatinine increased from 0.9 on [**7-6**] to
1.4 on [**7-8**], to 5.4 on [**7-10**], and to a peak of 7.4 on [**7-11**]. The
pt was transferred to the MICU on [**7-11**] for this worsening renal
function thought to be secondary to IVIG-mediated ATN, oliguria,
and increasing SOB with a mild increase in O2 requirement. In
the MICU, the pt was followed by renal. His Bumex was D/C'd,
Aspirin and Indomethecin were also D/C'd. Renal US and CXR were
obtained. Renal US showed no obstruction. CXR show no pulmonary
congestion. Prior to transfer to the floor, the pt was given
Lasix 120 mg IV x1 and chlorothiazide 500 mg IV x1. The pt
diuresed 2L in response to these doses, and then he further
autodiuresed 3-4 L each day subsequently. It was felt the pt
had entered into the diuresis phase of ATN prior to discharge.
The pt frequently required potassium repletion (K often 3.1-3.4)
likely secondary to tubulopathy and inability for K reabsorption
during the recovery phase of ATN. Indomethacin was held as was
his allopurinol, but prior to discharge his allopurinol was
restarted at a lower dose of 100 mg qod. The pts coumadin for
his PAF was initially held given the possible need for
hemodialysis, but this was restarted at 2.5 mg qhs and titrated
up to 5 mg qhs with an INR prior to discharge of 1.6. The pt
developed a hyponatremia of 128 on [**7-12**] which improved to 137
prior to discharge after he had been placed on fluid restriction
and diuresed. Prior to and after discharge, po intake was
encouraged as the pt was in the regeneration phase of his
tubules and at risk of dehydration secondary to loss of tubular
concentrating capacity.
.
The pts shortness of breath improved over his stay. The
etiology was likely multifactorial including ARF in the setting
of diastolic dysfunction and baseline CHF as well as restrictive
lung disease. The pt continued on his home BIPAP machine at
night. As the pt is on amiodarone IPF is also possible, but the
pt is unable to lie flat for a CT.
.
Prior to discharge the pt began to c/o intense L hand swelling,
throbbing, and numbnbess. This was more than at his usual ulnar
neuropathy baseline. Venous US on [**7-15**] ruled out venous
thrombus. The pt was started on a 6 day outpatient prednisone
taper as he has a history of gout and his recent ARF/diuresis
was a likely trigger (and his allopurinol had initially been
held).
Medications on Admission:
lopressor 12.5 mg [**Hospital1 **]
bumex 2 mg [**Hospital1 **]
aspirin 81 mg daily
KCL 10 meq daily
indomethacin 50 mg [**Hospital1 **]
allopurinol 300 mg daily
warfarin 2.5 mg daily
amiodarone 200 mg daily
mevacor 40 mg qhs
butalbital prn
stool softener
combivent
BIPAP at night
supplemental oxygen
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet, Chewable(s)* Refills:*2*
6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
[**Hospital1 **]:*15 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO once
a day for 5 days: take till potassium checked clinic on
[**2117-7-19**]-then take more potassium if indicated by your primary
care physician.
[**Name Initial (NameIs) **]:*10 packets* Refills:*0*
9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: start with this dose.
[**Name Initial (NameIs) **]:*6 Tablet(s)* Refills:*0*
10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: take after done with 60mg dose .
[**Name Initial (NameIs) **]:*4 Tablet(s)* Refills:*0*
11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: start after done with 40mg dose.
[**Name Initial (NameIs) **]:*2 Tablet(s)* Refills:*0*
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO use as
directed for 6 days: Take 3 tablets for 2 days, take 2 tablets
for 2 days, and take 1 tablet for 2 days.
[**Name Initial (NameIs) **]:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ulnar neuropathy
multifocal motor neuropathy w/ conduction block
Acute Renal Failure
Obstructive Sleep Apnea
Atrial Fibrillation
Discharge Condition:
stable
Discharge Instructions:
Please call your neurologist or return to the ED if you
experience increased shortness of breath, weakness, numbness,
decreased urine output.
Please do not take Cholchicine till further notice. Please
continue to maintain adequate fluid intake. Please keep all
follow up appointments.
Followup Instructions:
Provider: [**Last Name (NamePattern4) 35872**]/[**Last Name (NamePattern4) 35873**], MD Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2117-7-16**] 11:00
.
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2117-7-20**]
8:30
.
Provider: [**Name10 (NameIs) 2841**] LABORATORY Where: CLINICAL CTR-[**Location (un) 35874**]-NEUROLOGY
DEPT Date/Time:[**2117-7-20**] 10:00
Dr. [**Last Name (STitle) **]/[**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **]-PCP-[**Telephone/Fax (1) 3183**]-[**2117-07-19**] at 1:20PM-Please
have your K, Cr and Chem panel checked. Your Cr. at time of
discharge had decreased from 7.4 to 3.2
[**Hospital **] CLINIC-[**Hospital 35875**] CLINIC WILL CALL YOU by [**2117-7-16**]
with a follow up appointment. If you do not hear from the clinic
by [**2117-7-16**]-please call them immeditaly to schedule a follow up
appointment.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5845, 4280, 2761, 412, 2720, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5198
} | Medical Text: Admission Date: [**2175-6-22**] Discharge Date: [**2175-6-27**]
Date of Birth: [**2175-6-22**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 57689**] is a 39 week
gestational age infant admitted with respiratory distress.
MATERNAL HISTORY: Mom is a 23 year old gravida 2, para 1,
now 2, woman with the following antenatal screens.
Blood type O positive, antibody negative, hepatitis B surface
antigen negative, RPR nonreactive, rubella immune and group
beta strep status negative.
PREGNANCY HISTORY: Estimated date of delivery [**6-28**], for
an estimated gestational age of 39 and 1/7 weeks. Antepartum
course benign. Spontaneous onset of labor leading to
spontaneous vaginal delivery under epidural anesthesia. No
intrapartum fever or other clinical evidence of
chorioamnionitis. Spontaneous rupture of membranes 5.5 hours
prior to delivery yielding clear amniotic fluid. Infant
received bulb suction and given tactile stimulation. Apgar
scores 9 at 1 minute, and 9 at 5 minutes of age. In regular
nursery, noted at approximately 5 hours to have nasal
congestion with retractions and was transferred to the
Newborn Intensive Care Unit for further evaluation.
PHYSICAL EXAMINATION: Weight 2465 grams (25th percentile,
length 45 cm (10th percentile), head circumference 33 cm
(25th to 50th percentile).
VITAL SIGNS - heart rate 130, respiratory rate 56, oxygen
saturations 100 percent in room air, blood pressure 84/44,
mean arterial pressure of 53 and temperature 97.5 axillary.
HEENT: Anterior fontanel soft and flat, non-dysmorphic,
palate intact, neck and mouth normal, normocephalic, mild
nasal flaring. CHEST: Mild retractions, mild intermittent
stridor with moderate nasal congestion, good breath sounds
bilaterally. Transmitted upper airway sounds but no
crackles. CVS: Infant well perfused, regular rate and
rhythm. Femoral pulses normal. S1 and S2 normal. No murmurs.
ABD: Soft and nondistended. No organomegaly. No masses.
Bowel sounds active. Anus patent. Umbilical cord dry. GU:
Normal female genitalia.
SKIN: Normal. Normal spine, limbs, hips and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY - The
infant was admitted from Newborn Nursery with retractions and
nasal flaring, thought to be related to upper airway
congestion. He has remained on room air throughout his
hospitalization with oxygen saturations greater than 95
percent. Dexamethasone and Neo-Synephrine drops were started
on day of life 0 for upper airway congestion with improvement
over the next 2 days. The dexamethasone and Neo-Synephrine
were discontinued on day of life 2. Work up breathing has
decreased and oxygen saturations have remained in the high
90's. He is currently comfortable in room air with
respiratory rates in 30's to 60's.
CARDIOVASCULAR - the infant's blood pressure has been normal
throughout her hospitalization. No murmurs noted.
FLUIDS, ELECTROLYTES AND NUTRITION - Ad lib feeds were
initiated on day of delivery and he has continued to feed
well by breast and bottle over the course of his
hospitalization. Two days prior to discharge the patient had
abdominal distension associated with a large gastric aspirate
that prompted .
Subsequernlty was normal and has tolerated feedings well. KUB
unremarkable. Her weight at the time of discharge is
2490 grams.
GASTROINTESTINAL - the infant is not clinically jaundiced.
No bilirubin was drawn.
HEMATOLOGY - hematocrit at birth was 56. No blood products
were given.
INFECTIOUS DISEASE - CBC and blood cultures were sent on day
of life 1. White count of 18.8000, hematocrit of 56,
platelet count of 229,000 with 69 percent polys and 1 percent
bands. Blood culture was negative. No antibiotics indicated.
NEUROLOGY - not indicated for this 39 week old infant.
SENSORY - hearing screen was performed with automated
auditory brainstem responses. He passed in both ears on
[**6-25**].
OPHTHALMOLOGY - eye examination not indicated for this 39
weeker.
PSYCHOSOCIAL - [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Social
Work has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **].
DEVELOPMENTAL - the infant had issues with low temperatures
requiring isolette shortly after admission to the Newborn
Intensive Care Unit. She has been weaned from the isolette
and temperature has been stable for greater than 24 hours.
CONDITION AT DISCHARGE: Stable without increased work of
breathing in room air with good oxygen saturations.
Temperature stable in open crib.
DISCHARGE DISPOSITION: To home with parents.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 42437**], at [**Hospital 1411**] Community
Health Center - phone No. [**Telephone/Fax (1) **].
CARE RECOMMENDATIONS: Feeds at discharge ad lib, to amend
feeds of breast milk or formula.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Not indicated.
STATE NEWBORN SCREENING STATUS: First State Newborn Screen
was sent on [**6-25**], no abnormal results have been
reported.
IMMUNIZATIONS RECEIVED: The infant has received her first
hepatitis B vaccine on [**6-25**]. No other immunizations
given.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] if the infant meet any
of the following three criteria:
Born at less than 32 weeks.
Born between 32 and 35 weeks with two of the following:
Daycare during RSV season, smoker in the household,
neuromuscular disease, airway abnormalities, or school age
siblings.
Chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infant once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSIS: Mild respiratory distress related to
upper airway congestion.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2175-6-27**] 00:39:05
T: [**2175-6-27**] 02:50:46
Job#: [**Job Number 57690**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5199
} | Medical Text: Admission Date: [**2105-7-19**] Discharge Date: [**2105-7-22**]
Date of Birth: [**2031-10-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Neomycin Sulfate / Neomycin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 year old woman with past medical history significant for CKD
and diastolic heart failure was transferred to [**Hospital1 18**] from
[**Hospital 882**] hospital with severe respiratory distress due to
hypoxia. Patient has been a resident at [**Hospital 100**] Rehab since her
discharge from [**Hospital1 18**] on [**2105-6-3**]. During this admission she
was found to have narrow complex tachycardia and anemia. She has
had several admissions to [**Hospital 882**] hospital since that time with
a notable admission for c.diff colitis in early [**Month (only) **].
.
On day of admission, patient presented to [**Hospital1 882**] from [**Hospital 100**]
Rehab with cough, hypoxia, and shortness of breath that evolved
acutely over two hours prior to presentation to [**Hospital1 882**].
Patient was given Ceftazidime, 80mg IV Lasix, nitro paste, and
morphine prior to transfer to [**Hospital1 18**] ED.
.
Upon presentation to the ED vitals were: T 98.8, HR 81, BP
170/87, RR 30, O2Sat 70% on NRB. After confirming code status
with proxy (DNR/DNI) patient was placed on BiPAP with O2Sats
coming up to mid 90s. Patient the given levofloxacin IV and
admitted to MICU.
.
Pt has no complaints at this time and would like to leave the
hospital. She complains of no shortness of breath, no chest
pain, no abdominal pain, and no headache. She is -2.6 L total
and -1.5 L over the last 24 hours.
.
ROS: no fever, chills, night sweats, headache, sinus tenderness,
rhinorrhea, congestion, cough, wheezing, chest pain, chest
pressure, palpitations, weakness, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria, frequency, urgency
Past Medical History:
1) Chronic kidney disease
2) Alcoholic cirrhosis
3) Diastolic CHF
4) Cervical malignancy (reported from last hospitalization)
5) Severe c.diff pancolitis (Diagnosed [**2105-6-9**] and still on
oral vanco treatment until [**2105-7-25**])
6) Atrial flutter
7) h/o retinal vein occlusion
8) Ocular hypertension
9) Glaucoma
10) Cataract extraction
Social History:
Lives alone. Daughter recently passed away from drugs/etoh. Has
six children and is one of 16 herself.
- Tobacco: Former. Quit in [**2070**].
- Alcohol: History of alcoholism and hospitalized at the [**Hospital1 86076**] in the [**2065**]. Sober since then.
- Illicits: None
Family History:
Mom died of unknown cancer. Daughter died of drugs and alcohol.
Physical Exam:
Vitals - T: 96.8 BP: 112/46 HR: 72 RR: 24 02 sat: 92% on 4L NC
GENERAL: NAD, AAOx3
HEENT: sclera anicteric, PERRL, EOMI, MMM
NECK: no LAD, supple, +JVD
CARDIAC: RRR, S1/S2, no M/R/G
LUNG: light wheezes bilaterally, crackles present on both sides,
worse at bases
ABDOMEN: soft NT/ND, +BS
EXT: pitting edema evident at ankles
NEURO: AAOx3
DERM: no rash present
Exam upon discharge shows decreased crackles and wheezes and
less pitting edema on [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**].
Pertinent Results:
[**2105-7-19**] 07:07PM BLOOD WBC-13.2* RBC-3.54* Hgb-10.7*# Hct-33.4*#
MCV-94# MCH-30.1# MCHC-31.9# RDW-20.2* Plt Ct-502*
[**2105-7-19**] 07:07PM BLOOD PT-12.2 PTT-24.8 INR(PT)-1.0
[**2105-7-19**] 07:07PM BLOOD Glucose-113* UreaN-21* Creat-1.3* Na-141
K-4.4 Cl-104 HCO3-21* AnGap-20
[**2105-7-19**] 07:07PM BLOOD cTropnT-0.04*
[**2105-7-19**] 07:08PM BLOOD Lactate-2.4*
[**2105-7-21**] 05:30AM BLOOD WBC-8.5 RBC-2.94* Hgb-8.3* Hct-26.7*
MCV-91 MCH-28.4 MCHC-31.1 RDW-20.0* Plt Ct-436
[**2105-7-20**] 03:17AM BLOOD Glucose-87 UreaN-21* Creat-1.4* Na-139
K-4.5 Cl-101 HCO3-23 AnGap-20
[**2105-7-20**] 07:42PM BLOOD Glucose-100 UreaN-23* Creat-1.5* Na-139
K-3.8 Cl-100 HCO3-26 AnGap-17
[**2105-7-20**] 03:17AM BLOOD cTropnT-0.05*
[**2105-7-20**] 3:17 am URINE
[**2105-7-22**] 06:30AM BLOOD Glucose-87 UreaN-24* Creat-1.3* Na-142
K-4.0 Cl-104 HCO3-26 AnGap-16
**FINAL REPORT [**2105-7-20**]**
Legionella Urinary Antigen (Final [**2105-7-20**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 86080**] F 73 [**2031-10-4**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2105-7-20**] 2:43
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. MED MICU [**2105-7-20**] 2:43 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 86081**]
Reason: Interval change?
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with likely CHF and pneumonia
REASON FOR THIS EXAMINATION:
Interval change?
Final Report
CHEST RADIOGRAPH
INDICATION: Chronic heart failure, pneumonia, assessment of
interval change.
COMPARISON: [**2105-7-19**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Minimal tendency to increasing consolidation at both
lung bases, as
manifested by slight decrease in extent of the previously
visible air
bronchograms. The lung volumes, however, are smaller than on the
previous
image. In the ventilated parts of the lung parenchyma, the
extent of the
pre-existing opacity is unchanged.
Brief Hospital Course:
#.Hypoxia: Pt presented to [**Hospital1 18**] on [**7-19**] with respiratory
distress and decreased O2 sats. Patient was given Ceftazidime,
80mg IV Lasix, nitro paste, and morphine prior to transfer to
[**Hospital1 18**] ED. Once at [**Hospital1 18**], she was placed on BiPAP with O2Sats
coming up to mid 90s. She was started on broad coverage with
cefepime and levofloxacin for presumed healthcare-associated
pneumonia. CXR was taken and showed both findings suggestive of
pulmonary edema and opacity probably representing atelectasis or
pleural effusion, but could not rule out infectious processes.
It was decided to continue antibiotic regimen. Overnight, pt
showed improving oxygen saturation, good urine output, and was
taken off BiPap in the early morning. It is unclear whether she
suffered flash pulm edema from a supraventricular tachycardia or
infectious etiology, but pt had not produced sputum, and
remained afebrile throughout ICU course. On [**7-20**], pt was
transferred to the general medicine floor on 4L NC, with sats in
the low 90s. Pt did not feel short of breath at this time, and
for the remainder of her hospital course. Lasix was provided IV
upon arrival to the floor, and was switched to PO home dose of
Lasix on [**7-21**]. It was presumed that her hypoxia was due to
pulmonary edema from the patient's CHF. On the evening of [**7-21**],
pt was able to discontinue O2 and did well until discharge on
[**7-22**], without SOB.
.
#.Diastolic CHF: pt was found to be fluid overloaded on
admission, and pt was given 80 mg IV Lasix twice while in the
ICU. She was -2L when transferred to the floor, with a slight
rise in Cr. Lasix was held on the night of [**7-20**], due to this.
In the afternoon of [**7-21**], Cr approached baseline, pt was
switched to PO home dose of Lasix (20 mg qdaily) and continued
to diurese. Upon discharge, pt was approximately negative
3.5-4L. Pt was continued on metoprolol while in the hospital,
but was not on spironolactone. Home doses of Lasix, metoprolol
and spironolactone should be continued upon discharge, as
written.
.
#.C. difficile pancolitis: pt came to the hospital on PO
Vancomycin for C. diff pancolitis, and was originally due to
finish this regimen on [**7-25**]. Due to patient being discharged on
PO levofloxacin for possible HAP, we lengthened this regimen to
avoid relapse to be finished on [**7-31**]. Pt did not complain of
abdominal pain or diarrhea during admission.
.
#.Tachycardia: pt's tachycardia was controlled during
hospitalization with home doses of metoprolol and amiodarone, to
be continued as written.
.
#.Chronic kidney disease: pt's Cr showed a small increase during
diuresis for fluid overload, but normalized according upon
titrating down the dose.
.
#.Glaucoma: home doses of medications were continued throughout
hospital course, and should be continued upon discharge as
written.
Medications on Admission:
1) traZODONE 25 mg PO/NG HS:PRN insomnia
2) Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3) Magnesium Oxide 400 mg PO/NG TID
4) Lidocaine 5% Patch 1 PTCH TD DAILY
5) Ipratropium Bromide Neb 1 NEB IH Q6H
6) Ferrous Sulfate 325 mg PO DAILY
7) Vitamin D 1000 UNIT PO/NG DAILY
8) Calcium Carbonate 650 mg PO/NG [**Hospital1 **]
9) Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
10) Amiodarone 200 mg PO/NG DAILY
11) Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
12) Furosemide 20 mg daily
13) Spironolactone 12.5 mg PO/NG DAILY
14) Omeprazole 20 mg PO BID
15) Metoprolol Succinate XL 100 mg PO DAILY
16) Oxycodone 5 mg [**Hospital1 **]
17) Vancomycin 250 mg PO QID
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Daily weights
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-24**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H
(every 6 hours) as needed for High BP.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
19. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
20. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
21. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hypoxia, Congestive heart failure
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:
It was a pleasure to take care of you at the [**Hospital1 18**]. You came
for further evaluation of shortness of breath and low oxygen in
your blood. Tests showed that you had congestive heart failure.
You were treated with diuretics (water pills) and your shortness
of breath improved. You were treated with antibiotics for
possible pneumonia and for C. difficile colitis. It is
important that you continue to take all of your medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were added to your medications:
Added levofloxacin
Followup Instructions:
Name: [**Last Name (LF) 38274**],[**First Name3 (LF) **] X.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Tuesday [**2105-7-28**] 4:40pm
Please allow extra time to get to your appointment due to
construction in the garage. Thanks.
ICD9 Codes: 486, 5180, 4280, 5859 |
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