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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5200
}
|
Medical Text: Admission Date: [**2171-12-18**] Discharge Date: [**2172-1-26**]
Date of Birth: [**2118-7-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
SBP
Major Surgical or Invasive Procedure:
Paracentesis x 2, left IJ, right temp HD line, A-line x 3, Left
PICC
History of Present Illness:
53-year-old female with a history of alcohol abuse and cirrhosis
status post liver and kidney transplant in [**11/2169**] who presented
to [**Location (un) 12017**] with abdominal pain, vomiting and diarrhea, found
to have SBP, and transferred to [**Hospital1 18**] for further management.
She states the non-bloody/non-billous vomiting started Monday
evening as well as the diarrhea. She states she drank a boost
that exacerbated this. No fevers. She continued to have this
intermittently overnight and awoke Tuesday morning with severe
lower and left sided abdominal pain, 15/10, and constant and
releived with dilaudid. In the OSH, her blood pressures were
noted to be in the 80s with a lactate of 2.4. She was started on
ceftriaxone and given 1.5 grams/kg of albumin. On day of
transfer, other notable lab findings include a wbc of 19,900,
INR: 1.7, and Cr of 2.0 (baseline around 1.5).
.
Of note, the patient was recently admitted to [**Hospital1 18**] on
[**2172-11-16**] for acute renal failure due to volume overload, as
well as an E. Coli UTI. Her Cr prior to d/c was 1.4. With the
question of outflow obstruction vs. rejection in the outpatient
a transjugular liver biopsy [**12-12**] was attempted, but failed due
to diminutive right hepatic vein. There is also speculation from
her Hepatologist that her worsening liver failure is due to
recurrent EtOH use, and she admits to resuming EtOH use in the
fall.
.
On arrival to the MICU, the patient is complaining of abdominal
pain that has somewhat improved from initial presentation.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies constipation. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes
Past Medical History:
- Alcoholic cirrhosis c/b HRS. Dialysis dependent prior to
transplant.
- Status post orthotopic deceased liver-kidney transplant and
splenectomy on [**2169-11-28**], c/b jejunostomy leak requiring
exploratory laparotomy and small bowel resection.
- [**2169-12-25**] right hepatic artery stent placement on asa/plavix
- Hypothyroidism
- Dyslipidemia
- History of two enteroenterostomies and a small bowel
obstruction s/p exploratory laparotomy with lysis of adhesions
in 03/[**2169**].
- Osteoporosis
LIVER HISTORY:
- previously been on azathioprine, prednisone, and tacrolimus
immunosuppresion. Azathioprine, previously DC'd due to hair loss
in early [**2169**] and patient was, maintained on prednisone and
tacrolimus, before switching to, tacro sole therapy. Patient
recently restarted on azathioprine again in [**2171-8-24**].
Azathioprine dose decreased in mid [**Month (only) 1096**] for apparent concern
of peripheral edema. Given concern
of diarrhea, azathioprine was discontinued, and patient was
maintained on tacrolimus sole therapy. Due to sole therapy,
would target slightly higher goal of [**5-2**]. Continued atovaquone
for PCP [**Name Initial (PRE) 1102**].
.
Social History:
- Tobacco: Denies
- EtOH: Hx of heavy EtOH use.
- Drugs: Denies
- Home: Lives alone. Independent in ADL's. 2 grown children.
- Work: Quit job at convenience store due to health issues.
- She has two children ages 21 and 18, who live near her
Family History:
[**Name Initial (PRE) 6961**] are alive at ages 79 and 80 and in good health. She has
four siblings, none of whom have any chronic illnesses
Physical Exam:
Physical Exam:
Vitals: T:96.6 BP:89/53 P: 97 R: 15 O2: 95% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP mid neck, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, rales at the bases
Abdomen: Multiple surgical scars, distended, tender to deep
palpation of LLQ, bowel sounds present, no organomegaly, no
rebound
GU: foley
Ext: warm, well perfused, 2+ pulses, 1 + anasarca
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, gait deferred, no asterixis
Pertinent Results:
Admission Labs:
[**2171-12-18**] 03:46PM BLOOD WBC-15.6* RBC-2.28*# Hgb-6.7*# Hct-21.2*#
MCV-93 MCH-29.5 MCHC-31.8 RDW-14.7 Plt Ct-266#
[**2171-12-18**] 03:46PM BLOOD Neuts-86.2* Lymphs-10.2* Monos-2.6
Eos-0.6 Baso-0.4
[**2171-12-18**] 03:46PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Target-2+ Schisto-1+
Burr-1+ Stipple-1+
[**2171-12-18**] 03:46PM BLOOD PT-23.5* PTT-48.4* INR(PT)-2.2*
[**2171-12-18**] 03:46PM BLOOD Fibrino-173*#
[**2171-12-18**] 03:46PM BLOOD Glucose-101* UreaN-31* Creat-2.0* Na-132*
K-4.3 Cl-101 HCO3-21* AnGap-14
[**2171-12-18**] 03:46PM BLOOD ALT-15 AST-32 AlkPhos-75 TotBili-0.3
[**2171-12-18**] 03:46PM BLOOD Albumin-3.0* Calcium-7.2* Phos-4.8*#
Mg-1.3* Iron-30
[**2171-12-18**] 03:46PM BLOOD calTIBC-31* VitB12-1797* Folate-14.9
Hapto-70 Ferritn-296* TRF-24*
[**2171-12-24**] 09:44AM BLOOD TSH-2.9
[**2171-12-19**] 02:29PM BLOOD Cortsol-36.2*
[**2171-12-18**] 03:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2171-12-21**] 07:00PM BLOOD Vanco-14.8
[**2171-12-18**] 03:46PM BLOOD tacroFK-7.4
[**2171-12-18**] 04:26PM BLOOD Type-[**Last Name (un) **] pO2-27* pCO2-50* pH-7.25*
calTCO2-23 Base XS--6
[**2171-12-18**] 04:26PM BLOOD Lactate-1.4
[**2171-12-19**] 03:25AM BLOOD freeCa-1.00*
Imaging:
CXR: FINDINGS: In comparison with the study of [**2170-3-5**], there
are lower lung
volumes. There is enlargement of the cardiac silhouette with
diffuse
bilateral pulmonary opacifications, most prominent in the
central region,
consistent with pulmonary edema. Poor definition of the left
hemidiaphragm
could reflect atelectasis and effusion.
Although the radiographic abnormalities are most consistent with
pulmonary
edema, the possibility of supervening pneumonia would have to be
considered in the appropriate clinical setting.
.
[**1-18**] CXR: CHF with pulmonary edema and bilateral effusions,
together with bibasilar collapse and/or consolidation, similar
in appearance to [**2172-1-15**].
[**Last Name (un) 1372**]-/orogastric tube as described.
.
[**2172-1-14**] 4:48 pm URINE Source: Catheter.
**FINAL REPORT [**2172-1-16**]**
URINE CULTURE (Final [**2172-1-16**]):
MORGANELLA MORGANII. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORGANELLA MORGANII
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 32 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 0.5 S
NITROFURANTOIN-------- 256 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
53-year-old female with a history of alcohol abuse and cirrhosis
status post liver and kidney transplant in [**11/2169**] who presented
to an outside hospital with abdominal pain and found to have
SBP, and transferred to [**Hospital1 18**] for further management.
.
The patient was on the medical service for the first 27 days in
the hospital before being transferred to the liver service. She
was continued on daptomycin for VRE bacteremia, as well as
ultrafiltration, lasix, and hemodialysis was continued to reduce
volume as she remained oliguric. Supportive nutrition was
continued through Dobhoff. On occasion she developed a rapid
ventricular rate (atrial tachycardia) which responded to IV
metoprolol. Her standing PO metoprolol was stopped, as her
hypotension was limiting the amount of fluid removed at HD. She
developed an increasing leukocytosis, and work-up revealed a
UTI. She was initially treated with ceftriaxone, however
leukocytosis continued to trend up and other work-up was
negative so she was broadened to cefepime, which covered
Morganella, the organism that eventually grew. She did not make
any significant progress in her overall state, and a family
meeting was planned given that she had been hospitalized for
such a prolonged amount of time. However, on the 5th day of her
time on the liver service, she triggered for tachypnea after
returning from dialysis. Over the next 2-3 hours her mental
status declined, her vitals became unstable, and it became clear
she was going into septic shock. This decline happened very
acutely, and she was quickly transferred to the MICU for further
management.
.
In the MICU, the patient required intubation for airway
protection and was initiated on broad antibiotic and antifungal
coverage. Unfortunately, her septic shock was refractory to
broad antibiotic/antifungal coverage and she required 2
pressors. She was also given a trial of CVVH to try to optimize
her volume status. It became clear that her prognosis was grave
as she was not able to wean off of her pressors over the week in
the ICU. After a goals of care discussion with her husband and
multiple family members including her daughter and son, it was
decided that her care would be transitioned to comfort measures
only on the evening of [**1-25**]. She was started on a morphine drip
and extubated shortly thereafter. She passed away on [**2172-1-26**] at
9:05AM with her husband, daughter, and son at bedside. An
autopsy was offered and declined by her husband/HCP.
Medications on Admission:
Medications:
1. atovaquone 1500 mg PO DAILY
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
4. Boniva 3 mg/3 mL Syringe Sig: Three (3) mg IV every 3 months.
5. levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
7. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H
8. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID
9. aspirin 81 mg Tablet DAILY
10. calcium carbonate 500 mg calcium (1,250 mg) PO twice a day.
11. cholecalciferol (vitamin D3) 400 unit Tablet PO DAILY
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
13. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
15. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itchiness.
20. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily
21. Levothyroxine 150 daily
Discharge Medications:
Patient expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
ICD9 Codes: 0389, 5845, 486, 5990, 2761, 2449, 2724, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5201
}
|
Medical Text: Admission Date: [**2112-10-12**] Discharge Date: [**2112-10-21**]
Date of Birth: [**2032-7-22**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hematemasis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
80F with past medical of history of gastric ulcer, right
peroneal DVT in [**2111**] on indefinite anti-coagulation with
warfarin which has been held since [**2112-6-14**] in setting of
multiple admission to OSH for melanotic stools, PVD s/p multiple
lower extremity revascularization, hypertension, hyperlipidemia,
presenting with one day history of vomiting blood x 1 and
melanotic stool x 5 who presents as a transfer from the MICU to
[**Hospital1 139**] B wards.
Briefly, she presented 2 days ago with hematemsis and melana x1
day and was sent in by her PCP. [**Name10 (NameIs) **] the ED, she was transfused 2U
pRBC (Hct 23 on admission, baseline 33). She was admitted to
the ICU. Post transfusion Hct 29, then down to 27, another 1U
pRBC, then Hct 30. EGD showed gastric ulcers with likely recent
bleed, but no intervention was undertaken except for biopsies
which are still spending. GI service was consulted and
recommended [**Hospital1 **] IV PPI. She was Briefly electively intubated for
EGD for concerns of airway protection, then extubated without
complication. She has not been hypotensive since admision, and
atually was hypertensive to SBP200s due to discontinuing home BP
meds, and got IV labetalol. She has now been restarted on home
oral PO meds. Her stay in the ICU was unfortunately complicated
by a fever to 101.6- repeat CXR after extubation showed a
possible LLL infiltrate vs. effusion vs. atelectasis which was
suspicious for VAP and she was started on cefepime Vancomycin
today on [**10-14**]. Of note, she was scheduled for lower extremity
PVD revascularization, and the GI and vascular surgery services
have been coordinating her outpatient antiplatelet regimen in
the setting of this GI bleed
Pt is feeling well today and says she does not feel light
headed, dizzy, or fatigued. She reports no abdominal pain right
now. (States her presenting symptom other than hematemesis and
melena was only fatigue, no pain).
Review of systems:
(+) Per HPI, unintentional weight loss (25 lb over last year),
fatigue
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
PAD with re-stenosis of renal artery stent and bypass graft,
Hypertension, hyperlipidemia, remote h/o seizure disorder,
carotid disease, renal artery stenosis s/p bilateral renal
artery stenting with atrophic L kidney, non-Hodgkin's lymphoma
s/p chemotherapy [**2096**], R peroneal DVT [**2111**] on warfarin.
Past Surgical History:
[**2097**]: Bilateral renal artery stents.
[**2106**]: Right CFA to proximal PT artery bypass with in situ GSV
[**2107**]: Redo right femoral to AK popliteal with 8-mm PTFE, R AK
popliteal to PT with right cephalic vein graft
[**2107**]: Right femoral endarterectomy with Dacron patch angioplasty
of proximal anastomosis of the fem-AK-[**Doctor Last Name **] bypass. Revision patch
angioplasty with vein of the distal anastomosis of the
fem-AK-[**Doctor Last Name **] bypass into the proximal anastomosis of the
above-the-knee popliteal to PT bypass.
[**2109**]: Left CFA and SFA endarterectomy. Left CIA and EIA stent
and angioplasty. Left CFA to proximal AT artery bypass with in
situ SVG.
[**2109**]: Redo right femoral-popliteal bypass.
[**2110**]: Angioplasty of right renal artery stenosis within the
previously placed stent. Angioplasty of right CFA stenosis.
[**2110**]: Repair of left brachial pseudoaneurysm.
[**2110**]: Stenting of left common iliac artery.
[**2111**]: Right iliofemoral bypass with 8 mm propaten graft.
Social History:
Lives in [**Location (un) **] with her husband. Supportive family.
Independent in ADLs. Does not smoke, drink, or use illicit
substances.
Family History:
Mother and Grandfather with PVD
Physical Exam:
Admission Physical Exam
VS: 150/37; 66; 97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA
Neck: supple, JVP elevated to jaw, no LAD
CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM loudest
at LUSB with radiation to bilateral carotids, rubs, gallops
Lungs: Crackles up 1/2 of lung fields bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: warm, well perfused, DP/PT pulses dopplerable, no clubbing,
cyanosis or edema
Neuro: CNII-XII intact, Motor grossly intact
Discharge Exam
VS: 98.8 162/50 58 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA
Neck: supple, JVP elevated above clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM loudest
at LUSB with radiation to bilateral carotids, rubs, gallops
Lungs: CTAB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, DP/PT pulses dopplerable, no clubbing,
cyanosis or edema, post-operative scars noted biterally
Neuro: CNII-XII intact, Motor grossly intact
Pertinent Results:
Admission labs
[**2112-10-12**] 05:53PM GLUCOSE-137* UREA N-42* CREAT-1.0 SODIUM-144
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-33* ANION GAP-8
[**2112-10-12**] 07:19PM WBC-4.2 RBC-2.63*# HGB-7.4*# HCT-23.1*#
MCV-88 MCH-28.3 MCHC-32.2 RDW-16.2*
[**2112-10-12**] 07:19PM NEUTS-40* BANDS-0 LYMPHS-41 MONOS-15* EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2112-10-12**] 07:19PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL TARGET-2+ BURR-OCCASIONAL
ACANTHOCY-OCCASIONAL
[**2112-10-12**] 05:53PM PT-10.5 PTT-30.6 INR(PT)-1.0
Discharge Labs
[**2112-10-21**] 06:30AM BLOOD WBC-7.3# RBC-3.43* Hgb-9.7* Hct-30.2*
MCV-88 MCH-28.2 MCHC-32.1 RDW-15.8* Plt Ct-123*
[**2112-10-21**] 06:30AM BLOOD Glucose-101* UreaN-20 Creat-1.0 Na-140
K-4.2 Cl-105 HCO3-29 AnGap-10
Micro
[**2112-10-13**] Blood Culture, Routine-PENDING
[**2112-10-13**] Blood Culture, Routine-PENDING
URINE CULTURE (Final [**2112-10-15**]): NO GROWTH.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2112-10-14**]): NEGATIVE BY
EIA.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Pending)
Reports
EGD
Impression: Varix at the mid-esophagus. Multiple Gastric ulces
(biopsy, biopsy) Otherwise normal EGD to second part of the
duodenum
CXR PA And Lateral
Mild-to-moderate cardiomegaly is stable. Small bilateral
pleural effusions
are unchanged allowing the difference in positioning of the
patient.
Bibasilar opacity is likely atelectasis larger on the left.
Pneumonia cannot be excluded. There is no pneumothorax. The
aorta is tortuous.
Pathology
A. Gastric body biopsy:
Focal mild acute and chronic inflammation and focally
dilated glands, some with necrotic cells
B. Antrum biopsy:
Focal minimal chronic inflammation.
Brief Hospital Course:
Assessment and Plan:
80F with past medical of history of gastric ulcer, right
peroneal DVT in [**2111**] on indefinite anti-coagulation with
warfarin which has been held since [**2112-6-14**] in setting of
multiple admission to OSH for melanotic stools, PVD s/p multiple
lower extremity revascularization, hypertension, hyperlipidemia,
presenting with upper GIB confirmed on EGD during this admission
# Upper GI bleed, gastric ulcers
Patient presented reporting signs and symptoms of upper GIB with
melanotic stool and hematemsis and was supported by significant
BUN/Cr dissociation. The patient underwent EGD which showed
multiple ulcers in the stomach with evidence of recent bleed.
She was transfused 3 U pRBCs during the admission- two in the ED
and one in the MICU, and put on IV PPI and sucralfate. Patient
was hemodynamically stable throughout with and hematocrits held
around 30.
#VAP/Hypoxia
She developed a fever in the MICU, and given that it was 24 hrs
after intubtation with question of an infiltrate on CXR, she was
started on cefepime and vancomycin which she received for 24
hrs. These meds were d/ced on the floor as repeat CXR did not
show good evidence of pneumonia and she did not look clinically
infected. She was treated empirically with Vancomycin 75 mg q 12
and Cefepime 1 g q 12 hr. A repeat CXR PA and Lateral was
obtained which was not impressive for an infiltrate- the patient
remained asymptomatic and afebrile so the abx were discontinued
at 24 hrs. However, on exam the patient was noted to have
crackles about halfway up on both lung fields. She was given a
one time IV dose of lasix and restarted on her home regimen.
Her oxygen requirements were optimized by the time of discharge
and she was on her home lasix regimen.
#Drug-induced Pancytopenia
Patient has had thrombocytopenia on past labs of uncertain
etiology. She was noted to have downtrending WBCs to 1.6 by [**10-15**]
and was technically still anemic. A smear noted some occasional
schistocytes but hemolysis labs were negative. Hematology was
consulted and thought the vancomycin or cefepime was causing
marrow toxicity. She was monitored for the next few days until
her counts began to increase. They went up to WBC 2.6 21%
neutrophils (ANC still below 1000). Per heme recs she was given
1 dose of neupogen. Her CBC then increased to WBC 7.1 with
almost 70% neutrophils. She was discharged with close follow up
with her hematologist.Her CBC was closely monitored during her
hospital stay.
# Hypertension
The patient's home blood pressure medications were held when
admitted to the ICU for concern of GIB. She actually became
hypertensive during this time. Upon arrival to the floor her
home BP meds were restarted as below. She remained stable,
although with an episode of overnight hypertension 2 days prior
to discharge.
- diovan 320 mg PO qD
- labetalol 100 mg PO TID
- nidefipine ER 60 mg PO qD
#PVD: Patient was originally scheduled to have a revision of a
previous vascular surgery during the time frame of her
admission. This was obviously postponed, but the issue of her
anticoagulation remained. She had a prior DVT which she takes
warfarin for but this has been held since [**Month (only) 116**] due to recurrent
GI bleeds. The vascular surgery team expressed they would like
her anticoagulated for her PVD. After consulting with both GI
and Vascular it was decided that she could go out on plavix, and
hold aspirin given her risk of rethrombosis in her vascular
stents combined with the stability of the bleed.
# Acute renal insufficiency
Patient has baseline Cr ~ 0.7 with admission Cr 1, which came
down to 0.9- no issues since admission
CHRONIC ISSUES
# Chronic back pain
- continued tramadol prn
# Hyperlipidemia
- continued statin, ezetimibe
# History of DVT
- We held warfarin as above
Transitional Issues
-She will follow up with hematology in 3 days for repeat cbc.
-Patient has blood cultures and urine cultures that need follow
up
-She should also be optimized on home BP meds for better
hypertension control
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Atorvastatin 80 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Labetalol 100 mg PO TID
6. NIFEdipine CR 60 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
9. Scopolamine Patch 1 PTCH TP ONCE Duration: 1 Doses
10. Sucralfate 1 gm PO UNDEFINED
11. TraMADOL (Ultram) 50 mg PO UNDEFINED prn
12. Valsartan 160 mg PO BID
13. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Labetalol 100 mg PO TID
4. NIFEdipine CR 60 mg PO DAILY
5. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
6. Sucralfate 1 gm PO UNDEFINED
7. TraMADOL (Ultram) 50 mg PO UNDEFINED prn
8. Valsartan 160 mg PO BID
9. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Ezetimibe 10 mg PO DAILY
11. Furosemide 60 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed from gastric ulcer
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Mrs [**Known lastname 68391**],
You were admitted to [**Hospital1 69**] for
melanotic stools and hematemesis and were found to have an upper
gastrointestinal bleed. You were given 2 units of blood in the
emergency department and then transferred to the ICU and given 1
unit of blood. The gastroenterologists took you down for an
endoscopy which showed a recently bleeding ulcer- they took
biopsies of it which showed inflammation- there was no other
intervention performed. You were briefly given antibiotics for
pneumonia but were taken off after 24 hrs treatment. Your WBCs
were noted to be abnormally low and a hematology consult was
obtained. It was thought that either the vancomycin or cefepime
caused your low blood counts. We watched them for a few days
and they struggled to increase. You received one dose of
neupogen, which helps stimulate the bone marrow, and were
cleared for discharge as your WBC increased to 7.1 with almost
60% neutrophils.
The following changes have been made to your medications:
It was a pleasure taking care of you while at [**Hospital1 18**]
Followup Instructions:
You have an appointment on Monday [**10-24**] at 2 pm with
the nurse practitioner [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] hematology/oncology. Please
make this appointment. You also have an appointment with Dr.
[**Last Name (STitle) 68392**] listed as below.
Name: [**Last Name (LF) 54376**],[**First Name3 (LF) **] A
Address: [**Location (un) 54379**], [**Location (un) **],[**Numeric Identifier 54380**]
Phone: [**Telephone/Fax (1) 54377**]
Appt: [**Last Name (LF) 2974**], [**10-28**] at 1:45pm
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital1 **] HEMATOLOGY/ONCOLOGY
Address: 8 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 68393**]
Phone: [**Telephone/Fax (1) 60339**]
Appt: [**11-3**] at 12pm
****The office is working on a sooner appt for you and will call
you at home when one becomes available.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2112-11-8**] at 1:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 2851, 5849, 2760, 5859, 2768, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5202
}
|
Medical Text: Admission Date: [**2151-6-8**] Discharge Date: [**2151-6-12**]
Date of Birth: [**2151-6-8**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] is a full term
male who is with mild meconium aspiration who is now ready
for transfer to the Newborn Nursery. The infant was born by
spontaneous vaginal delivery to a 36 year old, Gravida 1,
para 0, now 1 woman. The prenatal screens are blood type B
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis surface antigen negative and group B Streptococcus
negative. This pregnancy was complicated by a labile blood
pressure and elevated HcG levels and a head ultrasound on the
day prior to delivery showing a prominent cisterna magna.
The Apgars were 7 at one minute and 8 at five minutes.
Rupture of membranes occurred seven hours prior to delivery.
The intrapartum fever, maximum was 103.4 and the mother did
receive intrapartum antibiotics.
The infant was also delivered through thick meconium fluid
but was vigorous at the time of delivery and so was therefore
not intubated.
The birthweight is 3,565 gm, birth length was 60.5 cm and the
birth head circumference is 35.5 cm.
PHYSICAL EXAMINATION: The admission physical examination
shows a vigorous nondysmorphic term appearing infant.
Anterior fontanelle is open and flat, some moderate cranial
molding with a right-sided cephalohematoma, some mild
tachypnea, no grunting, flaring or retracting. Lungsounds
were clear and equal. I/VI systolic murmur along the left
sternal border. Liver edge at the right costal margin,
femoral and brachial pulses +2 and equal. Abdomen is soft
with three vessel umbilical cord present. There is a
left-sided hip click during the Barlow procedure. The infant
has symmetric tone and reflexes.
HOSPITAL COURSE: Respiratory status - Baseline had some mild
tachypnea at the time of admission. The infant was
transferred to the Newborn Nursery briefly just for a couple
of hours but had persistent tachypnea that worsened to 100 to
120 breaths/minute and so was transferred back to the Newborn
Intensive Care Unit and then had developed an oxygen
requirement. A chest x-ray revealed mild meconium
aspiration. The infant required nasal cannula until day of
life #2 when he weaned to room air and had progressive
resolution of his tachypnea. At the time of transfer his
respirations were 40-60 breaths per minute and comfortable.
His lungsounds are clear and equal.
Cardiovascular status - The murmur that was present at the
time of admission resolved by day of life #2. He has
remained normotensive throughout his Nursery Intensive Care
Unit stay.
Fluids, electrolytes and nutrition - His weight at the time
of transfer is 3,500 gm. He is breastfeeding well and taking
Enfamil 20 on an ad lib schedule and maintaining euglycemia.
His electrolytes on day of life #1 at 24 hours of age were
sodium 139, potassium 4.9, chloride 101 and bicarbonate 23.
Gastrointestinal status - The bilirubin on day of life #3 was
total 5.3, direct 0.3.
Hematological status - His hematocrit at the time of
admission was 53.7%, his platelets were 302,000 and he has
never received any blood products.
Infectious disease status - The infant was started on
ampicillin and gentamicin at the time of admission for sepsis
risk factors. The plan is to complete a seven day course of
ampicillin and gentamicin. Blood cultures remained negative.
His gentamicin level on day of life #3 was trough level of
0.9 and peak level of 9.3.
A spinal tap performed on day of life #1 had a white blood
cell count of 15 and red blood cell count of 1,530, a protein
of 89, and a glucose of 46 with a negative gram stain.
Neurological status - A head ultrasound to follow up on
prenatal finding was completely within normal limits on [**2151-6-11**].
Hearing screen has not yet been done but is recommended prior
to discharge.
Psychosocial status - The parents are married and have been
very involved in the infant's care during the Nursery
Intensive Care Unit stay.
The infant is being transferred to the Newborn Nursery.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 42897**] of [**Hospital 42898**] Medical Associates.
CARE RECOMMENDATIONS:
1. Feedings at discharge - Enfamil 20 or breastfeeding on an
ad lib schedule.
2. Medications - Ampicillin every 12 hours and gentamicin
every 24 hours through a heparin block requiring heparin
flush every six hours.
3. State newborn screen - Sent on [**6-11**], results pending.
4. The infant has not yet received his hepatitis B
immunizations.
5. Follow up - Recommended also is if the left hip click
persists at the time of discharge an orthopedic evaluation.
DISCHARGE DIAGNOSIS:
1. Term newborn infant
2. Sepsis ruled out
3. Mild meconium aspiration
4. Left hip click
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2151-6-12**] 20:34
T: [**2151-6-12**] 21:39
JOB#: [**Job Number 42899**]
ICD9 Codes: V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5203
}
|
Medical Text: Admission Date: [**2148-11-29**] Discharge Date: [**2148-12-6**]
Date of Birth: [**2077-3-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
s/p arrest
Major Surgical or Invasive Procedure:
Intubation
Multiple defibrillations
History of Present Illness:
Mr. [**Known lastname 52932**] is a 71 yo M with PMH significant for CHF (EF:
20-25%), CAD s/p CABG, CKD, a-fib on coumadin, s/p ICD, presents
after VF arrest. Per the family the patient had been complaing
of dizziness over the last few months. He does have a history
of VT per the wife with 2 episodes of syncope in [**Month (only) 547**]. They
also state that he has just not been himself over the last few
months since he was cardioverted for his a-fib. He has been
having frequent falls and syncopal episodes. He has been
closely followed by his cardiologist who had been titrating his
medications including d/c spironolactone and decreasing his
lisinopril. He reportly underwent cardiac cath 3 months prior
that showed occluded grafts, but collateral flow, no
intervention was performed. He had been having worsening
function and unable to perform daily activities because of
dizziness. Today the patient was walking to his bedroom when he
had a syncopal episode. His wife heard him fall and raced to his
side and called 911. EMS arrived within 5-7 minutes and he was
found to be in he was found to be in VF arrest and was shocked
twice with return of spontaneous circulation. He was taken to
[**Hospital1 **].
At [**Hospital1 **] ECG showed a LBBB. Cardiac enzymes: MBI 2%,
Trop 0.16 and Cr. 6. Patient was intubated and sedated with
propofol. He was started on dopamine gtt for hypotension SBP
70-90s and lidocaine gtt. ABG: 7.35/37.8/340/20.8 on Tv:500,
RR:14, FiO2:60%, PEEP: 3. The patient was transferred to the
[**Hospital1 18**] ED.
In the ED: T: 97.8 BP: 87/62 HR: 118, the dopamine was stopped
and he was started on levophed 0.15mcg/kg/min and neo
2.5mcg/kg/min in the ED. He was continued on lidocaine gtt
4mg/min and given 1mg versed and 50mcg of fentanyl. A code
STEMI was called and given ASA 325mg and plavix 600mg. Upon
review the ECG that showed LBBB and discussion with the family
regarding his PMH it was decided that he would not be cathed and
would pursue medical management. CE: Trop 0.16 CK: 521 MB: 13
MBI: 2.5. INR 3.9, WBC 15.3, Cr 5.3, Gap 20. He had a CT-head
that did not show acute abnormality and CXR that showed
pulmonary edema.
The patient was transferred to the CCU and cooling protocol was
initiated.
Unable to obtain ROS.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
CABG
-PERCUTANEOUS CORONARY INTERVENTIONS: 3 months prior showed
occluded grafts, but collateral flow. No intervetion per wife.
- ICD
- a-fib on coumadin
- CHF (reported EF 20-25%)
- h/o VT
3. OTHER PAST MEDICAL HISTORY:
CKD
Gout
Social History:
Lives with his wife
-[**Name (NI) 1139**] history: unable to obtain
-ETOH: unable to obtain
-Illicit drugs: unable to obtain
Family History:
Unable to obtain
Physical Exam:
VS: T=95.2...BP=97/77...HR=65...RR=17...O2 sat=92%
GENERAL: intubated and sedated
HEENT: Sclera anicteric. minimally reactive to light.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP difficult to assess given habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
transmitted vent sounds. CTA anteriorly, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/ +2 edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: patient sedated with no purposful movement
PULSES:
Right: Carotid 2+ Femoral 2+ DP dopplerable
Left: Carotid 2+ Femoral 2+ DP dopplerable
Pertinent Results:
ADMISSION LABS [**2148-11-29**]:
[**2148-11-29**] 12:04AM WBC-15.3* Hgb-11.5* Hct-36.7* Plt Ct-205
[**2148-11-29**] 12:04AM Neuts-89.3* Lymphs-5.8* Monos-4.6 Eos-0.1
Baso-0.3
[**2148-11-29**] 12:04AM PT-37.3* PTT-36.9* INR(PT)-3.9*
[**2148-11-29**] 12:04AM Glucose-119* UreaN-98* Creat-5.3* Na-141 K-4.4
Cl-105 HCO3-16* AnGap-24*
[**2148-11-29**] 12:04AM ALT-91* AST-94* LD(LDH)-416* CK(CPK)-521*
AlkPhos-292* TotBili-0.6
[**2148-11-29**] 12:04AM CK-MB-13* MB Indx-2.5
[**2148-11-29**] 12:04AM cTropnT-0.16*
[**2148-11-29**] 12:04AM Albumin-3.7 Calcium-9.3 Phos-5.9* Mg-2.0
URINE:
[**2148-11-29**] 05:16AM Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2148-11-29**] 05:16AM Blood-LG Nitrite-NEG Protein-150 Glucose-NEG
Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2148-11-29**] 05:16AM RBC->50 WBC-[**2-22**] Bacteri-MOD Yeast-NONE Epi-0-2
[**2148-11-29**] 05:16AM Hours-RANDOM UreaN-430 Creat-114 Na-10
MICRO:
UCx - Staph species, ~1000/ml
UCx - Citrobacter
BCx - NGTD
Sputum Cx - MSSA, mixed flora
IMAGING:
[**11-29**] ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is borderline
dilated. There is severe regional left ventricular systolic
dysfunction with inferior and inferolateral akinesis. There is
moderate to severe hypokinesis of the remaining segments (LVEF
<20%). The estimated cardiac index is depressed (<2.0L/min/m2).
No masses or thrombi are seen in the left ventricle. The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload, as well as a conduction abnormality or RV apical
pacing. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is at least
mild pulmonary artery systolic hypertension, athough this may be
underestimated given severity of TR. There is no pericardial
effusion.
IMPRESSION: Dilated left ventricle with severe regional and
global systolic dysfunction, c/w prior extensive inferior
myocardial infarction and a superimposed process (or multivessel
CAD). Markedly dilated right ventricle with severe global
systolic dysfunction. Mild aortic regurgitation. Moderate mitral
and tricuspid regurgitation. Depressed cardiac index and at
least mild pulmonary hypertension.
[**11-29**] CXR:
ETT balloon hyperinflated. Low lung volumes, with possible mild
vascular congestion. Moderate cardiomegaly.
[**11-29**] CT head:
No acute intracranial abnormality. No intracranial hemorrhage
or loss of [**Doctor Last Name 352**]-white matter differentiation.
[**11-30**] CXR:
Development of pulmonary edema and left basilar atelectasis or
consolidation and possibly pleural fluid
[**12-2**] CT head:
1. No evidence of intracranial hemorrhage, edema, large masses,
mass effect, or large vascular territory infarction.
2. Mucosal thickening in bilateral maxillary sinuses and
sphenoid sinus.
3. Interval increase in opacification of the right middle ear
and mastoid air cells.
4. Lipoma is noted within the right occipital region, unchanged
from prior.
5. Coiling of NG tube within the nasopharynx.
[**12-5**] CXR:
Moderate cardiomegaly is stable. Left transvenous pacemaker
leads terminate in a standard position in the right atrium and
right ventricle. Left IJ catheter tip is in unchanged position
in the left brachiocephalic vein. Right central catheter tip is
in the right atrium. Small bilateral pleural effusions, larger
on the left side associated with atelectasis are unchanged.
Difference in density in the bases is consistent with difference
in redistribution of the pleural effusions. There is mild new
pulmonary edema. Right lower lobe opacity could be atelectasis,
but pneumonia cannot be excluded.
Brief Hospital Course:
Mr. [**Known lastname 52932**] is a 71 yo M with PMH significant for CHF (EF:
20-25%), CAD s/p CABG, CKD, a-fib on coumadin, s/p ICD, who
presented after VT arrest.
#. VT Arrest: The patient was brought in s/p shock x2 by EMS for
VT. The rhythm was unclear at first and thought to be VF, so the
patient was initiated on cooling protocol with Arctic Sun. He
was intubated and sedated for several days. CT head and EEG were
negative for intracranial events. The patient's ICD was
interrogated, and it was found that he had several episodes of
slow VT during the past few weeks that were below the threshold
for pacing by his ICD. His pacer was reset to detect VT as a
lower heart rate, but he continued to have episodes of VT
despite Amiodarone, Lidocaine, and several shocks by his ICD as
well as externally. The patient was made DNR/DNI by his family
on [**2148-12-5**]. He passed away at 10:55am on [**2148-12-6**] with his
family by his bedside.
# CORONARIES: The patient was continued on ASA 325mg and Lipitor
20mg. BB and ACEi were held [**1-22**] to hypotension.
# PUMP: Pt with severe CHF. He was dialyzed with CVVH x 2 days.
#. Resp Distress: Pt was intubated for airway protection in the
setting of VT arrest. Patient likely volume overloaded from CHF
and pulm edema on CXR. He also developed VAP and was treated
with Vanc/Zosyn/Cipro for 7 days.
Medications on Admission:
Imdur 30mg daily
Coumadin
Amiodarone 100mg daily
Mexiletine 150mg TID
ASA 81mg daily
Lisinopril 10mg daily
Colchicine 600mcg daily
Demadex 50mg daily
Lipitor 20mg daily
Coreg 25mg [**Hospital1 **]
Probenecid 500mg [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventricular Tachycardia
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 486, 5845, 4271, 5859, 2749, 4280, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5204
}
|
Medical Text: Admission Date: [**2172-11-21**] Discharge Date: [**2172-12-1**]
Date of Birth: [**2114-6-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
AVASTIN
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
empyema
Major Surgical or Invasive Procedure:
1. Right thoracotomy.
2. Decortication of lung.
3. Completion right middle lobectomy.
History of Present Illness:
58M, Polish speaking, s/p RUL lobectomy [**11-6**] for Stage III
NSCLC, discharged home on [**11-17**] (4d prior to this presentation)
on 2L home O2, returns to ED c/o 2 days of productive cough and
fevers as high as 102. Also notes decreased PO intake, nausea,
weakness, and fatigue. In the ED, the patient was afebrile, and
temp increased to 100.1. Hemodynamically stable, and maintaining
O2 sat of 99% on 3L. CXR showed a right-sided infiltrate. Labs
notable for WBC 20.9, Na 129, Cr 1.8 from baseline 1.4. The
patient was given vancomycin and Zosyn, and thoracic surgery was
consulted. Pt received RMLobectomy for RML collapse. The patient
was admitted to the ICU for emergent bronchoscopy. On arrival to
the ICU, he denies any pain or discomfort, but does note
subjective dyspnea.
Past Medical History:
PMH: CAD, MI, HTN, HLD, COPD (FEV1 69% [**2171**]), CVA, Stage III
NSCLC s/p neoadjuvant chemoradiation
PSH: hip repair, elbow fracture repair, [**2172-11-6**]:Right
thoracotomy, Right upper lobectomy, Buttressing of bronchial
closure with intercostal muscle flap. [**2172-11-8**], [**2172-11-9**],
[**2172-11-10**]: Bronchoscopy
Social History:
Polish speaking. Former 40 year pack history. No etoh, no drugs.
Currently unemployed but former factory worker in Poland.
Family History:
sister with CAD. No family history of cancers
Physical Exam:
PE on discharge:
Vitals: 99.3, 85, 110/60 18 95% RA
GEN: A+O x3, NAD
Cardiac: RRR, normal S1/S2, no MRG
Resp: CTA bilat with mild RLL crackles and some expiratory
weezing. Incisions c/d/i, minimal drainage from one chest tube
site.
Abd: soft, ND/NT, +bs
ext: no edema, palpable DP pulses bilaterally
Pertinent Results:
[**2172-11-21**] 03:12PM BLOOD WBC-20.9*# RBC-3.30* Hgb-9.8* Hct-30.0*
MCV-91 MCH-29.6 MCHC-32.7 RDW-14.1 Plt Ct-672*
[**2172-11-22**] 01:54AM BLOOD WBC-17.9* RBC-2.70* Hgb-7.8* Hct-24.5*
MCV-91 MCH-29.0 MCHC-32.0 RDW-14.1 Plt Ct-638*
[**2172-11-29**] 08:50AM BLOOD WBC-13.5* RBC-3.44* Hgb-10.1* Hct-30.9*
MCV-90 MCH-29.2 MCHC-32.6 RDW-14.3 Plt Ct-575*
[**2172-11-30**] 09:00AM BLOOD WBC-13.9* RBC-3.24* Hgb-9.4* Hct-29.0*
MCV-90 MCH-29.1 MCHC-32.5 RDW-14.9 Plt Ct-511*
[**2172-12-1**] 07:10AM BLOOD WBC-13.9* RBC-3.32* Hgb-9.8* Hct-30.0*
MCV-90 MCH-29.4 MCHC-32.6 RDW-15.0 Plt Ct-462*
[**2172-12-1**] 07:10AM BLOOD Plt Ct-462*
[**2172-12-1**] 07:10AM BLOOD PT-14.0* PTT-31.8 INR(PT)-1.2*
[**2172-11-23**] 01:22AM BLOOD Plt Ct-569*
[**2172-11-24**] 01:45AM BLOOD Plt Ct-536*
[**2172-11-21**] 03:12PM BLOOD Glucose-102* UreaN-31* Creat-1.8* Na-129*
K-5.4* Cl-92* HCO3-24 AnGap-18
[**2172-11-22**] 01:54AM BLOOD Glucose-100 UreaN-30* Creat-1.6* Na-132*
K-4.4 Cl-97 HCO3-22 AnGap-17
[**2172-11-30**] 09:00AM BLOOD Glucose-116* UreaN-14 Creat-1.2 Na-141
K-4.4 Cl-105 HCO3-28 AnGap-12
[**2172-12-1**] 07:10AM BLOOD Glucose-88 UreaN-13 Creat-1.2 Na-140
K-4.6 Cl-104 HCO3-26 AnGap-15
[**2172-11-29**] 01:00PM BLOOD ALT-34 AST-47* LD(LDH)-183 AlkPhos-168*
TotBili-0.2
[**2172-11-22**] 5:00 pm BRONCHIAL WASHINGS RIGHT BRONCHIAL
WASHING.
**FINAL REPORT [**2172-11-26**]**
GRAM STAIN (Final [**2172-11-22**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2172-11-26**]):
Commensal Respiratory Flora Absent.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Piperacillin/Tazobactam Sensitivity testing [**First Name8 (NamePattern2) **]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
PA ([**Numeric Identifier 76748**]).
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CXR [**11-21**]: Comparison is made to the prior chest radiograph
performed six hours earlier, as well as the chest CT. There has
been worsening of the area of consolidation with air-fluid
levels within the right upper lobe. This is consistent with
suspected empyema following right upper lobe resection. There
has been placement of endotracheal tube whose distal tip is 7 cm
above the carina, appropriately sited. The side port of
nasogastric tube is above the gastroesophageal junction and this
could be advanced 5-10 cm for optimal placement. The right lung
is relatively clear.
CT chest 11/12:1. Status post chest tube removal with increased
fluid accumulation in the right anterior and superior pleural
spaces in the post-surgical cavity. The presence of locules of
air is concerning for infection. A bronchopleural fistual cannot
excluded.
2. Persistent right middle lobe collapse with obliteration of
the right middle lobe bronchus. Evaluation for torsion is
limited but the configuration of the collapsed right middle lobe
appears similar to the prior examination where there was not
evidence for torsion.
3. Improved aeration of the right and left lower lobes.
4. Moderate-to-severe emphysema, stable.
CXR 11/13:2 right chest tubes in place. Suture line s/p right
upper lobectomy is seen, apical hydropneumothorax remains.SQ gas
is post operative. Left lung clear
CXR [**11-23**]: Unchanged appearance of the mild right apical
hydropneumothorax
CXR [**11-24**]: Moderate volume right apical pneumothorax is
unchanged. New opacification in the right mid lung could be
atelectasis, pneumonia, or hemorrhage. Only a small volume of
right pleural effusion, if any, remains. Two apical and one
basal pleural drain are still in place. Small left pleural
effusion and moderate left basal atelectasis are more
pronounced.
CXR [**11-26**]: 1. Unchanged right pneumothorax since removal of
basilar chest tube. No evidence of tension.
2. Slight worsening of left basilar atelectasis and small
effusion.
CXR [**2172-11-30**]
FINDINGS: In comparison with the study of [**11-28**], the right chest
tube has
been removed. There is progressive decrease in the pleural air
collection in the upper zone. The left lung remains essentially
clear.
On the lateral view, there is an air-fluid level anteriorly at
the
mid-to-lower zone, consistent with small loculated
hydropneumothorax.
Brief Hospital Course:
The patient was admitted to the thoracic surgery service on
[**2172-11-21**] and had 1. Right thoracotomy 2. Decortication of lung
and 3. Completion right middle lobectomy.
There were no complications during the procedure and the patient
tolerated the procedures well overall. Post op he was
transferred to the unit for close monitoring.
On [**11-6**] he underwent a successful RU lobectomy via thoracotomy
for for Stage III non-small-cell lung cancer. Then on [**11-21**] he
was admitted to ICU. Non-con chest CT was suspicious for
empyema. He was intubated for bronchoscopy, which was largely
unrevealing. He became hypotensive while on propofol, initially
responded to fluid bolus but did require phenylephrine. An
a-line was attempted without success. OG tube put out 450 mL
overnight, looked like old blood. The next day he went to OR for
redo thoracotomy, RML lobectomy and washout, received 2500 IVF
and 2 u PRBC. He was extubated post-op in OR. He had stridors
initially that resolved with albuterol but +crackles and a CXR
consistent with fluid overload- IVF were then stopped. Neo was
restarted to support MAPs. On POD 1, neo weaned off at 3 AM,
then turned back on at 5:30 AM to support BP, O2 sats were at
high 90s-100 on 50% face tent. His UOP decreasing in AM to <20
cc/hr. Albumin 250 x 1. And then he had adequate UOP. He was
taking adequate POs at this time and restarted home
atorvastatin. Neo was decreased to 0.2. His respiratory status
improved but still c/o significant pain with respiration and
movement. On POD 2 he was started on lopressor for tachycardia.
His foley dc'd on this day. One chest tube was removed and cxr
showed no pneumothorax. Tobramycin was added for double
pseudomonas coverage and his zosyn dose was increased. On POD 3
sputum cultures were growing out e.coli and the Tobramycin was
dc'd after discussion w/ ID given improvement on CXR and no
pseudomonas in cultures. Chest tube #3 was pulled on this day
and cxr showed no pneumothorax. Also, his creatinine bumped up
to 1.5 (concern for med toxicity). Shortly thereafter his cr
decreased and stayed at 1.2. That night he had episode of desat
to high 70's, improved to low 90's on 15L NRB. Repeat CXR shows
no acute changes and it was likely a mucous plug. On POD 4 his
pain regimen was adjusted with good results and he was placed on
PO meds only- his PCA was d/c'd. His antibiotics were tailored
and he was now on cetriaxone only. His POD 5 cxr was greatly
improved, pain control better, and he was transferred to the
floor. Thereafter he continued to improve each day. On POD 7,
his final chest tube was removed and cxr showed no pneumothorax.
He was gradually weaned off most oxygen and only required 1-2 L
when ambulating. Pt was originally home on oxygen before
preseting to the hospital.
Neuro: Post-operatively, the patient received Morphine IV/PCA
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications-
ms contin and oxycodone
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. Occasional episodes of
tachycardia were well treated with lopressor. BP needed to be
maintained occasionally as described above.
Pulmonary: The patient was eventually stable from a pulmonary
standpoint; vital signs were routinely monitored. Occasional
desaturations needed to be treated with a face mask and/or nasal
cannula as described above.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on POD#2. Intake
and output were closely monitored. His appetite decreased during
his hospitalization and was stimulated with Megestrol Acetate.
ID: Post-operatively, the patient was started on IV vancomycin,
zosyn, tobramycin and eventually switched to only ceftriaxone.
He was discharged on 2 weeks of bactrim. The patient's
temperature was closely watched for signs of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. Given his previous history of stroke, neurology was
consulted and pt was put back on his home comadin dose prior to
discharge. He was being bridged with lovenox and was set up with
his PCP for close follow up.
At the time of discharge on POD#9, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. He continued to have decreased saturation while
ambulating and was thus sent home on the same oxygen therapy
that he came in with. PT cleared him to go home with out VNA and
just suggested some PT follow up at home.
Medications on Admission:
Lipitor 80 mg daily, Advair Diskus 500 mcg-50 mcg [**Hospital1 **], Spiriva
18
mcg daily, Atenolol 100 mg daily, ProAir HFA 90 mcg QID prn,
Nitroglycerin 0.4 mg prn, amlodipine 10 mg daily
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-12**] Sprays Nasal
QID (4 times a day) as needed for dryness.
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
13. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg/ 0.7gm
Subcutaneous twice a day for 1 weeks.
Disp:*14 syringes* Refills:*0*
14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**6-17**]
hours.
Disp:*30 Tablet(s)* Refills:*2*
15. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1)
tablet PO DAILY (Daily).
Disp:*30 tablet* Refills:*0*
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
Please check INR regularly and have your PCP adjust Warfarin
(coumadin) dosage accordingly.
INR checks every 2-3 days for first 1-2 weeks. Per PCP.
18. quetiapine 25 mg Tablet Sig: 0.5 (Half) Tablet PO every six
(6) hours as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
19. Coumadin 6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Home Oxygen
Oxygen Pulse Dose for Portability: Continuous Oxygen 2 liters
by nasal cannula.
Dx: 1. SaO2 less than 88% room air.; 2. COPD; 3. S/p Right
Middle and Lower Lobectomy.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Non-expanded right middle lobe
Empyema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were re-admitted to the Thoracic surgery service on [**2172-11-21**]
for a chronically collapsed right middle lobe. Please Call Dr. [**Name (NI) 76749**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough (it is normal to cough up
blood tinge sputum for a few days) or chest pain
-Incision develops drainage
-Chest tube site: remove outer dressing and cover site with a
bandaid until healed.
-Should chest tube site begin to drain, cover with a clean dry
dressing and changes as needed to keep site clean and dry
Pain
-Acetaminophen 650 every 6 hours as needed for pain
-Oxycodone 5-10 mg every 4 hours as needed for pain
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed. Please take the prescribed
analgesic medications as needed. You may not drive or heavy
machinery while taking narcotic analgesic medications. You may
also take acetaminophen (Tylenol) as directed, but do not exceed
4000 mg in one day. Please get plenty of rest, continue to walk
several times per day, and drink adequate amounts of fluids.
Avoid strenuous physical activity and refrain from heavy lifting
greater than 20 lbs., until you follow-up with your surgeon, who
will instruct you further regarding activity restrictions.
Please also follow-up with your primary care physician.
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision site
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
-You did well on room air while at rest but required oxygen
while ambulating. Please use oxygen at home with ambulation or
as needed for shortness of breath.
Please take 1.5 pills of coumadin today after discharge for a
total of 9mg per your PCP's office. Then resume your normal
schedule of 6mg daily and adjust per their recommendations.
They will contact you this week about necessary changes.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2172-12-15**] 9:00
Please arrive 30 minutes early for a chest x-ray before your
visit.
Completed by:[**2172-12-2**]
ICD9 Codes: 496, 2724, 4019, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5205
}
|
Medical Text: Admission Date: [**2107-7-20**] Discharge Date: [**2107-7-28**]
Date of Birth: [**2022-2-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall, vertigo
Major Surgical or Invasive Procedure:
[**2107-7-22**] Right suboccipital crani for mass
History of Present Illness:
Ms [**Known lastname **] is 85 y/o female this morning in her apartment after
returning to the bathroom. She states she became suddenly dizzy
and fell. She was able to bring herself to her couch and call
her daughter who called EMS. She was transported to [**Hospital3 80253**] with a main complaint of left hip pain. As
part of her dizziness work up she was found to have right
cerebellar mass on CT. An initial hip xray did not see a
fracture the patient is exquistely tender so a further work up
is being completed at this writing of her hip. Ms [**Known lastname **] reports
3 months of dizziness with intermittent falls. She was recently
referred to a neurologist but has not been seen as of yet. She
states she has occasional headache but not more than usual. She
denies any visual problems.
Past Medical History:
Questionable Ear tumor (unable to provide type states no
treatment was done) Glucoma, Diabetes Type 2, COPD,
Social History:
Lives alone, has daughter who lives close by. Former smoker,
stopped 18 years ago with a 40+ year history. No alcohol used.
Family History:
Non-contributory
Physical Exam:
Exam on admission:
O: T: BP:140/88 HR:78 R16 O2Sats: 94%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: surgical EOMs full
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date (knew month and
year not day).
Recall: [**2-6**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils surgical unequal
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-8**] however unable to comepletely
test left leg do to hip pain. No pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger though has difficulty
following 2 step commands.
EXAM ON DISCHARGE:
Slightly confused, oriented to self and hospital and can recalll
year with multiple choice.
Patient able to follow commands and moves all extremities with
good strength.
Occipital incision is closed with Staples and is CDI
Pertinent Results:
LABS ON ADMISSION:
[**2107-7-20**] 12:13PM BLOOD WBC-9.9 RBC-4.17* Hgb-11.6* Hct-35.0*
MCV-84 MCH-27.8 MCHC-33.1 RDW-14.9 Plt Ct-203
[**2107-7-20**] 12:13PM BLOOD Neuts-80.8* Lymphs-14.4* Monos-4.0
Eos-0.5 Baso-0.3
[**2107-7-20**] 12:13PM BLOOD PT-12.0 PTT-24.2 INR(PT)-1.0
[**2107-7-20**] 12:13PM BLOOD Glucose-128* UreaN-24* Creat-1.0 Na-143
K-3.8 Cl-109* HCO3-25 AnGap-13
[**2107-7-20**] 12:26PM BLOOD Glucose-121* Lactate-1.0 K-3.8
[**2107-7-20**] 12:13PM BLOOD cTropnT-<0.01
LABS ON DISCHARGE:
------------------
IMAGING:
------------------
CT HEAD [**7-20**]:
1. Right cerebellar vasogenic edema concerning for underlying
cerebellar
mass. 1 cm right cerebellar rounded focus is concerning for
mass/satelitte
lesion. An additional mass underlying the region of edema
remains a
possibility. MRI recommended for further evaluation.
2. Some mass effect on the fourth ventricle which remains
patent. Prominence
of the lateral ventricles and third ventricle is thought to be
due to
generalized atrophy however developing hydrocephalus cannot be
entirely
excluded.
3. Opacification of the left mastoid air cells with minimal
opacification of the right mastoids air cells. Correlate
clinical for mastoiditis or other regional inflammatory process.
MRI HEAD [**7-21**]:
1. 18 x 16 mm single right cerebellar mass, with neighboring
edema and no
significant local mass effect. No other masses are detected.
2. Diffuse cortical atrophy and changes secondary to
microvascular ischemic disease.
CT TORSO [**7-21**]:
1. Right peri-hilar mass, measuring 1.8 x 1.9 x 2.1 cm. In the
setting of
cerebellar lesion, this is concerning for primary lung neoplasm.
2. Emphysema.
3. Cholelithiasis.
4. Diverticulosis.
5. Aortic atherosclerosis.
6. Fat-containing umbilical hernia.
7. Pagetoid changes in the left hip.
8. Known non-displaced left superior and inferior pubic rami
fractures,
better characterized on study performed one day prior with
dedicated bone
windows through the pelvis.
CT HEAD [**7-22**]
1. Status post right suboccipital craniotomy and resection of
mass with
expected post-surgical pneumocephalus. Tiny amount of linear
hyperdensity
along the craniotomy site, likely post-surgical blood products.
No large
intracranial hemorrhage.
2. Residual vasogenic edema in the right cerebellar hemisphere
with unchanged mass effect on the fourth ventricle. No change in
the size of the lateral and third ventricles compared to the
prior study.
MRI HEAD [**7-23**]
Status post resection of right cerebellar lesion with mild
residual enhancement at the anterior margin. Blood products and
expected
post-surgical changes. No significant change in mass effect or
new infarct
seen. No hydrocephalus.
Brief Hospital Course:
Patient is a 85F admitted to the neurosurgery service following
transfer from OSH in the setting of new cerebellar mass. At the
time of presentation, her physical examination was such that
admission to "floor" status was appropriate with q4h neurologic
examination. She was also administered steroids to treat
vasogenic edema. MRI of the head was obtained and showed 18 x 16
mm right cerebellar mass. CT of the torso showed 1.8 x 1.9 x 2.1
cm right perihilar mass, abutting the bronchus intermedius. We
contact[**Name (NI) **] hematology/oncology ([**Name6 (MD) **] [**Name8 (MD) **], MD) they
would not see the patient without the result from pathology,
they recommended calling the thoracic clinic on discharge once
final pathology is back. On [**7-22**] she underwent a suboccipital
craniotomy for without complication, she was monitored for 24
hour in the ICU and transferred to the floor. Her diet was
advanced, she was voiding without difficulty. She remained
pleasently confused/disorientated but was intact otherwise. PT
recommended rehab. Her steroid dosing will be weaned to 2mg [**Hospital1 **]
and her L hip fracture requires no surgical intervention, she
can TDWB. She was accepted to rehab on the morning of [**7-28**] and
was discharged on teh same day
Medications on Admission:
Benicar- Unknown Strength,Crestor 20mg QD, Norvasc 5mg [**Last Name (LF) 244**], [**First Name3 (LF) **]
81mg QD,Metformin ER 500 mmg 2 QD,Januvia 100mg QD,Glimepiride 4
mg QD, Dorzolamide 2 % 1 drop [**Hospital1 **] OU
Discharge Medications:
1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for asthma.
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
5000units Injection TID (3 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no BM>48hr.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain,fever.
15. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO Daily ().
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
18. Ondansetron 4 mg IV Q8H:PRN N/V
19. Morphine Sulfate 1-2 mg IV Q4H:PRN Pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 1110**]
Discharge Diagnosis:
Cerebellar Brain Mass **Preliminary pathology c/w non-small cell
Pubic rami fracture
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
*****[**Month (only) **] RESTART ASPIRIN IN ONE MONTH ([**2107-8-26**])****
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You were on Aspirin, prior to your admission, you may safely
resume taking this in approximatley one month's time. This will
be discussed at your follow up appointment.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
- You have staples closing your surgical wound, you will have to
have these removed in our office in [**8-13**] days from the date of
your surgery, please call to make an appointment to have your
wound checked and staples removed. The number to call
is:[**Telephone/Fax (1) 84989**]
??????You have will recieve a call to be seen with an appointment in
Brain tumor clinic. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their
phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change
your appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your hospitalization.
**HEMATOLOGY ONCOLOGY FOLLOW UP:
-Please call ([**2107**] to schedule a follow up appointment
within 1-2 weeks for the primary managment of your oncologic
process. Directions to the office will be given to you at the
time of your call.
Completed by:[**2107-7-28**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5206
}
|
Medical Text: Admission Date: [**2125-9-22**] Discharge Date: [**2125-9-25**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
abdominal pain, epigastric discomfort
Major Surgical or Invasive Procedure:
none
History of Present Illness:
20 F with history of type 1 diabetes mellitus with multiple
admissions for DKA in last 2 months presents with similar
complaints, mainly epigastric discomfort. Patient denies any
recent illness, any dietary indiscretion, or medical
non-compliance. Reports taking her insulin regularly as
prescribed.
Past Medical History:
1. Diabetes Type I diagnosed in [**2120**] after her first pregnancy.
Most recent Hgb A1C 10.4 % ([**7-/2125**])
2. Hyperlipidemia
3. S/P MVA [**5-4**] - lower back pain since then. + back muscle
spasm treated with tylenol.
4. Goiter
5. Depression
6. DKA admissions
7. G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p
C-section in [**2122**], not menstruating secondary to being on
Depo-Provera shots
Social History:
Completed high school in [**2122**]. She has a two-year-old son with
her current partner. [**Name (NI) 1139**]: [**12-1**] ppd x 3 years. No EtOH. No
marijuana, cocaine, heroin or other recreational drugs.
Unemployed. Sexually active. 4 life partners. Currently
monogamous over 1 year.
Family History:
GM with Type I diabetes. Otherwise non-contributory. Relatives
with "acid in blood" not related to diabetes.
Physical Exam:
PE on admission to the floor:
VS: 98.5 90/54 103 18 97%RA
Gen: well appearing, NAD
HEENT: MMM, EOMI, PERRL
CV: tachycardic but regular rhythm, nl S1/S2, no murmurs
appreciated
Pulm: CTAB
Abd: soft, mildly tender in RUQ to deep palpation, otherwise
nontender; NABS, no masses
Ext: no edema, clubbing, or cyanosis
Groin: small pea-sized lump in R groin consistent with small
abscess versus blocked gland; no visible drainage or discharge;
minimal surrounding erythema
Pertinent Results:
[**2125-9-22**] 12:44PM D-DIMER-516*
[**2125-9-22**] 12:44PM PT-12.9 PTT-18.9* INR(PT)-1.1
[**2125-9-22**] 12:44PM PLT COUNT-215
[**2125-9-22**] 12:44PM NEUTS-85* BANDS-0 LYMPHS-12* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2125-9-22**] 12:44PM WBC-11.3* RBC-5.02 HGB-14.8 HCT-48.7*# MCV-97
MCH-29.5 MCHC-30.5* RDW-13.2
[**2125-9-22**] 12:44PM ACETONE-LARGE
[**2125-9-22**] 12:44PM ALBUMIN-5.7* CALCIUM-11.3* PHOSPHATE-6.1*#
MAGNESIUM-2.3
[**2125-9-22**] 12:44PM LIPASE-28
[**2125-9-22**] 12:44PM ALT(SGPT)-17 AST(SGOT)-22 ALK PHOS-133*
AMYLASE-41 TOT BILI-0.3
[**2125-9-22**] 12:44PM GLUCOSE-691* UREA N-23* CREAT-1.2* SODIUM-135
POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-7* ANION GAP-38*
[**2125-9-22**] 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2125-9-22**] 01:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2125-9-22**] 07:42PM UREA N-16 CREAT-1.0 SODIUM-136 POTASSIUM-4.7
CHLORIDE-106 TOTAL CO2-9* ANION GAP-26*
[**2125-9-22**] 11:54PM UREA N-14 CREAT-0.8 SODIUM-134 POTASSIUM-4.3
CHLORIDE-105 TOTAL CO2-9* ANION GAP-24*
[**2125-9-23**] 04:10AM BLOOD Glucose-211* UreaN-11 Creat-0.8 Na-132*
K-3.7 Cl-106 HCO3-15* AnGap-15
[**2125-9-23**] 12:01PM BLOOD Glucose-257* UreaN-10 Creat-0.7 Na-130*
K-4.3 Cl-105 HCO3-15* AnGap-14
[**2125-9-24**] 07:00PM BLOOD Glucose-237* UreaN-8 Creat-0.7 Na-137
K-4.1 Cl-106 HCO3-21* AnGap-14
[**2125-9-25**] 07:45AM BLOOD Glucose-232* UreaN-7 Creat-0.6 Na-135
K-3.9 Cl-104 HCO3-24 AnGap-11
Brief Hospital Course:
1. DKA - Glucose initially 691 with an anion gap of 38. Pt was
admitted to the [**Hospital Unit Name 153**] and placed on an insulin drip and IVF and
treated appropriately with close monitoring of electrolytes and
glucose. Pt was transferred to the floor on [**9-24**], where she
was put on a sliding scale insulin with fingersticks checked
every 2 hours. An attending from [**Last Name (un) **] followed pt as well.
Pt's glucose was still somewhat high (in the low 200s) when she
left against medical advice. She was given appointments to
follow up at [**Last Name (un) **] with both her endocrinologist as well as a
nutritionist, as she needs close followup and education to
prevent another episode of her recurrent DKA. On the day of her
discharge, her anion gap had closed to 11.
2. acute renal failure - Cr was 1.2 on admission, which was
higher than her baseline of 0.6, and was likely due to prerenal
azotemia secondary to dehydration due to diabetic ketoacidosis.
Pt treated with aggressive IVF rehydration. Cr was 0.6 on
discharge.
3. groin lesion - a small abscess was noted on her right groin,
which was exquisitely tender and thought to be at the site of
her initial femoral line. This improved symptomatically with
hot packs and did not appear to be a significant source of
infection. Blood cultures were negative.
4. bacterial vaginosis - pt had Gardnerella growing in her
urine from a previous admission but had not been treated. She
was placed on a seven day course of Flagyl.
5. lower leg cellulitis - pt was placed initially on Ancef and
was sent home with a seven day course of po Keflex.
Medications on Admission:
glargine 28 units Q am
carb counting insulin sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **]
aspirin 325 mg po qd
lipitor 10 mg po qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD ().
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
().
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*2 Capsule(s)* Refills:*0*
4. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32)
units Subcutaneous Q AM: this is your lantus.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD ().
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
7. insulin
Continue to do carb counting as you did at home, dividing by 10
for your Humalog insulin dose.
In addition, take your Lantus as you have at home, at breakfast,
but at the higher dose of 32 units (not 28 units)
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Hypercholesterolemia
Discharge Condition:
Fair, patient still with elevated blood sugars but refusing to
stay in hospital longer.
Discharge Instructions:
morning lantus.
Continue to apply heat to right groin where area irritated.
Continue your antibiotics for the full 7 days even if the area
looks healed.
Followup Instructions:
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 17377**] Corner Health
center.
You have an appointment for with Dr. [**Last Name (STitle) 7537**] from [**Last Name (STitle) 17377**] Corner
at 2:15 pm on Thursday [**9-27**]. You can change this appointment
to your regular PCP if you call [**Month/Year (2) 17377**].
You also have the following [**Hospital **] Clinic appointments:
Nutrition: Thursday [**9-27**] at 10:30 am
Dr. [**Last Name (STitle) 3617**], your endocrinologist at Friday [**9-28**] at 10:30 am
ICD9 Codes: 2765, 5849, 2724, 3051, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5207
}
|
Medical Text: Admission Date: [**2127-10-30**] Discharge Date: [**2127-11-10**]
Date of Birth: [**2046-10-11**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
contained rupture of aortic
aneurysm.
Major Surgical or Invasive Procedure:
[**2127-10-30**] Repair of contained ruptured AAA
History of Present Illness:
The patient is an elderly male who presented
several weeks ago with a contained rupture of aortic
aneurysm. Due to his age and comorbidities we attempted an
endovascular repair. This was successful in a sense that it
stopped the rupture, but he had a persistent type 1 endoleak.
He decided that he wanted to go home for a week or two and
think about it and then return for essentially elective
removal of the graft and repair of his aortic aneurysm. This
was going to be difficult case because the Zenith graft has
suprarenal fixation. In addition to seal the graft, there is
a Palmaz stent that bridges across the mesenteric vessels and
there is an additional Zenith cuff. In addition, he only has
a functioning left kidney.
Past Medical History:
PMH: CABG in [**2-/2117**] with an LIMA to LAD and vein graft to the
first diagonal, obtuse marginal, and right coronary arteries
Carotid stenosis s/p bilateral carotid endarterectomies
COPD
hyperlipidemia
hypertension
mild congestive heart failure
anxiety
rotator cuff tear
sleep apnea
Social History:
FH: non-contributory
Family History:
SH: No ETOH or smoking. He is a remote smoker.
Physical Exam:
VS: T 98.9 P 71 BP 124/70 RR 18 O2 sat 96%
AAOX3, NAD
HENT: wnl
Heart: RRR, no murmur
Lungs: CTA, B/L
Abd: Incision with staple intact, minimal drainage, soft,
non-tender
Ext: warm and dry,
Pulses: Fem DP PT
Rt 2+ 1+ mono
Lt 2+ 1+ tri
Pertinent Results:
[**2127-11-7**] 03:52AM BLOOD WBC-8.7 RBC-3.14* Hgb-9.9* Hct-28.2*
MCV-90 MCH-31.5 MCHC-35.1* RDW-14.7 Plt Ct-276
[**2127-11-7**] 03:52AM BLOOD Plt Ct-276
[**2127-11-9**] 06:25AM BLOOD Glucose-113* UreaN-15 Creat-1.3* Na-141
K-3.9 Cl-106 HCO3-27 AnGap-12
PORTABLE CHEST X-RAY [**2127-11-6**]:
FINDINGS: Cardiomediastinal contours appear unchanged. New
poorly defined
opacities have developed in the mid and lower lungs bilaterally
with a
somewhat nodular quality, possibly representing airways disease
from
aspiration or infection. A dependent distribution of pulmonary
edema in the setting of underlying COPD is an additional
consideration. Improving aeration at left base is likely a
combination of improving atelectasis and effusion. Baseline
pleural thickening persists at right lung base with possible
superimposed small pleural effusion. Asymmetric biapical
thickening is unchanged dating back to [**2123-5-22**] and attributed
to scarring.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2127-11-6**] 2:51 PM
CT Torso without contrast [**2127-11-10**] - no official read
Brief Hospital Course:
[**2127-10-30**] Patient was admitted via holding room and taken to OR
for scheduled elective repair of contained ruptured AAA. Patient
recovered in the CV ICU intubated, with PA catheter in place,
patient was sedated and on pressors and insulin drip.
[**2127-10-31**] Remains in the ICU with pressors, sedated, and
intubated.
[**2127-11-1**] Remains in the ICU, weaned from vent and extubated.
Borderline urine output strted on low dose Lasix.
[**2127-11-2**] Remains in ICU, PA line pulled back to CVL. Continue to
diurese gently. Started on beta blocker and Amiodarone for
frequent irregular HR and atrial ectopies. Physical therapy
consult for out of bed to chair.
[**2127-11-3**] Remains in ICU, good urine output, HR controlled with
Amiodarone drip and IV Lopressor.
[**2127-11-4**] Off all drips, remains NPO- distended abdomen, HR and
respiratory stable. Transferred to [**Hospital Ward Name 121**] 5 VICU for further
observation. Hct drifting down, transfused with 2 unts of PRBCs,
continue to diurese gently.
[**2127-11-5**] Afebrile, VSS, no acute events. Started po's.
[**2127-11-6**] No acute events, Lasix prn. Monitor creatinine peaked
at 1.7 ([**11-1**]). Seen by Social work for coping support.
[**Date range (1) 42332**] No acute events, now on ADAT, continue to work with
physical therapy.
[**11-10**]- Rehab screen for dispo. CT- torso without contrast-report
not available wet red by Dr. [**MD Number(4) 42333**] concerning. Discharged
to rehab in stable condition.
Medications on Admission:
Aspirin 325 mg po qd
Zocor 80 mg po qd
Plavix 75 mg po qd
Metoprolol 50 mg po TID
Albuterol inhaler qid
Fluticasone-Salmeterol 250-50 [**Hospital1 **]
Tiotropium bromide 18mcg qd
Vicodin
Amlodipine 10 mg po qd
Simethicone
Senna
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for hypertension.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]-[**Location (un) **]
Discharge Diagnosis:
AAA s/p open repair
COPD
High Cholesterol
HTN
History of mild CHF
anxiety
sleep apnea
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-29**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2127-11-25**] 1:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2128-2-2**] 10:40
Completed by:[**2127-11-10**]
ICD9 Codes: 4280, 496, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5208
}
|
Medical Text: Admission Date: [**2135-6-20**] Discharge Date: [**2135-6-25**]
Date of Birth: [**2064-5-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
HPI: Pt is a 71M admitted overnight to the medicine service for
B/L LE pain with new DVT in the L calf. This morning R
foot/toes
noted to be cool, and a vascular surgery consult was obtained.
Patient reports several days of B/L LE pain which started in the
L leg and has moved to the R leg. Pain is now worse in the R
leg.
However, at the time of interview, patient says pain is minimal.
Patient denied weakness, numbness. No ulcers. He denies trauma.
Of note, patient was started on heparin gtt for the DVT. In the
ED he was also noted to be hyperkalemic with a K of 5.7. EKG
without peaked T waves. Patient is a poor historian; most of
the
history obtained from the medical record.
Major Surgical or Invasive Procedure:
Diagnostic abdominal aortogram, pelvic
arteriogram, and right lower extremity runoff; percutaneous
balloon angioplasty of the superficial femoral artery,
popliteal, and posterior tibialis; stenting of the posterior
tibialis, below-the-knee and above-the-knee popliteal, and
superficial femoral artery as well as the tibioperoneal
trunk; primary stenting of the right external iliac artery
History of Present Illness:
HPI: Pt is a 71M admitted overnight to the medicine service for
B/L LE pain with new DVT in the L calf. This morning R
foot/toes
noted to be cool, and a vascular surgery consult was obtained.
Patient reports several days of B/L LE pain which started in the
L leg and has moved to the R leg. Pain is now worse in the R
leg.
However, at the time of interview, patient says pain is minimal.
Patient denied weakness, numbness. No ulcers. He denies trauma.
Of note, patient was started on heparin gtt for the DVT. In the
ED he was also noted to be hyperkalemic with a K of 5.7. EKG
without peaked T waves. Patient is a poor historian; most of
the
history obtained from the medical record.
Past Medical History:
Past Medical History:
EtOH cirrhosis with diuretic resistant ascites(US guided para on
[**2135-5-19**] removing 8.5L and on [**2135-5-6**] removing 4 L): followed by
Dr [**Last Name (STitle) **]
DM
CKD
Laryngeal cancer status post XRT
Anemia
Colonic adenoma
GERD
Social History:
lives with daughter, smoked since age 12. Stopped drinking when
got diagnosis of cirrhosis years ago - now drinks only "milk,
water, and tea."
Family History:
Non-contributory
Physical Exam:
T 99.6 P 60 BP 111/95 RR 16 97%2L
The patient is in moderate pain ([**3-8**]) controlled with
medication. He is no acture distress, alert and orientated.
CVS regular rhythm and rate
Resp clear to auscultation bilat
Abdomen distended
lower legs DP/PT dopplerable bilat
right calf less tense.
Pertinent Results:
[**2135-6-24**] 08:45AM BLOOD WBC-6.5 RBC-3.22* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.5 MCHC-32.2 RDW-16.2* Plt Ct-347
[**2135-6-20**] 03:40PM BLOOD Neuts-72.1* Lymphs-18.6 Monos-5.0 Eos-3.0
Baso-1.3
[**2135-6-24**] 08:45AM BLOOD Plt Ct-347
[**2135-6-24**] 08:45AM BLOOD PT-11.4 PTT-52.5* INR(PT)-1.0
[**2135-6-24**] 08:45AM BLOOD Glucose-160* UreaN-16 Creat-1.6* Na-139
K-4.5 Cl-102 HCO3-30 AnGap-12
[**2135-6-24**] 08:45AM BLOOD CK(CPK)-4001*
Brief Hospital Course:
Pt is a 71M admitted [**2135-6-20**] overnight to the medicine service
for
B/L LE pain with new DVT in the L calf. This morning R
foot/toes
noted to be cool, and a vascular surgery consult was obtained.
Patient reports several days of B/L LE pain which started in the
L leg and has moved to the R leg. Pain is now worse in the R
leg.
However, at the time of interview, patient says pain is minimal.
Patient denied weakness, numbness. No ulcers. He denies trauma.
Of note, patient was started on heparin gtt for the DVT. In the
ED he was also noted to be hyperkalemic with a K of 5.7. EKG
without peaked T waves. Patient is a poor historian; most of
the
history obtained from the medical record.
ON [**6-21**] the patient underwent Right lower extremity angiogram
angioplasty and multiple stents placed. The patient tolerated
the procedure well and was transferred to the VICU for
monitoring.
The patient remained stable throughout.
On [**6-24**] the hepatology team performed a ascitic tap of his
abdomen. The patient tolerated the procedure well and was
discharged [**6-25**].
Medications on Admission:
RISS, NPH-Regular (70-30) - 12 units qam, 20 units qpm,
lactulose 30''', Folic Acid 1, pantoprazole 40
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
6. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge
Sig: Twelve (12) units Subcutaneous twice a day: 12 units qam
20 units qpm.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic right lower
extremity limb-threatening ischemia
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-1**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**1-30**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Patient should contact the office of Dr. [**Last Name (STitle) **] on Monday
for a follow up appointment.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2135-7-11**] 1:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2135-7-25**] 2:00
ICD9 Codes: 4280, 5859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5209
}
|
Medical Text: Admission Date: [**2104-2-28**] Discharge Date: [**2104-3-7**]
Service: MEDICINE
Allergies:
Xanax / Ativan
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Tachycardia, feeling unwell
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] M with pacemaker admitted for rapid afib. In [**2102**], he had a
dual chamber St. [**Male First Name (un) 1525**] pacemaker placed for symptomatic
bradycardia and chronitropic incompetence and has been doing
fairly well. He walks his dog 1.5 miles daily. This morning, he
woke up feeling lousy and tried to walk the dog but could only
make it down the block and had to turn back. Did not have enough
energy and felt some lightheadedness. No chest pain or shortness
of breath. He called [**Hospital **] clinic who interogatted the pacer over
the phone and found him tachycardic. He was told to go to the
ED.
Otherwise he feels well. On review of systems, denies fevers,
chills, nausea, vomit, abd pain, diarrhea. On cardiac review of
systems, denies orthopnea, PND or increase in peripheral edema.
In the ED, vitals were: 98.6, 128, 144/85, 24, 100%RA. Because
of his fast heart rates, he was given dilt 10 IV x 3 and dilt 30
mg PO followed by 60 mg PO.
Past Medical History:
# Chronic renal failure
- Followed by Dr. [**Last Name (STitle) **]. On Epogen.
- Baseline creatinine is 2.0 - 2.4.
# Claudication
- Walks 1.5 miles daily but has to stop and rest.
# Aortic stenosis
- Mean gradient 60 on last ECHO [**9-6**]
- Declined AVR or valvuloplasty
# B12 deficiency
# HTN
# GERD
# PVD
# H/O stomach cancer
- s/p total gastrectomy and Roux-en-Y in late [**2085**]
# Left renal artery stenosis
- s/p stenting [**2102-3-8**]
# Type 2 DM
# Hyperkalemia in the past attributed to dietary supplements
# Paroxysmal atrial fib
- reported after gastrectomy but no h/o recurrence
# COPD
# TIA
# Abdominal aortic aneurysm repair
# Right ICA 50% occluded, [**Doctor First Name 3098**] 90% occluded
Social History:
Lives at home with his wife. [**Name (NI) **] [**Name (NI) **] [**Known lastname 3937**] is a ED physician
in [**Name9 (PRE) 1727**]. Phone numbers are [**Telephone/Fax (1) 3938**] and [**Telephone/Fax (1) 3939**].
Patient is a retired jazz musician--- played the clarinet and
sax. No ETOH or drugs. Smoked [**3-4**] PPD for 30 years but quit
approximately 20 years ago.
Family History:
No fam hx or early CAD.
Physical Exam:
VITALS: 97.1, 143/62, 76, 20, 100%2LNC
GEN: A+Ox3, NAD, pleasant
HEENT: PERRL, EOMI, OP clear, MMM
NECK: No JVD
CV: Soft heart sounds, irregular and tachy, iii/vi SEM, no rubs
or gallops
PULM: Distant breath sounds, no wheezes, rhonchi rales.
ABD: Soft, ND, NT, +BS, murmur radiates to abdomen
EXT: Trace ankle edema
Pertinent Results:
CXR ([**2104-2-28**]): Left-sided pacer is again seen with leads
overlying the right atrium and ventricle. Cardiac and
mediastinal contours appear stable. Pulmonary vascularity
appears within normal limits. There is persistent eventration of
the right hemidiaphragm and mild hyperexpansion, not
significantly changed in appearance from prior. There are no
focal consolidations or large pleural effusions.
CT Head ([**2104-2-29**]):
FINDINGS: There is no intracranial hemorrhage, mass effect, or
shift of normally midline structures. The ventricles, cisterns,
and sulci are enlarged secondary to involutional change,
unchanged from [**2097**]. Periventricular white matter hypodensities
are the sequelae of chronic small vessel infarction. [**Doctor Last Name **]-white
matter differentiation, however, is preserved. The osseous
structures are unremarkable. The visualized paranasal sinuses
and mastoid air cells are clear.
CXR ([**2104-2-29**]): A new interstitial edema has developed in both
lungs more predominantly at the bases. The heart is enlarged.
Small subtle left pleural effusion might be present. A
left-sided pacer is again noted with leads overlying the right
atrium and right ventricle. Persistent eventration the right
hemidiaphragm.
ECHO:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. There is mild global left ventricular
hypokinesis (LVEF = 40-50 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (area <0.8cm2). Mild to moderate ([**1-2**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2102-9-25**], there is now moderate concentric left
ventricular hypertrophy with a small cavity, reduced ejection
fraction, and evidence of severe diastolic dysfunction. The
cardiac rhythm is now atrial fibrillation.
Renal US:
IMPRESSION:
1. Cortical atrophy of the right kidney and absence of diastolic
flow in the segmental arteries indicative of an intrinsic
vascular abnormality. The limited Doppler study on the right
does not allow for evaluation of renal artery stenosis.
2. Multiple simple bilateral renal cysts, unchanged from [**3-7**], [**2102**].
Brief Hospital Course:
[**Age over 90 **] year old male with a St. [**Male First Name (un) 923**] pacemaker placed for
symptomatic bradycardia in [**2102**] who presented with new onset
afib with RVR. The patient was initially anticoagulated with
heparin for new onset atrial fibrillation with RVR with
initiation of coumadin. Two of his home antihypertensives were
held (Amlodipine and Losartan) to leave room to uptitrate
beta-blockade for improved rate control. He was seen by EP who
decided to attempt chemical cardioversion which was successful.
On the day of cardioversion the patient became acutely
hypertensive to 270 systolic. He also had difficulty breathing
in this setting. He was treated with 30 of IV hydralazine, 25
mg of IV Lopressor, 25 mg po captopril and 20 IV lasix. His
blood pressure was fairly refractory to these interventions and
the patient was transferred to the cardiac intensive care unit
for closer monitoring. He also received 2 mg IV Ativan for
agitation. Upon arrival in the unit, the patient became
somewhat unresponsive with minimally reactive pupils. Given his
hypertensive emergency, there was suspicion for stroke. The
patient had a negative head CT scan. He was unable to have MRI
given his pacer. His mental status improved to baseline
overnight. According to his wife, he has had similar episodes
in the past with benzodiazapines and it was thought his mental
status change was most likely secondary to a medication effect.
The patient returned to the floor with difficult to control
blood pressure. He was treated aggressively with
anti-hypertensives. The patient experienced dizziness with both
blood pressure highs and when his blood pressure was too low.
Per his PCP, [**Name10 (NameIs) **] patient generally has a blood pressure between
140-160. Per his wife, the patient has had transient elevations
in his blood pressure over 200 in the past. From prior notes,
it appears the patient has some element of autonomic dysfunction
in addition to known left renal artery stenosis s/p stent and
critical aortic stenosis. As he became relatively hypotensive
(sbp of 90) on labetolol as well as hydralazine, both of these
agents were discontinued. The patient experienced acute on
chronic renal failure, most likely secondary to kidney
hypoperfusion while hypotensive. His creatinine had leveled off
at discharge. He was discharged with services and scheduled to
have electrolytes checked the Wednesday after discharge with
results to be faxed to both his PCP and nephrologist. The
patient was eventually discharged on his original home
medication regimen with uptitration of his amlodipine while his
losartan was being held.
The patient had a troponin leak consistent with NSTEMI in the
setting of his hypertensive emergency. He was medically managed
with beta-blockade and low dose aspirin as well as high dose
statin. He was already anticoagulated on heparin at the time.
He had an ECHO while in the hospital which showed moderate
concentric left ventricular hypertrophy with a small cavity,
reduced ejection fraction, and evidence of severe diastolic
dysfunction.
The patient was continued on his home Plavix regimen for his
left renal artery stenosis s/p stent by Dr. [**First Name (STitle) **]. He also has
known carotid disease.
The patient was noted to have a urinary tract infection during
this admission. Cultures grew out Klebsiella sensitive to
cipro. The patient was treated with cipro and discharged to
complete a course of antibiotics.
He also had a left hand thrombophlebitis from an IV. The IV was
removed and the thrombophlebitis resolved with no further
intervention.
He was discharged with home VNA for assessment of his
cardiopulmonary status, INR draws for his anticoagulation, which
should be maintained between two and three until decided
otherwise by his PCP and cardiologist as well as home CHF
monitoring, which the patient has had in the past. He should be
restarted on his losartan as an outpatient once his renal
function starts to return to his baseline ~2-2.5.
Medications on Admission:
NORVASC 5 mg--1.5 (one and a half) tablet(s) by mouth once a day
METOPROLOL TARTRATE 25 mg--0.5 tablet(s) by mouth twice a day
PLAVIX 75 mg--1 tablet(s) by mouth once a day
URSODIOL 300 mg--1 capsule(s) by mouth twice a day
ZANTAC 300 mg--1 tablet(s) by mouth daily
PROTONIX 40 mg--1 (one) tablet(s) by mouth daily
HYDROCHLOROTHIAZIDE 25 mg--1 tablet(s) by mouth daily
LIPITOR 10 mg--1 tablet(s) by mouth once a day
COZAAR 25 mg--1 tablet(s) by mouth twice a day
SENOKOT 8.6 mg--1 (one) tablet(s) by mouth twice a day as needed
for constipation
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
12. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO once a day
as needed for headache.
Disp:*10 Tablet(s)* Refills:*0*
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please start this medication on Saturday, [**2104-3-8**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
#Atrial fibrillation with rapid ventricular response
#Hypertensive emergency
Secondary:
#Chronic renal insufficiency on epogen
#Claudication
#Aortic stenosis
#GERD
#COPD
#Peripheral vascular disease
#Left renal artery stenosis
#Type II diabetes mellitus
#TIA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because your heart rate was
very fast. While in the hospital you underwent chemical
conversion with medication to change your heart rate to sinus.
Your heart rate has been controlled since the conversion. We
started you on a blood thinner which you will need to take until
you are instructed otherwise. If you have any bleeding from
your nose or blood in your stool, please notify your doctor
immediately.
Please do not take your warfarin tonight (the blood thinner).
Please take the warfarin tomorrow night (Saturday) and Sunday
night. The VNA will check your INR levels on Sunday.
You also had an episode of extremely high blood pressure. We
treated your blood pressure with medications. We are sending you
home on a slightly different medication regimen. We increased
your dose of amlodipine to 10 mg daily. We would like you to
hold your Losartan (Cozaar) until instructed otherwise by your
primary care physician.
We will check your kidney function on Wednesday, [**2104-3-12**].
Your outpatient doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] when you may restart your
losartan.
We did not change your dose of beta-blocker or
hydrochlorothiazide. We increased your cholesterol medication.
Please take all your other medications as prescribed.
Please call your doctor or come to the emergency room with any
chest pain, shortness of breath, increasing headaches or other
symptoms you find concerning.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3940**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2104-3-13**] 3:00 pm.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2104-3-20**] 11:00 AM.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2104-3-25**] 3:00 pm.
Provider: [**Name10 (NameIs) 3941**] CALL TRANSMISSIONS Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2104-4-7**] 9:00 AM.
You have an appointment with Dr. [**Last Name (STitle) 2232**] on [**2104-4-9**] at 11 AM
to follow up for your cardioversion. Please call ([**Telephone/Fax (1) 3942**].
ICD9 Codes: 5849, 5990, 2762, 5859, 4241, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5210
}
|
Medical Text: Admission Date: [**2106-5-17**] Discharge Date: [**2106-5-26**]
Date of Birth: [**2025-12-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Succinylcholine / Aspirin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Found down with subdural hematoma on CT
Major Surgical or Invasive Procedure:
Left sided craniotomy for subdural hematoma evacuation X2
History of Present Illness:
80 y/o male transferred from outside hospital with subdural
hematoma. Mr [**Known lastname 30119**] is a 80 y/o gentleman who was found down
by a friend this morning,? tripped over rug. However friend of
patient reports change in mental status the last 24 hours
driving
was off while driving to Foxwoods. His friend asked him to call
him when he got home but he didn't so friend went and checked on
him and found him down on the floor. He was found to have an INR
of 1.6 at outside hospital. Mr [**Known lastname 30119**] relates a fall
approximately 1 month ago when he hit his head on the corner of
the stove and had a LOC.
Past Medical History:
Diabetes not being treated, Paget Disease
Social History:
Lives alone in an apartment in [**Hospital1 392**], MA. Divorced, has nephew
and brother in local area, children in other states.
Former smoker
NO alcohol
Family History:
Non contributory
Physical Exam:
T:98.0 BP:143/75 HR:80 R18 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-11**] EOMs full
Neck: in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Bruise on right leg, poor toe nails, Warm and
well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: To name and hospital, date [**2077-3-9**]
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming impaired. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Right sided drift
UE [**5-14**] (Bicep/Tricep) hands are arthritic lower extremities IP
[**5-14**] AT [**Last Name (un) 938**] 3+/5 G [**4-14**] bilaterally
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2+ 2+
Left 2+ 2+
Pertinent Results:
[**2106-5-17**] 08:20AM PT-14.3* PTT-30.5 INR(PT)-1.3*
[**2106-5-17**] 08:20AM PLT SMR-NORMAL PLT COUNT-169
[**2106-5-17**] 08:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2106-5-17**] 08:20AM NEUTS-48* BANDS-1 LYMPHS-12* MONOS-38* EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2106-5-17**] 08:20AM WBC-5.1 RBC-4.10* HGB-12.8* HCT-36.2* MCV-88
MCH-31.2 MCHC-35.4* RDW-16.3*
[**2106-5-17**] 08:20AM CK-MB-13* MB INDX-3.7 cTropnT-0.06*
[**2106-5-17**] 08:20AM CK(CPK)-348*
[**2106-5-17**] 08:20AM GLUCOSE-102 UREA N-14 CREAT-0.5 SODIUM-142
POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
Brief Hospital Course:
Mr [**Known lastname 30119**] was admitted to the Trauma ICU on the Trauma
service. After discussion with the patient and his nephew it
was felt having a craniotomy to evacuate his large left sided
subdural would be in his best interest.
On [**5-18**] he went to the OR and had left sided craniotomy, he was
extubated post operatively and had a subdural drain in place.
He was moving all extremities with good strength however less
strenght on the right sided he continued to be disorientated at
time.
On POD#1 He has a CT which showed evacuation of the chronic
portion with some reaccumulation of the acute blood but overall
improved. He received 1 unit of blood for crit 27. He was
transferred to the step down unit, he had some agitation after
transfer however, a second CT was stable, repeat crit was 31.
On POD#3 he was noted have some increase lethargy, a repeat CT
showed an interval increase of acute subdural blood he was
brought to the OR for a repeat subdural evacuation of
craniotomy. He spent overnight in the PACU, his exam he was
having difficulty speaking (which was similar post his first
surgery) slightly weaker on the right side though moving all
extremities. He had an MRI Slow diffusion in the left posterior
frontal region indicative of an acute infarct. He continued to
follow one step commands, slightly weaker on the right.
On [**5-26**] his drain was removed and a repeat head CT showed
continued evidence for a mixture of acute and chronic blood
products, as well as gas within the left frontal-temporal
subdural hemorrhage. Additionally, there is slight widening and
a somewhat biconvex contour to what may be an epidural
collection of gas subjacent to the craniotomy flap.
Neurologically he was awake alert, following commands but
continued with some aphasia though had no difficulty swallowing
or eating. His right side appeared weaker than the left.
On [**5-27**] he appeared brighter following commands trying to speak
a few words. He continues to move the right arm less than the
left. He does have motor strength in that arm. His appetite is
excellent.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
13. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Keep incision clean and dry. Have staples removed on [**2106-6-3**]
Watch incision for redness, drainage, swelling, bleeding or
fever greater than 101.5 call Dr[**Name (NI) 4674**] office
Also call for any mental status changes such as lethargy
Followup Instructions:
Have staples out on [**2106-6-3**] at Dr[**Name (NI) 4674**] office or at
nursing facility
Have sutures on left side of head removed [**2106-5-28**]
Follow up with Dr [**Last Name (STitle) 739**] in 4 weeks with head CT at that
time
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2106-5-26**]
ICD9 Codes: 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5211
}
|
Medical Text: Admission Date: [**2168-1-18**] Discharge Date: [**2168-2-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
Melena, hypotension
Major Surgical or Invasive Procedure:
EGD x2
Intubated
History of Present Illness:
The patient is an 88 year old male with initially admitted with
the chief complaint of lethargy. Pt has MMP as noted below with
chronic diarrhea on immodium. Over the last 2 months he has
noted increased urgency of stooling but no clear change in
amount/freqency or consistancy, no black stool or blood in
stool. He did have occasional nausea but no vomiting or
abdominal pain. In this same time period he began to feel weak
and fell in the bathtub. At that time he initiated outpt PT.
Over the last week had increasing fatigue and malaise with LOA
and a 10 lb wt loss. He was found by PT to be hypotensive with
a BP 85/60 and lethargy w SOB. Sent to ED for evaluation. In ED
noted to have black guiaic pos stool with dark NG lavage output,
no clear coffee grounds, +congestion
In the ED on [**2168-1-18**], he was found to have on EGD a non-bleeding
large duodenal ulcer which was not cauterized at the time.
Instead, the patient was transfused as needed and his
hematocrits were followed serially.
On [**2168-1-21**], the patient was transferred to the MICU after having
large amounts of melanotic stool with a BP of 85/60. There, he
underwent repeat EGD where his duodenal bulb was cauterized and
he was transfused 1 unit PRBC although his Hct remained stable
above 30. On [**2168-1-22**], the patient was transferred back to the
floor as he was hemodynamically stable with a stable hematocrit.
Past Medical History:
PMH:
1.s/p CVA [**2163-4-2**], residual mild intermittent aphasia
2.Diverticular bleed while on coumadin for CVA [**2163**]
3.Post-op respiratory failure->trach->MRSA pneumonia [**2163**]
4.AAA d/x'd 10 years ago
5.Hypothyroidism
6.Renal failure due to dehydration complicated by heart block
[**2164**]
7.Left renal CA [**2157**]
8.Prostate CA [**2158**], s/p XRT,prostatectomy
9.Duodenal ulcers [**2164-6-1**] admission
10.H.pylori [**2164-6-1**] admission
11.Zoster right shoulder [**2164-6-1**] admission
12.Depression
PSH:
1.Bilateral inguinal hernia repair [**2117**]
2.TURP [**2149**]
3.Left nephrectomy ~[**2157**]
4.Prostatectomy, orchiectomy ~[**2158**]
5.Subtotal colectomy and ileostomy [**10/2163**]
6.Tracheostomy [**10/2163**], closed
7.PEG [**10/2163**], removed
8.Reversal of ileostomy and small bowel resection by Dr.[**Last Name (STitle) 519**]
[**6-1**]
Social History:
Lives with wife. Had 9 children, two deceased now. Ambulates
using walker.Quit smoking at age 39 after 40 pack years.
Occasional use of alcohol.
Family History:
One brother died of ruptured aneurysm. Another brother had AAA
repair.
Physical Exam:
Tc=95.9 P=68 BP=127/83 RR=16 97% RA
General: NAD, AOx3
HEENT: PERRL
CV: s1 s2 reg, no m/r
Pulm: Minimal bibasilar crackles
GI: NABS, soft, NT
Ext: trace pitting edema w/ chronic venous stasis changes in L
leg
Neuro: non-focal
Pertinent Results:
[**2168-1-18**] 09:28PM HCT-21.7*
[**2168-1-18**] 04:40PM PT-12.8 PTT-34.5 INR(PT)-1.0
[**2168-1-18**] 03:41PM WBC-6.3 RBC-3.06* HGB-9.5* HCT-28.3* MCV-92
MCH-31.0 MCHC-33.6 RDW-15.2
[**2168-1-21**]
Hct 6am: 34.2, plt 74
Hct 7pm: 35
Brief Hospital Course:
He was found by PT to be hypotensive with a BP 85/60 and
lethargy w SOB. Sent to ED for evaluation. In ED noted to have
black guiaic pos stool with dark NG lavage output, no clear
coffee grounds, +congestion
In the ED on [**2168-1-18**], he was found to have on EGD a non-bleeding
large duodenal ulcer which was not cauterized at the time.
Instead, the patient was transfused as needed and his
hematocrits were followed serially. On [**2168-1-21**], the patient
was transferred to the MICU after having large amounts of
melanotic stool with a BP of 85/60. There, he underwent repeat
EGD where his duodenal bulb was cauterized and he was transfused
1 unit PRBC although his Hct remained stable above 30. On
[**2168-1-22**], the patient was transferred back to the floor as he was
hemodynamically stable with a stable hematocrit.
1. Hypotension/ Sepsis:
Meets the septic criteria by lactates/ physiology. Found to
have positive C.diff +/- urosepsis (>100K E. coli) and
infiltrate on CXR. Found to have a random cortisol 70s so did
not need steroids. Was transiently on pressors to maintain MAP
> 65.
-TTE: mild global LV HK; no effusion
2. Respiratory failure: likely secondary to PNA
- [**1-29**]: doing great on PSV; RSBI 70, however, CXR without
improvement
- [**1-29**]: bronch'd only small plug in rll. airway looked okay
- [**1-30**] extubated
- [**2-1**] re-intubated for respiratory distress; ? recurrent
aspiration. Per family all hypoxic episodes noted after eating?
- currently on levo/vanco
- [**2-4**] doing well on cpap
- by discharge the patient was doing well on nasal canula
4. Trombocytopenia: No evidence of hemolysis. Held all heparin
products
Transfused to keep platelets > 35
3. ARF; FeNA 0.2%. Was likely pre renal. Cr trended down with
hydration.
4. UGIB: large duodenal bulb ulcer
[**2-3**]--recurrent melenotic stool with hct slowly trending
downwards.
BICAP applied to to clot inorder to achieve hemostasis. Kept on
sulcrafate and PPI
Family meeting was held [**2168-2-7**] where the family including the
wife decided to make the patient [**Name (NI) 3225**]. The patient was called
out to floor and comfort care was initiated. His TLC and NGT
were pulled on [**2167-2-7**]. He will be going home with [**Hospital 269**] hospice.
Medications on Admission:
Medications on transfer:
Neutra-Phos 1 PKT PO TID
Fentanyl Citrate 25 mcg IV ONCE
Midazolam HCl 1 mg IV ONCE
Pantoprazole 40 mg PO Q12H
Oxycodone 5 mg PO Q4-6H:PRN
Tolterodine 2 mg PO BID
Zolpidem Tartrate 5 mg PO HS:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Multivitamins 1 CAP PO DAILY
Loperamide HCl 2 mg PO QID:PRN
Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO q1h as
needed for pain. Disp:*30 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
GI bleed
Acute Renal Failure
Respiratory Failure
Discharge Condition:
Stable
Discharge Instructions:
Patient is going home with hospice care.
Followup Instructions:
Will follow up with home hospice
ICD9 Codes: 2851, 0389, 2762, 486, 2875, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5212
}
|
Medical Text: Admission Date: [**2192-12-3**] Discharge Date: [**2192-12-11**]
Date of Birth: [**2116-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
known CAD referred for CABG
Major Surgical or Invasive Procedure:
CABG
History of Present Illness:
known CAD w stable angina which progressed to exertional
symptoms. +ETT followed by cath which revealed LM and 2VD
preserved EF
Past Medical History:
CAD, HTN, NIDDM, ^chol, OA, BPH, Hernia repair, R LE vein
stripping, Colonic surgery, Appy,TURP,hemorroidectomy
Social History:
Retired, lives alone
remote tob (quit 25 yrs ago)
+ETOH/2-3 beers/day
Family History:
Mother/CAD
Physical Exam:
Gen: NAD
Chest: CTA
Cardiac: RRR no murmur
Abdm: Soft NT/ND/NABS
Ext: warm well perfused, bilat edema, left thigh varicosities
Neuro: nonfocal
Brief Hospital Course:
Direct admit to OR for CABG, see OR report for details, Pt had
cabg x3(LIMA->LAD, SVG->OM, SVG->PDA). Tolerated operation well.
1 day stay in ICU then transferred to flooor for increased
activity tolerance.
Postop Afib on POD 2, rate controlled w/Bblockers started on
Amiodarone and Warfarin.
Developed sternal drainage on POD4(nl WBC) started on Vancomycin
drainage resolved over next several days..
Activity level slow to improve, pt screened for rehab, and
cleared for d/c to rehab on POD8.
Medications on Admission:
amaryl 4mg qd, norvasc 5mg qd, zestril 20mg qd, amitriptyline
10mg qd, lipitor 10mg qd, toprol xl 25 mg [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg qd
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 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) for 2 weeks.
6. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
400mg QD x1wk then
200mg QD.
Disp:*60 Tablet(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Adjust dose to target INR 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**]
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD,SVG->OM,SVG->PDA)
PMH:CAD,HTN,DM2,^chol,diverticulitis,[**Last Name (un) 62429**]
diverticulum,BPH,OA,Neuropathy,GIBld,ventral hernia
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry, OK to shower, no bathing or swimming.
take all medications as prescribed.
Call for any fever, redness or drainage from wounds
[**Last Name (NamePattern4) 2138**]p Instructions:
wound clinic in 2 weeks
Dr [**Last Name (Prefixes) **] in 4 weeks
Dr [**Last Name (STitle) **] in [**3-16**] weeks
Completed by:[**2192-12-11**]
ICD9 Codes: 4019, 2724, 3572
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5213
}
|
Medical Text: Admission Date: [**2200-3-30**] Discharge Date: [**2200-4-3**]
Date of Birth: [**2153-8-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
dyspnea, lethargy
Major Surgical or Invasive Procedure:
Intubation and mechanical sedation
History of Present Illness:
46M w/PMH HTN p/w sob + weakness x 4d, found to be
hypotensive/tachycardic and admitted to [**Hospital Unit Name 153**] for c/f occult
infection/septic picture. Pt states that he recently returned
from [**Last Name (un) **], had a mild cough x 4d. Reports mild dyspnea, worse
on exertion. Patient reports that he did not get up at all
during the plane flight. Denies hemoptysis. Patient reports no
fever/chills/nausea/vomiting/diarrhea/dysuria. He did present to
his PCP yesterday morning and was tested with rapid strep
screen, results pending.
.
In the ED,
initial vitals: 97.2 74 105/50 16 96% 2L Nasal Cannula
Labs significant for:
WBC 6.6, Hct 35.6 Plts 192. PMN 82%
BUN 45, Cr 1.1, Gluc 258, P 0.9, ALT 41, AST 22, AP 28, u/a
+ketones 40, proBNP 171
Ca: 8.1 Mg: 1.6 P: 0.9
.
EKG: 1mm st depressions in anterior septal leads. tachycardia to
120s.
CTPA: showed no PE or aortic pathology. Bedside ultrasound did
not demonstrate any significant effusion or major wall
.
After CT the patient became tachycardic once again to the mid
130s. Received 2L NS. At this time he was febrile to 102
received Tylenol, vancomycin, levofloxacin and metronidazole.
Admitted for c/f occult infection
.
On arrival to the ICU, the pt was tachycardic to 130s-140. He
had an episode almost immediately of what was thought to be
seizure-like activity; He flailed himself across the bed with
jerking extremity movements. After this he appeared to be very
confused. Was given 1mg IV ativan. He was noted to have melena
and vomited coffee-ground appearing material. NG lavage was
performed, which showed coffee-grounds and did not clear even
after 400 ccs. GI was consulted. HCT was rechecked on arrival to
the unit and was now at 22 from 35 earlier. ABG performed which
did confirm this lab result. 3u pRBCs were ordered with plan to
give all. Also ABG showed that he had a primary respiratory
alkalosis. Pt was hypomagnesemic, hypophosphatemic, and
electrolytes were repleted.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
HTN
HLD
possible alcohol abuse
possible smoking
sleep apnea
Social History:
- Tobacco: denies but has previous documentation that he is a
smoker
- Alcohol: denies significant use but occasionally states he
has 3 drinks per night
- Illicits: denies
Family History:
Both parents with diabetes
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.3 BP:121/97 P:132 R:21 O2: 99% 3L NC
General: Alert, oriented, appears to have shallow breathing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: thick, but supple, JVP not elevated, no LAD
Lungs: mild crackles at the bases. no wheezing
CV: tachycardic, III/VI systolic murmur that radiates to the
axilla
Abdomen: distended, protuberant, but soft without pain on
palpation or guarding. no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2200-3-30**] 03:10AM BLOOD WBC-6.6 RBC-3.75* Hgb-11.6* Hct-35.6*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.4 Plt Ct-192
[**2200-3-30**] 03:10AM BLOOD Neuts-82.0* Lymphs-12.7* Monos-4.6
Eos-0.2 Baso-0.5
[**2200-3-30**] 03:10AM BLOOD PT-11.9 PTT-26.3 INR(PT)-1.1
[**2200-3-30**] 03:10AM BLOOD Glucose-258* UreaN-45* Creat-1.1 Na-135
K-4.8 Cl-100 HCO3-26 AnGap-14
[**2200-3-30**] 03:10AM BLOOD ALT-41* AST-22 AlkPhos-28* TotBili-0.2
[**2200-3-30**] 03:10AM BLOOD proBNP-171*
[**2200-3-30**] 03:10AM BLOOD cTropnT-<0.01
[**2200-3-30**] 03:10AM BLOOD Albumin-3.7 Calcium-8.1* Phos-0.9* Mg-1.6
[**2200-3-30**] 03:10AM BLOOD D-Dimer-<150
[**2200-3-30**] 03:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2200-3-30**] 03:33AM BLOOD Lactate-1.8
[**2200-3-30**] 10:59AM BLOOD WBC-4.7 RBC-2.37*# Hgb-7.4*# Hct-22.2*#
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.8 Plt Ct-153
[**2200-3-30**] 03:28AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2200-3-30**] 03:28AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-150 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2200-3-30**] 07:07AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2200-3-30**] 10:59AM BLOOD Ethanol-NEG
[**2200-3-30**] 10:59AM BLOOD CK-MB-2 cTropnT-<0.01
[**2200-3-30**] 10:59AM BLOOD CK(CPK)-96
MICROBIOLOGY:
Blood cultures 4/22: pending
Brief Hospital Course:
46 y/o M history of HTN, HLD presents with hypotension and
shortness of breath, with initial concern for PE given recent
travel. However d-dimer and CTA were negative. Patient
ultimately found to have anemia and UGI bleed and transferred to
[**Hospital Unit Name 153**].
.
# GIB: Pt presented with tachycardia, lethargy, found to have
melena on rectal exam and coffee grounds on NG lavage (not
clearing with 400cc). Denies n/v/epigastric pain. Denies
significant NSAID use or hx of ulcers, gastritis. Endorses some
EtOH use s/p trip to [**Last Name (un) **] but no h/o ETOH abuse. HCT 35 on
admission, down from [**2196**] HCT of 49.5. Repeat HCT was 22.2. got
5uprbc. No known cirrhosis or varices. Imaging here documented
fatty liver but no cirrhosis. [patient was electively intubated
for egd due to episodes of apnea. intubated [**3-30**], extubated [**3-31**]
w/o events] Patient undewent EGD on endoscopy showed dried blood
mixed with food in stomach, couldn't visualize well. on [**3-31**]
underwent repeat EGD which showed stomach ulcer with "cherry red
spot" that was clipped x2, likely source of bleeding, also had
some smaller erosions. Patient will need f/u with GI as well as
repeat EGD in [**5-16**] weeks.
Patient HCT were trended and remained stable. On day of transfer
out of ICU HCT was 31. Patient's diet was advanced to clears on
[**4-1**] and tolerated well. His H pylori serology was POSITIVE.
Since is currently on levofloxacin for possible pneumonia, he
can start a course of triple therapy for H. Pylori once he is
done with a course of levofloxacin. He remained on a protonix
drip for 72h to end on [**4-3**] and then transition to high dose
oral [**Hospital1 **] PPI. It will be important to document a treatment cure
for h. pylori during his future endoscopy because of the
presence of significant PUD.
He will be discharged on a prevpac
(lansoprazole/clarithromycin/amoxicillin) to take for 14d and
then take a [**Hospital1 **] PPI after completion.
# FEVER/Respiratory Distress requiring intubation and mechanical
ventillation after first EGD
Patient with fever to 102.9 on day of admission with
non-specific respiratory symptoms. His initial CXR not
suggestive of PNA. Patient at the time was hypotensive with
concern for sepsis so he was started on vanc/levoflox/flagyl.
Antibiotics were then narrowed to levofloxacin for ?CAP.
Following procedure patient developed productive cough and nasal
congestion with cxr note of bibasilar opacities suggesive of
?aspiration event given recent intubation. Upon arriving to the
medical floor he had a lower grade fever to 100.2, but no signs
of ongoing sepsis. The GI team reported copious purulent nasal
secretions at the time of his second endoscopy raising the
possibility of sinusitis. His fever curve continued to decline.
He will be discharged on clarithromycin/amoxicillin to treat
his H.Pylori and these antibiotics also have good coverage for
community acquired pneumonia organisms.
# Hyperglycemia: Patient was hyperglycemic on presentation,
possibly due to stress response. A1C of 6.2
# Seizure/Loss of Consciousness - on arrival to [**Name (NI) 153**] pt
experienced a short episode of seizure activity, followed by
confusion. Denies history of seizure disorder. Received 1mg
ativan. No further episodes since. [**Month (only) 116**] have been related to
metabolic disturbances. Unlikely withdrawal seizure, as patient
has not been [**Doctor Last Name **] on CIWA. No further seizure activity.
# ?Alcohol Abuse: Pt endorses [**2-9**] glasses of wine a night,
though this value changes with different encounters with various
medical providers. Recent trip to [**Location (un) 5354**] but denies drinking
to excess at that time. Pt with documented hx of alcohol use on
Atrius records but no clear documentation of abuse.
# [**Last Name (un) **]: Cr 1.1 at presentation (baseline 0.8). Improved to
baseline with fluid resuscitation.
.
# Fatty liver - seen on CT. c/f diabetes or could be [**1-9**] alcohol
use vs metabolic syndrome given A1c 6.2. Does not appear to have
progressed to cirrhosis. ALT mildly elevated, AST wnl. Alk phos
mildly elevated. No RUQ symptoms, no vomiting or pain. No
abdominal pain or tenderness. Recommend outpatient followup.
Plan At discharge
--clarithromycin/amoxicillin for possible pneumonia
--nasal saline rinse
--clarithromycin/amoxicillin/omeprazole x2 weeks for h. pylori
--arrange outpatient GI followup for repeat endoscopy
Medications on Admission:
Hydrochlorothiazide 25 mg Oral Tablet Take 1 tablet daily
Fluticasone 50 mcg/Actuation Nasal Spray, Suspension
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
gastric ulcer
acute blood loss anemia
duodenitis
Probable Aspiration Pneumonia
Mechanical Ventillation for respiratory distress
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with a GI bleed resulting from gastric
ulcers and inflammation of your duodenum. You should avoid all
NSAID medications and also avoid alcohol use. You will now be
treated for H. Pylori infection. You are recommended to have a
repeat endoscopy to evaluate these ulcers and look for healing.
You are also being treated for possible pneumonia vs. aspiration
pneumonitis. The antibiotics that treat h. pylori infection are
also effective at treating pneumonia. Please take these
medications as instructed and take with food to avoid nausea.
You are also on an antacid.
Take the prevpac that has the 2 antibiotics and the antacid for
2 weeks to treat the h.pylori. Then you should take the
protonix twice a day as instructed following the completion of
the prevpac.
You should also talk with your PCP about evaluation for fatty
liver disease.
Followup Instructions:
Name: [**Name6 (MD) 17529**] [**Name8 (MD) 17528**], MD
When: Wednesday [**4-9**] at 4:25pm
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**]
Phone: [**Telephone/Fax (1) 17530**]
*You need a repeat endoscopy in [**5-16**] weeks to ensure your ulcer
is healing, please discuss with your physician to schedule this.
Contact, Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] [**Telephone/Fax (1) 682**] about the endoscopy.
ICD9 Codes: 5070, 5849, 2851, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5214
}
|
Medical Text: Admission Date: [**2135-2-3**] Discharge Date: [**2135-2-12**]
Date of Birth: [**2060-8-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Morphine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
hypotension s/p surgical ASD closure
Major Surgical or Invasive Procedure:
ASD repair [**2135-2-3**]
History of Present Illness:
Ms. [**Known lastname 47091**] is a 74 yo F with h/o AF, IPF (on 4L home O2),
cardiomyopathy with EF 35%, and diabetes who was admitted today
for ASD closure with Dr. [**Last Name (STitle) 911**]. Plan was for her to be admitted
to the NP service post-procedure, repeat echo tomorrow AM and
discharge home. ASD closure was successful, but during the
procedure patient became bradycardic to 40s and hypotensive to
70s systolic. Received 500cc IVF with little improvement. She
was then was started on dopamine and neosynephrine gtt (now
weaned to only dopamine), and bolused with atropine 0.5mg IV x2.
In the PACU she was given another 1L IVF with little hemodynamic
improvement. Of note, midazolam, fentanyl, rocuronium and
etomidate were used for sedation and paralysis during the case.
Patient is now being admitted to the CCU for pressors and
monitoring overnight.
.
During ASD closure, patient was noted to have left to right
shunting at the level of the left brachiocephalic artery. She
was also found to have right to left shunting at the level of
the right atrium, causing hypoxemia (see below for blood
oximetry data). Filling pressures were found to be WNL: RAmean
9, RVEDP 8, PAP 54/24, PCWP 11. Ratio of pulmonary blood flow to
systemic blood flow (Qp/Qs) was 1.4. ASD was successfully
closed. Given her h/o IPF and right heart failure, selective
catheter placement in each of the 4 pulmonary arteries was
performed and angiography demonstrated no stenosis. Plan is for
patient to start ASA and Warfarin anticoagulation and f/u with
Dr. [**Last Name (STitle) 911**] in 1 month.
.
Patient has h/o cardiomyopathy with EF 35% and IPF diagnosed in
[**2131**]. Over the past 6 months she has become progressively more
short of breath, now becoming extremely dyspneic on minimal
exertion (e.g. walking to bathroom). She is on 2-4L O2 per NC at
home, normally satting in high 70s to low 80s on room air and
low 90s on 4L O2.
.
On arrival to the CCU, patient is hemodynamically stable (SBP
110s, HR 60s), satting 88-93% on 4L. She is awake and responding
to questions. Denies pain, dyspnea, chest pain, palpitations,
nausea, leg pain.
Past Medical History:
1. Atrial fibrillation, currently rate controlled with Toprol-XL
and Warfarin for thromboembolic prophylaxis.
2. Interstitial pulmonary fibrosis on 2L (4 liters with
exertion) home O2 initiated spring of [**2133**] only at night and
requiring oxygen around the clock at present.
3. Hospitalization last year for decompensated heart failure.
4. Cardiomyopathy, most recent LVEF of 35% in addition to RV
dysfunction and severe TR on a recent echo. NYHA III-IV.
5. Secundum ASD noted on recent echocardiogram with
left-to-right shunting.
6. Diabetes.
7. Chronic right hip pain due to hip fracture requiring the use
of a
crutch for ambulation.
8. Tonsillectomy
Social History:
patient worked previously as a nurse. She never smoked
cigarettes.
Family History:
Mother - DM, liver cancer, died at 70. Father - hypertension,
stroke, died at 70. No family history of cardiac disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: elderly asian F in NAD. AAOx3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm. Positive Kussmaul sign.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular. +RV heave. Split S1, loud S2. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Fine inspiratory
crackles throughout both lung fields. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Cool, no c/c/e. No femoral bruits.
SKIN: Right groin bandage C/D/I, no hematoma. No stasis
dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII grossly intact, 5/5 strength biceps,
triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES: DP/PT 1+ bilaterally
.
DISCHARGE PHYSICAL EXAM: unchanged.
Pertinent Results:
LABS ON ADMISSION:
[**2135-2-3**] 04:15PM BLOOD WBC-6.0 RBC-3.84* Hgb-9.2* Hct-31.1*
MCV-81* MCH-24.0* MCHC-29.6* RDW-17.0* Plt Ct-370
[**2135-2-3**] 07:26AM BLOOD PT-21.3* INR(PT)-2.0*
[**2135-2-3**] 04:15PM BLOOD Glucose-104* UreaN-15 Creat-0.6 Na-138
K-3.5 Cl-100 HCO3-31 AnGap-11
[**2135-2-3**] 04:15PM BLOOD ALT-11 AST-18 LD(LDH)-207 AlkPhos-60
TotBili-0.4
[**2135-2-3**] 04:15PM BLOOD Calcium-8.6 Phos-4.6* Mg-1.6
[**2135-2-4**] 03:46AM BLOOD Digoxin-0.8*
IRON STUDIES:
[**2135-2-5**] 06:00AM BLOOD calTIBC-382 Ferritn-17 TRF-294
TTE [**2135-2-3**]:
Pre-device deployment: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). A patent foramen ovale
is present. A right-to-left shunt across the interatrial septum
is seen at rest. Overall left ventricular systolic function is
mildly depressed (LVEF= 45-50 %). The right ventricular free
wall is hypertrophied. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion.
Trace aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. Severe
[4+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in
person of the results at time of procedure.
TTE [**2135-2-4**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. A septal occluder device is seen across the
interatrial septum. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic root is mildly dilated at the sinus level. 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. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Severe [4+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Ms. [**Known lastname 47091**] is a 74 yo F with h/o AF, secundum ASD, IPF (on
4L home O2), cardiomyopathy with EF 35%, and diabetes who was
admitted today for ASD closure, procedure c/b bradycardia and
hypotension.
.
#.HYPOXEMIA: Ms. [**Known lastname 47091**] was satting 88-93% on 4L O2 per NC
on arrival to CCU. With her end stage IPF, she reports home O2
sats of high 70s-low 80s on room air, and 90-94% on her usual
4L. CXR inconsistent with fluid overload. Worsening of PAH may
also be contributing to worsening hypoxemia/dyspnea. On the
floor, she would desaturate to the 70s on 4L NC with ambulation.
With preoxygenation with 100% NRB prior to and with ambulation,
these desaturations were avoided. Per most recent pulm notes,
her pulmonary and overall functional status has significantly
worsened over the past 6 months, now with dyspnea on minimal
exertion and requiring 4L home O2 at all times. Unfortunately
there is no effective therapy for IPF. Baseline CXR showed
interval worsening of IPF. Ms. [**Known lastname 47092**] outpatient
pulmonary provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] recommended diuresis, and Ms.
[**Known lastname 47091**] was 2L negative length of stay with 20mg PO daily
furosemide. Unfortunately, diuresis did not appear to cause a
improvement in dyspnea, and her SpO2 would still decrease to the
low 90s on 4L NC with minimal ambulation. In addition, her blood
pressure dropped to the high 70s after diuresis with pt
reporting subjective fatigue, prompting discontinuation of all
standing Lasix. On [**2-9**] per pulm recs patient underwent inhaled
NO trial with serial targeted echos assessing tricuspid
regurgitation jet before/after NO. After receiving NO, her
pulmonary hypertension improved moderately, with decrease in
pulmonary artery systolic pressure from 37-79mmHg to 39-54mm Hg.
She did not report subjective improvement in symptoms with NO
(trial performed at rest), and her O2 sats were 97-100%
throughout. She will be followed up as outpatient with
pulmonology, where she may be candidate for either pulmonary
vasodilator (sildenafil) or inhaled prostacyclin therapy. On
discharge she is satting between 90-100% on 4L NC, also
requiring pre-oxygenation with 8L by high-flow facemask prior to
exertion (e.g. chair to bed) in order to prevent dropping her O2
sats. Per her request, she is discharged to home rather than
pulmonary rehab.
.
#.BRADYCARDIA, HYPOTENSION: patient became bradycardic and
hypotensive during ASD closure, requiring both neosynephrine and
dopamine and atropine and IVF. She was weaned off dopamine over
the next day with stable BPs and HR. Most likely etiology was
slow clearance of sedative/paralytic anesthesia during the case,
as well as possible oversuppression of heart rate with home
digoxin and beta blocker. Patient was hypotensive to high
70s-low 80s multiple times throughout CCU stay, so her home
medications were tapered down: metoprolol was stopped, and lasix
was also stopped as she remained euvolemic without diuretics .
Her home digoxin was not changed, with goal of improving rate
control without sacrificing blood pressure, and she was
continued on 0.125mg daily
.
#.s/p SECUNDUM ASD CLOSURE: Procedure was successful, with
repeat echo showing well-seated septal occluder device. Patient
also noted to have right-to-left interatrial shunting
(Eisenmenger syndrome) as well as severe (3+) TR during
procedure, secondary to her chronically elevated right heart
pressures (which themselves are likely secondary to pulmonary
hypertension from IPF as well as earlier left-to-right shunting
across ASD). She became bradycardic and hypotensive in the OR,
which required dopamine drip which was maintained for 24 hours.
She was hemodynamically stable and off of pressors 24 hours
following the procedure and did not have a pressor requirement
at any later time this admission. Repeat TTE on [**2-4**] showed
improved LVEF (55%), but also worsening RV pressure overload and
worsening TR (4+). Another TTE on [**2-8**] demonstrated small
left-to-right shunt across the septal occluder device, and
slight improvement in pulmonary pressures. Home Warfarin and ASA
were continued for anticoagulation following the procedure. Home
digoxin and metoprolol were also continued.
.
#.ANEMIA: Ms. [**Known lastname 47091**] became anemic to HCT 26.8 this
admission with MCV 80; HCT 31 on arrival and drifting down since
then. Her baseline HCT is 37. Worsening microcytic anemia does
suggest likely iron deficiency, and iron studies were
consistent. Stools guaiac negative. Iron supplementation was
initiated, with slow improvement in her HCT. She would likely
benefit from outpatient colonoscopy to rule out occult
malignancy if her life expectancy improves from the current poor
(<6 month) prognosis.
.
#.AFib: Ms. [**Known lastname 47091**] was well rate-controlled on Metoprolol
and Digoxin and is on home Warfarin for thromboembolic
prophylaxis. Given bradycardia, her metoprolol was decreased
from 50 to 25mg PO daily, and she remained under good rate
control. She is also on home digoxin. Warfarin dose was also
decreased from 3mg to 2mg PO daily as her INR was
supratherapeutic.
.
#.CARDIOMYOPATHY: patient has h/o NYHA class III-IV
cardiomyopathy with echo from [**7-30**] showing LVEF 35%, RV
dysfunction and severe TR. Echo post-procedure showed LVEF
45-50%. Etiology of her heart failure could be IPF causing
pulmonary hypertension and increased right heart afterload, as
well as chronically increased right heart filling pressures [**1-20**]
ASD. In addition, her left-to-right brachiocephalic trunk may
have further increased right heart preload, further exacerbating
right overload. Right heart failure likely then led to left
heart failure. After an initial diuresis of 2L LOS, her standing
lasix dose was decreased to 20mg daily PO to keep her euvolemic,
and then discontinued altogether as it was suspected to be
contributing to her hypotension.
.
#.CODE STATUS: per conversation with pt's outpatient
pulmonologist [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **], patient and her husband decided
that she would like to be made DNR/DNI. Code status was updated
in her medical record. Patient refused inpatient pulmonary rehab
despite urging by her inpatient team, and will therefore be
discharged home with hospice (as well as continuation of all her
current medical therapies).
.
# NIDDM: Metformin was initially held, and SSI was started.
Metformin was restarted 3 days prior to discharge, but given
low-normal blood sugars 90s-100s in the morning and likely short
life expectancy, metformin was held upon discharge.
.
====================
TRANSITIONAL ISSUES:
1. Needs colonoscopy to f/u iron deficiency anemia
2. Patient needs to pre-oxygenate with 8L per facemask before
any movement/ambulation. She is on 4L per NC at rest, satting
90-100%.
3. Inhaled NO improved [**MD Number(3) 47093**]-invasive TTE studies, will need
to consider inhaled prostacyclin therapy as an outpatient.
4. Consider discontinuing beta blocker if appropriate rate
control is achieved with digoxin as the beta blocker may be
contributing to dyspnea.
Medications on Admission:
-Digoxin 125 mcg PO daily
-Warfarin 3.5mg PO qHS (instructed to take 1mg on [**2-1**] and
resume usual dose on [**2-2**])
-Furosemide 40mg PO BID
-Metoprolol succinate 50mg PO daily
-Metformin 1000mg PO BID
-Oxygen: 2L/min continuously 2lpm cont via pulse dose, 4L/min
with exertion via pulse dose. O2 sat 77% at rest. Dx=515. Please
provide appropriate oxygen conserving device.
-Ergocalciferol (Vitamin D2) 50,000 mg PO qmonth
-Calcium carbonate (Vitamin D3) 600mg Ca (1500mg)-400 unit tab
PO daily
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO daily.
Disp:*30 Tablet(s)* Refills:*2*
2. warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
6. oxycodone 5 mg/5 mL Solution Sig: 4-16 mg PO q1h PRN as
needed for pain.
Disp:*100 mg* Refills:*0*
7. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
8. haloperidol 1 mg Tablet Sig: One (1) Tablet PO q6h PRN as
needed for agitation.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Season's Hospice
Discharge Diagnosis:
Atrial fibrillation
Cardiomyopathy, EF 35%
Interstitail pulmonary fibrosis
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 47091**],
You were admitted to the hospital following a
catheterization and ASD repair. Following the procedure, your
oxygen levels increased and you were found to have a low oxygen
saturation with minimal activity. This improved a little with
getting a little fluid off of you, and also improved with giving
you oxygen by facemask before you exerted yourself. We felt you
were a bit weak and would benefit from some rehabilitation from
a pulmonary perspective. Therefore, we transferred you to [**Hospital 100**]
Rehab where rehab with a focus on the lungs would take place.
Also while you were here we discovered that you had iron
deficiency anemia. We started you on iron supplementation. We
also found that your heart rates was rather low, therefore we
decreased the doses of your metoprolol and digoxin which can
both lower your heart rate.
We made the following changes to your medications:
1. Stop Metoprolol
2. DECREASE Warfarin (blood thinner) from 3.5mg daily to 2 mg
daily
3. STOP taking furosemide (Lasix)
5. START Ferrous Sulfate 1 pill by mouth daily for
iron-deficiency anemia
6. STOP Metformin as your blood sugars have been normal
Please take Aspirin daily and continue Coumadin and Digoxin.
Weigh yourself every morning, and call your doctor if weight
goes up more than 3 lbs.
If you need to speak with Dr. [**Last Name (STitle) 911**], you can reach him on his
cell phone: [**Telephone/Fax (1) 47094**].
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2135-3-9**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2135-2-24**] at 3:30 PM
With: DRS. [**Name5 (PTitle) 4013**] & [**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2135-2-24**] at 3:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2135-2-24**] at 3:30 PM
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4254, 9971, 4280, 4168, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5215
}
|
Medical Text: Admission Date: [**2130-5-1**] Discharge Date: [**2130-5-1**]
Date of Birth: [**2130-5-1**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 32495**] is a 2.4 kg product of a 36 week
gestation, born to a 30 year-old, Gravida I, Para 0, now I
Mom. [**Name (NI) **] type A positive, antibody negative. Hepatitis
surface antigen negative. Rubella immune. RPR nonreactive.
GBS negative. Pregnancy complicated by gestational
hypertension, treated with Labetalol and fetal growth
restriction. Antepartum course notable for spontaneous labor.
Artificial rupture of membranes nine hours prior to delivery.
Maternal temperature maximum of 100.4. Treated with
antibiotics beginning four hours prior to delivery. Infant
was born via spontaneous vaginal delivery, emerging vigorous
with Apgars of 8 and 9. Breast fed with Mom and then was
brought to the Neonatal Intensive Care Unit for sepsis
evaluation. In the Neonatal Intensive Care Unit, initial D-
stick was 20. Fed 37 cc of formula without difficulty and
repeat D-stick was 45. Weight 2,410, 10th to 25th percentile.
PHYSICAL EXAMINATION: Thin, warm and pink, no rash.
Anterior fontanel soft and flat. Red reflex present
bilaterally. Palate intact. Clear to apex. No grunting,
flaring, retraction. Regular rate and rhythm. No murmur.
Abdomen: Soft, no hepatosplenomegaly. No masses. Active
bowel sounds. Normal male genitalia. Testes palpable
bilaterally. Anus patent. Extremities with no edema. Hips
and back stable. Tone and activity grossly normal.
HOSPITAL COURSE:
1. Respiratory: Infant has been stable throughout hospital
course in room air.
1. Cardiovascularly: Initially had small, soft murmur.
Murmur has since resolved. Otherwise stable.
1. Fluids, electrolytes and nutrition: Initial D-stick was
20. He fed. Repeat D-stick was 45. He was sent to the
newborn nursery. Following D-stick was 30. Infant was
brought to the Neonatal Intensive Care Unit at which time
D-10-W was initiated. Infant was ad lib feeding with
intravenous fluids. Intravenous fluids were weaned over
the next 48 hours and he is currently ad lib feeding,
taking in adequate amounts plus breast feeding. D-sticks
have been stable in the 70's to 80's and has required no
further interventions. Weight at the time of discharge is
2435 grams up 60.
1. Hematology: Hematocrit on admission was 54.7.
1. Gastrointestinal: Peak bilirubin was 10.4 over 0.3 on day
of life 2. Rebound bili on the day of discharge was 9.5.
1. Infectious disease: CBC and [**Name (NI) **] culture were obtained
as part of the sepsis evaluation and antibiotics were
initiated on admission to the Neonatal Intensive Care Unit
secondary to repeat hypoglycemia. [**Name (NI) **] cultures remained
negative, at which time Ampicillin and Gentamycin were
discontinued.
1. Neurology: Appropriate for gestational age.
1. Sensory: Hearing screen has been performed with automated
auditory brain stem responses .
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Name6 (MD) 61946**] [**Last Name (NamePattern4) 61947**], MD,
telephone number [**Telephone/Fax (1) 43701**].
FEEDS AT DISCHARGE: Continue ad lib breast feeding with
supplementation.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREENING: Not applicable.
STATE NEWBORN SCREEN: Sent per protocol and has been within
normal limits.
IMMUNIZATIONS RECEIVED:
DISCHARGE DIAGNOSES:
1. Premature male, born at 36 weeks.
2. Rule out sepsis with antibiotics.
3. Hypoglycemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2130-5-5**] 00:26:04
T: [**2130-5-5**] 05:40:29
Job#: [**Job Number 61948**]
ICD9 Codes: 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5216
}
|
Medical Text: Admission Date: [**2153-10-8**] Discharge Date: [**2153-10-10**]
Date of Birth: [**2153-10-8**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: This is the 2.59 kg product of a
39 week gestation born to a 31-year-old G5, P2 mother. The
pregnancy was uncomplicated. Prenatal screens were
completely unremarkable. The patient was delivered by
spontaneous vaginal delivery and did well with Apgars of 8
after seen in the delivery room.
In the Newborn Nursery, the patient was noted to have several
maroon colored stools. There did not appear to be a lot of
swallowed maternal blood at delivery, but she did have blood-
tinged amniotic fluid at time of ruptured membranes. She was
admitted to the NICU for further management.
HOSPITAL COURSE BY SYSTEM: She was made NPO and given IV
fluid. Several KUBs were obtained which showed an initial
distention which resolved over time. A complete blood count
and blood culture were obtained which were within normal
limits. No antibiotics were started.
The followup abdominal films were within normal limits.
Feeds were initiated given the probable diagnosis of
swallowed maternal blood. The patient tolerated these feeds
normally without any incident. The child passed normal
stools, and never had any other symptoms. At the time of
discharge, the patient was tolerating full feeds adlib
without any problems.
From a cardiovascular and respiratory point-of-view, the
patient was always stable without requiring any intervention.
The child was discharged home with instructions to followup
with the pediatrician.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
DISCHARGE INSTRUCTIONS: The patient was discharged home with
instructions to followup with the pediatrician and to monitor
for signs of abdominal distress.
DISCHARGE DIAGNOSES:
1. Ingestion of maternal blood.
2. Normal healthy infant.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Name8 (MD) 44795**]
MEDQUIST36
D: [**2153-10-22**] 10:24
T: [**2153-10-22**] 11:50
JOB#: [**Job Number 47477**]
ICD9 Codes: V053, V290
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5217
}
|
Medical Text: Admission Date: [**2130-6-22**] Discharge Date: [**2130-7-5**]
Date of Birth: [**2079-8-8**] Sex: F
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Infected ulcers, both legs.
HISTORY OF PRESENT ILLNESS: This is 50 year old white
female with congestive cardiomyopathy, diabetes mellitus,
chronic renal insufficiency, hypertension, anemia, and
tracheal stenosis, who developed severely swollen legs in
[**2130-2-7**], during an episode of congestive heart
failure. The patient's Lasix dose was increased with
improvement of symptoms. However, the patient developed
ulcerations of her legs secondary to the swelling and was
admitted to the Vascular Surgical Service from [**2130-3-7**]
until [**2130-3-11**]. Cultures of the patient's left heel during
that admission showed no growth. Non-invasive arterial
studies showed tibial disease, right greater than left. The
patient was discharged home on Unasyn for a total of two
weeks.
The patient was seen in the office with worsening ulcers,
right greater than left. The patient was no longer on any
antibiotics. The patient complained of severe leg pain,
[**1-16**]), which had been a problem since discharge home. The
patient had been seen at the Pain Clinic. A TENS Unit was
tried. However, the patient still had severe pain in her
legs. Most recently, the patient was using aspirin for pain
and Darvocet prior to that without any significant pain
relief. She has been unable to sleep through the night or
tolerate any dressings on her leg ulcers. The patient is
admitted for further treatment.
PAST MEDICAL HISTORY:
1. Congestive cardiomyopathy: Echocardiogram in [**2130-2-7**], showed severe global biventricular contractile
dysfunction with an ejection fraction of 20%; catheterization
in [**2119**] in [**State 2748**] showed no coronary artery disease.
2. Myocarditis in [**2119**].
3. Diabetes mellitus since age 11, with triopathy; F/P laser
treatment.
4. Chronic renal insufficiency.
5. Anti-phospholipid antibody syndrome.
6. Hypertension.
7. Anemia, status post multiple transfusions.
8. Peripheral vascular disease.
9. History of arterial embolus to the right first toe, right
fifth finger.
10. Tracheal stenosis following tracheostomy for respiratory
failure in [**2126-10-8**]; requires CPAP.
11. Osteoporosis.
PAST SURGICAL HISTORY:
1. Right hemiarthroplasty by Dr. [**Last Name (STitle) 23689**], [**6-/2126**], at [**Hospital1 1444**].
2. Tracheostomy in [**2126**].
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with her husband. She
does not smoke cigarettes. She does not use alcohol. She
has been very physically inactive since her leg ulcers
started in [**2130-2-7**].
ALLERGIES: Benadryl causes palpitations. The patient is
very sensitive to morphine.
ADMISSION MEDICATIONS:
1. Digoxin 0.125 mg p.o. q. 48 hours.
2. Diovan 80 mg p.o. q. day.
3. Lasix 80 mg p.o. twice a day.
4. Zestril 20 mg p.o. q. a.m.
5. Calcium carbonate 500 mg two tablets p.o. twice a day.
6. Calcitriol 0.25 micrograms p.o. q. day.
7. Iron sulfate 325 mg p.o. twice a day.
8. Epogen 4000 units subcutaneously Tuesday, Thursday and
Saturday.
9. NPH insulin 10 units subcutaneously q. a.m.
10. Insulin regular, zero to 6 units subcutaneously q. a.m.
11. Sliding scale Regular insulin at lunch and at dinner.
12. NPH insulin 5 units subcutaneously q. h.s.
PHYSICAL EXAMINATION: Vital signs with temperature 98.9 F.;
pulse 91; respirations 16; blood pressure 112/60; O2
saturation equals 95% on room air. In general, alert,
cooperative white female complaining of severe leg pain
secondary to ulcers. Skin warm and dry. No rashes. HEENT:
Sclerae anicteric. Mouth with no lesions. Neck: Range of
motion within normal limits; no lymphadenopathy or
thyromegaly. Carotids palpable. No bruits. Breast
examination not done. Chest: Lungs with decreased breath
sounds throughout. Heart: Regular rate and rhythm without
murmur. Abdomen soft, nontender; few bowel sounds. Rectal
examination deferred. Extremities with no ankle edema. Feet
equally warm. Large necrotic ulcer present on the right
lower anterior leg. Multiple small dry ulcers on the right
leg. Left lower extremity: Dry gangrene of the entire heel
present. Multiple dry surrounding ulcerations of the right
foot. Vascular examination: Carotids, radial and femoral
pulses two plus bilaterally. Abdominal aorta nonpalpable.
Popliteal pulses nonpalpable. Dorsalis pedis and posterior
tibial pulses have Doppler signals. Neurological examination
non-focal.
ADMISSION LABORATORY: White blood cell count 7.0, hemoglobin
8.8, hematocrit 28.8, platelets 524,000. Sodium 134,
potassium 4.8, chloride 98, carbon dioxide 22, BUN 108,
creatinine 3.6, glucose 157. PT 14.4, PTT 28.0, INR 1.4.
Albumin 3.2, calcium 7.3, phosphorus 4.5, magnesium 3.6, uric
acid 8.7, ALT 35, AST 30, alkaline phosphatase 150, total
bilirubin 0.1, digoxin level less than 0.3.
Urinalysis negative.
Portable chest x-ray shows cardiomegaly without congestive
heart failure or pneumonia.
EKG shows a normal sinus rhythm at 87, left axis deviation,
poor R wave progression, nonspecific ST-T changes. Possible
old inferior myocardial infarction. No significant change
since previous EKG.
HOSPITAL COURSE: The patient was admitted to the hospital
on [**2130-6-22**]. She was started on Levofloxacin and Flagyl in
renal doses. Right anterior leg ulcer was cultured. The
patient was unable to tolerate any dressings to her legs.
She was extremely fearful of taking pain medications which
might affect her respiratory function which was already
affected by residual tracheal stenosis after a tracheostomy
in [**2126**]. The patient uses CPAP routinely.
She agreed to try Ultram 50 mg p.o. for pain until the Pain
Service could be consulted in the morning; the patient had
moderate pain relief with one dose of Ultram.
On [**2130-6-23**], the [**Last Name (un) **] Service was consulted to manage the
patient's insulin requirements during hospitalization. The
patient was followed by Dr. [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 19862**] as an outpatient at
the [**Last Name (un) **]. The Renal Service was consulted also to monitor
the patient's renal function. She was followed by Dr.
[**Last Name (STitle) 21321**] of the Renal Service. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the
patient's Cardiologist was consulted for preoperative
clearance. The Pain Service was consulted and started on a
Fentanyl PCA.
On [**2130-6-24**], the patient expressed suicidal ideation. A
one-to-one sitter was ordered. A Psychiatry consultation was
requested. Psychiatry recommended that the patient restart
Zoloft, which she had been on in the recent past. The
patient started on 25 mg q. day and was titrated up to 100 mg
p.o. q. day. The one-to-one sitter was maintained until
[**2130-7-1**], when Psychiatry felt that the patient no longer
had any suicidal or homicidal ideations.
On [**2130-6-26**], the patient had a Persantine-MIBI study
requested by Dr. [**Last Name (STitle) **]. The study showed several moderate
fixed defects, with diffuse hypokinesis and an ejection
fraction of 19%. The patient was cleared for below the knee
amputation surgery.
Because of the patient's worsening renal status, she
underwent an MRA of her legs rather than an arteriogram. The
MRA done on [**2130-6-27**], showed moderate stenosis in the right
superficial femoral artery, two-vessel runoff and a good
quality dorsalis pedis with distal attenuation. The left SVA
and popliteal arteries were normal. There was two-vessel
runoff into the foot with a high-grade stenosis in the
mid-portion of the dorsalis pedis artery. The patient had
forefoot pulse volume recordings done on [**2130-6-28**], which
showed a 6 millimeter deflection on the right and a 16
millimeter deflection on the left. A left below the knee
amputation was recommended by Dr. [**Last Name (STitle) 1391**] because of the
extent of gangrene in the heel and the poor circulation in
the foot itself.
The patient underwent dialysis on [**2130-6-29**], and received
one unit of packed red blood cells for a hematocrit of 27.3.
Her post-transfusion hematocrit was 31.
On [**2130-6-30**], the patient underwent an uneventful left below
the knee amputation. Her dressing was taken down on
postoperative day number two. The incision was clean, dry
and intact. The patient had feared losing her legs for many
years. She expressed great relief at having the surgery over
and now being able to get on with her life. Psychiatry
recommended discontinuing the one-to-one sitter on
postoperative day number one. They recommended continuing
the Zoloft at 100 mg p.o. q. day. Follow-up outpatient
Psychiatry will be arranged at the [**Hospital **] Clinic by the
patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 19862**].
The patient's PCA was discontinued on postoperative day
number two. Her postoperative pain was managed with Dilaudid
2 to 4 mg p.o. q. four to six hours p.r.n.
Physical Therapy consultation was requested on postoperative
day number two. The patient will be seen on [**2130-7-4**],
following the long holiday weekend.
The patient will follow-up with Dr. [**Last Name (STitle) 1391**] in the office
per his instructions at time of discharge. The patient's
surgical staples will remain in place for one month following
surgery. In the meantime, she will have a dry sterile
dressing placed on the incision q. day pending further orders
at discharge.
The patient's right shin ulcer appears cleaner with a central
area of granulation tissue. The shin ulcer is to have a
saline dressing wet-to-dry q. a.m. and a Regranex dressing in
the evening per protocol.
DISCHARGE MEDICATIONS:
1. Levofloxacin 250 mg p.o. q. 48 hours.
2. Flagyl 500 mg p.o. twice a day.
3. Digoxin 0.125 mg p.o. q. 48 hours.
4. Lasix 80 mg p.o. twice a day.
5. Ferrous sulfate 325 mg p.o. twice a day.
6. Calcitriol 0.25 mg p.o. q. day.
7. Calcium carbonate 500 mg p.o. three times a day with
meals.
8. Calcium gluconate one gram p.o. twice a day.
9. Epogen 4000 units subcutaneously Tuesday, Thursday and
Saturday.
10. Zoloft 200 mg p.o. q. day.
11. Albuterol 1 to 2 puffs q. six hours p.r.n.
12. Fentanyl patch 50 micrograms per hour topically q. 72
hours.
13. Colace 100 mg p.o. twice a day.
14. Dulcolax one to two tablets p.o. q. day p.r.n.
15. Dulcolax suppository, one per rectum q. day p.r.n.
16. Heparin 5000 units subcutaneously twice a day.
17. Dilaudid 2 to 4 mg p.o. q. four to six hours p.r.n.
breakthrough pain.
18. NPH insulin 5 units subcutaneously q. a.m.
19. NPH insulin 1 unit subcutaneously q. h.s.; hold if blood
sugar less than 160.
20. Sliding scale Regular insulin four times a day.
CONDITION ON DISCHARGE: Satisfactory.
DISPOSITION: Rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Infected, gangrenous ulcers, both legs.
2. Left below the knee amputation on [**2130-6-30**].
SECONDARY DIAGNOSES:
1. Suicidal ideation, resolved.
2. Worsening renal failure, no hemodialysis at this time.
3. Chronic anemia, status post transfusion.
4. Tracheal stenosis requiring CPAP.
5. Type 1 diabetes mellitus with triopathy.
6. Cardiomyopathy.
7. Hypertension.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2130-7-3**] 22:06
T: [**2130-7-3**] 22:25
JOB#: [**Job Number 23883**]
ICD9 Codes: 4280, 5849
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5218
}
|
Medical Text: Admission Date: [**2190-8-24**] Discharge Date: [**2190-9-8**]
Date of Birth: [**2112-10-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2190-8-25**] Upper and Lower GI Endoscopy
[**2190-8-31**] Mitral Valve Replacement(29mm Mosaic Porcine valve) and
Three Vessel Coronary Artery Bypass Grafting(left internal
mammary to left anterior descending, vein grafts to obtuse
marginal and posterior descending artery)
History of Present Illness:
77 yo male with history of CAD and IMI. Elective cath done in
preparation for planned MVR. Cath revealed LM 50%, LAD 80%, CX
50%, RCA 100%, mild AI, EF 50%, moderate MR.Echo also showed 4+
MR and 2+ AI. Referred to Dr. [**Last Name (STitle) 1290**] for MVR/CABG/possible
AVR.
Past Medical History:
CAD/IMI
NIDDM
elev. chol.
HTN
CHF
DJD
very HOH
pacer for bradycardia [**2185**] ([**Company 1543**] Sigma 300 DR)
Social History:
retired, lives with wife
no ETOH
quit smoking 5 years ago, 55pack-yrs
no recr. drugs
Family History:
non-contrib.
Physical Exam:
HR 72 RR 16 right 124/60 left 120/58
5'8" 158#
WDWN in NAD
skin unremarkable
PERRL, EOMI, NC/AT, OP benign
neck full ROM, no JVD or bruits
CTAB
RRR 3/6 murmur
soft, NT, ND, + BS
warm, well-perfused, no edema, no varicosities
alert and oriented X 3, MAE, non-focal
2+ fem/DP/PT/radials
Pertinent Results:
[**2190-9-7**] 07:25AM BLOOD WBC-8.4 RBC-3.68* Hgb-8.9* Hct-28.1*
MCV-77* MCH-24.2* MCHC-31.7 RDW-21.9* Plt Ct-315#
[**2190-9-7**] 07:25AM BLOOD Plt Ct-315#
[**2190-9-7**] 07:25AM BLOOD PT-25.9* PTT-35.4* INR(PT)-2.6*
[**2190-9-7**] 07:25AM BLOOD Glucose-85 UreaN-24* Creat-1.4* Na-140
K-4.4 Cl-99 HCO3-32 AnGap-13
Brief Hospital Course:
Admitted for surgery on [**8-24**] and taken to the OR. Hematocrit
drawn prior to incision was 20.5. This represented a significant
drop from his last PAT Hct which was 27.5. Surgery cancelled in
the OR for anemia work-up to rule out a source of active
bleeding.Patient taken to CSRU in stable condition and extubated
there later in the day. Seen by general surgery team and GI
consult. Abd/pelvic CT scanning also done with no source of
bleeding or hematomas found. EGD and colonoscopy done on [**8-25**]
with were negative. Capsule endoscopy on [**2190-8-27**] showed
angioextasia in the distal small bowel. Angiography showed no
active bleeding. Hematology consult recommended iron
supplementation. General surgery deferred push enteroscopy via
laparotomy. He as taken to the operating room on [**2190-8-31**] where
he underwent a CABG x 3 and MVR (Porcine). Please see op note
for details. He was extubated on POD #1. He was seen by
electrophysiology who reprogrammed his PPM to a backup rate of
80 from 70, and turned off the sleep mode to help wean from his
epinephrine. The pacer was returned to its original settings on
[**2190-9-3**]. He was anticoagulated for underlying atrial
fibrilation.
Medications on Admission:
amiodarone 200 mg daily
lopressor 25 mg [**Hospital1 **]
omeprazole 20 mg daily
ASA 325 mg daily
glyburide 2.5 mg daily
combivent
lasix 40 mg [**Hospital1 **]
vytorin 10/40 mg daily
KCl
amoxicillin prn dental
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. 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*
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Vytorin 10/40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a
day.
Disp:*60 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
anemia
CAD
IMI
NIDDM
CHF
DJD
very HOH
pacemaker (bradycardia)[**Company 1543**] Sigma 300 DR
Discharge Condition:
good
Discharge Instructions:
follow up appts. as below
Followup Instructions:
see Dr. [**Last Name (STitle) 1057**] in [**1-11**] weeks
schedule follow up appt. with Dr. [**Last Name (STitle) 1290**] in 3 weeks ( after
hematology work-up is complete). Please call him this coming
Thursday [**9-2**] for update.
Completed by:[**2190-9-9**]
ICD9 Codes: 4240, 4280, 9971, 2724, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5219
}
|
Medical Text: Admission Date: [**2132-9-11**] Discharge Date: [**2132-9-18**]
Date of Birth: [**2057-9-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
s/p fall out of wheelchair
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74M w/h/o Afib, HTN, COPD, DM, PVD, CVA, s/p fall w/ SAH. Until
two days prior, when he presented to OSH for routine arterial
studies of RLE for PVD. Following studies, pt was brought to
entrance of clinic in wheelchair, and subsequently found to have
fallen out of wheelchair with abrasions to right frontal area of
head, as well as R arm. Taken there directly to OSH ED.
.
At OSH, initial labs INR 2.3, PTT 38, Hct 29.7, Plt 264. CT head
revealed bilat SAH, no midline shift. Pt was given two units
PRBCs and two units FFP. Received 1g fosphenytoin load, vitk 5mg
SC. Transferred to [**Hospital1 18**] for further evaluation.
.
At [**Hospital1 18**] ED, given 2units of Proplex, when INR on arrival was
1.9, Hct down to 25.2 from reported 29.7. Initially guaiac
negative in ED.
.
Since arrival, CT head again confirmed bilat SAH. Pt was started
on nimodipine to prevent cerebral vasospasm, all anticoagulation
held.
.
per wife: + DOE for the last year, only walk 20 ft, but no
CP/shoulder pain/neck pain/no palpitations/ n/v/diaphoresis. No
PND/orthopnea, syncope or presyncope. + bilateral claudication
+LE edema:R>L. Denies f/c/sweats, weight changes, abd pain,
melena, hematochezia, dysuria, urinary frequency,
arthralgia/myalgia or rashes. + cough and wheeze, but generally
well-controlled with inhalers, and not currently worse from
baseline.
Past Medical History:
HTN
NIDDM
Hypercholesterolemia
R rotator cuff injury s/p surgical repair
R knee surgery
R CEA
h/o polyps, nonmalignant
COPD (last PFTs this year, but unk results)
Atrial Fibrillation (on warfarin)
CVA w/ residual facial weakness 1/05
R CEA [**1-17**]
PVD s/p R Fem-[**Doctor Last Name **] bypass
R knee surgery
Last colonoscopy ?5 yrs ago, (+) polyps
BPH
Social History:
Lives with wife in [**Name (NI) **].
Tobacco: 2PPD X 52yrs, quit 10yrs ago.
Alcohol: 2drinks/day
Family History:
Noncontributory
Physical Exam:
T- 98.3 BP- 143/76 HR- 109 RR- 16 O2Sat 97% on RA
Gen: Lying in bed, NAD, in C collar
HEENT: NC/AT, moist oral mucosa
CV: irregular, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive. Speech
is fluent with normal comprehension. No dysarthria.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact V1-
V3. Mild R facial droop. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 4+ 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
(pt. reports R delt weakness 2/2 rotator cuff injury)
Sensation: Intact to light touch throughout.
Reflexes:
+2 and symmetric throughout, except absent in R patella (site of
R knee surgery)
Toes downgoing bilaterally
Coordination: finger-nose-finger normal
Pertinent Results:
[**2132-9-11**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-9-11**] 06:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2132-9-11**] 06:00PM PLT COUNT-237
[**2132-9-11**] 06:00PM ANISOCYT-1+ MACROCYT-1+
[**2132-9-11**] 06:00PM NEUTS-76.9* LYMPHS-17.2* MONOS-4.2 EOS-1.3
BASOS-0.5
[**2132-9-11**] 06:00PM WBC-7.6 RBC-2.69* HGB-8.6* HCT-25.2* MCV-94
MCH-31.9 MCHC-34.0 RDW-16.3*
[**2132-9-11**] 06:00PM URINE HOURS-RANDOM
EKG: AFib 80, borderline inf axis, nonspecific TW flattening in
III, avF.
.
CTA Head:
Wet read: No aneurysm seen although reconstructions are pending.
Absent right vertebral artery.
.
CT Head:
IMPRESSION: Subarachnoid hemorrhage, greatest in the areas of
the sylvian fissures bilaterally. Though the etiology is likely
traumatic, an underlying aneurysm is not excluded.
The extensive nature of the hemorrhage, and the apparent
spherical area of high density in the left sylvian fissure
(seires 2 image 15) raise a concern of aneurysmal bleeding.
Recommend CTA, MRA, or catheter arteriography for further
evaluation.
.
CT Abd/Pelvis [**2132-9-11**]
1. No definite acute traumatic injury identified. There is very
mild wedging of the anterior portion of the T11 vertebral body,
of undetermined age.
2. Indeterminate left adrenal lesion. This may represent an
adenoma, but further evaluation with CT or MR is recommended.
3. Small bilateral pleural effusions.
4. Atherosclerosis of the abdominal aorta, with mild dilation of
the
infrarenal portion to 2.8 cm.
5. Enlarged prostate.
.
TTE [**2132-9-16**]: left and right atriums moderately dilated; mild
symmetric left ventricular hypertrophy; left ventricular
systolic function is normal (LVEF 70%); increased left
ventricular filling pressure (PCWP>18mmHg). No masses or thrombi
are seen in the left ventricle. Mild to moderate mitral
regurgitation is seen- the severity
of mitral regurgitation may be significantly UNDERestimated;
borderline pulmonary artery systolic hypertension; no
pericardial effusion.
.
CXR [**2132-9-16**]:persistence of small bilateral pleural effusions,
with minimal congestive heart failure/volume overload, mild
improvement from [**2132-9-13**].
.
[**2132-9-18**] 07:00AM BLOOD WBC-7.9 RBC-3.23* Hgb-9.9* Hct-28.7*
MCV-89 MCH-30.5 MCHC-34.3 RDW-19.5* Plt Ct-258
[**2132-9-16**] 06:35AM BLOOD Glucose-111* UreaN-62* Creat-3.3* Na-138
K-3.9 Cl-102 HCO3-22 AnGap-18
[**2132-9-17**] 07:00AM BLOOD Glucose-163* UreaN-54* Creat-2.6* Na-140
K-3.8 Cl-102 HCO3-23 AnGap-19
[**2132-9-18**] 07:00AM BLOOD Glucose-126* UreaN-47* Creat-2.1* Na-142
K-3.8 Cl-105 HCO3-23 AnGap-18
[**2132-9-17**] 07:00AM BLOOD WBC-7.7 RBC-3.37* Hgb-9.7* Hct-28.8*
MCV-86 MCH-28.8 MCHC-33.6 RDW-20.0* Plt Ct-256
[**2132-9-16**] 06:35AM BLOOD WBC-7.9 RBC-2.75* Hgb-8.4* Hct-24.3*
MCV-88 MCH-30.7 MCHC-34.7 RDW-17.6* Plt Ct-221
[**2132-9-15**] 06:05AM BLOOD calTIBC-211* TRF-162*
[**2132-9-14**] 09:47PM BLOOD Hapto-237* Ferritn-373
[**2132-9-13**] 09:00PM BLOOD VitB12-178* Folate-GREATER TH Ferritn-209
[**2132-9-16**] 06:35AM BLOOD PTH-81*
[**2132-9-14**] 05:15PM BLOOD Type-ART pO2-82* pCO2-33* pH-7.44
calTCO2-23 Base XS-0
Brief Hospital Course:
A/P: 74yoM w/ h/o DM, HTN, PVD, COPD, here s/p fall w/ SAH now
w/ SOB and ARF.
.
# Cards- Vasculopath, longstanding h/o HTN now w/SOB and pleural
effusion, cardiomegaly on CXR
- Pump- echo shows EF 70%
-- Hold on standing lasix
- Rate/Rhythm- A. Fib; rate controlled
-- continue Atenolol, Diltiazem
-- anticoagulation held [**2-14**] falls (was on ASA, plavix, coumadin
when fell)
- Coronaries
-- Plan for outpt w/u w/exercise stress when stable.
- HTN
-- d/c Atenolol, start Metoprolol, start hydralazine/isosorbide
dinitrate; Plan to restart ACE [**Last Name (LF) **], [**First Name3 (LF) **] d/c hydral/isosorbide
at that time.
.
# Renal- ARF on CRI(baseline Cr unknown), initiall oliguric, now
autodiuresing
-- Cr on admission 1.7, discharge creatinine 2.1 Pt w/ recent
h/o contrast studies [**2132-9-11**], [**2132-9-12**]; FENA 0.2- Prerenal/ATN.
- transfusion of 1 unit overnight followed by Diuril 500 mg IV
and IV Lasix 120 mg with improvement in UO
- Urine Alb/Cr ratio 0.7 likely secondary to long standing DM
and Hypertension
- Plan to restart ACE [**Month/Day/Year **] as above.
.
# Pulm- SOB, 92% on 6L, 80's on RA; ABG: 7.44/33/82
- Pleural effusions- most likely [**2-14**] CHF
-- continue to diurese
-- renal consulted, recommending fluid challenge followed by
diuresis.
-- f/u CXR showing resolution of effusions,
-- [**2132-9-17**] 97% on RA
- COPD
-- continue inhalers, nebs prn
-- continue O2 to maintain Sat>92%
.
# Neuro- new subarachnoid hemorrhage, h/o CVA- stable
- Subarachnoid Hemorrhage
-- Neurosurg following recs:
-- Plan to restart Plavix [**2132-9-18**], Plan to restart coumadin
[**2132-10-12**]
-- continue Nimodipine/Dilantin for 3 wk course
- h/o CVA- stable hemiparesis R side
-- continue ASA
.
# Heme
- Anemia- ?[**2-14**] SC absorption from numerous ecchymoses- iron
studies reveal anemia of chronic inflammation
-- pretreat w/ Tylenol, Benadryl for a ? transfusion reaction
with no evidence of hemolysis
-- Transfused with clinical improvmement.
- Continue to hold Plavix, warfarin for now
.
# [**Name (NI) **] pt w/ h/o chronic bronchitis
- Treated with Azithromycin, Ceftriaxone for possible PNA;
?retrocardiac opacity
.
# GI- unlikely to be GI source given Guaiac negative stools.
- continue PPI.
- bowel regimen.
.
# Endocrine- DM2- SSI
.
# FEN.- regular diet, replete lytes.
.
# PPX. SC heparin, PPI, bowel regimen
.
# Code: Full
.
# Communication: Primary Care Physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20561**] MD
[**Telephone/Fax (1) 26190**], [**Name (NI) 1094**] Wife: [**Telephone/Fax (1) 69044**] (cell)
.
# Dispo: d/c home when stable; f/u w/ Dr. [**Last Name (STitle) 548**] 6 wks
[**Telephone/Fax (1) 1669**]; fax d/c summary to Dr. [**Last Name (STitle) 20561**] on D/c office
ph:[**Telephone/Fax (1) 26190**]
Medications on Admission:
Diltiazem 240 mg QD
Zocor 40 mg QD
Combivent 8x/day
Advair 500/50 [**Hospital1 **]
Atenolol 100 QD
Lasix 80 QD
Metformin 500 QID
Prevacid 30 QD
Cozaar 50 [**Hospital1 **]
Allopurinol 300 QD
Coumadin 5 mg Q sunday, 2.5 mg Mon-Sat
Plavix 75 mg QD
ASA 81 mg QD
Lisinopril 40 mg QD
Tramodol 50 mg QID PRN
Terazosin 2 mg QID
Discharge Medications:
1. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 2 weeks.
Disp:*168 Capsule(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Disp:*135 Tablet(s)* Refills:*2*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Traumatic subarachnoid hemorrhage
ARF
hypoxia
Discharge Condition:
stable
Discharge Instructions:
Return to ER or call Dr.[**Name (NI) 2845**] office if you develop sudden
worsening headaches or any neurologic changes
[**Month (only) 116**] restart coumadin [**2132-10-12**].
Return to ER or call Dr.[**Name (NI) 2845**] office if you develop sudden
worsening headaches or any neurologic changes
[**Month (only) 116**] restart coumadin in 1 month.
Please follow up with Dr. [**Last Name (STitle) 20561**] in the next 2 weeks.
Please take your medications as directed.
Please recheck your labs including creatinine outpatient with
your primary care physician; if your creatinine is below 2.0,
please stop taking hydralazine/isosorbide dinitrate and restart
your Cozaar per your primary care physician.
Followup Instructions:
You have the following appointments:
Follow up with Dr. [**Last Name (STitle) 548**] on [**2132-10-15**]- head CT at 11:45 AM please
do not eat for 4 hours before CT, 1 PM appointment with Dr.
[**Last Name (STitle) 548**], call [**Telephone/Fax (1) 2992**] if you have questions.
Follow up with Dr. [**Last Name (STitle) 20561**], please call for appointment.
Please recheck your labs including creatinine outpatient with
your primary care physician; if your creatinine is below 2.0,
please stop taking hydralazine/isosorbide dinitrate and restart
your cozaar per your primary care physician.
[**Name10 (NameIs) 357**] schedule follow up colonoscopy.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
ICD9 Codes: 2851, 5849, 5859, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5220
}
|
Medical Text: Admission Date: [**2178-10-14**] Discharge Date: [**2178-11-3**]
Date of Birth: [**2120-5-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lamictal /
Shellfish Derived
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
For full H&P please refer to Nightfloat admission note briefly
this is a 58 y.o. Female with a history of gastric bypass 4
years ago w/ multiple recent complications including spinal
abscess, osteomyelitis, intraabdominal leak, spinal
osteomyelitis with abscess, sepsis who was initially admitted
for weakness.
.
On review of her initial note it appears she was discharged
following the aforementioned complicated course on a course of
first Clindamycin x [**1-28**] wks which was changed to Levaquin and
Vancomycin. On the day of her admission she was found by her [**Month/Day (3) 269**]
to be extremely weak specifically with lower extremity weakness
but no bladder/bowel incontinence or anaesthesia. She initially
was seen at [**Hospital3 4107**] and then transferred to [**Hospital1 18**] as pt
did not want further care at [**Hospital1 112**].
.
She was then admitted to the [**Hospital1 1516**] service where she was noted to
have hypokalemia due to increased K+ wasting though it is
unclear as to why this was occuring. She was also noted to be in
[**Last Name (un) **] thought to be secondary to Vancomycin toxicity (her reported
Vancomycin was noted to be 80?). An MRI was obtained given her
lower extremity weakness and was notable for worsening L4-5
disco-osteomyelitis. Orthopaedics were consulted and pt
underwent a diskectomy, debridement and anterior fusion on
[**10-20**]. Following induction of her anaesthesia she was noted to
be tachycardic ranging from 80s-110s. She underwent a 1.5 hour
surgery which was uneventful. In the PACU though her BP was
noted to drop from 110s to 70s, though she was mentating well.
BP was not fluid responsive and pt was started on Neo ar 0.3 and
titrated up to a max of 0.8. Following IVF resuscitation 2.8L as
well as 1u PRBC post-op (she received 2u PRBC prior to surgery)
she was able to wean off pressors and have an increase in her
urine output. For work-up of her hypotension she underwent [**Last Name (un) **]
stim testing which was negative for adrenal insufficiency.
.
Her ICU course has also been notable for a diffuse morbilliform
rash with palm and sole sparing. Dermatology were consulted for
possible SJS. Given lack of mucosal involvement SJS was ruled
out however Dermatology is still following the patient. The
rash, which has steadily been improving, was thought to be due
to Lamotrigine toxicity given her progressively poor Creatinine
Clearance. Though interestingly enough unclear if Lamotrigine
has dose adjustments based on renal clearance.
.
With regards to her diskitis, her blood cultures have thus far
been negative and she is currently on Aztreonam and Vancomycin
per ID recs. She is still being followed by Ortho who will take
her to the OR tomorrow for posterior fusion, after which she
will be able to participate in PT.
.
She is also being followed by Renal for her [**Last Name (un) **] which is thought
to be AIN [**12-29**] Vancomycin toxicity. Renal are currently
considering possible biopsy to confirm AIN.
.
On review of her vitals in the unit over the past few hours her
Tmax has been 100.2, Tc 98.6, HRs 109-118, SBP 114-149/59-70, RR
24, 100% on RA.
.
ROS per HPI.
Past Medical History:
Gastric Bypass 4 years ago with multiple complications
Spinal Abscess and Osteo
Bipolar disorder requiring hospitalization in the [**2158**]
Congestive heart failure - apparently this resolved after her
bariatric surgery and subsequent weight loss (EF unknown).
Social History:
Living Situation: She lives with daughter and granddaughter. [**Name (NI) **]
[**Name2 (NI) 269**] at her house
Tobacco: denied
EtOH: denied
IVDU: denied
Family History:
FAMILY HISTORY:
Father: HTN
Mother: CHF
Brother: [**Name (NI) **] CA
Physical Exam:
PE: T:99.4 BP:142/67 HR:93 RR:18 O2 96% RA
Gen: NAD/ ill appearing/ Comfortable/ appears stated age/
pleasant
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor,
dryMM, clear oropharynx, no erythema, no exudates no rhinorrhea/
discharge,
NECK: supple, trachea midline, no LAD, no thyromegaly
LUNG: CTA-B/L, no R/R/W
CV: S1&S2, RRR, II/VI SEM no/G/M
ABD: well healed surgical scar, Soft/+BS/ mild tenderness in the
RLQ/ ND/no rebound/ no guarding/
EXT: No C/C/E
+2 pulses radial, DP, PT b/l & symetrical
SKIN: No lesions, rashes, bruises
BACK: tenderness in the L4-L5 region
RECTAL: normal tone
NEURO: AAOx3
CN II-XII grossly intact and non-focal b/l
5/5 strength in upper ext
[**3-1**] hip flexors, [**3-31**] in the rest of the lower ext b/l
Sensation to pain, temp, position intact b/l
Reflexes [**12-31**] brachioradialis, biceps, triceps,
Unable to elicit in the lower ext patellar, Achilles
Toes down going
Unremarkable finger/nose, unremarkable rapid/alternating
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
[**2178-10-14**] 08:21PM BLOOD WBC-7.0 RBC-3.57* Hgb-8.1* Hct-25.7*
MCV-72* MCH-22.7* MCHC-31.6 RDW-17.5* Plt Ct-250
[**2178-10-14**] 08:21PM BLOOD Neuts-84.2* Lymphs-9.6* Monos-3.6 Eos-2.1
Baso-0.5
[**2178-10-14**] 08:21PM BLOOD Glucose-86 UreaN-16 Creat-2.8* Na-138
K-2.2* Cl-94* HCO3-25 AnGap-21*
[**2178-10-14**] 08:31PM BLOOD Lactate-0.7 K-2.2*
Vancomycin 82.4* ug/mL (10 - 20)
[**2178-10-15**] 07:20AM BLOOD Vanco-78*
---------------
DISCHARGE LABS:
[**2178-11-3**] 05:04AM BLOOD WBC-10.2 RBC-3.16* Hgb-8.4* Hct-25.7*
MCV-81* MCH-26.5* MCHC-32.6 RDW-18.2* Plt Ct-253
[**2178-11-3**] 05:04AM BLOOD Glucose-102 UreaN-10 Creat-0.9 Na-141
K-3.4 Cl-105 HCO3-29 AnGap-10
[**2178-11-3**] 05:04AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.4
---------------
EKG ([**2178-10-14**] 20:35): NSR, rate 90, Left axis deviation, poor
R-wave progression, LVH
---------------
IMAGING STUDIES:
CXR ([**2178-10-14**]): No acute cardiopulmonary process.
.
Renal US ([**2178-10-15**]): Unremarkable renal son[**Name (NI) **]. [**Name2 (NI) **]
hydronephrosis.
.
CXR ([**2178-10-15**]):
1. Right PICC catheter terminates at the junction of right
subclavian and right internal jugular vein, without evidence of
pneumothorax.
2. New-onset small right pleural effusion.
.
MR spine ([**2178-10-15**]):
1. Signal changes at L4-5 which has progressed since [**2178-9-17**]
and is concerning for disco-osteomyelitis. No definite epidural
extension is identified, although the lack of intravenous
contrast does decrease sensitivity. Endplate degenerative
changes are also a differential consideration (type 1), but
considered less likely given the progression.
2. Transitional anatomy with sacralization of the L5 vertebral
body.
3. Mild degenerative disc disease at other levels as detailed
above, most significant at the T7-8 level, where there is mild
spinal canal narrowing and indentation of the ventral aspect of
the spinal cord.
.
CT Abd/Pelvis ([**2178-10-16**]):
1. Limited examination secondary to lack of intravenous and oral
contrast.
2. Free intra-abdominal air within the upper abdomen is somewhat
less in amount compared to the outside hospital CT exam from
[**2178-9-18**]. Evidence of extensive inflammatory changes in the
upper abdomen, not well assessed on this non-contrast
examination. No definte intra-abdominal collection..
3. Mesenteric adenopathy.
4. Left adrenal myelolipoma, stable.
5. Erosive changes involving the endplates of the L5 vertebral
body and S1 portion of the sacrum concerning for osteomyelitis,
better delineated on the recent MRI of the lumbar spine. No
other erosive changes evident throughout the visualized
skeleton.
6. Right lower lobe consolidation versus atelectasis.
.
Lumbar Spine Xray ([**2178-10-20**]):
Single intraoperative cross-table lateral image of the LS spine
shows placement of a metallic interbody fusion device at L4-5.
Normal vertebral body alignment and discs. We have no
preoperative comparison radiographs.
.
CXR ([**2178-10-21**]):
Lungs are fully expanded and clear. Previous mild vascular
engorgement has resolved and may reflect hypovolemia. Heart size
top normal, unchanged. No pleural effusion or pneumothorax.
Right-sided central venous line tip projects over the mid SVC.
[**2178-10-30**]: EGD
Impression: The stomach remnant appeared normal
Erythema in the lower third of the esophagus
Large small bowel ulcer which could represent the site of
bleeding (biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations:
Return patient to floor.
Continue high dose ppi.
Await biopsy report
Post discharge, patient needs outpatient GI follow up in fellow
clinic
[**2178-10-30**] Colonoscopy:
Impression:
Stool in the [**Month/Day/Year 499**] noted.
Otherwise normal colonoscopy to hepatic flexure of [**Month/Day/Year 499**]. No
obvious bleeding source was noted.
Recommendations:
Return patient to floor
Since the colonoscopy was aborted at the level of hepatic
flexure, patient will need a colonoscopy as an outpatient.
Brief Hospital Course:
ASSESSMENT: 58 y.o. Female s/p distant gastric bypass
complicated by recent hospitalization for leak s/p repair,
sepsis initially admitted for LE weakness, hospitalization c/b
diskitis s/p anterior fusion/debridement, ICU stay for
hypotension on pressors now transferred to floor awaiting
posterior fusion.
PLAN:
## Diskitis: Pt was initially admitted for lower extremity
weakness with mild weakness with the hip flexors, normal rectal
tone. MRI work up was notable for L4-L5 disco-osteomyelitis.
Unclear as to the source of her disco-osteomyelitis though given
her recent discharge for sepsis it is possible that she seeded
when she was bacteremic. Pt underwent debridement under OR and
anterior fusion and later posterior fusion. Anterior fusion
post-op course complicated by sepsis (discussed below). OR Swabs
and multiple subsequent bld cultures have been negative.
- Continued on Aztreonam and Vancoymcin per ID recs, switched
from aztreonam to levofloxacin. Now on Levofloxacin PO Q24H, and
vancomycin 1gm IV Q24H
- post-op pain control: PCA switched to morphine contin 15mg PO
Q12H, plus morphine 5-15mg PO Q6H PRN breakthrough pain (has had
little pain med requirements, pain well controlled)
- Ortho recommended PT
- [**Name (NI) **] need a vanc trough drawn on [**2178-11-4**] and dose adjustement
accordingly
##. Rash: Pt noted to have diffuse rash over entire body with
sparing of mucousal membranes, feet soles and palm. Dermatology
followed and concluded this was due to lamictal, secondary to
increased levels during ARF. Pt now noted to have lamictal
allergy.
-Held lamictal and rash resolved without signs of mucositis
-Pt to continue triamcinolone cream for a total of 2 weeks
(start date [**2178-10-23**])
## Sepsis: Pt admitted to the unit for sepsis. Although resolved
it is unclear as to the exact cause. Pt's hypotensive episode
occured several hours after anterior fusion surgery so unlikely
to be anaesthesia induced. Given requirement of pressors
following surgery in an area complicated by infection
hypotensive episode may be [**12-29**] transient bacteremia. Vanc and
levo broadened to vanc and aztreonam. After several days,
aztreonam switched back to levofloxacin. Bld cultures and swabs
have thus far been negative. Sepsis resolved after less than 24
hours and pt has been off pressors since.
- was continued on Aztreonam and Vancomycin per ID recs and
later switched back to levofloxacin
- To rehab facility: Pt has a f/u appointment at the [**Hospital **] clinic
of [**Hospital6 1708**] with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], MD on
[**2178-11-5**] 1000am. #: [**Telephone/Fax (1) 39041**]. They will decide the stop date
of patient's antibiotics.
.
## ARF: Unclear etiology. Creatinine peaked to 2.8 but
eventually resolved now at 0.9. Per renal, ARF may have been due
to vancomycin toxicity from too high dosing. (vanc level 80 at
one point). No signs of uremia and no dialysis was employed.
- To rehab facility: Please make sure to f/u vanc troughs every
three days, as pt has unstable vancomycin pharmacokinetics
## Guiac positive stool: Pt with guiac positive melena. Hct and
hemodynamics remained stable. Pt underwent EGD which showed a
large jejunal ulcer with stigmata of bleeding but no active
bleeding. This may have been due to the stress from all the
acute illnesses of osteo/discitis, sepsis, etc. No intervention
done. Colonoscopy non-diagnostic due to poor prep. Hct stable.
Pt continued on pantoprazole IV Q12H until GI follow determines
when to discontinue.
## Malnutrition: Pt malnourished with an albumin of 1.9 and INR
of 1.4 secondary to vitamin K deficiency thought to be related
to her severe illnesses during the last 2 months. Pt refusing
TPN initially, calorie count initiated, only 200-300 calories
per day, therefore, TPN initiated inhouse started [**2178-11-2**].
Patient also with K and Mg abnormalities.
- To rehab facility: Please see Page 2 for nutrition recs.
- To rehab facility: Please check daily K and Mg and replete
lytes as necessary.
Medications on Admission:
MEDICATIONS:
Vancomycin 1.5g Q12
Levaquin 500mg daily
Flexeril 10mg TID
Carvidilol 25mg [**Hospital1 **]
Paxil 40mg daily
Lamictal 100mg daily
Seroquel 50mg daily
Klonopin 1mg TID
Dilaudid 2mg prn
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
2. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SC
injection Injection TID (3 times a day).
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Please hold for sedation and RR <12.
8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain: hold for sedation
.
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Please hold for sedation and RR <12.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for diarrhea .
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for diarrhea.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Hypokalemia
Weakness
Osteomyelitis/Diskitis
S/p gastric bypass revision with leakage, intra-abdominal
abscess and Spinal abscess
Jejunal ulcer
Acute on chronic diastolic congestive heart failure
Malnutrition
Secondary:
HTN
Depression
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Vital signs stable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the [**Hospital1 18**] for weakness. You had gastric
bypass 4 years ago and a recent revision in [**2178-5-27**] that was
complicated by intra-abdominal leakage and spinal abscess with
osteomyelitis. During your hospital stay your surgery to debride
the osteomyelitis was complicated by sepsis, which promptly
resolved after IV fluids and IV antibiotics. You also developed
kidney failure, possibly due to vancomycin toxicity (high serum
levels at presentation) which also resolved over time. You
developed a rash thought to be related to a lamictal allergy in
the setting of increased reduced lamictal clearance given kidney
failure. This too resolved with time. Also, you developed an
ulcer which bled, and a scope showed that this ulcer remained
stable. You will follow up with GI regarding the ulcer here at
[**Hospital1 18**] and you will return to the [**Hospital **] clinic at [**Hospital1 112**], where they
know you quite well. You also developed malnutrition secondary
to all of these illnesses, which is requiring total parenteral
nutrition.
Please make sure to follow up with all your follow up
appointments.
Followup Instructions:
You have an appointment at the [**Hospital **] clinic of [**Hospital6 13185**] with [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], MD already an appointment on
[**2178-11-5**] 1000am. #: [**Telephone/Fax (1) 39041**].
Date/Time:[**2178-12-2**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 10314**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2178-11-17**] 1:30
Completed by:[**2178-11-5**]
ICD9 Codes: 0389, 5849, 2762, 2851, 2768, 4280, 5859, 2930, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5221
}
|
Medical Text: Admission Date: [**2187-1-31**] Discharge Date: [**2187-2-1**]
Date of Birth: [**2115-5-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
difficulty extubating after PVI
Major Surgical or Invasive Procedure:
Pulmonary vein isolation
Intubation
Extubation
Placement and removal of arterial line
History of Present Illness:
(Patient intubated, history from OMR and wife): 71 yo M with
atrial fibrillation, s/p PVI and flutter ablation on [**2186-11-21**],
s/p redo PVI today, now in sinus rhythm but still intubated.
.
Patient has a long history of atrial fibrillation (see below).
He came in today for a scheduled redo-PVI, after which he was
initially extubated. He complained of shortness of breath and
had poor mental status due to sedation. ABG at the time on CPAP
was 7.18/69/79 but then improved to 7.34/38/182 after
re-intubation. He received 2x 10 mg IV lasix. CXR at the time
was suggestive vascular congestion. He was thus transferred to
the CCU for weaning of sedation and ventillation.
.
In terms of patient's cardiac history, he has had hypertension
for the past 20 years. He developed atrial fibrillation 10 years
ago, which initially paroxysmal, but progressed to continous
since [**4-29**]. He was evaluated in [**8-29**] by Dr. [**Last Name (STitle) **] and started
on amiodarone
.
He had a PVI here on [**2186-11-21**], with isolationof all 4 pulmonary
veins with extensive lines in the left atrium, mitral isthmus,
coronary sinus, and also the right atrial isthmus. He organized
into slow regular atrial tachycardia and then was cardioverted
into sinus rhythm. At follow-up on [**2186-12-25**], his EKG showed
narrow-complex tachycardia at 128 bmp. Subsequently, he
underwent several cardioversions at [**Hospital3 **] but
reverted to A fib. His Amiodarone was cut down to 200mg qd in
[**Month (only) 1096**] and admitted to redo PVI.
.
ROS: Per wife, increased SOB and fatigue. No palpitations,
syncope, or orthopnea. Has had an URI over the past week with
cough and scant yellow phlegm but no fever. ROS otherweise
negative.
Past Medical History:
Hypertension
Afib s/p PVI [**11-29**] and prior cardioversions
Anxiety
? Hepatitis with mononucleosis as a teen
Ulcers/gastritis/PUD on Vioxx
s/p EGD with cautery of ulcer
shoulder surgery bilaterally
Right Knee surgery
BPH (patient had mild hematuria for several days after foley
insertion for PVI)
(-) TIA (-) CVA (+) GIB (-) sleep apnea (not diagnosed
but pt suspects he has)
Social History:
Retired, lives with wife and has 3 grown children. Never smoked
or used recreational drugs. Drinks wine occasionally.
Family History:
No family history of CAD, MIs, sudden death
Physical Exam:
ON ADMISSION:
GENERAL: Intubated, sedated, in no distress
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: JVP difficult to assess
CARDIAC: Regular rhythm, rate 80, normal S1/S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: ET tube in place. On A/C support. Unlabored, no accessory
muscle use. No obvious wheezes. Scattered crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ edema up to mid-calf bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
ON DISCHARGE:
GENERAL: extubated, speaking in full sentences, NAD
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: JVP difficult to assess
CARDIAC: Regular rhythm, rate 80, normal S1/S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: ET tube in place. On A/C support. Unlabored, no accessory
muscle use. No obvious wheezes. Scattered crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ edema up to mid-calf bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2187-1-31**] 07:05AM BLOOD WBC-5.4 RBC-5.19 Hgb-16.8 Hct-46.5 MCV-90
MCH-32.4* MCHC-36.1* RDW-14.5 Plt Ct-149*
[**2187-1-31**] 07:05AM BLOOD PT-24.0* INR(PT)-2.3*
[**2187-1-31**] 07:05AM BLOOD Glucose-135* UreaN-12 Creat-0.9 Na-134
K-3.8 Cl-98 HCO3-26 AnGap-14
[**2187-1-31**] 07:07PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.6
[**2187-1-31**] 07:07PM BLOOD Triglyc-113
[**2187-1-31**] 03:21PM BLOOD Type-ART Rates-12/ Tidal V-550 PEEP-5
pO2-122* pCO2-43 pH-7.32* calTCO2-23 Base XS--3 -ASSIST/CON
Intubat-INTUBATED
[**2187-1-31**] 03:21PM BLOOD freeCa-1.02*
[**2187-1-31**] 05:05PM BLOOD Hgb-14.0 calcHCT-42
.
DISCHARGE LABS:
[**2187-2-1**] 04:00AM BLOOD WBC-10.7 RBC-4.29* Hgb-13.9* Hct-39.9*
MCV-93 MCH-32.3* MCHC-34.7 RDW-14.7 Plt Ct-193
[**2187-2-1**] 04:00AM BLOOD PT-29.5* PTT-32.7 INR(PT)-2.9*
[**2187-2-1**] 04:00AM BLOOD Glucose-181* UreaN-17 Creat-1.1 Na-133
K-4.8 Cl-100 HCO3-23 AnGap-15
[**2187-2-1**] 04:00AM BLOOD Calcium-8.4 Phos-4.4 Mg-1.8
ABG [**2-1**]: 7.42/37/136
.
STUDIES:
TEE [**1-31**]:
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20
cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
masses or vegetations on aortic valve.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral valve. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. The patient was under
general anesthesia throughout the procedure. No glycopyrrolate
was administered. No TEE related complications. Results were
reviewed with the Cardiology Fellow involved with the patient's
care.
Conclusions
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). 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 leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. Trivial/physiologic pericardial effusion.
IMPRESSION: No intracardiac thrombus. Preserved left ventricular
function. No significant valvular regurgitation.
.
CXR [**1-31**]:
Overlying defibrillator pads limit this evaluation and there are
low lung
volumes. Endotracheal tube is appropriately positioned. There is
vascular
crowding likely secondary to the low lung volumes, although an
element of
vascular congestion cannot be entirely excluded. A retrocardiac
opacity may represent atelectasis.
.
CXR [**2-1**]:
FINDINGS: A previously placed nasogastric tube has been removed
in the
interval. Moderate cardiomegaly without evidence of pulmonary
edema. No
pleural effusions. No focal parenchymal opacity suggesting
pneumonia.
Moderate tortuosity of the thoracic aorta.
Brief Hospital Course:
71 yo M with atrial fibrillation, s/p PVI and flutter ablation
[**11-29**] and subsequent conversion, s/p PVI redo on [**1-31**]
complicated by respiratory failure.
.
# Atrial fibrillation: Pt underwent PVI on [**1-31**]. This is the
second PVI the patient has had here. He is also s/p multiple
cardioversions, as well as failed trials of Norpace and
Dronedarone in the past, and currently on amiodarone. TEE was
done pre-procedurally showing no thrombus. Following the PVI,
he remained in sinus rhythm with HR in the 70-90s overnight, and
MAPs>60 (breifly requiring neo). He was continued on amiodarone
200mg daily, as well as his home coumadin regimen (remained
therapeutic overnight), and was discharged on his home regimen.
He was also discharged on a prophylactic antibiotic regimen of
keflex 500mg QID x5 days post-procedurally.
.
# Respiratory distress: Patient developed shortness of breath
after extubation in the EP lab and had one ABG which showed
hypoxemia. He was re-intubated as a result and restarted on
phenylephrine for pressure support. On transfer to CCU he was on
A/C, PEEP of 5, and FiO2 of 100%, on propofol gtt. Likely
etiology included large body habitus, sedation for procedure,
and also an underlying URI that started about a week ago. CXR
from the EP lab was of poor quality but did show signs of fluid
overload which resolved on subsequent X-ray after 40mg IV lasix.
His respiratory status and oxygenation improved markedly and he
was extuabated early in the morning following his procedure
without complication.
.
# Anxiety: Patient has anxiety at baseline and this might have
played a role in the difficult extubation. As he is was weaned
off sedation, he was controlled with prn ativan without
complication.
.
# GERD/gastritis: Continued on home regimen of omeprazole 20 mg
po daily.
.
# Hypertension: Not currently on any antihypertensives. He was
weaned off neo, and his BPs remained stable.
.
# Gout: Renal function was intact with Cr of 0.9 the morning of
discharge. He was continued on home regimen of colchicine and
allopurinol.
.
# BPH: Continued home regimen of tamsulosin 0.4 mg daily. Of
note, pt with difficulty voiding on day of discharge likely
secondary to not receiving his tamsulosin the night before. He
did receive it the morning of discharge and subsequently voided
later in the afternoon.
.
# CAD prevention: Patient does not have documented CAD, though
he is on primary prevention with Aspirin and atorvastatin, which
was continued.
Medications on Admission:
ALLOPURINOL 300 mg daily
AMIODARONE 200 mg daily
ATORVASTATIN 10 mg daily
COLCHICINE 0.6 mg Tablet - 2 tabs daily
OMEPRAZOLE 20 mg daily
TAMSULOSIN [FLOMAX] 0.4 mg daily
WARFARIN 7mg M/W/F, 6mg all other days
ASPIRIN 81 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. colchicine 0.6 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO (MON, WED, FRI):
Please take one 5 mg tablet and one 2 mg tablet for a total of 7
mg on Mondays/Wednesdays/
Fridays. .
Disp:*12 Tablet(s)* Refills:*2*
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO (MON, WED, FRI):
Please take one 5 mg tablet and one 2 mg tablet for a total of 7
mg on Mondays/Wednesdays/ Fridays.
Disp:*12 Tablet(s)* Refills:*2*
10. warfarin 6 mg Tablet Sig: One (1) Tablet PO
(SUN,SAT,[**Last Name (LF) **],[**First Name3 (LF) **]).
Disp:*16 Tablet(s)* Refills:*2*
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 5 days: Please take from [**2187-2-1**] through [**2187-2-5**] for a
total of 5 days. .
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Gout
Anxiety
Benign prostatic hyperplasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 6608**], you were admitted to the Cardiac ICU at the [**Hospital1 1535**] because after the procedure to
help stop your atrail fibrillation, you had difficulty coming
out of sedation and breathing on your own. We were able to take
you off of the breathing machine by the morning. Your heart
rhythm was regular after the proceudre, and your blood pressure
stable.
.
We did not make any changes to you medications. However, you
should take keflex (antibiotic) as directed below
.
You should follow-up with your cardiologist Dr. [**Last Name (STitle) **] at the
time listed below.
Followup Instructions:
Department: CARDIOLOGY, DR [**Last Name (STitle) **]
When: THURSDAY [**2187-3-8**] at 4:40 PM
ICD9 Codes: 4019, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5222
}
|
Medical Text: Admission Date: [**2170-9-18**] Discharge Date: [**2170-10-3**]
Date of Birth: [**2112-4-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
[**9-18**] PROCEDURES:
1. Intramedullary nail left femur.
2. Closed treatment of pelvic ring fracture with manipulation.
PROCEDURE
1. Open reduction and internal fixation, unstable ring, with
orthogonal plate.
2. Inferior vena cava filter via the right femoral route.
History of Present Illness:
58 yo male driver of motorcycle s/p crash, was ejected and
reportedly struck by SUV. He was taken to an area hospital where
found to have multiple injuries and was then transferred to
[**Hospital1 18**] for further care.
Past Medical History:
RLE DVT [**4-29**] yrs ago, no longer on coumadin
HTN
GERD
Social History:
Married
Family History:
Noncontributory
Pertinent Results:
[**2170-9-18**] 02:40PM WBC-13.5* RBC-3.15*# HGB-9.0*# HCT-27.9*
MCV-89 MCH-28.6 MCHC-32.2 RDW-14.6
[**2170-9-18**] 02:40PM PLT COUNT-257
[**2170-9-17**] 10:39PM GLUCOSE-141* LACTATE-3.4* NA+-140 K+-3.7
CL--103
[**2170-9-17**] 10:39PM HGB-13.3* calcHCT-40 O2 SAT-63 CARBOXYHB-2
MET HGB-0
[**2170-9-17**] 10:25PM WBC-14.8* RBC-4.27* HGB-12.4* HCT-36.8*
MCV-86 MCH-29.0 MCHC-33.6 RDW-14.2
[**2170-9-17**] 10:25PM PLT COUNT-255
[**2170-9-17**] 10:25PM PT-12.5 PTT-18.9* INR(PT)-1.1
Imaging upon admission:
Right acetabular fracture with loose intraarticular fragment,
widened pubic symphsis and left SI joint
Left L3-5 TP fracture, T7-10 SP fracture, right ribs [**8-5**]
fracture
Right second metatarsal fracture
Left closed comminuted femur fracture
MR [**Name13 (STitle) 30171**] [**2170-9-25**]
IMPRESSION:
1. Edema in the infraspinatus, teres minor, and subscapularis
muscles. This could be related to trauma, especially given the
history. If symptoms
persist, repeat noncontrast MRI in approximately 2-3 months is
suggested to evaluate for other causes of muscular edema.
2. Partial thickness intrasubstance tear of the infraspinatus at
the
myotendinous junction. No full-thickness rotator cuff tears.
Brief Hospital Course:
He was admitted to the Trauma service. Orthopedics was consulted
and he was taken to the operating room for intramedullary nail
left femur and closed treatment of pelvic ring fracture with
manipulation. His metatarsal fracture was managed non
operatively.
On [**9-19**] he was noted with tachypnea/dyspnea and drop in his
hematocrit; a CTA of his chest was done which was positive for
PE. He was started on a heparin drip and transferred to the
Trauma ICU. He was later started on Coumadin and the Heparin
drip was stopped. His last INR on [**10-3**] was 2.7 (Goal INR [**2-27**]). He
required multiple blood transfusions during his hospital course
due to acute blood loss from his injuries. His last hematocrit
was 25 on [**2170-9-30**].
On [**9-27**] he was taken back to the operating room by Orthopedics
for open reduction and internal fixation, unstable ring, with
orthogonal plate; an IVC filter was placed at that time by
Trauma surgery. He was noted to complain of left shoulder pain
and underwent an MRI which showed a partial thickness
intrasubstance tear of the infraspinatus at the myotendinous
junction and no full-thickness rotator cuff tears. This will be
re-evaluated at his follow up orthopedic appointment.
He was eventually transferred back to the regular nursing unit.
His pain was controlled using IV narcotics initially and then he
was changed to oral narcotics prn with adequate control. He is
on an aggressive bowel regimen and is moving his bowels.
Physical and Occupational therapy were consulted and have
recommended rehab after his acute hospital stay.
Medications on Admission:
HCTZ, omeprazole, ASA
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: Two (2) Tablet PO at bedtime.
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for SOB/wheeze/cough.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for SOB/wheeze/cough.
10. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Goal INR [**2-27**].
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for indigestion.
12. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p Motorcycle crash
Bilateral femur fractures
Right acetabular fracture
Left sacroiliac fracture
Left L3-5 transverse process fracture
T7-10 spinous process fracture
Right rib fractures [**8-5**]
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
You may touch down weight bear on your left leg.
Followup Instructions:
Follow up in 2 weeks in [**Hospital 5498**] clinic with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], NP. Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks in clinic with Dr. [**Last Name (STitle) **], Trauma surgery
for evaluation of your rib fractures. You will need an end
expiratory chest xray for this appointment. Call [**Telephone/Fax (1) 2359**]
for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2170-11-6**]
ICD9 Codes: 2851, 486
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5223
}
|
Medical Text: Admission Date: [**2163-6-25**] Discharge Date: [**2163-7-2**]
Date of Birth: [**2117-7-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
IVC Filter [**2163-6-28**]
History of Present Illness:
55 y/o male s/p minimally invasive mitral valve repair on
[**2163-6-7**] presented to the ED for increasing dyspnea on exertion
and fatigue.
Past Medical History:
s/p minimally invasive mitral valve repair on [**2163-6-7**] (for
Mitral Regurgitation/Mitral Valve Prolapse)
borderline Hypertension
borderline Hypercholesterolemia
s/p ing. herniorrhaphy, appy, T & A, vasectomy
Social History:
lives with wife and children
auto repair business
no tobacco use
ETOH use socially
Family History:
non- contributory
Physical Exam:
VS: 99.8 100 130/68 20 95%
General: WD/WN, appears confortable
HEENT: NCAT, EOMI, OP WNL
Chest: +Crackles right base
Heart: RRR 3/6 SEM
Abd: +BS, soft, NT/ND
Ext: -C/C/E
Neuro: CN 2-12 intact, 5/5 strength, A&O x 3
Pertinent Results:
Chest CT [**6-25**]: Limited study due to poor enhancement of the
pulmonary artery. Massive filling defeat in bilateral main
pulmonary arteries, representing bilateral central PE, probably
extending to segmental branches of bilateral upper and lower
lobes, however, segmental branches are not fully evaluated.
Small right pleural effusion. Opacity in right upper and lower
lobes, which may be due to infartion, however, other processes
such as pneumonia or aspiration cannot be excluded. Opacity in
right upper lobe is somewhat rounded and measures 2 cm.
Echo [**6-25**]: Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). The right ventricular
cavity is markedly [**Month/Year (2) 6878**] with severe hypokinesis of the basal
2/3rds of the free wall. The apex is dynamic ([**Last Name (un) 13367**] sign).
Valvular [**Male First Name (un) **] is suggested, but an outflow tract gradient was not
assessed. A mitral valve annuloplasty ring is present. Mitral
regurgitation is present (?mild-moderate) but cannot be fully
quantified. Compared with the study of [**2163-6-7**] (images
reviewed), the right ventricular cavity dilation and systolic
dysfunction are new and c/w acute pulmonary process (e.g.,
pulmonary embolism). Tha mitral valve repair has been performed
and the severity of mitral regurgitation is reduced.
Abd CT [**6-27**]: Thrombus identified within the distal IVC,
measuring upwards of 5-6cm in length. 2. Peripheral-based
opacities in the right lower lung, consistent with atelectasis,
although possibly representing infarct if patient has known clot
on the right side.
[**2163-6-25**] 02:48PM BLOOD WBC-12.6* RBC-4.84 Hgb-14.4 Hct-40.7
MCV-84 MCH-29.7 MCHC-35.4* RDW-13.6 Plt Ct-189
[**2163-6-29**] 05:50AM BLOOD WBC-6.6 RBC-4.37* Hgb-12.6* Hct-36.4*
MCV-83 MCH-28.9 MCHC-34.7 RDW-13.3 Plt Ct-92*
[**2163-6-25**] 07:34PM BLOOD PT-12.5 PTT-23.4 INR(PT)-1.1
[**2163-6-30**] 05:50AM BLOOD PT-23.6* PTT-30.4 INR(PT)-2.4*
[**2163-6-25**] 02:48PM BLOOD Glucose-99 UreaN-20 Creat-1.3* Na-137
K-4.0 Cl-100 HCO3-25 AnGap-16
[**2163-6-29**] 05:50AM BLOOD Glucose-100 UreaN-13 Creat-1.3* Na-140
K-4.3 Cl-102 HCO3-27 AnGap-15
[**2163-6-26**] 12:27AM BLOOD HEPARIN DEPENDENT ANTIBODIES-POSITIVE
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] presented to the ED with
increased dyspnea on exertion since his minimally invasive
mitral valve repair on [**2163-6-7**]. He underwent a chest CT which
showed a "massive" bicentral pulmonary embolism. He was
immediately started on anticoagulation (Heparin, Coumadin) and
admitted to the Cardiac surgery ICU. TPA was not indicated
secondary to bleeding risk from recent surgery. He also
underwent an Echo which appeared consistent with an acute
pulmonary process (e.g., pulmonary embolism). Subsequently had a
bilateral lower extremity U/S which was negative for DVT. He had
a Hematology consult and HIT panel on hospital day two. HIT
panel came back positive on hospital day three and Argatroban
was started (Heparin stopped). Platelet count decreased 3
straight days to a low of 58 and then trended back upwards after
Heparin was stopped and while on Argatroban. He was transferred
to the cardiac surgery telemetry floor and later on this day an
Abdominal/Pelvic CT was performed which revealed a large
thrombus in the distal IVC. On hospital day four Vascular
surgery was consulted and brought patient to the catheterization
lab and placed a IVC filter proximal to the thrombus. He then
returned to the cardiac surgery step down floor. Over hospital
course he remained on Coumadin and it was titrated for a goal
INR of 2.5-3.5. Mr. [**Known lastname **] remained stable over the next
several days. Argatroban was stopped prior to discharge and he
was discharged with a platelet count of 111K on [**6-30**] and an INR
of 3.3 on [**7-2**]. His Coumadin will be followed by Dr. [**Last Name (STitle) 12816**]. He
was discharged home with VNA services and the appropriate
follow-up appointments on hospital day #8. Hypercoagulability
workup recommended as oupt. with Dr. [**Last Name (STitle) 12816**]. First blood draw
on Monday [**7-4**] with VNA with results to be faxed to Dr. [**Last Name (STitle) 12816**].
Medications on Admission:
Motrin, Lopressor, Aspirin, Amiodarone, Lipitor
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
3. Coumadin 5 mg Tablet Sig: 2.5mgm Tablets PO once a day: Take
as directed by Dr. [**Last Name (STitle) 12816**] for a goal INR 2.5 - 3.5.
Disp:*30 Tablet(s)* Refills:*1*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Pulmonary Embolism
IVC Thrombus
Heparin Induced Thrombocytopenia (HIT)
PMH: s/p minimally invasive mitral valve repair on [**2163-6-7**] (for
Mitral Regurgitation/Mitral Valve Prolapse), borderline
Hypertension,
borderline Hypercholesterolemia, s/p ing. herniorrhaphy, appy, T
& A, vasectomy
Discharge Condition:
good
Discharge Instructions:
Please resume previous discharge instructions.
Take Coumadin as directed by Dr. [**Last Name (STitle) 12816**]. (Goal INR is 2.5 -
3.5)
Followup Instructions:
Dr. [**Last Name (STitle) **] if decision is made to remove IVC filter.
[**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A Date/Time:[**2163-7-7**] 2:00
Dr. [**Last Name (STitle) 12816**] in [**1-17**] weeks (will follow Coumadin and INR, goal
2.5-3.5)
Dr. [**Last Name (STitle) **] in [**2-18**] weeks (if you have not seen since surgery)
Completed by:[**2163-7-18**]
ICD9 Codes: 2720, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5224
}
|
Medical Text: Admission Date: [**2168-5-14**] Discharge Date: [**2168-5-24**]
Date of Birth: [**2093-10-31**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 74 year-old man who
presented to [**Hospital6 3872**] with increased dyspnea
on exertion and worsening exertional chest pain since one
month. On [**5-12**] the patient developed 10 out of 10 chest pain
lasting several hours. Troponin level was 0.07 and was
transferred to [**Hospital1 69**] for
catheterization.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Glaucoma.
3. Hypertension.
4. Chronic constipation.
5. Chronic sinusitis.
6. Thoracic outlet syndrome.
7. Right carpal tunnel syndrome.
ALLERGIES: Sulfa.
MEDICATIONS AT HOME:
1. Glyburide 5 mg b.i.d.
2. Glucophage 1000 mg q day.
3. Zestril 10 mg q.d.
4. Aspirin 81 mg q.d.
5. Multivitamin.
6. Vitamin C.
7. Vitamin E.
8. Zinc.
9. Xalatan eye drops q.d.
10. Cosopt eye drops in each eye b.i.d.
11. Senna.
12. Insulin sliding scale.
13. Aspirin 325 mg q day.
14. Lipitor 80 q day.
15. Protonix q day.
16. Lopressor 75 b.i.d.
17. Lovenox.
The patient's cardiac catheterization results showed an EF of
58%, 78% stenosis of the left anterior descending coronary
artery, 80% of the obtuse marginal and 80% of the right
coronary artery.
REVIEW OF SYSTEMS: The patient denies any strokes or
transient ischemic attacks. Positive history of sciatica,
which is resolved. No gastrointestinal bleed. No dysphagia.
Positive dyspnea on exertion times one year. No orthopnea.
Positive paroxysmal nocturnal dyspnea. Recent wheezing.
Positive diabetes. No claudication. Positive chronic
dermatitis treated with steroids.
SOCIAL HISTORY: The patient denies tobacco use. Occasional
alcohol. Lives with his wife. Primary care taker for wife
who is ill.
PHYSICAL EXAMINATION: The patient is afebrile. Heart rate
of 74 and in sinus rhythm. Blood pressure 126/64.
Respiratory rate 16. Satting 98% on room air. The patient
was in no acute distress alert and oriented times three.
Pupils are equal, round and reactive to light. Extraocular
movements intact. The patient's neck was supple. There was
no lymphadenopathy and no JVD. Heart was regular rate and
rhythm with no murmurs, rubs or gallops. Respirations lungs
were clear to auscultation bilaterally. Gastrointestinal
positive bowel sounds. Abdomen nontender, nondistended. No
masses or hepatosplenomegaly. Extremities were cool. No
edema and no varicosities. Pulses were +2 throughout.
Carotids showed no bruits.
LABORATORY: White blood cell count of 7.3, hematocrit 38.3
and a platelet count of 165. Sodium 136, potassium 4.1,
chloride 106, bicarb 23, BUN 20, creatinine 1.3, glucose
224. PT 12.8, PTT 32.5 and INR was 1.1, ALT was 14, AST 18,
alkaline phosphatase 46, amylase 110, bilirubin 0.5.
ASSESSMENT/PLAN: This is a 74 year-old male with coronary
artery disease. The patient is to be preoped for coronary
artery bypass graft. On [**2168-5-19**] the patient was brought to
the Operating Room for elective coronary artery bypass
grafting. The patient had a left internal mammary coronary
artery to left anterior descending coronary artery and
saphenous vein graft to obtuse marginal. The patient was
transferred to the CSRU intubated on a neo-synephrine drip,
insulin drip and Propofol drip. The patient had chest tubes
to suction and pacing wires. Immediately postoperatively,
the patient was hemodynamically labile. The patient was
rehydrated with electrolyte repletion. The patient was
extubated and his glucose was monitored. On the night of
postoperative day one the patient had anginal pain similar
pain to the angina that he had preop. The patient was given
nitroglycerin and Lopressor. The patient was also given 2 mg
of morphine, pain free. Electrocardiogram done at the time of
the patient's pain showed no changes. Heart rate was in the
110s with pain and was in the 90s after Lopressor. Systolic
blood pressure was 100, mean arterial pressure was in the
60s, PA pressures were 22/11, CVP was 7. Cardiac index was
2.6. The patient's blood gases were within normal limits.
This was discussed with Dr. [**First Name4 (NamePattern1) 26196**] [**Last Name (NamePattern1) **] who felt just to
monitor the patient's hemodynamics.
On postoperative day one the patient was continued on insulin
drip, given Lopressor overnight. He had a temperature max of
100.0. Heart rate was in the 100s in sinus tachycardia,
otherwise other vital signs were stable. The patient was
satting 100% on 2 liter nasal cannula. The patient's
immediate postoperative laboratories showed a white blood
cell count of 12.3, hematocrit 29.3 and a platelet count of
128. Otherwise laboratory values were within normal limits.
The patient was out of bed to chair with physical therapy.
On postoperative day two the patient was on no drips. The
patient continued to be tachycardic to the low 100s with some
premature ventricular contractions overnight. However, the
patient's other vital signs were all stable. The patient's
hematocrit was 27.2. Chest tubes were continued. The
patient had air leak in his chest tubes. Chest tubes were
placed to water-seal. Lopressor was increased to 50 b.i.d.
and the patient was started on diuresis with Lasix 20 b.i.d.
Chest x-ray was obtained. The patient was transferred to the
floor. On postoperative day number three the patient had no
events overnight. The patient was afebrile, vital signs were
stable. The patient's Lopressor was increased to 75 b.i.d.
The patient's hematocrit was 29.7. Chest tubes were
continued. The patient had an air leak, which was deemed to
be part of the system. The system was completely changed and
the air leak was no longer present. The patient was working
with physical therapy and was out of bed to chair and
ambulating the hallways.
On postoperative day four the patient had no events
overnight. The patient was continued on aspirin, Lasix 20
b.i.d., Metoprolol 75 b.i.d. The patient's temperature max
was 98.3, heart rate was 90 in sinus rhythm. Blood pressure
was 104/55. The patient was making good urine and had a
minimal output from chest tubes. The patient's chest tubes
were removed on postoperative day four. The patient was
screened for rehab due to the fact that his wife was in the
hospital and no one would be at home to help with care. The
patient was again out of bed with physical therapy. On
postoperative day five the patient was afebrile, vital signs
were stable. The patient was out of bed with physical
therapy with a physical therapy level of four. The patient
is in no acute distress, regular rate and rhythm, had some
bibasilar crackled. Abdomen was soft. Incision was clean,
dressed and intact. There was no erythema. The patient was
transferred to [**Hospital3 26197**] for further rehab.
FOLLOW UP PLANS: The patient will follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in two weeks. The patient will call up for an
appointment. The patient will follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in six weeks. The patient will call up for an
appointment. The patient will be discharged to [**Location 26198**].
DISCHARGE MEDICATIONS:
1. Lasix 20 mg tablet one tablet po b.i.d.
2. Potassium chloride 20 milliequivalents b.i.d.
3. Colace 100 mg tablet po b.i.d.
4. Zantac 150 po b.i.d.
5. Tylenol 325 two tablets po q 4 hours as needed for pain
6. Percocet 5/325 mg tablet one to two tablets po q 4 to 6
hours as needed for pain.
7. Aspirin 325 one tablet po q day.
8. Timolol one drop in the right eye b.i.d.
9. Metoprolol 75 mg po b.i.d.
10. Glyburide 5 mg po b.i.d.
11. Glucophage 500 b.i.d.
12. Insulin regular per sliding scale.
DISCHARGE STATUS: Discharged to [**Location 26197**] for further
rehab, physical therapy and nutrition in stable condition.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 10638**]
MEDQUIST36
D: [**2168-5-23**] 10:47
T: [**2168-5-24**] 06:47
JOB#: [**Job Number 26199**]
ICD9 Codes: 4111, 4019, 2720
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5225
}
|
Medical Text: Admission Date: [**2135-8-13**] [**Month/Day/Year **] Date: [**2135-8-27**]
Date of Birth: [**2087-8-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Acute respiratory Distress
Major Surgical or Invasive Procedure:
Tracheostomy Tube Placement
Central Venous Acces through Right Internal Jugular Vein
Phimosis retraction
History of Present Illness:
47M with history of OSA/COPD, bipolar, schizophrenia presenting
with increased somnolence and respiratory distress. At
approximately 940 this morning, patient was found by staff at
nursing home to be acute SOB with altered MS. [**Name14 (STitle) 103309**] to 53% on
RA. Was placed on 15L O2 non-rebreather, and O2 sat came up to
88%. [**Name6 (MD) **] by NP, who called EMS. On EMS arrival, GCS
reportedly 8. Given nebs, BiPAP, manually bagging, then with
improvement to GCS of 11. But even after nebs, poor breath
sounds bilaterally.
Nursing home reports patient has been well and at baseline
(independent except in bathing and dressing) until yesterday,
when we felt fatigued. This morning he did not come to
breakfast, so staff went to see him in his room, where he was
found to be SOB, as above. Was oriented and asked to see
doctor, but fatigued and with occassional jerking motions of
hand. Last med change was increase in metformin on [**7-19**]. No
other recent med changes. Nurse gives him meds. No vomiting,
diarrhea, or decreased PO intake. Has been using BiPAP
consistently for OSA/COPD at night.
In the [**Name (NI) **], pt continued to have poor breath sounds B/L. He
responded to voice and sternal rubs, not responding to commands.
No wheezing or crackles, just poor air movement. He was on
BiPAP in ED, then woke up and complained of back pain, and he
was given 30mg IV Toradol. First ABG showed PO2 140, PCO2 93,
pH 7.21, bicarb 39. He then desatted again, and became more
somnolent. At that point, he was intubated (1 attempt, not
difficult airway). He does have trach scar (hx of difficulty
weaning from vent). He had fluffy infiltrates on CXR and very
dry, tea-colored urine. He got fluid, but was hypotensive. He
got RIJ line and was started on levophed once placement was
confirmed. Potassium was 7.7 on arrival, so he was given 10U of
insulin, 1 amp of calcium gluc, 1 amp D50, repeat 7.3. In ED
was satting 88% on 100% FiO2 on vent with good air movement.
Azithromycin and solumedrol 125 for presumed copd. In terms of
hi BP, he 75/50 before pressor. He came up to 101/64 now after
levophed. His HR was 64, rr18, sat 87%. Before pt came up to
MICU, he bradyed to 35, then came back up to 70. ED talked to
cardiology, may have had mobitz 2 or complete heart block when
bradyed, then 1st degree avblock after. Renal fellow will see
in micu.
On arrival patient is responsive to voice and sternal rub. Does
not follow commands.
Review of systems:
(+) Per HPI
Past Medical History:
1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia
Social History:
Has been living at [**Location 1268**] [**Hospital1 1501**] (RossCommons) since [**Month (only) 958**]
[**2134**] for his sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none
Family History:
Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.
Physical Exam:
Admission exam:
Admit Vitals:
General Appearance: Overweight / Obese / Intubated / Not
responsive to voice
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric)
Abdominal: Soft, Non-tender, Distended, Obese
Extremities: No(t) Cyanosis, No(t) Clubbing
Skin: Warm
Neurologic: Not following commands
[**Name (NI) **] Exam:
Vitals Tmax: 37.7 ??????C (99.9 ??????F)
Tcurrent: 37.4 ??????C (99.4 ??????F)
HR: 83 (69 - 104) bpm
BP: 140/69(83) {119/40(63) - 150/129(134)} mmHg
RR: 20 (16 - 38) insp/min
SpO2: 93%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 134.8 kg (admission): 132.9 kg
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 417 (271 - 470) mL
PS : 12 cmH2O
RR (Set): 16
RR (Spontaneous): 31
PEEP: 16 cmH2O
FiO2: 50%
PIP: 29 cmH2O
Plateau: 28 cmH2O
Compliance: 25 cmH2O/mL
SpO2: 93%
ABG: 7.36/50/64/35/1
Ve: 12.5 L/min
PaO2 / FiO2: 128
General Appearance: Overweight / Obese / trached / awakes
follows commands
Cardiovascular: distal heart sounds no MRG.
Respiratory / Chest: Distant breath sounds
Abdominal: Soft, Non-tender, Obese, +hypoactive BS
Skin: Warm
Neurologic: trached, interactive, follows commands, MAE. writes
on paper coherently to communicate.
Pertinent Results:
ADMISSION LABS
[**2135-8-13**] 11:00PM URINE HOURS-RANDOM
[**2135-8-13**] 11:00PM URINE UHOLD-HOLD
[**2135-8-13**] 10:36PM CARBAMZPN-3.2*
[**2135-8-13**] 09:29PM TYPE-ART TEMP-37.7 PO2-79* PCO2-54* PH-7.39
TOTAL CO2-34* BASE XS-5 INTUBATED-INTUBATED
[**2135-8-13**] 09:29PM LACTATE-1.7 K+-5.8*
[**2135-8-13**] 09:29PM freeCa-1.28
[**2135-8-13**] 08:13PM TYPE-ART TEMP-37.1 PO2-60* PCO2-44 PH-7.43
TOTAL CO2-30 BASE XS-3 INTUBATED-INTUBATED
[**2135-8-13**] 08:13PM LACTATE-2.8*
[**2135-8-13**] 08:13PM O2 SAT-91
[**2135-8-13**] 08:13PM freeCa-1.14
[**2135-8-13**] 08:00PM GLUCOSE-126* UREA N-50* CREAT-2.2* SODIUM-136
POTASSIUM-7.5* CHLORIDE-100 TOTAL CO2-27 ANION GAP-17
[**2135-8-13**] 08:00PM CK(CPK)-63
[**2135-8-13**] 08:00PM CK-MB-2 cTropnT-0.09* proBNP-2275*
[**2135-8-13**] 08:00PM CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-1.8
[**2135-8-13**] 08:00PM URINE HOURS-RANDOM UREA N-391 CREAT-97
SODIUM-49 POTASSIUM-68 CHLORIDE-85
[**2135-8-13**] 08:00PM URINE OSMOLAL-391
[**2135-8-13**] 08:00PM WBC-12.4* RBC-6.05 HGB-17.2 HCT-55.9* MCV-92
MCH-28.3 MCHC-30.7* RDW-15.7*
[**2135-8-13**] 08:00PM PLT COUNT-235
[**2135-8-13**] 07:57PM TYPE-ART TEMP-37.7 PH-7.42 COMMENTS-GREEN TOP
[**2135-8-13**] 07:57PM freeCa-1.09*
[**2135-8-13**] 05:25PM GLUCOSE-152* UREA N-51* CREAT-2.3* SODIUM-138
POTASSIUM-7.9* CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
[**2135-8-13**] 05:25PM ALT(SGPT)-18 AST(SGOT)-16 LD(LDH)-245 ALK
PHOS-65 AMYLASE-333* TOT BILI-0.4
[**2135-8-13**] 05:25PM ALBUMIN-3.8 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2135-8-13**] 05:25PM TYPE-ART TEMP-37 PO2-57* PCO2-47* PH-7.38
TOTAL CO2-29 BASE XS-1 INTUBATED-INTUBATED
[**2135-8-13**] 05:25PM GLUCOSE-143* LACTATE-2.1* K+-7.3*
[**2135-8-13**] 05:25PM freeCa-1.14
[**2135-8-13**] 05:25PM WBC-12.7* RBC-6.20 HGB-17.3 HCT-57.6*
MCV-92.9 MCH-27.6 MCHC-30.0* RDW-15.9*
[**2135-8-13**] 05:25PM PT-13.0* PTT-29.6 INR(PT)-1.2*
[**2135-8-13**] 05:25PM PLT COUNT-228
[**2135-8-13**] 03:31PM K+-7.7*
[**2135-8-13**] 02:57PM COMMENTS-QNS TO [**Last Name (un) **]
[**2135-8-13**] 02:57PM GLUCOSE-125* K+-GREATER TH
[**2135-8-13**] 02:40PM VoidSpec-GROSSLY HE
[**2135-8-13**] 02:38PM TYPE-ART TEMP-37.8 RATES-18/0 TIDAL VOL-1000
O2-100 PO2-56* PCO2-62* PH-7.29* TOTAL CO2-31* BASE XS-1
AADO2-601 REQ O2-97 -ASSIST/CON INTUBATED-INTUBATED
[**2135-8-13**] 12:19PM PO2-161* PCO2-80* PH-7.25* TOTAL CO2-37* BASE
XS-5 COMMENTS-SPECIMEN A
[**2135-8-13**] 11:38AM TYPE-ART PO2-140* PCO2-93* PH-7.21* TOTAL
CO2-39* BASE XS-5
[**2135-8-13**] 11:25AM PH-7.25* COMMENTS-GREEN TOP
[**2135-8-13**] 11:25AM GLUCOSE-111* LACTATE-2.0 NA+-140 K+-7.7*
CL--93* TCO2-33*
[**2135-8-13**] 11:25AM freeCa-0.99*
[**2135-8-13**] 11:05AM UREA N-54* CREAT-2.6*
[**2135-8-13**] 11:05AM estGFR-Using this
[**2135-8-13**] 11:05AM LIPASE-19
[**2135-8-13**] 11:05AM WBC-11.9* RBC-6.25* HGB-17.7 HCT-59.4* MCV-95
MCH-28.3 MCHC-29.8* RDW-15.6*
[**2135-8-13**] 11:05AM PT-12.7* PTT-27.8 INR(PT)-1.2*
[**2135-8-13**] 11:05AM PLT COUNT-263
[**2135-8-13**] 11:05AM FIBRINOGE-363
[**Month/Day/Year 894**] LABORATORY DATA
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2135-8-27**] 04:03 8.3 4.04* 11.0* 36.3* 90 27.2 30.2* 16.7*
419
Source: Line-central
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2135-8-14**] 04:02 72* 2 18 5 0 0 3* 0 0
Source: Line-aline
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2135-8-27**] 04:03 419
Source: Line-central
[**2135-8-27**] 04:03 13.1* 27.5 1.2*
Source: Line-central
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2135-8-25**] 08:00 570*
LAB USE ONLY
[**2135-8-27**] 04:03
Source: Line-central
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2135-8-27**] 04:03 114*1 13 0.5 147* 3.4 104 35* 11
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2135-8-20**] 20:49 Using this1
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2135-8-23**] 04:17 9 14 192 43 0.2
Source: Line-a-line
OTHER ENZYMES & BILIRUBINS Lipase
[**2135-8-13**] 11:05 19
TRAUMA; MODERATELY HEMOLYZED SPECIMEN
CPK ISOENZYMES CK-MB cTropnT proBNP
[**2135-8-14**] 04:02 2 0.07*1
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2135-8-27**] 04:03 8.4 3.3 2.0
LIPID/CHOLESTEROL Cholest Triglyc
[**2135-8-20**] 02:14 1461
ANTIBIOTICS Vanco
[**2135-8-18**] 06:18 21.0*
Source: Line-[**Female First Name (un) 71368**]#1; Vancomycin @ Trough
TOXICOLOGY, SERUM AND OTHER DRUGS Carbamz
[**2135-8-22**] 02:15 6.6
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent Comment
[**2135-8-26**] 12:01 ART 37.5 /19 50 64* 50* 7.36 29 1
INTUBATED SPONTANEOU1
[**2135-8-26**] 04:17 ART 37.6 20 80* 55* 7.46* 40* 12
INTUBATED
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2135-8-26**] 12:01 3.3
[**2135-8-26**] 04:17 0.8
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat
[**2135-8-25**] 11:51 12.5* 38
[**2135-8-25**] 11:03 12.6* 38
[**2135-8-25**] 08:08 13.9* 42
CALCIUM freeCa
[**2135-8-26**] 12:01 1.14
[**2135-8-26**] 04:17 1.11*
CXR [**8-13**] AP
Semi-upright portable radiograph of the chest was obtained.
Left lower lung opacification likely reflects a combination of
atelectasis, possible
aspiration or pneumonia, and external soft tissues. No
pneumothorax is seen. Small left greater than right pleural
effusions are likely also present. Moderate cardiomegaly is
presumed. Low lung volumes results in crowding of the
bronchovascular markings, though there is likely a degree of
pulmonary vascular congestion.
IMPRESSION: Left basal opacification, which may reflect,
atelectasis,
aspiration and/or infection. Small bilateral pleural effusions
and pulmonary vascular congestion.
CXR [**8-13**] AP-ETT placement
FINDINGS: Endotracheal tube terminates 1.5 cm above the carina.
However,
given kyphotic positioning and neck flexion it is likely at the
lower limits of acceptable positioning it should not be advanced
any further, but does not need to be withdrawn. Asymmetric
pulmonary opacities, left greater than right, likely reflect a
combination of edema and atelectasis. The costophrenic angles
are not well assessed, though small right effusion is likely
present. The heart size is moderately enlarged. Previously
noted left basilar opacities persists.
CXR- [**8-13**] central line
FINDINGS: As compared to the previous radiograph, the patient
has received a nasogastric tube. The course of the tube is
unremarkable, the tip of the tube is not included in the image.
The patient has also received a new right internal jugular vein
catheter. The course of the catheter is unremarkable, the tip
of the catheter projects over the lower SVC. No evidence of
complications, notably no pneumothorax.
Better seen than on the previous image are areas of bilateral
atelectasis as well as small bilateral pleural effusions.
Borderline size of the cardiac silhouette. No pneumothorax.
Need final reads on other us
Echo [**8-15**]:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis. Normal left ventricular
cavity size with preserved global systolic function.
Compared with the prior study (images reviewed) of [**2135-2-11**], the
findings are similar. The RV appears mildly dilated and
hypokinetic on review of the prior study images.
CTA Chest:
IMPRESSION: Study somewhat limited by poor contrast bolus
timing, with:
1. No evidence of central pulmonary embolus to the level of the
segmental
pulmonary arteries.
2. Dilatation of the main pulmonary artery, which appears to
have progressed
since [**12/2132**] and likely reflects pulmonary hypertension
secondary to the
patient's known obstructive sleep apnea.
3. No evidence of thoracic aortic dissection.
4. Left lower lobe, particularly posterior basal segmental,
consolidation and
collapse, with no definite evidence of airway obstruction; a
pneumonic process
is a consideration.
5. Cardiomegaly with small bilateral pleural effusions but no
pulmonary
edema.
CXR [**2135-8-19**]
Note is made that the original dictation was lost and the study
was brought to our review today on [**2135-8-20**], approximately
around 4:00 p.m.
The ET tube tip is 7 cm above the carina. The NG tube tip
passes below the diaphragm, most likely terminating in the
stomach. Multiple parenchymal consolidations appear to be
progressed as compared to the prior study. The findings are
worrisome for continuous progress of multifocal infection. No
pneumothorax is seen.
ECHO [**2135-8-24**]:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). with mild global free
wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion. Ecmo cannulas placed
with tee guidance. Aortic contours intact throughout. No changes
to cardiac structures throughout the exam.
CXR [**2135-8-25**]
Tracheostomy tube is in standard placement. There is no
mediastinal air or widening. Previous moderately severe
pulmonary edema has improved, with the most pronounced residual
around the left hilus and in the right infrahilar lung.
Substantial atelectasis persists at the left lung base. There
is no pneumothorax or more than minimal pleural effusion. Heart
size normal. Right jugular line ends in the mid-to-low SVC and
a nasogastric tube passes below the diaphragm and out of view.
PRELIMINARY ECHO REPORT AT TIME OF [**Month/Day/Year 894**]
(ECHO FROM [**2135-8-25**])
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Findings
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: No TEE related complications.
Conclusions
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). with mild global free
wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion. Ecmo cannulas placed
with tee guidance. Aortic contours intact throughout. No changes
to cardiac structures throughout the exam.
Brief Hospital Course:
47 yo with obesity hypoventilation, severe obstructive sleep
apnea, and asthma presenting with somnolence, hypoxia,
hyperkalemia, and shock. Etiology of acute decompensation was
not clear, but he has had other similar admissions for
respiratory failure.
Respiratory failure: Patient had been living in a skilled
nursing facility since [**2134-3-30**] for his sleep apnea and BIPAP
use. He presented with hypoxemia in the setting of somnolence.
Has longstanding history of complex breathing disorder,
including components of OSA, with history of acute respiratory
failure. Additionally, there was possiblity of a health care
associated pneumonia on imaging. The patient was intubated on
presentation, requiring high levels of PEEP> 20 cmH20 to
maintain oxygenation. He was empirically started on vancomycin,
aztreonam, and metronidazole for possible aspiration pneumonia.
Pulmonary emobolism was considered, and although the patient had
negative lower extremity ultrasounds, he was empirically started
on heparin for a possible pulmonary embolism (PE). After his
renal failure improved (see below), he was CT scanned which was
negative for a PE, and his heparin drip was discontinued. His
blood cultures came back positive for coagulase negative
Staphylococcus, and his antibiotics were weaned down to
cefazolin. Several attempts were made at weaning from the
ventilator, however the patient would become hypoxic with PEEP
amounts below 17 cmH20. Given multiple failed attempts at
extubation, an open surgical tracheostomy was placed. During
the procedure extra-corporeal oxygenation was required.
Post-operatively he did well. His trach should NEVER be removed
as it is unlikely emergent replacement or intubation would be
successful. Patient continued to require PEEP amounts between 10
and 16 cm of H20 for oxygen saturations between 86 and 92
percent.
*Given mechincal ventilation, was started on mouth care with
chlorhexadine.
*Was started on oral lansoprazole disolving tablet for peptic
ulcer disease prophylaxis while on ventilator.
*Again - he can NEVER BE DECANNULATED given that another
tracheostomy tube placement, should he need it, would be
technically complicated if not impossible and highly morbid.
Hypotension: Initially presented with blood pressures with
systolics in the 90 mmHg range. Felt to be consistent with
dehydration with possible component of heart failure. Echo
performed showed normal systolic function, with mild dilation
and mild global free wall hypokenesis. Given his associated
renal failure, IVF boluses were provided, which helped increase
his blood pressures. The patient remained hemodynamically
stable after IVF hydration.
Acute Renal Injury ([**Doctor First Name 48**]): Unclear cause of [**Doctor First Name 48**]. No recent
changes in medications or fluid intake. Likely prerenal
azotemia in setting of K+ supplementation, possible
decompensated diastolic CHF, and hypovolemia. We treated
medically with insulin, D50, bicarb, and Ca gluconate, but the
K+ did not normalize. A hemodialysis line could not be placed
in femoral by MICU/renal teams. IR placed line, and patient
received dialysis, which corrected the creatinine and K+. Both
have been normal since the 3rd day of hospital admission.
Schozaffective disorder: While in the MICU he was on his home
carbamazepine, doxepin, and risperidone. For assitance with
agitation while intubated, he was additionally placed on
quetiapine for several days, which was discontinued prior to
[**Doctor First Name **] from the MICU as he appeared less agitated.
Phimosis: Patient found to have a phimosis due to foreskin
entrapping the glans of the penis. Urology saw the patient and
reduced phimosis. Has been receiving topical bacitracin
topically, and can continue for the next 2 weeks (can
discontinue around [**2135-9-9**]). Should evaluate genitalia as
clinically indicated (and, at a minimum at least once per week)
to ensure no recurrence of phimosis.
Chronic Issues
Diabetes: on metformin at home. Maintained on sliding scale
insulin at home. Restarted metformin at [**Month/Day/Year **]. Was taking
aspirin 325 mg daily presumably for coronary artery disease
risk. No history of stroke per notes or physical exam. Changed
dosing from 325 mg qday to 81 mg qday to decrease risk of
gastrointestinal bleed.
Chronic diastolic congestive heart failure: At nursing home,
patient was receiving 100 mg [**Hospital1 **] furosemide and metolazone 2.5
mg 1 tablet po daily. Given issues with hypernatremia, his
diuresis was held and he was supplmented with free water flushes
via his tube feeds. On [**Hospital1 **], his diuresis with furosemide
was resumed, but his metolazone was still held. Should be kept
on low sodium diet with weights checked daily, with more acute
diuresis with a 3 lbs weight gain in 24 hours. At time of
[**Hospital1 **] from the ICU the patient was approximately 15 Liters
positive.
Erythrocytosis: On admission had elevated hematocrit. Given his
chronic respiratory issues, felt to be secondary to chronic
hypoxemia.
Hypertension: His lisinopril and metoprolol were held during
his MICU admission. Given the low dose medications (lisinopril
2.5 mg and metoprolol tartrate 12.5 mg [**Hospital1 **]), they were
discontinued in house while as his HR remained around 80 beats
per minute and his blood pressures were around 130mmHg systolic.
At time of [**Hospital1 **], his metoprolol was resumed for management
of chronic heart failure, and his lisinopril was held given
complications with [**Last Name (un) **] at time of admission.
Code Status: Confirmed Full
Communication: Sister [**Name (NI) **] [**Name (NI) 103310**] (HCP) - [**Telephone/Fax (1) 103299**] cell:
[**Telephone/Fax (1) 103311**]
TRANSITIONAL ISSUES
*Chronic Diastolic Heart Failure: Patient's diuresis was held
while hospitalized due to hypernatremia. Furosemide was
restarted however metolazone was still held upon [**Telephone/Fax (1) **] to
[**Hospital **] Rehab. He will need clinical evaluation to determine
when to resume metolazone. (Please see chronic dCHF above
regarding dosing). For hypernatremia he is receiving 200 cc
free water flushes through his dobhoff.
*Patient was on theophyline at nursing home prior to admission
to the hospital. His theophyline was DISCONTINUED while at the
hospital and was continued to be held at time of dischare to
rehab.
*Regarding his hypertension, patient was normotensive and
nontachycardic while in the hospital. His metoprolol was held
as well as his lisinopril given his inital hypotension. Given
his complications of acute kidney injury on presentation, his
lisinopril was continued to be held at time of [**Hospital **], but
his metoprolol was resumed (more so for management of his
chronic diastolic heart failure). Can reevaluate renal function
and whether to start lisinopril at rehab.
*Regarding feedings and ventilation, the patient had a
tracheostomy tube placed on [**2135-8-24**]. Speech and swallow was
consulted who said the patient will need further evaluation
first for a Passy-Muir valve, and then further speech and
swallow evaluation to deterimine if he can receive PO feedings.
Thus, a dobhoff tube was placed to provide the patient with tube
feedings and a route for oral medications while speech and
swallow evaluation should be on going at rehabilitation. The
patient has been having sips of water for comfort, however he
should NOT be allowed to have PO feedings/fluids in general as
he is currently at risk of aspiration.
*Regarding his tracheostomy tube, the patient had an open
tracheostomy procedure. If his tracheostomy tube should fall
out, it is a medical emergency and will need emergent transfer
to a facility for replacement of his tracheostomy tube. As he
had an open procedure, if his tracheostomy tube falls out
attempts at reinserting his endotracheal tube SHOULD NOT BE
ATTEMPTED as there is a risk of cannulation of a false lumen and
intubation of a tissue plane rather than his trachea.
Additionally, as noted above - he CANNOT BE DECANNULATED without
clearly and unambiguously understanding that repeat tracheostomy
(should he need it) would be technically complicated if not
impossible, and decannulation would place him at great clinical
risk including death.
Medications on Admission:
Medications: This is old list -- check against nursing home
records
albuterol nebs prn
combinebs prn
asa 325
carbamazepine 200 qid
doxepin 10 qhs
furosemide 100mg [**Hospital1 **]
lisinopril 2.5 daily
metolazone 2.5 daily
metoprolol 12..5 [**Hospital1 **]
omeprazole 20 daily
kcl 60meq daily
risperidone 4mg [**Hospital1 **]
acetaminophen 650 q4 prn
benztropine 0.5mg daily prn dystonia
atrovent nebs q 6 hours prn
[**Hospital1 **] Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Albuterol Inhaler [**7-10**] PUFF IH Q4H:PRN shortness of breath,
wheeze
3. Albuterol-Ipratropium [**7-10**] PUFF IH Q6H
4. Bacitracin Ointment 1 Appl TP QID
Please apply to glans and under foreskin
5. Bisacodyl 10 mg PO/PR DAILY constipation
6. Carbamazepine 200 mg PO QID
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Doxepin HCl 10 mg PO HS
10. Heparin 5000 UNIT SC TID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Risperidone 4 mg PO BID
13. Senna 1 TAB PO BID constipation
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Benztropine Mesylate 0.5 mg PO Q24 PRN dystonia
16. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
17. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR<60/ SBP<100 mmHg
18. Aspirin 81 mg PO DAILY
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
[**Location (un) **] Diagnosis:
Primary Diagnosis:
Acute respiratory failure secondary to pnemonia
Secondary Diagnosis:
OBSTRUCTIVE SLEEP APNEA
CHRONIC DIASTOLIC DYSFUNCTION
ACUTE KIDNEY FAILURE
OBSTRUCTIVE SLEEP APNEA
DIABETES-NON INSULIN DEPENDENT
OBESITY UNSPECIFIED
SECONDARY POLYCYTHEMIA
ASTHMA, UNSPECIFIED
MANIC-DEPRESSIVE DISORDER
SCHIZOAFFECTIVE DISORDER
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
Mr. [**Known lastname 732**]
[**Last Name (NamePattern1) **] were admitted to [**Hospital1 18**] in the intensive care unit because
of your difficulty breathing. Your breathing became so
difficult that you were placed on a machine ("ventilator") to
assit your ventilation. Unfortunately, you were not able to
adequately breath on your own without assistance from the
ventilator, and required the placement of a tracheostomy tube.
This allows you to receive assitance from the ventilator, while
attempting trials without assitance, through access from the
tracheostomy tube.
Additionally, you developed a pneumonia and a blood stream
infection for which you were treated.
You will be going to [**Hospital **] Rehab for further physical
rehabilitation as well as assitance with your new tracheostomy,
including speech and swallow studies.
Take your medications as directed. It has been a pleasure
taking care of you.
Followup Instructions:
Please follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
The following specialty appointments have already been made.
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2135-9-8**] at 3:30 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 1570**]
When: THURSDAY [**2135-9-8**] at 3:30 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2135-9-8**] at 4:00 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2135-8-28**]
ICD9 Codes: 5070, 5849, 7907, 2760, 5180, 2767, 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5226
}
|
Medical Text: Admission Date: [**2145-3-12**] Discharge Date: [**2145-3-19**]
Service: MEDICINE
Allergies:
Amoxicillin / Morphine
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 y/o F w/osteoporosis, restrictive lung disease on home o2
(felt [**2-5**] scoliosis), who presented to the ED on [**2145-3-12**] c/o leg
pain. She got up from the sofa and twisted her knee, and after
this developed leg pain. She did not fall at that time, did not
have syncope. In the ED, she had a plain film concerning for
fracture, so she had a CT scan of her lower extremity showing a
tibial plateau fracture. Ortho saw her and recommended pain
control and a knee immobilizer. She was admitted to medicine.
.
Last night, she developed worsening hypoxia. At her baseline per
office notes she is in the mid-80s when off oxygen. (She wears 2
liters O2 at home). Initially she was 93% on 2L but dropped to
86% last night, so was turned up to 4-5 L with response to 96%.
She refused to wear her bipap secondary to back pain. At her
routine vitals check at 7 this morning, she was noted to have a
pulse 152, bp 104/60, RR 36, and O2 sat 84% on 4L which improved
to 96% on a NRB. ECG showed rapid afib. She was given metoprolol
5 mg IV x3 without response. ABG was 7.42/60/161 on a NRB. She
then was given diltiazem 15 mg IV with response in her pulse
down to the 90s, which improved her shortness of breath
somewhat. She was transferred to the MICU for further
monitoring. Currently, she states that she is having some chest
pressure. She reports she has been having worsening shortness of
breath with eating that has been going on for weeks (mentioned
in Dr.[**Name (NI) 21360**] note [**11-9**]), and does think that her
breathing got worse this morning.
Past Medical History:
# congenital rickets
# Osteoporosis with numerous fractures
# spinal fusions for her scoliosis
# history of cataracts
# HTN
# Pulm HTN
# Restrictive Lung Disease: most recent PFTs [**11-9**]: FVC 0.58
(38%pred), FEV1 0.44 (48%pred), FEV1/FVC 76 (128%pred). Felt to
be related to her scoliosis
# Tonsillectomy and adenoidectomy
# Benign breast cysts
# L-femoral trochanteric fracture '[**41**] (s/p repair at [**Hospital1 18**])
Social History:
She used to smoke intermittently in the past but quit 40 years
ago. She was never a heavy smoker. She denies alcohol use and
recreational drug use. She does not have any children. Lives
with her husband, who has recently been ill.
Family History:
Remarkable for her mother who had a CVA. A sister had coronary
artery disease and mitral valve disease. Her father died in an
advanced old age of an unknown cause.
Physical Exam:
PE: T: 97.2 BP: 117/59 P: 105 R: 28 94% on NRB I/O over last 24
hours: 1140/1200 (?unclear how well recorded this is)
Gen: elderly woman, tachypneic, using accessory muscles,
speaking in [**2-6**] word sentences, using abd muscles significantly
during exhalation
HEENT: Clear OP, MMM
NECK: Supple, JVD 7-8 cm at 60 degrees
CV: tachycardic, irregularly irreg, no murmur
LUNGS: diffuse inspiratory crackles, poor air movement with some
end-exp wheezing
ABD: Soft, NT, ND. NL BS.
EXT: 1+ LLE edema. 2+ DP pulses BL. In knee immobilizer
SKIN: No lesions
Pertinent Results:
[**2145-3-18**] 04:30AM BLOOD WBC-6.7 RBC-3.65* Hgb-11.1* Hct-33.1*
MCV-91 MCH-30.5 MCHC-33.6 RDW-14.5 Plt Ct-290
[**2145-3-18**] 12:00PM BLOOD PTT-102.1*
[**2145-3-15**] 09:06AM BLOOD Fibrino-990*
[**2145-3-18**] 04:30AM BLOOD Glucose-190* UreaN-56* Creat-0.9 Na-137
K-4.9 Cl-93* HCO3-33* AnGap-16
[**2145-3-14**] 03:01AM BLOOD proBNP-[**Numeric Identifier 21361**]*
[**2145-3-12**] 04:35AM BLOOD PTH-157*
[**2145-3-12**] 04:35AM BLOOD TSH-0.48
[**2145-3-18**] 12:18PM BLOOD Type-ART Temp-37.6 Rates-/14 pO2-134*
pCO2-101* pH-7.25* calTCO2-46* Base XS-12 Intubat-NOT INTUBA
.
CXR [**2145-3-12**]: AP SUPINE CHEST: There is moderate cardiomegaly. A
large hiatus hernia is redemonstrated. Significant distortion is
appreciated at the thoracic cavity secondary to marked scoliotic
change. Patchy air space opacities are present in the left upper
and right mid lung concerning for aspiration or multifocal
pneumonia. Asymmetric edema is also a consideration. There is no
pleural
effusion or pneumothorax. No fractures are identified.
IMPRESSION: Study limited by distortion from severe S-shaped
thoracic scoliosis. Cardiomegaly with alveolar opacity in the
right mid and left upper lung concerning for aspiration or
multifocal pneumonia. Evolving asymmetric edema cannot entirely
excluded and follow up radiographs are recommended.
.
repeat CXR [**2145-3-12**]: Cardiac silhouette remains enlarged. There is
vascular engorgement and worsening bilateral perihilar haziness.
Additional more confluent area of opacification in the right
middle and retrocardiac portion of the right lower lobe are
noted. Left retrocardiac area is difficult to assess to large
hiatal hernia.
IMPRESSION:
1. Worsening perihilar edema.
2. Worsening right middle and lower lobe opacity which may be
due to
asymmetrical edema or superimposed aspiration or pneumonia.
.
ECG this morning: rapid afib at 137, normal axis, ST dep in I,
aVL, II, III, and V2-V6 all of which are new compared to both
old ECG in [**2141**] and compared to admission
.
ECHO [**3-17**]: The left atrium is elongated. A left-to-right shunt
across the interatrial septum is seen at rest consistent with
the presence of small secundum type atrial septal defect. 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 ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. Mild (1+) aortic regurgitation is seen. 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.
.
CXR [**3-17**]: Compared with 3/11, there has been considerable
clearing and
re-aeration of the right lung. There appears to be mild edema.
The left lung base also appears better aerated, but there is
some persistent
infrahilar atelectasis.
.
CXR [**3-18**]: Moderate CHF, increased compared to one day prior. 2.
Large hiatal hernia.
Brief Hospital Course:
A/P: 85 y/o F w/osteoporosis, restrictive lung disease on home
o2 (felt [**2-5**] scoliosis) transferred to MICU for hypoxia.
.
# Respiratory distress: Pt. required constant BiPap while in the
MICU to maintain a decent respiratory status. She failed
multiple attempts off BiPap and would become tachypneic,
hypoxic, and with markedly increased work of breathing. The last
day of admission, she became progressively dyspneic and
somnolent this taken off of BiPAP, It was unclear why she
required so much BiPap. Pulomary edema [**2-5**] to rapid AFIB/CHF vs.
pneumonia vs. COPD exacerbation was initially thought to be the
cause but the patient's respiratory status did not improve with
rate control (with metoprolol and diltiazem), frequent attempts
at aggressive diuresis, IV steroids, antibiotics, or frequent
nebulizers (albuterol, atrovent). Her blood gases continued to
deteriorate, with PCO2 rising, even on BiPAP, and she became
progressively acidotic. PAtient's family was contact[**Name (NI) **] and goals
of care were discussed, as patient did not seem to be improving.
It was decided to make patient comfort measures only [**3-18**]. She
started receiving hydromorphone IV as needed. Continue with
nebulizers, furosemide for comfort. Antibiotics discontinued
[**3-18**].
Ms. [**Known lastname **] quietly passed away [**3-19**] at 0728 with her two neices
at her bedside.
Medications on Admission:
MEDS at home:
Combivent inhaler two puffs four times a day
Lasix 20 mg twice a day
Toprol 75 mg daily
diltiazem 120 mg once a day
potassium chloride 20 mEq per day
calcium two tablets per day
aspirin 81 mg per day
[**Doctor First Name **] 60 mg daily
Fosamax 70 mg once a week.
vitamin E daily
Oscal + D
Salmeterol 50mcg [**Hospital1 **]
.
Meds on transfer:
metoprolol 5 mg iv x3
diltiazem 15 mg iv x1
lasix 40 mg iv x1
albuterol/atrovent
alendronate 70 mg q thursday
lasix 20 mg po daily (did not receive this AM)
salmeterol
vitamin E
Vitamin D
colace
calcium carbonate
diltiazem 120 mg po daily (did not receive this AM)
toprol 50 mg daily (did not receive this AM)
atrovent nebs q6h
levofloxacin 500 mg q24h (begun [**2145-3-12**])
flagyl 500 mg iv q8h (begun [**2145-3-12**])
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratry failure
Discharge Condition:
Patient died at 0728 [**3-19**]
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 2762, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5227
}
|
Medical Text: Admission Date: [**2126-5-16**] Discharge Date: [**2126-6-12**]
Date of Birth: [**2065-5-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Phenergan
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
PICC Line placement
History of Present Illness:
61 year old spanish-speaking female with CAD s/p recent RCA bare
metal stent [**1-2**], DM, HTN presented to OSH with chest pain. By
report, the chest pain has been intermittent for at least a
month, but she did not tell her family about it until this week.
She presented to [**Hospital6 3105**] On [**5-15**] for
increased severity of this pain. She describes the pain as a
"sharp" pain starting in left shoulder blade and radiating
around to left anterior chest associated with some shortness of
breath. Pain is worse with exertion and improves w/ rest. By
report, she also has been having left shoulder pain and started
on percocet at [**Hospital6 5016**]. At [**Hospital3 **], she
had nausea with emesis x 3 (non-bloody). She initially received
sl NTG. First set two sets of cardiac enzymes were negative; on
eve of [**5-16**], however, by report new TW in precordial leads and +
TnT --> started on heparin gtt and transfered to [**Hospital1 18**].
.
Currently denying active chest pain or shortness of breath,
though endorses mild nausea.
.
ROS: On review of symptoms, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. Denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
*** Cardiac review of systems is notable for absence of
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. Reports worsened ability
to do stairs (stops frequently), but unable to quantify it
exactly.
.
Past Medical History:
PAST MEDICAL HISTORY:
CAD cath in [**2119**] at OSH with 70% LAD stenosis, 60% LCX stenosis
Cath in [**1-2**] with stent to RCA
ETT in [**2123**] at OSH with no ischemia and 60% LVEF
DM2 with retinopathy adn nephropathy
HTN
Hypercholesterolemia
obesity
OA
depression
SEVERE NONCOMPLIANCE
GERD with hiatal hernia
anxiety
tension HA
CRI 1.0-1.3 baseline Cr
PAD
h/o cholecystectomy
Social History:
Has lived in U.S. since [**2098**] from [**Male First Name (un) 1056**]. She lives with
granddaughter. She quit smoking 15 years ago and denies alcohol
or drug use.
Family History:
mother with diabetes and CAD and an aunt with the same.
Physical Exam:
Vitals: 97.4F HR 87 BP 137/65 20 100% 3L
Gen: obese, fatigued, NAD.
HEENT: anicteric, EOMI, MMM. JVD unable to assess.
CV: regular, 80s, normal s1 and S2. No murmurs or rubs. ?mild
exacerbation of pain on palpation of shoulder
Resp: CTAB
Abd: obese, soft, NT/ND.
Ext: no LE edema, 2+ DP pulses
Skin: no jaundice, no rash
Pertinent Results:
[**2126-5-16**] 11:02PM BLOOD WBC-14.4* RBC-4.05* Hgb-12.2 Hct-36.5
MCV-90 MCH-30.1 MCHC-33.4 RDW-13.8 Plt Ct-364
[**2126-5-16**] 11:02PM BLOOD Glucose-345* UreaN-46* Creat-1.3* Na-136
K-6.3* Cl-104 HCO3-20* AnGap-18
[**2126-5-16**] 11:02PM BLOOD CK(CPK)-289* CK-MB-33* MB Indx-11.4*
cTropnT-0.80*
[**2126-5-17**] 05:30AM BLOOD CK(CPK)-466* CK-MB-50* MB Indx-10.7*
cTropnT-1.01*
[**2126-5-17**] 12:45PM BLOOD CK(CPK)-502* CK-MB-49* MB Indx-9.8*
cTropnT-1.47*
[**2126-5-17**] 07:40PM BLOOD CK(CPK)-468* CK-MB-40* MB Indx-8.5*
cTropnT-1.82*
[**2126-5-18**] 07:15AM BLOOD CK(CPK)-318* CK-MB-25* MB Indx-7.9*
cTropnT-1.67*
[**2126-5-19**] 07:05AM BLOOD CK(CPK)-141* CK-MB-12* MB Indx-8.5*
cTropnT-1.73*
[**2126-5-20**] 06:55AM BLOOD CK(CPK)-84 CK-MB-NotDone cTropnT-1.81*
.
[**2126-5-17**] 05:30AM BLOOD ALT-22 AST-53* CK(CPK)-466* AlkPhos-113
TotBili-0.3
[**2126-5-20**] 06:55AM BLOOD ALT-121* AST-62* LD(LDH)-409* CK(CPK)-84
AlkPhos-158*
.
[**2128-5-24**] %HbA1c: 7.6
.
ECHOCARDIOGRAM [**2126-5-18**]
Mild left ventrical apical aneurysm with severe global systolic
dysfunction c/w multivessel CAD or other diffuse process. Right
ventricular free wall hypokinesis. Mild mitral regurgitation.
Mild pulmonary artery systolic hypertension.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2126-5-19**] 12:35 PM
Very mildly echogenic liver consistent with questionable fatty
infiltration. Portal vein is patent and gallbladder has been
removed.
.
[**2126-5-20**] Cardiac Catheterization:
1. Coronary angiography showed severe three vessel coronary
artery disease. The left main coronary artery had moderate
calcification but no angiographically apparent flow limiting
stenoses. The LAD was diffusely calcified with a proximal
stenosis of 90% followed by another 90% stenosis in mid segment.
The LCX was nondominant vessel with modest calcification. The
RCA was a large dominant vessel with severe instent restenosis
proximally. 2. Arterial conduit angiography revealed a robust
patent LIMA with no lesions. 3. Limited resting hemodynamics
revealed severely elevated left sided filling pressures (LVEDP
was 32 mm Hg). Systemic arterial pressures were severely
elevated (aortic pressure was 179/83 mm Hg). There was no
significant gradient across the aortic valve upon pullback of
the catheter from the left ventricle to the ascending aorta.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severely elevated left sided filling pressures.
3. Severely elevated systemic arterial pressure.
.
[**2126-5-21**] Myocardial Viability Study: 1. Severe resting perfusion
defects of the apex, distal inferior wall and the mid and basal
inferoseptal walls. This is consistent with poor probability of
recovery of function after revascularization. 2. Mild resting
perfusion defects of the inferior wall and distal ventricle and
normal perfusion of the mid and basal anterior and anterolateral
walls, consistent with high probability of recovery of function
after revascularization. 3. Inreased right ventricular uptake,
consistent with global reduction in left ventricular perfusion.
4. Increased left ventricular cavity size.
Brief Hospital Course:
Ms. [**Known lastname **] was taken to the OR on [**2126-5-29**] for CABG X 4 (LIMA>LAD,
SVG>OM, SVG>Diag, SVG>PDA) and ASD closure. Post-op, she was
taken to the CSRU on epinephrine, milrinone, norepinephrine
drips. She remained on mechanical ventilation for the first few
post-operative days, while improving hemodynamically and weaning
off vasopressors and inotropes. She was extubated on POD # 3.
She went in to rapid atrial fibrillation, which was treated with
metoprolol and amiodarone. The electrophysiology service was
consulted, and followed her for this. For the next few days,
her rhythm varied from bradycardia (junctional and sinus) in the
30's to rapid AFib. She remained in the ICU due to continued
need for pacing (via her epicardial wires). For this reason, she
underwent permanent pacmaker palcement on [**2126-6-6**]. Her
epicardial wires were removed. Anticoagulation for AFib was
initiated with warfarin, with a target INR 2.0-2.5. This will
be dosed by the pt's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] once discharged from rehab.
She has remained stable hemodynamically, and is ready to be
discharged to rehab on [**2126-6-12**]. She has progressed slowly from
a mobility standpoint, and should continue with physical
therapy.
Medications on Admission:
CAD cath in [**2119**] at OSH with 70% LAD stenosis, 60% LCX stenosis
Cath in [**1-2**] with stent to RCA
ETT in [**2123**] at OSH with no ischemia and 60% LVEF
DM2 with retinopathy adn nephropathy
HTN
Hypercholesterolemia
obesity
OA
depression
SEVERE NONCOMPLIANCE
GERD with hiatal hernia
anxiety
tension HA
CRI 1.0-1.3 baseline Cr
PAD
h/o cholecystectomy
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
CAD
DM
HTN
OA
depression
GERD
AF
Tachy/brady syndrome
Discharge Condition:
good
Followup Instructions:
with [**Hospital **] clinic on Friday, [**6-14**] at 1pm ([**Telephone/Fax (1) 2361**]
With Dr. [**Last Name (STitle) **] in [**3-31**] weeks ([**Telephone/Fax (1) 1504**]
with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-2**] weeks [**Telephone/Fax (1) 66039**]
with Dr. [**Last Name (STitle) **] in 1 month, please call for appt. ([**Telephone/Fax (1) 5425**]
For your diabetes, please follow-up in the [**Hospital **] [**Hospital 32231**] Clinic
- please call [**Telephone/Fax (1) 14404**] to make an appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2126-6-12**]
ICD9 Codes: 4280, 9971, 2767, 5990, 5859, 2761, 2720, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5228
}
|
Medical Text: Admission Date: [**2116-10-12**] Discharge Date: [**2116-10-17**]
Date of Birth: [**2045-10-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Heparin Agents
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
CABG x4/repair LV aneurysm/CX endarterectomy [**2116-10-12**]
(LIMA to LAD, SVG to OM, SVG to OM, SVG to PDA)
History of Present Illness:
70 yo female with DOE and wheezing noted in early [**9-16**]. PCP rx
with [**Name9 (PRE) 621**], but no improvement. She worsened and ruled in for
NSTEMI in the ER. Cath revealed severe 3VD.
Past Medical History:
CAD s/p silent MI c/b LV mural thrombus (resolved, off warfarin)
PAD s/p left SFA angioplasty and stent
DM2
HTN
OA
spinal stenosis
Hyperthyroidism
s/p cholecystectomy
s/p appendectomy
s/p TAH
Social History:
Denies tobacco, EtOH
lives with husband
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
at discharge:
VS: 97.4, 121/54, 80SR, 20, 97%RA
Gen: NAD, overweight WF
Lungs: crackles b/l bases, o/w clear
heart: RRR, no murmur or rub
abd: obese, NABS, soft, non-tender, non-distended
ext: warm, trace edema b/l
sternal wound: c/d/i, no erythema or drainage
EVH: c/d/i, no erythema or drainage
Pertinent Results:
PRE-CPB: 1. The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left
atrium. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is an antero-apical
left ventricular aneurysm. There is moderate regional left
ventricular systolic dysfunction with anteroseptal and
anteroapical hypokinesis. There is an inferoapical aneurysm with
no thrombus seen.. No masses or thrombi are seen in the left
ventricle. Overall left ventricular systolic function is
moderately depressed (LVEF= 35 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma,
nonmobile, in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened.
8. There is a trivial/physiologic pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusions of epinephrine, phenylephrine. There is
improvement of global LV systolic function on inotropic support.
LVEF is now 40%. There is evidence of a suture-repair of the lv
apical aneurysm. MR remains trace. The aortic contour is normal
post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2116-10-13**] 08:38
?????? [**2110**] CareGroup IS. All rights reserved.
[**2116-10-16**] 05:45AM BLOOD WBC-8.8 RBC-3.53* Hgb-10.1* Hct-30.4*
MCV-86 MCH-28.6 MCHC-33.2 RDW-15.0 Plt Ct-189
[**2116-10-16**] 05:45AM BLOOD Glucose-91 UreaN-18 Creat-0.5 Na-138
K-4.5 Cl-105 HCO3-24 AnGap-14
[**2116-10-17**] 07:15AM BLOOD WBC-8.7 RBC-3.35* Hgb-10.0* Hct-29.0*
MCV-86 MCH-29.9 MCHC-34.6 RDW-15.1 Plt Ct-293#
[**2116-10-17**] 07:15AM BLOOD Glucose-267* UreaN-16 Creat-0.6 Na-134
K-4.1 Cl-97 HCO3-30 AnGap-11
Brief Hospital Course:
Admitted [**10-12**] and underwent surgery with Dr. [**Last Name (STitle) **]. transferred
to the CVICU in stable condition on epinephrine, insulin and
propofol drips. Extubated later that evening. Transferred to the
floor on POD #2, but went into rapid A Fib and was transferred
back to the CVICU for better IV access. Amiodarone was started.
Transferred back to the floor on POD #3 to begin increasing her
activity level. [**Last Name (un) **] was consulted regarding glucose
management. Gently diuresed toward her preop weight. The
patient made excellent progress with physical therapy, showing
good strength and balance before discharge. Chest tubes and
pacing wires were discontinued without complication. By the
time of discharge on POD 5, the patient was ambulating freely,
the wound was healing and pain was controlled with oral
analgesics.
Medications on Admission:
lipitor 80 mg daily
ASA 325 mg daily
isosorbide MN 30 mg daily
methimazole 10 mg daily
protonix 40 mg daily
lisinopril 20 mg daily
chlorazepate dipotassium 3.75 mg daily
toprol XL 50 mg daily
insulin levemir 32 units Q PM
novolog 8 units Q AM
novolog 14 units Q PM
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. 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*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day for 4 days, then 200mg 2x/day for 1 week,
then 200mg/day.
Disp:*120 Tablet(s)* Refills:*0*
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 2 weeks.
Disp:*qs * Refills:*0*
10. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Packet(s)* Refills:*0*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
13. Insulin Detemir 100 unit/mL Insulin Pen Sig: 40 units
Subcutaneous q am.
Disp:*30 * Refills:*0*
14. Novolog Flexpen 100 unit/mL Insulin Pen Sig: per scale
Subcutaneous ac, hs: dose to be determined by sliding scale.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD/apical aneurysm
s/p CABG x4/rep. LV aneurysm
postop A Fib
MI
IDDM
hyperthyroidism
OA
spinal stenosis
retroperitoneal bleed s/p cath
PVD with L SFA stent/PTCA
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
no driving for one month and until off all narcotics for pain
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness or drainage
call for weight gain greater than 2 pounds in one day, or 5
pounds in a week
Followup Instructions:
Dr. [**Last Name (STitle) **] 1 week
see Dr. [**Last Name (STitle) 75782**] in [**12-11**] weeks
see Dr. [**Last Name (STitle) **] in [**1-12**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
please call for all appts.
Completed by:[**2116-10-17**]
ICD9 Codes: 9971, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5229
}
|
Medical Text: Admission Date: [**2150-4-2**] Discharge Date: [**2150-4-22**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Melena, hematocrit drop
Major Surgical or Invasive Procedure:
EGD
Tunneling of temporary HD line
History of Present Illness:
75 yo male with ESRD on HD, trach for resp failure who presents
from [**Hospital **] rehab with a hematocrit drop and melena in his
rectal tube. Per notes he had HD yesterday and received 2 units
PRBCS during HD and hct was 35 during HD. Today hct was
re-checked and was 19. Stools were noted to guaiac positive. INR
was noted to be 4.3 , so pt received 5 mg of vitamin K. VS at NH
were T 97.5 HR 104 BP 108/59 and sats of 98%.
.
In the ER he was noted to have melena in his rectal tube. Hs HR
was initialy in the 90s with BP 108/53. He had a lavage of his
g-tube that was clear and received protonix 40 IV x2. He
received an additional 5 mg of vitamin K and 2 units of FFP
here. He received ~1.5 L of fluid and had starte receiving 1
back of PRBCs prior to txfr to the ICU. While in the ER his SBPs
dropped to the 80s-90s.
.
Upon arrival to the floor, the pt's initial SBP was in the 70s,
with HR in the 120s. This improved to SBP of 90s. The pt
appeared comfortable and denied abdominal pain, chest pain,
lightheadedness or nausea. Said he had fevers several weeks ago
and one recent episode of emesis. He thinks he may have had
black stool for weeks.
.
Of note, pt recently admitted [**Date range (1) 77791**] for new atrial
fibrillation, septic shock (urosepsis), and acute on chronic
renal failure now requiring dialysis and was discharged to
[**Hospital1 **].
Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].
Family History:
N/C
Physical Exam:
VS: T: HR: 120s BP: SBP 70s-90s RR: O2 sat:
Gen: obese male, mentating appropriately, NAD, pale
HEENT: anicteric sclera, dry MM
Neck: supple, dialysis line in place
Cardio: distant heart sounds, tachycardic, no murmur appreciated
Pulm: CTAB anteriorly, no w/r/g
Abd: soft, obese, NT, ND, +BS, G tube in place
Ext: hyperpigmentation on shins, 1+ peripheral edema, 1+ DP
pulses b/l
Neuro: Alert, awake, mentating appropriately and responding to
commands. Moves all extremities
Skin: hyperpigmentation on shins, dry gauze wrapped on both
shins
Pertinent Results:
Admission labs:
[**2150-4-1**] 11:05PM WBC-12.0* RBC-2.01* HGB-5.8* HCT-18.6* MCV-92
MCH-28.9 MCHC-31.3 RDW-20.0*
[**2150-4-1**] 11:05PM NEUTS-77.0* BANDS-0 LYMPHS-16.4* MONOS-3.7
EOS-2.7 BASOS-0.2
[**2150-4-1**] 11:05PM PLT SMR-NORMAL PLT COUNT-162
[**2150-4-1**] 11:05PM GLUCOSE-127* UREA N-99* CREAT-3.5* SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2150-4-1**] 11:05PM CALCIUM-8.1* PHOSPHATE-3.4 MAGNESIUM-2.8*
[**2150-4-1**] 11:05PM ALT(SGPT)-6 AST(SGOT)-13 ALK PHOS-121* TOT
BILI-0.2
[**2150-4-1**] 11:05PM LIPASE-52
[**2150-4-1**] 11:05PM PT-24.5* PTT-36.1* INR(PT)-2.4*
.
Studies:
ECG Study Date of [**2150-4-1**]
Rate PR QRS QT/QTc P QRS T
117 0 124 346/445 0 20 0
Baseline artifact. Probable atrial fibrillation with rapid
ventricular
response. However, there are periods of regularization but no
discernible
flutter waves. There is right bundle-branch block. Since the
previous tracing of [**2150-3-15**] the ventricular response is more
regular.
.
CHEST (PORTABLE AP) [**2150-4-2**]
Tracheostomy tube tip terminates about 9 cm above the carina,
and the cuff is overdistended, as communicated by telephone to
Dr. [**Last Name (STitle) **] on [**2150-4-2**]. Heart is enlarged, pulmonary
vascularity is engorged, and there is bilateral perihilar
haziness attributed to pulmonary edema. More confluent left
retrocardiac opacification is present, likely a combination of
atelectasis and moderate effusion, but underlying infectious
consolidation is not excluded. Small right pleural effusion is
also evident.
.
EGD [**2150-4-2**]
Impression: Internal bumper of the recently placed PEG tube was
seen in place. There was a blood clot underneath the bumper
suggesting a site of bleed. It was washed, and did not reveal
any visible vessel or active bleeding.
There was no fresh or old blood (except the clot under the
bumper) seen in the stomach.
There was no fresh or old blood in the duodenum.
Erythema in the first and 2nd part of the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations:
- Bleeding likely to be from the site of the internal bumper of
the PEG in the setting of high INR, but seems to have stopped
now.
- PPI [**Hospital1 **]
- Watch Hct
.
TTE (Complete) Done [**2150-4-4**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Moderately dilated left ventricular cavity. Left
ventricular function is probably low-normal, a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen. Thickened aortic leaflets without frank stenosis.
Pulmonary artery systolic pressure could not be determined.
.
RENAL U.S. PORT [**2150-4-13**]
IMPRESSION: No hydronephrosis. No collections identified. Thin
cortex bilaterally consistent with chronic interstitial disease.
.
CHEST (PORTABLE AP) [**2150-4-17**]
FINDINGS: The image did not include the lung bases; however,
there is opacification in the right lung base secondary to
atelectasis and effusion. The left lung base cannot be
evaluated. The heart size is mildly enlarged and stable. More
opacification adjacent to the left heart border may indicate
left lower lobe atelectasis. A double-lumen central line tip is
in the proximal-to-mid one-third of the SVC. The tracheostomy
tube projects approximately 5 cm from the carina, unchanged.
Brief Hospital Course:
75 year old male with h/o ESRD on HD, tracheostomy who initally
presented with anemia and melena. The patient was recently
discharged from [**Hospital1 18**] to rehab. At rehab, he was found to have
a drop in his hematocrit from 35 to 18.6 associated with
hypotension and tachycardia.
.
# GI Bleed: On admission, he had melena in his rectal tube and
gtube lavage was reportedly negative. His melena at that time
was felt most likely to LGIB, in the setting of recent
initiation of anticoagulation and supratherapeutic INR. ASA and
coumadin were held on admission as well as his BB. The patient
had a tagged red blood cell scan to identify the source of
bleeding, which was negative. GI was consulted and performed
EGD on admission which demonstrated the source of bleeding to be
most likely from the site of the internal bumper of the PEG in
the setting of high INR, with no active bleeding noted. Aspirin
and coumadin were held in the setting of active GI bleeding. He
was transfused 8 units of PRBCs as well as 2 units of FFP on day
of admission, and his HCT remained stable above 30. Although
his HCT remained stable, he continued to be guaiac positive. He
was a second EGD on [**4-20**], which showed no source of bleeding.
His ASA and coumadin were restarted.
.
# Acute blood loss anemia: As above.
.
# Hypotension, Hemorrhagic, Hypovolemic and Septic: Pt was
initially hypotensive, likely hemorrhagic [**1-17**] GI bleed. With
aggressive IVF resuscitation and transfusions on admission,
patient became volume overloaded. With CVVH, over 40L of fluids
were removed. However, in the setting of diuresis, the patient
dropped his blood pressures and required Neo to maintain SBP
over 90 and MAP greater than 55. Neo was able to be weaned off
with IVF boluses. He was also treated for UTI and bacteremia.
At discharge, his SBP ranged at 100s-110s.
.
# Relative adrenal insufficiency: Pt was started on a course of
stress dose steroids after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test had a less than
target range increase after cosyntropin was administered. This
was discontinued after 6 days as he was not displaying other
signs of adrenal insufficiency.
.
# Chronic kidney disease, stage V: The patient was started on
dialysis for renal insufficiency during his previous admission.
He was seen by renal while in the hospital, who felt he could
benefit from CVVH while in the intensive care unit to help
mobilize some of his fluid overload. He was on CVVH initially
and then transitioned to HD 3x/week. Throughout his course of
stay, he was negative 29L at discharge; weight at time of
discharge is 147 kg. His temporary line was also tunneled in IR
during this admission without complication. However, the
insertion site became infected; catheter tip culture has no
growth to time of discharge. A second tunneled line was placed
by IR on [**4-20**]. He was started on midodrine to support his BP
during dialysis.
.
# Atrial fibrillation with RVR: On admission, the patient was
in afib with RVR. His beta blocker and anticoagulation was
initially held in the setting of his GIB. He was restarted on
his BB as tolerated by his BP. He was also transiently on
digoxin for improved rate control while on CVVH; this was
discontinued as his HR came under better control with BB. HR on
discharge was in the 50-60s.
.
# UTI: Pt was found to have pan-resistant Klebsiella UTI and
received a 10 day course of Meropenam.
.
# Bacteremia: Pt was found to have 2/2 bottles of coag.
negative Staph from the arterial line. The line was pulled and
a new one place. The catheter tip culture has no growth to time
of discharge. Pt was treated with a 14 day course of Vancomycin
given his hypotension, tachycardia, and elevated WBC at the
time.
.
# Respiratory failure: Pt has a tracheostomy and initially
required vent support. With mobilization of his excess fluid,
the patient was weaned to a trach mask while in the hospital.
On [**4-20**] he desatted to 80%, in the setting of having increased
volume (7L positive in the last two days). He had HD, where 3L
were removed and his sats did not improve significantly. He was
requiring .7% FiO2, CXR showed partial collapse of his left
lung. Mechanical ventilation was restarted and he was
maintained on this until discharge. Sputum culture from [**4-8**]
showed acinetobacter and stenotrophomonas, initially not treated
because it was felt these could be colonizers. However, in the
context of his increased oxygen requirement and cxr findings he
was started on tobramycin and was already on vanc for a presumed
line infection (positive blood cultures). He underwent a BAL on
[**4-21**] and results are pending. He will need to have his
tobramycin and vancomycin dosed at HD. Please give 80 mg of IV
tobramycin after HD and check level prior to HD. If tobramycin
level is >2, dose will required adjustment. IV vancomycin
should also be dosed after HD with levels drawn prior to HD.
Results of the BAL should be followed up and if pt has
clinically improved the antibiotics should be discontinued.
.
# ?MGUS: Pt had an elevated kappan and lambda. Heme/onc was
consulted and performed a bone marrow biopsy. Preliminary
results suggest MGUS. Heme/onc had recommended outpatient
follow up in Benign [**Hospital **] Clinic in [**1-19**] weeks.
.
# DM2: Pt was covered with a sliding scale for his Type II
Diabetes.
.
# Hyperlipidemia: Pt was continued on his simvastation.
.
# FEN: Pt received tube feeds via G-tube at goal.
# FULL CODE
# HCP: [**Name (NI) 77789**] [**Name (NI) 77792**] (wife) [**Telephone/Fax (1) 77790**]
Medications on Admission:
Insulin SS
lantus 48 units qhs
Simvastatin 10 mg daily
ASA 81 mg daily
Metoprolol 50 mg TID
Citalopram 20 mg daily
Lansoprazole 30 mg daily
Coumadin
Silver Sulfadiazine 1%
Epoetin 1000 units with HD
Acetaminophen 650 q6 hours prn
clonazepam 0.5 mg tid prn
trazodone 50 mg hs prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Insulin Glargine 100 unit/mL Solution Sig: Fifty Two (52)
units Subcutaneous once a day.
4. Insulin Regular Human 100 unit/mL Solution Sig: 0-18 units
Injection four times a day: As directed by sliding scale.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 4 PM).
16. Tobramycin in NS 80 mg/100 mL Piggyback Sig: Eighty (80) mg
Intravenous QHD (each hemodialysis) for 10 days: Please dose
after HD. Please call [**Hospital1 18**] to follow up BAL results from [**4-21**],
if no growth and pt clinically improving can d/c anitbiotics.
17. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
18. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous HD PROTOCOL (HD Protochol) for 10 days.
19. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
20. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary:
upper GI bleed
urosepsis with ESBL
Volume overload
Hypotension
.
Secondary:
ESRD on dialysis
Atrial fibrillation
Urinary tract infection
Bacteremia
Monoclonal gammopathy of undetermined significance
Hyperlipidemia
Type II Diabetes
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital with a drop in your blood
counts and melena (or blood in your stool). While you were in
the hospital, an EGD showed a clot around your PEG tube site,
which likely contributed to your bleeding. Your INR was also
high, which was a contributing factor. While in the hostpial
you had an infection of your urinary tract that was treated,
your blood pressure was also low. You had alot of fluid removed
in dialysis and your current weight, which is your dry weight is
147 kg.
GI reevaluated your upper GI tract and found no source of
bleeding, you were restarted on warfarin.
At the time of discharge your blood level (hematocrit) was
stable, and should be checked in 3 days.
.
You were also on CVVH, a type of dialysis, while you were in the
hospital to help remove some of the excess fluid in your
tissues. During work up of causes of renal failure, you were
noted to have abnormal blood tests leading to a bone marrow
biopsy. You were diagnosed with possible MGUS (monoclonal
gammopathy of undetermined significance). You will see a
hematologist as an outpatient for this.
.
For a brief time, you needed medications to help support your
blood pressure. Your blood pressure is now fine off the
medications.
.
You were also treated for a urinary tract infection and bacteria
in your blood with antibiotics. In addition you were started on
tobramycin for acetinobacter and stentrophomonas in your sputum
when your oxygen requirement increased. A BAL was done [**4-21**],
with no growth to date. This will need to be followed up.
.
Please continue to take your medications as directed.
.
Please keep your follow up appointments.
.
If you have more bleeding from the rectum, vomiting of blood,
abdominal pain, lightheadedness, palpitations, chest discomfort,
shortness of breath, or any other concerning symptoms, please
call your primary care provider or go to the Emergency
Department.
Followup Instructions:
Please follow up with your PCP within two weeks of discharge.
.
Please also follow up with the Benign [**Hospital **] Clinic in [**1-19**] months
regarding the diagnosis of MGUS. The clinic number is
[**Telephone/Fax (1) 68451**].
Completed by:[**2150-5-5**]
ICD9 Codes: 5849, 5789, 2851, 5856, 5990, 7907, 4280
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5230
}
|
Medical Text: Admission Date: [**2159-7-5**] Discharge Date: [**2159-7-29**]
Date of Birth: [**2091-9-16**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 67-year-old female
with a history of coronary artery disease (status post
coronary artery bypass graft), also with a history of
congestive heart failure, type 1 diabetes, hypothyroidism,
and hypertension, who initially presented to the [**Hospital3 **]
clearance because of a C2 fracture back in [**2158-12-23**];
status post a mechanical fall.
She was cleared for surgery and switched from Coumadin to
heparin at the time but requested to go home and have her
surgery electively scheduled for [**2159-7-13**].
had a transoral resection of her odontoid and associated
second soft tissues. She received 2 units of packed red blood
cells and was extubated and given high-dose narcotics for
pain management.
On [**7-16**], she had a hypercarbic respiratory failure with an
arterial blood gas demonstrating 7.02/99/134. She then had
two episodes of bradycardia secondary to vagal stimuli, and a
pulseless electrical activity/asystole arrest. She was
brought back from both codes, and Electrophysiology was
consulted.
Electrophysiology placed a pacer wire (temporary). She was
also maintained on broad spectrum antibiotics for lower
extremity cellulitis.
On [**7-24**], she was transferred from the Surgery Service to
the Medical Intensive Care Unit for further management of
renal failure as well as difficulty to wean. Her Medical
Intensive Care Unit course was complicated by worsening
mental status and ongoing acute renal failure.
Her mental status was questionably attributed to narcosis
versus uremia, and her narcotics were held at this time. On
[**7-27**], a CT scan of her head was obtained for just ongoing
mental status changes. A massive cerebral hemorrhage was
noted at the time obstructing the fourth ventricle.
Neurosurgery was consulted and a ventriculostomy drain was
placed at the bedside. However, the patient remained in
neurogenic shock and continued to demonstrate
unresponsiveness by all objective clinical measures. She
remained pressor-dependent to keep her mean arterial pressure
greater than 70.
Her code status was changed to do not resuscitate/do not
intubate on [**2159-7-29**]. She remained in neurogenic shock.
Her apnea test was positive for corneal reflexes and
pupillary reflexes were absent.
At 3:45 p.m., on [**7-29**], the patient was found to be
unresponsiveness following a cardiac arrest. She expired at
this time. The family denied postmortem examinations.
[**First Name8 (NamePattern2) 900**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 1908**]
Dictated By:[**Name8 (MD) 17844**]
MEDQUIST36
D: [**2159-11-13**] 14:55
T: [**2159-11-15**] 20:17
JOB#: [**Job Number 18711**]
ICD9 Codes: 4280, 4275, 3572
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5231
}
|
Medical Text: Admission Date: [**2162-3-23**] Discharge Date: [**2162-4-6**]
Date of Birth: [**2106-9-19**] Sex: F
Service: MEDICINE
Allergies:
Librium
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hematemesis, Encephalopathy
Major Surgical or Invasive Procedure:
Feeding Tube Placement
Intubation
EGD
History of Present Illness:
55-year-old female with alcohol cirrhosis with ?esophageal
varices (last variceal bleed 6 years ago) presenting from OSH
with hematemesis. Pt states that she has been drinking heavily
recently due to recent life stressors, about a quart of vodka
daily. Last drink at 7pm on [**2162-3-22**]. Had 3 episodes of
hematemesis yesterday morning; could not quantify amount. Also
noted dark stools for the last three days. Denies abdominal
pain or diarrhea. She was seen at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she had two
more episodes of hematemesis. She received 1unit PRBC, zofran
iv 8mg, and was placed on octreotide gtt. She was transferred
here because endoscopy suite was not available until 7AM.
In the ED, initial VS were: 98.4 100 167/71 16 96% 2L nc. Hct
was 39. INR 1.3. Serum etoh level 16. GI was called who
stated that they would perform EGD in AM. She was given 1g
ceftriaxone and placed on protonix and octreotide gtts. She
received 1L IVFs. She remained hemodynamically stable, mildly
hypertensive. She had another episode of emesis 150cc in ED of
frank blood. Vitals on transfer: 96 169/70 21 94%RA.
Past Medical History:
1. Major Depression
2. Alcoholic dependance
3. Post traumatic stress disorder
4. H/o pancreatitis
5. Hypertension
6. Alcoholic cirrhosis
Social History:
Lives alone in subsidized housing in [**Hospital1 1562**]. 20 year history
of alcoholism. States that she was sober for 6 weeks in [**Month (only) **]-[**Month (only) **]
[**2161**] but recently struggled with several tragedies (death of
close friend, separation of oldest son from his wife, another
close friend involved in [**Name (NI) 8751**]) and has relapsed. Drinks about a
quart of vodka daily. Reports hx of DTs previously when
withdrawing. Has three children; son and daughter live nearby
but oldest son is in [**Name (NI) 4565**]. Has 25 pack year history;
curently smoking about 1ppd. Remote hx of cocaine and IVDU,
none recently.
Family History:
- Mother: died lung CA > 60yo, alcoholism, ? psychiatric illness
- Father: 76, alive & well, no h/o heart disease, cancer,
diabetes
- 4 Siblings; 3 are alcoholics
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.6 166/67 107 22 95%3L
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, dry MM, erythema of posterior
oropharynx, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Mildly tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no asterixis
Neuro: CNII-XII intact
DISCHARGE EXAM:
98.5, 117/42, 77, 18, 96% RA
NAD, AOx3, slightly slowed mentation
Anicteric, Dobhoff in place
Heart: RRR, no MRG
Lungs: scattered crackles, no consolidations or wheezes
Abd: soft, obese, nontender, no fluid appreciated
Exdt: trace edema
Neuro: no asterixis, nonfocal
Pertinent Results:
ADMISSION LABS
[**2162-3-23**] 03:54AM BLOOD Hgb-12.8 calcHCT-38
[**2162-3-23**] 03:40AM BLOOD ASA-NEG Ethanol-16* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2162-3-23**] 03:40AM BLOOD Albumin-3.8 Calcium-8.5 Phos-2.7 Mg-1.7
[**2162-3-23**] 03:40AM BLOOD ALT-34 AST-93* AlkPhos-153* TotBili-1.7*
[**2162-3-23**] 03:40AM BLOOD cTropnT-<0.01
[**2162-3-23**] 03:40AM BLOOD Lipase-44
[**2162-3-23**] 03:40AM BLOOD Glucose-300* UreaN-19 Creat-0.6 Na-141
K-4.9 Cl-103 HCO3-27 AnGap-16
[**2162-3-23**] 03:40AM BLOOD PT-14.2* PTT-32.2 INR(PT)-1.3*
[**2162-3-23**] 03:40AM BLOOD Plt Ct-101*
[**2162-3-23**] 03:40AM BLOOD Neuts-69.8 Lymphs-19.4 Monos-7.6 Eos-2.3
Baso-0.9
[**2162-3-23**] 03:40AM BLOOD WBC-7.5 RBC-3.86* Hgb-12.6 Hct-39.2
MCV-101* MCH-32.6* MCHC-32.1 RDW-16.9* Plt Ct-101*
Micro:
- Ucx (5/8,14,16): neg
- Bcx (5/14,15,16): NGTD
- Cdiff ([**4-1**]): neg
Studies:
- Head CT ([**3-31**]): IMPRESSION: No acute intracranial process;
bifrontal cortical atrophy.
- RUQ U/S with Dopplers ([**3-31**]):
IMPRESSION:
-> No portal vein thrombus identified. Reversed flow is
again seen in the main, right and left portal veins.
-> The liver is very heterogeneous and nodular.
Ultrasound cannot
exclude an underlying liver mass. A CT is recommended for
further evaluation of the hepatic architecture.
-> Cholelithiasis. No biliary dilatation seen.
- Bilateral LE U/S ([**4-1**]):
IMPRESSION: Negative study for bilateral lower extremity deep
vein
thrombosis.
DISCHARGE LABS:
[**2162-4-5**] 06:05AM BLOOD WBC-6.9 RBC-2.47* Hgb-7.7* Hct-25.6*
MCV-104* MCH-31.3 MCHC-30.2* RDW-17.3* Plt Ct-79*
[**2162-4-5**] 06:05AM BLOOD PT-14.2* PTT-33.3 INR(PT)-1.3*
[**2162-4-5**] 06:05AM BLOOD Glucose-227* UreaN-15 Creat-0.5 Na-133
K-4.1 Cl-103 HCO3-22 AnGap-12
[**2162-4-5**] 06:05AM BLOOD ALT-37 AST-85* AlkPhos-146* TotBili-2.0*
[**2162-4-5**] 06:05AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1
Brief Hospital Course:
55-year-old female with alcohol cirrhosis with known varices
(last variceal bleed 6 years ago) presenting from OSH with
hematemesis. Hospital course complicated by significant
encephalopathy.
1. Hematemesis: Pt with several episodes of hematemesis at home
and at OSH. She has been prescribed propranolol but was not been
taking this consistently at home. Hct on admission was stable
at 39. She was initially placed on IV PPI gtt and IV
octreotide. Initially, she was intubated for EGD which showed
varices at lower third of esophagus that was ligated as well as
varices at GE junction and fundus and portal gastropathy. She
did not have further episodes of hematemesis during hospital
stay and Hct remained stable. She completed a 7 day course of
ABX for infection prophylaxis. She was started on nadolol for
her varices. She should have repeat EGD as outpatient.
2. ST elevations: After being intubated for planned EGD, patient
had ST elevations on telemetry. 12 lead EKG revealed ST
elevations were in leads I/AVL with reciprocal depressions in
AVF/III. She was seen urgently by cardiology and taken to
cardiac catheterization which revealed clean coronaries. The
likely diagnosis was coronary vasospasm. TTE showed EF > 75%,
mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. No
pathologic valvular abnormality seen. No further cardiac
complications during admission.
3. Altered Mental Status: Initially was admitted to the MICU for
GI bleeding reasons, but was sent to floor on [**3-29**]. However,
readmitted to the MICU on morning of [**3-31**] for worsening mental
status. Infection was ruled out. The patient's decompensation
was likely due to holding of lactulose, polypharmacy, and GI
bleed. CXR, LE U/S, Head CT, RUQ U/S were all unrevealing for
cause of AMS and all cultures of blood/urine were negative. She
was not placed on antibiotics and slowly cleared with aggressive
lactulose. At discharge, she is alert and oriented x 3.
4. Alcoholic cirrhosis with alcoholic hepatitis: Pt with
alcoholic cirrhosis that decompensated due to GI bleed and
continued alcohol/drug use. Her bili started to trend up,
peaking at 4.4 on [**3-31**]. She was not started on steroids due to
GI bleed. A biopsy was not done. The patient was treated with
aggressive nutrition and her bilirubin trended down on
discharge.
5. Polysubstance abuse: Pt had active alcohol abuse. Urine tox
was also positive for methadone and benzos. She was seen by
social work and addictions consult. She was started on MVI,
thiamine, and folic acid. She initially had significant alcohol
withdrawal and required high doses of IV ativan and haloperidol
that was eventually weaned. The patient had family support
throughout her hospital stay.
6. COPD: Pt with questionable hx of COPD. Currently smokes
1ppd, on nicotine patch. She was continued on albuterol and
advair inhalers.
7. Depression: Pt with severe depression, particularly in
setting of recent life tragedies. Her home psych meds were held
in the setting of confusion, and only duloxetine and seroquel
have been restarted prior to discharge. The patient will need
psychiatry follow-up after discharge for management and
uptitration of her medications. She reports also taking 100mg
Zoloft daily and 50mg [**Hospital1 **] of Topamax.
8. Vaginal pruritis: Patient complained of vaginal discomfort on
day of discharge and was started on empiric treatment for
candidiasis with intravaginal Miconazole cream.
9. Hyperglycemia: Patient had elevated blood sugars requiring
glargine and insulin sliding scale while in the hospital. This
should be further evaluated by her PCP at discharge and workup
for possible underlying diabetes should be done.
TRANSITIONAL ISSUES:
- Continue 7 day course of intravaginal miconazole
- Slowly restart psychiatric medications as above, patient
reports her psychiatrist is Dr. [**Last Name (STitle) 90873**] ([**Telephone/Fax (1) 90874**]
- Titrate lactulose to achieve 3 bowel movements daily
Medications on Admission:
Medications: (has not been taking consistently)
1. topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. sertraline 100 mg Tablet Sig: 1 Tablet PO at bedtime.
3. prazosin 5 mg Capsule Sig: One (1) Capsule PO QHS (once a day
(at bedtime)).
4. propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): 9a, 9p.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Seroquel 100 mg Tablet Sig: 2.5 Tablets PO at bedtime.
8. dextroamphetamine 10 mg Tablet Sig: Three (3) Tablet PO twice
a day.
9. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QAM (once a day (in the
morning)).
10. lactulose 10 gram/15 mL Solution Sig: Two (2) tablespoons PO
four times a day: to maintain [**1-17**] BMs daily.
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-16**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
12. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H PRN ()
as needed for pain.
8. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for sore throat.
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
12. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. quetiapine 100 mg Tablet Sig: 2.5 Tablets PO QHS (once a day
(at bedtime)).
14. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 7 days: start date [**4-6**].
17. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
18. Humalog insulin sliding scale
Please continue Humalog insulin sliding scale.
19. Lidocaine Viscous 2 % Solution Sig: Five (5) milliliters
Mucous membrane every 4-6 hours as needed for sore throat.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Alcoholic Cirrhosis
Upper GI bleed
Encephalopathy
Poor Nutrition
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital with GI bleeding and confusion
due to buildup of chemicals related to your liver disease. You
were initially stabilized in the ICU where an endoscopy was
performed and a vessel was banded in the esophagus. You
continued to have confusion, which slowly resolved as your liver
improved. You required a feeding tube to help with your
nutrition as your liver recovers. You will be discharged to
rehab.
You must refrain from any further substance abuse or your liver
will get more sick and you may die. Please take your medications
as prescribed. Please make all of your follow-up appointments.
Your medication list will be sent with you to rehab.
Followup Instructions:
Department: LIVER CENTER
When: MONDAY [**2162-5-10**] at 11:50 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 2760, 4019, 3051, 496, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5232
}
|
Medical Text: Admission Date: [**2143-10-23**] Discharge Date: [**2143-10-26**]
Date of Birth: [**2078-3-15**] Sex: F
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
resident of a nursing home with a history of mild mental
retardation, schizophrenia, and seizure disorder who presents
after a fall with altered mental status and was found to have
a small subarachnoid hemorrhage. She was admitted to the
Medical Intensive Care Unit for close monitoring of her
neurological status.
She fell backwards on stairs on the day of admission and
struck her occiput, sustaining a laceration. She had no loss
of consciousness. She was initially anxious but alert and
given 0.5 mg of Ativan. A few hours later she was noted to
have a new mental status changes with agitation, garbled
speech, and an inability to ambulate or follow commands.
On arrival to the [**Hospital1 69**]
Emergency Department she was febrile to 102.8 rectally and
hypertensive to 200/100. She was in sinus tachycardia at 120
beats per minute, and slightly tachypneic at a rate of 30 to
40 with an oxygen saturation of 98% on 2 liters. She was
agitated, confused, and mumbling incoherently. Her initial
chest x-ray was negative. A head CT showed contusions at the
base of the frontal lobes bilaterally and a small temporal
lobe subarachnoid hemorrhage. She also had an old right
subdural hemorrhage. She has no mass effect or midline
shift. Neurosurgery was consulted and recommended a CT
angiogram to look for aneurysm.
Laboratories of note included a white blood cell count of 15
with a left shift, and a urinalysis that was positive for
nitrites with many bacteria. She had some ST depressions
inferiorly, so cardiac enzymes were cycled. Her blood
pressure was lowered with Nipride and labetalol. She also
received ceftriaxone and vancomycin. She was admitted to the
Medical Intensive Care Unit after her CT angiogram.
PAST MEDICAL HISTORY:
1. Mild mental retardation, although she is independent in
all her activities of daily living at baseline.
2. Schizophrenia.
3. Type 2 diabetes, diet controlled.
4. Collagenase colitis diagnosed in [**2140-8-2**] by
colonoscopy.
5. Lactose intolerance.
6. Mild thrombocytopenia from valproate.
7. Facial seborrhea.
8. History of falls.
9. Seizure disorder, on Depakote. Electroencephalogram in
[**2141-1-2**] within normal limits.
MEDICATIONS ON ADMISSION:
1. Depakote 500 mg p.o. q.a.m. and 250 mg p.o. q.p.m.
2. Cogentin 0.5 mg p.o. b.i.d.
3. Olanzapine 5 mg p.o. q.d.
4. Haldol 2 mg p.o. q.a.m. and 5 mg p.o. q.p.m.
5. Ativan 1 mg p.o. q.a.m. and 0.5 mg p.o. q.4h. p.r.n.
6. Vitamin E 400 IU p.o. b.i.d.
7. Zantac 150 mg p.o. b.i.d.
8. Milk of Magnesia 30 cc p.o. p.r.n.
9. Multivitamin 1 tablet p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives at the [**Hospital1 2670**] [**Hospital **]
nursing home. Her next of [**Doctor First Name **] is her sister, [**Name (NI) **]
[**Name (NI) 19864**], whose telephone number is [**Telephone/Fax (1) 19865**].
PHYSICAL EXAMINATION ON PRESENTATION: This is an elderly
woman who was obtunded and moaning, and not following
commands. She was febrile with a temperature of 102.8
rectally, a blood pressure of 132/53, a pulse of 112, a
respiratory rate of 28, and an oxygen saturation of 100% on 4
liters. Her pupils were equal, round, and reactive to light.
She had an laceration on her occiput. Her neck was supple
with no jugular venous distention or lymphadenopathy. Her
heart rate was tachycardic but regular. She had no murmurs,
rubs or gallops. Her lungs were clear to auscultation
anteriorly. Her abdomen was benign. Her extremities were
without edema and with good distal pulses. She had numerous
scratches and small bruises especially over her elbows. Her
neurologic examination revealed normal tone with no posturing
or meningeal signs. She had symmetric deep tendon reflexes
and downgoing toes bilaterally.
LABORATORY DATA ON PRESENTATION: Laboratories showed a white
blood cell count of 15.5, a hematocrit of 38.4, and a
platelet count of 185. Her differential showed 82% polys,
7% bands, 5% lymphocytes, and 2% monocytes. Her electrolytes
were within normal limits, as were her BUN and creatinine.
Her coagulations were within normal limits. Her liver
function tests, amylase, and lipase were likewise within
normal limits. Her valproate level was 76 which was
therapeutic. Her urinalysis showed positive nitrites and
many bacteria, but 0 white blood cells.
RADIOLOGY/IMAGING: Her chest x-ray showed no acute air space
disease.
Her electrocardiogram showed sinus tachycardia with normal
axis and intervals, and left atrial enlargement. She also
had 1-mm ST depressions in I, V5, and V6. There was no
comparison electrocardiogram available.
HOSPITAL COURSE: Ms. [**Known lastname **] was observed in the Medical
Intensive Care Unit and by the next morning her mental status
had improved to her baseline. A repeat head CT was obtained
that showed no change in the size of her bleed.
She was agitated overnight that evening and received 12 mg of
Haldol. The next morning she was more somnolent, and though
arousable had a decreased mental status overall.
Neurosurgery had been following throughout this course and
determined that she would not likely benefit from surgery as
her subarachnoid hemorrhage was small and not expanding. Her
CT angiogram of the head was consistent with her head CT
findings and showed no aneurysm. Given her overall stable
status, she was transferred to the floor.
Of note, she had a urinalysis that was nitrite positive, and
so she was treated for a urinary tract infection with a 3-day
course of levofloxacin. Her urine culture was positive for
Escherichia coli. Given her ST depressions on
electrocardiogram, she was ruled out for myocardial
infarction with three sets of enzymes.
On hospital day four her mental status improved again as the
Haldol she had received wore off to the point where she was
conversant, and appropriate, and back at her baseline. It
was felt that it was safe at that point to discharge her back
to [**Hospital1 2670**].
CONDITION AT DISCHARGE: Condition on discharge was improved.
DISCHARGE STATUS: To [**Hospital1 2670**] [**Hospital **] nursing home.
DISCHARGE DIAGNOSES:
1. Fall complicated by subarachnoid hemorrhage causing
transient altered mental status.
2. Mild mental retardation.
3. Schizophrenia.
4. Type 2 diabetes.
5. Seizure disorder.
MEDICATIONS ON DISCHARGE:
1. Depakote 500 mg p.o. q.a.m. and 250 mg p.o. q.p.m.
2. Cogentin 0.5 mg p.o. b.i.d.
3. Olanzapine 5 mg p.o. q.d.
4. Haldol 2 mg p.o. q.a.m. and 5 mg p.o. q.p.m.
5. Ativan 1 mg p.o. q.a.m. and 0.5 mg p.o. q.4h. p.r.n.
6. Vitamin E 400 IU p.o. b.i.d.
7. Zantac 150 mg p.o. b.i.d.
8. Milk of Magnesia 30 cc p.o. p.r.n.
9. Multivitamin 1 tablet p.o. q.d.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2143-10-27**] 16:43
T: [**2143-10-30**] 12:02
JOB#: [**Job Number 19866**]
(cclist)
ICD9 Codes: 5990
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5233
}
|
Medical Text: Admission Date: [**2164-3-10**] Discharge Date: [**2164-3-15**]
Date of Birth: [**2091-1-21**] Sex: M
Service: [**Hospital1 139**]
DISCHARGE DIAGNOSES:
1. Acute-on-chronic renal failure with flash pulmonary
edema.
2. Constipation.
3. Coronary artery disease.
4. Pleural disease.
5. Hypertension.
6. Dyslipidemia.
7. Gastroesophageal reflux disease.
8. Chronic obstructive pulmonary disease.
9. Benign prostatic hypertrophy.
HISTORY OF PRESENT ILLNESS: The [**Hospital 228**] medical doctor is
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**] (telephone number [**Telephone/Fax (1) 904**]). His renal
doctor is Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 174**]. His history of present
illness is as follows.
This 73-year-old male came in with a chief complaint of
constipation times five days and increase in creatinine. He
has coronary artery disease and chronic renal insufficiency
and presented with a 4-day to 5-day history of constipation.
He said he had problems with this before; however, this was
more severe. He reports a decrease in his appetite over this
same period as well as emesis times two. There was no
fevers, no chills, and no sweats. He did have some abdominal
pain. He has tried mineral oil (two doses worth) as well as
Dulcolax without relief.
In the Emergency Department, rectal examination and abdominal
films were unrevealing. However, because of his increased
creatinine to 4.5 from a baseline of about 3 to 3.5 and
bicarbonate of 18, he was admitted for further workup and
evaluation.
REVIEW OF SYSTEMS: On review of systems he had low back
pain. He reported about a 10-pound weight loss over the past
week.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Coronary artery disease, status post an anterior
myocardial infarction in [**2161-11-23**] with a stent to the
left anterior descending artery, percutaneous transluminal
coronary angioplasty to second diagonal. Catheterization in
[**2161-11-23**]; the proximal right coronary artery was 30%,
distal right coronary artery 70%, proximal left anterior
descending artery 100% with a stent placed, and middle
circumflex with 100%; deemed a poor a surgical candidate
secondary to his history of cerebrovascular accidents. An
echocardiogram in [**2162-7-24**] revealed an ejection fraction
of 30%, diffuse akinesis, right ventricle was normal, 1+
aortic regurgitation, 1+ mitral regurgitation. Stress MIBI
in [**2162-5-24**] showed 59% maximum heart rate, partially
reversible anterior defect, fixed apical and cervical
defects.
2. He also has a history of hypertension.
3. Dyslipidemia.
4. Cerebrovascular accident back in [**2162-5-24**].
5. Chronic renal insufficiency with a baseline creatinine
of 3 to 3.5 secondary to atherosclerotic renal disease;
formerly has had some end-stage renal disease one and a half
years ago.
6. Gastroesophageal reflux disease.
7. He is legally blind.
8. He has chronic obstructive pulmonary disease.
9. Benign prostatic hypertrophy; and elevated
prostate-specific antigen.
ALLERGIES: He has no known drug allergies, but ACE
INHIBITORS and [**Last Name (un) **] are contraindicated in this man.
MEDICATIONS ON ADMISSION:
1. Amitriptyline 40 mg p.o. q.h.s.
2. Zoloft 50 mg p.o. q.h.s.
3. Colace 100 mg p.o. t.i.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Lipitor 60 mg p.o. q.d.
6. Rocaltrol 0.25 mg p.o. q.d.
7. Nephrocaps 1 tablet p.o. q.d.
8. Phos-Lo 1 tablet p.o. t.i.d.
9. Tylenol 650 mg p.o. q.4-6h. p.r.n.
10. Plavix 75 mg p.o. q.d.
11. Lopressor 50 mg p.o. b.i.d.
12. Norvasc 5 mg p.o. q.d.
13. Ambien 5 mg to 10 mg p.o. q.h.s. p.r.n.
14. Ultram 50 mg p.o. q.6h. p.r.n.
15. Prilosec 20 mg p.o. q.d.
16. Fibercon 3 tablets per day.
SOCIAL HISTORY: He drinks two drinks per night. He quit
tobacco in [**2161**] but has a 50-pack-year smoking history by
report.
FAMILY HISTORY: His family history in this particular
situation was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: His physical
examination on admission revealed review of systems again
with low back pain. He was an elderly white man in no
apparent distress. Alert and oriented times three.
Temperature was 96.7, heart rate of 77, blood pressure
of 182/85, respiratory rate of 18, and oxygen saturation of
97% on room air. His skin was warm and dry. The oropharynx
was clear and moist. The neck was supple. He had positive
crackles in the right lung base. First heart sound and
second heart sound. A regular rate and rhythm. A 2/6
systolic murmur at the base. The abdomen was nondistended.
He had positive bowel sounds. There was no guarding and no
rebound, but tenderness to palpation in the right upper
quadrant and the left lower quadrant. Rectal examination in
the Emergency Department showed guaiac-negative stool, and he
also had decent rectal tone with an enlarged prostate on
rectal examination. He had no peripheral edema.
PERTINENT LABORATORY DATA ON PRESENTATION: His laboratory
values were significant for a white blood cell count of 11.6,
hematocrit of 32.5, platelets of 406, mean cell volume of 91.
SMA-7 revealed sodium of 140, potassium of 4.5, chloride
of 104, bicarbonate of 18, blood urea nitrogen of 42,
creatinine of 4.5, and glucose of 97. Differential with
83 neutrophils, lymphocytes 6.4, no bands. His urinalysis
showed specific gravity of 1.02, pH of 5, moderate blood,
nitrite negative, 6 to 10 red blood cells, 3 to 5 white blood
cells. Urine electrolytes revealed creatinine of 75, sodium
of 114, osmolalities of 462, with a FENa of 4.3.
RADIOLOGY/IMAGING: Abdominal x-ray was negative. No free
air. No dilated loops.
Electrocardiogram showed sinus rhythm at 83, left axis
deviation, left ventricular hypertrophy, T wave inversions in
aVL, and changes consistent with an anterior septal
myocardial infarction. No changes from [**2164-1-16**].
HOSPITAL COURSE: The patient was treated according to the
following hospital course:
He was given D-5-W with 3 amps of sodium bicarbonate, and he
was continued on the gentle rehydration, and strict
ins-and-outs were watched. Over time, the patient's blood
urea nitrogen and creatinine remained essentially stable in
the 4 range, and on the day of discharge he actually dropped
down to a blood urea nitrogen of 37 and creatinine of 3.8;
which was approaching his baseline renal function. He was to
follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] for further issues related to
management of his chronic renal insufficiency.
In addition, he was started on Epogen 4000 units subcutaneous
twice per week which will be provided by [**Hospital6 1587**] services.
From a gastrointestinal perspective, the patient had
constipation and was treated with an aggressive bowel regimen
including Colace, Senna, lactulose; and he eventually had
bowel movements, and by the time of discharge he had one on
the morning of his discharge; so he will be maintained with
his bowel regimen. It was thought that his constipation
might have been due to either the chronic renal insufficiency
leading to his not feeling well and not eating much; and
therefore not providing enough bulk as the cause. Liver
function tests were normal.
From a pulmonary perspective, during the rehydration of the
patient (he came in on [**2-8**]), and on the morning of
[**3-12**], the patient experienced difficulty breathing,
shortness of breath, with a blood pressure of up 210/110,
tachycardic to 110/150, normal sinus rhythm, with a narrow
complex. Electrocardiogram showed question of ST changes in
V1 through V2. Chest x-ray was done, and he was given 60 mg
of intravenous Lasix. A nitroglycerin drip was started, and
a heparin was started without a bolus, and the patient was
given aspirin. His oxygen saturations were at 78% on 4
liters nasal cannula, and intravenous fluids were stopped.
Pulmonary examination showed decreased breath sounds on the
right side and wet crackles bilaterally, and his skin with
mauled with red and white patches. So the patient actually
responded to this treatment to a blood pressure of 138/80,
heart rate 96, and respiratory rate of 28, and he was satting
only at 92% on 100% nonrebreather, and put out a small amount
of urine. He was feeling a little bit better.
So he was therefore transferred to the Intensive Care Unit
for monitoring of his oxygenation, but since he had been
determined to be do not resuscitate/do not intubate it was
preferred that he would not be intubated and maintained on
100% nonrebreather.
The patient's x-ray on [**3-11**] which showed mild
congestive heart failure with interstitial edema, opacity in
the right hemithorax, with volume loss (increased from the
previous study that was done a few months before), so a CT
was done, and there were found to be extensive diffuse
nodular thickening of the right pleura involving the
posterolateral as well as the mediastinal pleura. His
pericardial irregularity along the right side was concerning
for pericardial involvement. The thickened nodular
appearance of this lesion was concerning for metastatic
adenocarcinoma or malignant mesothelioma. He also had a 7-mm
indeterminate parenchymal nodule in the right lower lobe that
was noted on x-ray. There was also an area of increased
attenuation in the right upper lobe posteriorly adjacent to
the area of pleural abnormality which was consistent possibly
with atelectasis or less likely a neoplastic involvement of
the lungs. There was also mediastinal lymphadenopathy and
emphysema.
It was determined that no further workup of his lung
abnormalities would be done within the hospital, and so the
patient could be discharged from a pulmonary perspective as
it was determined by Physical Therapy toward the day before
discharge that his oxygen saturation was 92% on room air and
98% on 2 liters nasal cannula.
The patient's heart was measured, in terms of its ejection
fraction, just to determine that his pulmonary edema was not
a result of worsening ejection fraction; and the
echocardiogram done on [**3-12**] showed an ejection
fraction of 30%, and a left atrium that was mildly dilated;
however, the left ventricular wall thickness were normal.
The left ventricular cavity size was normal. Overall left
ventricular systolic function was severely depressed
secondary to severe hypokinesis of the anterior septum and
anterior free wall, and extensive circumferential apical
hypokinesis/akinesis, but no obvious apical thrombi were
seen. Right ventricular chamber size and free wall motion
were normal. The aortic root was mildly dilated and a number
of aortic valve leaflets were not determined. The aortic
valve were, however, mildly thickened. There was no
significant aortic valve stenosis. There was trace aortic
regurgitation. The mitral valve leaflets were mildly
thickened. There was no mitral valve prolapse. There was
mild 1+ mitral regurgitation. The tricuspid valve leaflets
were mildly thickened. There was no pericardial effusion.
So, compared with the previous study on [**2162-8-20**], there
were no major changes evident; although, technically the
studies were suboptimal. Thus, his heart had not changed
significantly during this time, and his flash pulmonary edema
may have been a result of hydration too quickly under the
circumstances.
From a gastrointestinal perspective, the patient was
maintained with Zoloft 50 mg p.o. q.d., amitriptyline 40 mg
p.o. q.h.s., and he was given Ultram and Tylenol p.r.n. The
patient was recommended by his renal physician to be taken
down from the Ultram at which he was taking up to six tablets
per day down to at most four tablets per day; which is what
he was discharged on. The patient will need to follow up
with the Pain Service to determine if there is a better
mechanism to deal with his low back pain. However, any
significant neurologic abnormalities were excluded and any
neurovascular problems within his lower back, spine, spinal
cord, and lower extremities.
For prophylaxis he was maintained on Protonix 40 mg p.o.
q.d., heparin intravenous drip while we were concerned for
his having a myocardial infarction; however, he had ruled
out. Again, the patient remained with a code status of do
not resuscitate/do not intubate.
DISCHARGE STATUS: He was discharged to home on [**2164-3-15**].
CONDITION AT DISCHARGE: In improved condition with [**Hospital6 3429**] services.
DISCHARGE FOLLOWUP: He was to follow up with his primary
care physician (Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**]) and his renal physician
(Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 174**]) within the next week. He will need a
referral from his primary care physician (Dr. [**First Name (STitle) 452**] for the
Pain Service followup.
MEDICATIONS ON DISCHARGE: (Discharge medications are very
similar to his admission medications including)
1. Amitriptyline 40 mg p.o. q.h.s.
2. Zoloft 50 mg p.o. q.h.s.
3. Colace 100 mg p.o. t.i.d.
4. Enteric-coated aspirin 325 mg p.o. q.d.
5. Lipitor 60 mg p.o. q.d.
6. Rocaltrol 0.25 mg p.o. q.d.
7. Nephrocaps 1 tablet p.o. q.d.
8. Phos-Lo 1 tablet p.o. t.i.d.
9. Tylenol 650 mg p.o. q.4-6h. p.r.n.
10. Plavix 75 mg p.o. q.d.
11. Lopressor 50 mg p.o. b.i.d.
12. Norvasc 5 mg p.o. q.d.
13. Ambien 5 mg to 10 mg p.o. q.h.s. p.r.n.
14. Ultram 50 mg p.o. q.6h. p.r.n.
15. Prilosec 20 mg p.o. q.d.
16. Fibercon 3 tablets per day.
17. Epogen 4000 units subcutaneous twice per week; which
will be done by [**Hospital6 407**] services (the only
additional medication).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], M.D. [**MD Number(1) 7938**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2164-3-15**] 11:14
T: [**2164-3-17**] 06:32
JOB#: [**Job Number **]
ICD9 Codes: 5849, 5119, 412, 496, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5234
}
|
Medical Text: Admission Date: [**2132-3-20**] Discharge Date: [**2132-4-17**]
Date of Birth: [**2057-12-23**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Zosyn
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Myocardial infarction
Major Surgical or Invasive Procedure:
Cardiac catheterization
Central venous line placement
Intubation and mechanical ventilation
PICC placement
Tracheostomy
PEG-tube placement
History of Present Illness:
74 y.o. male with COPD, anemia, GERD who presented to [**Hospital 6451**] Medical Center on [**3-17**] with a chief complaint of
shortness of breath, weakness and decreased PO. Patient had
additionally experienced reflux symptoms, specifically citing
burping and gaseous distention after eating, but denying chest,
jaw or arm pain or palpitations. He was brought to the [**Hospital **]
Medical Center ER where he was found to be in respiratory
distress with a respiratory rate of 24, and new oxygen
requirement of 3L, sat'ing 100%. Patient was additionally
relatively hypotensive to 98/60 with a HR of 124, sinus
tachycardia. The work-up thereafter revealed a Hct of 26.2, as
well as a troponin I of 11.82. EKG was without ST changes and
thus patient was felt to be having an NSTEMI. Given the anemia,
he was not anticoagulated, but was given Metoprolol,
Nitroglycerin and Lipitor.
.
During his hospitalization at [**Hospital3 417**], patient's CEs were
cycled and peaked at 12.07 and trended down. CKs peaked at 468
and trended down and CK-MB peaked at 31.8 and trended down.
Coincident with this, the patient developed a leukocytosis,
peaking at 16, but likewise trending down with no evidence of
infection suggested by fever, CXR or UA. An anemia work-up
ensued which revealed an iron of 13 and TIBC of 445 with normal
B12 and folate levels. He was started on Iron 325 mg for
presumed iron deficiency anemia. Patient continued to be
dyspneic and hypoxic while in-house and an echo revealed an EF
of 20-25% with severe global hypokinesis of the left ventricle,
mild tricuspid regurgitation and a marked deterioration of LV
function when compared to a prior study in [**2130-3-4**]. He was
then started on Lasix and Enalapril 0.625 mg IV Q6 as well as
Plavix for his new heart failure and in preparation for cardiac
catheterization, to be done at [**Hospital1 18**].
.
Upon transfer to [**Hospital1 18**], patient went to cardiac catheterization,
which revealed a left main that was 50% occluded and an RCA that
was 100% occluded, but with complete collateral circulation.
Dynamics revealed an elevated cardiac output of 8 and a wedge of
30. Upon completion of the cardiac catheterization, it was felt
that the patient did not have significant CAD to explain the
elevation of his troponin and given the elevated cardiac output,
along with prior leukocytosis, it was felt that the patient
might be septic. Patient was thus transferred to the MICU for
evaluation of potential sepsis. Of note, patient was not noted
to be febrile throughout his hospitalization at [**Hospital3 417**]
nor upon admission to [**Hospital1 18**] and WBC had normalized to 10.
Past Medical History:
COPD
Asbestos Exposure
Anxiety
GERD
Depression
Positive PPD
Social History:
Patient reportedly works as a painter. He has a log history of
tobacco use, though he quit many years ago. He reported no
alcohol or illicit drug use.
Family History:
NC
Physical Exam:
Vitals: T - 98.1, BP - 109/64, HR - 74, RR - 22, O2 - 100 AC
500/22/1/5
General: Sedated, intubated
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: Supple, neck veins appreciated at the level of the
mandible
Chest/CV: S1, S2 nl, no m/r/g appreciated
Lungs: CTAB anteriorly
Abd: Soft, NT, ND, + BS
Ext: Cyanosis of bilateral feet, R>L, cool to touch, but pulses
dopplerable. No edema
Neuro: Limited by sedation
Skin: No lesions
Pertinent Results:
ADMISSION LABS
[**2132-3-20**] 02:20PM BLOOD WBC-10.7 RBC-4.44* Hgb-8.0* Hct-28.1*
MCV-63* MCH-18.0* MCHC-28.4* RDW-22.0* Plt Ct-251
[**2132-3-20**] 02:20PM BLOOD Neuts-74.9* Bands-0 Lymphs-13.5*
Monos-6.2 Eos-5.0* Baso-0.4
[**2132-3-20**] 02:20PM BLOOD Plt Ct-251
[**2132-3-20**] 05:26PM BLOOD PT-12.7 PTT-33.7 INR(PT)-1.1
[**2132-3-23**] 04:22PM BLOOD Ret Man-1.4
[**2132-3-20**] 02:20PM BLOOD Glucose-150* UreaN-33* Creat-0.8 Na-141
K-3.4 Cl-104 HCO3-28 AnGap-12
[**2132-3-20**] 02:20PM BLOOD ALT-66* AST-32 CK(CPK)-64 AlkPhos-72
Amylase-83 TotBili-0.6 DirBili-0.2 IndBili-0.4
[**2132-3-25**] 02:02AM BLOOD Lipase-84*
[**2132-3-20**] 02:20PM BLOOD CK-MB-NotDone cTropnT-1.93*
[**2132-3-20**] 02:20PM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.2*
Mg-2.0
[**2132-3-22**] 04:38PM BLOOD calTIBC-334 Ferritn-62 TRF-257
[**2132-3-23**] 03:27AM BLOOD Hapto-311*
[**2132-3-21**] 08:10AM BLOOD Cortsol-35.2*
[**2132-3-21**] 08:55AM BLOOD Cortsol-46.8*
[**2132-3-21**] 09:35AM BLOOD Cortsol-48.2*
[**2132-4-13**] 06:33AM BLOOD Digoxin-0.3*
[**2132-3-20**] 02:27PM BLOOD Glucose-140* Lactate-1.5 K-3.4*
MICRO DATA
GRAM STAIN (Final [**2132-4-10**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2132-4-14**]):
DUE TO LABORATORY ERROR, PLANTED [**2132-4-12**].
SPECIMEN REFRIGERATED FASTIDIOUS ORGANISMS [**Month (only) **] NOT GROW.
PATIENT CREDITED.
OROPHARYNGEAL FLORA ABSENT.
YEAST. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
GRAM STAIN (Final [**2132-3-21**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2132-3-25**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Please contact the Microbiology Laboratory ([**6-/2430**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
CARDIAC CATH [**3-20**]
1. Coronary angigraphy of this right dominant system revealed
40%
ostial LMCA stenosis and chronic total occlusion of the mid RCA
with
left to right collaterals. The LAD and LCx had no
angiographically
evident CAD.
2. Resting hemodynamics measured with patient mechanically
ventilated
on dobutamine for hypotension revealed elevated right and left
sided
filling pressures with RVEDP of 14 mmHg and LVEDP of 26 mm Hg.
PASP was
severely elevated at 68 mmHg. Mean PCWP was 24 mm Hg. Cardiac
index
was elevated at 4.25 l/min/m2.
3. Left ventriculography was not performed.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Hypotension with high cardiac output.
3. Elevated biventricular filling pressures.
Brief Hospital Course:
74 y.o. male with NSTEMI and cardiomyopathy with EF of 25,
transferred to [**Hospital1 18**] for cardiac catheterization which revealed
unintervenable CAD, elevated wedge and cardiac output, the
latter of which was concerning for possible sepsis.
.
# Severe septic shock from community acquired pneumonia: Pt was
initially suspected to be in septic shock based on elevated
cardiac output seen at the cardiac catheterization. Following
his cardiac catheterization, he was transferred to the MICU team
and subsequently became more septic with hypotensive requiring
pressors and evidence of evolving pneumonia on CXR. Sputum
cultures grew MRSA and Klebsiella pneumoniae. Legionella
antigen negative. He was treated initially with vanco and
zosyn, which was changed to vanco and cipro after sensitivities
returned to complete 10 day course. Pressors were weaned off.
.
# Ventilator-associated pneumonia: His blood pressure decreased
again, and required pressors (levophed), cultures were taken and
his sputum grew out Klebsiella again in addition he developed
increased sputum production and had fevers. He was treated with
zosyn for two weeks for a VAP, during which his blood pressure
improved, but he had intermittent fevers. The differential on
his CBC showed an eosinophilia and it is thought that Zosyn
likely caused a drug fever with eosinophilia. Zosyn was
discontinued on [**4-15**] and pt remained afebrile.
.
# Respiratory Failure: This was likely due to pneumonia as
above and new heart failure, which is presumably ischemic in
nature given his recent NSTEMI. PE was a consideration at one
time given hypoxemia and tachycardia, but PE CT was negative.
He remained intubated on the ventilator; he was unable to be
weaned off, likely due to his underlying COPD, CHF, and
agitation, and received a tracheostomy. He was eventually
weaned down to a trach mask with FiO2 of 0.5 over the course of
three weeks. His trach was switched on [**4-15**] for a cuff leak.
.
He was diuresed aggressively once sepsis was treated as he had a
net positive fluid balance in the context of a very diminished
EF (20%). Initially he was on a lasix drip, and diuresed
briskly. He was transitioned to lasix 40mg IV bid. His
bicarbonate decreased as a result of the contraction alkalosis
from diuresis. He was started on diamox in order to prevent his
bicarb from rising enough to prevent him from breathing
spontaneously. The diamox should be continued until his bicarb
is 28-30 while he is being diuresed. His SBP dropped to 70 and
his Lasix was decreased to 40 mg IV daily for maintainence. He
appears to be euvolemic at discharge. Unfortunately, his bed
scale is broken and a discharge weight could not be obtained.
Please check his weight on arrival; this should be his dry
weight.
.
#.CARDIAC
ISCHEMIA-NSTEMI: This was evidenced by troponin leak to 12. CAD
was present, but not intervenable in the cath lab. Once his
sepsis had resolved, he was started on metoprolol and captopril
as tolerated by BP with goal MAP>50 as pt will not likely get a
BP higher than that due to poor EF. In addition, he was started
on aspirin and a statin.
RHYTHM-ECTOPY/NSVT: He frequently displayed ectopy, in addition
he had an 11 beat Vtach on [**4-4**]. This was in setting of
aggressive diuresis on PS. Pt was asymptomatic, hemodynamically
stable. EKG after the event was unchanged without evidence of
ischemia. On [**4-13**], he had 20 minutes of intermittent vtach, he
was started on an amiodarone drip. He also had his PICC line
pulled back 2 cm. His electrolytes were monitored and corrected
aggressively. Cardiology was consulted and a transition from an
amiodarone drip to a two week po loading was initiated. He will
remain on po amiodarone.
PUMP: Repeat ECHO after his MI showed EF of 15-20%-worsening
biventricular systolic function with akinesis of
inferior/inferolateral LV and hypokinesis in the remaining
segments, worse than his inital EF of 30% post MI. He was
aggressively diuresed with lasix gtt as above and transitioned
to lasix IV, which is now the maintainence dose. In addition,
he was maintained on metoprolol and captopril.
.
# COPD: Pt was continued on outpatient inhalers.
.
# Deconditioning: Pt had [**Month/Year (2) 65**]. generalized weakness, perhaps
L>R, though neurologic exam is intact given level of
cooperation. Physical therapy was consulted and worked with him
during his hospitalization.
.
# Abnormal VBG, ?ASD: On [**4-16**] and [**4-17**], pt had VBG drawn from R
sided PICC line that were pH 7.47, pCO2 51, pO2 186 and pH 7.44,
pCO2 49, and pO2 146. Previous VBG drawn from the same PICC
line were more consistent with VBGs with pCO2 in 50s and pO2 in
30s. This may be displacement of the PICC or ASD with L to R
shunt. On CXR, the PICC appears to be in the SVC. Pt currently
is clinically improved. He may need outpatient workup for ASD
or sooner if he clinically worsens.
.
# RLE edema/pain: LENIs were obtained and were negative for
DVT.
.
# GERD: Pt was continued on PPI.
.
# Nutrition: Pt received a PEG-tube and was continued on tube
feeds, at goal.
.
# Code: DNR
.
# Communication: [**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 174**] (daughter) [**Telephone/Fax (1) 77514**]
Medications on Admission:
Advair
Requip 1 tab PO BID
Valium 10 mg PO TID
Aspirin 325 mg PO QD
Tylenol PRN
Albuterol Nebs TID
Spiriva QAM
Nexium 40 mg PO QD
Discharge Medications:
1. Acetazolamide 250 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO three
times a day: Please administer for a goal serum bicarb 28-30,
pls discontinued once bicarb is <28. This is to counteract the
contraction alkalosis from diuresis.
2. Potassium Chloride 10 mEq/50 mL Piggyback [**Telephone/Fax (1) **]: as per sliding
scale mg Intravenous twice a day.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: 5000 (5000)
units Injection TID (3 times a day).
4. Atorvastatin 80 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
5. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
6. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Telephone/Fax (1) **]:
Eighty (80) mcg Inhalation [**Hospital1 **] (2 times a day).
7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
8. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: as directed
units Injection ASDIR (AS DIRECTED).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
10. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily).
11. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
12. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
13. Hydrocortisone 2.5 % Cream [**Hospital1 **]: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
14. Ropinirole 0.25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3
times a day).
15. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
16. Captopril 12.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day).
17. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed.
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical QDAY ().
19. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day) as needed.
21. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3
times a day).
22. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
23. Fentanyl 75 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
24. Lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
26. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: One (1) ML
Intravenous PRN (as needed).
27. Metoclopramide 10 mg IV Q8H:PRN
high tube feed residuals
28. Morphine 10 mg/mL Solution [**Last Name (STitle) **]: 1-4 mg Intravenous Q4H
(every 4 hours) as needed for pain: hold for respiratory
depression.
29. Amiodarone 400 mg Tablet [**Last Name (STitle) **]: One (1) gram PO twice a day
for 7 days: please administer until [**4-23**], then he will take
200mg po tid for three weeks, after which he will take 300mg po
daily indefinitely.
30. Furosemide 10 mg/mL Solution [**Month Day **]: Forty (40) mg Injection
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**]
Discharge Diagnosis:
Primary:
Non-ST-elevation myocardial infarction
Acute on chronic systolic congestive heart failure
Severe septic shock from community acquired pneumonia
Ventilator-associated pneumonia
.
Secondary:
Chronic obstructive pulmonary disease
Restless leg syndrome
Right lower leg edema
Discharge Condition:
Stable on trach mask at FiO2 50%, SBP 80s-110s, HR 80s-100s with
frequent PVCs.
Discharge Instructions:
You were admitted for a heart attack and underwent a cardiac
catheterization. You were found to have clogged arteries in
your heart; unfortunately, a stent could not be placed. You
will need to continue metoprolol, captopril, aspirin, and
atorvastatin to help protect your heart.
.
On echocardiogram (ultrasound of the heart), you were found to
have severe congestive heart failure, which means your heart is
not squeezing adequately. This leads to the build up of fluid
in your lungs, which can make it difficult for you to breathe.
You will need to continue on your metoprolol, captopril, and
furosemide.
.
You were also found to be very sick from a pneumonia and were
treated with antibiotics. However, your lungs have been so
affected from the pneumonia and the congestive heart failure
that you required a breathing tube and a machine to help you
breathe. Attempts to remove the breathing tube have failed and
you now have a tracheostomy. You also have a G-tube, which will
allow you to be fed and take your medications.
.
Please take your medications as prescribed.
.
Please follow up with your physicians.
.
If you develop shortness of breath, chest discomfort,
palpitations, fevers, or any other concerning symptoms, please
call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10740**] at [**Telephone/Fax (1) 40144**] or go
to the Emergency Department.
Followup Instructions:
Please follow up with your primary care physican Dr. [**Last Name (STitle) 10740**]
within 3 weeks. His clinic number is [**Telephone/Fax (1) 40144**].
Completed by:[**2132-4-22**]
ICD9 Codes: 0389, 486, 4254, 4280, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5235
}
|
Medical Text: Admission Date: [**2172-8-18**] Discharge Date: [**2172-8-21**]
Date of Birth: [**2133-4-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
39M with history of alcohol abuse and withdrawal seizures found
by [**Location (un) **] FD in hotel room with abdominal pain and coffee
ground emesis all over the room. pt reports that last drink was
4 days ago. Brought to [**Hospital3 **] where patient had
witnessed seizure. Intubated for airway protection and altered
mental status. CT head negative at [**Hospital1 **]. Patient had coffee
ground emesis prior to intubation. K 2.3 at OSH. CK 3000. Sent
to [**Hospital1 18**] for further eval. Received ceftraixone, vanc and flagyl
for presumed aspiration PNA.
In the ED, initial VS were: T: 97.6 P: 72, RR: 16, BP: 107/68,
Rhythm: NSR, O2Sat: 100, O2Flow: (Intubation). In the ED he was
given 2L NS and 40 K. Started on IV pantoprazole and IV profopol
was continued. WBC 14 with left shirt (N:96). Na126 K 2.3
HCO3:38, Mildly AST/ALt (80/45), lipase 39. ABG 7.51/51/260/38
Preliminary read of CXR revealed ?R middle lobe atelectasis vs
consolidation. CT scan abd without contrast RML, RLL and LLL
consolidations and no acute intraabdominal or intrapelvic
process.
Past Medical History:
ETOH Abuse
ETOH withdrawl sz
Social History:
Heavy ETOH, denies illicts
Family History:
no early CAD
Physical Exam:
Admission exam:
General: intubated sedated no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: R base significantly decreased BS, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU:foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. Neurologic: Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
DISCHARGE:
General: no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear,
Neck: supple, no LAD
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: CTAB
Abdomen: soft, non-distended, bowel sounds present, no
tenderness to palpation, Ext: Warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: alert, answering questions appropriately, moving all
extremities
Pertinent Results:
Admission Labs:
[**2172-8-18**] 01:00AM BLOOD WBC-14.0* RBC-4.80 Hgb-14.0 Hct-39.8*
MCV-83 MCH-29.1 MCHC-35.1* RDW-14.2 Plt Ct-142*
[**2172-8-18**] 01:00AM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2172-8-18**] 01:00AM BLOOD PT-10.6 PTT-22.6* INR(PT)-1.0
[**2172-8-18**] 01:00AM BLOOD Glucose-124* UreaN-29* Creat-1.1 Na-126*
K-2.3* Cl-79* HCO3-38* AnGap-11
[**2172-8-18**] 01:00AM BLOOD ALT-45* AST-80* AlkPhos-62 TotBili-0.7
[**2172-8-18**] 05:32AM BLOOD ALT-36 AST-65* CK(CPK)-1378* AlkPhos-50
TotBili-0.6
[**2172-8-18**] 01:00AM BLOOD Albumin-3.6 Calcium-7.4* Phos-3.8 Mg-2.2
[**2172-8-18**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2172-8-18**] 01:12AM BLOOD Type-ART Rates-16/ Tidal V-400 PEEP-5
FiO2-100 pO2-260* pCO2-51* pH-7.51* calTCO2-42* Base XS-15
AADO2-403 REQ O2-70 -ASSIST/CON Intubat-INTUBATED
[**2172-8-18**] 01:12AM BLOOD Lactate-1.2
Brief Hospital Course:
39 y/o w/etoh abuse and withdrawal seizures found with coffee
ground emesis and intubated at OSH for airway protection s/p
seizure. Transferred first to [**Hospital Unit Name 153**], then to medicine for
continued care.
Active issues:
#Altered mental status requiring intubation: Pt was intubated
for airway protection s/p seizure. Most likely etiology was
alcohol withdrawal given his hx of withdrawal seizures. Pt was
extubated without complication and mental status improved. Pt
initially on a CIWA scale. Did not receive any benzos for
greater than 48hr prior to discharge.
#Metabolic alkalosis: Most likely [**3-12**] to vomiting. Resolved with
IVF during ICU stay.
#EtOH withdrawal: CIWA and benzos as above
#Leukocytosis: pt with left shift and consolidations on Chest CT
most likely represents aspiration pneumonitis vs aspiration
pneumonia. Started on vanc/CTX/flagyl in ED and changed to
Unasyn/Azithro in [**Hospital Unit Name 153**]. to complete 5 day course on [**8-22**].
#Elevated CK to 3000: most likely from immobility and
dehydration. Improved with IV fluids.
#?coffee ground emesis: guaiac positive gastric secretions.
[**Doctor First Name **] [**Doctor Last Name **] tear from history of vomiting is most likely.
Other diagnoses include gastritis and PUD. Hct remained stable
during ICU stay. GI was consulted who recommended PPI [**Hospital1 **], daily
Hct, no further bleeding and thus no EGD performed during
admission.
HTN: pt developed persistent HTN during stay with SBP steady in
150s. As pt with oustide PCP and does not know his name, contact
information or location, poor history of follow up, and no
desire to arrange [**Hospital1 18**] PCP, [**Name10 (NameIs) **] not start medication.
Instructed him to follow up with PCP to start [**Name9 (PRE) **] regimen.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 325 mg tablet Sig: Two (2) tablet PO Q6H (every
6 hours) as needed for back pain.
2. amoxicillin-pot clavulanate 875-125 mg tablet Sig: Two (2)
tablet PO twice a day for 4 days.
Disp:*8 tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
alcoholic seizure, high blood pressure
Discharge Condition:
Alert and oriented. No signs or symptoms of withdrawl.
Ambulating without difficulty.
Discharge Instructions:
Avoid alcohol. You will need to discuss starting a medication
for blood pressure with your primary doctor.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**Hospital1 1474**] within 2 weeks.
ICD9 Codes: 5070, 2761, 2768, 311, 2875
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5236
}
|
Medical Text: Admission Date: [**2131-8-22**] Discharge Date: [**2131-8-28**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
hypotension in cardiology clinic
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]-year-old female admitted for hypotension,
fevers, leukocytosis, and decreased PO intake x1 week. Pt is
mildly disoriented and a poor historian at time of admission.
The pt has a PMHx of CAD s/p CABG x3, severe aortic stenosis s/p
valvuloplasty [**4-4**] with improved ischemic & valvular
cardiomyopathy (EF 50% in [**6-4**]), who was sent in from
cardiology clinic after a routine scheduled visit showed that
the pt had a leukocytosis, hypotensive reportedly to SBP 80s (BP
80/40, T 100.7, WBC 16 in nursing home today), and fever to 101.
For that she was sent to the ED. The pt reports that if she
weren't referred to the ED that she wouldn't have wanted to go
by herself. The pt at the time of clinic visit had no chief
complaint except decreased PO intake x1 week, and increased b/l
leg edema, but reports that she is normally edematous. Pt
denies SOB and CP, no abdominal pain, no change to bowel or
bladder habbit, no headache, no neck pain, no change in vision,
no new confusion. Patient reportly endorsed minimal dry cough
reported by cardiologist but denies to us.
.
In the more recent past, the patient was recently admitted with
pancolitis in [**7-30**] through [**2131-8-2**]. During that stay she was
treated non-operatively, had two negative C.diff toxins, and
that the pt improved with medical management, and was
subsequently discharged from the hospital on [**8-2**]. On the day of
discharge she suffered a fall at home that resulted in a
subdural hematoma and the pt was re-admitted here for neuro
checks, during which time the pt's coumadin and asprin were
stopped. She was discharged to a rehab facility and over the
past week she has felt progressively weaker with less energy.
Notes from the rehab facility indicate that about a week ago her
blood pressures started to drop. On [**8-8**] her lisinopril and
lasix were both held for hypotension and her BP has not
recovered. Of note, during past admission and clinic visits her
BP has been in the 80's to the low 110's.
.
Even more distantly, the pt is s/p a balloon aortic
valvuloplasty in [**2131-3-25**], which was complicated by a CVA
without lingering defiecits. Intervally after that the pt had a
repeat echo which showed that her LVEF improved from 25% to 50%.
.
In the ED, initial VS were 97.6, 74, 89/42, 20, 93%RA. Labs were
notable for WBC 16.3 w/85% polys & no bands and BNP [**Numeric Identifier 27150**] (was
[**Numeric Identifier 18214**] on [**2131-7-30**]). Troponin <0.01 & lactate 1.8. Hematocrit
stable at 32; creatinine 1.5 (recent baseline 1.2-1.6). UA
negative; 10 hyaline casts. Patient received ~300cc fluid.
Bedside U/S showed collapsing IVC, was negative for pericardial
effusion. CXR with no acute process. Blood cultures were sent
and she was started empirically on vancomycin 1g IV,
levofloxacin 750mg IV, flagyl 500mg IV. Given ongoing
hypotension, a left IJ central venous line was placed and she
was started on levophed (currently SBP 110s on levophed @
0.09mcg/min). An hour prior to transfer in the ED, had a rectal
temp 100.8. VS on transfer were 99.6 PO, HR 94, 105/48, 21,
100%RA.
Past Medical History:
1. CAD, Severe aortic stenosis with [**Location (un) 109**] of 0.8 cm2, CABG: 3V
CABG
recent catheterization with widening of her aortic valvuloplasty
[**4-4**]
complicated by CVA.
2. Diabetes mellitus type 2.
3. Hypertension
4. Hyperlipidemia.
5. Ischemic and valvular cardiomyopathy with an EF 20-25%
6. History of left breast cancer, grade 3.
7. Right rotator cuff tendinopathy.
8. Right biceps tendinitis.
9. Polymyalgia rheumatica.
10. Osteoporosis.
11. Moderate mitral regurgitation
12. History of squamous cell carcinoma.
13. Moderate MR
14. Severe AS: symptoms started in [**2127**]
15. Atrial fibrillation: coumadin, amiodarone
.
PAST SURGICAL HISTORY:
1. Right mastectomy.
2. Coronary artery bypass graft 22 years ago.
3. Hysterectomy.
4. Excision of left dorsal hand squamous cell carcinoma.
5. Right fourth trigger finger release.
Social History:
Housing: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital3 400**] Facility. Has a daughter
nearby who is her emergency contact.
Occupation: Was a homemaker.
Functional Status: Very active, exercises 3x week, does
treadmill, aerobics and yoga.
Tobacco/EtOH/Illicit Drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
VS: T: 100.4 BP: 117/37 P: 66 R: 14 O2: 95% RA
General: Alert but not completley oriented. Oriented to person,
place, generally to events, to date and month and year and
president. Pt seems confused why she's here, is slow to speak,
but does so with complete and fluent sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear. No step offs,
depressions, or tenderness to palaption. LIJ in place and
covered with occlusive dressing.
Neck: supple, JVP to 2cm above clavicles when 45* recumbant, no
LAD
CV: Regular rate and rhythm, diminished S1 and S2 with
pan-systolic systolic murmurs in RUSB, LUSB, and at left apex.
Lungs: Diffuse mid-inspiratory crackles in bases, left more than
right, about [**11-27**] way up chest wall.
Abdomen: no body wall ecchymoses, no percussion tenderness,
soft, non-tender, non-distended, bowel sounds present, no
organomegaly
GU: foley to gravity with dark colored urine.
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis.
Noted for 2+/3+ symmetric edema to the legs b/l coming up to
mid-calf.
Skin: intact without any defects. Reported birth mark to
anterior left thigh.
.
DISCHARGE PHYSICAL EXAM
Vitals - Tm/Tc 100.7/97.9 BP 103-47 (102-116/40-50) HR 66
(66-80)
RR 18 SaO2 95%RA (94-98%RA)
In/Out: 2180/920
Weight: 53 kg
GENERAL: Frail, elderly lady, NAD. Alert and oriented x3. Very
pleasant.
HEENT: NCAT. EOMI, MMM.
NECK: Supple with JVP of 3cm above sternal notch.
CARDIAC: RRR, diminished S1 and S2 with pan-systolic murmur in
RUSB, LUSB, and at left apex, which radiates to the carotids.
LUNGS: Diffuse mid-inspiratory crackles in bases, about [**11-26**] the
way up chest wall.
ABDOMEN: Soft, NTND. Normoactive bowel sounds.
EXTREMITIES: 1+ symmetric edema to the legs b/l coming up to
mid-calf.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission labs
[**2131-8-22**] 05:50PM BLOOD WBC-16.3*# RBC-3.79* Hgb-11.0* Hct-32.9*
MCV-87 MCH-29.1 MCHC-33.6 RDW-16.5* Plt Ct-221
[**2131-8-22**] 05:50PM BLOOD Neuts-85* Bands-0 Lymphs-9* Monos-5 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2131-8-22**] 05:50PM BLOOD PT-13.7* PTT-26.8 INR(PT)-1.2*
[**2131-8-22**] 05:50PM BLOOD Glucose-98 UreaN-35* Creat-1.5* Na-135
K-4.7 Cl-95* HCO3-30 AnGap-15
[**2131-8-22**] 05:50PM BLOOD ALT-10 AST-24 AlkPhos-71 TotBili-0.4
[**2131-8-22**] 05:50PM BLOOD proBNP-[**Numeric Identifier 27150**]*
[**2131-8-22**] 05:50PM BLOOD cTropnT-<0.01
[**2131-8-22**] 05:50PM BLOOD Albumin-2.6*
.
Discharge labs:
[**2131-8-28**] 06:10AM BLOOD WBC 7.2, RBC 3.69, HGB 10.3, HCT 33.4,
MCV 91, MCH 27.8, MCHC 30.7, RDW 15.6, PLT 275
[**2131-8-28**] 06:10AM BLOOD PT 14.8, PTT 28.6, INR 1.3
[**2131-8-29**] 06:10AM BLOOD GLUC 101, BUN 24, CR 1.2, NA 134, K 4.9,
CL 103, HCO3 27
[**2131-8-29**] 06:10AM BLOOD CA 6.9, PHOS 2.4, MG 2.4
.
IMAGING
[**2131-8-23**] TTE: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
hypokinesis of the basal and mid septal, inferior, and
inferolateral segments. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The ascending
aorta is mildly dilated. The aortic valve leaflets are
moderately thickened. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild to moderate ([**11-26**]+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal left ventricular cavity size. Mild to moderately
depressed left ventricular hypokinesis of the basal and mid
septal, inferior, and inferolateral segments. Mild global right
ventricular free wall hypokinesis. Critical aortic stenosis with
mild to moderate aortic regurgitation. Mild to moderate mitral
regurgitation. Normal pulmonary artery systolic pressure. Left
pleural effusion.
Compared with the prior study (images reviewed) of [**2131-6-15**],
the mildly to moderately depressed left ventricular systolic
function and regional wall motion abnormalities are new. The
severity of aortic stenosis has increased and is now critically
stenosed (the LVOT gradient has decreased), although visually
and by transvalvular aortic gradient it is more consistent with
moderate to severe aortic stenosis and appears unchanged. The
pulmonary artery systolic pressure has normalized.
.
[**2131-8-23**] CHEST (PORTABLE AP): Persistent cardiomegaly without
evidence of congestive heart failure. Slightly improved left
retrocardiac opacity is likely due to a combination of
atelectasis and effusion. Remainder of the lungs are grossly
clear, but lung apices are partially obscured and cannot be
fully assessed.
.
[**2131-8-24**] UNILAT UP EXT VEINS US: Grayscale, color and Doppler
images were obtained of the right IJ, subclavian, axillary,
brachial, basilic, and cephalic veins. Normal flow, compression,
and augmentation are seen in all of the vessels. No evidence of
deep vein thrombosis in the right arm.
.
[**2131-8-25**] Head CT w/o contrast: Previously seen right parietal
subdural hematoma has significantly decreased in size and
density with a small residual subdural hemorrhage (series 2,
image 19).
There is no new acute intracranial hemorrhage, edema, masses,
mass effect, or acute territorial infarction. Unchanged
encephalomalacia in the left superior parietal lobe (series 2,
image 20) from prior injury. Small lacunar infarcts are seen in
the basal ganglia and in the left subinsular region.
Moderate-to-severe atherosclerotic calcification of the
cavernous segments of the carotid artery. Paranasal sinuses and
mastoids are clear. No fracture.
Brief Hospital Course:
[**Age over 90 **]F with hx of severe AS, moderate AR/TR, A-fib, sent from
cardiology clinic for hypotension and found to have c diff.
.
ACUTE
# C. Difficile Infection - Pt presented with hypotension, low
grade fever and leukocytosis to 12.5 without bandemia. She
developed diarrhea and was found to be positive for C. Diff
toxin. She was started on PO flagyl on [**8-24**] and will continue
treatment for a total of 14 days.
.
#. Hypotension: The pt's blood pressure seems to be baseline
about SBP 80-110. Etiology of her hypotension is most likely
contributed to by [**12-27**] worsening AS and hypovolemia secondary to
gastrointestinal losses due to C. difficile infection. A repeat
ECHO showed critical AS, worsened after the valvuloplasty in [**Month (only) 116**]
[**2130**]. Pt's BP is 70s/40s with good mentation when not on
pressor. Her Troponin is neg X2 with no EKG changes. She was
first started on lisinopril 2.5mg daily and her carvedilol was
held due to persistently low blood pressures. She was given
small fluid boluses to maintain intravascular volume.
.
#. [**Last Name (un) **]: Was 1.5 on admission, but back to baseline of 1.2 by
[**8-26**]. Could have been pre-renal or [**12-27**] end organ dysfunction
from poor perfusion. Pt was given small fluid boluses to
maintain UOP and Cr back to baseline. Creatinine was 1.2 upon
discharge.
.
CHRONIC
#. Afib: Longstanding problem with no acute issues this
admission. She was continued on amiodarone at her home dose.
.
#. DM2: Home metformin was held and put her on ISS while
in-house.
.
#. CAD: ASA was initially held due to recent SAH but Head CT on
[**8-25**] showed a significant interval decrease in size and density
of the right parietal
subdural hematoma. ASA was re-started on [**8-27**] per her PCP.
.
#. HTN: Due to hypotension this admission, her home carvedilol
was held.
.
#. HL: Pt was continued on her home simvastatin.
.
#. Hypothyroidism: Pt was continued on her home levothyroxine.
.
#. Osteoporosis: On alendronate at home. Held while in house.
Medications on Admission:
- ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet
PO twice a day: Do not take with thyroid hormone
- carvedilol 3.125 mg Tablet Sig: One (1) Tab PO BID (2 times a
day)
- simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
- alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
- metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
- levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day
- amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
- multivitamin Tablet Sig: One (1) Tablet PO DAILY
- cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY
- ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
- Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
once a day as needed for pain
- ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
- docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day)
- recently discontinued from Lasix and lisinopril
Discharge Medications:
1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day): after lunch and dinner.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: please hold for
diarrhea.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
give on Monday.
5. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day:
give after lunch.
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): give before breakfast.
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO at bedtime:
give at hs.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO at bedtime.
10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 9 days.
11. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
give after lunch, hold SBP < 100.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
Please start once diarrhea is resolved.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
C difficile Colitis
Acute on Chronic Kidney Injury
Atrial fibrillation
Severe Aortic Stenosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had fevers and an elevated white blood cell count that we
believe was due to the infection in your colon. You were started
on flagyl, an antibiotic to treat this infection for a 2 week
course. Your kidney function also worsened because of
dehydration, your kidney function is almost normal now. Weigh
yourself every morning, call Dr. [**Last Name (STitle) 911**] if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1.Discontinue carvedilol as your blood pressure has been low
2. START Metronidazole pills to treat your bowel infection
3. Restart Lasix when the diarrhea goes away
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2131-9-27**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: RADIOLOGY
When: THURSDAY [**2131-9-6**] at 1:15 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: NEUROSURGERY
When: THURSDAY [**2131-9-6**] at 2:15 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2131-11-21**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**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: 4240, 5859, 4241, 2724, 5849, 4254, 4589, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5237
}
|
Medical Text: Admission Date: [**2115-10-23**] Discharge Date: [**2115-10-28**]
Service: SURGERY
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
fall from standing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88F s/p fall from standing with + [**Hospital 63213**] transferred from outside
hospital to [**Hospital1 18**] for management of L frontal IPH w/ small SDH,
and a L orbital wall fracture.
Past Medical History:
HTN
Echo [**2108**]: EF 55%, 2+ MR/TR
depression
Claudication with negative LE arterial studies
Social History:
Lives at home with husband. [**Name (NI) **] 2 grown children on the West
Coast. [**12-23**] drinks/week. Smoking hx 1 ppd x 20 years, quit 30
yrs ago. no other drug use.
Family History:
Non-contributory, no heart disease on family.
Physical Exam:
Gen: NAD
Chest: CTAB RRR
Abd: S/S/NT
Ext: WNL
Pertinent Results:
[**2115-10-25**] 07:35AM BLOOD WBC-7.8 RBC-4.40 Hgb-13.4 Hct-37.5 MCV-85
MCH-30.5 MCHC-35.8* RDW-13.5 Plt Ct-185
[**2115-10-23**] 12:20PM BLOOD PT-12.5 PTT-26.1 INR(PT)-1.1
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**], where neurosurgery was
consulted. They recommended a repeat Head CT, and an MRI of the
head and C-spine with the patient to remain in a C-collar until
this had been done. The Head CT showed unchanged hemorrhages,
while the MRI of the brain was consistent with a bleed, and did
not show any underlying lesion. The MRI C-spine was unchanged
from previous and the patient's C-spine was subsequently
cleared. Plastic surgery recommended antibiotics for 7 days and
non operative management of the patient's orbital fracture. The
etiology of the patients' fall was discussed with cardiology -
they recommended an echocardiogram which showed significant L
ventricular outflow obstruction with an EF of 75%, with mild AR,
MR, and moderate TR. A CTA of the chest requested by cardiology
was also negative for PE. At this time, the cardiology service
recommended a further arrhythmia workup as an outpatient. The
patient is tolerating regular diet, having bowel function, and
was cleared to go home by physical therapy. She is therefore
being discharged to follow up with cardiology.
Medications on Admission:
asa 81, ativan 0.5 qhs prn, cartia xt 120', ditropan 5', fosamax
70 qwk, lopressor 25", ritalin 0.5", simvastatin 20'
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO twice a day for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for Insomnia.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) dose PO
DAILY (Daily) as needed.
10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Fall from standing
Left frontal intraparenchymal hemorrhage with subdural hematoma
Left medial/lateral orbital wall frcature
Discharge Condition:
Stable, pain well controlled
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as prescribed.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 80069**] to arrange appropriate
follow-up regarding your heart monitoring.
Please call the [**Hospital **] [**Hospital **] at [**Telephone/Fax (1) 1669**] to arrange
appropriate follow-up with Dr. [**Last Name (STitle) **].
You can follow-up with the Trauma [**Last Name (STitle) **] as needed. They can be
reached at [**Telephone/Fax (1) 2359**].
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2115-10-30**] 10:00
Provider: [**Name10 (NameIs) 13644**],NURSE [**First Name (Titles) 13644**] [**Last Name (Titles) **] Date/Time:[**2115-11-7**] 1:15
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2115-12-16**] 1:40
ICD9 Codes: 496, 4019, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5238
}
|
Medical Text: Admission Date: [**2166-8-25**] Discharge Date: [**2166-8-27**]
Service: [**Hospital Unit Name 196**]
Allergies:
Prednisone
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
amaurosis fugax and syncope
Major Surgical or Invasive Procedure:
L Internal carotid artery stent placement.
History of Present Illness:
82 yo Male with symptomatic [**Doctor First Name 3098**] stenosis admitted to CCU after
carotid stent placement. Pt has severe vascular disease - 90%
[**Doctor First Name 3098**] stenosis, 30-60% [**Country **] stenosis, CAD - NQWMI in [**2-11**] (found
2VD - 70% ostial RCA, TO LCx distally with collateral flow). Pt
also has PVD and ?RAS. Sig risk factors include DM,
hyperlipidemia, heavy tobacco use. Pt tolerated procedure well.
Of note he did have low BP on arrival before procedure started
(had taken captopril at home). He was asymptomatic with sBP in
the 70's. Was brought to the CCU on neosynephrine.
Pt is relatively poor historian - unable to explain why he
had procedure. Per notes, pt began to become symptomatic with L
sided amaurosis fugax x 2 episode (pt describes vision going
dark all around a pinpoint of light in the center of his vision)
and syncopal episode ~1month prior where he was sitting in a
chair and lost consciousness although he maintained his seated
position but had urinary incontinence.
Past Medical History:
1. Severe chronic obstructive pulmonary disease on 1.5-3L home
O2.
2. CAD - s/p NQWMI in [**2-11**] as above.
3. Diabetes mellitus - controlled by diet and glyburide.
4. Common Bile duct stones - had cholangitis ~1month ago with
placement of percutaneous drain. CCK planned for [**9-9**].
5. S/p benign lung nodule removal [**2149**].
6. s/p appy.
Social History:
Pt lives with wife. Smoked 4 ppd x 40 years, quit 9 months ago.
Used to drink 6 beers/night but has not had much EtOH in the
last 2 months. Denies other drug use.
Family History:
Mother died of cancer (unknown type) in her 80's.
Father died in 80's of unknown disease.
No known h/o CAD, CVA's, PVD.
Physical Exam:
aF, HR 71, BP 150/70 RR 11, O2sat 100% on 3L NC.
Gen: in NAD
HEENT: PERRLA, EOMI, no sceral icterus
Neck: supple, no lymphadenopathy.
CV: decreased heart sounds. +S1, S2. No m/r/g appreciated.
Pulses 1+ R carotid. L carotid pulse not palpable. B DP/PT not
dopplerable.
Lungs: (ant auscultation) CTA bilaterally. No wheezes or
crackles
Abd: S/NT/distended. +BS. No HSM. Percutaneous biliary drain in
place with tan/brown drainage.
Ext: no c/c/ trace edema B LE. Cold feet. Eczema on R hand.
Neuro: A&Ox3. CN II-XII in tact. Strength 5/5 throughout.
Sensation in tact to light touch.
Pertinent Results:
[**Doctor First Name 3098**] stent report:
1. Access was retrograde via the right CFA.
2. Thoracic aorta: Type I arch without flow-limiting disease.
3. Renal arteries: bilateral disease, mild on the RRA. The
LRA had a
focal 80% lesion.
4. Subclavian arteries: The RSCA had a focal 60% lesion after
the
origin of the vertebral. The LSCA had mild disease.
5. Carotid/vertebral arteries: The right vertebral is patent
without
lesions. There was mild disease at the origin of the left
vertebral.
The cerebellar arteries are normal. The basilar system filled
the left
MCA from a patent PCOM. The RCCA was normal. The [**Country **] had a
60% lesion
and filled the ipsilateral ACA, MCA and contralateral ACA via
the ACOM.
The LCCA was normal. There was a focal 90% lesion at the
bifurcation.
The [**Doctor First Name 3098**] filled the ipsilateral MCA.
6. Successful stenting of the [**Doctor First Name 3098**] was performed with a 7.0 x
40 mm
Precise stent.
7. Right femoral angiography demonstrated severe diffuse
disease in the
RCFA with almost complete obstruction of distal filling from the
6F
sheath.
FINAL DIAGNOSIS:
1. Severe [**Doctor First Name 3098**] stenosis.
2. Stenting of the [**Doctor First Name 3098**].
3. Severe left RAS.
4. Severe right CFA disease.
Brief Hospital Course:
82 yo man with severe vascular disease with symptomatic [**Doctor First Name 3098**]
disease, 90% stenosis on U/S with amaurosis fugax and possible
syncopal episode now s/p carotid stent with good restoration of
flow.
1. CV:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] s/p stent: Keep pt on ASA, plavix, atorvastatin. sBP was
kept between 140-160 initially to keep flow brisk in setting of
new stents and then overnight as Neo was weaned BP started to
fall. Neo was increased for a few hours, but then BP remained
stable and Neo was titrated off. Etiology for hypotension was
felt to most likely be increased vagal tone after [**Doctor First Name 3098**] surgery.
Pt will continue to refrain from taking BP meds for the next few
days and follow up for a BP check on [**8-29**].
B. CAD: Continue ASA, plavix, simvastatin. Restart BP meds (BB
and ACE) as outpt after BP check.
2. Pulm: COPD - continue inhalers and nebs prn. Nasal Cannula O2
to keep sats ~92%.
3. Renal: RAS seen on cath. Dr. [**First Name (STitle) **] likely to place stents in
future. Cr remained stable after surgery.
4. ID: stable.
5. GI: percutaneous biliary drain in place. Scheduled for
surgery [**9-9**] in [**Hospital1 1474**].
6. GU: pt voided easily with good UOP. Restart Proscar on
discharge.
7. Heme: post-procedure hct stable. No s/sx hematomas. No
bruits.
8. Endo: NIDDM. Continue RISS and restart glyburide as outpt.
Diabetic diet.
9. Neuro/Psych: reports no recent EtoH. Pt showed no s/sx of
withdrawal.
10. Ppx: DVT ppx - encouraged ambulation. PT/OT helped. Eating.
11. Comm: with pt and family.
12. Code: Full
13. Dispo: To home with good follow up on [**8-29**] with Dr. [**Last Name (STitle) **]
and with Dr. [**First Name (STitle) **] on [**2166-10-14**].
Medications on Admission:
Lasix 20 mg daily
Imdur 30 mg daily
Proscar 5 mg daily
Glyburide 2.5 mg daily
Captopril 25 mg twice daily
ASA 325 mg daily
Simvastatin 10 mg daily
Amitriptyline 10 mg dialy
Serevent discus 50 mcg twice daily
Flovent 220 mcg 2 puffs twice daily
Albuterol/Atrovent inhalers prn
Albuterol/Atrovent Nebulizer prn 2-4 times daily
Plavix 75 mg dialy
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 30 days.
3. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol Sulfate 0.083 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Amitriptyline HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Severe vascular disease
2. Severe chronic obstructive pulmonary disease on 1.5-3L home
O2.
3. CAD
4. Diabetes mellitus - controlled by diet and glyburide.
5. Common Bile duct stones - had cholangitis ~1month ago with
placement of percutaneous drain. CCK planned for [**9-9**].
Discharge Condition:
stable
Discharge Instructions:
Please do NOT take your BP medications (Furosemide, Isosorbide,
and captopril) until you see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday, [**8-29**]. If you develop changes in vision, new numbness, or loss of
consciousness, call Dr. [**First Name (STitle) **] right away.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday [**8-29**] to
have your blood pressure checked. Dr. [**Last Name (STitle) **] can restart your BP
medications at this time if it is appropriate. Call [**Telephone/Fax (1) 3183**]
to verify your appointment.
Also, please follow up for VASCULAR STUDY Where: CC CLINICAL
CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2166-10-14**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2166-10-14**] 2:00
ICD9 Codes: 496, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5239
}
|
Medical Text: Admission Date: [**2172-5-5**] Discharge Date: [**2172-5-13**]
Service: cardiac surgery
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
female with diabetes, hypertension and congestive heart
failure who was seen at [**Hospital 1474**] Hospital one week ago for
chest pain associated with nausea, vomiting radiating down
both arms. It was relieved with oxygen and nitroglycerin.
Patient was diagnosed with a non-ST elevation MI. She was
treated with Lovenox, beta blockers and nitrates. Patient
was catheterized and shown to have three vessel disease.
Patient has been transferred to [**Hospital1 18**] for coronary artery
bypass graft procedure.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes
mellitus. Pulmonary fibrosis. Hypertension with diastolic
dysfunction. CHF. DVT. PVD. Diverticulosis. Basal cell
carcinoma. History of endometrial cancer. Cholecystectomy.
Mitral regurgitation.
MEDICATIONS: Coumadin 2.5 q.o.d. and 5 q.o.d., Imdur 30
q.d., captopril 25 mg t.i.d., regular insulin sliding scale,
Lopressor 12.5 mg b.i.d., aspirin 325 mg q.d., Cystospaz 0.15
mg b.i.d., digoxin 0.25 mg q.d., Advair 50/500 one puff
b.i.d., potassium chloride 20 mEq q.d., Tylenol 650 mg p.r.n.
ALLERGIES: Sulfa drugs.
SOCIAL HISTORY: The patient is married and lives with
husband. Does not smoke.
PHYSICAL EXAMINATION: In general, patient was obese, not in
acute distress. She is alert and oriented times three.
HEENT pupils equally round and reactive to light.
Extraocular movements intact. Mucous membranes moist. No
JVD. No bruits. Chest clear to auscultation bilaterally.
Heart regular rate and rhythm, 1/6 systolic ejection murmur.
Abdomen soft, nondistended, nontender, no masses.
Extremities 4+ pitting edema bilateral lower extremities.
HOSPITAL COURSE: Cardiac cath showed an ejection fraction of
30%, mitral regurgitation, three vessel disease. Pulmonary
medicine was consulted due to patient's pulmonary problems.
Pulmonary function tests were obtained. Chest x-ray was
obtained. ABG was obtained. It was decided per these
results to take patient to the operating room. Patient was
operated on [**2172-5-7**]. Coronary artery bypass times two was
performed with LIMA to LAD and 5 mm [**Doctor Last Name 4726**]-Tex graft to distal
RCA. Patient appeared to tolerate the procedure all right
and was transferred to the cardiothoracic surgery ICU
postoperatively. She had chest tubes and pacing wires in
place. She initially required a Levophed drip. She was
started on beta blockers, digoxin. She received vancomycin
times four perioperatively. Patient was started on captopril
in addition to digoxin and Lopressor. She was recoumadinized
with a temporary heparin drip. She was also started on Lasix
to help treat her extensive positive fluid status.
The patient was transferred to the regular cardiothoracic
floor on [**2172-5-11**] in good condition, chest tubes and pacing
wires having already been removed. Lopressor was increased
to improve her blood pressure. Physical therapy has worked
extensively with patient and has judged that patient would
benefit greatly from outpatient rehab. It is now [**2172-5-12**] and
patient will likely be discharged tomorrow on [**2172-5-13**] to a
rehab facility. Patient should follow up with Dr. [**Last Name (STitle) **] in
four weeks, with her PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **], in one to two
weeks and her cardiologist in two to three weeks. She should
avoid strenuous activity. She should not drive while on pain
medications. She may shower, but should not take baths for 3
weeks. DISCHARGE MEDICATIONS:
1. Coumadin to keep INR 2.0-2.5 and possibly a heparin drip
if needed. 2. Insulin sliding scale.
3. Lopressor 25 mg p.o. b.i.d.
4. Albuterol one to two puffs q.six p.r.n.
5. Digoxin 0.25 mg p.o. q.d.
6. Ibuprofen 400 mg p.o. q.six p.r.n.
7. Benadryl 25 mg p.o. q.h.s. p.r.n. sleep.
8. Milk of magnesia 30 ml p.o. q.h.s. p.r.n. constipation.
9. Percocet one to two tabs p.o. q.four p.r.n. pain.
10. Tylenol 650 mg p.o. q.four p.r.n.
11. Ranitidine 150 mg p.o. b.i.d.
12. Colace 100 mg p.o. b.i.d.
13. Potassium 20 mEq p.o. q.12 times 10 days.
14. Lasix 40 mg po q.p.m. times 10 days.
15. Lasix 80 mg po q.a.m. times 10 days.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 5919**]
MEDQUIST36
D: [**2172-5-12**] 14:31
T: [**2172-5-12**] 15:13
JOB#: [**Job Number 49025**]
ICD9 Codes: 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5240
}
|
Medical Text: Admission Date: [**2165-8-7**] Discharge Date: [**2165-8-25**]
Date of Birth: [**2165-8-7**] Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 75247**], twin number 1, is a 33-2/7-week
twin, delivered prematurely by cesarean section due to
preterm labor, rupture of membranes, and breech presentation.
The mother is a 35-year-old gravida 2, para 0, now 2. This is
an IVF dichorionic-diamniotic twin gestation, estimated date
of confinement of [**2165-9-23**]. Maternal prenatal screens:
Blood type AB positive, antibody negative, RPR nonreactive,
rubella immune, hepatitis B surface antigen negative, GBS
status unknown. This pregnancy was complicated by
hypothyroidism and preterm labor. She received a full course
of betamethasone, and then had rupture of membranes of this
twin, 30 minutes prior to delivery. Therefore due to breech
presentation of this twin she was delivered via C-section.
She emerged with a spontaneous cry. She was given brief
blow-by O2 and routine care in the OR. Apgar scores were 8 at
1 minute, and 9 at 5 minutes of age. She was transferred to
the NICU secondary to prematurity.
PHYSICAL EXAMINATION: At discharge: Active infant with good
tone and color. Skin: Smooth and pink. There is a small
hemangioma adjacent to the tragus of the left ear. Anterior
fontanel open and flat. Positive red reflex bilaterally. Lips,
gums and palate intact. Chest: Symmetrical. Breath sounds:
Clear and equal bilaterally. Heart: Normal S1, S2. Soft
intermittent murmur LSB to axilla. Normal pulses in upper and
lower extremities. Abdomen: Soft, active bowel sounds, no
hepatosplenomegaly. Normal female genitalia. Patent anus.
Spine: Straight without hair [**Hospital1 **], dimples. Clavicles
intact. Hips stable. Good tone and normal reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
1. Respiratory: [**Known lastname 41356**] has been in room air throughout her
NICU admission. She has had occasional episodes of apnea of
prematurity; the last episode being on [**8-28**]. She
has completed a 5 day countdown.
2. Cardiovascular: This infant's blood pressure has been
normal throughout her hospitalization. Heart rate has
been stable in the 140 to 160 range. She has not
required any extra IV fluid boluses or pressors to
maintain blood pressure. On a few occasions a soft murmur
which radiates to the axilla has been heard. It is
consistent with peripheral pulmonic stenosis or flow and
should be followed.
3. Fluid electrolytes and nutrition. Upon admission to the
newborn ICU, [**Known lastname 41356**] was started on IV fluids of D10W at
60 cc/kg/day. Her electrolytes at 24 hours of age showed
a sodium of 134, a potassium of 6.4 which was a
hemolyzed specimen, chloride of 104 and bicarb of 16. She
was started on enteral feeds on day of life 1 of
premature Enfamil at 30 cc/kg/day. She successfully
advanced to a volume of 150 cc/kg/day by day of life 7
at which point caloric density was increased to 24
cal/ounce of premature Enfamil or breast milk. She is
currently ad lib feeding and taking in as much as 163
cc/kg of 24 calorie formula or breast milk enriched to
24 calories. Her weight at time of discharge is 2425
grams. Length 18.9 inches. Head circumference 31 cm.
4. GI: [**Known lastname 71633**] peak bilirubin on day of life 5 was 11/0.3
at which time phototherapy was initiated. Phototherapy
was discontinued on day of life 8 for a bilirubin of 5.5
with a rebound bilirubin on day of life 9 of 5.6.
5. Hematology: This patient has not received any blood
products during her hospitalization. Her hematocrit at
birth was 50. Her blood type at this time is not known.
6. Infectious disease: Upon admission to the newborn ICU, a
complete blood count and differential and a blood
culture was drawn. The CBC showed a white count of 11.6,
a hematocrit of 50, a platelet count of 257 with 26%
polys and 0% bands. She was started on ampicillin and
gentamycin. Those medications were discontinued when the
blood culture was negative at 48 hours of age. There
have been no other concerns of infection during her
hospitalization.
7. Neurology: A head ultrasound was not indicated for this
33-2/7 weeker.
8. Sensory: A hearing screen was performed with automated
auditory brainstem responses and was passed.
9. Ophthalmology: An eye exam was not indicated for this 33-
[**1-23**] weeker.
10.Psychosocial: [**Hospital1 69**]
Social Work has been involved with the family. The
contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Infant stable in room air without
recent apnea of prematurity. She is bottling her feeds well
and gaining adequate weight, and maintaining her temperature
in an open crib.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) 40494**] [**Name (STitle) 40493**]
([**Telephone/Fax (1) 75248**]).
CARE RECOMMENDATIONS:
1. Feeds at discharge: Ad lib demand feeds of Enfamil or
breast milk enriched to 24 calories.
2. Medications: Trivisol 1 ml po daily, Ferinsol 0.2 ml po
daily
3. Iron and Vitamin D supplementation. Iron supplementation
is recommended for preterm and low birth weight infants
until 12 months corrected age. All infants fed
predominantly breast milk should be receive Vitamin D
supplementation at 200 international units; this may be
provided as a multivitamin preparation daily, until 12
months corrected age.
4. Car seat position screening passed.
5. State Newborn Screening Status: The last State Newborn
Screen was sent on [**8-21**] at 2 weeks of age; no
abnormal test results have been reported.
6. Immunizations received: [**Known lastname 41356**] received her first
hepatitis B vaccine on [**8-21**]. Immunizations
recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 4 criteria:
a. Born at less than 32 weeks.
b. 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.
c. Chronic lung disease.
d. Hemodynamically significant congenital heart
disease.
Influenza immunization is recommend 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 Rotavirus vaccine. The American Academy
of Pediatrics recommends initial vaccination of preterm
infants at or following discharge from the hospital if
they are clinically stable, and at least 6 weeks, but
fewer than 12 weeks of age.
Follow-up appointment with Dr. [**Last Name (STitle) 40493**] will be scheduled
within 2-3 days. Hip ultrasound will be needed at 4-6 weeks
since she was breech.
DISCHARGE DIAGNOSES:
1. Prematurity at 33-2/7 weeks.
2. Rule out sepsis.
3. Hemangioma of left ear.
4. Apnea of prematurity, resolved.
5. Breech female.
6. Flow murmur.
7. Hyperbilirubinemia, treated.
[**Name6 (MD) **] [**Name8 (MD) 75249**], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2165-8-25**] 04:32:33
T: [**2165-8-25**] 09:39:29
Job#: [**Job Number 75250**]
ICD9 Codes: 769, 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5241
}
|
Medical Text: Admission Date: [**2176-10-18**] Discharge Date: [**2176-10-27**]
Date of Birth: [**2120-11-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
mitral regurgitation
Major Surgical or Invasive Procedure:
Mitral valve repair/ligation of left atrial appendage [**2176-10-18**]
History of Present Illness:
This 55 year old white male recently was noted to have a murmur.
Echocardiography demonstrated severe mitral regurgitation. A
cardiac catheterization revealed 4+ regurgitation without
coronary disease. He was referred for surgical evaluation and
was now admitted for operation.
Past Medical History:
depression
prostatism
Social History:
dental last exam [**10-15**]
Works as a carpenter
smokes a pack a day for 20 years
episodic heavy ETOH use. None in a week he says.
Family History:
noncontributory
Physical Exam:
admission:
Pulse: 78 Resp: 16 O2 sat: 98%
B/P Right: 131/92 Left: 140/96
Height: Weight: 210 #
General: WDWN male in no acute distress
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 [**5-21**] holosystolic murmur
best
heard at LLSB
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: None Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right/Left: None
Pertinent Results:
[**2176-10-25**] 04:40AM BLOOD WBC-5.8 RBC-3.40* Hgb-10.8* Hct-30.9*
MCV-91 MCH-31.9 MCHC-35.1* RDW-13.6 Plt Ct-338
[**2176-10-24**] 05:05AM BLOOD PT-13.1 INR(PT)-1.1
[**2176-10-25**] 04:40AM BLOOD Glucose-98 UreaN-15 Creat-1.0 Na-136
K-4.5 Cl-97 HCO3-28 AnGap-16
ECHO [**2176-10-25**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild global left
ventricular hypokinesis (LVEF = 45-50%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. A mitral valve annuloplasty ring is present. The
mitral annular ring appears well seated with normal gradient.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild global left ventricular systolic dysfunction.
Normally-functioning mitral annuloplasty. No significant
pericardial effusion seen.
Compared with the prior study (images reviewed) of [**2176-10-15**],
the native regurgitant mitral valve has been repaired. LV
function is slightly less vigorous, although given recent
correction of severe MR, the intrinsic LV systolic function is
probably similar.
Brief Hospital Course:
Following admission he was taken to the Operating Room where P2
resection, annuloplasty (30mm ring) and ligation of the left
atrial appendage were performed. He weaned from bypass on low
dose Epinephrine and Propofol. He weaned from pressors and the
ventilator easily. Intra-operatively he had brief atrial
fibrillation and was begun on Amiodarone. In the morning after
surgery he was in a junctional rhythm in the 40s and required
ventricular pacing. Amiodarone was stopped and his rate
gradually increased to the 50s with a return of sinus mechanism
alternating with junction. Chest tubes were removed on POD#1
and he was transferred to the floor. Physical therapy was
consulted for mobility and strength. The electrophysiology
service was consulted for consideration of a permanent
pacemaker, but as his atrial activity began to recover. He
expereinced an 11 beat run of asymptomatic, non-sustained VT. He
was able to tolerate low dose lopressor and he was deemed to no
longer need one. Attempts to increase lopressor resulted in
junctional rhythm. Electrophysiology will titrate lopressor as
an outpatient. On post-operative day eight his epicardial wires
were removed, he was ambulatory, stable and ready for discharge
home with VNA follow up. All follow-up appointments were
advised.
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:*50 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 mdi* Refills:*2*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**]
Discharge Diagnosis:
mitral regurgitation
prostatism
depression
s/p appendectomy
s/p mitral valve repair (#30mm ring)/left atrial ligation
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
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) Date/Time:[**2176-11-18**] 1:15
Cardiologist: Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] [**12-13**] at 2:30pm
Please call to schedule appointments with:
Primary Care Dr. [**First Name5 (NamePattern1) **] [**Last Name (un) **] in [**5-20**] 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:[**2176-10-27**]
ICD9 Codes: 4240, 4271, 9971
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5242
}
|
Medical Text: Admission Date: [**2192-10-10**] Discharge Date: [**2192-10-21**]
Date of Birth: [**2116-10-26**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 75-year-old gentleman
admitted with a history of diabetes, hyperlipidemia, and
transient ischemic attacks, who presents with a chief
complaint of chest pain and shortness of breath.
He was initially admitted to an outside hospital with chief
complaint beginning on [**2192-10-7**]. He went to an
outside hospital and mild ST elevations and was ruled in for
myocardial infarction by creatine phosphokinase and troponin.
The patient was placed on a heparin drip at the outside
hospital with a 5-beat run of ventricular tachycardia. He
was transferred to [**Hospital1 69**] for
catheterization and subsequent coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes mellitus.
2. Hyperlipidemia.
3. Recurrent transient ischemic attacks, on Coumadin.
4. Chronic mild azotemia.
5. Depression.
MEDICATIONS ON ADMISSION: Colace 100 mg p.o. b.i.d.,
NPH 36 units q.a.m. and 6 units q.p.m., Humalog 3 units
q.a.m., Zocor 10 mg p.o. q.d., Celexa 20 mg p.o. q.d.,
Lopressor 12.5 mg p.o. q.d., captopril 6.25 mg p.o. b.i.d.,
aspirin 81 mg p.o. q.d., heparin drip from the outside
hospital, nitroglycerin 0.4 mg sublingual p.r.n., Tylenol
p.r.n., Ativan 0.5 mg p.o. q.h.s. p.r.n.
ALLERGIES:
SOCIAL HISTORY: He lives with his wife. Denies a history of
alcohol use, drug abuse, tobacco use.
FAMILY HISTORY: Father died at age 86. Mother died at
age 84. He denies a history of heart disease in either
parent.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were
temperature of 96.6, pulse 66, blood pressure 143/69,
respirations 20, 96% on room air. Blood sugar was 132.
General impression revealed a pleasant and well-appearing
gentleman in no apparent distress. HEENT revealed left
cataracts. Extraocular muscles were intact. Moist mucous
membranes. Neck was supple. No bruits. Jugular venous
distention of 5 cm. Lungs were clear to auscultation
bilaterally. Cardiac revealed a regular rate and rhythm. A
grade 2/6 systolic murmur best heard at the left upper
sternal border. The abdomen was soft, nontender, and
nondistended, bowel sounds were present. No
hepatosplenomegaly. Extremities had no clubbing, cyanosis or
edema. Dorsalis pedis pulses were 2+ bilaterally.
Neurologically, cranial nerves II through XII were intact. A
nonfocal examination.
LABORATORY DATA ON PRESENTATION: White blood cell count 6.5,
hematocrit 31.1, platelets 175. Coagulations were PT 14.1,
PTT 41.9, INR 1.4. Creatine kinase was 90, MB flat, troponin
of 21.1.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization which he received on [**2192-10-11**].
Significant findings from this catheterization were left main
coronary artery had 20% stenosis, proximal left anterior
descending artery ulcerated 95% stenosis, followed by
moderate diffuse disease and a second focal 95% stenosis in
the origin of the major diagonal artery. The distal left
anterior descending artery had mild diffuse disease up to 30%
stenosis. The major diagonal artery had ostial 30% stenosis.
There was a moderate-sized ramus artery present which had a
90% stenosis in the proximal portion. The left circumflex
had a 60% stenosis at its proximal portion. The right
coronary artery was moderately to severely diffusely diseased
with up to 70% stenosis in the proximal and middle portions.
The distal right coronary artery had some mild luminal
irregularities. The left ventricular branch and the right
RPI had some moderate diffuse disease with up to 60%
stenosis.
Resting hemodynamics revealed elevated right-sided and
left-sided filling pressures.
The patient developed supraventricular tachycardia to 105
during Swan-Ganz catheterization. Her ....................
output was noted to be 4.6 liters per minute, and cardiac
index was 2.3 liters per minute/m2. Because of the above
information, an intra-aortic balloon pump was inserted during
the procedure.
The patient was evaluated and deemed a surgical candidate.
On [**2192-10-11**], the patient went to operating room with
Dr. [**Last Name (STitle) 70**] for a coronary artery bypass graft times three.
The anastomoses were left internal mammary artery to left
anterior descending artery, saphenous vein graft to ramus,
saphenous vein graft to posterior descending artery. Please
see previously dictated Operative Note for more details. The
patient tolerated the procedure well and was transported to
the Coronary Care Recovery Unit. Coronary artery bypass
graft time was 82 minutes, cross-clamp time was 60 minutes.
The patient was transferred to the unit on a Neo-Synephrine
drip.
The patient's postoperative course began in the Intensive
Care Unit. On postoperative day one he was still intubated,
had a chest tube, and was on propofol, insulin, and
Neo-Synephrine drips.
On postoperative day two the patient remained intubated, but
at this point all cardioactive drips were weaned off. On
postoperative day three the patient had been extubated and
placed on a nitroglycerin drip, and chest tubes were in
place, a Foley catheter was still in place as well.
On postoperative day three the patient was transferred to the
patient care floor. At this point he was able to ambulate
for brief periods of time in the hallway and was tolerating
p.o. without complaints.
On postoperative day five, Neurology was consulted because
the patient was having some difficulty with word finding, was
having a little difficulty with motor ability in terms of
getting food into his mouth, as well being agitated in the
Intensive Care Unit which had been resolving by the time he
was transferred to the floor. A carotid Duplex revealed
widely patent right carotid artery and left carotid artery
with 40% stenosis. Neurology recommended to begin Aggrenox 1
tablet p.o. b.i.d. They recommended against Coumadin as the
patient was at a high risk for falls. they also recommended
follow up with outpatient neurologist, Dr. [**Last Name (STitle) **], to
reassess anticoagulation status. They also recommended a
future evaluation to be performed by Dr. [**Last Name (STitle) **].
On postoperative day five the patient's pacer wires came out,
his internal jugular triple lumen came out, his Foley was
discontinued, and rehabilitation screening began.
On postoperative day six, the patient was noted to have some
difficulty swallowing by the patient's wife and Speech and
[**Name (NI) **] was consulted. This was indeterminate and revealed
the patient was possibly aspirating. Because of this he was
started on a pureed diet with thickened liquids. His
medications were taken with apple sauce.
Between postoperative days seven and eight, the patient was
noted to have some sternal drainage, although he had no fever
or elevation in his white count. Given the high instance of
sternal wound infection the patient was empirically placed on
vancomycin. His drainage decreased by postoperative day 11;
his day of discharge, and vancomycin can be taken off.
By postoperative day 11, the patient was ambulating,
tolerating his pureed with thickened liquid diet. The pain
was control. Sternal drainage had stopped. He was stable to
be transferred to rehabilitation.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. q.d.
2. Celexa 20 mg p.o. q.d.
3. NPH insulin 36 units subcutaneous q.a.m. and 6 units
subcutaneous q.p.m.
4. Zocor 10 mg p.o. q.6h.
5. Lopressor 7.5 mg p.o. b.i.d.
6. Aggrenox (25/200) 1 tablet p.o. b.i.d.
7. Lasix 20 mg p.o. b.i.d. times one week.
8. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. when on Lasix.
9. Percocet one to two tablets p.o. q.4-6h. p.r.n.
10. Colace 100 mg p.o. b.i.d. while on Percocet.
DISCHARGE DIET: Pureed foods with thick liquids.
Medications are to be taken crushed with apple sauce.
DISCHARGE RESTRICTIONS: No heavy lifting.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) 70**] in three to four weeks and was to follow up
with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34792**], in three weeks.
Additionally, the patient was to follow up with
Dr. [**Last Name (STitle) **] of [**Hospital1 69**]
Neurology; the patient should call Dr.[**Name (NI) 36076**] office
for an appointment.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
graft times three on [**2192-10-11**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2192-10-19**] 19:02
T: [**2192-10-20**] 05:34
JOB#: [**Job Number 36077**]
(cclist)
ICD9 Codes: 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5243
}
|
Medical Text: Admission Date: [**2103-12-6**] Discharge Date: [**2103-12-10**]
Date of Birth: [**2103-12-6**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 60933**] is a 3.115
kilogram product of a term gestation born to a 43-year-old
G4 P2 now 3 mother. Prenatal screens, B positive, antibody
negative, hepatitis surface antigen negative, RPR
nonreactive, rubella immune, GBS positive. Maternal history
of mitral valve prolapse. This pregnancy complicated by
spontaneous demise of 1 twin. Perinatal substance risk
factors include less than 4 hours of intrapartum maternal
chemoprophylaxis in the setting of positive maternal GBS
colonization. No maternal fever. No prolonged rupture of
membranes. Clear amniotic fluid. Maternal anesthesia by
epidural, plus received Nubain. Spontaneous vaginal delivery
with Apgars of 7 and 8.
PHYSICAL EXAMINATION: On admission active, nondysmorphic,
anterior fontanelle soft and flat. Ears normal set. Red
reflex deferred. Positive erythromycin ointment. Palate
intact. Neck supple with intact clavicles. Lungs clear to
apex and equal. Cardiovascular, regular rate and rhythm. No
murmur. 2+ femoral pulses. Abdomen soft, positive bowel
sounds. GU, normal female. Hips negative. Borderline Barlow.
No bilateral hip clicks present. No sacral anomalies. Skin
with marked facial bruising.
HOSPITAL COURSE: Respiratory. Infant has been stable in room
air with occasion desaturations with feeding. She has been
without desaturations with feedings since [**12-8**].
Cardiovascular. Has been cardiovascularly stable.
Fluid and electrolytes. Birth weight was 3.115 kilograms.
Infant has been ad lib feeding taking an adequate amount. Her
discharge weight is 3065 gm
GI, bilirubin on day of life #3 was 7.9/0.4.
Hematology. Hematocrit on admission was 45.5. She did not
require any blood transfusion.
Infectious disease. CBC and blood culture obtained on
admission. CBC was benign. Blood cultures remained negative
at 48 hours at which time ampicillin and gentamycin were
discontinued.
Neuro. Infant has been appropriate for gestational age.
Sensory, hearing screen was performed with automated auditory
brain stem responses in the infant
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRIC PROVIDER: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Telephone number is
[**Telephone/Fax (1) 41579**].
CARE AND RECOMMENDATIONS: Continue ad lib feedings.
Medications, not applicable. Car seat position screening, not
applicable. State newborn screen was sent on day of life 3
and is pending. Immunizations received infant received
hepatitis B vaccine on [**2103-12-9**]. 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, born at less than 32 weeks, born
between 32 and 35 weeks with 2 of the following, daycare
during RSV season, a smoker in the household, neuromuscular
disease and weight 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 immunizations against influenza is
recommended for household contacts and out of home care
givers.
DISCHARGE DIAGNOSES: Rule out sepsis on antibiotics.
Respiratory immaturity resolved.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) 58700**]
MEDQUIST36
D: [**2103-12-9**] 21:07:48
T: [**2103-12-10**] 06:52:45
Job#: [**Job Number 69944**]
ICD9 Codes: V053, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5244
}
|
Medical Text: Admission Date: [**2121-10-15**] Discharge Date: [**2121-10-22**]
Date of Birth: [**2060-12-29**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient had previously
undergone a surgical placement of LV leads via a small left
anterior thoracotomy on [**2121-10-7**], prior to his
admission. He was discharged without any complications. Three
days later on [**2121-10-12**], he was admitted with chest
pain and shortness of breath to [**Hospital6 3872**]. He
ruled out for myocardial infarction, and previous cardiac
catheterization revealed normal coronaries.
At 3 a.m. on [**2121-10-15**], he complained of increasing
chest pain and increasing shortness of breath. By 6 a.m., his
systolic had dropped into the 60s. He was transferred from
the emergency room to the floor to the CCU for evaluation.
Echocardiogram showed pericardial effusion with narrow pulse
pressures. He continued to have increasing shortness of
breath with some modeling and [**Doctor Last Name 352**] tones to his skin color.
He is followed by Dr. [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 1295**] at [**Hospital6 3874**] prior to his transfer to the hospital.
PAST MEDICAL HISTORY:
1. Surgical LV lead placement by a left anterior
thoracotomy.
2. Atrial fibrillation.
3. Migraine headaches.
MEDICATIONS: On admission to [**Hospital3 1280**] he was on Coumadin,
Toprol, Verapamil, Klonopin, Imdur.
ALLERGIES: Codeine.
On [**10-15**] at [**Hospital6 3872**] prior to
admission, he continued to have increasing dyspnea.
Echocardiogram showed pericardial effusion. Cardiology there
decided to proceed with pericardiocentesis. The patient
received 2 mg of vitamin K, 2 units of FFP, and packed red
blood cells prior to going to the cath lab for a
pericardiocentesis. INR was between 3.5 and 3.7 at the time.
Prior to his admission here during the placement of the
pericardiocentesis catheter, the patient arrested in the cath
lab. CPR was instituted. Repeat pericardiocentesis per
cardiology's note there was able to obtain about 100-150 cc
of pericardial fluid. Echocardiogram showed resolution of
effusion. By echocardiogram the EF looked poor, and so
monitoring lines were placed.
Dr[**Last Name (Prefixes) 4558**] was contact[**Name (NI) **] at [**Hospital1 **], and
the patient was transferred to [**Hospital6 2018**] by Life Flight.
The patient was admitted on [**2121-10-15**], and was
evaluated with repeat chest x-ray which showed left
hemothorax and possible tamponade and was taken to the
operating room for sternotomy and reopening of the left
anterior thoracotomy site for evacuation of clot and hematoma
from both mediastinum and left chest. This was done
emergently.
On postoperative day 1, the patient remained V-paced, had a
blood pressure of 120/48, remained ventilated and sedated,
with a white count of 12.4, hematocrit 32.7, creatinine 1.8.
He was alert and oriented later in the day with a nonfocal
exam while he was intubated, but sedation was lightened to
check his neurologic status. He had scattered rhonchi
throughout his chest. His heart was regular rate and rhythm
with a S1 and S2, no murmur, and sternum was stable. Sternal
incision was clean, dry, and intact, as was his thoracotomy
incision. He remained on the epinephrine drip at 0.01
mcg/kg/min and an insulin drip at 2 min/hr. Ventilatory wean
was begun later that evening.
On postoperative day 1, the patient continued to have a
hemothorax present on chest x-ray, and he was returned to the
operating room for evacuation of clot. Again on postoperative
day 2 and 1, the patient's creatinine was 1.2-2.4. He was on
no drips at the time. He was transfused 2 units of packed red
blood cells for a hematocrit of 26.4, and he was alert and
oriented and extubated on 4 L nasal cannula. He was seen and
evaluated by clinical nutrition team. On postoperative day 3,
he remained V-paced. His chest tubes were discontinued, and
he remained hemodynamically stable. He did have some
confusion early on which became agitation periodically. We
had a sitter for a single day, and then his confusion
cleared.
On postoperative day 4 and 3, he was transferred out to the
floor. His Coumadin was held. On postoperative day 5 and 4,
follow-up chest x-ray was done. He remained in sinus rhythm,
hemodynamically stable, creatinine rose slightly again to
2.3, hematocrit was 35.7. Beta-blockade continued with
Lopressor. He began to work with physical therapy increasing
his activity level and tolerance.
On house-day 6, his oxygen saturation was 94% on room air and
continued to work on increasing his activity level. Beta-
blockade was increased again. On postoperative day 7 and 6,
his creatinine dropped slightly to 2.0. Incisions were clean,
dry, and intact with no erythema or drainage. His central
venous line was removed. His JP drain from the left
thoracotomy site had minimal sanguineous drainage and was
discontinued, and the patient was discharged to home with VNA
services.
DISCHARGE DIAGNOSIS:
1. Status post left ventricle lead pace placement, left
anterior thoracotomy.
2. Status post sternotomy and left thoracotomy for clot
evacuation and mediastinal exploration.
3. Status post reexploration of mediastinum.
4. Atrial fibrillation.
5. Migraine headaches.
6. Lyme disease.
7. Tachy-brady syndrome.
8. DDD pacemaker.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. twice a day x 7 days.
2. Potassium chloride 20 mEq p.o. twice a day for 7 days.
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Enteric coated aspirin 81 mg p.o. once daily.
6. Metoprolol 100 mg p.o. twice a day.
7. Percocet 5/325 1-2 tablets p.o. q.4 hours p.r.n. pain.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was instructed to follow
up with Dr. [**Last Name (STitle) **] at 2 weeks. He is to follow up with
Dr. [**First Name (STitle) 1075**] his cardiologist at [**Hospital3 1280**] after discharge, and
he is to follow up with Dr. [**Last Name (Prefixes) **] in 4 weeks for his
postoperative surgical appointment.
The patient was discharged in stable condition to home with
VNA services on [**2121-10-22**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2121-11-12**] 15:54:09
T: [**2121-11-12**] 20:47:54
Job#: [**Job Number 110030**]
ICD9 Codes: 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5245
}
|
Medical Text: Admission Date: [**2158-9-27**] Discharge Date: [**2158-11-6**]
Date of Birth: [**2106-7-14**] Sex: M
Service: SURGERY
Allergies:
Erythromycin Base / chocolate
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 y/o healthy M transferred from [**Hospital **] Hospital for severe
abdominal pain secondary to necrotizing pancreatitis. The
patient describes a sudden sharp onset of pain occureing last
night at around 11:30PM. He describes it as a constant ache,
which just continued to get worse. He admits to chills, nausea,
and vomiting. He states that his pain feels best when sitting up
and when lying down in the fetal position on his R side. CT scan
performed at outside hospital was positive for necrotizing
pancreatitis. He recieved IV Zosyn at outside hospital prior to
arrival. His labs at this hospital showed a WBC 23, lipase 2958,
amylase 1568. He was transferred to [**Hospital1 18**] for further
management. He denies fevers , but admits to chills, nausea,
only triggered by pain.
Past Medical History:
EtOH abuse
Social History:
Drinks a couple times a week, those time oftern to excess. Last
time he admits to drinking is [**9-16**]. He states he has been
drinking like this for years. Although he has told a different
drinking history to each doctor/ nurse.
Smokes: 1 pack/3days
Family History:
Non- Contributory
Physical Exam:
VITALS: 98 130/78 70 22 97%RA
NEUROLOGIC: A+OX3
GENERAL: moderate distress
HEENT: PERRL, EOMI
NECK: no carotid bruits, elevated JVD at mandible
LUNGS: CTA
HEART: RRR, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly, Pain on palpation to
the right upper and lower quadrants.
EXTREMITIES: no LE edema
Pertinent Results:
[**2158-9-27**] 09:30AM GLUCOSE-144* UREA N-20 CREAT-1.0 SODIUM-142
POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-24 ANION GAP-14
[**2158-9-27**] 09:30AM estGFR-Using this
[**2158-9-27**] 09:30AM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-74 TOT
BILI-0.3
[**2158-9-27**] 09:30AM LIPASE-1394*
[**2158-9-27**] 09:30AM WBC-13.9* RBC-5.64 HGB-16.5 HCT-51.2 MCV-91
MCH-29.2 MCHC-32.2 RDW-13.6
[**2158-9-27**] 09:30AM WBC-13.9* RBC-5.64 HGB-16.5 HCT-51.2 MCV-91
MCH-29.2 MCHC-32.2 RDW-13.6
[**2158-9-27**] 09:30AM NEUTS-92.3* LYMPHS-4.4* MONOS-2.9 EOS-0.1
BASOS-0.3
[**2158-9-27**] 09:30AM PLT COUNT-205
Brief Hospital Course:
52 y/o healthy M transferred from [**Hospital **] Hospital with
epigastric pain, nausea and vomiting, and a CT concerning for
necrotizing pancreatitis. Patient did admit to heavy drinking,
and this was determined to be the most likely the cause of his
pancreatitis. Patient was admitted to the hospital for
supportive care. As pancreatitis was resolving as above, diet
was advanced. Pt began to feel distension in abdomen and nausea
and vomiting. CT abdomen was consistent with ileus secondary to
pancreatitis and had a 14 x 3 cm new fluid collection in the
region of the pancreas. Pt. was made NPO and has an NG tube
placed to suction. He was started on Zosyn. He was initally
managed medically w/ antibiotics. He received Zosyn and
Meropenem. His CT scan was concerning for a pseudocyst. He was
started on TPN and a PICC line was placed for administration of
abx therapy. He was eventually transferred to the TSICU after he
triggered on the floor for tachycardia in 140s and new fevers,
concerning for an infected pseudocyst. While he was in the
TSICU, he was transferred to the West 2A service. An ERCP was
carried out on [**10-13**], which demonstrated a pancreatic leak at
the neck of the pancreas and they were unable to advance a wire
due to stricture of the duct. He was briefly on an inpatient
floor, but he developed increasing adominal distension, low
urine output and appeared worse from a respiratory standpoint.
He was transferred to the SICU for further management on [**2158-10-15**].
Subsequent CT showed multiple fluid collections, that were able
to be drained by IR in the right gutter, also the left gutter
and perisplenic. Patient developed worsening respiratory
failure, unable to wean from the vent, thus a tracheostomy tube
was placed on [**2158-10-23**]. The cultures from the Right grew
Pseudomonas [**10-17**] multisensitive. Patient was unable to wean from
the vent for 2 weeks after the trach. Spiked fevers
intermittently, and due to agitation was able to pull the left
sided drains. Eventually after patient spiked again, he was
rescanned showing reacumulation of the left flank collection and
the pelvic one, that we are able to be drained again by IR. From
a nutritional standpoint, patient remained on TPN for over 3
weeks, and once was able to get a postpyloric dobhoff, he was
started on tube feeds for the last week of his hospitalization.
By HD 41, he was able to tolerate trach collar for more than
48hrs, his drains were in place, on on the right, one on the
left flank and one in the pelvis. He was able to pass his
swallow eval and started thin liquids, ground solids. His WBC
remained in the 10-12 range and will continue his care at rehab.
Patient will continue on cipro/flagyl for 2 weeks and will
follow up with Dr [**First Name (STitle) **] to reevaluate the drain outputs and
possibly reimage his abdomen. If clinically well and fluid
collections/subcapsular collections resolved, possibly will stop
antibiotics.
Medications on Admission:
none
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Nicotine Patch 7 mg TD DAILY
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Heparin 5000 UNIT SC TID Sliding Scale
hold am dose on [**11-2**] for IR drainage
7. Albuterol Inhaler 6 PUFF IH Q6H:PRN wheeze
8. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain/fever
9. Docusate Sodium 100 mg PO BID
10. Metoprolol Tartrate 12.5 mg PO TID
Hold for HR < 60 and SBP < 100
11. Miconazole Powder 2% 1 Appl TP TID:PRN intertriginous rash
12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
13. Octreotide Acetate 200 mcg SC Q8H
14. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Weeks
further antibiotic planning per ID
15. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 2 Weeks
further antibiotic planning per ID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Pancreatitis secondary to alcohol use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for necrotizing pancreatitis complicated
by respiratory failure requiring a tracheostomy on [**2158-10-23**] and
complicated by multiple fluid collections, treated with drains
placed by interventional radiology.
You will go to rehab to continue your recovery and will followup
with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for further care from your pancreatitis.
Followup Instructions:
Please choose a primary care doctor to follow up with as it is
important to be regularly evaluated after being admitted to the
hospital.
Please follow up with Dr. [**First Name (STitle) **] from surgery in [**3-17**] weeks
Completed by:[**2158-11-6**]
ICD9 Codes: 5119, 2760, 2930, 2768, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5246
}
|
Medical Text: Admission Date: [**2164-1-11**] Discharge Date: [**2164-1-16**]
Date of Birth: [**2120-8-12**] Sex: F
Service: MEDICINE
Allergies:
Topiramate / Aripiprazole / Shellfish / Bee Pollen
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
gastrointestinal bleeding
Major Surgical or Invasive Procedure:
EGD
TIPS dilatation
History of Present Illness:
Ms. [**Known lastname 45209**] is a 43F with a history of alcoholic cirrhosis
s/p TIPS, active alcoholism, and prior UGIB attributed to
duodenal varix who presents with dark red blood per rectum since
2AM. She has had approximately 4-5 episodes of bleeding
overnight. This AM, felt lightheaded and called EMS; she was
brought into ED by ambulance. Of note, last alcoholic drink was
at ~3AM.
In the ED, initial VS were T 98.2, HR 110, BP 90/60, RR 16, O2
sat 100% 4L Nasal Cannula. After arrival, BP dropped to 70s/40s
and patient received 1L IVF with NS; she was then ordered for 1
unit universal pRBCs and T&C for additional 4 units (2nd unit on
standby at time of signout). Hct returned at 20 from remote
baseline in upper 20s-low 30s, and INR was 2.0. Gastric lavage
was negative. Hepatology consult was called, and the patient was
started on pantoprazole and octreotide gtt and received one dose
of ceftriaxone. RUQ U/S with Doppler was performed; no report
available at the time of signout. BPs were back in 90s/60s at
time of signout. Current access is 4 peripheral IVs: 20G, 22G,
16G, 18G.
.
On arrival to the MICU, patient reports feeling overall poorly,
though no pain except at site of left antecube IV. Endorses
nausea. No other symptoms. Transport staff report she has filled
two hats with what looks like "pure blood" since arrival in the
ED.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
Alcoholic cirrhosis
s/p cholecystectomy [**2153**]
Gastroesophageal reflux disease
Bipolar disorder
Htn
Depression/anxiety
Social History:
She lives with her husband and 2 children, ages 16 and 17.
Smokes 1pack every few weeks. Used to be an accountant. Denies
other drug use. Currently requests that husband and [**Name2 (NI) **] not
be allowed to call her room and not be told any information.
Family History:
Non-contributory.
Physical Exam:
Discharge Exam
Vitals: T: 99.6 98.3 BP: 103/58 P: 83 R:16 O2:99% RA
General: Alert, oriented X 3, no acute distress. Smells of
[**Name2 (NI) **].
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP flat, no LAD
CV: Regular rate and rhythm (borderline tachycardic), normal S1
+ S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: No foley.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No tremor/asterixis.
Skin: Grafting to the first and second digits of the hands
bilaterally.
Left arm has large bicep hematoma and swelling with
discoloration, 2 + left and right radial pulses with no
numbness, and good motor function of fingers.
Pertinent Results:
Admission Labs
[**2164-1-11**] 11:58PM D-DIMER-1732*
[**2164-1-11**] 10:21PM GLUCOSE-124* UREA N-13 CREAT-0.5 SODIUM-129*
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-10
[**2164-1-11**] 10:21PM LD(LDH)-178
[**2164-1-11**] 10:21PM ALBUMIN-2.6* CALCIUM-7.8* PHOSPHATE-3.3
MAGNESIUM-2.6
[**2164-1-11**] 10:21PM HAPTOGLOB-<5*
[**2164-1-11**] 10:21PM WBC-4.8 RBC-3.14* HGB-9.5* HCT-26.2* MCV-84
MCH-30.2 MCHC-36.1* RDW-16.2*
[**2164-1-11**] 10:21PM PLT COUNT-72*
[**2164-1-11**] 10:21PM PT-16.3* PTT-28.8 INR(PT)-1.5*
[**2164-1-11**] 10:21PM FIBRINOGE-131*
[**2164-1-11**] 06:18PM GLUCOSE-142* UREA N-13 CREAT-0.4 SODIUM-128*
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-10
[**2164-1-11**] 06:18PM CALCIUM-7.0* PHOSPHATE-3.4 MAGNESIUM-2.9*
[**2164-1-11**] 06:18PM WBC-3.5* RBC-2.97* HGB-8.9*# HCT-24.6* MCV-83
MCH-29.9 MCHC-36.0* RDW-15.9*
[**2164-1-11**] 06:18PM PLT SMR-VERY LOW PLT COUNT-68*
[**2164-1-11**] 06:18PM PT-18.1* PTT-28.3 INR(PT)-1.7*
[**2164-1-11**] 04:03PM HCT-26.3*#
[**2164-1-11**] 03:45PM URINE HOURS-RANDOM
[**2164-1-11**] 03:45PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2164-1-11**] 08:57AM COMMENTS-GREEN TOP
[**2164-1-11**] 08:57AM LACTATE-2.2*
[**2164-1-11**] 08:51AM GLUCOSE-120* UREA N-16 CREAT-0.5 SODIUM-128*
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-22 ANION GAP-15
[**2164-1-11**] 08:51AM ALT(SGPT)-28 AST(SGOT)-64* ALK PHOS-125* TOT
BILI-3.1*
[**2164-1-11**] 08:51AM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.8
MAGNESIUM-1.3*
[**2164-1-11**] 08:51AM ASA-NEG ETHANOL-238* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-1-11**] 08:51AM WBC-3.6*# RBC-2.42*# HGB-6.7*# HCT-20.2*#
MCV-84 MCH-27.7 MCHC-33.2 RDW-17.4*
[**2164-1-11**] 08:51AM NEUTS-73.3* LYMPHS-17.8* MONOS-7.8 EOS-0.5
BASOS-0.6
[**2164-1-11**] 08:51AM PLT COUNT-120*#
[**2164-1-11**] 08:51AM PT-21.4* PTT-36.2 INR(PT)-2.0*
.
Discharge Exam
[**2164-1-16**] 06:05AM BLOOD WBC-2.7* RBC-3.39* Hgb-10.4* Hct-29.1*
MCV-86 MCH-30.6 MCHC-35.6* RDW-18.1* Plt Ct-43*
[**2164-1-15**] 02:58PM BLOOD Hct-28.2*
[**2164-1-15**] 06:20AM BLOOD WBC-2.3* RBC-3.69* Hgb-11.3* Hct-32.0*
MCV-87 MCH-30.6 MCHC-35.3* RDW-16.3* Plt Ct-46*
[**2164-1-14**] 05:44PM BLOOD Hgb-10.7* Hct-29.9*
[**2164-1-14**] 06:35AM BLOOD WBC-2.6* RBC-3.46* Hgb-10.2* Hct-28.4*
MCV-82 MCH-29.4 MCHC-35.8* RDW-16.1* Plt Ct-40*
[**2164-1-13**] 05:00PM BLOOD Hct-27.4*
[**2164-1-13**] 12:53PM BLOOD Hct-26.2*
[**2164-1-11**] 08:51AM BLOOD Neuts-73.3* Lymphs-17.8* Monos-7.8
Eos-0.5 Baso-0.6
[**2164-1-16**] 06:05AM BLOOD Plt Ct-43*
[**2164-1-16**] 06:05AM BLOOD PT-20.2* PTT-34.9 INR(PT)-1.9*
[**2164-1-15**] 06:20AM BLOOD PT-18.0* PTT-31.7 INR(PT)-1.7*
[**2164-1-14**] 06:35AM BLOOD Plt Ct-40*
[**2164-1-14**] 06:35AM BLOOD PT-19.0* PTT-33.3 INR(PT)-1.8*
[**2164-1-13**] 02:31AM BLOOD Plt Ct-47*
[**2164-1-12**] 02:36AM BLOOD Plt Ct-60*
[**2164-1-12**] 02:36AM BLOOD PT-15.7* PTT-25.0 INR(PT)-1.5*
[**2164-1-12**] 01:46PM BLOOD Fibrino-191
[**2164-1-12**] 02:36AM BLOOD Fibrino-178*
[**2164-1-11**] 10:21PM BLOOD Fibrino-131*
[**2164-1-16**] 06:05AM BLOOD Glucose-126* UreaN-5* Creat-0.5 Na-133
K-3.0* Cl-99 HCO3-27 AnGap-10
[**2164-1-15**] 06:20AM BLOOD Glucose-112* UreaN-8 Creat-0.7 Na-134
K-3.4 Cl-101 HCO3-19* AnGap-17
[**2164-1-14**] 05:44PM BLOOD Glucose-116* UreaN-9 Creat-0.6 Na-137
K-3.4 Cl-101 HCO3-27 AnGap-12
[**2164-1-16**] 06:05AM BLOOD ALT-18 AST-37 LD(LDH)-184 AlkPhos-102
TotBili-4.3*
[**2164-1-15**] 06:20AM BLOOD ALT-19 AST-44* LD(LDH)-285* AlkPhos-89
TotBili-4.9*
[**2164-1-12**] 02:36AM BLOOD ALT-20 AST-45* LD(LDH)-183 AlkPhos-81
TotBili-5.8*
[**2164-1-15**] 06:20AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.1
Mg-1.4*
[**2164-1-14**] 05:44PM BLOOD Calcium-8.0* Phos-2.9 Mg-1.6
[**2164-1-14**] 06:35AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.7 Mg-1.6
[**2164-1-11**] 11:58PM BLOOD D-Dimer-1732*
[**2164-1-11**] 08:51AM BLOOD ASA-NEG Ethanol-238* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-1-12**] 02:49AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2164-1-11**] 08:57AM BLOOD Lactate-2.2*
[**2164-1-12**] 02:49AM BLOOD Lactate-0.8
.
Reports
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MICU-7 [**2164-1-11**] 5:41 PM
MESSENERTIC Clip # [**Clip Number (Radiology) 45330**]
Reason: Please perform a mesenteric angiograms and perform
coiling o
Contrast: OMNIPAQUE Amt: 145
[**Hospital 93**] MEDICAL CONDITION:
43 year old woman with history of alcoholic cirrhosis s/p
TIPS, active
alcoholism, who presents with lower GI bleed
REASON FOR THIS EXAMINATION:
Please perform a mesenteric angiograms and perform coiling of
any bleeding
vessels
Final Report
PROCEDURES:
1. Portal venogram via the TIPS shunt.
2. Pressure measurements in the portal and systemic venous
circulation across
the TIPS shunt.
3. Transcatheter coil embolization of the bleeding duodenal
varix.
4. Stenting and balloon angioplasty up to 10 mm of the right
hepatic vein
stenosis.
CLINICAL INDICATION: 43-year-old woman with history of alcoholic
cirrhosis
status post TIPS with active alcoholism who presents with acute
lower GI
bleeding.
Informed consent for the procedure was obtained from the
patient's husband,
[**Name (NI) **] [**Name (NI) 45209**] after risks, benefits, and potential
complications had been
discussed. The patient was placed on the angiographic table in
supine
position and was intubated and sedated per MICU protocol. Skin
of the right
anterior neck was prepped and draped in a sterile manner.
Timeout protocol
and huddle protocol were carried out prior to the procedure
according to the
[**Hospital 18**] hospital policy.
ANESTHESIA: Local, 1% lidocaine.
Under real-time ultrasound guidance, using the high-frequency
linear array
transducer, Dr. [**Last Name (STitle) 45331**] punctured the patent and fully
compressible right
internal jugular vein using the 21 gauge micropuncture needle.
Over a 0.018
guidewire, 21 gauge micropuncture needle was exchanged for a 4
French
micropuncture sheath followed by advancement of 0.035 Bentson
guidewire into
the infrarenal inferior vena cava. Over a Bentson guidewire, a
9.0 French 35
cm [**First Name8 (NamePattern2) **] [**Last Name (un) 2493**] Tip sheath was advanced into the inferior vena
cava.
Cannulation of the right hepatic vein was expedient using a
combination of 5.0
French MPA 1 catheter in combination with angled tip 0.035
Glidewire. The
Glidewire was exchanged for a 0.035 Amplatz guidewire through
the MPA catheter
and MPA catheter was exchanged for a 5 French straight flush
catheter over the
Amplatz guidewire. Portal venogram was obtained. TIPS shunt was
noted to be
patent. Pressure measurements demonstrated 17 mmHg portosystemic
gradient;
with 25 mmHg pressure measurements throughout the TIPS shunt and
in the portal
venous basin, 18 mmHg in the right hepatic vein and 8 mmHg in
the right
atrium. Massive duodenal varices are demonstrated on portal
venogram. Large
duodenal varix was cannulated expediently using 5.0 French Cobra
gliding
catheter. Cobra catheter entered the duodenal [**Last Name (un) 2432**] varix in
tandem with 0.035
angled tip Glidewire. Injection of the varix demonstrated active
bleeding
into the C-loop of the duodenum. Coil embolization of the
bleeding varix was
performed using stainless steel coils of 3 cm x 8 mm profile and
8 cm x 10
profile, respectively. Following coil embolization, active
bleeding stopped
on followup contrast injection. Through the 5.0 French Cobra
gliding
catheter, Amplatz guidewire was reintroduced into the portal and
splenic vein.
A 10 mm x 42 mm Wallstent was deployed in a telescopic manner
through the TIPS
shunt and across the right hepatic vein stenosis. Balloon
angioplasty was
performed using 8 mm x 2 cm high-pressure balloon within the
lumen of the TIPS
shunt and 10 mm x 2 cm balloon outside the lumen of the TIPS
shunt in the free
right hepatic vein. Portosystemic pressure gradient was reduced
to 10 mmHg
following stenting and balloon angioplasty.
Hemostasis at the puncture site was achieved without difficulty
by manual
compression. Sterile dressing was applied.
CONCLUSION:
1. Portosystemic gradient of 17 mmHg was detected. No
intra-stent gradients
were present.
2. Right hepatic vein outflow stenosis.
3. Stenting and balloon angioplasty of the right hepatic vein
stenosis
resulted in reduction of the portosystemic gradient to 10 mmHg.
4. Massive duodenal varices with active bleeding in to the third
portion of
the duodenum demonstrated upon selective injection of the
megavarix.
5. Successful stainless steel coil embolization of the bleeding
duodenal
varix.
The study and the report were reviewed by
CXR [**2164-1-12**]
FINDINGS:
Portable semi-upright view of the chest demonstrates low lung
volumes, which
accentuate bronchovascular markings. There is no pleural
effusion, focal
consolidation or pneumothorax. Perihilar vascular congestion is
noted. There
is no pulmonary edema. Heart size is normal.
There is interval removal of endotracheal tube. Multiple
surgical clips and
TIPS shunt catheter project over right upper abdomen.
IMPRESSION:
Low lung volumes following ET tube removal. No focal
consolidation to suggest
pneumonia.
Brief Hospital Course:
43F with a history of alcoholic cirrhosis (still actively
drinking), history of prior UGIB though now s/p TIPS, who
presents with several episodes of dark red blood per rectum,
drop in BP, and Hct of 20 concerning for active upper vs. lower
GIB.
# Respiratory Failure: She was intubated on admission to the ICU
for airway protection for her EGD and [**Last Name (un) **]. When these were
negative, she remained intubated for her CTA and angio
procedure. After the angio procedure, she was extubated in early
PM, and performed well, but had prolonged sedation following
extubation so PO was not started. She was given 40 mg IV Lasix
for volume overload on her CXR, with a plan to restart her home
Furosemide regimen on the floor. Was on room air on discharge
with no respiratory symptoms.
# GI BLEED: Negative [**Last Name (un) **] and EGD,except for medium non-bleeding
grade 1 internal & external hemorrhoids were noted on [**Last Name (un) **] with
BRB, and therwise normal EGD to jejunum
. Had duodenal varices on CTA. S/p IR guided coiling of duodenal
varices, balloon dilation of TIPS, and stenting of the Rt
hepatic vein, reducing portosystemic pressure from 15 mg to 10
mg. GI bleed apprears to have stopped. She got a total of 11 U
pRBC, 2 U plt, 1 U FFP, 2 U Cryo. She was given CTX, started on
an IV PPI, as well as IV octreotide. Upon leaving the ICU, her
octreotide was DC'ed, and she was placed on CTX and IV PPI.
Ceftriaxone discontinued on [**2164-1-16**] and she was discharged on
home PPI.
.
# PANCYTOPENIA: Likely secondary to liver cirrhosis. Plts and
WBC count are comparable to prior values; Hct baseline is upper
20s-lower 30s as above.
.
# ALCOHOLIC CIRRHOSIS: TIPS, portal vein are patent. Current
MELD is 18-22 and Child-[**Doctor Last Name 14477**] class B-C. She remains an active
drinker. Followed by Dr. [**Last Name (STitle) 497**] though no recent visit in our
system. Transaminases, alk phos are roughly at her baseline;
Tbili and INR are higher than prior baseline. [**1-11**] US reveals
Patent TIPS
Continued lactulose for [**1-22**] BM per day. Restarted home
aldactone and Lasix,
# ACTIVE ALCOHOLISM: Active drinker, no known history of
DTs/seizure. Blood alcohol 238 on arrival to ED.
.
Transitional Issues
Of note her potassium was 3.0 on discharge, she was
supplemented, her primary care physician was called to follow up
on electrolytes on Friday [**2164-1-19**] and they are aware of the low
potassium.
Medications on Admission:
Reglan 10 mg PO TID PRN
- Omeprazole 40 mg PO daily
- Trazodone 100 mg QHS
- Furosemide 60 mg PO daily
- Spironolactone 150 PO BID
- Lidoderm 5% patch last few months
- thiamine HCl 100 mg PO DAILY
- folic acid 1 mg PO DAILY
- lactulose 10 gram/15 mL 30 ML PO QID
- Lorazepam 0.5 mg PO PRN
- multivitamin 1 Tablet PO DAILY
Meds on D/C summary [**6-/2163**]:
- rifaximin 550 mg PO BID (per pt no longer taking)
- risperidone 1 mg PO BID (per pt no longer taking)
Discharge Medications:
1. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety : Do not drive a vehicle with
this medication .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Gastrointestinal Bleeding
Alcohol Hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital because of bleeding in the
gastrointestinal tract. This bleeding was caused by your active
alcohol abuse. Please do not drink alcohol as it is life
threatening.
.
We made no changes to your home medication list.
.
Please follow up with the outpatient appointments below:
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital6 **]
Address: [**First Name8 (NamePattern2) **] [**Last Name (un) 45332**] BLDG, 5TH FL, [**Location (un) **],[**Numeric Identifier 45328**]
Phone: [**Telephone/Fax (1) 45333**]
Appointment: Friday [**2164-1-20**] 10:00am
Department: LIVER CENTER
When: WEDNESDAY [**2164-1-25**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
ICD9 Codes: 2761, 4019, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5247
}
|
Medical Text: Admission Date: [**2102-9-28**] Discharge Date: [**2102-10-1**]
Date of Birth: [**2030-6-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 72 y.o. female who p/w SAH after falling at home down 5
stairs with 20 min LOC. She remembers tripping down the stairs
but has no memory from there until awaking in the ambulance. Her
husband states that here was no bleeding or visual injuries. She
was taken to [**Hospital6 1597**], with nausea and vomiting.
Outside head CT showed R frontal SAH. She was loaded with 1000
mg
of Dilantin and transferred to [**Hospital1 18**] ED. CT of C-spine, L-spine,
thorax, abdomen and pelvis were within normal limits per [**Hospital3 **] Radiology.
Past Medical History:
PMHx:
L breast CA s/p lumpectomy and axillary node disection in [**2093**]
Depression
Hyperactive bladder
Constipation
Social History:
Social Hx: non-smoker, non-drinker, lives with husband
Family History:
Family Hx:
Noncontributory.
Physical Exam:
PHYSICAL EXAM:
O: T:98 BP: 110/84 HR: 74 R 18 O2Sats 99% RA
Gen: WD/WN, comfortable, NAD, no raccoon or battle signs, no
visual trauma/lacerations/bleeding. Tympanic membranes intact,
nasal passages intact.
HEENT: Pupils: reactive bilaterally 4-2mm EOMs intact
Neck: C-collar, non-tender to palpation.
Extrem: Warm and well-perfused, non-tender
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.
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 mm to 2 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,
with positional tremor of bilateral upper extremities. Strength
full power [**4-15**] throughout. No pronator drift
Sensation: Intact to light touch.
Reflexes: B T Br Pa
Right 2 1+ 2 2
Left 2 1+ 2 2
Toes downgoing bilaterally, no clonus
Pertinent Results:
NCHCT: No interval change in intraparenchymal hemorrhage in
bilateral frontal lobe, scattered SAH, pooling in
interpeduncular
fossa and posterior horns of the lateral ventricles bilaterally.
No midline shift or hydrocephalus or ischemia or bony fractures.
[**2102-9-28**] 04:13PM GLUCOSE-182* UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
[**2102-9-28**] 04:13PM CK(CPK)-108
[**2102-9-28**] 04:13PM cTropnT-<0.01
[**2102-9-28**] 04:13PM CK-MB-5
[**2102-9-28**] 04:13PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.8
[**2102-9-28**] 04:13PM WBC-20.3* RBC-4.17* HGB-13.5 HCT-37.7 MCV-91
MCH-32.3* MCHC-35.7* RDW-12.8
[**2102-9-28**] 04:13PM NEUTS-94.4* BANDS-0 LYMPHS-4.2* MONOS-1.3*
EOS-0.1 BASOS-0.1
[**2102-9-28**] 04:13PM PLT SMR-NORMAL PLT COUNT-278
[**2102-9-28**] 04:13PM PT-12.8 PTT-27.8 INR(PT)-1.1
Brief Hospital Course:
The patient was admitted with IPH and SAH. She was
neurologically intact. Her repeat CT scan showed no change and
she safe to be discharged home from a neurosurgical standpoint
on [**9-29**]. However physical therapy felt that she needed to be
seen by them again prior to discharge. PT saw her again on [**9-30**]
and [**10-1**] and deemed her safe to go home on [**10-1**].
Medications on Admission:
All: NKDA
Medications prior to admission:
Zoloft daily
Fozamax 70 mg weekly
Loratadine 10 mg daily/prn
Calcium 600 mg TID
Femara 2.5 mg daily
Glucosamine daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): use while on Perocet.
Disp:*40 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*25 Tablet(s)* Refills:*0*
3. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO QD ().
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right frontal contusion
Discharge Condition:
Neurologically stable
Discharge Instructions:
Return to the ER if your headache worsens (not relieved with
pain medication), you have vomiting not relieved by medication,
weakness, or dizziness
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 4 weeks with a head CT call
[**Telephone/Fax (1) 2731**] for an appointment
Completed by:[**2102-10-3**]
ICD9 Codes: 5990, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5248
}
|
Medical Text: Admission Date: [**2122-1-10**] Discharge Date: [**2122-1-25**]
Date of Birth: [**2052-4-9**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Erythromycin Base / Oxycodone
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Fever, [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line and Swan Ganz catheter placement
Chest tube placement
History of Present Illness:
69 year-old female with CAD s/p RCA stent x 2 (last one [**2121-12-26**]
post IMI), CHF with EF 60%, PVD s/p aorto-bifem bypass, and s/p
left brachial pseudoaneurysmal repair, transferred from
[**Hospital3 3834**] with fever and hypotension, as well as
troponin leak. Of note, she was recently admitted to [**Hospital1 18**] on
[**2121-12-26**] with sudden onset right-sided CP and SOB, and was found
to have NSTEMI (ST depressions in lateral leads, peak troponin
of 5.0), with mild CHF. A cardiac catheterization revealed 95%
RCA stenosis (in-stent re-stenosis). A RCA Cypher stent was
placed with 10% residual stenosis. She was discharged home on
[**2121-12-27**].
On [**2122-1-8**], she presented to [**Hospital3 3834**] [**Hospital3 **] with
non-exertional right-sided CP, along with SOB, which is her
anginal equivalent. Symptoms lasted approximately 1/2 hour, and
were improved but not resolved with SLNTG. In the ER her vital
signs were stable with T 97.0, BP 147/64, RR 18, Sat 98%RA. JVP
was elevated at 6cm, lungs with end expiratory wheezes. An EKG
revealed NSR with RBBB, no acute changes. Her initial CK was 25,
trop 0.04, WBC 4.8, and Cr 0.9. She was treated with aspirin,
nebs for possible COPD flare, and started on heparin IV for
possible unstable angina. While in the hospital, she had a
Myoview, showing an inferior filling defect.
On the night prior to admission to the [**Hospital1 18**], she became
hypotensive with SBP to low 80's, temperature to 104, CK of 300
and CKMB 15.7, trop I 13.5. Her BP did not improve with fluid
resuscitation, and she was transferred to the [**Hospital1 18**] CCU on
neosynephrine and heparin IV for possible re-cath. Of note, she
was on 50% FM, with decreased UO.
Further history revealed a sister with recent influenza and
hospitalization. ROS otherwise negative for worsening orthopnea,
PND, DOE, diarrhea, dysuria.
Past Medical History:
1. CAD. Cardiac cath in [**2117**] with 80% proximal RCA lesion,
50-60% distal RCA lesion, 50% OM and a 40% distal LM/PLAD
lesion. S/p PTCA and stent placement to the proximal RCA.
Cardiac cath [**2118**]: RCA had an ostial 30-40% stenosis and mild
30-40% diffuse in-stent restenosis. EF of 60%. Cardiac cath
[**2121-12-26**], with 30% instent restenosis in the previously placed
RCA stent, and 95% mid vessel stenosis. PTCA with Cypher stent
placement performed, with 10% residual stenosis.
2. CHF, last EF 60% in [**2118**].
3. Hypothyroidism
4. Diabetes mellitus type 2
Past Surgical History:
1. Aorto-bifem bypass [**2111**]
2. Pseudoaneurysm repair '[**17**]
3. Bilateral cataract surgery
Social History:
She lives with her sister, no etOH. Ex-smoker, stopped smoking 9
years ago (smoked [**12-21**] ppd X 35 yrs).
Family History:
N/A
Physical Exam:
Physical examination on admission per resident note:
VITALS: T 99.9, HR 125, BP 101/42, RR 18, Sat 100% on 4L
HEENT: WNL
NECK: JVP 6 cm ASA.
RESP: Bibasilar crackles.
CVS: Tachycardic, regular. Normal S1, S2. No S3, S4. No murmur
or rub.
GI: BS normoactive. Abmone soft, non-tender.
Ext: No bruit at cath site. No hematoma. No clubbing, cyanosis.
No pedal edema.
Pertinent Results:
Relevant laboratory data on admission:
WBC-5.2 RBC-3.49* HGB-10.3* HCT-31.2* MCV-89 MCH-29.6 MCHC-33.2
RDW-14.9
PLT COUNT-267
GLUCOSE-177* UREA N-25* CREAT-1.2* SODIUM-136 POTASSIUM-4.7
CHLORIDE-102 TOTAL CO2-22 ANION GAP-17
CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-1.1*
Cardiac enzymes:
[**2122-1-10**] 11:30AM CK(CPK)-234*
[**2122-1-10**] 11:30AM CK-MB-14* MB INDX-6.0 cTropnT-1.22*
[**2122-1-10**] 07:48PM CK-MB-10 MB INDX-5.1 cTropnT-1.11*
[**2122-1-10**] 07:48PM CK(CPK)-198*
EKG: NRS, rate 125 bpm. [**Street Address(2) 4793**] depressions in V3-6, ST
depressions in II (old). TW flattening in III+aVF.
Relevant studies in hospital:
[**2122-1-10**] ECHO:
1. The left atrium is normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed. Resting regional wall
motion abnormalities include inferior, inferoseptal, and
inferolateral akinesis with relative preservation of the lateral
and anterior walls..
3.Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets are mildly thickened. Insufficent
doppler studies performed of the aortic valve to determine the
presence of stenosis or regurgitation.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen but studies limited..
6.There is no pericardial effusion.
****************
[**2122-1-13**] ECHO:
The left atrium is normal in size. The left ventricular cavity
is dilated.
There is severe global left ventricular hypokinesis (LVEF
25-30%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a fat pad, though
a loculated anterior pericardial effusion cannot be excluded.
****************
[**2122-1-19**] ECHO:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated with severe global
hypokinesis. No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size is normal with mild
global right ventricular free wall hypokinesis. The aortic valve
leaflets appear structurally normal. Mild (1+) aortic
regurgitation is seen. The mitral leaflets and supporting
structures are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2122-1-13**], the
findings are similar (Overall LVEF was somewhat overestimated on
the prior study).
Brief Hospital Course:
69 year-old female with CAD s/p RCA stent on [**2121-12-27**] for
in-stent restenosis, CHF, PVD, who returned to [**Location **] on [**1-8**]
with chest pain, initially ruled out, and who then developed
fever to 104, hypotension and rise in troponin I, transiently on
Neo drip, transferred to [**Hospital1 18**] for further management. Her
hospital course will be reviewed by problems.
1) CAD: On arrival, an echo revealed an EF of 25%, and resting
regional wall motion abnormalities with inferior, inferoseptal,
and inferolateral akinesis with relative preservation of the
lateral and anterior walls. CK was 250, Troponin 1.22 (peak),
EKG without ST elevations. Her picture was felt most consistent
with sepsis with demand-related ischemia rather than stent
thrombosis, and the decision was taken not to proceed to cardiac
catheterization. Her most recent cath in [**Month (only) 404**] revealed
single-vessel CAD which was stented. A PA line was placed on
admission, with initial numbers CVP 11, PA 43/16, SVR 620, CO/CI
7.1/3.76 felt most consistent with sepsis physiology, and MUST
protocol was initiated, with fluid resuscitation. She required
pressors intermittently, intially Neosynephrine, then Levophed,
which were eventually weaned off. She was continued on Heparin
IV for 48 hours, then D/C'd.
While in hospital, she was continued on ASA, Plavix and Lipitor.
BB and ACE were temporarily held in the setting of hypotension.
BB therapy was eventually resumed when BP stable. ACE inhibitor
held pending recovery of renal function, resumed on [**2122-1-21**]
with improving renal function and titrated up.
Follow-up arranged with Dr. [**Last Name (STitle) 11493**] 1 week following discharge.
She will need repeat LFT's as an out-patient given dose
titration of Lipitor.
2) CHF: On admission, an echo revealed a depressed EF with
inferior, inferoseptal, and inferolateral akinesis. She
eventually developed pulmonary edema secondary to aggressive
fluid resuscitation in the setting of likely sepsis. Diuresis
was initiated when the patient was hemodynamically stable, and
she was intermittently placed on a Lasix drip prior to
extubation, with good diuresis. Subsequent echocardiograms
revealed poor EF approximately 20% (overestimated on [**2122-1-13**])
with global LV hypokinesis. It is unclear whether her current
cardiomyopathy can all be accounted for by ischemic
cardiomyopathy. Mycoplasma titers were sent (given her
respiratory illness, possible contribution to cardiomyopathy)
and still pending at discharge. Please repeat an out-patient
echo in 2 weeks to reassess LVEF.
Post-extubation, she was given Lasix intermittently, with a goal
negative daily fluid balance. Her CXR picture slowly improved.
ACE inhibitor therapy was held pending recovery of her renal
function, and was resumed on [**2122-1-21**]. She was discharged on
Lasix 20 mg PO QD. She will need daily weights, with titration
of Lasix to 40 mg PO QD if weight increases >3 lbs. Weight at
discharge 68.7 (likely still [**1-22**] kg from goal weight). Again,
please consider a repeat echo in 2 weeks as an out-patient to
reassess LVEF.
3) Pulmonary: On admission, a PA line was placed via the left
subclavian vein, complicated by a tension pneumothorax requiring
intubation and emergent chest tube placement. Her course was
complicated by reaccumulation of the pneumothorax on water seal,
replaced on suction. She was difficult to extubate. Serial ABGs
and labs revealed a non-anion gap metabolic acidosis, with
compensatory hyperventilation. Bicarbonate was repleted. She was
also aggressively diuresed pre-extubation, and was finally
extubated on [**2122-1-17**]. The chest tube was pulled on [**2122-1-18**],
without subsequent reaccumulation. Her oxygen requirements
slowly declined with continued diuresis. She was also started on
a Prednisone taper for possible COPD exacerbation, to be
continued as an out-patient. She was given bronchodilator
therapy via nebulizers, changed to inhalers at discharge. She is
on room air to 1L/min at discharge.
4) ID: As mentionned above, her initial presentation was felt
consistent with sepsis, and the MUST protocol was instituted.
The initial CXR revealed atelectasis but no definite
consolidation. She was ruled out for influenza. All cultures
were unremarkable, including sputum, urine and blood cultures.
She was empirically started on Levofloxacin on admission.
Vancomycin and Flagyl were added on [**2122-1-11**] in the setting of
ongoing fever and hypotension and she completed an empiric 7-day
course of antibiotics, D/C'd on [**2122-1-16**]. Serial CXRs failed to
reveal a definite consolidation, and it was felt that she may
have had a viral pneumonia. She defervesced around hospital day
#6, and has been afebrile since.
5) Renal failure: Patient with baseline creatinine of 0.5-0.7,
up to 1.2 on admission. Her creatinine rose to a peak of 1.7 in
hospital. Renal was consulted to address her renal failure and
non-anion gap metabolic acidosis. The latter was felt to be
likely secondary to her renal failure and also dilutional in the
setting of large volume resuscitation. Her renal failure was
felt most likely secondary to ATN (although FeNA<1%), and renal
function gradually recovered. Creatinine 1.1 on [**2122-1-22**].
6) Heme: While in hospital, her WBC count was noted to be
trending down (nadir 2.7), which was felt most likely secondary
to myelosuppression in the setting of acute illness. She was
also anemic, and was transfused 2 units of PRBCs on [**2122-1-12**] to
maintain her hematocrit above 30. Hematocrit at discharge 33.2.
Please consider out-patient work-up of anemia (? GI work-up).
Medications on Admission:
Medications prior to admission to outside hospital:
Aspirin 325 mg PO QD
Plavix 75 mg PO QD
Losartan 50 mg PO QD
Lipitor 40 mg PO QD
Imdur 60 mg PO QD
Glyburide 5 mg PO QAM, 10 mg PO QHS
Levothyroxine 100 mcg PO QD
Toprol XL 100 mg PO QD
Albuterol, Atroven inhalers
Metformin
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
7. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: [**12-21**]
inhalations Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
8. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
Disp:*1 diskus* Refills:*2*
12. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) Inhalation
four times a day.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: Please take first dose on [**2122-1-23**].
Disp:*3 Tablet(s)* Refills:*0*
15. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: Please start after 20 mg tapered dose. .
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease
Congestive heart failure
Pneumothorax
Acute renal failure resolving
Probable viral pneumonia
Diabetes mellitus type 2
Hypothyroidism
Discharge Condition:
Patient discharged to rehabilitation facility in stable
condition.
Discharge Instructions:
increases > 3lbs.
We have scheduled an appointment for you with Dr. [**Last Name (STitle) 11493**] on
Wednesday [**1-28**] at 10:45. It is important that you go to
this appointment.
We have made some changes to your medications. Please take only
the medications that we have prescribed.
Followup Instructions:
We have scheduled an appointment for you with Dr. [**Last Name (STitle) 11493**] on
Wednesday [**1-28**] at 10:45. It is important that you go to
this appointment.
Completed by:[**2122-1-22**]
ICD9 Codes: 0389, 5849, 4280, 496, 2859, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5249
}
|
Medical Text: Admission Date: [**2138-3-20**] Discharge Date: [**2138-4-12**]
Date of Birth: [**2138-3-20**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 67097**], twin #2, is a 33
and [**1-28**]-week infant twin with a birth weight of 1570 grams
who was admitted to the NICU for prematurity.
MATERNAL HISTORY: She delivered at 33 and 3/7 weeks to a 38-
year-old G2/P1 (now 3) mother with prenatal labs of maternal
blood type A+, antibody negative, rubella immune, RPR
nonreactive, hep B surface antigen negative, GBS status
unknown. Pregnancy was remarkable for twins, dichorionic-
diamniotic.
DELIVERY COURSE: This infant was delivered via C-section
because of worsening maternal pregnancy-induced hypertension.
[**Known lastname **] was crying and vigorous at delivery with Apgar's 8 and
9.
PHYSICAL EXAMINATION: Upon admission to the NICU her weight
was 1570 grams (25th percentile), length 44 cm (50th
percentile), head circumference 29 cm (25th to 50th
percentile). Her oxygen saturations were 98% on room air.
Blood pressure was stable at 72/23 with a mean of 42. She was
a nondysmorphic, well-appearing, twin, premature, female
infant in no acute distress.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: [**Known lastname **] required no oxygen. No intubation or
surfactant. She did have episodes of apnea and bradycardia
with feeds primarily. She
finished a 5-day countdown prior to discharge on
[**4-12**]. She received no caffeine.
2. CARDIOVASCULAR: No issues.
3. FLUIDS, ELECTROLYTES, NUTRITION/GASTROINTESTINAL: She
attained full enteral feeds by day of life #4. Her maximum
bilirubin was 7.1. She received phototherapy for 3 days
early on in life.
4. HEMATOLOGY: Her hematocrit was 52.3% on day of birth. She
never received a transfusion, and she is on iron therapy.
She has not received a second subsequent CBC.
5. INFECTIOUS DISEASE: She never received any antibiotics.
Blood cultures were no growth to date.
6. NEUROLOGY: Neurologic exam has been within normal limits.
Neuroimaging was not indicated.
7. SENSORY:
1. AUDIOLOGY: Hearing screen was performed on [**2138-4-11**]
with automated auditory brain stem
responses; results were a pass in both ears.
2. OPHTHALMOLOGY: The patient's eyes were not examined
given gestational age of 33 weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 18412**] at [**Location (un) **]; phone number
is ([**Telephone/Fax (1) 67099**]. PMD was updated prior to discharge.
CARE/RECOMMENDATIONS:
1. Feeds at discharge will be breast milk 24-kilocalories
per ounce supplemented with Enfamil Powder or Enfamil 24.
2. Medications include iron.
3. Car seat position screening was performed and passed prior to
discharge.
4. State newborn screening was sent on [**4-3**] with results
pending.
5. She received hepatitis B vaccine on [**2138-4-11**].
IMMUNIZATIONS RECOMMENDED:
1. 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
gestation; (2) born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
or school-age siblings; or (3) with chronic lung disease.
2. Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age.
Before this age (and for the first 24 months of the
child's life) immunization against influenza is
recommended for household contacts and out of home
caregivers.
FOLLOW-UP APPOINTMENTS: Include with the primary
pediatrician, Dr. [**Last Name (STitle) 18412**]. A VNA appointment will be set up
for the home prior to discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 weeks.
2. Hyperbilirubinemia, resolved.
3. Apnea of prematurity, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) 66322**]
MEDQUIST36
D: [**2138-4-11**] 16:29:06
T: [**2138-4-12**] 11:54:37
Job#: [**Job Number 67100**]
ICD9 Codes: 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5250
}
|
Medical Text: Admission Date: [**2177-5-19**] Discharge Date: [**2177-6-2**]
Date of Birth: [**2123-11-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
IR Embolization (coil) of Left Gastric Artery
EGD x 3
History of Present Illness:
53 yo M with h/o St. [**Initials (NamePattern4) 1525**] [**Last Name (NamePattern4) 1291**] on [**Hospital 197**] transferred from
[**Hospital3 6592**] where he presented with melena mixed with BRBPR
since 2 am morning of [**2177-5-19**]. Patient reports not feeling well
for 2 days prior to presentation - decreased po intake and
emesis x 1 (non-bloody non-bilious). Then he was awoken at 2 am
morning of admission with melenous BM. Had about 7 BMs before
arrival at [**Hospital1 18**] ICU. Patient reported feeling lightheaded and
diaphoretic. His INR one week prior to presentation was in the
therapeutic 2.5-3.5 range. He also complained of lower abdominal
cramping discomfort that he developed the night prior to
admission, non-radiating. Denied NSAIDs use. On presentation to
the OSH BP 80/palp, pulse of 68. INR was 4.89, HCT 28.4. He was
transfused 2 unit p RBCs, given 2 units FFP, Vit K 10 mg Sc,
Protonix 40 mg IV once, and transferred here. INR here 2.5. Hct
23.4.
.
On the review of systems, he denies chest pain, nausea,
vomiting, fevers, chills, abdominal pain, urinary urgency,
frequency or dysuria. He complains of mild lower back pain.
Past Medical History:
1. Endocarditis, s/p St. [**Male First Name (un) 1525**] AV placement in [**2172**]
2. HTN
3. Hyperlipidemia
4. Panic attacks/anxiety
5. S/p Vasectomy
6. Wisdom teeth removal
7. Had a colonoscopy/EGD in RI in [**2166**] "normal" per patient.
Social History:
Divorced. Lives with parents. Currently unemployed and applying
for SSI/disability. Previously worked as a chef. Has three
daughters ages 27, 19 and 18. Mother is next of [**Doctor First Name **]. Tobacco:
none for many years. Alcohol: occasional EtOH. IVDU denies.
Family History:
Father had a bleeding ulcer.
No family history of colon cancer.
Physical Exam:
Admission exam
VS: 98.3; 86/59; 65; 16; 100 % on RA
GENERAL: alert and oriented x 3; anxious appearing; lying in bed
HEENT: NC, AT, no scleral ictrus, PERRL, conjunctiva slightly
pale, MMM
NECK: supple, no LAD
CV: regular, mechanical S2, no m/r/g
PULM: CTA bilaterally
ABD: + BS, soft, NT, ND
EXTR: no c/c/e
Pertinent Results:
[**2177-5-19**] 12:15PM PT-24.6* PTT-30.5 INR(PT)-2.5*
[**2177-5-19**] 12:15PM PLT COUNT-230
[**2177-5-19**] 12:15PM NEUTS-72.7* LYMPHS-21.0 MONOS-4.2 EOS-1.3
BASOS-0.8
[**2177-5-19**] 12:15PM WBC-7.0 RBC-2.72* HGB-8.2* HCT-23.4* MCV-86
MCH-30.3 MCHC-35.2* RDW-14.3
[**2177-5-19**] 12:15PM GLUCOSE-117* UREA N-38* CREAT-0.6 SODIUM-143
POTASSIUM-4.3 CHLORIDE-115* TOTAL CO2-21* ANION GAP-11
[**2177-5-19**] 05:42PM ALT(SGPT)-11 AST(SGOT)-13 LD(LDH)-169 ALK
PHOS-31* TOT BILI-0.5
[**2177-5-19**] 04:37PM ALBUMIN-2.4* CALCIUM-6.5*
[**2177-5-19**] 05:48PM LACTATE-0.5
[**2177-5-19**] 09:01PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2177-5-19**] 09:01PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
EGD [**2177-5-19**]:
Findings:
Esophagus: Other There was a moderate sized hiatal hernia
present about 38 centimers from the incisors. At the base of the
hernia sac there was a 6 mm pigmented protuberence that
resembled [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**]-[**Doctor Last Name **] tear. The area was injected with 7
cc's total of a 1:10,000 epi solution. The injections were
performed in a four quadrant distribution. There was very good
hemostasis and no evidence of further bleeding. 7 1
cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for hemostasis
with success.
Stomach: Contents: There was a large fundic clot present.
Repeated attempts to aspirate the clot were unsuccessful. A
orogastric lavage using and [**Doctor First Name **] tube was then performed and
small amounts of clot were removed. Despite these manuevers the
entire clot could not be fully cleared. Erythromycin 250 mg IV
was given in an attempt to facilitate gastric removal of the
clot. We also switched to the endoscope with the largest suction
channel that we had available to facilitate clot removal.
Duodenum: Other There was no evidence of active bleeding in the
duodenum. There was no evidence of any mucosal abnormalities to
suggest a bleeding source in the duodenum.
Impression: There was a moderate sized hiatal hernia present
about 38 centimers from the incisors. At the base of the hernia
sac there was a 6 mm pigmented protuberence that resembled a
[**Doctor First Name 329**]-[**Doctor Last Name **] tear. The area was injected with 7 cc's total of a
1:10,000 epi solution. The injections were performed in a four
quadrant distribution. There was very good hemostasis and no
evidence of further bleeding. (injection)
Blood in the fundus
There was no evidence of active bleeding in the duodenum. There
was no evidence of any mucosal abnormalities to suggest a
bleeding source in the duodenum.
EGD [**2177-5-20**]:
Findings:
Esophagus: Normal esophagus.
Stomach: Other Large blood clot encompassing entire fundus. We
were able to suction approximately 500 cc of clot material and
liquid blood.
Duodenum: Normal duodenum.
Impression: Large blood clot encompassing entire fundus. We were
able to suction approximately 500 cc of clot material and liquid
blood.
EGD [**2177-5-26**]:
Findings:
Esophagus: Normal esophagus.
Stomach: Excavated Lesions Two superficial ulcers ranging in
size from 2 mm to 4 mm were found in the stomach body.
Erythematous mucosa with patchy bluish areas and small erosions
was noted along the posterior wall of gastric body along the
lesser curvature. No active bleeding was noted.
Duodenum: Normal duodenum.
Impression: Superficial ulcers and surrounding gastritis in the
posterior wall of gastric body along the lesser curvature.
Recommendations:
Sulcrafate suspension one gram four times daily
Continue PPI twice daily
Repeat upper endoscopy in 8 weeks.
Blood cx [**5-22**]: no growth
Urine cx [**5-19**], [**5-22**]: no growth
H pylori ab: negative
CXR [**2177-5-22**]:
INDICATION: Fever.
There has been interval extubation. The heart is upper limits
of normal in size. There has been near complete resolution of
left basilar atelectasis and interval decrease in size of a
small left pleural effusion. There are no new areas of
consolidation to suggest pneumonia.
Brief Hospital Course:
53 yo M with h/o St. [**Male First Name (un) 1525**] aortic valve, on coumadin, who
presents with melena, borderline hypotensive.
.
1.
UGI Bleed - Patient was admitted to the ICU and seen immediately
upon arrival to the ICU by GI. GI began to perform an EGD to
investigate cause of bleeding. Passing of the scope was
difficult due to patient continually vomiting blood. They sucked
out about 500cc of blood and clot. GI was able to visualize a
hyperpigmented lesion next to an existing hiatal hernia that
resembled [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear. There was a very large clot in
the fundus as well and they chose not to dislodge it. He was
given a dose of erythromycin to later remove the clot. There was
a concern that there was bleeding underneath the clot. He was
transfused a total of 4 PRBC's in the ICU at [**Hospital1 **] and 2 units of
FFP. Upon repeat scope the next day ([**2177-5-20**]) the clot in the
fundus was still present and enlarged. Since his HCT was stable
but not responding to the transfusion of PRBC's appropriately,
it was decided to involve IR for possible embolization of the
left gastric artery. On [**2177-5-21**], the patient underwent
angiography via IR and the left gastric artery was coiled. No
active bleeding was seen at this time. Afterwards, the patient
was stable and returned to the ICU.
He was tx'ed out of the ICU on [**2177-5-25**]. Within hours of arrival
to the floor, he developed melena. The GI team took him back for
an EGD which revealed the following:
Findings: Esophagus: Normal esophagus.
Stomach:
Excavated Lesions Two superficial ulcers ranging in size from 2
mm to 4 mm were found in the stomach body. Erythematous mucosa
with patchy bluish areas and small erosions was noted along the
posterior wall of gastric body along the lesser curvature. No
active bleeding was noted.
Duodenum: Normal duodenum.
Impression: Superficial ulcers and surrounding gastritis in the
posterior wall of gastric body along the lesser curvature.
Recommendations: Sulcrafate suspension one gram four times daily
Continue PPI twice daily
Repeat upper endoscopy in 8 weeks.
His hct remained stable and he had no further issues with
bleeding during his hosp stay.
2. Fever: On [**2177-5-22**], the patient spiked a temperature of 101
and blood cultures, sputum culture, and urine culture were drawn
along with a STAT CXR. He was found to have a swollen right hand
at the site of a previous peripheral IV lock. He was initially
given iv vanco and then was subsequently changed to iv cefazolin
when blood cultures remained negative. He completed a course of
po dicloxacillin and his cellulitis completely resolved. He had
no further fevers. All culture data was negative.
.
3. St. Jude's valve: Patient's anticoagulation was reversed in
the setting of his life-threatening bleed. Once his hematocrit
stabilized, anticoagulation was restarted. He was maintained on
a heparin gtt and coumadin was started. His hematocrit remained
stable. Once his INR reached 2.3, decision was made to
discharge the patient on lovenox for the remainder of his
bridge. He is to have his INR drawn the day after discharge to
continue coumadin dose adjustment.
.
4. Anxiety: Patient has a history of anxiety with panic
attacks. He has taken klonopin prn for this in the past and
required a few doses while in house for mild anxiety.
.
5. Hypertension: Patient's blood pressure was well controlled
on atenolol 25 mg po qd. He was not sure what dose of beta
blocker he normally takes at home.
.
6. Hypercholesterolemia: Patient was continued on his home dose
of atorvastatin.
Medications on Admission:
Lipitor 20 mg po qd
Celexa (off lately)
Baby ASA
Coumadin 5/7.5 mg alternating daily
Vicodin prn
Atenolol ? dose
Lasix ? dose
Clonazepam ? dose
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous [**Hospital1 **] (2 times a day): until INR greater than or
equal to 2.5.
Disp:*10 injection* Refills:*0*
3. 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*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for Mechanical [**Hospital1 1291**]: Please discuss with Dr. [**Last Name (STitle) 5193**] to
determine your dose for Tuesday night.
Disp:*10 Tablet(s)* Refills:*0*
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day): Take this 1 hour apart from any of your other medications
and 1 hour before meals.
Disp:*120 Tablet(s)* Refills:*2*
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO bid:prn.
Discharge Disposition:
Home
Discharge Diagnosis:
upper GI bleed
St. Jude's valve
hand cellulitis
Discharge Condition:
good, no further bleeding, hematocrit stable, tolerating regular
diet
Discharge Instructions:
Please call your doctor or go to the emergency room if you
experience temperature > 101, abdominal pain, blood in your
stool, chest pain, shortness of breath, dizziness, or other
concerning symptoms.
Please take the lovenox injections until your INR is greater
than or equal to 2.5. You are to follow closely with your
doctor [**First Name (Titles) **] [**Last Name (Titles) 7941**] of your INR until then.
Please take 10 mg of coumadin tonight. You will have your INR
checked tomorrow and should discuss with Dr. [**Last Name (STitle) 5193**] how much
coumadin to take on Tuesday night.
Please stop taking your aspirin.
Please take all medications as prescribed.
Followup Instructions:
Please have your blood drawn at Dr.[**Name (NI) 67865**] office tomorrow to
check your INR.
Please follow-up with Dr. [**Last Name (STitle) 5193**] on [**2177-6-10**] at 11:20 AM.
Phone [**Telephone/Fax (1) 5194**].
Please call to confirm your follow-up EGD scheduled for
[**2177-7-25**] at 11:00 AM with Dr. [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 79**]. Phone:
[**Telephone/Fax (1) 463**].
ICD9 Codes: 5789, 2851, 5849, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5251
}
|
Medical Text: Admission Date: [**2141-2-10**] Discharge Date: [**2141-2-27**]
Date of Birth: [**2075-12-22**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
intubation
paracentesis
exploratory laparotomy, supracervical hysterectomy, bilateral
salpingo-oophorectomy, partial omentectomy, pelvic mass
resection for large mass from R ovary.
History of Present Illness:
This is a 65 y/o woman with no known past medical history (she
has not had medical care in about 20 years), who presented to
the ED at an OSH complaining of abdominal pain. She says she
was getting out of the shower when she all of a sudden developed
a [**9-27**] pressure like abdominal pain. She denies any nausea,
vomiting associated with the pain, was not eating at the time.
The pain was so severe she became diaphoretic. She has never
had this abdominal pain before. She denies any chest pain,
shortness of breath, lower extremity edema, fevers. She states
that she feels that her abdomen has been growing slowly over the
last 6 months, and had attributed it to weight gain, although
she had only gained three pounds over this period of time. She
denies any family history of breast or ovarian cancer.
.
The only other time she had been in the hospital was when she
gave birth. Of note, she was recently treated at a walk in
clinic for a UTI with nitrofurantoin. Because she still wasnt
feeling well after the course of nitrofurantoin, she returned to
clinic where they gave her two days of ciprofloxacin.
.
In the ED at the OSH, she had an abdominal ultrasound which
showed a ascites. This prompted a CT scan which was notable for
a complex cystic low abdominal and pelvic mass, measuring 16 x
16.5 x 11.5 cm, positioned superior to the uterus.
.
She was admitted to the OSH, and overnight, she developed a
leukocytosis to 23,600, up from 11,000 on admission with a
bandemia of 25%. She was started on levo/vanco/flagyl. Her
creatinine was noted to increase from baseline of 0.8 on
admission to 2.8 ([**2-10**] at 6:45). Bicarbonate decreased from 24
--> 16. Her blood pressures transiently decreased to SBP of the
70s, and she was started on a dopamine gtt (1 mcg/min). She
received one dose of mucomyst at 1700. Was started on NS with 2
amps of bicarb at 250cc/hr for 800cc.
.
On arrival, the patient denied shortness of breath. She denied
nausea, vomiting, abdominal pain. She denied fevers, chills,
sweats. She denied diarrhea, constipation, BRBPR, melena. Her
last episode of hematuria was ~1-2 weeks ago.
.
ROS: She denies lightheadedness, palpitations. She denies chest
pain. She denies weakness, blurry vision.
Past Medical History:
None - except for recent presumed UTI (although pt has not seen
a physician [**Last Name (NamePattern4) **] 20 years)
Social History:
Smoked 1 pack per day for 50 years, she quit smoking 15 years
ago. She drinks socially and has never had a problem with
alcohol abuse. She lives with her husband at home. Has one
child who is alive and well. She used to work as a telephone
operator.
.
Family History:
She has a father who died of lung disease at 59 and a mother who
died of "[**Last Name **] problem" at 70s. She has no FH of breast or
ovarian cancer.
.
Physical Exam:
Temp 100.3 BP 110/70 Pulse 120 Resp 22 O2 sat 87% FM UO 0 cc.
Pulsus 5
Gen - sleepy, arousable, accessory muscle use
HEENT - PERRL, extraocular motions intact, sclera anicteric,
mucous membranes moist, no OP lesions
Neck - no JVD, no thyromegaly
Nodes - no cervical, supraclavicular, axillary lymphadenopathy
Chest - distant breath sounds throughout, no w/c/r.
CV - Normal S1/S2, tachy, regular, no murmurs, rubs, or gallops
Abd - Distended, (+) fluid wave, no HSM, normoactive bowel
sounds
Back - No spinal, costovertebral angle tenderness
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses
bilaterally. No calf pain, erythema or cords palpable.
Neuro - Alert and oriented x 3, cranial nerves [**1-30**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact.
Skin - No rashes
Pertinent Results:
.
OSH:
2/22 [**2-10**] 7am 9am 1815
Cr 0.9 2.8 3.2 3.8
BUN 8 22 8 32
.
[**2141-2-9**]: CXR: LLL atelectasis
.
[**2141-2-9**]: Abd US: Multiple shadowing gallstones. GB wall not
thickened. IH ducts not dilated. Common hepatic duct 4mm.
Ascites
.
[**2141-2-9**]: 1301: CT abd/pelvis with contrast - complex cystic and
solid irregular mass - midline low abdomen and pelvis -
16x16.5x11.5cm. Irregularly enhancing mural components and
several low attenuation areas within the complex fluid
commponents. Extensive ascites. Midline uterus. Mild small bowel
dilatation. Kidneys normal without hydro/masses
.
ECG: HR 101, sinus tachycardia, normal intervals, no ST
depressions, normal axis, no q waves. No ECG available for
comparison.
ECG: here - sinus tach 111, nl axis, interval, sl peaked T waves
in V2, otherwise no acute ST T wave changes
.
CXR: left sided pleural effusion. mild vascular congestion
.
[**2141-2-11**] CT head
1.9 x 1.7 cm hyperdense, likely extra-axial lesion seen to the
right of the cerebellum, most likely representing meningioma.
Comparison with prior studies if available would be helpful. If
none are available, MRI would be recommended for further
evaluation. MRI would also be more sensitive in the evaluation
for potential metastases.
*
[**2141-2-22**] EKG
Sinus rhythm
Poor R wave progression - possible old anteroseptal myocardial
infarction
Low QRS voltage in limb leads Nonspecific T wave changes
Since previous tracing of [**2141-2-10**], sinus tachycardia absent, and
further T
waves changes seen
*
[**2141-2-23**] LENI
No evidence of right or left lower extremity deep vein
thrombosis.
*
[**2141-2-26**] CXR
Large right pleural effusion has increased slightly since [**2-22**] with
worsening of right basilar atelectasis. Smaller left pleural
effusion is
unchanged. Upper lungs show vascular redistribution but no
indication of
pneumonia. Heart size is slightly larger today, but difficult
to assess and the presence of adjacent pleural effusion. There
is no mediastinal vascular engorgement to suggest elevated
central venous pressure. No pneumothorax.
*
[**2141-2-10**] 08:43PM BLOOD WBC-25.3* RBC-4.94 Hgb-14.6 Hct-45.7
MCV-93 MCH-29.5 MCHC-31.9 RDW-13.8 Plt Ct-487*
[**2141-2-16**] 02:25AM BLOOD WBC-17.0* RBC-2.45* Hgb-7.1* Hct-21.8*
MCV-89 MCH-29.1 MCHC-32.6 RDW-14.3 Plt Ct-219
[**2141-2-18**] 05:31AM BLOOD WBC-23.9* RBC-3.90* Hgb-11.7* Hct-33.2*
MCV-85 MCH-29.9 MCHC-35.1* RDW-15.1 Plt Ct-295
[**2141-2-26**] 07:05AM BLOOD WBC-11.4* RBC-3.31* Hgb-9.8* Hct-28.7*
MCV-87 MCH-29.7 MCHC-34.2 RDW-15.3 Plt Ct-572*
[**2141-2-10**] 08:43PM BLOOD PT-14.0* PTT-36.7* INR(PT)-1.2*
[**2141-2-10**] 08:43PM BLOOD Fibrino-916* D-Dimer-8124*
[**2141-2-23**] 07:20AM BLOOD D-Dimer-3722*
[**2141-2-14**] 03:30AM BLOOD Ret Aut-1.4
[**2141-2-10**] 08:43PM BLOOD Glucose-140* UreaN-35* Creat-3.4* Na-138
K-5.5* Cl-108 HCO3-15* AnGap-21*
[**2141-2-17**] 05:06AM BLOOD Glucose-134* UreaN-42* Creat-0.9 Na-146*
K-4.2 Cl-112* HCO3-24 AnGap-14
[**2141-2-22**] 11:35AM BLOOD Glucose-95 UreaN-18 Creat-0.5 Na-139
K-3.3 Cl-106 HCO3-26 AnGap-10
[**2141-2-10**] 08:43PM BLOOD ALT-20 AST-51* LD(LDH)-487* CK(CPK)-1081*
AlkPhos-53 Amylase-78 TotBili-0.3
[**2141-2-13**] 04:01AM BLOOD ALT-17 AST-35 LD(LDH)-329* AlkPhos-41
Amylase-86 TotBili-0.3
[**2141-2-12**] 03:30PM BLOOD Lipase-12
[**2141-2-10**] 08:43PM BLOOD CK-MB-22* MB Indx-2.0
[**2141-2-10**] 08:43PM BLOOD cTropnT-<0.01
[**2141-2-11**] 05:54AM BLOOD CK-MB-22* MB Indx-1.8 cTropnT-0.01
[**2141-2-14**] 08:26AM BLOOD Hapto-212*
[**2141-2-16**] 02:25AM BLOOD Hapto-247*
[**2141-2-17**] 04:53PM BLOOD TSH-13*
[**2141-2-17**] 04:53PM BLOOD T4-5.3 T3-87
[**2141-2-10**] 08:43PM BLOOD Cortsol-107.4*
[**2141-2-11**] 05:54AM BLOOD Cortsol-136.8*
[**2141-2-10**] 08:43PM BLOOD CEA-10* CA125-96*
[**2141-2-11**] 06:15PM BLOOD AFP-8.4
[**2141-2-17**] 04:53PM BLOOD Anti-Tg-LESS THAN Thyrogl-22
[**2141-2-10**] 09:04PM BLOOD CA [**52**]-9 -Test
[**2141-2-11**] 02:00AM BLOOD ACTH - FROZEN-Test
Brief Hospital Course:
This patient is a 65yo G3P2 with no known PMH presenting to OSH
with several weeks of abdominal bloating and a 16x16 pelvic mass
and ascites, transferred with hypoxia and ARF following CT with
contrast. The patient was transferred to the MICU. In the MICU,
her main issues were as follows:
*
1. Respiratory failure
In the MICU, she underwent evaluation to r/o pulmonary embolus
given her rapid decompensation. She was started on empiric
therapy with heparin. Given the likelihood of acute renal
failure from CT contrast, she could not be evaluated with CTA.
As a result, she had LENIs that were neg and an echo that showed
good ejection fraction with no RV strain. In consultation with
Pulmonary Medicine, the decision was made not to treat her for
pulmonary embolus. Her respiratory failure was thought to be
secondonary to mod/large bilat effusions seen on chest CT and
large ascites, as well as volume overload from acute renal
failure. She was intubated and remained on ventilatory support
for 8 days. A left subclavian line was placed for hemodynamic
monitoring. Her first attempt at extubation was not successful
due to pt drowsiness. A CT of the head was performed to r/o
neurological injury. No hemorrhage was seen. She was eventually
extubated the following day without complications.
*
2. Acute Renal failure:
On presentation to the MICU, the patient was anuric and her
creatinine was significantly higher than at the OSH. This rapid
rise was thought to be secondary to contrast induced
nephropathy. A CT of the abdomen on [**2-9**] showed no evidence of
obstruction. The Renal service was consulted and they
recommended CVVHD dialysis which she underwent over the
following 7 days with improvement in her urine output and
creatinine measurement.
*
3. Fevers - On arrival, the patient was noted to have a fever
with leukocytosis. Blood, urine, sputum cultures were obtained
that did not reveal any signs of infection. The CXR had no
evidence of infiltrates. The abdominal ultrasound showed some
cholelithiasis but no evidence of cholecystitis. She was treated
empirically with vancomycin, ciprofloxacin and flagyl. Her
fevers improved after her second day in the MICU, and her
antibiotics were discontinued after surgery.
*
4. Altered mental status: On presentation, the patient had
altered mental status that was thought to be secondary to taking
dilaudid and benzodiazepine at OSH. Her neuro exam was
non-focal. Once stable from her respiratory status, she
underwent CT Head that revealed a small hyperdense mass in right
cerebellum c/w meningioma. She was recommended for further
imaging with MRI.
*
5. Elevated cortisol: On arrival, the patient was found to have
elevated cortisol levels. This was thought to be due to acute
stress reaction and leukomoid reaction. As rare forms of ovarian
cancer can also cause ectopic ACTH production, ACTH was also
measured and found to be mildly elevated at 52. No further
work-up was done.
*
6. Hypothyroidism:
The patient was found to have an elevated TSH of 13 during her
ICU stay. This likely represents a stress response. She should
have this retested 4-6 weeks after discharge to determine
whether she has hypothyroidism.
*
7. Pelvic mass: CT of the abdomen from OSH suggested a large
pelvic mass. This was associated with ascites. On her second
day, she underwent paracentesis under ultrasound guidance to
improve her respiratory status and to R/O bacterial peritonitis.
Four liters were drained. Although the fluid seemed suggestive
of peritonitis, this was not associated with bacteria on gram
stain. No malignant cells were seen. A second paracentesis was
performed under ulstrasound guidance with 1l fuild drained. An
attempt to further chracterise this mass, the patient underwent
testing for a number of tumour markers. Her CA-125 was mildly
elevated at 96, CEA as measured at 10, a 19-9 was significantly
elevated at >[**Numeric Identifier 38500**] and her HCG was negative. Given the elevation
in CA [**52**]-9, she was seen by the surgical oncology who did not
feel that this was consistent with pancreatic cancer despite
such an abnormally elevated CA [**52**]-9. Dr [**Last Name (STitle) 2028**] from
gynecology-oncology recommended exploratory laparotomy for
likely ovarian cancer once stabilised. She was taken to the OR
on [**2-18**], eight days following her initial presentation.
*
The patient was taken to the operating room where she underwent
exploratory laparotomy, supracervical hysterectomy, bilateral
salpingo-oophorectomy, partial omentectomy, pelvic mass
resection for large mass from R ovary. Please see operative
note for full details.
*
Her post-op course was complicated by:
1. wound infection
2. tachypnea likely secondary to atelectasis and pneumonia and
presumed pulmonary embolus
*
1. Wound: On post-op day #2, the patient was found to have a
wound infection for which she completed a 5 day course with
vancomycin with complete resolution.
*
2. Tachypnea: On post-op day #4, the patient was found to be
tachypneic with considerable shortness of breath at rest. This
was a change from her baseline. A chest X-ray revealed worsening
collapse of her RLL and her RML. An infiltrate could not be
ruled out. An ABG was performed that did not show evidence of
hypoxemia. There was concern for pulmonary embolus given that
the patient had initially developed respiratory failure and had
not been treated for embolus. Pulmonary medicine was consulted
and they felt strongly that this was likely secondary to
atelectasis and mucus plugings but could not rule out pneumonia
or pulmonary embolus. Given her renal failure from CT contrast,
she was not recommended for CTA. Moreover, given her ventilatory
defects, a VQ scan was not recommended either. US of the LE was
performed that did not show evidence of DVT. D-Dimer was
measured and was elevated. As pulmonary embolus could not be
definitively ruled out, they recommended empiric therapy with
lovenox. She was started on lovenox and will continue this for 6
months. She also received chest PT, nebuliser and Advair and
improved significantly. She was weaned off of oxygen on post-op
day #7. She has a follow-up with Pulmonary medicine after
discharge.
*
Otherwise, the patient's post-op course was uneventful. At the
time of discharge, she was evaluated by PT who recommended some
PT services at home. Otherwise, her pain was well controlled,
she was tolerating a regular diet and urinating without
difficulty.
*
Medications on Admission:
MEDS outpatient:
Nitrofurantoin
Cipro x 2 days
.
MEDS on transfer:
Levo
Vanco
Flagyl
colace
MOM
Maalox
Tylenol
Reglan prn
protonix
xanax 0.25 prn
dilaudid prn
mucomyst
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: 70mg Subcutaneous [**Hospital1 **]
(2 times a day) for 6 months: This dose may need to be
readjusted in case your weight changes over the next 6 months.
Disp:*QS * Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every [**3-24**]
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Likely ovarian cancer
Post-op wound infection
Pneumonia
Presumed pulmonary embolus
Discharge Condition:
Good
Discharge Instructions:
vomiting, worsening abdominal pain, difficulty with urinating,
vaginal bleeding, worsening shortness of breath or any other
worrisome symtom.
*
No driving while taking narcotics.
*
Nothing in your vagina for 4 weeks (this includes intercourse)
*
No heavy lifting for 4 weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 5777**] Date/Time: [**3-6**], 11:45, [**Hospital Ward Name 23**] [**Location (un) **].
*
The following appts are on [**Hospital Ward Name **] 7 (medical specialties)
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2141-3-16**] 1:10
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2141-3-16**] 1:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] /DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2141-3-16**] 1:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
Completed by:[**2141-3-3**]
ICD9 Codes: 5849, 486
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5252
}
|
Medical Text: Admission Date: [**2141-10-23**] Discharge Date: [**2141-10-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
left hemiarthroplasty
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year old Yiddish-speaking man with a h/o HTN
and atrial fibrillation who presents to the hospital s/p
witnessed mechanical fall onto his left side. The patient was
walking and is unsure as to why he fell. No h/o head trauma,
LOC, lightheadedness.
In the emergency department, vitals were T 97 BP 152/96 P 64 RR
18 O2sat 88%RA -> high 90s% 2LNC. The patient had hip/pelvis
xrays, which showed a fracture in the left femoral neck. CXR
showed mild pulmonary vasculature congestion. Pt received IV
zofran and IV morphine 4mg in the ED. Pt was evaluated by ortho
- will go to OR for hemiarthroplasty. He was admitted to the
medical service for further evaluation and management of
hypoxia.
On transfer to the floor, the vitals were T 99.7 BP 140/80 P
100 RR 22 O2sat 86%RA, 92% 4LNC. The patient currently has some
mild pain in his left hip, but no other complaints at this time.
No numbness or tingling in his LE. No SOB, CP, palpitations,
lightheadedness, fevers, chills, cough, nausea, vomiting,
constipation, diarrhea.
Past Medical History:
Atrial fibrillation - not on coumadin
HTN
OA
bursitis
s/p peds struck 25 years prior - multiple fractures in b/l UE
and LE
No h/o pulmonary problems or CHF
Social History:
Lives alone, able to perform all ADLs without assistance.
Previous tobacco user, quit 30 years ago. Minimal EtOH use - [**12-30**]
glass of wine every Friday. No illicit drug use
Family History:
No family h/o heart disease. Son died of colon ca.
Physical Exam:
VITAL SIGNS: T 98.8 BP 102/73 HR 97 RR 22 O2 89% 4LNC
GENERAL: Pleasant, well appearing elderly man, in NAD; AAOx2 -
not oriented to year, but is aware of month and current
president
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. EOMI. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: regular rate, tachycardic. S1, S2. No murmurs, rubs or
gallops.
LUNGS: b/l crackles, no wheezing
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: trace pitting edema b/l, 2+ dorsalis pedis/
posterior tibial pulses.
LLE: shortened, externally rotated, +distal pulses
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout - unable to asses
LLE [**1-30**] to pain. No pronator drift. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS [**2141-10-23**]:
BLOOD:
WBC-8.8 Hgb-13.7* Hct-38.7* Plt Ct-182
Neuts-84.5* Lymphs-11.8* Monos-2.3 Eos-1.0 Baso-0.5
PT-12.2 PTT-25.6 INR(PT)-1.0
Glucose-114* UreaN-26* Creat-1.0 Na-142 K-4.0 Cl-106 HCO3-25
AnGap-15
CK(CPK)-57
cTropnT-<0.01
proBNP-329
Calcium-9.4 Phos-2.7 Mg-2.2
Lactate-2.2*
CARDIAC [**Last Name (un) **]:
[**2141-10-23**] 08:00AM BLOOD CK(CPK)-57
[**2141-10-23**] 09:00PM BLOOD CK(CPK)-61
[**2141-10-24**] 03:00AM BLOOD CK(CPK)-77
[**2141-10-24**] 05:15PM BLOOD CK(CPK)-114
[**2141-10-25**] 03:49AM BLOOD CK(CPK)-166
[**2141-10-23**] 08:00AM BLOOD cTropnT-<0.01
[**2141-10-23**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2141-10-24**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2141-10-24**] 05:15PM BLOOD CK-MB-8 cTropnT-0.25*
[**2141-10-25**] 03:49AM BLOOD CK-MB-7 cTropnT-0.17*
LIPID PANEL:
Cholest138 Triglyc-107 HDL-45 CHOL/HD-3.1 LDLcalc-72
MICRO:
BCx: ***
IMAGING:
[**2141-10-23**]:
XR L HIP - Left femoral neck fracture
CXR - Findings compatible with mild pulmonary vascular
congestion. Please note there may be a component of underlying
interstitial lung disease. Clinical correlation is advised.
Follow-up films post-diuresis advised
CT LLE -
1. Impacted femoral neck fracture with external rotation of the
distal femoral shaft.
2. OA with chondrocalcinosis.
3. Diffuse calcified atherosclerotic disease.
4. Fat-containing inguinal hernia on the left.
5. Fatty atrophy of gluteus medius muscle.
CTA CHEST -
1. No pulmonary embolus. No aortic dissection.
2. Ground-glass opacification, bilateral effusions, smooth
septal thickening and reflux of contrast into the IVC consistent
with congestive heart failure.
3. Emphysema.
4. Nodule in the right upper lobe may represent asymmetirc
pulmonary edema, however follow-up after treatment is
recommended to ensure resolution and exclude an underlying mass.
5. Multilevel spinal degenerative changes.
6. Mediastinal and hilar adenpathy likely due to CHF, this will
be
reevaluated at the time of follow-up CT scan.
7. Secretions in the trachea raise the possible of aspiration.
[**2141-10-24**]:
CXR -
1. New left basal increase in left basal consolidation,
concerning for
aspiration given short-term interval change.
2. Background of emphysema and bilateral perihilar opacities,
worrisome for chronic aspiration. Improvement in the
interstitial edema. Right upper lobe nodular density as
described in the prior CT, followup to resolution remains
recommended.
[**2141-10-25**]:
ECHO - The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 10-20mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension
CXR - In comparison with the study of [**10-24**], there is continued
bibasilar
opacification consistent with atelectasis and effusion. The
possibility of supervening pneumonia must be considered. No
evidence of elevated pulmonary venous pressure persists.
Brief Hospital Course:
[**Age over 90 **] year old man with a history of atrial fibrillation not on
coumadin, HTN, who presented after a mechanical fall with a left
hip fracture. Hospital course by problem.
.
#.Left Hip Fracture: The patient had a fracture of his left
femoral neck. He was seen by orthopedics who recommended
hemi-arthroplasty once medically stable. His tachycardia and
dyspnea were treated and he went to the operating room on
hospital day #3. He tolerated the surgery well with
approximately 300ccs blood loss. He received fentanyl
post-operatively which made him hypotensive. Further pain
control was with Tylenol only. He was started on Calcium and
Vitamin D for prevention of future fractures. He was started on
Lovenox DVT prophylaxis which he should take for four weeks. He
should follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Dr.[**Name (NI) 8091**]
office. His hip has full weight-bearing capacity.
.
# Atrial fibrillation with RVR: The patient has known baseline
atrial fibrillation, rate controlled with metoprolol and
nifedipine, on just Aspirin at home. On hospital day #2 he
became tachycardic to the 130s in the setting of delirium and
agitation. His rate could not be controlled with extra doses of
PO and IV metoprolol and small fluid boluses. He was
transferred to the ICU because of difficulty managing him on the
floor nad persistent tachycardia. He was continued on his home
dose of metoprolol and started on a diltiazem drip. His heart
rate then improved along with his mental status. He is being
discharged on an increased dose of short-acting metoprolol but
can be transitioned back to metoprolol XL. He is being
discharged on short-acting diltiazem but can be transitioned to
longer-acting diltiazem.
.
# Altered mental status: The patient was alert and oriented
during the day but would become altered at night, pulling out
lines and becoming acutely agitated. On hospital day 2 he was
persistently agitated and tachycardic and had to be transferred
to the ICU. He responded partially to small doses of haldol.
He had to be restrained to keep him from removing all of his
lines. The next day his mental status improved post-operatively
and he is now alert and oriented at his baseline.
# Hypoxemia: The patient had persistent oxygen saturations in
the high 80s and low 90s requiring supplemental oxygen. There
was concern for pulmonary embolism but he had a negative CTA
chest. However, the CT scan of his chest showed pulmonary edema
and changes consistent with chronic aspiration. He was
initially covered for community-aquired PNA on the floor with
Azithromycine and Ceftriaxone based on concern on CXR today for
consolidation; however, he had no fevers or leukocytosis and
antibiotics were stopped. He was given no further fluids and
his hypoxia improved postoperatively. An echocardiogram was
essentially normal, showing just mild LVH and an LVEF>55%, but
his BNP was increased. His oxygenation improved with rate
control and not receiving further fluids, and he was satting 92%
on room air at discharge.
.
#.ARF: His creatinine increased to 1.6 on hospital day #2 from 1
on admission, BUN/Cr> 20 in the setting of receiving Lasix and
an IV contrast load. His creatinine improved to his baseline
with gentle hydration.
.
#.NSTEMI: Patient had elevated troponins, [**10-24**] 3am 0.17, [**10-24**]
5:15pm 0.25. This was most likely secondary to demand ischemia
as EKG showing no focal specific changes. His troponins trended
down prior to discharge.
Medications on Admission:
1. Procardia 30 mg PO daily, 2. Toprol XL 25 mg PO daily, 3. ASA
81 mg PO daily
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Primary diagnosis:
- hip fracture
.
Secondary diagnoses:
- atrial fibrillation with rapid ventricular response
- delirium
- congestive heart failure
Discharge Condition:
Stable. Improved tachycardia and stable hip pain.
Discharge Instructions:
You were admitted because you fell at home and fractured your
hip. You had surgery on you hip, and are now ready to go for
rehabilitation to get strong again. While you were here you
were temporarily confused and had fast heart rates. You are now
oriented again and your heart rate is being treated with
medications.
.
Changes were made to your medications:
- You were switched to short-acting metoprolol at a higher dose.
You now take 25mg every 8 hours. They can transition you back
to long-acting metoprolol at rehab.
- Your Procardia (nifedipine) was stopped.
- You were started on short-acting diltiazem, 30mg every 4
hours.
- You should take Tylenol 1000mg every 8 hours for pain control.
- You should take Lovenox every 12 hours for four weeks.
- You were started on Calcium and Vitamin D to make your bones
stronger.
- You can continue taking Aspirin every day.
.
Please call your doctor or return to the hospital if you have
chest pain, palpitations, difficulty breathing, fevers, chills
or severe pain.
Followup Instructions:
Please call the orthopedics clinic at [**Telephone/Fax (1) 1228**] to make an
appointment in 2 weeks after discharge with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
the nurse practitioner in Dr.[**Name (NI) 8091**] office.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2141-10-30**]
ICD9 Codes: 5849, 9971, 4280, 4019, 2875, 2859
|
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|
Medical Text: Admission Date: [**2142-5-2**] Discharge Date: [**2142-5-3**]
Date of Birth: [**2076-8-1**] Sex: M
Service: MEDICINE
Allergies:
vancomycin / Ace Inhibitors
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Leukocytosis
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
65 M w recent dx lymphoboplasmacytic lymphoma now in remission
s/p 4 cycles R-C-medrol [**2140**], who was recently hospitalized at
[**Hospital1 18**] ([**2142-3-7**] - [**2142-4-16**]) for a saccular aneurysm of the
lateral aspect of the aortic arch that was emergenctly
intervened upon under deep hypothermic circulatory arrest on
[**2142-3-11**] (descending aorta was replaced with 28 mm Gelweave
graft).
.
The patient had a prolonged and complicated hospital course. He
failed extubation on POD 2 and multiple times thereafter.
.
He had persistent leukocytosis, fevers, and diarrhea during
hospitalization and was empirically treated for C. Diff with a
10-day course of vancomycin & flagyl (despite 7 negative C. Diff
toxin tests).
.
His thoracotomy wound developed erythema and blistering and he
had an incision & drainage of [**2142-3-21**] (fluid culture returned
without growth). He becam septic on [**2142-4-8**] and, in addition
to persisent leukocytosis & fevers, he also became hypotensive
and required pressors. He was treated with broad spectrum
antibiotics per ID recommendations. He was found to have a graft
infection (noted on CT) requiring IR drainage on [**2142-4-8**]. All
OR swabs were without growth.
.
The patient had a tracheostomy & PEG tube placed on [**2142-4-1**] for
multile failed attempts at extubation.
.
Ultimately, his sputum was showed enterobacter; the patient was
started on meropenem. He was transferred to [**Hospital1 49145**] on [**2142-4-16**] on meropenem (course to end on [**2142-4-22**]).
.
On [**2142-4-24**], the patient presented to the [**Hospital3 **] from NESH
with hypoxic respiratory failure with hypotension & fever to
101.3. At that time, according to the OSH notes, he was still
on meropenem and this was initially continued. In he ED he was
found to have a PNA which was ultimately determined to be due to
Enterobacter resistant to all tested antibiotics except
tigecycline. He initially required ventilatory support, but
transitioned to trach mask on [**2142-4-30**]. He has since been
stable from a hemodynamic & respiratory standpoint.
.
A CT chest with contrast performed (& read) at OSH demonstrated
a 7 x 3.4 x 1.7 cm loculated pleural fluid collection at the
lateral posterior aspect of the L lung base.
.
Serial chest x-rays during his admission at [**Hospital3 **]
demonstrated development of a a R lower lobe PNA.
.
The patient has had an intermittent leukocytosis with bandemia
at the [**Hospital3 **]. A tagged WBC scan was performed on [**4-30**] in an
attempt to identify an infectious source. The scan demonstrated
increased update in the L chest adjacent to the aortic arch
which was suspicious for a periarotic infection. According to
notes, he has been afebrile for several days but developed WBC
12.3 with 13% bands [**Last Name (un) **]. As such, the patient is being
transfered to [**Hospital1 18**] for further evaluation and treatment.
.
REVIEW OF SYSTEMS: Unable to obtain.
Past Medical History:
- Descending Aortic Aneurysm s/p emergent repair
----> s/p replacement with 28 mm graft [**2142-3-11**]
----> c/b graft infection requiring IR draining [**2142-4-8**]
- Respiratory Failure
----> VAP (Enterobacter)
- Tracheostomy placement
- PEG placement
- Lymphoplasmacytic lymphoma (dx in [**4-7**]) - see onc history
below
- Hypertension
- Gout
- Anemia: B12 & iron deficiency
- Hx/o EtOH overuse
- Hx/o esophageal stricture
- Diverticulitis
- Inflammatory arthritis (on chronic prednisone)
- CVA
- GERD
- Laparoscopic cholecystectomy
- s/p vein stripping on left leg
ONCOLOGIC HISTORY:
- [**2140-3-7**] Initial consult. CT C-A-P unremarkable.
- [**2140-4-13**] Bone marrow: path = lymphoplasmacytic lymphoma
- [**2140-4-25**] Cycle #1 Rituxan-Cytoxan-Medrol 16mg qd
- [**2140-5-18**] Cycle #2 R-C-Medrol 16mg qd taper
- [**2140-6-6**] Cycle #3 R-C-Medrol 8mg [**Hospital1 **] ordered celebrex
- [**2140-7-4**] Cycle #4 R-C, medrol tapered off, MRI: meniscal
injury, bone infarct?
- [**2140-7-5**] Admitted [**Hospital1 18**] transfused for HCT 22% d/c [**7-7**]
- [**2140-7-12**] Admitted [**Hospital1 18**] severe pain, Rheum, Ortho evals, d/c
[**7-15**]
- [**2140-7-19**] Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 11422**] [**Location (un) 2274**] ortho, relief with R knee
steroid & lidocaine injection
- [**2140-7-25**] Heme Onc follow-up, Aranesp
- [**2140-7-28**] Flare of joint pain
- [**2140-8-28**] Medrol per Dr. [**Last Name (STitle) **]
- [**2140-9-20**] Joint pain back to baseline, IgM down to 862, plan to
continue steroids and IgM
- [**2141-3-9**] At baseline level of compensated health, IgM stable.
Followup in 6 months
- [**2141-6-7**] Worsening joint pain Dr. [**Last Name (STitle) **] [**Name (STitle) **] Rituximab
1000mg/m2
- [**2141-6-21**] Rituximab 1000mg/m2
- [**2141-7-20**] Start sulfasalazine 3g/d, cont medrol
- [**2141-9-7**] Hematology follow up: baseline level of malaise,
tapering medrol per Rheum
- [**2142-2-2**] Follow up IgM 500s, stable, stable anemia
Social History:
Prior to [**Hospital1 18**] hospitalization, he lived with his wife
- [**Name (NI) **] children
- Was most recently in rehab
- Contact = wife: [**Telephone/Fax (1) 96773**]
- Retired [**Company 2318**] inspector
- Tobacco: Quit smoking in [**2122**] (previously 2-3 packs/day x 30
years)
- EtOH: none in 2 years (-pack or more a last week)
Family History:
Father with EtOH abuse and liver cancer, hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
71 102/51 99% on 40% FM
GEN: Appears slightly agitated. Follows basic commands. Frail.
HEENT: PERRL. OP clear.
NECK: Trached.
PULM: Faint breath sounds throughout both lung fields,
diminished at bases. Intermittent transmission of upper
respiratory sounds
[**Last Name (un) **]: +NABS. PEG in place. Soft, NTND
EXT: Trace LE. No rashes.
GU: Excoriated rash on buttocks.
NEURO: Follows basic commands. MAEE.
DISCHARGE PHYSICAL EXAM:
Unchanged.
Pertinent Results:
ADMISSION LABS:
[**2142-5-2**] 04:15PM BLOOD WBC-9.8 RBC-3.89* Hgb-11.8* Hct-38.4*
MCV-99*# MCH-30.5 MCHC-30.9* RDW-14.4 Plt Ct-192
[**2142-5-2**] 04:15PM BLOOD Neuts-79* Bands-0 Lymphs-11* Monos-7
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2142-5-2**] 04:50PM BLOOD ALT-22 AST-17 CK(CPK)-29* AlkPhos-122
TotBili-1.0
DISCHARGE LABS:
[**2142-5-3**] 05:20AM BLOOD WBC-7.3 RBC-3.63* Hgb-10.8* Hct-34.0*
MCV-94 MCH-29.9 MCHC-31.9 RDW-14.5 Plt Ct-196
[**2142-5-3**] 05:20AM BLOOD Plt Ct-196
[**2142-5-3**] 05:20AM BLOOD Glucose-99 UreaN-30* Creat-0.4* Na-142
K-4.1 Cl-111* HCO3-23 AnGap-12
[**2142-5-3**] 05:20AM BLOOD Albumin-2.6* Calcium-9.0 Phos-3.7 Mg-1.7
IMAGING STUDIES:
LEFT LATERAL DECUB FILM: ([**2142-5-2**])
FINDINGS: As compared to the previous radiograph, a left lateral
decubitus
view has been added. The likelihood of a left pleural effusion
is low. No
PICC line is seen on the radiograph. Tracheostomy tube in
unchanged position.
Brief Hospital Course:
65 M with recent complicated hospitalization at [**Hospital1 18**] for
emergent aortic surgery for a saccular aneurysm which was
complicated by graft infection requiring IR drainage on
[**2142-4-8**], enterobacter VAP now represents after initial
hospitalization at OSH for ongoing enterobacter pneumonia &
respiratory failure.
# Chronic Respiratory Failure: The patient is now s/p
tracheostomy on [**2142-4-1**] for multiple failed extubation
attempts. He has been requiring 40% FiO2 by trach mask. His
most recent CT scan shows evidence of bronchiectasis. The
patient's respiratory failure was recently complicated by
enterobacter PNA now s/p 7-day course of tigecycline. He will
continue supplemental oxygen via trach mask on discharge; he
will likely having an ongoing oxygen requirement.
# Leukocytosis: The patient was transferred from [**Hospital3 **] for
leukocytosis 12.3 with 13% bandemia. There was no evidence of
leukocytosis during his short hospitalization. The patient
remained afebrile without signs of systemic infection. There
was some concern for a L-sided loculated effusion on OSH CT
scan, but on review of these scans (compared to prior) these
changes appear to be chronic. As such, there was low suspicion
for empyema. Furthermore, the effusion was thought to be too
small to be amenable to thoracentesis. Given the patient's
ongoing diarrhea which has been unremitting since his initially
hospitalizaton for cardiac surgery as well as his exposure to
multiple antibiotics, it was felt that a C. Diff PCR should be
sent. This test was pending at the time of discharge. Given
the patient's lack of abdominal pain, fever, & leukocytosis
suspicion for C. Diff infection remained low. This patient's
care was discussed with his CT surgery & ID team.
# Hypernatremia: Admission sodium 146. Free water deficit 1.5
liters, which was repleted with D5W. Sodium corrected to 142.
CHRONIC DIAGNOSES:
# Hypertension: Pt's BP on presentation was in the low 100s. As
such his metoprolol, hydralazine and isosorbide were held during
hospitalization. These medications should be restarted at rehab
after evaluation by a physician.
# Anemia: Hematocrit stable 34-38. The patient takes B12
injections monthly.
# Diverticulosis: Continue bowel regimen.
# GERD: Continue pepcid 20 mg daily.
# Gout: Continue allopurinol.
# Nutrition: The patient was discharged on the tube feed
schedule he received at [**Hospital1 700**]. He should
be evaluated by nutrition at rehab.
TRANSITIONAL ISSUES:
# Pending Labs: C. Diff PCR.
# Code Status: The patient is a DNR. Since he has a trach, it
would be acceptable for him to be ventilated.
Medications on Admission:
- Tigecycline (completed on [**2141-5-1**])
- Lopressor 100 mg [**Hospital1 **]
- Hydralazine 10 mg TID
- Pepcid 20 mg QD
- RISS
- 300 cc free water for tube feds Q4H
- Allopurinol 200 mg QD
- Isosorbide dinitrate 20 mg TID
- Dilaudid 0.5 mg IV Q2H PRN pain
- Zyprexa 5 mg QHS
- Albuterol nebs Q2H PRN
- Tylenol 650 mg Q4H PRN
- Heparin 5000 units SC Q8H
- Celexa 20 mg QD
- Miconazole powder topically
- Ativan 2 mg IV Q2H PRN agitation
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q2H PRN as needed for
SOB, wheeze.
2. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. allopurinol 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
4. citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) application
Topical [**Hospital1 **] : to buttocks rash.
7. Lopressor 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day:
This medication should not be restarted until the patient can be
evaluated by a rehab physician.
8. isosorbide dinitrate 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO
three times a day: This patient should not be restarted at rehab
until the patient is evaluated by a physician.
9. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution [**Hospital1 **]: One
(1) injection Injection once a month.
10. insulin regular human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED).
11. hydralazine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times
a day: This medication should not be restarted until the patient
is evaluated by a rehab physician. .
12. Free flushes
Purified water 300 mL q$H
13. tube feeds
Isosource 1.5 Cal Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 60
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 250 ml water q4h
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Recent aortic aneurysm repair
SECONDARY DIAGNOSES:
- Enterobacter Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname **], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to [**Hospital1 18**] from an outside hospital
due to concern that you had a recurrent infection in near the
site of your aortic graft. While you were here, we reviewed the
films from the outside hospital and determined that you did not
have evidence of an infection. We felt that it was safe for you
to return to your rehab facility.
MEDICATION INSTRUCTIONS:
- MEDICATIONS ADDED: None.
- MEDICATIONS STOPPED:
---> We stopped your zyprexa 5 mg at night because we did not
feel you required this medication at night.
- MEDICATIONS CHANGED:
---> We did not administer your lopressor, hydralazine, or
isosorbide during your hospitalization. These medications may
need to be restarted while you are at rehab, but you should be
evaluated by a physician [**Name Initial (PRE) **].
Followup Instructions:
Department: CARDIAC SURGERY
When: TUESDAY [**2142-5-8**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2142-5-4**]
ICD9 Codes: 2760, 4019, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5254
}
|
Medical Text: Admission Date: [**2159-10-10**] Discharge Date: [**2159-10-14**]
Date of Birth: [**2098-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic with known aortic stenosis and aortic aneurysm
Major Surgical or Invasive Procedure:
1. Bentall procedure with a 27-mm [**Company 1543**] Freestyle
prosthesis with coronary button reimplantation.
2. Replacement of ascending aorta and hemiarch with a 28-mm
Dacron tube graft using deep hypothermic circulatory
arrest.
History of Present Illness:
60 year old gentleman with a known aortic aneurysm which was
originally discovered in [**2154**]. Since then he has been followed
by
serial echocardiograms or MRA's of his aorta with his most
recent
MRA showing his ascending aorta to be 5.6cm.
Cardiac Catheterization: Date:[**2159-9-13**] Place:[**Hospital1 18**]:
Right dominant system
LM:normal
LAD:normal
LCx:normal
RCA: normal
Supravalvular Angio: 3+AR, marked enlargement ofaortic root and
asc ao
Cardiac Echocardiogram: *[**2158-9-26**]*
[**Doctor Last Name **], LVEF>60%, trileaflet AV, 1+ AI, trivial TR/MR, aorta sinus
4.9cm, ascending aorta 5.2cm
Echo [**2159-7-31**]: LVEF 55%, 2+AI, trivial MR/TR, sinus 4.1, asc. 5.6
Chest MRA: [**2159-6-13**]
Ascending thoracic aortic aneurysm measuring 5.6 x 5.2 cm.
Past Medical History:
Past Medical History:
Aortic root aneurysm
Hypertension
Hypercholesterolemia
Varicose veins
Thrombophlebitis
Sleep apnea
Allergic rhinitis
Disk herniation
Past Surgical History:
[**2157-7-15**] - Radiofrequency ablation of the right greater saphenous
vein
s/p Tonsillectomy
s/p Basal cell resection from face
s/p cyst removal right arm
Social History:
Race: Caucasian
Last Dental Exam: Severak months ago
Lives with: Wife
Occupation: [**First Name8 (NamePattern2) **] [**Last Name (un) 7295**] Police officer
Tobacco: very distant use (teenager). none currently
ETOH: several beers/day
Family History:
Family History: Mother deceased, breast CA. Father deceased,
throat Cancer. Both with hypertension. Son/bicuspid aortic
valve.
Physical Exam:
Physical Exam:
Pulse:79 Resp:16 O2 sat:99%RA
B/P Right:164/76 Left:177/83
Height: 6'1.5" Weight: 245 lb
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 II/VI diastolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema +1
Varicosities: +1
Neuro: Grossly intact
Pulses:
Femoral Right: dressing Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2159-10-10**] 10:10PM TYPE-ART PO2-112* PCO2-51* PH-7.41 TOTAL
CO2-33* BASE XS-6
[**2159-10-10**] 10:10PM GLUCOSE-134*
[**2159-10-10**] 10:10PM O2 SAT-98
[**2159-10-10**] 10:08PM SODIUM-140 POTASSIUM-4.3 CHLORIDE-109*
[**2159-10-10**] 10:08PM HCT-24.5*
[**2159-10-10**] 04:53PM UREA N-10 CREAT-0.7 SODIUM-144 POTASSIUM-3.6
CHLORIDE-110* TOTAL CO2-27 ANION GAP-11
Brief Hospital Course:
Mr. [**Known lastname 13195**] is a 60 yr old male admitted with Ascending aortic
aneurysm, Proximal aortic arch aneurysm, Aortic insufficiency of
[**4-5**]+ and taken to the operating room for Bentall procedure with
a 27-mm [**Company 1543**] Freestyle prosthesis with coronary button
reimplantation and Replacement of ascending aorta and hemiarch
with a 28-mm
Dacron tube graft using deep hypothermic circulatory arrest. See
operative note for details. Admitted to the CVICU on propofol
and Apaced due to underlying rhythm of sinus brday with a rate
of 40's. He awoke neuologically intact and was weaned from the
ventilator and extubated without incident. His intrinsic rate
recovered and he was started on betablocker. His statin therapy
was resumed and he was gently diuresed toward his pre-operative
weight. He was transferred from the ICU on POD#2. His chest
tubes and temporary pacing wires were removed per protocol. Mr.
[**Known lastname 13195**] has known sleep apnea and while in hopsital was on
continuous oxygen saturation monitoring with oxygen saturations
as low at 85% while sleeping. He was sent home on 2 liters of
oxygen for noctural use. He was evaluated by physical therapy
for strength and conditioning and was cleared for discharge to
home with noctoural oxygen and VNA services on POD#5 by Dr.
[**Last Name (STitle) 914**]. Discharge instructions and follow up appointmnents were
advised.
Medications on Admission:
Medications at home:
Alprazolam 0.25mg prn
Flonase 50mcg spray - 2sprays/nostril per day
Procardia XL 90mg daily
Accupril 20mg daily
Simvastatin 20mg daily
Aspirin 81mg daily
Loratadine 10mg po daily
Compression Stockings daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily ().
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
11. Oxygen
2 liters oxygen by nasal cannula for noctornal use.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic root aneurysm- [**2159-10-10**] Asc aortic root replacement/AVR
(#27mm)
HTN, hypercholesterol, varicose veins, thrombophlebitis, sleep
apnea, disk herniation, radiofrequency ablation of the right
greater saphenous, Tonsillectomy, Basal cell CA, cyst removal
right arm.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Trace LE Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr[**Name (NI) 9379**] office will contact you for a follow up
appointment.
Cardiologist: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2159-10-23**] 1:00
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 4775**] in [**5-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2159-10-14**]
ICD9 Codes: 4241, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5255
}
|
Medical Text: Admission Date: [**2181-1-8**] Discharge Date: [**2181-1-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Fatigue and unsteadiness
Major Surgical or Invasive Procedure:
[**2181-1-11**] L craniotomy and subdural evacuation.
History of Present Illness:
89M R hand dominant male on coumadin for afib who fell [**10-12**]
hitting R side of head with +LOC and amnesia. Had neg. CT at
that time for bleed. Since then has had increased fatigue which
has worsened significantly worsened over the past 2-3 weeks.
Recently more unsteady and has started using walker. Also c/o
intermittent mild HA over last 2-3 days. No recent falls or
trauma. Has MRI as outpatient which showed 16cmx3.5cmx8cm L
frontoparietal SDH. Tx to [**Hospital1 18**] for care. Denies N/V/D/F/C,
changes in vision, hearing, saddle anesthesia, urinary
retention,
or bowel incontinence.
Past Medical History:
A-fib, HTN, BPH, Venous insufficiency, Mitral valve
valvuloplasty, pulmonary HTN, Raynaud's syndrome
Social History:
Lives with wife in [**Name (NI) **]. Retired. Never smoked. 1 glass of
wine daily.
Family History:
Both sons with AF
Sister with PPM/AF
Physical Exam:
On admission
O: T: 97.3 BP:154/105 HR: 18 R 18 O2Sats 96RA
Gen: comfortable, NAD.
HEENT: Pupils: 4->2 B EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Irregularly irregular rhythm, reg rate, no murmurs.
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 or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength diminished to [**3-10**] on RUE. Other wise strength
full power [**4-9**] on LUE, LLE, and RLE. No pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+, 2+
Left 2+, 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
Pertinent Results:
[**2181-1-8**] - CT: Shows L SDH 26mm in its greatest width with mild
3mm
subfalcine herniation
Labs: hct 47, Plt 215, PTT 27.2, INR 1.9, Chem wnl with Cr 1.0
EKG: Atrial fibrillation, TW inversino III, no ST elevation
.
[**2181-1-10**] - Duplex: Minimal plaque with bilateral less than 40%
carotid stenosis.
.
[**2181-1-11**] Pathology - Blood and fibrin, consistent with hematoma.
(OR specimen)
.
[**2181-1-12**] Interval resorption of subdural hemorrhage and
pneumocephalus with increase in soft tissue swelling at
craniectomy site.
.
[**2181-1-14**] CT chest 1. Bilateral pleural effusions with parenchymal
opacities most compatible with compressive atelectasis. No
findings worrisome for pneumonia. 2. Lobulated contour of the
liver, perhaps of little clinical significance, although the
appearance may be due to hepatic congestion in the setting of
right heart failure. Consideration of ultrasound investigation
is recommended if there is concern for hepatic dysfunction. 3.
Marked pancreatic atrophy. 4. Status post sternotomy, mitral
valve repair, apparently CABG, and again with very large right
atrium. 5. Sludge and/or stones in the gallbladder, but no
gallbladder distension.
.
[**1-15**] EEG EEG Study Date of [**2181-1-15**]
ABNORMALITY #1: Throughout the recording, there was loss of
faster
frequencies over the left side. There were no associated
epileptiform
discharges.
ABNORMALITY #2: Throughout the recording, the background was
disorganized, slow, typically in the [**5-12**] Hz frequency range, and
admixed
with frequent bursts of prolonged moderate amplitude generalized
mixed
theta and delta frequency slowing.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as this was a portable
study.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: No normal waking or sleeping morphologies were noted.
CARDIAC MONITOR: Showed an irregularly irregular rhythm with an
average
rate of 90 bpm.
IMPRESSION: This is an abnormal portable EEG due to loss of
faster
frequencies over the left side, which could suggest underlying
cortical
and subcortical dysfunction but could also be related to
presence of
material interposed between the cortex and skull (e.g. subdural
hemorrhage). In addition, the background was disorganized, slow,
and
interrupted by frequent bursts of generalized mixed theta and
delta
frequency slowing consistent with a mild encephalopathy which
suggests
dysfunction of bilateral subcortical or deep midline structures.
Medications, metabolic disturbances, and infection are among the
common
causes of encephalopathy. There were no epileptiform discharges
noted.
No electrographic seizure activity was noted.
.
[**2181-1-16**] CT Head Since [**2181-1-14**], increase in size of mixed density
left subdural hematoma, now with a maximal thickness of 2.1 cm.
No significant change in the minimal left to right shift of
normally midline structures. Reviewed with Dr. [**Last Name (STitle) 739**] who
thought CT essentially stable.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2181-1-18**] 3:36 PM
FINDINGS: No DVT was demonstrated in either the right or left
leg.
.
[**1-17**] NON-CONTRAST HEAD CT: No significant change compared to
one day prior. Again seen is a mixed density extra-axial fluid
collection extending along the left cerebral convexity measuring
up to 12 mm in greatest diameter with mass effect and sulcal
effacement on the subjacent cortex. Scattered foci of
pneumocephalus are also unchanged. The ventricles are stable in
size and configuration. There is stable mild subfalcine
herniation and 3 mm of rightward midline shift. Periventricular
hypoattenuation is consistent with chronic microvascular
ischemic disease. Bilateral basal ganglia calcification is
noted. Osseous structures are significant for a left
frontoparietal craniotomy. Left subgaleal fluid collection has
increased in size measuring up to 13 mm, previously up to 10 mm.
Bilateral scleral bands noted. NG tube is in the right nostril.
IMPRESSION:
1. No significant change in left mixed density subdural
hematoma.
2. Increasing left subgaleal hematoma.
.
[**1-18**] [**Last Name (un) **] DUP EXTEXT BIL FINDINGS: No DVT was demonstrated in
either the right or left leg.
.
[**2181-1-21**] Portable CXR: Moderate cardiomegaly is stable. Bilateral
pleural effusions moderate in size, greater on the right side,
are grossly unchanged allowing the difference in position of the
patient. Bibasilar atelectasis are present. NG tube tip is in
the stomach. There is no pneumothorax. Patient is post median
sternotomy. There has been improvement with almost complete
resolution of mild CHF.
.
[**2181-1-22**] NON-CONTRAST CT HEAD: There is slightly larger mixed
density extra-axial fluid collection extending along the left
cerebral convexity measuring up to 2.4 cm in greatest diameter
with mass effect and sulcal effacement on the subadjacent
cortex. Scattered foci of pneumocephalus are unchanged since
[**2181-1-17**]. There is a stable mild subfalcine herniation of 4 mm
and slight rightward midline shift. Periventricular
hypoattenuation consistent with chronic microvascular ischemic
disease is unchanged since [**2181-1-17**]. Bilateral basal ganglia
calcification is unchanged since [**2181-1-17**]. A left frontoparietal
craniotomy is unchanged since [**2181-1-17**]. The left subgaleal fluid
collection measures 12 mm, previously 13 mm, grossly unchanged.
The visualized paranasal sinuses and mastoid air cells are
unremarkable.IMPRESSION:
1. Slight increased size of left mixed density subdural
hematoma.
2. Stable left subgaleal hematoma.
3. No significant change in minimal left to right shift of
midline structures.
.
[**2181-1-22**] CTA Chest- 1. Slightly limited study by motion artifact,
particularly vessels in the right lower lobe. No evidence of
central or segmental pulmonary embolism. Apparent filling defect
within a left lower lobe subsegmental branch raises question of
a single subsegmental pulmonary embolus, but diagnosis is not
confident because of artifact through this area. If clinically
indicated, repeat study could be helpful for further evaluation.
2. 3.7 cm ovoid density seen at the posterior wall of the left
atrium, thrombus or mass such as myxoma. Further evaluation with
cardiac MRI without and with contrast is recommended.
3. Persistent bilateral pleural effusion with associated
compressive atelectasis.
.
[**2181-1-23**] NON-CONTRAST HEAD CT:
IMPRESSION: Exam is slightly limited by motion; however, there
is no interval change in regards to the mixed density left
subdural hematoma causing minimal midline shift. No new focus of
hemorrhage is identified.
.
[**2181-1-25**] The left atrium is elongated. A possible mass is seen in
the body of the left atrium along the posterolateral wall at the
mitral annulus at the ostium of the residual left atrial
appendage. The right atrium is markedly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Overall left ventricular systolic
function is normal (LVEF 60%). Diastolic function could not be
assessed. There is no ventricular septal defect. The right
ventricular cavity is markedly dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate ([**12-6**]+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. A mitral valve annuloplasty ring is present. Mild
(1+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. The tricuspid valve leaflets are
mildly thickened. Severe [4+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2180-10-24**], a left atrial mass is now seen. Consider
transesophageal echocardiography for better visualization of the
mass.
.
MICROBIOLOGY
[**2181-1-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2181-1-24**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
[**2181-1-24**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
[**2181-1-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2181-1-24**] URINE URINE CULTURE-FINAL NEG
[**2181-1-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2181-1-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2181-1-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
NEG
[**2181-1-17**] URINE URINE CULTURE-FINAL NEG
[**2181-1-17**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
[**2181-1-15**] URINE URINE CULTURE-FINAL NEG
[**2181-1-15**] MRSA SCREEN MRSA SCREEN-FINAL NEG
[**2181-1-15**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL NEG
[**2181-1-15**] MRSA SCREEN MRSA SCREEN-FINAL NEG
[**2181-1-15**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
NEG
[**2181-1-10**] URINE URINE CULTURE-FINAL NEG
.
LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2181-1-31**] 05:50AM 8.6 4.74 15.3 48.0 101* 32.2* 31.8 15.2
253
[**2181-1-30**] 10:00AM 9.4 4.06* 13.2* 40.7 100* 32.5* 32.4 14.4
341
[**2181-1-29**] 05:53AM 10.7 4.02* 12.9* 39.9* 99* 32.0 32.3 14.5
412
Source: Line-PICC
[**2181-1-28**] 04:54AM 9.1 3.40* 11.9* 34.0* 100* 34.9* 35.0
14.7 356
Source: Line-PICC
[**2181-1-27**] 05:26AM 12.5* 3.75* 12.4* 36.5* 97 33.2* 34.1
14.9 493*
ADD ON
[**2181-1-26**] 04:45AM 10.5 3.76* 12.4* 36.3* 97 33.1* 34.2 14.8
432
Source: Line-PICC
[**2181-1-25**] 10:31AM 11.4* 4.08* 13.1* 39.1* 96 32.1* 33.5
14.8 446*
Source: Line-picc
[**2181-1-25**] 05:20AM 11.7* 3.91* 12.9* 38.0* 97 33.1* 34.1
14.9 436
Source: Line-PICC
[**2181-1-24**] 05:45AM 16.9* 4.59* 15.2 45.9 100* 33.2* 33.2
14.0 425
DIFF ADDED 12:07PM
[**2181-1-22**] 05:50AM 12.8* 4.07* 13.3* 40.2 99* 32.6* 33.0
14.5 316
[**2181-1-21**] 02:04PM 12.7* 4.21* 13.9* 42.0 100* 32.9* 33.0
14.8 264
[**2181-1-20**] 06:42AM 11.1* 3.97* 12.9* 39.5* 100* 32.4* 32.6
14.4 204
Source: Line-picc
[**2181-1-19**] 05:18AM 12.9* 4.11* 13.5* 40.0 97 32.9* 33.9 15.0
186
Source: Line-picc
[**2181-1-18**] 02:58AM 17.7* 4.46* 14.4 43.6 98 32.2* 33.0 14.3
142*
Source: Line-ALine
[**2181-1-17**] 09:54PM 20.5* 4.62 15.4 44.4 96 33.3* 34.6 15.0
185
Source: Line-ALine
[**2181-1-17**] 04:56AM 14.0* 4.57* 14.9 45.1 99* 32.5* 32.9 14.1
142*
Source: Line-rt/picc
[**2181-1-16**] 04:01PM 14.3* 4.46* 14.5 44.2 99* 32.5* 32.7 14.5
139*
Source: Line-PICC
[**2181-1-15**] 02:42AM 13.1* 4.40* 14.3 44.5 101* 32.5* 32.2
14.0 145*
[**2181-1-14**] 02:36AM 10.1 4.21* 13.5* 41.9 100* 32.1* 32.3
14.0 157
[**2181-1-13**] 04:25AM 8.9 4.24* 13.6* 42.1 99* 32.1* 32.2 14.0
147*
[**2181-1-12**] 05:55AM 10.6 4.11* 13.7* 40.6 99* 33.3* 33.7 14.1
162
[**2181-1-12**] 02:38AM 11.6* 4.23* 14.2 43.2 102* 33.7* 33.0
14.4 179
[**2181-1-11**] 02:01AM 10.0 4.57* 14.7 46.0 101* 32.1* 32.0 14.0
173
[**2181-1-10**] 01:16PM 12.9*# 4.32* 13.9* 43.4 100* 32.1* 31.9
14.4 165
[**2181-1-9**] 03:34AM 7.9 4.47* 15.1 45.0 101* 33.8* 33.5 14.3
186
[**2181-1-8**] 02:15PM 7.6 4.71 15.3 46.5 99* 32.6* 33.0 13.9
215
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2181-1-27**] 05:26AM 85* 1 11* 2 1 0 0 0 0
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2181-1-31**] 05:50AM 120* 20 0.9 146* 3.81 107 27
CPK ISOENZYMES CK CK-MB cTropnT
[**2181-1-17**] 04:59PM 68 NotDone1 0.05*2
[**2181-1-17**] 04:56AM 128 3 0.05*1
.
LACTATE
[**2181-1-17**] 05:48PM 1.9
[**2181-1-17**] 05:48AM 1.5
Brief Hospital Course:
89 year old gentleman with history of afib on coumadin,
presented with SDH status-post evacuation, complicated by
hospital acquired pneumonia, CHF exacerbation, new atrial
thrombus/mass on CTA and delirium.
.
#. Subdural hematoma: The patient was admitted to the ICU for
VitK and FFP to keep INR <1.4, with q1 hour neurochecks, and
blood pressure control to <140 systolic. Was taken to the OR
[**1-11**] for L craniotomy and subdural evacuation and tolerated the
procedure well. He returned to the ICU and INR was monitored.
He had episodes of confusion and globally depressed neuro
function. Repeat CT's were negative for hydrocephalus, rebleed,
or increased shift. He was transferred to the stepdown unit and
slowly his neuro exam improved. He was started on keppra to
decrease risk of seizure. Repeat CT head slight worsening but
stable. He has follow up with neurosurgery in one month at which
time he will have a repeat Head CT and neurosurgery can decide
if patient is safe to anticoagulate.
.
#. Delirium: Likely multifactorial, primarily related to his
SDH. AAO x 2. Patient has a waxing and [**Doctor Last Name 688**] mental status.
Initially required 1:1 sitter as he would repeatedly attempt to
get out of bed at night. He responded to zyprexa which was given
qhs with an occasional extra dose prn. During the day, mental
status woud improve but still fluctuate. Needs frequent
reorientation. The patient should see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to
assist with his behavioral issues when he is at rehab.
.
# L atrial mass: A L atrial mass was noted on a CTA that was
obtained in order to work up tachypnea. This is likely a
thrombus as the patient has atrial fibrillation and has not been
anticoagulated during this hospitalization. He underwent a TTE
for further evaluation but this study was unable to distinguish
thrombus vs myxoma. Neurosurgery requested a cardiac MRI.
However the family was reluctant to agree as they felt patient
would not be able to tolerate the study. The patient was
delirious and would not be able to lie still for a long period
of time. Because the team was unable to confirm presence of
thrombus and because a repeat CT head showed slight increase in
size of subdural hematoma, the patient was not started on
anticoagulation. He was started on daily aspirin.
.
#. Aspiration risk: The patient was able to pass speech and
swallow once his mental status was improved, but the patient was
at high risk for aspiration and required 1:1 feeding. See below
for dietary recommendations.
.
#. Congestive heart failure: Acute on chronic right-sided
systolic and left-sided diastolic heart hailure. The patient is
known to have moderate pulmonary hypertension, RV free wall
hypokinesis. Weights and I/Os were monitored. Patient was
diuresed with improvement in respiratory status. However this
was intially difficult to balance, given that the patient took
in minimal PO intake and at times would require IV fluids as he
was hypovolemic. Over the last 3 days of admission he has
remained euvolemic. 40mg IV lasix can be given prn volume
overload.
.
#. Leukocytosis: The patient developed leukocytosis and
tachypnea and there was concern for hospital acquired pneumonia.
He completed an 8 day course of vancomycin and zosyn with
improvement in his white blood cell count. Cultures remained
negative.
.
#. Atrial fibrillation: The patient remained in atrial
fibrillation with rate ranging 50-100. He was not anticoagulated
given his SDH. He was started on aspirin. He was continued on
lopressor for rate control.
.
#. Hypertension: Continued metoprolol. BPs on day of discharge
ranged from 108-137/62-92.
.
#. BPH: Patient falled voiding trial and has foley in place.
#. Hyperglycemia: On admission, patient was hyperglycemic. FS
were monitored and improved. He was not started on hypoglycemics
and ISS was discontinued.
.
#. FEN: ground foods, nectar thick liquids;.
.
#. Access: PICC line was placed for access.
.
#. Code: DNR/DNI, confirmed w/ wife; Family requested no
pressors or central lines if patient were to decompensate.
.
#. Communication: Wife [**Name (NI) 794**] [**Name (NI) **]. [**Telephone/Fax (1) 32417**]
.
Medications on Admission:
Lasix 40'', metoprolol 50'',
Coumadin 2', Ranitidine 150'', Cyclobenzaprine 5', Clotrimazole,
Mupirocin, Triamcinilone
Discharge Medications:
1. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2
times a day).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
5. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Five (5) Tablet PO Q 8H
(Every 8 Hours): hold for SBP<90 or HR<60.
8. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
9. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: 0.25 Tablet PO TID (3 times a
day): hold for SBP<100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Subdural hematoma, hospital acquired pneumonia
Secondary: Atrial fibrillation, hypertension
Discharge Condition:
Vital signs stable, oriented to self and date.
Discharge Instructions:
You were admitted to the hospital because you fell and developed
bleeding into your skull which required surgery. You also
developed a pneumonia which required a stay in the intensive
care unit. Lastly you were noted to have an abnormal finding on
CT scan of your heart. This would require further evaluation.
Per discussions with family, it was felt you would benefit from
not undergoing those studies.
.
.
Do not start coumadin until you are seen by Neurosurgery.
.
Please follow up with Neurosurgery in one month. YOu will need a
repeat Head CT scan to evaluate interval improvement.
.
Please have patient seen by Neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to
assist with behavior issues.
.
Please call your doctor or return to the emergency room if you
develop any worrisome symptoms such as bleeding,
lightheadedness, dizziness, passing out, weakness, change in
behavior, severe headache, etc.
Followup Instructions:
Please have patient seen by Neurology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to
assist with behavior issues.
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2181-2-21**] 11:45
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2181-2-21**] 1:00 ( Neurosurgery)
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2181-6-5**] 1:40
Completed by:[**2181-1-31**]
ICD9 Codes: 2930, 5070, 2761, 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5256
}
|
Medical Text: Admission Date: [**2122-4-25**] Discharge Date: [**2122-4-28**]
Date of Birth: [**2050-9-11**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Lopid
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
71 M with hx CAD and hyperlipidemia was admitted to [**Hospital 107367**]
Hospital for TURP [**4-24**] (day of admission to CCU). ASA was held
for sx which proceeded uneventfully. Postop, he developed CP
and neck pain. ECG was obtained demonstrating SR in the 70s and
5mm inferior ST elevation; pt was given ASA, nitrates, IV
heparin and xferred to [**Hospital1 18**].
.
In the cardiac cath lab, the SVG graft to RCA was down w/biliary
stent visualized. The lesion was felt to be high risk for
intervention and was thus not intervened upon. LCx was
occluded. FIC CO was 7.48.
Past Medical History:
CAD- several right coronary angioplasties in mid [**2096**]. Single
vessel bypass to RCA. Biliary stent to RCA bypass in [**2112**] c/b
MI. Report of LV dysfunction following cath; specific EF not
known.
Prostate hypertrophy s/p TuRP
Multiple urinary infections
Ulcerative colitis
Kidney stones
Arthritis
Colonic polyps
Social History:
Former smoker; quit mid [**2119**]. No excess EtOH. Wife passed away
in recent months.
Family History:
nc
Physical Exam:
81 89/54 20
Lying in bed s/p cath in NAD
PERRLA, MMM, no carotid bruits
CTAB
Nl S1/S
Soft, NT, ND, +BS
Ext warm X 4 w/+DP bil
A&O X 3; moving all 4 ext
Pertinent Results:
138 103 12
101
4.5 28 1.2
...............
15 300
35.5
.
Cath: Graft to RCA w/large biliary stent not patent. CO by Fick
7.48.
Brief Hospital Course:
A/P: 71 M with hx CAD and hyperlipidemia admitted with inferior
MI s/p TURP.
.
IMI: RCA lesion felt to not be ammenable to cath. Medical
management of AMI to consist of ASA 325 daily, Lipitor 80mg
daily, metoprolol 25mg [**Hospital1 **]. Patient was restarted on Toprol XL
at outpatient dose of 50mg QD prior to discharge. He was also
started on cozaar25mg daily. He is to continue the regimen on
discharge. His cardiac enzymes trended down by time of discharge
- 132 on d/c with peak of 1688 on [**2122-3-25**]. He was walking the
floor without chest pain/sob. TTE on [**4-27**] revealed 20%EF and:
1. The left atrium is mildly dilated.
2. The left ventricular cavity is moderately dilated. There is
severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is
severely depressed.
3. The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
4. The aortic valve leaflets are mildly thickened.
5. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**11-23**]+)
mitral regurgitation is seen.
EF severely depressed - out of proportion to damage likely to
occur from his acute event. The etiology of this is likely
ischemia vs HTN. Recommend nuclear stress test or other study
(ie cardiac MR) in future to assess viability of cardiac tissue.
Repeat TTE 1 month to consider ICD placement. F/u with
outpatient cardiologist within 2 weeks.
Plan for outpatient cardiac rehab.
.
S/P TURP- Patient was seen by urology during admission. CBI was
continued until early am of [**2122-4-28**]. Foley then d/c'ed and
patient had no difficulty with urination thereafter. Denied
dysuria. On day of d/c, he was day [**1-26**] of cipro with plans to be
placed back on bactrim ppx after cipro course complete.
.
FEN- Cardiac/HH diet.
.
Medications on Admission:
Cardizem CD 180mg QD, Toprol XL 50mg, lipitor 10mg QD, prilosec
20 QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain: Please take one
tablet if you develop chest pain. [**Month (only) 116**] repeat up to 2 more times
every 5 minutes if pain not resolved. Call you PCP if you
require this medication.
Disp:*15 tablets* Refills:*0*
8. Bactrim Oral
9. bactrim
Please continue your outpatient bactrim doses once you have
completed the course of ciprofloxacin.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Inferior MI s/p TURP
2. Hematuria s/p TURP
Secondary Diagnosis:
1. CAD s/p CABG (SVG-RCA) [**2101**]
2. Prostate Hypertrophy s/p TURP
3. ulcerative colitis
4. kidney stones
5. arthritis
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP or return to the ED if you develop chest
pain, shortness of breath, difficulty with urination, or other
worrisome symtpoms.
Please complete your course of ciprofloxacin and once complete,
please restart your outpatient bactrim prophylaxis medication
Please take all medications as precribed.
Followup Instructions:
Follow up with your urologist, Dr. [**Last Name (STitle) 107368**] [**Telephone/Fax (1) 88926**]
Please call your cardiologist, Dr. [**Last Name (STitle) **], to schedule a follow up
appointment within 2 weeks of discharge. Please discuss with him
being set up with cardiac rehabilitation.
Please call your PCP to schedule [**Name Initial (PRE) **] follow up appointment within
6 weeks.
ICD9 Codes: 4280, 4240, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5257
}
|
Medical Text: Admission Date: [**2189-3-31**] Discharge Date: [**2189-4-3**]
Service: MEDICINE
Allergies:
Boric Acid
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
supratherpeutic INR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known firstname **] [**Known lastname 16528**] is a [**Age over 90 **] year old female with a history of
afib on coumadin, metastatic GE junction adenocarcinoma, and
dCHF who presents with supratherapeutic INR and anemia. The
patient had been on coumadin for years and this was
discontinued, but subsequently restarted ([**10/2188**]) in the
setting of worsening PVD with arterial cloth in the setting of
metastatic esophageal cancer. She usually gets her INR checked
every 2 weeks but almost a month passed between her last INR
check and the one she had today. Her coumadin dose has remained
relatively stable, however, she has had increased constipation
and decreased appetite and PO intake over the past month. Her
INR check today was > 10 and her PCP advised [**Name9 (PRE) **] evaluation. Over
the past week Mrs. [**Known lastname 16528**] has had darker colored stools,
but has not had any hemetemesis, hematuria, BRBPR, or chest
pain. She has had one episode of epistaxis from her left nostril
and dry heaves for several days.
.
In the ED, initial vs were: Pain 0, T 97.8, HR 97, BP 111/49, RR
18, O2 sat 96% RA. On exam, patient was noted to be guaiac
positive with brown stool. Her labs were notable for an INR > 20
and Hct 22.8, approximately 10 points lower than her recent
baseline. She was given vitamin K 10 mg IV, FFP x 2, and
pantoprazole IV. Blood was also ordered. GI was called and
advised against NGT placement given recent epistaxis. They will
see the patient in the morning.
.
On arrival to the ICU, the patient was comfortable without any
chest pain, shortness of breath, or nausea.
.
Review of sytems:
(+) Per HPI, + intermittant left foot pain, + cough (chronic), +
post-nasal drip (chronic), + vision loss (chronic).
(-) Denies fever, chills. Denies headache, sinus tenderness.
Denied shortness of breath. Denied chest pain or tightness,
palpitations. Denied diarrhea, constipation or abdominal pain.
No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. Atrial fibrillation on Coumadin
2. dCHF with EF 60%, Echo in [**11-6**]
3. Constipation alternating with loose stools
4. Hypothyroidism
5. Depression
6. Anemia, iron deficiency
7. Poor vision due to macular degeneration
8. Vertigo - evaluated multiple times in the past by neurology.
9. Metastatic GE junction adenocarcinoma - not on treatment
10. History of PVD with bilateral common femoral occlusions
(10/[**2188**]). Coumadin restarted for palliative reasons for lower
extremity pain.
Social History:
Lives at home. Nephew and boarder also live in the house. Quit
smoking in [**2143**], 30 pack year history. No EtOH. Formerly worked
as an artist.
Family History:
Father died of "heart failure"
Physical Exam:
PE: 99.1F 102 112/76 17 100%RA
Gen: lying in bed, in nad
HEENT: eomi, mmm, NGT in place draining greenish materials
CV: S1S2+
Chest: ctab
Abd: distended, tympanic sound, sluggish bs+, tenderness
diffusely, worse at center of the abdomen, nr, with guarding
Ext: no edema, dp2+
CNS: aox3
Pertinent Results:
[**2189-4-1**] 05:30AM BLOOD WBC-8.6 RBC-2.67* Hgb-7.9* Hct-23.0*
MCV-86 MCH-29.8 MCHC-34.5 RDW-15.7* Plt Ct-364
[**2189-3-31**] 05:55PM BLOOD Neuts-89.0* Lymphs-7.8* Monos-2.8 Eos-0.4
Baso-0.1
[**2189-3-31**] 05:55PM BLOOD PT-150* PTT-49.2* INR(PT)->20.2*
[**2189-4-1**] 05:30AM BLOOD PT-16.2* PTT-26.5 INR(PT)-1.4*
[**2189-3-31**] 05:55PM BLOOD Glucose-148* UreaN-31* Creat-1.2* Na-137
K-3.3 Cl-98 HCO3-39* AnGap-3*
[**2189-4-1**] 05:30AM BLOOD Glucose-95 UreaN-24* Creat-0.8 Na-141
K-3.2* Cl-100 HCO3-30 AnGap-14
[**2189-4-1**] 05:30AM BLOOD CK(CPK)-29
[**2189-3-31**] 05:55PM BLOOD cTropnT-<0.01
[**2189-4-1**] 05:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2189-4-1**] 05:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.9
[**2189-3-31**] 05:55PM BLOOD TSH-2.2
Brief Hospital Course:
This is a [**Age over 90 **] year old female with a PMH of afib on coumadin,
metastatic GE junction cancer, and dCHF who presented with an
INR > 20 and anemia with hematocrit 22.8, markedly decreased
from prior.
# Acute blood loss anemia: Patient with a Hct of 22.8 on
admission and dark guaiac positive stool in the setting of an
INR of 20. She had no evidence of brisk bleeding and remained
hemodynamically stable during her ICU stay. She received 2u of
pRBC's in the ICU with a Hct of 29.3 on discharge. She was
placed on an IV PPI q12H and was monitored on telemetry
throughout her course without incident.
# Supratherapeutic INR: Patient with an INR >20 on admission.
She received vitamin K 10 mg IV and 2 units FFP in the ED. Her
INR was reversed to 1.4 following these measures. Her PCP
recommended that the patient not restart it as an outpatient.
# EKG changes: Patient admitted with new TWI and ST depressions
on EKG without chest pain, though to be from demand ichemia in
the setting of anemia. CE's were negative x 2. A repeat EKG was
improved.
# Acute renal failure: Patient with an admission creatinine of
1.2 up from baseline of 0.6 - 0.9, likely secondary to
hypovolemia from anemia and poor PO intake from cancer. After
fluid repletion with blood products, her Cr dropped to 0.8. Her
Lasix was held in the ICU, but restarted prior to discharge.
# Atrial fibrillation: Patient remained rate-controlled with
home dose of Metoprolol. Her ASA was held due to blood loss and
her physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**], was consulted who recommended
stopping her Coumadin permanently.
#. Chronic Diastolic CHF: This was not an active issue during
her stay. She remained stable, but volume status was observed
carefully to prevent fluid overload in the context of receiving
blood products and holding home Lasix. Her ASA was held, but
restarted at 81mg prior to discharge, her Metoprolol was
continued, and her Lasix was restarted prior to discharge.
.
#. Hypothyroidism: TSH was normal and she was continued on her
home dose of levothyroxine.
#. Glaucoma: Home Lumigan was substituted for Latanoprost in
house.
#. Depression: Continued home Sertraline and started patient on
mirtazapine 15mg at bedtime to facilitate sleep and stimulate PO
intake.
#. Chronic post-nasal drip: Patient uses a Rhinocort nasal spray
at home that was substituted with fluticasone. She was also
continued on her home Hyoscamine.
.
Code: Patient remained DNR/DNI throughout this hospitalization.
Medications on Admission:
Bimatoprost [Lumigan] 0.03 % Drops 1 drop OU daily
Budesonide [Rhinocort Aqua] 32 mcg/Actuation Spray, 1 spray NU
daily
Fluticasone 110 mcg/Actuation Aerosol 2 puffs daily
Furosemide 40 mg daily
Levothyroxine 100 mcg daily
Metoprolol Succinate SR 100 mg daily
Prednisolone Acetate 1 % Drops, Suspension 1 drop OU every other
day
Sertraline 25 mg daily
Vit C-Vit E-Copper-ZnOx-Lutein [PreserVision] 226-200-5
mg-unit-mg Capsule PO BID
Warfarin 2 mg daily except takes 3 mg on fridays
Hyoscyamine 0.125 mg SL QHS (not on OMR list)
Recently ordered medications in OMR not on home list
Acetaminophen 325 mg Tablet 1-2 tabs PO Q4-6H prn pain
Aspirin 325 mg daily
Prochlorperazine [Prochlorperazine Maleate] 10 mg daily prn
nausea
Prednisone 2 mg daily
Simvastatin 10 mg daily
Morphine Concentrate 20 mg/mL Solution [**2-3**] ml by mouth Q1h prn
pain or dyspnea 1-5 mg for mild pain, 5-10 mg for moderate pain,
10-20 mg for severe pain
Discharge Medications:
1. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as
needed for cough.
Disp:*120 ML(s)* Refills:*0*
2. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic once a
day: into both eyes.
3. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: One
(1) spray Nasal once a day: intranasally.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic every other day: into both eyes.
9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QHS (once a day (at bedtime)).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
14. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
once a day as needed for nausea.
15. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day.
16. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Morphine Concentrate 20 mg/mL Solution Sig: as directed mL
PO q1h as needed for pain: [**2-3**] mL for mild pain, [**6-8**] mL for
moderate pain, and [**11-18**] mL for severe pain.
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
GI bleed
Atrial Fibrillation
Secondary:
Diastolic Congestive Heart Failure
Hypothyroidism
Glaucoma
Discharge Condition:
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
evaluation of increased constipation and decreased appetite. It
was found that your Coumadin level was extremely high and that
you had anemia likely due to a bleed in your intestines. You
needed to be admitted to the intensive care unit for close
monitoring. You received 2 units of blood in a transfusion and
your anemia stabilized. Your Coumadin was stopped altogether.
You were also started on a medication called mirtazipine which
helps improve your appetite.
.
The following changes have been made to your home medication
regimen:
1. We started you on a medication for sleep and anxiety, called
Mirtazapine, which you can use at night, as needed, for sleep.
2. We stopped your Coumadin, as your INR was very high on
admission.
3. We restarted you on Aspirin 81 mg daily
4. We started you on a cough syrup, Dextramethorphan, to use as
needed.
Followup Instructions:
Please follow-up with all of your scheduled appointments below:
.
You should contact your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**], if
you don't hear from her by early next week.
.
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2189-4-8**] 11:20
.
2. Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2189-6-8**]
2:30
.
3. Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2189-6-8**] 2:50
ICD9 Codes: 5789, 5849, 2851, 4280, 2449, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5258
}
|
Medical Text: Admission Date: [**2186-5-31**] Discharge Date: [**2186-6-3**]
Date of Birth: [**2128-2-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Transfer for GI bleed
Major Surgical or Invasive Procedure:
EGD s/p Epi injection of bleeding ulcer and endoclip placement
on [**2186-6-1**]
History of Present Illness:
58 yo female with hypothyroidism, h/o PUD in duodenum 7 and 10
years ago which were cauterized, presenting with melanotic
stools x2 on Monday in setting of 1 week-2 week long of crampy,
squeezy abdominal pain not related to food intake. Patient
denies NSAID use and reports previously being tested for H
pylori which was negative. She states that after her 2nd
melatonic BM, she called her PCP and reported to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Upon admission to OSH, patient states she passed out. Her HCT at
that time was 25 (baseline Hct =39 [**11-21**]).
.
At OSH, pt had mild hypotension, SBP ~90 mmHg (admission ~110
mmHg). EGD [**2186-5-29**] reportedly demonstrated "diffuse bleeding in
stomach with no ulcers." No specific bleeding site identified.
Pt was started on pantoprazole drip, did have 24 hours of
octreotide, and received 3 units PRBC total, last transfused
[**5-30**] in am. Serial Hct since last transfusion 30 --> 29 --> 27.
No coagulopathy. Repeat EGD [**2186-5-31**] demonstrated some fresh
blood in stomach through small intestine, but no bleeding site,
varcies, or AV malformations.
.
Of note, EGD performed on [**2186-5-29**] revealed diffuse bleeding in
the stomach and no ulcers. EGD on [**2186-5-31**] with push through
jejunum showed fresh blood in the stomach through small
intestine without ulcers, evidence of varices or AV malformation
(this is all per notes arrived with patient).
.
Prior to transfer her vitals were reported to be 92/60, Heart
64, RR 20, Saturation 100% on 2L.
.
Pt had upper EGD three years ago which was normal. She also had
colonscopy at age 50 which was normal.
.
On arrival to the MICU, patient's VS. BP 123/67 HR 74, SP02 99%.
Pt with no complaints. No abdominal pain. Denies any
lightheadedness or dizziness. Denies chest pain, SOB. Recent
mahagony colored stools.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation,. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. Hypothyroidism.
2. Peptic Ulcer Disease (reports in duodenum)
3. Pancreatitis
4. Chronic neck and back pain
5. Borderline hyperlipidemia
Social History:
Works as a dental hygenist for 30 years.
No tob/etoh/drugs.
Family History:
Mother deceased at 46 from ovarian/breast cancer.
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, no
pallor
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
PERTINENT LABS
[**2186-5-31**] 09:00PM BLOOD WBC-11.5* RBC-3.48* Hgb-10.1* Hct-29.8*
MCV-86 MCH-29.2 MCHC-34.1 RDW-15.3 Plt Ct-261
[**2186-6-1**] 04:21AM BLOOD Hct-27.1*
[**2186-6-1**] 08:47AM BLOOD Hct-29.6*
[**2186-5-31**] 09:00PM BLOOD PT-11.4 PTT-28.2 INR(PT)-1.1
[**2186-5-31**] 09:00PM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-144 K-3.7
Cl-110* HCO3-30 AnGap-8
[**2186-5-31**] 09:00PM BLOOD ALT-17 AST-21 LD(LDH)-113 AlkPhos-43
TotBili-0.2
[**2186-5-31**] 09:00PM BLOOD Albumin-3.7 Calcium-8.4 Phos-2.7 Mg-1.8
.
MICRO
[**2186-6-1**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST-PENDING INPATIENT
.
STUDIES
CT SCAN AT OSH: 1. Mild mural thickening of the antrum the
stomach wich couble secondary to undefilling.
2. Normal size spleen and normal appearance of the portal vein
3. Heamngionma in the posterior segment of the right lobe of the
liver.
4. Diverticulosis with no evidence of diverticulitis.
5. Hiatal hernia.
Brief Hospital Course:
Blood clearly seen on both scopes at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], but there
were unable to identify source. Patient was initially
transferred to the [**Hospital1 18**] MICU for close overnight monitoring.
She was continued on a protonix drip. HCT was 29 on admission
and remained stable between 27-29 overnight. She was seen by GI,
who opted to repeat her endoscopy which showed a single 2.5 cm
ulcer with spurting visible vessel in the duodenal sweep, which
was injected with Epinephrine. Three endoclips were successfully
applied for hemostasis. She was transitioned to IV Protonix [**Hospital1 **].
Hct trended down to 25, for which she was transfused 1U PRBC. H.
pylori serology was negative. She remained hemodynamically
stable and was transferred to the general medicine floor. She
remained stable on the floor and tolerated a regular diet
without any signs of GI bleeding. She was discharged on [**Hospital1 **]
Protonix. She was told to avoid NSAIDs. No other changes were
made to her home medications. She has PCP [**Name9 (PRE) 702**] early next
week.
Medications on Admission:
1. Synthroid 0.1mg daily
2. Cytomel 5mcg
3. Trazodone 50mg daily at night
4. Calcium with vit D.
5. Omega 3 fish oil
6. Vitamin B6
7. Prilosec 20mg daily
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. liothyronine 5 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer with bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
treatment of bleeding from your small intestine. You had a
procedure that found and treated the source of bleeding. You
received 1 unit of blood at our hospital. After the procedure,
your blood counts were stable. You were started on an acid
blocker called Pantoprazole, which you should take twice a day.
No other changes were made to your home medications. You should
not have an MRI for 1 month from the time of your procedure.
Please avoid Ibuprofen, Motrin, Aleve, or other non-steroidal
anti-inflammatory pain relievers in the future.
Followup Instructions:
Please call your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up
appointment within 1 week of discharge.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
Completed by:[**2186-6-3**]
ICD9 Codes: 2449, 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5259
}
|
Medical Text: Admission Date: [**2110-9-21**] Discharge Date: [**2110-10-25**]
Date of Birth: [**2080-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
fevers, tachycardia, infected spinal stimulator hardware
Major Surgical or Invasive Procedure:
-[**9-22**]: Explantation of spinal cord stimulator and drainage of
lumbar wound hematoma
-[**10-2**]: Drainage of hematoma at past surgical site
History of Present Illness:
Mr. [**Known lastname **] is 29 yo M w/ h/o complex regional pain syndrome s/p
phase II spinal cord stimulator implant on [**2110-9-10**] (POD 12) who
presented with with a four day history of worsening back pain.
.
The pt went to [**Hospital3 **] Hospital on [**9-21**] with 4D of worsening
low back pain at the site of his spinal stimulator. There, he
had a temp to 100.1 w/ chills , WBC 16.2 and he recieved
vancomycin IV prior to transfer to [**Hospital1 18**].
.
In the ED, the patient was noted to have erythema around the
site with a sm amt yellow serosanguinous/purulent drainage.
Neuro exam was WNL. CT L Spine outlined a 5.7 x 3.4 cm
subcutaneous hematoma with a small amount of gas. Given that the
patient had temp to 100.1 in ED, and was tachy to 120-140s,
patent was taken to the OR for drainage and removal of his
hardware. While in the ED, the pt was given dilaudid IV 6mg,
tylenol 500mg PO, diazepam 5mg IV, zosyn IV.
.
In the OR, the patient was noted to have extension of the
hematoma to the fascia and all of his hardware was removed.
Patient had a JP drain placed. He recvied Vancomycin and
Clindamycin at 1am in the PACU and started on a dilaudid PCA for
pain control.
.
On transfer to the floor, patient's VS were 98.6, 130/84, 115
(100-120), 16, 100%3L NC.
.
Review of systems:
(+) Per HPI (fever, chills)
(-) 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:
Past Medical History:
Cervical DDD s/p C3-4 fusion
complex regional pain syndrome left knee
s/p appendectomy
spinal cord stimulator placement [**2110-9-10**]
.
Social History:
Patient lives at home with his wife and two young
children, he denies any tobacco abuse or recreational drug use.
Has 1 drink of etoh every few weeks.
Family History:
Non contributory
Physical Exam:
Admission exam:
Tc: 96.6, BP:108/78 HR:103 RR:18 SaO2:98% RA
General: pleasant, nad
HEENT: op clear, mmm, no lesions; no cervical LAD
Neck: supple, no LAD, no thyromegaly
Cardiovascular: RRR, no MRG
Respiratory: CTA bilat w/o wheezes/rhonchi/rales
Back: + TTP over L-spine at surgical site
Gastrointestinal: +bs, soft, non-tender, non-distended
Musculoskeletal: moving all extremities
Lymph: no cervical, axillary or inguinal LAD
Skin: surgical dressing in place with JP drain with
serosanguinous drainage
Neurological: aaox3, cn 2-12 intact
.
.
DISCHARGE EXAM:
VS: 96.8 (tmax was 98.6 in the last 24 hours), 99/80, 89, 18,
97% on RA
GEN: pleasant, appears comfortable in NAD
HEENT: MMM, sclera non-icteric, intact EOM, PERRLA
RESP: CTAB bil, no increase in WOB
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: Soft, +b/s, non distended, mildly tender on right LQ around
inc site (overall improving), no masses or hepatosplenomegaly.
Large mid line scar well approximated, healing well, no
drainage.
Back: mildly tender on lower back on area of hematoma, with
small bulge (improving) no drainage noted
EXT: no c/c/e, pain to palpation of entire left knee
(unchanged), +2 pulses. Ambulating without assist. Sl decrease
in ROM of LLE due to L knee discomfort
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout, mild
decrease in sensation on R anterior thigh area
Pertinent Results:
Admission labs:
[**2110-9-21**] 05:10PM NEUTS-76.0* LYMPHS-18.9 MONOS-3.5 EOS-1.1
BASOS-0.6
[**2110-9-21**] 05:10PM WBC-13.9* RBC-4.11* HGB-12.5* HCT-36.4*
MCV-89 MCH-30.4 MCHC-34.4 RDW-14.5
[**2110-9-21**] 05:24PM LACTATE-1.3
ESR/CRP:
[**2110-9-23**] 07:00AM BLOOD ESR-65*
[**2110-10-18**] 05:13PM BLOOD ESR-30*
[**2110-9-23**] 07:00AM BLOOD CRP-150.8*
[**2110-10-18**] 05:13PM BLOOD CRP-17.0*
.
MICROBIOLOGY:
.
#[**2110-10-22**] 7:00 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
.
# [**2110-10-21**] 1:17 am CATHETER TIP-IV Source: PICC line.
**FINAL REPORT [**2110-10-23**]**
WOUND CULTURE (Final [**2110-10-23**]): No significant growth.
# [**2110-10-20**] 6:02 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
# [**2110-10-19**] 11:20 am BLOOD CULTURE
**FINAL REPORT [**2110-10-25**]**
Blood Culture, Routine (Final [**2110-10-25**]): NO GROWTH.
# [**2110-10-18**] 2:00 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Preliminary):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Aerobic Bottle Gram Stain (Final [**2110-10-20**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 2034 ON [**10-20**] - FA9A.
[**Month/Year (2) **](S).
# [**2110-10-19**] 9:34 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Preliminary):
MORGANELLA MORGANII. FINAL SENSITIVITIES.
sensitivity testing performed by Microscan.
MORGANELLA MORGANII. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORGANELLA MORGANII
| MORGANELLA MORGANII
| |
CEFEPIME-------------- 8 S 8 S
CEFTAZIDIME----------- =>32 R =>32 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN--------- <=0.5 S <=0.5 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- S S
PIPERACILLIN/TAZO----- =>128 R <=8 S
TOBRAMYCIN------------ <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2110-10-21**]):
REPORTED BY PHONE TO DR. [**First Name4 (NamePattern1) 3750**] [**Last Name (NamePattern1) 86954**] PAGER# [**Serial Number 86955**] @
0425 ON
[**2110-10-21**].
GRAM NEGATIVE ROD(S).
#[**2110-10-14**] 9:17 am CSF;SPINAL FLUID
Source: spinal fluid collection.
**FINAL REPORT [**2110-10-20**]**
GRAM STAIN (Final [**2110-10-14**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2110-10-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2110-10-20**]): NO GROWTH.
# [**2110-10-12**] 7:25 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2110-10-13**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2110-10-13**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
# [**2110-10-4**] 11:51 am BLOOD CULTURE
**FINAL REPORT [**2110-10-7**]**
Blood Culture, Routine (Final [**2110-10-7**]):
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 86956**],
[**2110-10-5**].
MORGANELLA MORGANII.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 86956**],
[**2110-10-5**].
Anaerobic Bottle Gram Stain (Final [**2110-10-5**]): GRAM
NEGATIVE RODS.
Aerobic Bottle Gram Stain (Final [**2110-10-5**]): GRAM NEGATIVE
RODS.
.
#[**2110-10-2**] 1:03 pm FLUID,OTHER LOWER BACK FLUID COLLECTION.
**FINAL REPORT [**2110-10-13**]**
GRAM STAIN (Final [**2110-10-2**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2110-10-13**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
DR. [**First Name4 (NamePattern1) 674**] [**Last Name (NamePattern1) 86957**] 9-0841 [**2110-10-7**] WANTS VANCOMYCIN
SENSITIVITY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance 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.
VANCOMYCIN Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC CULTURE (Final [**2110-10-7**]): NO ANAEROBES ISOLATED.
# [**2110-10-2**] 2:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2110-10-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2110-10-3**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2110-10-3**] 11:21AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
#[**2110-9-22**] 7:15 am SWAB GENERATOR POCKET.
**FINAL REPORT [**2110-9-26**]**
GRAM STAIN (Final [**2110-9-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2110-9-25**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2110-9-26**]): NO ANAEROBES ISOLATED.
# [**2110-9-22**] 7:15 am SWAB LUMBAR WOUND.
**FINAL REPORT [**2110-9-26**]**
GRAM STAIN (Final [**2110-9-22**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2110-9-24**]):
ENTEROCOCCUS SP.. MODERATE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2110-9-26**]): NO ANAEROBES ISOLATED.
DISCHARGE LABS:
[**2110-10-24**] 07:40AM BLOOD WBC-14.4* RBC-3.96* Hgb-11.4* Hct-34.2*
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.8 Plt Ct-716*
[**2110-10-24**] 07:40AM BLOOD Neuts-65.0 Lymphs-26.5 Monos-4.5 Eos-2.7
Baso-1.4
[**2110-10-21**] 07:10AM BLOOD Hypochr-3+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Burr-OCCASIONAL
[**2110-10-22**] 07:00AM BLOOD Glucose-109* UreaN-6 Creat-0.9 Na-141
K-3.9 Cl-100 HCO3-30 AnGap-15
[**2110-10-23**] 06:40AM BLOOD ALT-37 AST-23 AlkPhos-130 TotBili-0.6
[**2110-10-23**] 06:40AM BLOOD Calcium-9.5 Phos-4.5 Mg-1.9
[**2110-10-5**] 11:13PM BLOOD HCV Ab-NEGATIVE
RBC MCH MCHC RDW Ct
[**2110-10-25**] 07:00
WBC 11.1/ Hgb 10.6* / Hct 30.9*/MCV 87/ Plt 609*
DIFFERENTIAL: Neuts 61/ Bands 0/ Lymphs 25/ Monos 10/Eos 3/Baso
1/Atyps 0
IMAGING:
ECHO ON [**2110-10-23**]:
=================
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2110-10-6**], findings are similar.
IMPRESSION: normal study; no vegetations seen
MRI LUMBAR SPINE ON [**2110-10-19**]:
===============================
FINDINGS:
Numbering used is shown on Vertebral body height and sagittal
alignment are maintained. There remains diffusely low although
somewhat heterogeneous marrow signal on T1-weighted images,
unchanged.
Compared to the prior study the fluid collection in the
posterior soft tissues has decreased in size, now measuring at
this point 1.7 TV x 1.2 AP x 3.4 CC cm in widest dimensions.
There remains a thick rind of enhancing soft tissue surrounding
collection, and there are foci of low signal both within and
around the fluid which may represent small foci of air or
residual metallic fragments from hardware removal. There is
unchanged paraspinal muscular abnormal stir signal, left greater
than right.
The enhancement abuts the spinous processes of L2 and 3, but
there is no
abnormal signal within the spinous processes or the osseous
structures
elsewhere. There is no abnormal intrathecal enhancement, or
abnormal
enhancement within the epidural space.
The conus terminates at L1. There is normal signal within the
conus
medullaris and the cauda equina. There is mild clumping of some
of the nerve roots along the periphery of the thecal sac within
the lower lumbosacral spine which is unchanged from the prior
study. There is no abnormal enhancement within the nerve roots.
The visualizedretroperitoneal structures are unremarkable.
Mild facet degenerative changes are possibly noted at L4/5 and
l5/S1 levels. Small Schmorl's nodes are noted at T11-T12 level
indenting the adjacent endplates.
IMPRESSION:
1. Decrease in the size of the peripherally enhancing fluid
collection in the posterior lumbar soft tissues, which now
measures 1.7x1.2x3.4cm. No evidence of osteomyelitis.
2. Stable minimal clumping of the nerve roots in the inferior
spinal canal
could reflect a component of arachnoiditis, which could be
postprocedural,
although post infectious/inflammatory etiologies cannot be
excluded. No abnormal intrathecal enhancement.
3. Distended blader- correlate clinically.
CXRAY ON [**2110-10-19**]:
REASON FOR EXAMINATION: Rigors and sepsis.
Portable AP chest radiograph was compared to [**2110-10-15**].
Cardiomediastinal silhouette is stable. Bibasal linear
atelectasis is
redemonstrated, but no focal consolidation definitely
demonstrating infectious process is seen. Further evaluation
with lateral view would be beneficial to exclude the possibility
of posterior basal infection hidden on the AP projection.
CT ABD/PELVIS ON [**2110-10-19**]:
TECHNIQUE: Multiple axial images of the abdomen and pelvis from
lung bases
through the pubic symphysis were obtained following the
uneventful administration of oral and 130 cc Optiray IV
contrast. Coronal and sagittal images were reformatted and
reviewed.
FINDINGS:
There is minor, dependent atelectasis. No pleural or pericardial
fluid.
The liver, spleen, adrenal glands, and pancreas are normal in
appearance.
There is a hypodensity in the mid pole of right kidney which is
too small to adequately characterize and unchanged from prior.
There is no hydronephrosis. The ureters are normal caliber.
Bowel loops are normal caliber. The colon demonstrates no
evidence of wall thickening with stool present throughout the
colon. There are surgical clips in the right lower quadrant. No
right lower quadrant inflammatory change. The gallbladder is
fluid filled. There is minor stranding and inflammation in the
midline of the anterior abdominal wall likely related to prior
incision. There is no abdominal ascites. No pneumoperitoneum. No
pneumatosis.
CT PELVIS: The bladder is relatively well distended and
unremarkable. There is no pelvic lymphadenopathy.
There is no upper abdominal adenopathy, retroperitoneal or
mesenteric.
There is a residual, small fluid collection posterior to the
L3/L4 vertebral bodies which has been seen on prior examinations
and previously sampled. The fluid component appears slightly
smaller than on prior study and there is no associated gas
within this collection or the surrounding soft tissues.
There is sclerosis in the left femoral head and a defect along
the weight
bearing surface that may be related to chronic AVN.
IMPRESSION:
1. No evidence of acute intra-abdominal pathology or focal
abdominal fluid
collection on today's examination.
2. Subcutaneous fluid collection posterior to L3/L4 vertebral
bodies as seen
on prior examinations.
3. Question chronic AVN left femoral head.
Cardiology Report ECG Study Date of [**2110-10-19**] 2:55:20 PM
EKGS ON [**2110-10-19**]:
Sinus tachycardia. Otherwise, probably normal tracing. Since the
previous
tracing of [**2110-10-18**] tachycardic rate is slower and delayed R
wave progression pattern is now absent.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
120 142 88 318/423 22 8 18
Brief Hospital Course:
Mr [**Known lastname **] has had a long and protracted hospitalization between
[**2110-9-21**] to date. He's had multiple transfers between the floor
and intensive care requiring multiple practioners in his
management. To summarize his course: in the ED he presented
with an infection around his TENS stimulator and went to the OR
for hardware removal. He grew out enterococcus and coag
negative staph from the wound and was started on antibiotics
accordingly. He was started on a dilaudid PCA initially for
pain control and then needed a ketamine drip for escalating pain
requirements. Repeat drainage of L3, L4 was then required,
drained by IR. He then developed gram negative bacteremia, had
C diff in his stool, and devloped peritoneal signs that required
an ex-lap. This revealed no perforation. He was intubated
peri-procedure and then in the MICU was transiently extubated
and then again re-intubated for increased work of breathing and
CXR findings suggestive of ARDS. He ultimately had 6/6 bottles
of positive BCx for GNR (Klebiella and Morganella). Broad
spectrum antibiotic coverage was initiated for Klebsiella and
Morganella (meropenem) PO vanc and IV flagyl for C difficile
(initially needed tigacycline), and daptomycin for MRSA. His
gram negative sepsis was thought to be secondary to
translocation in the setting of C diff colitis. He had
hypotension on 2 pressors, potential DIC with new coagulopathy,
transaminitis to the 600s, and acute kidney injury with a rising
creatinine to 2.8.
.
He underwent another MRI on [**10-7**] that showed a persistent L2
fluid collection, which was aspirated on [**10-14**]. This aspirate
revealed neutrophils but culture has been negative. The patient
was switched from Meropenem to Zosyn and tigecycline was
discontinued after sensititives were obtained. Dapto was
switched to Vancomycin as well. He was continued on vancomycin
IV and zosyn until [**10-19**] when he developed rigors and
tachycardia
.
His fevers and tachycardia began on [**10-18**]. On [**10-19**], these were
accompanied by a mild hypotension ~ SBP 90's, a fleeting feeling
of pain in the right thigh, a generalized sense of weakness, and
severe chills and rigors that were controlled with meperidine
and tylenol. He received 3L of NS with response in SBP to 120's.
His Tachycardia persists at 120-130. ID recommended switching
antibiotics from vanco and zosyn to Linezolid and Meropenem. He
was continued on oral vanco for C.diff. His HR and BP are now
stable and he returned to the general medicine floor.
He was transferred back to the medicine floor on [**10-20**] and has
been stable and afebrile since his transfer. He has been feeling
much better. His WBC had a sl.increase on [**10-24**] but is now
trending back down. He continues to have pain on L knee and mild
pain on back and abd which are now much better controlled on MS
contin and MSIR, as well as on clonodin and gabapentin.
.
# Enterococcus and Coag negative staph lumbar hematoma
infection: This was patient's initial presentation to [**Hospital1 18**].
Mr [**Known lastname **] had underwent spinal stimulator implantation on
[**2110-9-10**] for complex regional pain syndrome. On [**2110-9-21**], he
had presented to OSH with fevers, chills, and back pain and was
transferred to [**Hospital1 18**] for further evaluation. CT L spine had
shown a large subcutaneous fluid collection, c/w hematoma that
was evacuated in the OR with hardware removal. The patient's
hematoma cx had grown enterococcus and coagulase neg staph and
was to be on a 4 week course of IV Vancomycin given elevated
ESR/CRP. He had repeat MRI on [**9-29**] that showed a 2.3 x 2.5cm
subcutaneous fluid collection. He underwent IR aspiration
yielding 10cc serosanguinous fluid, which grew coagulase
negative staph. In the setting of his sepsis, he underwent
another MRI on [**10-7**] that showed a persistent L2 fluid
collection, which was aspirated on [**10-14**]. This aspirate
revealed neutrophils but culture has been negative. He developed
rigors on [**10-18**] and was transferred to the ICU on [**10-19**] for
concern of sepsis. Since it appeared that he was septic while on
vancomycin IV his antibiotic was changed to Linezolid due to
concern for VRE. His antibiotics were switched and he has been
afebrile and hemodynamically stable. He had repeat MRI that
showed decrease in size of fluid collection.
-He will be following up with ID and chronic pain.
-He is scheduled to have repeat US of lumbar spine on [**2110-11-5**]
for evaluation of size of fluid collection.
-Cont Linezolid for 3-4 weeks ( day 1 was on [**2110-10-14**]). ID will
reassess
.
#. Klebiella and Morganella Sepsis: Likely a result of GI
bacterial translocation in the setting of C Diff. The patient
on [**2110-10-4**] was found to have an acute onset of rigors,
respiratory distress, hypotension, and acute abdomen. Patient
underwent an urgent ex-lap that was unremarkable, however was in
gram negative septic shock (6/6 bottles). The patient's MICU
course was complicated by ARDS, needing pressors, renal failure,
and shock liver. The patient was initially treated with
Daptomycin (for possible MRSA), Vancomycin PO, IV Flagyl,
Meropenem, and Tigecycline. The patient was switched from
Meropenem to Zosyn and tigecycline was discontinued after
sensititives were obtained. Dapto was switch to Vancomycin as
well. He was continued on vancomycin IV and zosyn until [**10-19**]
when he developed rigors and tachycardia. He was transitioned
back to Meropenem and continued on Vancomycin. he was
transfered to the MICU on [**10-19**] and antibiotic coverage was
changed to meropenem and linezolid. Pt has since then grown GNR
that found to be 2 different colonies of Morganella with one
that was resistant to Zosyn, but both were sensitive to Cipro.
So his PICC line was D/c and he as discharge on cipro for a
total of 14 days (last day will be on [**2110-11-4**]). He has been
hemodynamically stable and afebrile
- Cipro for total of 14 days (last day on [**11-4**]). He will need
to have QT intervals checked since Quetiapine may cause
prolonged QT intervals. He has script to have EKG done on [**10-28**]
and I will call the PCP on [**Name9 (PRE) 766**].
- He will f/u with ID on [**11-7**]
.
#. C. diff: The patient developed C Diff ten days into his
hospitalization while he was being treated for pain control and
was treated initially with IV Flagyl. The patient developed an
acute abdomen on [**10-4**], and given concerns of possible bowel
perforation, the patient underwent an urgent exploratory
laparotomy which revealed no significant findings needing
surgical intervention. The patient's treatment was increased to
IV Flagyl and PO Vancomycin, and had briefly been treated with
tigecycline. He no longer has diarrhea and his antibiotic was
changed to PO vanco 125mg. He will need to be on this until he
finishes the Linezolid
- Continue PO vanco for ~ 10 days after stopping the Linezolid
.
#.Fungemia: Currently afebrile, HD stable. He was found to have
[**Last Name (LF) **], [**First Name3 (LF) 564**] Albicans, growing from the blood culture from
PICC line site on [**10-18**]. PICC line tip NGTD. Repeat of MRI
improving in L2 fluid collection, and arachnoiditis. Abd CT was
negative and cxray showed atelactasis. So this is unlikely that
he had other source of infection, besides the PICC.
- Switched from Micafungin to Flucanozole (800mg loading dose
and 400mg daily for total of 14 days (Day 1 was on [**2110-10-22**])
- Ophthalmology evaluated pt on [**10-21**] due to the fungemia- No
ocular involvement was found. He will need to follow-up as out
patient in 2 weeks.
- He also had ECho on [**10-23**] that showed no vegetation and was
normal.
- ID will follow-up in [**2110-11-7**]
.
#. Lumbar Pain/CRPS/Abd pain: The patient was given a diagnosis
of complex regional pain syndrome by the pain service, for which
he had the initial stimulator placed. He was found to have an
infected hematoma that was evacuated and then had fluid
aspiration. The patient had persistent lumbar pain and left knee
pain after the surgery. He was on IV Dilaudid PCA, and weaned to
PO dilaudid which did not control his pain. He was treated with
IV Ketamine and was briefly in MICU for airway monitoring. IV
Ketamine was discontinued. He has then switched to PO pain meds
which have have been better controlled. He required increased
amounts of pain mediction, including ketamine drip and this was
concerning for prior opiate abuse.
.
Now fluid collection size on posterior lumbar soft tissues is
decreasing, measuring 1.7x1.2x3.4cm. No evidence of
osteomyelitis and stable minimal clumping of the nerve roots in
the inferior spinal canal could reflect a component of
arachnoiditis seen on MRI on [**10-19**]. He was cleared by PT for
home. He is currently been followed by chronic pain service and
ID. He will have f/u appoitment with both in 2 wks. Currently
cont to have decrease in sensation of right ant thigh region
which is likely related to inflammation and pain on left knee.
- pain service following appointment on [**11-10**] or sooner if
needed. Pt was sent home with MS contin 45mg [**Hospital1 **]. Initially
dispenced enough medication until follow-up pain appointment as
recommended by the inpatient pain team. I was then called by the
pain fellow, Dr. [**Last Name (STitle) 86958**] who was working with Dr. [**Last Name (STitle) 1625**],
his primary pain attending who recommended that the pain
medication dispenced was decresed to last until the patient's
visit with his PCP. [**Name Initial (NameIs) **] was able to changed the prescription and
the MSIR 15mg # disp was 20 and MS contin 30mg (total # dispense
of 15). I also contact[**Name (NI) **] his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] and explained current
concern for narcotic abuse and the fact that pt may need
additional prescription to tx his post-op pain. Dr. [**First Name (STitle) **] did not
feel comfortable in prescribing Mr. [**Known lastname **] [**Last Name (Titles) 1795**] given that
he only saw him once in [**Month (only) 205**]. Dr. [**First Name (STitle) **] then spoke to Dr.
[**Last Name (STitle) 1625**] on [**10-29**] to formulate a plan. I have also called Mr.
[**Known lastname **] x3 to check on how he was doing and to explain the
changes in his treatment plan and he did not answer the phone.
At one point, the phone was answer and then disconnected.
- on MS Contin 45mg [**Hospital1 **] (disp# 15 and pt has not picked up
prescription from pharmacy as of [**10-30**]) and MS IR 15mg Q4hrs as
needed (Disp # 20- prescription filled [**10-26**])
- Pt was also started on CloniDINE 0.1 mg PO TID and on
Gabapentin 300mg TID which should be continued for L knee pain.
.
.
#. Respiratory failure/ARDS: Resolved. Breathing well on room
air. Patient was intubated on [**10-4**] in the setting of gram
negative sepsis, and was extubated on [**2110-10-12**]. Last Cxray on
[**10-19**] showed atlectasis will encourage pt to use inspirometer.
Lungs clear on exam.
.
#. Acute liver injury: Resolved, likely secondary to shock
liver in the setting of sepsis. Patient had transaminitis to the
600s and bilirubin up to 2.2, now improved to normal range. Of
note, the patient has a history of fulminant hepatitis two years
ago at [**Hospital3 **] with transaminases > 10K of unclear
etiology.
- Follow up with PCP
.
# Prophylaxis - SC heparin while inpatient, bowel regimen
.
# Code status - Full
..
# Dispo - going home
.
Medications on Admission:
Oxycodone SR (OxyconTIN) 20 mg PO Q12H
CefTAZidime 1 g IV Q8H
HYDROmorphone (Dilaudid) 0.5 mg IVPCA Lockout
Vancomycin 1000 mg IV Q 12H
Discharge Medications:
1. Outpatient Lab Work
Please check weekly CBC with Differential, ESR, CRP, LFTs (AST,
ALT, Alk Phos and t.bili), BUN and Creatinine.
Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 86959**]
2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
3. morphine 30 mg Tablet Sustained Release Sig: 1.5 Tablet
Sustained Releases PO Q12H (every 12 hours): You should take one
and half tablet every 12hours. You should not drive or do
anything that requires alertness while taking this medication.
Disp:* 15 Tablet Sustained Release(s)* Refills:*0*
4. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: You should not drive or do anything
that may require alertness while taking this medication.
Disp:*20 Tablet(s)* Refills:*0*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*0*
6. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: You should take this medication when you
are ready to go to sleep. You should not drive or do anything
that may require alertness while using this medication. .
Disp:*30 Tablet(s)* Refills:*0*
7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 12 days: This should end on [**2110-11-4**].
Disp:*24 Tablet(s)* Refills:*0*
8. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 24 days: This medication is for C.diff infection in
your gut. It is very important that you continue to take as
prescribe. Last dose on [**2110-11-17**].
Disp:*96 Capsule(s)* Refills:*0*
9. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 20 days: It is very important that you take all the
antibiotic as prescribed.
Disp:*40 Tablet(s)* Refills:*0*
10. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Cipro 500 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours for 10 days: Last day will be on [**2110-11-4**].
Disp:*20 Tablet(s)* Refills:*0*
12. EKG
Please check an EKG on [**2110-10-28**] and then on [**2110-11-7**] when you go
to the infectious disease appointment to evaluate for QTc
prolongation while on cipro and Quetiapine.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary
- Gram negative septic shock
- Acute respiratory distress syndrome
- Acute renal failure
- Enterococcus infected subcutaneous lumbar hematoma
- Clostridium Difficile infection
- Acute shock liver
- Fungemia ([**Female First Name (un) **] Albicans)
- Bacterimia with gram negative rods
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear [**Doctor First Name **],
You were hospitalized because you had an infection of the spinal
stimulator placed in your back. You were treated with IV
antibiotics, however your course was complicated by CDiff
infection, acute abdomen requiring surgery, and septic shock
requiring intubation and medications to keep your blood pressure
up. You have also developed bacterial and fungal infection in
your blood. After a prolonged hospitalization, you have made a
full recovery, however you will need to finish a course of
antibiotics and antifungal medication.
We have made the following changes to your medications:
- Linezolid 600mg every 12 hours until [**2110-11-13**]. The length of
treatmetn will be evaluated by infectious diseases
- Flucanozole 400mg once daily for 10 more days (ending on
[**2110-11-4**])
- Vancomycin 125mg for your C.diff until approximately [**2110-11-20**],
but this will further evaluated by infectious diseases when they
see you on [**11-7**]
- Cipro 500mg orally every 12 hours for another 10 days (last
day will be on [**2110-11-4**]
- Clonodine 0.1mg for your the pain
- Gabapentin 300mg every 8 hours for neuropathic pain
- Morphine SR (MS Contin) 45 mg orally every 12 hours for your
pain. You should not drive or do anything that requires
alerteness since this medication may cause drowsiness
- Morphine Sulfate IR 15 mg orally every 4 hours as needed for
pain.
You should not drive or do anything that requires alerteness
since this medication may cause drowsiness
- We have stopped your Duoxetine since this medication can
interact with your antibiotics and you should discuss with your
doctor when to restart this medication once the antibiotics have
finished.
Followup Instructions:
You have an appointment with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**10-29**], Wed, at 3:20 PM. At that time you will
also need to have blood work done and this will need to be sent
to the infectious diseases office, as in the prescription.
Location: [**Location (un) **] PRIMARY CARE
Address: [**Last Name (NamePattern4) 30770**], [**Location 30771**],[**Numeric Identifier 30772**]
Phone: [**Telephone/Fax (1) 30773**]
Fax: [**Telephone/Fax (1) 30774**]
Department: INFECTIOUS DISEASE
When: FRIDAY [**2110-11-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2110-11-5**] at 1 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PAIN MANAGEMENT CENTER
When: MONDAY [**2110-11-10**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
You will need to call Ultrasound to schedule your appointment
time on [**11-5**], for evaluation of your back. [**Telephone/Fax (1) 327**]
You will need to have blood work done weekly while on
antibiotics and the results will need to be faxed to the
Infectious Diseases office. Your primary care doctor will also
need to repeat an EKG (electrocardiogram) while on cipro to
monitor for changes.
ICD9 Codes: 5185, 5849, 2851, 2930
|
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|
Medical Text: Admission Date: [**2138-7-31**] Discharge Date: [**2138-9-4**]
Date of Birth: [**2138-7-31**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the former 1.81-
kilogram product of a 34-2/7-weeks gestation pregnancy born
to a 29-year-old G1, P0 woman. EDC [**2138-9-9**].
PRENATAL SCREENS: Blood type A-positive, antibody negative,
rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, group B Strep status unknown.
The maternal history was notable for chronic hypertension and
hypothyroidism treated with methyldopa and Synthroid. The
pregnancy was also notable for diet-controlled gestational
diabetes and was otherwise unremarkable until the day of
delivery when oligohydramnios and fetal growth restriction
were noted on prenatal ultrasound.
An induction of labor was undertaken. The mother was taken to
primary cesarean section for failure to progress in labor.
Membranes were intact at the time of delivery. There was no
maternal fever, and mother did receiving intrapartum
antibiotics for prophylaxis due to the prematurity and
unknown group B Strep status initiated 12 hours prior to
delivery.
At delivery, the infant emerged with good tone and cry
requiring blow-by oxygen and stimulation. Apgars were 7 at 1
minute and 9 at 5 minutes. She was admitted to the neonatal
intensive care unit for treatment of prematurity.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 1.81 kilograms (25th percentile), length 44.5
cm (25th-50th percentile), head circumference 30.5 cm (25th
percentile). General: Well-developed, preterm female, mild
respiratory distress. Responsive to exam, but overall mildly
diminished activity. Skin: Warm, pink, no rashes. Head, eyes,
ears, nose, throat: Fontanel: Soft and flat. Ears and nares:
Normal. Palate: Intact. Positive red reflex bilaterally.
Neck: Supple, no lesions. Chest: Coarse, poor-to-moderate
aeration, symmetric chest movement, mild retractions, and
grunting. Cardiac: Regular rate and rhythm, no murmur.
Femoral pulses +2. Abdomen: Soft, no hepatosplenomegaly, no
masses, 3-vessel cord, quiet bowel sounds. GU: Normal preterm
female. Anus: Patent. Extremities, back, and hips are normal.
No lesions. Neuro: Mildly diminished tone and activity.
Intact grasp, weak suck.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Known lastname **] was placed on continuous positive
airway pressure upon admission to the neonatal intensive
care unit. She had persistent respiratory distress on the
continuous positive airway pressure and was electively
intubated and received 1 dose of surfactant. She was
extubated to CPAP later on day of life 1. On day of life
3, she weaned to room air and continued in room air for
the remainder of her neonatal intensive care unit
admission. She did not have any episodes of spontaneous
apnea during admission. At the time of discharge, she is
breathing comfortably in room air with a respiratory rate
of 30-50 breaths per minute.
2. Cardiovascular: [**Known lastname **] has maintained normal heart rates
and blood pressures. A soft intermittent murmur was noted
over the last week prior to discharge thought to be
related to her anemia. At the time of discharge, she has
a baseline heart rate of 130-150 beats per minute and a
recent blood pressure of 79/34 mmHg with a mean arterial
pressure of 48 mmHg.
3. Fluid, electrolytes, and nutrition: [**Known lastname **] was initially
NPO and administered intravenous fluids. Enteral feeds
were started on day of life 1 and gradually advanced to
full volume. Her calories were increased in her expressed
mother's milk to 24 calories per ounce with human milk
fortifier. Within 48 hours of starting the human milk
fortifier, she experienced loose stools which eventually
also showed frank blood. She was made NPO at that point
and treated with 14 days of bowel rest. She had a
percutaneously inserted central catheter and received
total parenteral nutrition. Her feeds were restarted on
day of life 24 and gradually advanced without problems.
At the time of discharge, she is taking expressed breast
milk fortified to 24 calories per ounce with 4 calories
corn oil. The goal is to try to avoid all cow's milk,
protein products. Weight on the day of discharge is 2.285
kilograms with a corresponding length of 48.5 cm and a
head circumference of 33.5 cm. Serum electrolytes were
checked periodically during the time that she was NPO and
were all within normal limits.
4. Infectious disease: [**Known lastname **] was evaluated for sepsis upon
admission to the neonatal intensive care unit. A blood
culture prior to starting intravenous ampicillin and
gentamicin was no growth at 48 hours, and the antibiotics
were discontinued. With the onset of her feeding
intolerance and the bloody stools, [**Known lastname **] was again
started on ampicillin and gentamicin and later
clindamycin was added. She received a 14-day course of
these antibiotics which were discontinued on [**8-24**], [**2137**].
5. Hematological: [**Known lastname 58495**] blood type: A-positive. Her
hematocrit at birth is 47.4%. A recheck of her hematocrit
on [**2138-8-28**] had a hematocrit of 24.6% with
reticulocytes of 1.9%. This was repeated on [**2138-9-3**], and the hematocrit was 23.3%, again, with a
reticulocyte count of 1.8%. After discussion with her
parents, the decision was made to transfuse, and she
received a 20 mL per kilogram red blood cell transfusion.
She has also been started on supplemental iron.
6. Gastrointestinal: As mentioned, [**Known lastname **] had concern for
possible necrotizing enterocolitis. Abdominal x-rays were
reassuring with only a mildly abnormal bowel gas pattern
and no pneumatosis. She was treated with 14 days of bowel
rest and antibiotics, and has refed without problems.
[**Known lastname **] also required treatment for unconjugated
hyperbilirubinemia with phototherapy. Her peak serum
bilirubin occurred on day of life #3, total of 10.5 mg
per deciliter. She received approximately 96 hours of
phototherapy. Most recent serum bilirubin was on day of
life 12, total of 7.5 mg per deciliter.
7. Neurology: [**Known lastname **] has maintained a normal neurological
exam from the time of admission, and there were no
neurological concerns at the time of discharge.
8. Sensory: Audiology: Hearing screening was performed with
automated auditory brainstem responses. [**Known lastname **] passed in
both ears.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the family.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 13823**] [**Last Name (NamePattern1) **], [**Hospital 27252**]
Medical Group, [**Last Name (NamePattern1) 46236**], [**Location (un) 27252**], [**Numeric Identifier 46237**].
Phone number [**Telephone/Fax (1) 69036**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Ad-lib p.o. feeding either breast-feeding or expressed
breast milk fortified to 24 calories per ounce with 4
calories of corn oil.
2. Medications: Ferrous sulfate 25 mg per mL dilution, 0.4
mL p.o. once daily.
3. Car seat position screening was performed. [**Known lastname **] was
observed for 90 minutes in her car seat without any
episodes of oxygen desaturation or bradycardia.
4. State newborn screens were sent on [**8-3**] and
[**2138-8-14**]. The screens on [**2138-8-14**]
showed all results within normal ranges.
5. Immunizations: Hepatitis B vaccine was administered on
[**2138-8-29**].
6. 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 32-35 weeks with 2 of the
following: Daycare 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 1st 24 months of the child's
life, immunization against influenza is recommended for
household contacts and out-of-home caregivers.
7. Follow-up appointments: Appointment with Dr. [**First Name (STitle) **]
within 3 days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34-2/7 weeks gestation.
2. Respiratory distress syndrome.
3. Suspicion for sepsis ruled out.
4. Unconjugated hyperbilirubinemia.
5. Suspicion for necrotizing enterocolitis.
6. Anemia.
7. Infant of a diabetic mother.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2138-9-4**] 01:43:42
T: [**2138-9-4**] 03:51:50
Job#: [**Job Number 69037**]
ICD9 Codes: 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5261
}
|
Medical Text: Admission Date: [**2199-8-8**] Discharge Date: [**2199-8-16**]
Date of Birth: [**2138-1-7**] Sex: M
Service: SURGERY
Allergies:
Protonix / Cortisone / Motrin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
referral for paraesophageal hernia repair contributing to GI
bleed
Major Surgical or Invasive Procedure:
Laparoscopic repair of paraesophageal hernia,
laparoscopic [**Last Name (un) **] gastroplasty, fundoplication and flexible
gastroscopy.
History of Present Illness:
61-year-old man who was referred from PCP to Dr. [**Last Name (STitle) 57300**] for
surgical evaluation of a large hiatal hernia with ulcer and
significant blood loss- microcytic anemia. Patient c/o of
fatigue from blood loss. He obtained a
barium swallow and a motility study to evaluate the
anatomy and propulsive force and the decision to proceed to
surgery was made with patient.
Past Medical History:
His past medical history is notable for a history of
cardiomyopathy and some mild congestive heart failure. He has
had atrial fibrillation in the past and been cardioverted twice.
He has been on Coumadin and amiodarone in the past, but has now
been in sinus rhythm and is off both medications. There is some
question history of a septal defect of the heart but has not had
any surgery.
His past surgeries include an appendectomy, several knee
surgeries including five arthroscopic surgeries on the left
knee.
Social History:
The patient drinks socially. He lives alone. He smoked three
packs of cigarettes a day for approximately 10 years, but quit
40
years ago. He works as a social worker in a psychiatric [**Hospital1 **].
Family History:
Family history is notable for diabetes in his mother and lung
disease in his father.
Physical Exam:
At time of discharge:
Afebrile, VSS
Alert, oriented x 3, NAD
RRR
CTAB
Abdomen soft; steri strips in place over surgical incisions
LE warm, some edema of L knee, 2+pulses
Pertinent Results:
[**2199-8-16**] 07:00AM BLOOD WBC-7.8 RBC-3.71* Hgb-7.9* Hct-27.4*
MCV-74* MCH-21.3* MCHC-28.9* RDW-18.2* Plt Ct-403
[**2199-8-16**] 07:00AM BLOOD PT-16.2* INR(PT)-1.4*
[**2199-8-16**] 07:00AM BLOOD Plt Ct-403
[**2199-8-13**] 07:30AM BLOOD Glucose-126* UreaN-10 Creat-0.9 Na-137
K-3.7 Cl-102 HCO3-25 AnGap-14
[**2199-8-11**] 05:09AM BLOOD TSH-1.2
[**2199-8-11**] 05:09AM BLOOD T4-7.2 T3-91
[**2199-8-12**] 03:00PM BLOOD CRP-170.8*
[**2199-8-12**] 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.0 Leuks-NEG
[**2199-8-12**] 05:52PM JOINT FLUID WBC-[**Numeric Identifier 82586**]* RBC-4833* Polys-87*
Lymphs-0 Monos-13
[**2199-8-12**] 05:52PM JOINT FLUID Crystal-FEW Shape-NEEDLE
Locatio-INTRAC Birefri-NEG Comment-c/w monoso
Brief Hospital Course:
Mr. [**Known lastname **] was admitted post-op to the surgical [**Last Name (un) 12003**] after
undergoing a laproscopic paraesophageal hernia repair. For
details of the operation please see Dr.[**Name (NI) 1482**] operative
report. Initially he did well postoperatively. On hospital day
2, POD1 he began to feel short of breath. CXR found bilateral
effusions and O2 sats decreased to 92% on RA. Sats successfully
increased with 2L NC. He was found to be in atrial fibrillation
and was sent to the ICU d/t need of diltiazem gtt. He had a
temperature of 101.7 and increased to 11.3 from 10.0 so blood
cultures were sent and came back negative. Cardiology was
consulted on the patient and he was successfuly weaned off dilt
and rate controlled on lopressor (100TID). Patient was able to
be transferred out of the SICU to the floor with telemetry where
his rate-controlled Afib was monitored. Cardiology recommended
coumadin for anticoagulation before cardioversion. While
awaiting cardioversion, he converted to normal sinus rhythm. He
had an episode of bradycardia POD He also experienced knee pain
on POD3. His knee was swollen and warm. An xray showed no
fractures. A joint fluid evaluation revealed high WBC and
crystals consistent with gout.
At time of discharge his temperature and WBC were normal x3d.
He was in normal sinus rhythm. He was sent home on coumadin to
be followed up with by his PCP (Dr. [**Last Name (STitle) 18835**] for cardioversion in
1 month with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2232**] if he returned to atrial
fibrillation. He was given a prescription for Toprol 200mg to
be taken daily with plans to follow this up with Dr. [**Last Name (STitle) 18835**]. His
knee pain was improving. Physical therapy was set up to assist
him at home and he received a colchicine prescription to be
discharged by Dr. [**Last Name (STitle) 18835**] on Monday if he is improving. He was
given Dilaudid 2mg PO for pain from surgery, colace for
constipation, and acetaminopen.
This discharge information and his EKGs will be sent to Dr. [**Name (NI) 82587**] office.
Medications on Admission:
Bupropion HCl [Wellbutrin XL]
Dosage uncertain
(Prescribed by Other Provider) [**2199-6-10**]
Recorded Only DELORIE,
[**Doctor Last Name **]
nr Enalapril Maleate
Dosage uncertain
(Prescribed by Other Provider) [**2199-6-10**]
Recorded Only DELORIE,
[**Doctor Last Name **]
nr Esomeprazole Magnesium [Nexium]
Dosage uncertain
(Prescribed by Other Provider) [**2199-6-10**]
Recorded Only DELORIE,
[**Doctor Last Name **] Allergy Alert
nr Furosemide [Lasix]
Dosage uncertain
(Prescribed by Other Provider) [**2199-6-10**]
Recorded Only DELORIE,
[**Doctor Last Name **]
nr Iron-B12-IF-FA-MV-Min-DSS [HEMAX]
nr Metoprolol Succinate [Toprol XL]
nr Modafinil [Provigil]
nr Sucralfate [Carafate]
Dosage uncertain
nr Chlorpheniramine-Acetaminophen [Coricidin]
Dosage uncertain
nr Vitamin E
Dosage uncertain
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
Disp:*60 Tablet(s)* Refills:*0*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO PRN (as
needed) as needed for pain: please take for knee pain only as
needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
please adjust with Dr. [**Last Name (STitle) 18835**] on [**2199-8-19**].
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
paraesophageal hernia
Chronic blood loss anemia
Atrial fibrillation
Chronic congestive heart failure
Acute gouty arthritis
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the emergency department
for any of the following: increasing rednessswelling around your
incision, increasing discharge from your incision, fevers,
chills, vomiting, abdominal pain, shortness of breath, chest
pain or any other symptoms which may concern you.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call to make
appointment. Phone: ([**Telephone/Fax (1) 1483**]
You have an appointment with Dr. [**Last Name (STitle) 18835**] on Monday [**2199-8-19**]. It
is important that you make this appointment to have your blood
drawn for an INR check. Please call Dr. [**Last Name (STitle) 18835**] if there is any
reason you cannot make this appointment: [**Telephone/Fax (1) 18067**]
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2232**] at([**Telephone/Fax (1) 82588**] or another
Electrophysiologist of Dr.[**Name (NI) 82589**] choice regarding
cardioversion one month from now.
Completed by:[**2199-8-19**]
ICD9 Codes: 4254, 2767, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5262
}
|
Medical Text: Admission Date: [**2120-9-4**] Discharge Date: [**2120-9-9**]
Date of Birth: [**2052-7-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
DOE, fatigue
Major Surgical or Invasive Procedure:
[**9-4**] CABG x 5 (LIMA->LAD, SVG->RCA, OM, OM, Diag), ASD Closure
History of Present Illness:
68 yo F with recent exertional SOB referred for surgical
revascularization after cath showed CAD.
Past Medical History:
HTN
lipids
TAH
tonsillectomy
Social History:
retired opthamologist
albanian
- tob
- etoh
Family History:
NC
Physical Exam:
59.8 inches 56.3 kg
NAD
Lungs CTAB
RRR No M/R/G
Abd benign
No C/C/E
Pertinent Results:
[**2120-9-9**] 06:10AM BLOOD WBC-4.7 RBC-3.39*# Hgb-10.8*# Hct-30.4*
MCV-90 MCH-31.9 MCHC-35.5* RDW-15.0 Plt Ct-237#
[**2120-9-9**] 06:10AM BLOOD Plt Ct-237#
[**2120-9-6**] 03:49AM BLOOD PT-13.6* PTT-27.5 INR(PT)-1.2*
[**2120-9-9**] 06:10AM BLOOD Glucose-99 UreaN-15 Creat-0.4 Na-141
K-3.6 Cl-106 HCO3-27 AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 52343**] [**Hospital1 18**] [**Numeric Identifier 52344**] (Complete)
Done [**2120-9-4**] at 11:29:04 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-7-15**]
Age (years): 68 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG.
ICD-9 Codes: 440.0, 424.1, 424.0
Test Information
Date/Time: [**2120-9-4**] at 11:29 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 35981**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2006AW02-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Valve Level: 1.7 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 220 ms 140-250 ms
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Left-to-right shunt across the
interatrial septum at rest. Secundum ASD.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness, cavity size,
and systolic function (LVEF>55%). Normal regional LV systolic
function. Overall normal LVEF (>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in ascending aorta. Simple atheroma in aortic
arch. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: No MVP. No MS. Mild to moderate ([**11-27**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was under
general anesthesia throughout the procedure. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left
ventricular wall motion is normal.
2. The aortic valve leaflets (3) appear mildly thickened with
good leaflet excursion. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
3. Mild to moderate ([**11-27**]+) mitral regurgitation is seen. There
is no mitral valve prolapse.
4. A secundum type atrial septal defect is present with a
left-to-right shunt across the interatrial septum seen
at rest.
5. Right ventricular chamber size and free wall motion are
normal.
6. No spontaneous echo contrast is seen in the left atrial
appendage.
POST-BYPASS:
1. Preserved [**Hospital1 **]-ventricular systolic function.
2. Mitral regurgitation is slightly improved - now mild.
3. No evidence of aortic dissection.
4. Chordal [**Male First Name (un) **] without LVOT obstruction.
5. Interatrial septum thickened - consistent with placement of
pledgets. Small "pin-hole" areas of left to right flow seen
across septum - normal for this repair.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
FINAL REPORT
INDICATION: Pleural effusion.
PA and lateral chest radiograph compared to bedside AP chest
radiograph dated
[**2120-9-6**]. In the interval, there has been development of
bilateral
pleural effusions, left larger than the right. There are
multiple linear
densities in the left lung, representing probably atelectasis.
Cardiomediastinal silhouette is unchanged, given differences in
technique.
There are no infiltrates. Osseous structures are unremarkable.
IMPRESSION: Interval development of bilateral pleural effusions,
left larger
than the right.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: MON [**2120-9-9**] 6:24 PM
Procedure Date:[**2120-9-9**]
?????? [**2116**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Ms. [**Known lastname **] was taken to the operating room on [**2120-9-4**] where she
underwent a CABG x 5 . She was transferred to the ICU in
critical but stable condition on propofol and neosynephrine. She
was extubated later that day. Her vasoactive drips were weaned
by POD #2 and she was transferred to the floor. She did well
postoperatively and was ready for discharge to home with VNA on
POD #5.
Medications on Admission:
asa, plavix, toprol, hctz, lipitor
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 tablets* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 1
weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva Health Services
Discharge Diagnosis:
s/p cabg x5
CAD
HTN
lipids
TAH
tonsillectomy
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2120-9-11**]
ICD9 Codes: 2768, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5263
}
|
Medical Text: Admission Date: [**2105-1-11**] Discharge Date: [**2105-1-17**]
Date of Birth: [**2021-12-18**] Sex: M
Service: MEDICINE
Allergies:
Blue Dye / Aspirin / Dyazide / Lisinopril / Ace Inhibitors
Attending:[**First Name3 (LF) 509**]
Chief Complaint:
bloody stool
Major Surgical or Invasive Procedure:
EGD polypectomy
History of Present Illness:
83yoM w/ PMH cerebral palsy, afib/recent DVT on coumadin+lovenox
with h/o bleeding gastric polyp s/p polypectomy [**9-22**] (this same
polyp was partial removed 5 years prior) and also w/
hospitalization [**Date range (1) 12661**] with UGIB p/w severe anemia and
melena. Patient states he has been having dark stools over the
past 3 days, but this morning while on the commode felt very
lightheaded after passing a very large amount of dark tarry
stool. He states that after this he was sufficiently concerned
enough to call EMS.
.
On most recent hospitalization earlier this month, patient
transfused 2 units. Upper endoscopy again revealed numerous
gastric polyps, the likely source of slow GI bleeding. His
warfarin was temporarily reversed and then restarted with
Lovenox in light of recent DVT. He is currently on a
coumadin/lovenox bridge.
.
In the ED, initial vs were: T 97 P 105 BP 110/52 R 24 O2 sat
100% 4LNC. Initial Hct was 16, INR 3.4. Patient was given 2
units PRBC's and 2 units FFP, as well as 1 liter NS in the ED.
Protonix drip was started, NGT/lavage was attempted x 2 (by ED
and surgery) but patient unable to tolerate. Femoral cordis
placed in ED, also w/ 3 PIV's.
.
On the floor, patient stated he felt lightheaded. Denied CP,
SOB, dyspnea, abdominal pain, dysuria, fevers, chills, BRBPR.
.
Past Medical History:
-h/o bleeding gastric polyp s/p polypectomy [**9-22**] (this same
polyp was partial removed 5 years prior)
-cerebral palsy (left HP)
-GERD
-DM2
-left ankle fracture s/p ORIF complicated by LLE DVT in [**11-23**]
(on coumadin)
-Bladder Ca
-HTN
-Hypercholesterolemia
-BPH
-pancreatic tail lesion (MRI sched as outpt)
-CRI - baseline Cr 1.7
PSH:
-ORIF - ankle fx
-appy
-heria repair
-AVR - '[**85**] - tissue valve
-TURBT s/p ORIF
DM
Social History:
Lives alone, has multiple friends come by the house to help w/
dog. Has a sister and [**Name2 (NI) 802**] on the West [**Name (NI) **], has a cousin who
lives nearby. No smoking, EtOH.
Family History:
Mother with melanoma.
Physical Exam:
Vitals: T: 97.1 BP: 138/60 P: 82 R: 16 O2: 95% on 2L NC
General: Alert, oriented, no acute distress, mildly dyspneic
with talking.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Ronchorus bronchial sounds. Basilar crackles bilaterally,
improved per MICU nurse. Lipoma on right chest and back.
CV: Irregularly irregular, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
[**Name (NI) **]: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2105-1-11**] 01:30PM BLOOD WBC-9.5 RBC-2.01*# Hgb-4.9*# Hct-16.1*#
MCV-80* MCH-24.5* MCHC-30.7* RDW-16.4* Plt Ct-370
[**2105-1-11**] 06:08PM BLOOD WBC-9.7 RBC-2.32* Hgb-6.3*# Hct-19.2*
MCV-83 MCH-27.3# MCHC-33.0 RDW-16.1* Plt Ct-231
[**2105-1-11**] 09:36PM BLOOD WBC-9.3 RBC-2.83* Hgb-7.9*# Hct-23.4*
MCV-83 MCH-27.9 MCHC-33.7 RDW-15.5 Plt Ct-199
[**2105-1-14**] 06:20AM BLOOD WBC-6.4 RBC-3.45* Hgb-10.1* Hct-30.1*
MCV-87 MCH-29.3 MCHC-33.5 RDW-17.1* Plt Ct-173
[**2105-1-16**] 04:55PM BLOOD WBC-6.9 RBC-3.93* Hgb-11.5* Hct-34.0*
MCV-87 MCH-29.4 MCHC-33.9 RDW-16.4* Plt Ct-179
[**2105-1-11**] 01:30PM BLOOD Neuts-82.4* Lymphs-14.2* Monos-2.4
Eos-0.6 Baso-0.5
[**2105-1-11**] 01:30PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-1+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**]
[**2105-1-11**] 01:30PM BLOOD PT-33.8* PTT-29.1 INR(PT)-3.4*
[**2105-1-11**] 06:08PM BLOOD PT-24.1* PTT-28.2 INR(PT)-2.3*
[**2105-1-16**] 06:45AM BLOOD PT-15.6* INR(PT)-1.4*
[**2105-1-17**] 07:00AM BLOOD PT-16.5* INR(PT)-1.5*
[**2105-1-11**] 01:30PM BLOOD Glucose-163* UreaN-63* Creat-1.9* Na-140
K-5.6* Cl-110* HCO3-23 AnGap-13
[**2105-1-11**] 06:08PM BLOOD Glucose-146* UreaN-61* Creat-1.7* Na-147*
K-5.3* Cl-115* HCO3-22 AnGap-15
[**2105-1-13**] 04:37AM BLOOD Glucose-133* UreaN-44* Creat-1.6* Na-149*
K-4.4 Cl-118* HCO3-24 AnGap-11
[**2105-1-16**] 06:45AM BLOOD Glucose-71 UreaN-25* Creat-1.2 Na-142
K-3.8 Cl-108 HCO3-26 AnGap-12
[**2105-1-11**] 06:08PM BLOOD CK(CPK)-57
[**2105-1-13**] 04:37AM BLOOD ALT-15 AST-18 AlkPhos-93 TotBili-0.4
[**2105-1-11**] 01:30PM BLOOD cTropnT-0.03*
[**2105-1-11**] 06:08PM BLOOD CK-MB-4 cTropnT-0.02*
[**2105-1-11**] 01:30PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
[**2105-1-13**] 03:00PM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1
[**2105-1-16**] 06:45AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0
[**2105-1-12**] 02:23AM BLOOD Lactate-1.3
[**2105-1-11**] 01:36PM BLOOD Hgb-5.1* calcHCT-15
[**2105-1-12**] 02:23AM BLOOD freeCa-1.01*
[**2105-1-12**] 05:44AM BLOOD freeCa-1.09*
[**2105-1-11**] 03:05PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2105-1-11**] 03:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
[**2105-1-11**] 3:05 pm URINE Site: CATHETER
**FINAL REPORT [**2105-1-12**]**
URINE CULTURE (Final [**2105-1-12**]): NO GROWTH.
[**2105-1-11**] CT abd/pelvis
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Small bilateral pleural effusions.
3. Stable pancreatic tail cystic lesion since [**2104-12-22**], though
lesion has
increased in size since [**2095**]. Please note, this lesion has been
characterized
on prior MRI Abdomen.
4. Large hiatal hernia.
[**2105-1-11**] Chest xray
IMPRESSION: AP chest compared to [**8-2**] and [**2104-11-25**]:
Large hiatus hernia, filled with air and fluid occupies the
midline. Heart
size is top normal, but there is greater mediastinal vascular
engorgement
reflecting mild volume overload. Lung volumes are lower and
making it
difficult to distinguish between mild dependent edema and
atelectasis,
particularly on the left. Small right pleural effusion is new.
No
pneumothorax.
[**2105-1-12**] LENI
FINDINGS: Grayscale, color and Doppler images were obtained of
bilateral
common femoral, superficial femoral, popliteal and tibial veins.
There is
normal flow, compression and augmentation seen in all the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in either leg.
[**2105-1-15**] Pathology Report Tissue: GI BX (1 JAR) Study Date of
[**2105-1-15**]
Report not finalized.
Assigned Pathologist BROWN,[**Hospital1 **] F.
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**-1/4919**]
EGD [**2105-1-12**]
Impression: Hiatal hernia noted.
Erythema and friability in the whole stomach compatible with
gastritis
Polyps in the stomach body
Bile noted in duodenum. Small lipoma visualized in 2nd portion
of the duodenum.
Otherwise normal EGD to second part of the duodenum
Recommendations: Hemorrhagic appearing gastric body polyps
likely source of melena. No other ulcer or source of bleeding
identified. Recommend continued PPI gtt, will discuss carafate
at a later date to aid. Do not initiate currently in the event
of recurrent bleed and need for endoscopic intervention. Will
discuss need for endoscopic resection given recurrent bleeding.
Please remain in ICU.
EGD [**2105-1-15**]
Findings: Esophagus: Normal esophagus.
Stomach: Protruding Lesions Four mixed polyps of benign
appearance with stigmata of recent bleeding and ranging in size
from 10 mm to 20 mm were found in the stomach body. Small
ulcerations were seen on the surface of 2 of the larger polyps.
Single-piece polypectomies were performed using a hot snare in
the stomach body. The polyps were completely removed. Two polyps
were retrieved for path.
Duodenum: Normal duodenum.
Impression: Polyps in the stomach body (polypectomy)
Recommendations: In patient care. NPO for 24 hours, then clear
liquids for another day. FFP as planned, serial hematocrits, PPI
Rx and carafate slurry for 72 hours.
Additional notes: The attending was present for the entire
procedure. FINAL DIAGNOSES are listed in the impression section
above. Estimated blood loss=zero. Specimens were taken for
pathology as listed.
Brief Hospital Course:
MICU Course [**Date range (1) 14898**]
.
#. GI Bleed: Patient presented with UGIB in setting of
supratherapeutic INR (3.4). He remained hemodynamically stable
during course. He was transfused a total of 7 U PRBCs, 3 [**Location 61464**], and received Vitamin K IV and PO. General surgery and GI
teams were consulted for further management. GI performed EGD
which demonstrated no active bleeding, but did identify polyps
as the likely source of his HCT drop. His HCT stabilized by the
time of transfer.
.
#. History of DVT: Supratherapeutic INR on admission;
lovenox/coumadin held in the setting of GI bleed. Duplex scan
demonstrated no residual clot in either leg.
.
#. Hypernatremia: The patient's sodium trended from 140 to 150
in setting of GI bleed. Derangement was believed to be
hypovolemic hypernatremia, as he was made NPO and lacked access
to free water. The patient was started on a slow infusion of D5W
to correct the metabolic abnormlity. This was corrected at time
of transfer to general wards.
.
*General Wards Course [**Date range (1) 103906**]*
# GI bleed: Pt was transferred form the MICU with plans to
undergo polypectomy w INR reversal to <1.4. His coumadin was
held on admission and he was given vit K x2 prior to transfer.
On [**1-15**] prior to EGD INR was 1.4 and he was transfused 1u FFP
pre-procedure and 2u FFP post-procedurally to encourage
hemostasis of polypectomy sites. EGD showed 4 polyps requiring
resection (+ulceration noted). He was started on carafate slurry
x 72 hours post procedure (stopped Sat evening), continued on
[**Hospital1 **] pantoprazole 40mg IV, and monitored w Q8 hct levels. His hct
was noted to be stable in his postprocedural course. He did not
require tranfusion of pRBCs on the general wards.
Anticoagulation was witheld for concern for rebleeding and
multiple episodes of GIB on coumadin in recent months. He was
discharged on PO omeprazole 40mg [**Hospital1 **] per GI recs. Tolerating
regular foods (passed speech/swallow evaluation).
Since pt is independent and lives alone, it was decided to send
pt for close monitoring for 3-4 days at rehab center and
physical therapy services. Pt was made aware that he may
continue to experience melenic stools for additional 5-7 days
given his current constipation. This does not necessarily
indicate re-bleed.
Plan to monitor clinically (BP, HR) and check Hct Sunday AM,
Monday AM, Wednesday AM, and Friday AM. If Hct stable, then
assume GI hemostasis. Hct level may fluctuate between 28 - 34
depending on lab variability and volume status/po intake.
Pt will follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] on [**2105-1-22**].
#. History of DVT: DVT diagnosed [**2104-11-25**], on coumadin prior
to admission for DVT treatment and afib w high CHADS score. DVT
was in setting of recent immobilization after ankle fracture,
and patient received approx 7 weeks of anticoagulation. Recent
LENI was negative for DVT obtained in MICU. Discussion was held
between PCP and inpatient team and given his recurrent GIB and
gastric polyps decision was made to avoid anticoagulation for
now. Decision for aspirin therapy deferred to outpt pending full
stability from GIB standpoint in [**3-19**] weeks. Dr. [**Last Name (STitle) 131**] aware of
plan.
.
#. Afib: Currently in paroxysmal afib with long PR, holding
anticoagulation as above. Repeat EKG showed NSR. He was
monitored and did not require any rate controlling meds.
.
# HTN: Restarted home dose of antihypertensives.
.
# HL: continued on home statin
.
# Pancreatic tail lesion: Unclear significance. MRCP ordered as
outpt. PCP aware, plan to follow as outpt.
.
# Urethral irritation: Foley cath was discontinued on [**1-16**] and
pt reports some urethral discomfort since it was removed. No
polyuria, WBC or fever to suggest UTI. Would expect some mild
discomfort for couple days but if symptoms persist would obtain
a UA to check for possible UTI. UA checked prior to discharge on
[**1-17**] was negative for WBC and suggested contamination rather
than infection. Pt is noted to be incontinent of urine at
baseline.
Medications on Admission:
ATORVASTATIN [LIPITOR] 10mg daily
ENOXAPARIN [LOVENOX] - 80 mg/0.8 mL Syringe SQ daily
GLIPIZIDE - 5 mg daily
LISINOPRIL - 10mg daily
OMEPRAZOLE - 20 mg daily
OXYBUTYNIN CHLORIDE [DITROPAN XL] - 5 mg daily
TAMSULOSIN [FLOMAX] - 0.4 mg daily
WARFARIN - 1 mg Tablet - 1.5-3 Tablet(s) by mouth as directed
AMLODIPINE [NORVASC] 10 mg daily
FERROUS SULFATE [SLOW RELEASE IRON] - (OTC) - Dosage uncertain
Discharge Medications:
1. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day for 14 days.
Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 3 days: mix tab w/ hot water to make a slurry and
drink 4 times daily. This medicine protects your stomach after
your procedure.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Upper GI bleed - ulcerated polyps
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for bleeding in your stomach
from polyps. These were removed by endoscopy (swallowed camera
test) and we consider them the likely source of your bleeding.
You were treated with IV anti-acid medication, carafate (protect
the stomach), and blood products to boost blood clotting
ability. We stopped your coumadin since the blood thinning
function was causing you to bleed.
It was decided to hold any anticoagulation at this time given
your multiple recent bleeding episodes. A leg ultrasound showed
resolution of the blood clot in your leg.
.
It is important to note that some bleeding is still expected
from your recent procedure. We recommend hematocrit checks on
Sunday and Monday, and this can be done 2x/week (Wed/Fri) next
week. Subsequently, hematocrit labs can be stopped and you can
be followed clinically for any concern for bright red bleeding.
.
You missed your MRCP as scheduled by your primary care doctor
due to your admission for your bleeding. Please discuss setting
this up as an outpatient if your primary care doctor would like
this completed.
.
The following changes were made to your medications:
- STARTED Carafate, mix tab w/ hot water to make a slurry and
drink 4 times daily. This medicine protects your stomach after
your procedure.
- STARTED Omeprazole 40 mg twice a day for acid control and to
prevent ulcers from forming
- STOPPED Coumadin
- STOPPED Enoxaparin
.
Please follow up with your doctors as stated below. Your primary
care doctor may decide to place you on an aspirin in the future,
once your bleeding has completely resolved.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2105-2-18**] at 1 PM
With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**]
When: Thursday [**2105-1-22**] at 10 AM
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
ICD9 Codes: 2760, 5849, 2720, 5859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5264
}
|
Medical Text: Admission Date: [**2167-10-29**] Discharge Date:
Date of Birth: Sex:
Service:
HISTORY: This 2040 gram IVF triplet #3 was born at 53+5
weeks gestation by cesarean section for maternal indications.
The patient is a 39-year-old Gravida 1, para 3. Pregnancy
was complicated by pregnancy hypertension since [**93**] weeks
gestation. Mother received prenatal betamethasone.
cesarean section on the day of the delivery.
PRENATAL LABS: Mother was Group B positive, antibody
negative, Hepatitis B surface antigen negative. RPR
nonresponsive. Rubella immune. The infant was born with
spontaneous respirations and received blow-by oxygen. Apgars
were 8 at one minute and 8 at five minutes.
PHYSICAL EXAMINATION: Weight 2040, less than 50 percentile.
Length 43.75 cm which is less than 50th percentile. Head
circumference 35 cm which was less than 50th percentile. Of
note in the physical examination the infant had tachypnea,
grunting, nasal flaring and retractions with bilateral
inspiratory crackles and was placed on nasal CPAP on
admission.
SUMMARY OF HOSPITAL COURSE BY SYSTEM:
Respiratory: The infant exhibited evidence of [**Last Name (un) 46909**]
membrane disease which was confirmed by videography which
showed ground glass appearance with air bronchograms
consistent with Surfactin deficiency on chest x-ray. The
infant was intubated and given endotracheal Surfactin. He
was extubated with 24 hours on nasal cannula oxygen. He
currently has oxygen requirement and is in nasal cannula with
an FIO2 of 1.0 and flow of 30 at 25 cc's per minute to
maintain saturation in the 90's. Respiratory rate today was
40 to 80 per minute with mild possible retractions.
Cardiovascular: He has had no cardiovascular issues and does
not have a murmur.
Fluids, Electrolytes and Nutrition: Initially was NPO and
commenced with 80 cc's per kilo of D10-W. Feeds were
commenced on day one of life and have been advanced as
tolerated at 120 cc's per kilo per day, of breast milk 22 or
PE 22 without any gastrointestinal intolerance. His weight
on discharge is 1895 grams.
Gastrointestinal: He developed hyperbilirubinemia of
prematurity and was commenced on phototherapy on [**2167-11-1**].
His maximum bilirubin was 10.6 with a direct 0.4 on [**2167-11-1**].
He is currently under phototherapy with a plan to discontinue
therapy tomorrow and recheck bilirubin subsequent to this.
Hematology: His initial hematocrit was 46.4, he has not
required any transfusions.
Infectious Disease. in view of his premature respiratory
distress he underwent a sepsis evaluation. His initial CBC
did not show any left shift and blood cultures were negative.
Antibiotics were discontinued at 40 hours of life.
Sensory/Audiology: Will require screening prior to discharge
from hospital.
Social: Parents have been updated on his progress at regular
intervals.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**Hospital **] Hospital.
NAME OF PRIMARY PEDIATRICIAN: Undetermined at this time.
CARE AND RECOMMENDATIONS: Feeds at discharge breast milk 22
or PE 22 at 120 cc's per kilo. Please advance his calories
as tolerated to maintain optimal growth.
MEDICATIONS: None.
State newborn screening: Sent on [**2167-11-2**].
IMMUNIZATIONS RECEIVED: None.
IMMUNIZATIONS RECOMMENDED: As per AP guidelines. He will
require Hepatitis B prior to discharge.
DISCHARGE DIAGNOSIS
1. Prematurity Triplet 3.
2. Respiratory distress syndrome requiring Surfactin times
one.
3. Sepsis evaluation.
4. Hyperbilirubinemia of prematurity requiring phototherapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2167-11-2**] 14:50
T: [**2167-11-2**] 19:15
JOB#: [**Job Number 34607**]
ICD9 Codes: 769, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5265
}
|
Medical Text: Admission Date: [**2180-5-3**] Discharge Date: [**2180-5-11**]
Date of Birth: [**2121-1-4**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
left sided headaches
Major Surgical or Invasive Procedure:
[**2180-5-3**] Left Suboccipital Craniotomy
History of Present Illness:
58 year old woman who is formerly a patient of Dr [**Name (NI) 14075**] for spinal issues who was originally referred to
us after she began to develop severe left sided headaches. She
has a history of headaches however these are different in
nature. She had an MRI scan which showed a left tentorial lesion
consistent with Meningioma and also had an audiogram which
showed no objective dB-hearing loss. It has been recommended
that the patient undergo surgical resection. She presents today
to discuss the surgery.
Past Medical History:
DM, HTN, HL, GERD
Social History:
on disability formerly worked in assembly for an electronics
company
Family History:
NC
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs full
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 or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice. (subjectively describes left as
decreased.)
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 [**4-13**] throughout. No pronator drift
Sensation: Intact to light touch
PHYSICAL EXAM UPON DISCHARGE:
awake a+ox3
PERRL, EOMI
face symmetric
no drift
MAE's with 5/5 strengths
following all commands.
Pertinent Results:
[**5-3**] MRI Brain: IMPRESSION: Unchanged left CP angle dural-based
enhancing mass, most likely a meningioma.
[**5-3**] CT Head: IMPRESSION: Status post left suboccipital
craniotomy and left CP angle tumor resection, with expected
post-surgical changes including a small amount of
pneumocephalus, small left-sided extra-axial fluid collection
and minimal blood products. No parenchymal hematoma.
[**5-4**] MRI Brain: IMPRESSION:
1. Status post recent left suboccipital craniectomy for subtotal
resection of left tentorial meningioma, with a small amount of
residual enhancing tissue in left Meckel's cave extending toward
foramen ovale. In addition, mild residual thickening and
enhancement of the tentorium could represent postoperative
changes versus a small amount of residual tumor.
2. Edematous post-operative changes in the posterior fossa are
seen with
downward displacement of the cerebellar tonsils and crowding of
the foramen magnum.
3. Mild lateral ventriculomegaly is new compared to the
preoperative
examination.
4. Decreased flow void and decreased enhancement of the left
sigmoid sinus. Patency of this structure is not well assessed
due to adjacent postoperative changes.
Brief Hospital Course:
Patient presented electively on 5.25 for left suboccipital
craniotomy for meningioma resection. She toelrated the procedure
well and was trasnported to the ICU for post-operative
monitoring. Post operatively patient was lethargic, but intact.
Post op head CT was stable with no new hemorrhage. On [**5-4**],
patient reported headache and n/v. She was still lethargic, but
neurologically stable. MRI head showed a small amount of
residual tumor.
Ms. [**Known lastname 10010**] was transferred to the floor form the ICU on [**5-6**].
She has some increased headaches on [**5-7**] for which Fioricet was
started, and a decadron wean was also initiated on this day.
Her blood pressure continued to be elevated between 160 and 180
and so her oral antihypertensive medications were titrated to
goal SBP less than 160.
On [**5-8**] her headaches continued to improved. She was encouraged
to get OOB and mobilize. Metformin was restarted.
On [**5-9**] she was again neurologically stable and was moving
better with improvements in dizziness and improvements in
headache. PT and OT consults for mobility and ADLs and
recommended acute rehab.
At the time of rehab she was tolerating a regular diet,
ambulating with a walker, afebrile with stable vital signs. On
[**5-11**], patient's exam remained stable, she was discharged to
rehab.
Medications on Admission:
amlodipine 10mg, Atenolol 50mg, lisinopril-HCTZ 20mg 2.5mg,
metformin 1000mg [**Hospital1 **], omeprazole 20mg, pravastatin 80mg,
rosiglitazone (avandia) 4mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
11. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q8 () for 2
days.
15. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q12 () for
2 days.
16. dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO q12 () for 2
days.
17. dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO qd () for 1
days.
18. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
19. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
20. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain.
21. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
22. 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.
23. Ondansetron 4 mg IV Q8H:PRN nausea
24. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
25. HydrALAzine 10 mg IV Q6H:PRN SBP>160
26. butalbital-acetaminophen-caff 50-325-40 mg Capsule Sig: [**12-12**]
Capsules PO every 4-6 hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you
should not resume taking these until cleared by your surgeon.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**6-18**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2180-5-11**]
ICD9 Codes: 2859, 2724
|
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|
Medical Text: Admission Date: [**2164-6-21**] Discharge Date: [**2164-8-6**]
Date of Birth: [**2086-9-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
This patient is a 77-year-old male diabetic who presents with
left foot abscess of the lateral aspect.
Major Surgical or Invasive Procedure:
1. Incision and drainage with partial resection of left fifth
ray.
2. Left common femoral to dorsalis pedis bypass graft, in-situ
angioscopy with valve lysis.
3. Exploration of left leg wound, status post bypass and control
of the bleeding.
4. Left transmetatarsal amputation with flap closure,
debridement of left ankle wound, and placement of a vacuum
dressing.
5. EGD
6. EGD
History of Present Illness:
This patient is a 77-year-old male diabetic who presents with
left foot abscess of the lateral aspect. Radiographs show
evidence of gas within the soft tissues.
Past Medical History:
PMH:
DM,
HTN
PSH:
s/p appy,
s/p crani for SDH (chronic)
Social History:
pos smoker - remote
pos alcohol - remote
Family History:
non contributary
Physical Exam:
PE:
Elderly male no apparent disress
AFVSS
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l, except lung bases there are fine cracles
CARDIAC: RRR with 2/6 sem
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp / Right TMA noted / open wound C/D/I
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2164-8-2**]
WBC-8.4 RBC-3.59* Hgb-10.7* Hct-32.1* MCV-90 MCH-29.7 MCHC-33.2
RDW-15.7* Plt Ct-277
[**2164-8-2**]
PT-13.1 PTT-27.6 INR(PT)-1.1
[**2164-8-2**]
Plt Ct-277
[**2164-8-2**]
Glucose-86 UreaN-24* Creat-1.4* Na-139 K-4.0 Cl-103 HCO3-25
AnGap-15
[**2164-8-2**]
Calcium-9.0 Phos-4.2 Mg-1.8
[**2164-7-25**]
calTIBC-156* Ferritn-337 TRF-120*
[**2164-7-5**]
%HbA1c-7.9
[**2164-7-25**]
TSH-1.7
[**2164-7-2**]
CRP-78.0
[**2164-7-10**]
freeCa-1.12
[**2164-8-1**]
DISCHARGE EKG:
Sinus rhythm. Poor R wave progression in leads VI-V3. No
diagnostic
abnormality. Compared to the previous tracing of [**2164-7-24**] low
amplitude T waves in leads V5-V6 have normalized.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 162 96 [**Telephone/Fax (2) 64197**] 2 19
[**2164-7-24**] 11:58 AM
CHEST (PORTABLE AP)
COMMENTS: A single AP upright view of the chest was reviewed and
compared with serial chest radiographs from [**2164-7-9**] to
the most recent of [**2164-7-17**].
The tip of a left-sided subclavian vascular catheter overlies
the mid SVC. There has been interval removal of a right
subclavian venous catheter. No pneumothorax is identified. The
heart size is normal. The mediastinal and hilar structures are
within normal limits. Small bilateral pleural effusions are
stable. Left retrocardiac opacification reflecting atelectasis
and/or pneumonia is unchanged. The pulmonary vasculature is
within normal limits.
IMPRESSION:
1. No pneumothorax.
2. Stable small bilateral pleural effusions.
3. Left retrocardiac opacification representing atelectasis
and/or developing pneumonia.
SCROTAL U.S.
SCROTAL ULTRASOUND: The right testicle measures 3.0 x 2.3 x 3.4
cm. The left testicle measures 3.0 x 2.5 x 4.0 cm. The
echogenicity of the testicle throughout is unremarkable. There
is a tiny, right-sided hydrocele. The epididymides are normal
bilaterally. There is a moderate-to-large amount of subcutaneous
soft tissue swelling.
IMPRESSION: Marked subcutaneous soft tissue edema. The testicles
are unremarkable.
[**2164-7-12**] 7:17 AM
PROCEDURE: The patient was placed supine on the angiographic
table and his left arm was prepped and draped in the sterile
fashion. Under ultrasound guidance, a 21-gauge needle was used
to enter the left brachial vein and a 0.018 guidewire was
advanced via the needle. The needle was removed and a 4.5
micropuncture introducer sheath was placed. An appropriate
length of a PICC line was then measured using the graded
guidewire and the length of the PICC line was accordingly
trimmed. The PICC line was then inserted via the peel- away
introducer sheath following removal of the internal dilator. The
tip of the PICC line was positioned within the SVC, which was
confirmed fluoroscopically.
The PICC line was secured to the skin with StatLock and a dry
sterile dressing was applied. The patient tolerated this
procedure well and was transported to the floor in good
condition.
IMPRESSION: Successful placement of a left brachial PICC line
with the tip in the SVC. The line is ready for use.
[**2164-6-26**]
VEIN MAPPING:
REASON: Preop for bypass.
FINDINGS: Duplex evaluation was performed of the left greater
saphenous vein. The vein is noted to be patent from the
saphenofemoral junction down through the ankle with vein
diameters ranging from 0.25 to 0.46. Other than a single
diameter of 0.25 in the mid calf vein, diameters are greater
than 0.3 cm throughout the remainder of the vein.
CT OF THE CHEST, ABDOMEN AND PELVIS
CT THORAX PRE- AND POST-CONTRAST FINDINGS: There is no dense
intramural hematoma involving the aorta. There is diffuse
atherosclerosis involving the aorta and coronary arteries. There
is concentric mural thrombus present at the proximal portion of
the left subclavian artery. There is no thoracic
lymphadenopathy. There is no pericardial or pleural effusion.
Lung windows demonstrate subsegmental atelectasis at the bases
bilaterally. Bone windows demonstrate degenerative changes in
the spine.
CT ABDOMEN PRE- AND POST-CONTRAST FINDINGS: Pre-contrast images
demonstrate no dense intramural hematoma involving the abdominal
aorta. In the right lobe of the liver, there is a heterogeneous
enhancing mass measuring 5.7 x 4.5 x 7.5 cm. Smaller enhancing
masses are also seen in the right lobe of the liver, best seen
on series 3 image 90 and series 3 image 98. The very large
lesion is barely visible on the pre-contrast images. The liver
is otherwise unremarkable. The spleen, pancreas, adrenal glands,
and kidneys are unremarkable. There are tiny low-density lesions
in the kidneys, which are too small to characterize on CT or any
other modality. The kidneys enhance symmetrically. There are no
dilated bowel loops. Degenerative changes are present in the
spine.
CT PELVIS FINDINGS: There is no pelvic free fluid or
lymphadenopathy. The prostate gland is enlarged. Degenerative
changes are present in the lumbosacral spine.
CTA FINDINGS: As mentioned above, there is a moderate amount of
mural hematoma involving the proximal left subclavian artery.
There is atherosclerosis of the thoracic aorta, but no
dissection or aneurysm present. Images of the abdominal aorta
demonstrate a focal outpouching of the right aspect of the
infrarenal aorta. An intimal flap is present over approximately
2 cm. This focal outpouching measures 2.1 x 1.1 cm in the
craniocaudal and transverse dimensions. More caudally, there is
a focal collection of a mural hematoma, which demonstrates
ulceration. There is a large amount of atherosclerosis
surrounding the focal aortic outpouching. No inflammatory
changes are present in the periaortic fat. There is diffuse
atherosclerosis of the iliac and femoral arteries. The celiac
axis, SMA, and [**Female First Name (un) 899**] are patent. There is patency of the renal
arteries demonstrated. There is mild atherosclerotic disease
involving the origins of the celiac axis, SMA, and renal
arteries. The splenic artery is patent proximally, but is
occluded in the pancreatic body. It is reconstituted more
distally. No flow is seen over approximately 9 mm through the
splenic artery. This is confirmed on the 0.5 mm thick images.
IMPRESSION:
1. Focal outpouching of the infrarenal aorta consistent with
focal dissection or penetrating ulcer. This is almost definitely
due to atherosclerotic disease and not infection as clinically
questioned.
2. Focal occlusion of the proximal splenic artery with distal
reconstitution. The spleen appears normal.
3. A large amount of mural thrombus in the infrarenal aorta,
caudal to the focal dissection. This thrombus is ulcerated. This
large amount of the thrombus could serve as a source of emboli.
The above findings are visualized on the 3D VR images.
4. Moderate amount of mural thrombus in the left subclavian
artery. Correlate with any evidence of ischemic symptoms or
signs involving the left upper extremity.
[**2164-6-25**]
ECHO
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
Aorta - Valve Level: *3.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.8 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 1.6 m/sec
Mitral Valve - E/A Ratio: 0.63
Mitral Valve - E Wave Deceleration Time: 274 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. No LV
aneurysm. Overall normal LVEF (>55%). No resting LVOT gradient.
No LV mass/thrombus. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic root. Focal calcifications in
aortic root. Mildly dilated ascending aorta. Focal
calcifications in ascending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve
leaflets. No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
Moderate mitral annular calcification. Mild thickening of
mitral valve chordae. Calcified tips of papillary muscles.
Prolonged (>250ms) transmitral E-wave decel time. LV inflow
pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. No left ventricular aneurysm is seen. Overall left
ventricular systolic function is normal (LVEF 60%). No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated.
The ascending aorta is mildly dilated. The number of aortic
valve leaflets cannot be determined. The aortic valve leaflets
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The left
ventricular inflow pattern suggests impaired relaxation. There
is no pericardial effusion.
STRESS Study Date of [**2164-6-25**]
EXERCISE RESULTS
INTERPRETATION: This 77 yo diabetic male was referred to the lab
for
evaluation prior to surgery. The patient was infused with 0.142
mg/kg/min of IV Persantine over 4 minutes. The patient denied
any arm,
neck, back or chest discomfort throughout the study. There were
no
significant ST segment changes noted. The rhythm was sinus with
rare
APB's. There was an appropriate hemodynamic response. Persantine
was
reversed with 125 mg of IV Aminophylline.
IMPRESSION: No anginal symptoms or ischemic EKG changes noted.
Nuclear
report sent separately.
[**2164-6-25**]
PERSANTINE MIBI
SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142
milligram/kilogram/min. Two minutes after the cessation of
infusion, Tc-[**Age over 90 **]m
sestamibi was administered IV.
INTERPRETATION:
Image Protocol: Gated SPECT
Resting perfusion images were obtained with thallium.
Tracer was injected 15 minutes prior to obtaining the resting
images.
This study was interpreted using the 17-segment myocardial
perfusion model.
The image quality is adequate
Left ventricular cavity is normal.
Resting and stress perfusion images reveal mild attenuation
artifact in the
anterior wall which correct; otherwise uniform tracer uptake
throughout the
myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 58%.
IMPRESSION: Normal myocardial perfusion study; EF 58%.
[**2164-6-25**] 3:52 PM
ABDOMINAL A-GRAM
FINDINGS: Patent infrarenal aorta with a saccular aneurysm. We
have arranged for a CT angiogram for assessment for possible
stent-graft placement.
Mural irregularity with mild narrowing of the origin of the
right common iliac artery. Further mural irregularity consistent
with atherosclerotic disease in the mid right common iliac
artery. The right external and internal iliac arteries are
patent.
The left common iliac, external iliac, and internal iliac
arteries are patent. The left common femoral artery is patent.
Mild mural irregularity consistent with atherosclerotic disease
in the left superficial and profunda femoral arteries. The left
superficial femoral and profunda femoral arteries are patent.
Mural irregularity consistent with atherosclerotic disease
involving the popliteal artery. There is a flow-limiting lesion
in the above knee popliteal artery. The popliteal artery more
distally is patent. The anterior tibial artery is occluded. The
peroneal artery is occluded. The posterior tibial artery is
patent in its most proximal aspect, but then has multiple areas
of stenoses proximally and then occludes in its mid portion. The
left posterior tibial artery is reconstituted in the distal
third of the leg by way of collaterals. The peroneal artery also
reconstitutes distally by way of collaterals. A collateral
vessel runs from the posterior tibial to the peroneal and distal
anterior tibial artery. The distal anterior tibial artery is
reconstituted by this collateral. The anterior tibial artery
continues into the left foot as a dorsalis pedis artery. The
distal peroneal artery provides a collateral to a plantar branch
in the foot. The distal anterior tibial artery just above the
ankle and continuing into the foot is of reasonable caliber.
PRESSURE MEASUREMENTS: Left common iliac artery, 218/95 mmHg,
mean 138 mmHg; distal aorta, 214/95 mmHg, mean 138 mmHg; right
common iliac artery, 210/96 mmHg, mean 138 mmHg; right external
iliac artery, 212/100 mmHg, mean 144 mmHg.
[**2164-6-21**] 2:26 PM
FOOT AP,LAT & OBL LEFT
Three views of the left foot show gas within the soft tissues
around the fifth toe and in relationship to the distal fourth
and fifth metatarsals. No bone destruction or fractures. Normal
joints. Vascular calcifications. Relatively normal bone
mineralization (noteworthy in the face of infection). No soft
tissue ulceration seen in profile. No comparison exams on PACS.
IMPRESSION: Gas gangrene. No radiographic evidence of
osteomyelitis.
[**2164-6-21**] 2:32 PM
ART EXT (REST ONLY)
FINDINGS: Bilateral 4-segmental cuff pressures, wave form
analyses and pulse volume recording were obtained. On the right
side is a biphasic wave form pattern at the femoral level with
monophasic patterns further peripherally. This is associated
flattening of the PVR curves. The right ankle vessel site
incompressible.
On the left side is also triphasic wave form pattern at the
femoral level. Monophasic signals with associated flattened PVR
curve than later seen. The left ankle pressure is 128 which was
a brachial pressure of 174 mm mercury gives a left-sided ankle
brachial index of .74.
SWAB
Site: FOOT - LEFT 5TH RAY FOOT.
GRAM STAIN (Final [**2164-6-22**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
WOUND CULTURE (Final [**2164-6-26**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
PROBABLE ENTEROCOCCUS. RARE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH OF THREE COLONIAL
MORPHOLOGIES.
NO ANAEROBES ISOLATED.
Brief Hospital Course:
Pt admitted on [**2164-6-21**], pt admitted to the Vascular service for
5th left toe ischemia.
Podiatry consult obtained.
Antibiotics started.
Cx taken.
[**2164-6-21**] - Incision and drainage with partial resection of left
fifth ray. Pt tolerated the procedure well. There were no
complications. Pt was extubated in the OR. He was transfered to
PACU in stable condition.
Once recovered from aneshtesia pt transfered to the VICU in
stable condition.
Pre-op meds started.
Wet to dry dsg changes.
[**2164-6-22**] - [**2164-6-24**]
Pt recovered from the above operation in the usual fashion. The
wound was watched.
Cardiology Consult obtained for clearence.
Pt scheduled for TEE / PMIBI.
Pt heart rate was tachy. Beta blocker increased.
[**2164-6-25**]
Pt recieves peripheral angiogram, Pt tolerates the proceudre
well there are no complications. Sheath is pulled without
incidence.
Antibiotics tailored to sensitivities.
Cardiology clears pt for anticipated surgeries.
[**2164-6-26**]
Pt becomes febrile / wound demarcating / Ischemic appearence, it
is decided that the pt needs revascularization.
Angiogram reveals that the pt needs BPG.
ID consult obtained.
Cat scan ordered.
[**2164-6-27**]- [**2164-7-4**]
Pt is stable.
Awaiting BPG. Antibiotics tailored. Labs followed. Standard
wound care. Pan cx for fevers.
Antibiotics dosed for appropriate levels.
[**Last Name (un) **] consult for diabetes.
Pt pre-op'd for procedure on the 17th for the 18th.
[**2164-7-5**] - Left common femoral to dorsalis pedis bypass graft,
in-situ angioscopy with valve lysis. Pt tolerated the procedure
well. There were no complications. Pt was extubated in the OR.
He was transfered to PACU in stable condition.
EKG checked according to cardiologist recommendations. No acute
changes noted.
While in the PACU it was noticed that the pt had some surgical
bleeding. It was decided to take the pt back to the OR.
[**2164-7-5**] - Surgical bleeding, status post femoral to dorsalis
pedis artery bypass graft. Pt tolerated the procedure well.
There were no complications. Pt was extubated in the OR. He was
transfered to PACU in stable condition.
Once recovered from aneshtesia pt transfered to the VICU in
stable condition.
Pt required post operative transfusions.
[**2164-7-6**] - [**2164-7-9**]
Pt monitered in the usual fashion. Remained stable. Pt was
deined. Diet advanced as toleraed. Foley left in place.
Case management and rehab consulted.
Pt lopressor increased for increase HR. Norvasc added.
Creatinie watched, pt had slight elevation. TMA planned. waiting
for decrease in creatinine.
Pt pre-op'd on the 22nd for procedure on the 23rd
[**2164-7-10**] - Left transmetatarsal amputation with flap closure,
debridement of left ankle wound, and placement of a vacuum
dressing. Pt tolerated the procedure well. There were no
complications. Pt was extubated in the OR. He was transfered to
PACU in stable condition.
Wound vac placed intra - op.
Once recovered from aneshtesia pt transfered to the VICU in
stable condition.
Pt non weight bearing on surgical site.
[**2164-7-11**] - [**2164-7-16**]
Pt transfered to the floor status
Nutrition consult obtained.
Vac dsg change accordingly, pt remained on Antibiotics.
PICC line placed.
Pt transfused for low HCT. Pt guiac pos.
Antibiotics tailored.
[**2164-7-17**]
HCT 17 - transfered to the VICU.
A-line placed without difficulty.
GI consulted for GI bleed. - Pt gets emergent EGD /
electrcautery and epi was used to successfully obtain
hemostasis.
Protonix started.
Pt transfered to the SICU after the EGD.
[**2164-7-19**] - [**2164-7-23**]
Pt transfused for HCT ovewr 30.
lytes / coags / cbc - monitered
Pt watched untill HCT stabalized. Once stabalized pt pt
transfered to floor staus.
[**2164-7-24**]
It was noticed that the pt had scrotal edema. A urology consult
was obtained. This was likely due to fluid ovrload. Pt started
on lasix.
Also a hospitalist consult was obtained. It was noticed that the
pt also had anascoria. Again lasix was used to diuresis the pt.
Lytes were follwed. Electrolytes were replenished.
Daily weights follwed.
Vac continued to be changed.
Pt has insurance issues. A social consult obtained.
[**2164-7-25**] - [**2164-7-30**]
Pt monitered.
Social people working on placement. Pt has no insurance.
Awaiting placement.
HCT stable.
GI wants to rescope pt before discharge to check for bleeding.
HCT remains stable.
[**2164-7-31**] - EGD, Pt tolerated the procedure well. There were no
complications.He was transfered to recovery room in stable
condition.
Once recovered pt transfered to the Floor in stable condition.
Nutrition epaorts that pt has adaquate calories from intake. No
TF at this time.
[**2164-8-1**] - present
awaiting DC
Pt stable on discharge, taking PO, pos urination, pos BM,
ambulating with asst.
[**2164-8-6**] awaiting for d/c home. Onset over week end of loose
stools . started on flagyl emperically. Should continue for
total of four weeks.Stool for cdiff sent results pending.
Medications on Admission:
insulin 22/12 (?NPH);
?antihypertensive
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Megestrol 40 mg/mL Suspension Sig: One (1) PO DAILY (Daily).
Disp:*30 40 mg* Refills:*2*
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. 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*
12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
14. Insulin Sliding Scale & Fixed Dose Fingerstick QACHS,
3AMInsulin SC Fixed Dose Orders Breakfast Bedtime NPH 8 Units
NPH 12 Units Insulin SC Sliding Scale Glucose Insulin Dose 0-60
mg/dL 8 oz orang juice Breakfast Lunch Dinner Bedtime Regular
Regular Regular Regular 61-110 mg/dL 2 Units 2 Units 0 Units 0
Units 111-160 mg/dL 4 Units 3 Units 6 Units 0 Units 161-200
mg/dL 7 Units 4 Units 8 Units 0 Units 201-240 mg/dL 9 Units 6
Units 9 Units 2 Units 241-280 mg/dL 11 Units 8 Units 11 Units 3
Units 281-320 mg/dL 13 Units 10 Units 13 Units 4 Units > 320
mg/dL Notify M.D.
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 8 units
8 units Subcutaneous breakfast. Disp:*5 100 unit/mL *
Refills:*2*
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 12 unts
12 units Subcutaneous bedtime. Disp:*5 100 unit/mL * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
CAREGROUP
Discharge Diagnosis:
Perpheral Vascular Disease and Necrotic Toe
presumtive c diff
Discharge Condition:
to be filled in
Discharge Instructions:
ACTIVITY: There are restrictions on activity. On the side of
your toe amputation you are non weight bearing for 4-6 weeks.
You should keep this amputation site elevated when ever
possible. You may use the heel of your amputation site for
transfer and pivots. But try not to exert to much pressure on
the site when transferring and or pivoting. If possible avoid
using the heel of your amputation site when transferring and
pivoting.
.
No driving until cleared by your Surgeon.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your leg wound(s).
.
New pain, numbness or discoloration of your foot or toes.
.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Exercise:
.
Limit strenuous activity for 6 weeks.
.
Do not drive a car unless cleared by your Surgeon.
.
No heavy lifting greater than 20 pounds for the next 14 days.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
MEDICATIONS:
.
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
.
No strenuous activity for 6 weeks after surgery.
.
DIET:
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
Please Call Dr.[**Name (NI) 7257**] Office for a follow up visit
Completed by:[**2164-8-6**]
ICD9 Codes: 2851, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5267
}
|
Medical Text: Admission Date: [**2164-1-25**] Discharge Date: [**2164-2-9**]
Date of Birth: [**2105-6-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillin G / Sulfa (Sulfonamide Antibiotics) / Meperidine /
Hydrochlorothiazide / Furosemide
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
This is a 58 year-old female with a history of CHF, COPD on 2L
NC, DM, HTN, HL, h/o DVT not on coumadin, psychogenic polydipsia
who was transferred from [**Hospital3 **] with a sodium of
111 thought secondary to polygenic polydipsia. The patient
reports that she had gained 4lbs over the last few days, but
otherwise was in her normal state of health. The patient
reports that today she felt weak and fell while going to the
bathroom. She could not recall if she had LOC or had head
trauma, but no obvious trauma on exam. When she was in the
ambulance en route to the OSH she developed acute SOB and was
placed on CPAP without much benefit. Her labs were significant
for Na 111 and given 1L NS x1. They did not have bed and
transferred her to [**Hospital1 18**].
In the ED, afebrile 105 139/86 16 99% 4L NC. Her labs were
significant for a sodium of 117. She had CE negative x1 and BNP
273. She was given ASA 325mg. She reported continued SOB. She
was given albuterol/ipratropium nebs and 60mg prednisone. A CXR
showed cardiomegaly. They performed a bedside U/S and did not
appreciate a pericardial effusion. There was concern for volume
overload and she was started on a nitro gtt for pre-load
reduction. She was also placed on CPAP. A gas was obtained
7.44/48/148/34 that the ED reported as a VBG. A CT-head was
negative.
On arrive to the ICU she remained on CPAP. She stated that her
breathing had improved some what, but was still labored. During
repositioning the patient had an acute desat to the low 80's
with significant, audible wheeze. Her sats improved with a
combivent neb and she was placed back on CPAP. Her breathing
improved and she then rested comfortably.
Of note, the patient reports that in [**9-29**] she was admitted to an
OSH ICU for aggressive diuresis and lost 87lbs during that
admission. She then spent another 3 weeks at rehab and has been
at home since.
ROS:
stable 2 pillow orthopnea, denied PND and reported stable lower
ext edema.
The patient denies any fevers, chills, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, cough urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
CHF
COPD on 2L NC at home
Diabetes
HTN
Hyperlipidemia
Pulmonary HTN
h/o DVT not on anti-coagulation
Psychogenic Polydipsia
Osteoporosis
Fibromyalgia
Occipital Neuralgia
Trigiminal Neuralgia
Osteoarthritis
Degenerative Disc Disease
.
Surgical History:
Tonsillectomy age 4
Cholecysectomy at age 75
s/p hysterectomy
Social History:
The patient lives with her husband, mother-in-law, daughter at
home. She smoked [**3-23**] ppd x 46 years, but recently quit in [**Month (only) **].
No EtOH or IVDU.
Family History:
Adopted.
Physical Exam:
Admission:
GEN: obese, labored breathing with accessory muscle use.
moderate distress.
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM, OP Clear
NECK: difficult to assess JVD given habitus, carotid pulses
brisk, no bruits, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: bibasilar crackles otherwise no W/R
ABD: obese, soft, NT, ND, +BS
EXT: No C/C/ +2 edema to the knees
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing.
Discharge:
Pertinent Results:
[**2164-1-25**] ECG:
Moderate baseline artifact. The rhythm appears to be a narrow
complex
tachycardia at a rate of 109. P waves are seen in some of the
leads and it
appears to be sinus tachycardia with occasional atrial premature
beats.
There are non-specific ST-T wave changes noted in leads II, III
and aVF. No other diagnostic abnormality. No previous tracing
available for comparison.
[**2164-1-25**] CXR:
Mild cardiomegaly with small bilateral effusions and possible
mild
pulmonary congestion.
[**2164-1-25**] HEAD CT W/O CONTRAST:
No acute intracranial process.
[**2164-1-26**] CXR PORTABLE:
As compared to the previous radiograph, there is massive
unchanged
cardiomegaly without evidence of overhydration. No pleural
effusions, no
focal parenchymal opacity suggesting pneumonia.
ECHO [**2164-1-26**]:
Left ventricular wall thicknesses are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). The aortic valve is not well seen. There is
no valvular aortic stenosis. The increased transaortic velocity
is likely related to high cardiac output. No aortic
regurgitation is seen. The mitral valve leaflets are not well
seen. Physiologic mitral regurgitation is seen (within normal
limits). The pulmonary artery systolic pressure could not be
determined. There is a small to moderate sized, circumferential
pericardial effusion, measuring 1.8 centimeters in greatest
dimension. The effusion is echo dense, consistent with [**Month/Day/Year **],
inflammation or other cellular elements. No right atrial
diastolic collapse is seen. No right ventricular diastolic
collapse is seen.
IMPRESSION: Small to moderate sized, circumferential pericardial
effusion, measuring 1.8 centimeters in greatest dimension. Echo
dense effusion, consistent with [**Month/Day/Year **], inflammation or other
cellular elements. No echocardiographic evidence of pericardial
tamponade.
CTA CHEST ([**2164-1-30**]):
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions, moderate on the left and small
on the right with associated compressive atelectasis. No
definite parenchymal
abnormalities identified.
3. Cardiomegaly and atherosclerotic calcification of the
coronary arteries.
4. Small hiatal hernia.
[**2164-1-31**] CXR:
As compared to the previous radiograph, there is no relevant
change. Moderate cardiomegaly with mild overhydration.
Retrocardiac
atelectasis. Potential minimal left pleural effusion. No focal
parenchymal
opacity suggesting pneumonia.
[**2164-2-7**] ECHO: (FOCUSED STUDY, PERICARDIAL EFFUSION)
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. with normal free wall
contractility. There is a small to moderate sized pericardial
effusion. The effusion is echo dense, consistent with [**Month/Day/Year **],
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2164-1-26**], the
pericardial effusion appears similar.
[**2164-2-8**] ABDOMINAL ULTRASOUND:
No ascites.
[**2164-2-5**] 07:20AM [**Month/Day/Year 3143**] WBC-5.3 RBC-3.61* Hgb-10.5* Hct-31.8*
MCV-88 MCH-28.9 MCHC-32.9 RDW-15.4 Plt Ct-265
[**2164-1-25**] 06:17PM [**Year/Month/Day 3143**] WBC-9.4 RBC-3.34* Hgb-9.6* Hct-27.8*
MCV-83 MCH-28.7 MCHC-34.5 RDW-14.8 Plt Ct-353
[**2164-2-9**] 07:40AM [**Month/Day/Year 3143**] PT-29.9* INR(PT)-3.0*
[**2164-1-25**] 06:17PM [**Year/Month/Day 3143**] PT-13.3 PTT-25.1 INR(PT)-1.1
[**2164-2-9**] 07:40AM [**Month/Day/Year 3143**] UreaN-22* Creat-0.7 Na-135 K-4.3 Cl-97
HCO3-29 AnGap-13
[**2164-1-25**] 06:17PM [**Year/Month/Day 3143**] Glucose-176* UreaN-11 Creat-0.5 Na-117*
K-4.9 Cl-75* HCO3-31 AnGap-16
[**2164-1-27**] 03:38AM [**Year/Month/Day 3143**] ALT-17 AST-27 AlkPhos-186* TotBili-0.2
[**2164-1-28**] 12:59AM [**Year/Month/Day 3143**] CK-MB-2 cTropnT-LESS THAN
[**2164-1-27**] 06:58PM [**Year/Month/Day 3143**] CK-MB-3 cTropnT-<0.01
[**2164-1-27**] 11:25AM [**Year/Month/Day 3143**] CK-MB-3 cTropnT-<0.01
[**2164-1-26**] 04:33AM [**Year/Month/Day 3143**] CK-MB-6 cTropnT-<0.01
[**2164-1-25**] 06:17PM [**Year/Month/Day 3143**] CK-MB-10 MB Indx-1.3 cTropnT-<0.01
proBNP-273*
[**2164-2-5**] 07:20AM [**Month/Day/Year 3143**] Calcium-9.5 Phos-4.5 Mg-1.8
[**2164-2-9**] 07:40AM [**Month/Day/Year 3143**] Mg-1.8
[**2164-1-26**] 04:33AM [**Year/Month/Day 3143**] Calcium-9.0 Phos-3.2 Mg-1.9 Iron-15*
[**2164-1-26**] 04:33AM [**Year/Month/Day 3143**] calTIBC-274 Hapto-368* Ferritn-256*
TRF-211
[**2164-1-25**] 06:17PM [**Year/Month/Day 3143**] Osmolal-244*
[**2164-1-27**] 07:55PM [**Year/Month/Day 3143**] Type-ART pO2-86 pCO2-49* pH-7.49*
calTCO2-38* Base XS-12
[**2164-1-27**] 11:22AM [**Year/Month/Day 3143**] Type-ART Temp-37.2 FiO2-40 pO2-100
pCO2-62* pH-7.39 calTCO2-39* Base XS-9 Intubat-NOT INTUBA
[**2164-1-26**] 11:57AM [**Year/Month/Day 3143**] Type-ART Temp-37.8 PEEP-6 pO2-63*
pCO2-48* pH-7.48* calTCO2-37* Base XS-10 Intubat-NOT INTUBA
Vent-SPONTANEOU Comment-AXILLARY
[**2164-1-25**] 09:23PM [**Year/Month/Day 3143**] Type-[**Last Name (un) **] Temp-37.2 O2 Flow-2 pO2-148*
pCO2-48* pH-7.44 calTCO2-34* Base XS-7 Intubat-NOT INTUBA
[**2164-1-26**] 3:01 am URINE Source: Catheter.
**FINAL REPORT [**2164-1-29**]**
URINE CULTURE (Final [**2164-1-29**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
[**2164-1-28**] 1:02 pm URINE Source: Catheter.
**FINAL REPORT [**2164-1-29**]**
URINE CULTURE (Final [**2164-1-29**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
313-4832M
([**2163-1-26**]).
[**2164-1-26**] 8:30 am [**Year/Month/Day 3143**] CULTURE X2 Source: Venipuncture.
**FINAL REPORT [**2164-2-1**]**
[**Year/Month/Day **] Culture, Routine (Final [**2164-2-1**]): NO GROWTH.
Brief Hospital Course:
Congestive heart failure, diastolic, acute on chronic. Admitted
with dyspnea and hypoxia with CXR showing cardiomegaly and
pulmonary edema. She had an episode of respiraory decompensation
where she became cyanotic, O2 sat 67%, tachycardic and went into
rapid AF. After diuresis in the ICU, her respiratory status
improved with continuation of home oxygen at 2 liters via nasal
canula. Was continued on [**Last Name (un) **] with initiation of beta-blocker
(toprol xl 50mg po daily). Her diuretic regimen was adjusted to
ethacrynic acid 50mg po bid (was on 12.5mg po bid), bumex was
discontinued for simplification and spironolactone 25mg po bid.
She was set up with the advanced heart failure clinic at [**Hospital1 18**]
for follow up and set up with tele-health for closer home
monitoring. Per the patient's daughter there may be a
significant component of dietary / fluid restriction non
compliance. In the hospital the patient's fluid restriction was
2000cc, on this and on the current diuretic regimen she was
observed and was net negative 500cc so I have liberalized her
fluid restriction for home slightly to 2.5 liters per day. In
addition the patient complained of difficulty breathing that she
thought was associated with her abdomen pressing up on her
diaphragm, this was most likely related to obesity given that
her abdominal ultrasound revealed no ascites.
Paroxysmal atrial fibrillation. One episode of atrial
fibrillation which terminated with metoprolol IV. Spoke with PCP
who has OK with long-term anticoagulation with coumadin though
was concerned over potential compliance issues. She was
discharged on coumadin 5mg po daily, INR was 3.0 on [**2164-2-18**].
Hyponatermia. Na of 111 at the OSH and 117 on arrive to [**Hospital1 18**].
Uosm on admission (150) suggested polydipsia, a diagnosis she
has previously carried. Sodium improved with fluid rescriction.
Urinary tract infection, ESBC e.coli. Completed 8 days of
meropenem.
COPD. On 2L home oxygen. During ICU stay, treated for a COPD
exacerbation with 5 days of azithromycin and 2 days of high dose
prednisone. Her steroids were then decreased to prednisone 5mg
daily then weaned off (discussed with PCP). Continued on BiPAP
at night.
Chronic Pain. History of chronic back and LE pain. Continued on
home regimen.
Possible pericardial effusion. Moderate sized echodense effusion
noted on TTE measuring 1.8 centimeters in greatest dimension,
however, this has been previously seen on earlier imaging and
may have represented a fat pad. Echo on [**1-26**] suggested that
since this was echo dense it could be [**Last Name (LF) **], [**First Name3 (LF) **] this echo was
repeated on [**2164-2-7**] to see if the effusion worsened while she
was anticoagulated, actually per echo attending [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**]
the effusion has decreased slightly in size and the echo dense
portion very likely represented a fat pad. She will f/u with
cardiology as an outpatient.
DNI/DNR during this admission, discussed with patient and
daughter
Medications on Admission:
Benacar 40mg QDay
Cymbalta 60mg QDay
Lyrica 50mg TID
Ethacrynic Acid 12.5mg [**Hospital1 **]
Spironolactone 25mg [**Hospital1 **]
Bumex 2mg [**Hospital1 **]
Ferrous sulfate 325mg [**Hospital1 **]
Spiriva daily
Advair 250/50 1 puff [**Hospital1 **]
Prednisone 5mg daily
Calcium- Vitamin D
Trazadone 25mg qhs
Lantus 38units
amitriptyline 150mg qhs
Soma 350mg 2 tablets QID
Vicodin 750mg 1 tablet QID
Combivent nebs prn QID
Simvastatin 80mg QDay
Omeprazole 40mg [**Hospital1 **]
Calcium-Vitamin supplementation
Tylenol prn
Meclizine prn
Discharge Medications:
1. olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. pregabalin 50 mg Capsule Sig: One (1) Capsule PO three times
a day.
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Calcium 500 + D Oral
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime.
10. amitriptyline 150 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Soma 350 mg Tablet Sig: Two (2) Tablet PO four times a day.
12. hydrocodone-acetaminophen Oral
13. Combivent 18-103 mcg/Actuation Aerosol Sig: [**1-22**] Inhalation
four times a day as needed for shortness of breath or wheezing.
14. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
16. ethacrynic acid 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
17. insulin glargine 100 unit/mL Solution Sig: Thirty Eight (38)
units Subcutaneous at bedtime.
18. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
19. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
the dose of this will change based on your level (INR).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Respiratory failure (pulmonary edema) with hypoxemia
2. Hyponatremia
3. UTI, bacterial
4. Atrial fibrillation
5. Diabetes, type II
6. Hypertension
7. Back pain, chronic
8. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with low sodium levels (hyponatremia) and
breathign difficulties. The sodium level is likely related to
excess intake of fluids.
Please be sure to limit your intake to no more than 2500mL (2.5
liters) per day.
Note the following changes to your medication list:
START metoprolol
START warfarin
STOP prednisone
STOP bumex
INCREASE the dose of ethacrynic acid
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2164-2-27**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S. , [**Location (un) **],MA
Phone: [**Telephone/Fax (1) 15916**]
Fax: [**Telephone/Fax (1) 83587**]
****NOTE--You Visiting Nurse will be drawing [**Telephone/Fax (1) **] during her
visit this Friday. Please have her fax [**Telephone/Fax (1) **] results to Dr
[**Last Name (STitle) 89479**] office at number above.
ICD9 Codes: 4280, 2761, 5990, 4019, 4168, 2859, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5268
}
|
Medical Text: Admission Date: [**2101-5-16**] Discharge Date: [**2101-6-14**]
Date of Birth: [**2032-12-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Right renal tumor.
Major Surgical or Invasive Procedure:
[**2101-5-16**]: Open partial nephrectomy from the transplanted kidney
[**2101-5-24**]: Exploratory laparotomy with lysis of adhesions
History of Present Illness:
68 y/o male who developed renal failure likely secondary to
hypertension and underwent a cadaveric kidney transplant at
[**Hospital6 **] in [**2097**]. He has done well since his
transplant, but on routine screening he was found to
have a mass in the upper pole of his transplant kidney in the
right iliac fossa as well as a left adrenal mass. He has no
complaint of pain and has been feeling fine. He has not had
chest pain, shortness of breath, hematuria or flank pain. He has
been seen by Dr [**Last Name (STitle) 3748**] in urology and is to undergo surgery with
Drs [**Last Name (STitle) 3748**] and [**Name5 (PTitle) 816**] for mass excision from the transplant
kidney.
Past Medical History:
HTN
s/p cadaveric renal transplant [**2097**] at [**Hospital1 2177**]
s/p cataract surgery
Social History:
Married with 2 grown children. Moved to US from Bangaladesh
Family History:
Mother with HTN, father with DM
Physical Exam:
Post Op
VS: 97.8, 73, 134/51, 17, 98% 3LNC
Gen: Sleepy, NAD Pain [**3-26**] on pCA
Card: RRR
Lungs: CTA bilaterally
Abdomen: distended, soft, appropriately tender
Pertinent Results:
On Admission: [**2101-5-16**]
WBC-17.5*# RBC-3.57* Hgb-10.5* Hct-30.8* MCV-86 MCH-29.3
MCHC-34.0 RDW-13.5 Plt Ct-169
Glucose-184* UreaN-18 Creat-1.7* Na-134 K-4.8 Cl-107 HCO3-20*
AnGap-12
Calcium-8.2* Phos-3.3 Mg-2.3
On Discharge: [**2101-6-14**]
WBC-10.0 RBC-3.13* Hgb-9.1* Hct-28.4* MCV-91 MCH-29.0 MCHC-31.9
RDW-15.8* Plt Ct-374
PT-14.6* PTT-31.2 INR(PT)-1.3*
Glucose-104 UreaN-30* Creat-1.5* Na-139 K-4.8 Cl-110* HCO3-23
AnGap-11
Albumin-3.1* Calcium-8.9 Phos-2.7 Mg-1.8
tacroFK-6.8
Iron Studies [**2101-6-12**]:
Iron-24* calTIBC-237* Ferritn-676* TRF-182*
Brief Hospital Course:
68 y/o male admitted following partial transplant nephrectomy
for mass in transplant kidney found on routine screening. Due to
the complex nature of this case, patient went to the OR with Dr
[**Last Name (STitle) 3748**] from urology and Dr [**Last Name (STitle) 816**] with Transplant. It was stated
that due to the complex nature of this case, two attendings were
present for the case involving Open partial nephrectomy from the
transplanted kidney.
In summary, the transplanted kidney was completely encased in a
large amount of scar
tissue making dissection difficult. The tumor was excised, and
JP drain was placed. Please see the surgical notes of both Dr
[**Last Name (STitle) 816**] and Dr [**Last Name (STitle) 3748**] for details.
In the post op period, his pain was controlled using a PCA.
Urine output and residual renal function were excellent.
Pathology of the tumor revealed "Oncocytoma, margin free of
tumor"
On about POD 6, the patient was noted to be increasingly
distended. Bowel function was very sluggish post op, in addition
to a notation on labs of increased WBC as well as development of
fever. A CT of the abdomen was obtained showing "Moderate grade
partial small bowel obstruction with transition point noted
within the right lower quadrant, slightly anterior to the
transplant kidney."
He was taken back to the OR on [**2101-5-24**] again with Drs' [**Name5 (PTitle) 816**] and
[**Name5 (PTitle) 3748**] for Exploratory laparotomy with lysis of adhesions and
freeing up obstruction. Per the operative report lysis of
adhesions of the bowel was done and the finding that the
terminal ileum had been plastered down to the area of the
kidney. This was felt to be the transition point seen on CT and
this was the cause of the obstruction. No bowel perforation was
found or other evidence of intra-abdominal pathology seen. There
was a significant amount of fluid encountered when the patient
was opened. This fluid was sent for culture and lab tests.
Creatinine was low, so it was not felt to be a urine leak.
Enterococcus (Vanco sensitive) did grow from the fluid as well
as from blood cultures obtained the same day. Urine cultures
from the day previous were also positive for Enterococcus and he
was started on Vancomycin and Flagyl which were given x 7 days.
An ID consult was obtained.
He was switched to Ampicillin on [**2101-5-27**] and this was continued
for 9 days. In addition he received Levaquin for a total of 11
days.
The patient was started on TPN via a PICC line, this was
continued for about two weeks. PO diet was started back slowly,
he will be seen as an outpatient by nutrition. PICC line was
d/c'd prior to his discharge.
The patient started with increased stooling, and C diff A&B was
sent. The cultures were negative x 5, however he was started on
PO Vanco as his WBC remained elevated, and no other source was
identified. A CMV viral load was sent which was positive at 909
copies, he was started on a 3 week course of Valcyte. He also
has a positive HSV screen from a lesion on his lip. The Valcyte
will cover both. In addition, he had a stool for CMV sent, which
was negative up to this time, but had not yet been finalized.
Approximately 2 weeks into the hospitalization, the patient
developed new onset AFib. He was chemically converted on
Amiodarone and was started on a heparin drip. Due to the
interaction between amiodarone, Prograf and Coumadin, the
patient was started on half dose Coumadin on [**6-3**]. Over the next
2 days, his Hct was noted to fall from 27% to 17%. The
anticoagulation was stopped and he received 3 units of pRBC's.
Of note, his stool at this time was noted to be dark and guaiac
positive. The heparin drip and coumadin were placed on hold. The
amiodarone was discontinued and it was decided to rate control
the patient which was well achieved with beta blockade. The
coumadin was restarted at an even lower dose, as well, the
heparin remained off and he was started on Lovenox injection,
which he will be continuing at home short term.
Dr [**Last Name (STitle) 3748**] performed a cystoscopy on [**6-7**] due to concern for
fluid from the JP drain from initial surgery was found to have a
creatinine of 22.9. He underwent cystoscopy, a 4.8 French x 10
cm double-J stent was placed with the proximal coil in the
collecting system and distal coil in the bladder. A Foley drain
was left in place which should be left in place for two weeks.
Patient to be seen in followup clinic with Dr [**Last Name (STitle) 3748**]. A JP drain
is also in place, removal will be following Foley removal by
several days and will be determined by urology.
Patient was given a glucometer and will check blood sugars at
home. Given signs and symptoms of low blood sugar and started on
Glipizide [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations.
Scripts were given to the patient for new medications which will
be filled at patients home transplant center [**Hospital 86**] Med Center
at their free pharmacy as this has been his usual source for his
medications.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (pager [**Telephone/Fax (1) 78181**], fax [**Telephone/Fax (1) 77542**], his PCP
will be monitoring PT/INR and was contact[**Name (NI) **] on [**6-14**] to verify
this. VNA will draw and fax results of first two INRs and then
they will be arranged as an outpatient.
Medications on Admission:
lopressor 100", cozaar, hctz, spironolactone, hydralazine,
lipitor 10, asa 81, colace, hytrin
Discharge Medications:
1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
2. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
twice a day.
9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Hytrin 10 mg Capsule Sig: One (1) Capsule PO at bedtime.
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
12. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
13. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 17 days.
Disp:*17 Tablet(s)* Refills:*0*
14. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
16. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous once
a day for 5 days.
Disp:*5 syringes* Refills:*0*
17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
18. One Touch II Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] once
a day.
Disp:*1 vial* Refills:*2*
19. Lancets Misc Sig: One (1) Miscellaneous once a day.
Disp:*1 vial* Refills:*2*
20. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right renal tumor - oncocytoma
Afib
CMV
anemia
urinary leak
ileus, resolved
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 816**] at [**Telephone/Fax (1) 673**] if you have
temperature>101.5, chills, nausea or vomiting, worsening
abdominal pain, vomiting blood or bloody/black bowel movements,
redness/pus or drainage around incision, or drains, cloudy foul
smelling urine, or drain output stops or increases
Empty the drain (JP) and foley (urine bag) when half full and
record volume of outputs. Bring this record of drain/urine
outputs to next appointment with Dr. [**Name (NI) 816**]
PT and INR will be drawn by the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 16337**] [**6-16**]
and Monday [**6-20**]. Results to be faxed to Dr [**Last Name (STitle) **], who will be
managing your anticoagulation
Check your blood sugar by fingerstick at least once daily. If
you feel sweaty, clammy, confused or anxious, these can be signs
of low blood sugar. Have some juice and then check your blood
sugar. A low [**Location (un) 1131**] is less than 70
No Heavy lifting
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD (Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2101-6-16**]
8:30
DR. [**First Name (STitle) **] [**Doctor Last Name **] (Urology) Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2101-6-23**] 9:45
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Infectious Disease) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2101-7-8**] 10:00
Completed by:[**2101-6-14**]
ICD9 Codes: 5849, 9971
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5269
}
|
Medical Text: Admission Date: [**2182-3-25**] Discharge Date: [**2182-3-29**]
Date of Birth: [**2114-11-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Acetaminophen
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2182-3-25**] - CABGx4 (Left internal mammary artery->Left anterior
descending artery, Saphenous vein sequential graft->Obtuse
marginal artery 1 and 2, Saphenous vein graft->Diagonal artery).
History of Present Illness:
67 yo Spanish speaking male with increasing shortness of breath
and chest pain with exertion with +ETT referred today for
cardiac catheterization. Cardiac surgery is asked to evaluate
for surgical revascularization.
Past Medical History:
Hypercholesterolemia
CAD
Asthma
Benign prostatic Hypertrophy s/p laser treatment 3 yrs ago
Hepatitis in [**2142**]
Depression
h/o Typhoid fever
Social History:
Lives with:daughter while in MA; patient travels back and forth
from [**Country 149**]
Occupation:
Tobacco:denies
ETOH:occasional
Family History:
Non contributory
Physical Exam:
Pulse:67 Resp: 18 O2 sat: 97%RA
B/P Right:175/98 Left: 168/88
Height:5'7" Weight:190lbs
General:
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] mostly clear with end
inspiratory wheezes
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [] non-distended [x] non-tender [x] bowel sounds
+
[x] slightly firm throughout
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] no edema or varicosities, hair loss anterior/lateral
legs
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left: no bruits appreciated
Pertinent Results:
Preop:
[**2182-3-25**] 07:53AM HGB-13.4* calcHCT-40
[**2182-3-25**] 07:53AM GLUCOSE-108* LACTATE-1.5 NA+-140 K+-4.0
CL--106
[**2182-3-25**] 12:58PM PT-12.2 PTT-31.3 INR(PT)-1.0
[**2182-3-25**] 12:58PM PLT COUNT-354
[**2182-3-25**] 12:58PM WBC-26.3*# RBC-4.06* HGB-13.0* HCT-37.7*
MCV-93 MCH-32.0 MCHC-34.4 RDW-12.9
[**2182-3-25**] 12:58PM UREA N-14 CREAT-1.0 CHLORIDE-111* TOTAL
CO2-23
Post-op:
[**2182-3-29**] 05:15AM BLOOD WBC-15.8* RBC-3.35* Hgb-10.7* Hct-31.8*
MCV-95 MCH-32.0 MCHC-33.7 RDW-13.1 Plt Ct-386
[**2182-3-29**] 05:15AM BLOOD Plt Ct-386
[**2182-3-29**] 05:15AM BLOOD Glucose-107* UreaN-28* Creat-1.2 Na-139
K-4.3 Cl-103 HCO3-30 AnGap-10
[**2182-3-29**] 05:15AM BLOOD Mg-2.3
[**2182-3-25**] ECHO
PRE-CPB:1. The left atrium is mildly dilated. 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. Doppler parameters are most
consistent with Grade II (moderate) left ventricular diastolic
dysfunction. LVEF = 50%.
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. There are
simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of Phenylephrine and temporary A-pacing.
LV function remains intact LVEF 60%. RV function remains normal.
Trace aortic regurgitation, mild mitral regurgitation, mild
tricuspic regurgitation. Aortic contour remains normal post
decannulation.
Radiology Report CHEST (PA & LAT) Study Date of [**2182-3-28**] 6:05 PM
Preliminary Report !! WET READ !!
Similarly low lung volumes/vascular crowding but possible
superimposed
interstitial edema. Small left effusion/atelectasis similar.
DR. [**First Name (STitle) **] [**Doctor Last Name 3900**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
Mr. [**Known lastname 26649**] was admitted to the [**Hospital1 18**] on [**2182-3-25**] as a same
day addmission for coronary bypass grafting. He was taken
directly to the operating room where he underwent four vessel
coronary artery bypass grafting. Please see operative note for
details. In summary he had: Coronary artery bypass graft x4,
left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to diagonal and a saphenous vein sequential graft obtuse
marginal one and two.
2. Endoscopic harvesting of the long saphenous vein.
His bypass time was 60 minutes with a crossclamp of 49 minutes.
He tolerated the operation well and was transferred from the
operating room to the intensive care unit in stable condition.
Over the next 24 hours, he awoke neurologically intact and was
extubated. Beta blockade, aspirin and a statin were resumed.
Later on postoperative day one he was trnasferred to the step
down unit for further recovery. He was gently diuresed towards
his preoperative weight. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. The remainder of his hospital stay was uneventful. On
POD 4 he was discharged home with visiting nurses. He will
follow-up in wound clinic in 2 weeks and with Dr [**Last Name (STitle) 7772**] in
4 weeks.
Medications on Admission:
ASA 81 mg po daily, Albuterol Sulfate 90mcg ii puffs q 4-5 hrs
PRN, Lipitor 40mg po daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
CAD s/p CABGx4
Hypercholesterolemia
Asthma
Benign prostatic Hypertrophy s/p laser treatment 3 yrs ago
Hepatitis in [**2142**]
Depression
h/o Typhoid fever
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
sternal wound healing well, no eryhtema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon Dr. [**First Name (STitle) **] on [**2182-4-29**] @ 3:30 PM [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]([**Telephone/Fax (1) 250**]) in [**1-5**] weeks
Cardiologist Dr. [**Last Name (STitle) 911**] in [**1-5**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2182-3-29**]
ICD9 Codes: 2720, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5270
}
|
Medical Text: Admission Date: [**2134-3-22**] Discharge Date: [**2134-3-26**]
Date of Birth: [**2053-1-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
SDH/SAH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81F s/p unwitnessed mechanical fall at [**Hospital3 **]
center. Denies feeling dizziness before fall and states no LOC.
Was a little unsteady on standing and so was taken to OSH where
CT showed SAH/SDH. Transferred here for treatment. Has mild
headache and denies other injuries but has fibromyalgia pain.
Had
cardiac stent in [**1-1**] and is on ASA and Plavix. No h/o MI.
Past Medical History:
Cardiac stent [**1-1**] drug eluting, HTN, RA, Anxiety,
Fibromyalgia, Appendectomy, Cholecystectomy, Hysterectomy, C5-C7
ACDF
Social History:
Lives at [**Location **] park, no tob, etoh, ivdu. Son - [**Name (NI) **]
Family History:
Non contributory
Physical Exam:
: 99.0 BP: 152/60 HR:60 R18 97RA O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 to 3 EOMI
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 or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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 [**5-31**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B Pa
Right 2 1
Left 2 1
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
[**2134-3-24**] 02:46AM BLOOD WBC-4.4# RBC-3.25* Hgb-10.1* Hct-28.8*
MCV-89 MCH-31.0 MCHC-35.0 RDW-12.4 Plt Ct-175
[**2134-3-22**] 04:40PM BLOOD Neuts-84.8* Lymphs-11.6* Monos-3.4
Eos-0.1 Baso-0.1
[**2134-3-24**] 02:46AM BLOOD Plt Ct-175
[**2134-3-24**] 02:46AM BLOOD Glucose-84 UreaN-7 Creat-0.8 Na-141 K-3.7
Cl-105 HCO3-28 AnGap-12
[**2134-3-22**] 04:40PM BLOOD CK(CPK)-78
[**2134-3-22**] 04:40PM BLOOD cTropnT-<0.01
[**2134-3-24**] 02:46AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0
[**2134-3-23**] 03:08AM BLOOD Phenyto-10.0
CT HEAD W/O CONTRAST
Reason: evasl for ich, interval change
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with known ICH at OSH
REASON FOR THIS EXAMINATION:
evasl for ich, interval change
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 81-year-old female after fall, found at an outside
hospital to have intracranial hemorrhage, referred for further
care.
COMPARISON: Non-contrast head CT performed at [**Hospital3 18201**] at 11:34 A.M. on [**2134-3-22**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: Subdural hematoma is noted to layer along the falx and
left frontal lobe, where it measures 1 cm and 4 mm maximal
thickness, respectively. There is no appreciable associated mass
effect or shift of the normally midline structures. A few small
hyperdense foci are noted of both frontal lobes near the vertex,
right greater than left, most of which have morphology
suggesting subarachnoid hemorrhage, although a small amount of
parenchymal contusion is possible. Two small hyperdense foci are
noted in the left quadrigeminal plate and ambient cisterns,
consistent with subarachnoid hemorrhage. There is a small
well-demarcated focus of hypodensity of the left thalamus,
presumably an old lacunar infarct. There is no evidence of acute
major vascular territorial infarction. The ventricular system
and extra-axial CSF spaces are prominent consistent with
age-related involutional change. Atherosclerotic calcifications
are noted of both internal carotid and vertebral arteries. The
visualized paranasal sinuses and mastoid air cells are clear.
There is no fracture or soft tissue abnormality.
IMPRESSION: Subdural hematoma layers along the falx and left
frontal lobe without appreciable mass effect. Small foci of
subarachnoid hemorrhage/parenchymal contusion of the frontal
lobes, right greater than left, near the vertex. Small foci of
subarachnoid hemorrhage in the basilar cisterns on the left.
Overall, similar in appearance to outside hospital non- contrast
head CT performed at [**Hospital3 7571**]Hosp. at 11:34 a.m. today.
Cardiology Report ECG Study Date of [**2134-3-22**] 2:47:02 PM
Sinus rhythm. Non-specific anteroseptal ST-T wave changes.
Compared to the
previous tracing of [**2132-12-26**] the findings are similar.
[**2134-3-25**] Head CT
IMPRESSION: Again noted is subdural along the falx with some
blood now visualized along the lateral aspect of the frontal
lobe which could be secondary to redistribution of the blood
products in the subdural space. Small area of intraparenchymal
hemorrhage with surrounding edema and associated subarachnoid
hemorrhage is again noted. There is slightly prominent
hypodensity adjacent to the parenchymal lesion at the right
frontal lobe which could be due to development of a small area
of edema. No midline shift or hydrocephalus is seen.
Brief Hospital Course:
Ms [**Known lastname 70647**] was admitted to the TSICU for observation and Q1
Neurochecks. She was started on Dilantin, a repeat CT showed no
significant short interval change with subarachnoid, subdural,
and intraparenchymal hemorrhages, centered in the convexity.
Neurologically she remained intact without deficits no
headaches. She was transferred to the surgical floor on [**3-24**].
Pt resumed her usual dose of ASA and Plavix on [**2134-3-24**]. A
repeat head CT was obtained on [**2134-3-25**] showing no change of
SDH/SAH.
Diet was advanced to regular diet.
Pt was seen by PT with a recommendation for rehab due to RUE/LE
weakness.
Pt discharged to rehab with follow up appointment with Dr.[**Last Name (STitle) **]
and a head CT.
Medications on Admission:
Methadone 5''''
Oxycodone 5 q4 prn
Tylenol q6 hours
Buproprion 150 XR'
Trazadone 50'
Neurontin 400'''
Colace 100''
MVI
ASA 81'
Plavix 75'
Zocor 40'
Prilosec 20'
Lidocaine patch
Lotrisone
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QAM (once a day (in the morning)).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain/HA.
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Subdural Hematoma with Subarachnoid extension
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting heavier than
10lbs,no straining, no excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your next 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
Followup Instructions:
Please follow up:
[**2134-4-20**] 1:45pm - Dr. [**Last Name (STitle) **] in the [**Hospital 4695**] clinic
([**Telephone/Fax (1) 1669**]). You will also need a head CAT Scan prior to your
appointment, which is scheduled at 1:00pm on [**4-20**]
ICD9 Codes: 5180, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5271
}
|
Medical Text: Admission Date: [**2101-6-9**] Discharge Date: [**2101-6-24**]
Date of Birth: [**2033-10-2**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
[**2101-6-11**]: intubation/mechanical ventilation for respiratory
failure
History of Present Illness:
This is a 67 year old female s/p rollover motor vehicle crash
the patient was a restrained driver. There was airbag
deployment. Denies LOC. She was taken to an area hospital and
transferred to [**Hospital1 18**] for further management. FAST in the ED was
negative.
Past Medical History:
hypothyroidism, diabetes, RLS, anxiety, s/p hip ORIF [**5-24**]
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
O: T: 97.2 BP: 104/59 HR: 94 R 27 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 bilat EOMs intact
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 or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] throughout except L leg, no
movement secondary to pain. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
- [**2101-6-9**] CXR: Multiple left-sided rib fractures
- [**2101-6-9**] CT head: foci of hyperdense material within the sulci
at the vertex concerning for SAH. no other acute intracranial
findings. large left posterior scalp laceration. with multiple
radiodense foreign bodies.
- [**2101-6-9**] CT cspine: non-displaced T2 and T3 spinous process
fractures. no fracture of the cervical spine. DJD with posterior
disk osteophytes at C5/6 cause central canal narrowing and can
predispose to cord injury. if there is concern for cord injury
then MRI should be performed.
- [**2101-6-10**] CT Lspine: Severe wedge compression deformity at L2,
with minimal retropulsion, sclerotic features of L2 and S1 with
possible lytic changes within L1, chronic wedge compression
deformities at L4 and L5, moderate multilevel degenerative
changes
- [**2101-6-10**] CXR: Lung volumes are very low, small amount of left
pleural effusion, the extent of the left lower lobe
opacification has increased and most likely reflect area of
atelectasis, mild degree of pulmonary edema, that when compared
to prior radiograph is unchanged
- [**2101-6-11**] CXR: prominence of the cardiomediastinal silhouette
and bibasilar collapse and/or consolidation is noted, but likely
accentuated by low inspiratory volumes, probably a small left
and possible tiny right effusion
- [**2101-6-11**] KUB: Air surrounding the tube may lie within the
stomach or
alternatively relate to air in the splenic flexure projecting
over the NG tube
- [**2101-6-11**] CT torso:No hematoma. Bibasilar atelectasis and simple
pleural effusion, L>R Rib and pelvic, saccrum and l-spine
fractures
- [**2101-6-11**] L-spine MRI: L2 vertebral body fracture without
retropulsion. The cord ends normally at the L1 vertebral body
level, there is no cord, or nerve root compression. No epidural
hematoma. Mild disc bulges at L1-2 and L2-3.
- [**2101-6-12**] CXR: No large hematoma is identified.
- [**2101-6-12**] CT pelvis: no obvious hematoma or active extravasation
- [**2101-6-12**] CT head: small SAH at the right vertex, less denser
than prior, no new intracranial hemorrhage is identified
- [**6-13**] CXR: unchanged evidence of bilateral pleural effusions
with subsequent atelectasis, particularly at the right lung base
and left retrocardiac areas but no evidence of pneumothorax
- [**6-14**] CXR: unchanged evidence of left-sided slightly displaced
rib fractures, unchanged moderate pulmonary edema
- [**6-15**] CXR: interval progression of left lung opacities that
might be reflecting asymmetric pulmonary edema given the
presence of
interstitial edema in the right lung with interval improvement
in the right lung aeration
[**2101-6-9**] 04:09AM GLUCOSE-166* LACTATE-2.2* NA+-142 K+-3.3*
CL--103 TCO2-28
[**2101-6-9**] 04:09AM HGB-9.3* calcHCT-28 O2 SAT-75 CARBOXYHB-2 MET
HGB-0
[**2101-6-9**] 04:00AM UREA N-27* CREAT-0.8
[**2101-6-9**] 04:00AM LIPASE-23
[**2101-6-9**] 04:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-6-9**] 04:00AM WBC-10.5 RBC-2.99* HGB-9.1* HCT-25.2* MCV-85
MCH-30.6 MCHC-36.2* RDW-15.4
[**2101-6-9**] 04:00AM PLT COUNT-351
[**2101-6-9**] 04:00AM PT-19.2* PTT-25.8 INR(PT)-1.7*
Brief Hospital Course:
She was admitted to the Acute Care Service and transferred to
the Trauma ICU in stable condition. She had active bleeding from
a scalp laceration and Plastic Surgery was consulted who closed
the wound at the bedside. Neurosurgery was consulted for the
small subarachnoid hemorrhage and have recommended follow up in
4 weeks with a repeat head CT scan, otherwise her GCS has been
normal at 15. She was previously on Coumadin following her
recent hip surgery in [**Month (only) 547**] of this year, but this has been
placed on hold and should not be restarted for at least 4 weeks
when she will have follow up in [**Hospital 4695**] clinic.
She had significant amount of chest wall pain due to her rib
fractures and a left rib space block was performed with little
relief of her symptoms. She was given IV narcotics which
provided better relief. On HD3, she was noted with worsening
respiratory distress likely secondary to splinting with rib pain
and was intubated. Her hematocrit also dropped to 21 requiring 2
units of PRBC transfusion. Her hematocrit remained low at 21.
Given the inappropriate bump in her hematocrit, a CT torso was
obtained to evaluate for a source for the blood loss. The CT was
negative. MRI of the lumbar spine was also performed to evaluate
the L2 retropulsion which was stable. Later in the evening on
HD3, she also developed a long pause and required [**3-3**] chest
compressions. Her HR and BP normalized nearly immediately. On
HD5, she underwent a left thoracentesis in attempt to improve
her pulmonary mechanics; 500 cc of fluid was drained. She was
transfused and diuresed again for persistent anemia.
On HD6, she was started on a Lasix drip and on HD8 she was
extubated. She remained hemodynamically stable and was
transferred to the regular nursing unit.
Orthopedics had been consulted early during her stay for the
femur fracture but because of unstable hemodynamics surgery was
deferred. Once stable she was taken to the operating room on
[**6-20**] for repair of her femur fracture. Postoperatively she was
made TDWB LLE and fitted for a hinged knee brace. She was also
started on Lovenox 70 mg daily for DVT prophylaxis.
She was evaluated by Physical and Occupational therapy and is
being recommended for rehab after her acute hospital stay.
Medications on Admission:
coumadin 4, synthroid 100, requip 4 TID ([**2100-8-30**]), vitd 50K Qw,
Gabapentin 100, Doxycycline 100 [**Hospital1 **] x 10d (prophylaxis s/p hip
fracture repair), alprazolam 0.5 TID PRN, furosemide 20Qd,
zolpidem 10 QHS, dilaudid 4 Q4 PRN hip pain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for PRN
Wheezing/SOB.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for PRN
Wheezing.
5. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
6. ropinirole 1 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. insulin regular human 100 unit/mL Solution Sig: One (1) Dose
Injection ASDIR (AS DIRECTED) as needed for per sliding scale.
10. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for anxiety.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) MG
Subcutaneous DAILY (Daily): For DVT prophylaxis.
13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuires:
Large posterior scalp laceration
Small focus of acute subarachnoid hemorrhage
Left rib fractures [**5-7**]
Non-displaced T2 and T3 spinous process fractures
C5-6 osteophyte with central cord narrowing
Left distal femur periprosthetic fracture
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:
DO NOT restart your Coumadin until follow-up with Dr.
[**Last Name (STitle) 739**], Neurosurgery in 4 weeks.
You were admitted to the hospital after a motor vehicle crash
where you sustained a large scalp laceration, a small bleeding
injury in your head, rib fractures and a broken femur (leg)
bone. Your femur fracture required an operation to fix it. You
are allowed to only touchdown weight bear on your left leg. You
were fittedfor a brace which will need to be worn at all times -
only may be removed 3 times/day to check the skin integrity and
for hygiene purposes.
You were seen by Physical therapy and they are recommending that
you go to a rehabilitation facility after you leave the hospital
to help you rebuild your strength and endurance.
Followup Instructions:
Follow up in 2 weeks in [**Hospital 5498**] clinic, call [**Telephone/Fax (1) 1228**]
for an appointment.
Follow up in [**3-3**] weeks in Acute Care clinic for your rib
fractures. You will need to have a standing end expiratory chest
xray for this appointment so please inform the office of this
when calling to schedule.
Follow up in 4 weeks with Dr. [**Last Name (STitle) 739**], Neurosurgery; call
[**Telephone/Fax (1) 1669**] to schedule the appointment.
Completed by:[**2101-6-29**]
ICD9 Codes: 5185, 2851, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5272
}
|
Medical Text: Admission Date: [**2192-1-20**] Discharge Date: [**2192-2-2**]
Date of Birth: [**2112-9-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Mr. [**Known lastname 1104**] is a 79 yo pt. of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with alzeihmers
who was found down at his living facility after an unwitnessed
fall. There is some question of whether there was witnessed
shaking. Per his daughter, he has episodes of worsening
agitation, but not as bad as today. He was at his baseline
before the fall, but after was acutely agitated until receiving
Haldol in the emergency department.
.
He was recently seen by gerontology on [**1-12**] for worsening
agitation. At that time, olanzapine 2.5mg was started.
.
In the ED, initial VS were: HR 99 BP 170/palp RR 21 94%RA
He was agitated. He was noted to have gap acidosis with lactate
of 8 down to 3 with fluid. CEs were negative. EKG with RBBB, no
old EKGs though RBBB is noted on his problem list. [**Name2 (NI) **] received a
total of 12.5mg of haldol, IVF fluid, and tetanus shot. He
vomited once and was given 4mg zofran. Urine tox and UA ok. Nl
CK and LFTs.
.
He had a CT of his neck and his head without acute findings.
.
On the floor, he is sleepy but agitated. History is obtained
through his daughter.
.
Review of systems:
unable to obtain
Past Medical History:
hypercholesterolemia
low vitamin D
osteoarthritis with left knee pain
BPH
chronic prostatitis
Social History:
Lives [**Street Address(1) 83359**] [**Hospital3 **]. No smoking history or
EtOH history. Mr. [**Known lastname 1104**] was born in the Bronx and grew up in
[**State 531**]. He graduated from City College and worked as a
chemist. He has been married for many years, now widowed.
Family History:
His father died at age 75 of prostate cancer. His mother died at
age 78 of heart problems. His sister died of heart disease. His
brother, [**Name (NI) 3788**] is healthy and his brother [**Name (NI) **] has heart
problems.
Physical Exam:
Vitals: 98.2 125/88 97%RA HR 62
General: responds to voice with agitation, intermittently opens
eyes
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, 1/6 sem at RUSB, no
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moves all extremities
Pertinent Results:
LABS ON ADMISSION:
.
[**2192-1-20**] 03:45PM BLOOD WBC-11.2* RBC-3.74* Hgb-11.6* Hct-35.4*
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.6 Plt Ct-425
[**2192-1-20**] 03:45PM BLOOD PT-12.1 PTT-20.3* INR(PT)-1.0
[**2192-1-20**] 03:45PM BLOOD Glucose-202* UreaN-20 Creat-1.3* Na-139
K-3.9 Cl-99 HCO3-18* AnGap-26*
[**2192-1-20**] 03:45PM BLOOD ALT-23 AST-38 CK(CPK)-197 AlkPhos-80
TotBili-0.5
[**2192-1-20**] 03:45PM BLOOD Lipase-25
[**2192-1-20**] 03:45PM BLOOD cTropnT-<0.01
[**2192-1-20**] 03:45PM BLOOD CK-MB-5
[**2192-1-20**] 03:45PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.5
[**2192-1-21**] 04:45PM BLOOD VitB12-446 Folate-15.9
[**2192-1-21**] 04:45PM BLOOD %HbA1c-6.9* eAG-151*
[**2192-1-20**] 03:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-1-20**] 03:49PM BLOOD pH-7.31* Comment-GREEN TOP
[**2192-1-20**] 11:24PM BLOOD Type-[**Last Name (un) **] pO2-105 pCO2-44 pH-7.38
calTCO2-27 Base XS-0 Comment-GREEN TOP
[**2192-1-20**] 03:49PM BLOOD Glucose-200* Lactate-7.8* Na-143 K-3.7
Cl-99* calHCO3-22
.
CSF:
[**2192-1-22**] 04:15PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1350*
Polys-25 Lymphs-47 Monos-28
[**2192-1-22**] 04:15PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-255*
Polys-22 Lymphs-60 Monos-18
[**2192-1-22**] 04:15PM CEREBROSPINAL FLUID (CSF) TotProt-90*
Glucose-102
.
MICRO:
CSF - Bacillus species, felt to be contaminant
.
STUDIES:
[**1-20**] ECG: Sinus rhythm with first degree A-V block. Right
bundle-branch block and left anterior fascicular block.
Non-specific ST-T wave changes. Ventricular premature beats. No
previous tracing available for comparison.
.
[**1-20**] Head CT: 1. Right frontal subgaleal hematoma. No
intracranial hemorrhage. 2. Chronic small vessel ischemic
disease. 3. Age-related parenchymal involution.
.
[**1-20**] C-Spine CT: 1. No fracture or malalignment. 2. Chronic
degenerative changes with posterior disc bulges resulting in
mild to moderate effacement of the thecal sac at C4-C5, C5-C6
and C6-C7. These findings predispose the patient to cord injury
even in the setting of minimal trauma. Clinical correlation is
recommended, and MR can be obtained for further evaluation.
.
[**1-20**] Pelvis film: No fracture or dislocation.
.
[**1-20**] CXR: Left-sided rib deformity, unknown chronicity. If there
is clinical concern a dedicated rib series may be obtained to
further assess with skin marker at the site of pain
.
[**1-22**] EEG: This telemetry captured no pushbutton activations.
Routine
sampling showed a slow and encephalopathic background. This
usually
results from medications, metabolic disturbances, or infections
although
there are many other possible causes. There were no prominently
focal
findings. There were fairly frequent bifrontal sharp waves,
sometimes
appearing more prominent on one side or the other but usually
with
symmetry. These sharp waves may also be seen in
encephalopathies, but
they likely indicate a greater potential for cortical
hypersynchrony or
seizures. Nevertheless, despite a prolonged recording and use of
seizure detection programs, none of the sharp waves were
persistent or
rhythmic enough to suggest actual seizures.
.
[**1-22**] Head CT: Apparent areas of hypodensity in the right frontal
lobe and splenium of the corpus callosum may represent sequelae
of trauma. In case of clinical concern for intracranial
abnormality such as diffuse axonal injury, an MRI may be helpful
for further evaluation. No definite acute intracranial
hemorrhage.
.
[**1-22**] CXR: Cardiomediastinal contours are similar in appearance to
the prior
examination. Lungs are clear except for a subtle area of
increased
opacification in the left retrocardiac region, which could
reflect either
atelectasis or a developing area of infection. Postoperative
changes are
noted in the right hemithorax, similar to the previous exam.
.
[**1-25**] CT head with contrast:
IMPRESSION: No intracranial hemorrhage. Multiple hypodense areas
in the
right frontal lobe and splenium are likely sequelae of trauma.
If there is
clinical concern for abnormalities such as diffuse axonal
injury, MRI can be ordered.
.
[**2192-1-25**]
Foot xray:
IMPRESSION: Small [**Hospital1 **] fracture at the distal tip of the great
toe.
Brief Hospital Course:
79 y/o male with moderate dementia transferred to ICU for
obtundation after an unwitnessed fall 2 days ago and question of
possible seizure like activity, subsequently with hyperactive
delerium.
# Altered Mental Status: markedly improved on discharge. Head CT
without intracranial hemorrhage. Highest concern initially for
bacterial meningitis given fall and rapid decline in
consciousness with fever. Nuchal rigidity concerning in setting
of fever to 100.9. Empirically received meningitis dose abx
within a few hours of initial change in mental status; however,
CSF was not consistent with infection. Bacillus species in CSF
was felt to be contaminant. Empiric antibiotics were stopped.
Repeat CT without cause for AMS and no evolving change. Status
epilepticus unlikely given no overt seizure on EEG. Patient was
seen by neurology, and keppra was started for cortical
irritability. Mental status markedly improved over the next 24
hours. No source of infection was found. Patient will likely
have prolonged recovery regardless of cause given underlying
dementia which family is aware of.
.
# Fever: unclear cause, ddx included meningitis as above vs
pulmonary cause given ? LLL atelectatsis vs early infiltrate.
Patient defervesced quite rapidly and no source of infection was
found. LP was not consistent with meningitis, and all cultures
remainded negative.
.
# Hyperactive delerium: likely in setting of unfamiliar
environment and progression of underlying dementia. Has seen his
primary care physician who initially started prn olanzapine for
agitation. As an inpatient, patient was started on a seroquel
regimen, which markedly improved patient's hyperactive delerium.
He will take 6.25 mg qAM, and 12.5 mg at 4 pm and 9 pm for a
total daily dose of 31.25 mg. He may take olanzapine as
prescribed for severe agitation.
.
# Hyperlipidemia: held in acute setting, but may resume statin
and ASA when able to take oral medications.
.
# left small [**Hospital1 **] fracture at the distal tip of the great toe:
no surgical intervention indicated. Scheduled tylenol was
provided for patient for pain control. On discharge, healing
appropriately with no pain.
Medications on Admission:
Medications:
DONEPEZIL 5 mg by mouth once a day
ERGOCALCIFEROL 50,000 unit by mouth once a month
OLANZAPINE [ZYPREXA] - 1.25 mg by mouth daily as needed for
agitation
SIMVASTATIN - 10 mg by mouth once [**Last Name (un) 5490**]
.
Medications - OTC
ASPIRIN 81 mg once a day
Discharge Medications:
1. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for agitation.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Donepezil 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
10. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO QAM (once a day
(in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID AT 4PM AND
9PM (): please dose at 4PM AND at 9PM, in addition to the 6.25mg
qAM, for a total daily dose of 31.25mg.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Street Address(1) 19127**]
Discharge Diagnosis:
PRIMARY:
1. unwitnessed fall
2. delerium
.
SECONDARY:
1. advanced Alzheimer's disease
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Discharge Instructions:
You were admitted to [**Hospital1 69**] after
you were found down after an unwitnessed fall at your [**Hospital 4382**] facility. You underwent head imaging, EEG, and lumbar
puncture. Head imaging did not show any bleeding in the brain.
You were started on a new medication called KEPPRA to reduce the
risk of seizure. Your lumbar puncture was not consistent with
infection. You were also started on a medication called SEROQUEL
during this hospitalization.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- START Keppra 500 mg by mouth at night
- START Quetiapine (Seroquel) 6.25 mg by mouth in the morning
- START Quetiapine (Seroquel) 12.5 mg by mouth at 4 pm and again
at 9 pm
- START Olanzapine (zydis) 2.5 mg by mouth for severe agitation
.
Please seek medical attention for worsening mental status,
confusion, anxiety, agitation, fevers, chills, chest pain,
shortness of breath, abdominal pain, inability to tolerate food,
or any other concerning symptom.
Followup Instructions:
Please attend the following appointments below.
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2192-2-7**] 10:00
.
Provider [**First Name8 (NamePattern2) 161**] [**Name9 (PRE) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2192-2-13**] 3:30
Completed by:[**2192-2-2**]
ICD9 Codes: 2930, 2762, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5273
}
|
Medical Text: Admission Date: [**2127-1-8**] Discharge Date: [**2127-1-15**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
code stroke Right Face/Arm/LEg weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 yo M with h/o NIDDM, no old strokes arrived at 5.40pm
as a Code stroke to ED with acute onset of R F/A/L weakness and
slurred speech. He was last seen nml at 1pm by wife who went out
and then had returned at 5pm. Pt was found with TV off, sitting
with some dessert, with slurred speech and R facial droop and
RUE
and RLE lack of movement. Wife called EMS. EMS noted the R
F/A/L paralysis and slurred speech. His FSG was 328 in field
and
VS on route were BP 168/92, 58 SR, 16, 97 RA, 99 on FM. His exam
stayed the same en route. Pt says he tried to stand up and
could
not, and that was the only event that he can describe. He says
that he is not sure what time that deficit occurred. He denies
HA and denies having any difficulty moving his arms and legs.
He initially thought the event happened at 4PM, but he was later
unsure of the exact time. As he was sitting down during the
event, last well known time was felt to be when his wife saw
him, at 1PM.
His NIHSS score at 6.10pm was 11, with points for right sided
paralysis, right hemineglect, and visual neglect (versus field
cut). Exam notable for R sided visual, tactile neglect and no
mvt at RUE or RLE, R facial droop, visual paralysis to the R
side. Speech was intact with no slurring.
Past Medical History:
DM
HTN
High Chol
BPH
Social History:
Lives with wife, former church saxon. Lives in [**Location **].
Former smoker, 20pk year history. Denies etoh.
Family History:
No strokes or neurological disorders run in the family.
Physical Exam:
Initial exam in ED showed:
VS: T: 195/70 then 188/67 P: 58 RR: 18 O2 sat:
98 RA
General: WNWD, NAD
HEENT: Anicteric, MMM without lesions, OP clear
Ext: WWP
Skin: Rash on chest, no petechiae
MS: A&O x 3, interactive, appropriate, following all commands
Able to give history, but not clear on what time this happened.
Speech fluent w/o paraphasic errors, +naming of wholes & parts,
+repetition, +comprehension
No evidence of neglect with visual or tactile stimulation
No apraxia: able to comb hair, screw in light bulb
CN: I - not tested, II,III - PERRL, VFF decreased on the R with
neglect; III,IV,VI - EOM limited to the R side, track object
only slightly past midline, then tries to turn his head, no
ptosis, no nystagmus; V- masseters strong symmetrically; VII -
R
facial droop UMN pattern; VIII - hears finger voice B; IX,X -
voice normal, [**Doctor First Name 81**] - SCM/Trapezii [**5-23**] B; XII - tongue protrudes
midline
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia.
No
pronator drift. No asterixis.
Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB
Axill mscut [**Month/Day (1) 21443**] [**Name6 (MD) 21443**] [**Name8 (MD) 21443**] md/ul ulnar medin
C5 C5-6 C7 C6-7 C7 C8 T1 C8-T1
L 5 5 5 5 5 5 5 5
R ALL 0 -----------'
Ilpso Addct Glmed Glmax Qufem Hamst TibAn
[**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
Femor obtur supgl infgl femor [**First Name9 (NamePattern2) 21444**] [**Last Name (un) 18709**] tibil
dpper
L1-2 L2-3 L4-5 L5-S1 L3-4 L5-S2 L4-5 S1-2
L5
L 5 5 5 5 5 5 5 5 5
R ALL 0 ------------'
When RUE held to face he does say that that is his hand. He
says
he is trying to move it, but there is no movement at all.
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 1 1 1 1 1 down
R 1 1 1 1 1 down
Sensory: PP is intact bilat but has extinction to DSS on R whole
side.
Coord: deferred - taken to imaging.
Pertinent Results:
[**2127-1-8**] 05:50PM FIBRINOGE-390
[**2127-1-8**] 05:50PM PT-11.6 PTT-23.9 INR(PT)-0.9
[**2127-1-8**] 05:50PM PLT COUNT-170
[**2127-1-8**] 05:50PM NEUTS-65.4 LYMPHS-24.1 MONOS-4.3 EOS-5.5*
BASOS-0.7
[**2127-1-8**] 05:50PM WBC-6.7 RBC-3.99* HGB-12.2* HCT-36.5* MCV-92
MCH-30.7 MCHC-33.5 RDW-13.5
[**2127-1-8**] 05:50PM CALCIUM-9.2 PHOSPHATE-2.8 MAGNESIUM-2.0 URIC
ACID-7.7*
[**2127-1-8**] 05:50PM CK-MB-19* MB INDX-4.2
[**2127-1-8**] 05:50PM cTropnT-0.01
[**2127-1-8**] 05:50PM LIPASE-28
[**2127-1-8**] 05:50PM ALT(SGPT)-26 AST(SGOT)-27 LD(LDH)-249
CK(CPK)-454* ALK PHOS-115 AMYLASE-67 TOT BILI-0.3
[**2127-1-8**] 05:50PM GLUCOSE-312* UREA N-36* CREAT-1.3* SODIUM-139
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2127-1-8**] 06:24PM %HbA1c-7.9* [Hgb]-DONE [A1c]-DONE
[**1-8**] CT BRAIN:
CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is
identified. The ventricles are symmetric, and there is no shift
of normally midline structures. There is an area of slightly
decreased attenuation within the region of the left lentiform
nucleus and anterior limb of the left internal capsule, without
definite mass effect. There is also subtle decreased attenuation
in the periventricular white matter of both cerebral
hemispheres, consistent with chronic microvascular ischemic
infarction. Soft tissue and osseous structures are within normal
limits.
IMPRESSION: No intracranial hemorrhage or definite mass effect
is identified. There is a subtle area of decreased attenuation
with the left lentiform nucleus and anterior limb of the left
internal capsule, suspicious for a new infarct. Further
evaluation with [**Month/Year (2) 4338**] with diffusion- weighted imaging is
recommended.
[**1-8**] [**Month/Year (2) 4338**]/A
FINDINGS: There are areas of abnormal diffusion signal involving
the left basal ganglia and left posterior temporal lobe,
consistent with acute infarction. There are no areas of
susceptibility artifact to suggest the presence of hemorrhage.
These two regions of infarction do demonstrate slight increased
FLAIR signal as well. Some FLAIR signal hyperintensity is noted
within the periventricular white matter areas of both cerebral
hemispheres, consistent with chronic microvascular infarction.
3D time-of-flight MR angiography of the circle of [**Location (un) 431**]
demonstrates diminished flow within the left middle cerebral
artery compared to the flow on the right side. Additionally,
branches of the left middle cerebral artery cannot be traced as
far distally as those on the right. No aneurysms are
appreciated.
IMPRESSION:
1. Subacute left basal ganglia and posterior temporal lobe
infarction, corresponding to the inferior division of the left
middle cerebral artery.
2. Diminished flow within the left middle cerebral artery
compared to the right on the MR angiogram images, suggestive of
possible focal occlusions, embolic or thrombotic in nature.
ECHO [**1-9**]:
Conclusions:
1. The left atrium is moderately dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Overall left ventricular systolic
function is low
normal (LVEF 50-55%). Inferior hypokinesis is probably present.
3. The ascending aorta is mildly dilated.
Repeat Head CT [**1-10**]:
There is no sign of intracranial hemorrhage. Again noted is
hypodensity involving the left basal ganglia, similar in size
and extent
compared to the prior two studies. New hypodensity in the
posterior left
temporal lobe is seen corresponding to the region of abnormal
diffusion on the recent prior brain [**Month/Year (2) 4338**]. Apart from these two
areas, no other areas of new
hypodensity are seen. Chronic microvascular changes are seen in
the
periventricular white matter areas bilaterally, as before. There
is no sign
of fracture or bone destruction.
RIGHT SHOULDER XRAY, THREE VIEWS.
In keeping with the provided history, although three views of
the shoulder
were obtained, they were all obtained in the same position. No
fracture is
detected. No gross degenerative changes are identified. There is
mild
degenerative spurring about the inferior glenoid and about the
AC joint. There is borderline narrowing of the acromiohumeral
distance, which can be
associated with rotator cuff thinning or tearing. No soft tissue
calcification is identified. Limited assessment of the
glenohumeral joint
suggests that the joint is congruent, but if there is strong
clinical suspicion for dislocation, then additional imaging
would be
recommended.
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. No cardiac source of embolus seen.
Brief Hospital Course:
81 yo man with vascular risk factors of DM, HTN, High Chol, who
p/w right hemiplegia involving leg, arm, face, slurred speech
(not apparent on exam), and right hemineglect of both sensation
and vision on exam. Language was spared, but the patient is
left handed. Exam the following morning was also notable for
inattention. CT scan showed no hemorrhage, and the patient was
considered to be a good candidate for the [**Last Name (un) **]-2 study protocol,
which tests a new thrombolytic within a 9 hour window. Risks
and benefits of enrolling in the study were discussed with his
family and Dr. [**Last Name (STitle) **], and he was consented. [**Last Name (STitle) 4338**] with both DWI
and PWI (as well as MRA) were obtained and positive diffusion
abnormalities were seen in the left lenticulostriate and left
temporo-parietal cortex (suggesting inferior division left MCA)
stroke. The MRA showed decreased flow signal in the distal M1
segment on the left MCA. He received an injection at 7.5 hours
from last known well time, of either thrombolytic (desmoteplase)
or placebo after randomization. He was admitted to the neuro
ICU for close post-lytic monitoring of blood pressure and vital
signs. Head CT repeated in 72 hours (or sooner if change in
exam) and was stable. CBC, lytes were monitored. Hba1c was
checked for risk stratification and was 7.9. His primary care
physician should consider increasing his diabetes medications
for better glycemic control. TTE was unremarkable and showed no
source of clot.Carotid ultrasounds were checked and showed
nonhemodynamically significant stenosis of less than 40% was
demonstrated in the internal carotid arteries bilaterally.
Neurologically, on the floor the facial droop and right
hemiparesis improved significantly after he was transferred out
of the ICU to the floor. His language also improved and he was
aable to name "hammock" and other objects. Speech was fluent
and he was able to read, repeat and write with He was initially
kept NPO with tube feeds.
FLP was checked, although he was on maximal statin therapy and
showed an elevated LDL. The patient was startd on adjunct
therapy with niacin. ASA was started 24 hours after the study
medication injection and afterward Aggrenox was added at 1 cap
po qd x 3 days, followed by [**Hospital1 **] dosing to be taken after
discharge. He was mildly hypertensive on the floor to SBP 160's
and patient was started on captopril 6.25 mg tid with good
response, in additiion to clonidine patch.
He was seen by physical therapy and occupational therapy and
cleared for rehabilitation. He was also seen by speech and
swallow and cleared for a diet.
His main issues on d/c:
1)Neuro:
-Continue Aggrenox 1 cap po bid for stroke prophylaxis.
2)CV:
-[**Month (only) 116**] increase captopril TID if needed for BP control, cont.
Catapres patch.
3)Endo:
-Continue [**Hospital1 **] glyburide and regular insulin coverage. The
patient had FS in 200-300 range prior to leaving and so sliding
scale may have to be tightened. Outside PCP should be [**Name (NI) 653**]
for addition or increase of oral hypoglycemics.
4)FEN: Would advance diet as tolerated by speech and swallow
eval. Aspiration precautions.
Medications on Admission:
glyburide 5mg QD, hydroxyzine 25mg QD, Fosinopril 40 mg
QHS, simvastatin 80 mg QD, proscar 5 mg QHS, clonidine TTS2, 2
patches Q7days, Travatin eye drops one gtts OU QHS
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal Q7DAYS ().
4. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO HS (at bedtime).
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
8. Sodium Chloride 0.9 % Parenteral Solution Sig: Three (3) ML
Intravenous DAILY (Daily) as needed: FLUSH for peripheral iv
lines.
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Insulin Regular Human 100 unit/mL Solution Sig: 0-8 units
Injection ASDIR (AS DIRECTED): Patient will need finger sticks
q6hrs. Follow regular insulin sliding scale sent with paperwork.
12. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
ischemic stroke
Discharge Condition:
stable
Discharge Instructions:
Please follow up for your [**Location (un) 4338**] and neurology clinic appointments.
Please also have your diabetes and blood sugar well controlled
by your primary care physician after rehab.
Followup Instructions:
Provider: [**Name10 (NameIs) 4338**] Phone: [**Telephone/Fax (1) 327**] Date/Time:[**2127-2-11**] 10:45 AM.
Please come to the [**Hospital Ward Name **] clinical center basement. at
10:30 AM for your appointment.
Please call ([**Telephone/Fax (1) 22692**] to arrange follow up with Dr. [**Last Name (STitle) **]
on [**2127-2-11**] at 12:30 PM following your [**Date Range 4338**]. The appointment has
been arranged
F/u with PCP within one month of d/c.
Completed by:[**2127-1-15**]
ICD9 Codes: 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5274
}
|
Medical Text: Admission Date: [**2193-11-3**] Discharge Date: [**2193-11-6**]
Date of Birth: [**2158-5-17**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 35 year-old
male with a history of severe depression and prior suicide
attempt found unresponsive at restaurant and brought in by
ambulance to [**Hospital 8**] Hospital where he had a witnessed
generalized tonic clonic seizure and was given Ativan and
Dilantin and intubated for airway protection and then
transferred to [**Hospital1 69**] for
further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Major depressive disorder, prior suicide attempts with
ethylene glycol requiring dialysis with some residual renal
injury.
MEDICATIONS:
1. Hydrochlorothiazide 25 mg q.d.
2. History of use of Paxil, Risperdal, Wellbutrin, Effexor,
though current medications and doses are unknown.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with sister. Not married, no
children, unemployed. Positive history of tobacco use, but
none currently. Occasional alcohol approximately two drinks
per day, recently broke up with girlfriend.
FAMILY HISTORY: Negative.
PHYSICAL EXAMINATION: General, sedated, intubated. HEENT
pupils are equal, round and reactive to light 6 mm to 4 mm.
Normocephalic, atraumatic. Oropharynx and nasopharynx clear.
Neck supple. No JVD or lymphadenopathy. Cardiovascular
regular rate and rhythm. No murmurs, rubs or gallops.
Pulmonary decreased breath sounds at bilateral bases, clear
to auscultation bilaterally otherwise. Abdomen soft,
nontender, nondistended. Positive bowel sounds. Extremities
atraumatic. No clubbing, cyanosis or edema. Neurological
withdraws from pain in extremities times four.
LABORATORY: White blood cell count 15.0, hematocrit 38.1,
platelets 240. Chemistries sodium 138, potassium 3.7,
chloride 104, bicarb 24, BUN 18, creatinine 1.2, glucose 96.
Liver function tests within normal limits, albumin 4.7, serum
osms 291, magnesium 2.0, calcium 9.2. Urine tox negative.
Urinalysis negative. Serum tox negative. Arterial blood gas
on pressure support 15 to 5, 7.35, 44, 438.
Electrocardiogram sinus tachycardiac at 127, no acute ST or T
wave changes. Normal QT interval and normal QRS interval.
Chest x-ray right lower lobe opacity. Head CT negative.
HOSPITAL COURSE: 1. Overdose: The patient ingested an
unknown substance, however, upon waking up he states that it
was a large number of pills, which he states were his own.
There is no evidence of ethylene glycol ingestion as the
patient never had an anion gap. A toxicology consult was
obtained and the patient demonstrated evidence of
anticholinergic __________ and with dilated pupils and
somnolence, which resolved after two to three days. The
patient was extubated on [**2193-11-3**] and had slow mental status
improvement and was at baseline mental status on discharge.
He had no medical sequela from his ingestion beside the
seizure at the outside hospital. He was observed with a one
on one sitter with no significant events and continued
supportive care. A psychiatric consult was obtained and they
were following throughout his hospital course. The patient
does admit that this was a suicide attempt, however, upon
being extubated he denied that he currently had suicidal
ideation throughout his hospital course.
2. Seizure: This is the first time that the patient has had
a seizure likely secondary to the ingestion of the large
number of psychiatric medications, which could lower his
seizure threshold. Initially loaded with Dilantin and kept
at a therapeutic level with po Dilantin. His head CT was
negative. His B-12, TSH and RPR were normal. He had an MRI
and an esophagogastroduodenoscopy both of which were negative
for a possible focus of seizure. Neurology was following
throughout his hospital course and determined that there was
no indication for him to be on anticonvulsants as this likely
does not represent epilepsy.
3. Pulmonary: After extubation he had a chest x-ray, which
showed bilateral _________ infiltrates, which was consistent
with aspiration pneumonia versus pneumonitis. He initially
had an elevated white blood cell count and fever and was
started on Levo and Flagyl, however, never became symptomatic
and he maintained his O2 sats on room air. He did not have a
cough and was not short of breath and the Levofloxacin and
Flagyl were discontinued prior to discharge.
4. Psychiatric: The Psychiatry Service was following the
patient after extubation. They were unable to determine,
which medications he was on prior to his suicide attempt.
All psychiatric medications were held until further
information was obtained and the patient was observed at his
baseline state and was continued on a one on one sitter with
suicide precautions and will be transferred to [**Hospital 8**]
Hospital for inpatient psychiatric hospitalization for
further management.
DISPOSITION: The patient was transferred from the Intensive
Care Unit on [**2193-11-4**] and was observed on the medical floor
for two days. The patient had no further events and no
sequela from his ingestion. He was deemed medically and
neurologically stable for transfer and the patient was
transferred for inpatient psychiatric management.
DISCHARGE DIAGNOSES:
1. Overdose.
2. Suicide attempt.
3. Seizure.
4. Aspiration pneumonitis.
5. Severe depression.
6. Hypertension.
FOLLOW UP:
1. Psychiatric follow up as arranged post inpatient
hospitalization.
2. Follow up with primary care physician in one to two
weeks.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg po q.d.
2. Multivitamins one po q.d.
DIET: Regular.
ACTIVITY: As tolerated.
CONDITION ON DISCHARGE: Medically and neurologically stable.
Needs inpatient psychiatric care with suicide precautions.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 17848**]
MEDQUIST36
D: [**2193-11-6**] 09:52
T: [**2193-11-6**] 09:55
JOB#: [**Job Number 53395**]
ICD9 Codes: 5070
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5275
}
|
Medical Text: Admission Date: [**2129-11-20**] Discharge Date: [**2129-11-29**]
Date of Birth: [**2080-5-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
nausea, vomitting
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 49M with medical history of type I diabetes,
narcotics abuse, hypertension presented to [**Hospital3 **]hospital on [**2129-11-18**] after several day history of nausea and
vomiting. Per the wife who had spoken with him over phone daily
prior to hospitalization, he had been sick to his stomach on
Wednesday and thursday with poor po intake. He sounded confused
and short of breath on the phone. Not clear if fever or chills
or diarrhea. Of note, the patient obtained a perocet rx on
wednesday [**11-16**] for #30 tablets that was supposed to last 10
days but by Friday all the tablets were gone (of note two weeks
prior very depressed, sent to [**Hospital1 **]? psychiatric unit, from
there went to day program [? drug recovery] in [**Location (un) 1157**]
although not clear that going).
.
In the ED, initial vitals were BP 215/78 HR:107, RR 24, O2 96%
NRB. WBC of 24.4, HCT of 37.8, platelets 327. Glucose of 581,
anion gap of 23, urine with positive ketones. Na 136, K 5.5, Cr
1.4. EKG sinus tachycardia with rate of 116, CK 165 and troponin
I of 0.05. Blood gas 7.31/29/96 15 on NRB. CXR read as bilateral
upper lobe infiltrates suspicious for pulmonary edema,
pneumonia, or both. CT head with no abnormality except for air
fluid level in maxillary sinus consistent with sinusitis. He was
given ceftriaxone and azithromycin for suspected pneumonia,
insulin gtt and 2L IVF and admitted to the ICU.
.
The patient was maintained on an insulin gtt until his anion gap
closed after which he was transitioned on [**2129-11-19**] to his daily
lantus and insulin sliding scale with FS in 200s. He developed
worsening respiratory distress with repeat ABG showing hypoxemic
respiratory failure with PO2 of 35 and was intubated on
[**2129-11-19**]. Chest x-ray reported showed pulmonary edema and he was
given lasix 40mg IVx2 with good response. Looks like antibiotics
changed from ceftriaxone/azithro to levaquin on [**11-20**]. Vent
settings on tranfer AC TV 400, 65% FiO2, PEEP 10. Today temp of
101.3, has been hemodynamically stable with BP 132/50 HR 70s.
Was given lasix 40IV and has put out 1300cc. Has 2PIV (20 in R
foot and 20 in L forearm). Labs on transfer ([**11-20**]) sodium 143,
K 4.0, Chloride 112, CO2 26, anion gap 9, Cr 1.1, BUN 21,
calcium 7.2, magnesium 2.2, phosphorus 2.9, BNP 1190 ([**11-20**]).
.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + HTN
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- IDDM c/b peripheral neuropathy, gastroparesis, CKD
- Mild regional LV systolic dysfxn on [**1-/2128**] TTE (on lasix in
past)
- Impaired speech and swallow, hx of aspiration (thin
liquid/puree).
- History of hospital acquired MRSA pneumonia ([**2128-12-21**])
- History of C. diff s/p 14 days of flagyl [**1-/2128**]
- Chronic kidney disease (baseline 0.9-1.3)
- Medullary sponge kidney
- foot ulcers
- Nephrolithiasis
- history of narcotic abuse
- gastritis
- depression/anxiety
- HTN
Social History:
Divorced though still in contact with ex-wife. Lived with his
father in [**Name (NI) **], MA, prior to hospitalization in [**Month (only) 1096**].
Smoked [**1-22**] ppd x 20 yrs but no longer smokes. ?history of
substance abuse based on prior OMR notes.
Family History:
Mother: Leukemia, currently undergoing chemotherapy
Father: CAD, HTN
Physical Exam:
Admission Exam:
VS: Temp (rectal) 102 140/76 78
Vent: 550 80% FIO2 8 PEEP
GENERAL: intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm, no carotid bruits.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: symmetric expansion, crackles bibasilarly
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: trace lower extremity edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**11-21**] CXR:
The decreased radiodensity of widespread heterogeneous pulmonary
consolidation
may be due to decrease in edema, but the abnormality itself is
still
concerning for widespread pneumonia. Careful followup advised.
No pleural
effusion, mediastinal widening, cardiomegaly or vascular
congestion. ET tube
in standard placement. Nasogastric tube ends in the region of
pylorus. No
pneumothorax. Dr. [**First Name (STitle) 4587**] and I discussed the findings and their
clinical
significance over the telephone at the time of dictation.
[**2129-11-20**] 08:56PM proBNP-1675*
[**2129-11-20**] 11:48PM %HbA1c-11.1* eAG-272*
.
[**2129-11-29**] 05:49AM BLOOD WBC-7.7 RBC-3.50* Hgb-10.5* Hct-31.2*
MCV-89 MCH-30.2 MCHC-33.8 RDW-14.8 Plt Ct-483*
[**2129-11-28**] 06:07AM BLOOD WBC-8.5 RBC-3.58* Hgb-10.8* Hct-31.8*
MCV-89 MCH-30.3 MCHC-34.1 RDW-14.5 Plt Ct-466*
[**2129-11-25**] 04:57AM BLOOD WBC-10.6 RBC-3.54* Hgb-10.6* Hct-31.5*
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.8 Plt Ct-322
[**2129-11-24**] 12:40PM BLOOD WBC-8.0 RBC-3.59* Hgb-10.7* Hct-33.2*
MCV-93 MCH-29.9 MCHC-32.3 RDW-13.7 Plt Ct-291
[**2129-11-29**] 05:49AM BLOOD Plt Ct-483*
[**2129-11-29**] 05:49AM BLOOD PT-14.3* PTT-25.5 INR(PT)-1.2*
[**2129-11-28**] 06:07AM BLOOD Plt Ct-466*
[**2129-11-25**] 04:57AM BLOOD Plt Ct-322
[**2129-11-24**] 12:40PM BLOOD Plt Ct-291
[**2129-11-29**] 05:49AM BLOOD Glucose-297* UreaN-13 Creat-1.1 Na-135
K-4.4 Cl-104 HCO3-22 AnGap-13
[**2129-11-27**] 04:56AM BLOOD Glucose-250* UreaN-12 Creat-1.0 Na-136
K-3.9 Cl-100 HCO3-24 AnGap-16
[**2129-11-26**] 05:47AM BLOOD Glucose-186* UreaN-11 Creat-1.0 Na-135
K-3.9 Cl-99 HCO3-23 AnGap-17
[**2129-11-27**] 03:49PM BLOOD CK(CPK)-36*
[**2129-11-26**] 10:05PM BLOOD CK(CPK)-48
[**2129-11-24**] 12:40PM BLOOD ALT-21 AST-28 LD(LDH)-325* AlkPhos-120
TotBili-0.3
[**2129-11-23**] 04:56PM BLOOD ALT-15 AST-14 LD(LDH)-297* AlkPhos-79
TotBili-0.1
[**2129-11-27**] 04:56AM BLOOD CK-MB-3 cTropnT-<0.01
[**2129-11-26**] 10:05PM BLOOD CK-MB-3 cTropnT-<0.01
[**2129-11-21**] 03:57AM BLOOD cTropnT-<0.01
[**2129-11-20**] 08:56PM BLOOD proBNP-1675*
[**2129-11-29**] 05:49AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1
[**2129-11-28**] 06:07AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.3 Iron-85
[**2129-11-27**] 04:56AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2
[**2129-11-28**] 06:07AM BLOOD calTIBC-280 VitB12-839 Folate-13.7
Ferritn-158 TRF-215
[**2129-11-20**] 11:48PM BLOOD %HbA1c-11.1* eAG-272*
[**2129-11-21**] 03:40PM BLOOD Osmolal-308
[**2129-11-22**] 05:59AM BLOOD Vanco-14.8
[**2129-11-21**] 03:40PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2129-11-24**] 01:05PM BLOOD pH-7.39 Comment-GREEN TOP
[**2129-11-22**] 03:36PM BLOOD Type-ART Temp-37 Tidal V-550 FiO2-50
pO2-109* pCO2-52* pH-7.44 calTCO2-36* Base XS-10
Intubat-INTUBATED Vent-SPONTANEOU
[**2129-11-20**] 10:24PM BLOOD Lactate-1.4
[**2129-11-24**] 01:05PM BLOOD freeCa-1.02*
.
Microbiology: Ucx, Bcx, Sputum Cx were all NTD at time of
discharge
.
Urine legionella was negative. Stool for C.dif toxins was
negative.
Brief Hospital Course:
49M with history of type I diabetes, hypertension presented with
nausea found to be in DKA, hypoxic respiratory failure likely
secondary to pneumonia and course complicated by DKA who was
initially admitted to the ICU.
.
#HYPOXIC RESPIRATORY FAILURE: CXR on admission equivocal for
multifocal PNA vs. pleural effusions. He has been treated for
both with antibiotics (broadened to vancomycin, zosyn, and
azithromycin) as well as IV lasix diuresis complicated by
hypernatremia. TTE showing preserved EF and therefore unlikely
to be cardiogenic.. Patient was successfully extubated and
tolerated room air/NC well,with no tachypnea and oxygen
saturations above 95%. Continued HCAP tx with vanc, zosyn X 7
days , azithromycin X 5 days. ubsequently extubated and
transferred to the medical floor where he was observed for
another two days and started physiotherapy. On discharge patient
respiratory status is improved with normal oxygen saturations.
Will need repeat CXR 6 weeks following discharge.
.
#.ALTERED MENTAL STATUS: Patient mental status post extubation
remained altered in the ICU where he was was slow in answering
questions, slept for prolonged amounts of time alternating with
episodes of agitation. This was attributed to prolomnged effect
of sedatives he was receiving during intubation. Mental status
on the medical floor was back at baseline and zyprexa was
discontuinued.
.
# DIABETIC KETOACIDOSIS: Presented with DKA likely secondary to
infection. Was followed in the ICU by [**Last Name (un) **], initially treated
with Insullin gtt then after Anion gap closed transitioned to
lantus + insulin sliding scale.
..
# NARCOTIC ABUSE - question of ingesting large amount of
oxycodone before admission , which the patient currently
denies.Avoided narcotics. Held neurontin for given mental
status changes.
.
#Diarrhea: may be due to opiate withdrawal. C.diff was
negative.
.
#HYPERTENSION Continued metoprolol po. Started low dose acei
lisinopril 5mg daily for elevated BPs; uptitrate to 10mg daily
.
#DEPRESSION Continued celexa
Medications on Admission:
Lantus 20u in AM
-NPH 12 units at bedtime
-novolog sliding scale
-Toprol xL 100mg daily
-Remeron 30mg daily
-Propranolol 10mg TID
-Celexa 40mg daily
-Neurontin 1600mg TID
Discharge Medications:
1. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) as needed for diarrhea for 3 days.
Disp:*6 Capsule(s)* Refills:*0*
6. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
Four (24) units Subcutaneous once a day.
7. insulin lispro
please use according to attached sliding scale
Discharge Disposition:
Home
Discharge Diagnosis:
Multifocal pneumonia
Respiratory failure
Diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were originally admitted to the intensive
care unit due to respiratory failure and found to have a
pneumonia as well as a diabetic ketoacidosis. You were given a
long course of IV antibiotics with significant improvement in
your symptoms. You were evaluated by physical therapy and have
been cleared to return home. You will need to follow up with
the diabetes physicians as an outpatient to ensure that your
sugars are well controlled.
We have made the following changes to your medications:
1) Loperamide 2mg tablet was started for your diarrhea. Please
take one tablet once every 12h as needed. only for 3 more days
2) Lisinopril 10mg tablet was started. Please continue taking 1
tablet once daily for control of your blood pressure.
3) Propranolol was stopped. Please consult your primary care
doctor about the need to continue this medication.
4) Neurontin was stopped. Please consult your PCP about
restarting this medication.
5) We have made changes to your insulin:
- Please stop NPH insulin
- continue to take Lantus injection 24 units once every morning.
- continue to take Insulin lispro according to attached sliding
scale
Followup Instructions:
Please follow up with your primary care physician.
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 28955**]
Address: [**Location (un) 28950**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) **]
Please follow up with your diabetes physician as below:
............
Completed by:[**2130-3-19**]
ICD9 Codes: 486, 2760, 2930, 4280, 3572
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5276
}
|
Medical Text: Admission Date: [**2169-10-30**] SUMMARY Date: [**2169-11-2**]
Date of Birth: [**2169-10-30**] Sex: F
Service: NB
THIS IS AN INTERIM SUMMARY
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] number two, was
twin number two of a mono-mono gestation born on [**10-30**]
to a 22-year-old, gravida 1, para 0 mom, whose prenatal
screens as follows: Blood type B positive, antibody screen
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, GBS status unknown, who received
a course of Betamethasone in [**Month (only) 216**].
Cesarean section was performed secondary to growth
restriction in twin number two. Her Apgar scores were 8 and
8. She was transferred to the Newborn Intensive Care Unit.
Her admission physical was notable for a birth weight of 1145
g, less than 10th percentile, length of 37.5 cm, less than
10th percentile, and a head circumference of 29.5 cm, 40th
percentile. Her physical examination was notable for a
growth restricted infant with notable head sparing. She was
pink and active. Her anterior fontanele was soft and flat.
Her palate was intact. Her breath sounds were decreased
bilaterally with occasional retractions and grunting. Her
cardiovascular examination showed a regular, rate, and rhythm
without murmur. Her abdominal examination was benign, and
her tone was symmetric.
HOSPITAL COURSE: Respiratory: She was intubated and
received two doses of Surfactant. She was weaned and
extubated to room air the next day. She has had a few mild
apneic and bradycardic spells but has not received Caffeine.
Cardiovascular: She has had a normal cardiovascular
examination with stable blood pressure and perfusion
throughout her stay.
Fluids, electrolytes, and nutrition: She was initially on
intravenous fluids with normal electrolytes and glucose, but
feeds were initiated on day of life two. She is currently on
55 cc/kg/day of enteral feeds, Similac Special Care 20
cal/oz. She had normal urine output.
Gastrointestinal: She has had no significant feeding
intolerance. She is on phototherapy, two lights, for a
bilirubin that has peaked on day of life two at 9.2. It is
currently 7.7. She continues under phototherapy.
Hematology: Her admission hematocrit was 48 percent.
Infectious disease: She had an initial CBC that was
concerning for neutropenia in the absence of a left shift.
She had been started on Ampicillin and Gentamicin after blood
culture was obtained. Her repeat complete blood count on day
of life two had normalized with a total white blood cell
count of 7.3, 50 percent polys, and no bands. Her platelets
were 193,000. Her antibiotics were discontinued after 48
hours, and her blood cultures was negative at that time.
INTERIM DIAGNOSIS: Prematurity.
Growth restriction.
Respiratory distress syndrome.
Rule out sepsis.
Hyperbilirubinemia.
REVIEWED BY: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 57163**]
MEDQUIST36
D: [**2169-11-2**] 19:08:12
T: [**2169-11-2**] 20:45:31
Job#: [**Job Number 57164**]
ICD9 Codes: 769, 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5277
}
|
Medical Text: Admission Date: [**2173-1-20**] Discharge Date: [**2173-1-23**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female
with multiple medical issues including chronic renal failure,
coronary artery disease, atrial fibrillation, congestive
heart failure, congestive obstructive pulmonary disease,
hypertension, gout, who is transferred from an outside
hospital for hypoxia and shortness of breath, and oxygen
requirement above her baseline. She was also transferred for
a surgical evaluation for severe pain in her lower
extremities.
At the outside hospital, she was diuresed with Natrecor and
Bumex and ruled out for a myocardial infarction. However,
her oxygen requirement remained despite improvement in her
jugular venous distention and chest x-ray. While at the
outside hospital, she was noted to have a left ankle
effusion, and this was catheterized. Ultimately, she was
transferred to [**Hospital1 69**] for
further evaluation.
On admission, the patient complained of bilateral ankle and
feet pain enabling, her pain so severe she was unable to
walk. On admission, she denied chest pain, shortness of
breath, fever, chills, palpitations, lightheadedness, or
dizziness. She did notice a cough with occasional sputum
production.
PAST MEDICAL HISTORY:
1. Atrial fibrillation status post pacemaker [**2172-12-24**].
2. Chronic renal failure baseline of [**3-2**].0.
3. Coronary artery disease angioplasty in [**2172-9-29**]
status post two stents, silent myocardial infarction in [**2167**].
4. Congestive heart failure. Echocardiogram on [**2172-10-29**] showed ejection fraction of 50%, [**3-2**]+ mitral
regurgitation, and [**3-2**]+ tricuspid regurgitation.
5. Congestive obstructive pulmonary disease.
6. Hypothyroid.
7. Chronic anemia secondary to chronic renal failure.
8. Hypertension.
9. Gout.
MEDICATIONS ON TRANSFER:
1. Coumadin 2 mg po q day.
2. Epogen 8,000 units q Tuesday.
3. Synthroid 25 mcg q day on empty stomach.
4. Calcium 1,000 mg tid.
5. Digoxin 0.125 q Thursday.
6. Lopressor 25 [**Hospital1 **].
7. Norvasc 5 mg q day.
8. Protonix 40 q day.
9. Sovilamil 800 mg tid.
10. Floredil.
11. Seroquel.
12. Nitropatch.
13. Colace.
14. Albuterol nebulizers.
15. Atrovent nebulizers.
16. Amiodarone.
17. Imdur.
18. Prednisone taper.
19. Bumex.
20. Home O2.
PHYSICAL EXAM ON ADMISSION: Temperature 96.4, blood pressure
112/62, heart rate 50, respiratory rate 18, SPO2 95% on 4
liters. In general, the patient appeared in no acute
distress. HEENT: Anicteric sclerae. Moist oropharynx.
Neck: No bruits. Of note, a murmur at the left carotid, no
lymphadenopathy, no jugular venous pressure appreciable.
Cardiovascular: Normal S1, S2 with a [**3-4**] crescendo
holosystolic murmur heard best at the left upper sternal
border. Pulmonary: Bibasilar crackles left greater than
right. Abdomen: Bowel sounds positive, soft, tender to deep
palpation in the right upper quadrant. Extremities cool,
left worse than right. Very tender to palpation and 1+ edema
at the ankles. Neurologic: Bilateral lower extremity muscle
atrophy noted.
Electrocardiogram on admission showed a left bundle branch
paced without ischemic changes.
Admission laboratories are significant for a creatinine of
4.6, bicarb 18.
Chest x-ray on admission showed pacemaker device in place.
Also of note, is a small area of hazy ill defined focal
density in the right lower lung zone that could represent
atelectasis and/or aspiration.
HOSPITAL COURSE: Patient was evaluated by Vascular for
severe peripheral vascular disease. Cardiology was also
consulted for possibility of surgery. She was treated with
antibiotics for the pneumonia. The day after admission the
patient progressively got worse requiring increased oxygen
and having complaints of shortness of breath. She was
transferred to the Intensive Care Unit.
She was placed on pressors to maintain her blood pressure and
was intubated to aid ventilation and oxygenation. She was
also started with empiric treatment of Heparin for
possibility of a pulmonary embolus. Throughout the course of
the stay in the unit, she developed shock and multisystem
organ failure including renal cardiac, and respiratory.
Given the higher risk of mortality despite aggressive care,
family decided patient to become comfort measures only.
Pressors were removed, and patient passed away on [**2173-1-23**].
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2173-2-23**] 17:49
T: [**2173-2-26**] 04:06
JOB#: [**Job Number 34217**]
ICD9 Codes: 5849, 7907, 486
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5278
}
|
Medical Text: Admission Date: [**2148-10-25**] Discharge Date: [**2148-11-1**]
Date of Birth: [**2097-5-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
fever, chills, tacchypnea
Major Surgical or Invasive Procedure:
Percutaneous biliary tube exchange with internal drainage
[**2148-10-30**]
History of Present Illness:
Pt is a 51 yo man with metastatic renal cell carcinoma who
presented to the ED today with fever. Patient was discharged
from the hospital on [**10-22**] and since been having low grade temps
around 99. This am temp was 100.8 and patient was noted to be
tacchycardic and tacchypneic by the VNA. Patient is not
neutropenic. He was noted to be tachypneic with sats as low as
90s on nasal cannula and was placed on nrb with good response in
the ED. He was also tacchy to the 130s and PE was considered
given his recent PE earlier this month for which he did not
receive coumadin given high bleeding risk with RCC and mets to
his pancreas. CTA done in ED was negative. CT did however show a
RLL consolidation. He was given vanco and ceftazidime in the ED.
He was also given dilaudid and tylenol as well as 2 liters of IV
NS. Surgery was consulted in ED and ext bag was placed for
further drainage of perc biliary tubes.
In the [**Hospital Unit Name 153**], initial VS were: T 100.7, P 120-130s, BP 94/59, R
24. Patient was sleepy but able to answer questions
appropriately. He reported some sob, no dizziness, chest pain,
abd pain, nausea, vomiting, dysuria, URI symptoms, muscle or
joint pain. Had bm yesterday and ate breakfast this am without
problem. [**Name (NI) **] wife, biliary tube was flusing fine but she noticed
more output this am.
.
Of note, patient has had two previous admissions this past
months. the first admission was [**2148-9-19**]. He was admitted with
RCC with new pancreatic head mass. Underwent exploratoy lap and
gastroenterostomy and open cholecystectomy and ileocolic bypass
and appendectomy. During that admission he had a PE and as
heparanized but not given coumadin for risk of bleed. He was
admitted again on [**2148-10-15**] for worsening abdominal pain and ERCP
was done which showed large fungating mass in the duodenum. Next
day went for cholangiogram and showed complete obstruction of
CBD, intrahepatic ducts-->int/ext biliary drainage catheter and
ext bag drainage. Celiac plexus block was done on [**10-21**] for
chronic pain. Patient was discharged on [**2148-10-22**]. Patient was
intubated for procedures but then extubated. He did have foley
while in the hospital.
Past Medical History:
Onc Hx: diagnosed with rcc in [**5-/2147**] when he presented
with hematuria and abdominal pain. The CT showed a large right
renal mass and he underwent nephrectomy on [**2147-6-6**].
Nephrectomy showed an 11 cm tumor with invasion into the
perinephric tissues and major veins, with clear cell histology,
Furhman nuclear grade 2. His preoperative workup had revealed
pulmonary emboli requiring anticoagulation. CT scans following
nephrectomy showed recurrence in the nephrectomy bed site as
well as increased mediastinal lymphadenopathy. He received HD
IL-2 treatment in [**2147-9-1**] without response. He was
enrolled in the phase I
avastin/sorafenib trial initiating treatment in [**11-5**].
Metastatic cancer to the pancreas. Last chemo was sutent stopped
early [**Month (only) 462**] before whipple.
.
PAST SURGICAL HISTORY:
1. Exploratory lap, cholecystectomy, appendectomy and an
antecolic retrogastric isoperistaltic gastroenterostomy and an
ileocolic bypass [**2148-9-19**]
2. Status post partial colectomy after perforated bowel
secondary to a motorcycle accident.
3. Status post right knee surgery.
4. Status post left knee arthroscopy.
5. History of pulmonary emboli on anticoagulation.
Social History:
He worked in the telecommunication industry and often drives for
hours at a time. Remote ETOH hx.Tob: 1 ppd x 30 years
Married and lives with wife and 7 yr old child.
Family History:
Father and uncle with lung CA
[**Name (NI) **] with [**Name2 (NI) 499**] CA
Sister with lung problems
[**Name (NI) **] family hx of kidney cancer
Physical Exam:
VS T 100.8 P 120-130s BP 94/59 R 28 O2sat 100 % on NRB
Gen- lethargic but awake and responsive to questions
HEENT- NCAT, anicteric, no injections, MM dry, OP clear
Neck- neck veins flat
Cor- RR, tacchy, no MGR
Pulm- crackles at right base
Abd- +bs, soft, slightly distended, non-tender, well-healing
midline scar
Extrem- no cce, pedal pulses 2+ b/l
Skin- no rashes or jaundice
Pertinent Results:
Labs:
Lactate:1.6
.
134 98 13 AGap=11
-----------< 145
4.0 29 1.1
.
estGFR: 71 / >75 (click for details)
Ca: 8.4 Mg: 1.7 P: 2.5
.
ALT: 35 AP: 572 (stable) Tbili: 0.9 Alb:
AST: 42 LDH: Dbili: TProt:
[**Doctor First Name **]: 72 Lip: 128 (stable)
.
wbc 11.0 hgb 7.0 crit 22.9 plt 472 (baseline crit is 20-25 in
last month) N:85.3 L:7.3 M:6.2 E:1.2 Bas:0.1
.
PT: 13.6 PTT: 23.9 INR: 1.2
.
ekg:
.
Imaging:
CTA [**10-25**]: . Interval increase in size of the right lower lobe
consolidative process now encompassing the previously noted
ground-glass opacity. Also interval development of air
bronchograms. These findings raise the suspicion for right
lower lobe pneumonia.
2. Interval development of loculated right-sided pleural
effusion.
3. Right middle lobe and left lower lobe atelectasis.
4. No definite evidence of residual PE.
5. Differential enhancement of the right and left lobe of the
liver which is only partially visualized. The vessels cannot be
evaluated on this study. This is of uncertain etiology and
significance.
6. Biliary drain with expected pneumobilia.
.
CXR [**10-25**]: Stable chest radiograph.
.
Biliary cath check: Persistently dilated common bile duct and
mildly dilated intrahepatic ducts due to known metastatic mass
of the duodenum. Internal- external drainage catheter in place,
without evidence of leakage. The tube was connected to the bag.
Brief Hospital Course:
ASSESSMENT/PLAN: 51 yo man with met RCC to pancreas s/p biliary
stent who presented w/ fever, tacchycardia, tacchypnea and
possible RLL consolidation on chest CT.
.
# CAP: presented with sepsis requiring stay in intensive care
unit, with fluid resusitation, supplemental O2 and IV antibiotic
therapy. Pt with consolidation on CT chest consistent with
pneumonia. Transferred to OMED after stabilization. Pt remained
afebrile with improving leukocytosis - continued on vanc & zosyn
for 72h, then vanc discontinued. Pt to complete 2 week course of
antibiotic with augmentin at home.
.
# Respiratory Failure/pneumonia: Pt with hypoxia, tachypnea and
increasing O2 requirement as above. Pt with consolidation on CT
scan, CTA negative for PE. Provided nebulizers as needed, gentle
diuresis with furosemide as pt fluid overloaded. He was weaned
off O2 to room air without difficulty. He is to complete 2 week
course of augmentin for community acquired pna.
.
# Pancreatic mets s/p biliary stent with perc.drainage:
Cholangiogram done on admission, with external drainage bag
placed per surgery. Leakage noted around insertion site during
OMED stay, required IR to change perc. biliary drainage tube.
Now with internal drainage. Family was taught drain care by the
nurses. There was no evidence of abdominal infection during
stay.
.
# Metastatic RCC: s/p Whipple due to mets to head of pancreas.
Last chemotherapy, Sutent, stopped [**8-/2148**] prior to whipple
procedure. Palliative care involved. Possibility of further
treatment to be addressed by Dr.[**Last Name (STitle) **].
.
# Pain: Chronic pain r/t malignancy. Well controlled during
hospitalization. Palliative care with pain recommendations for
patient. Regimen included Methadone and Dilaudid.
.
# Anemia: Chronic since early [**Month (only) 462**] coinciding with Whipple
procedure. Nml folate & B-12, however with iron deficiency as
well as anemia of chronic disease. Initiated Ferrous sulfate for
iron replacement.
.
# Hypothyroid: Continued levothyroxine on home regimen
.
Pt reached maximal hospital benefit and was discharged home with
services. Pt is to follow up with primary oncologist at 1-2
weeks after discharge
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for anxiety.
Disp:*45 Tablet(s)* Refills:*0*
7. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
9. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
10. Reglan 10 mg QID
11. Pt was also taking amoxicillin which he was on prior to
surgery
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).
3. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours)
as needed for anxiety.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) for 1 months.
Disp:*30 Capsule(s)* Refills:*0*
8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four
times a day: Before meals & at bedtime.
11. Methadone 10 mg Tablet Sig: One (1) Tablet PO three times a
day: Take 20mg qam, 10mg at midday & 30mg qpm.
12. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
RLL pneumonia
Anemia: iron deficiency & chronic disease
Metastatic renal cell CA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with fevers and hypotension, found to have
pneumonia. You have been treated for this.
You have anemia which is in part due to the cancer but also due
to iron deficiency.
.
Please complete your antibiotic therapy by taking Augmentin for
7 additional days. We have made some changes to your pain
regimen. Methadone 30mg qam, 10mg at midday & 20mg qpm. We have
started you on iron pills daily.
.
Please come to the emergency room or call your PCP if you
develop fevers, worsening abdominal pain or any other worrisome
symptoms.
Followup Instructions:
Please call Dr.[**Last Name (STitle) **] within 2 weeks of discharge for
followup.
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
ICD9 Codes: 0389, 486, 2859, 2449, 4589
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5279
}
|
Medical Text: Admission Date: [**2138-12-23**] Discharge Date: [**2138-12-29**]
Date of Birth: [**2091-2-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
SOB, nausea, diarrhea
Major Surgical or Invasive Procedure:
Central venous line with temporary pacer wire placement
History of Present Illness:
46M h/o CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1), HTN, DM2,
hyperlipidemia, CRI, obesity presents with progressive weakness,
nausea, SOB, diaphoresis, non-bloody diarrhea, and
lightheadedness x 24 hours. Denies CP, vomiting, fevers, or
chills. Endorses cough. No sick contacts. [**Name (NI) 25122**] all meds.
.
In the ED, vitals were T 97.0, HR 40, BP 125/50, RR 21, SaO2
100%, and FSBG 350. ECG revealed ventricular escape rhythm with
new wide QRS and peaked T-waves. K+ 5.9, AG 14, lactate 7, Cre
2.1 (baseline 1.7), and WBC 17. Given 8U insulin sc, 2.5L NS,
and 1mg IV glucagon given concern for BB toxicity. Intubated and
sent to cath lab for emergent placement of temp pacer wire where
he was started on dopamine gtt for bradycardia and given
calcium, bicarb, insulin for hyperkalemia and presumed DKA. Temp
wire set at 80bpm. Transferred to CCU for further management.
Past Medical History:
CAD s/p CABG [**2127**] (LIMA->LAD; SVG->D1,OM1)
DM2 with gastroparesis
HTN
Hyperlipidemia
CRI (baselin Cre 1.7; renal bx [**2138**] c/w diabetic etiology)
BPPV
OSA on BiPAP
Obesity
Social History:
Lives at home with wife. [**Name (NI) 1403**] in office. No tobacco, no EtOH.
Family History:
mother with CAD s/p CABG at age 70, mother with DM, no cancer,
no strokes
Physical Exam:
T 95.2 HR 64 BP 120/49 RR 19 SaO2 100% on AC/600/12/5/100%
General: Intubated, NAD
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, +ET tube, right IJ temp wire
Cardiac: RRR, s1s2 normal, no m/r/g, unable to assess JVD
Pulmonary: coarse BS b/l
Abdomen: +BS, soft, nontender, obese
Extremities: warm, 1+ DP/PT pulses, 1+ bilateral ankle edema
Neuro: Intubated and sedated, follows commands appropriately,
moves all extremities
Pertinent Results:
ECG ([**12-23**]): ventricular escape, 40bpm, axis normal, wide QRS,
peaked T-waves
.
ECG ([**12-24**]): Sinus rhythm. Since tracing #2, sinus rhythm has
resumed and the rate has increased. QRS complexes are now narrow
and there are non-specific T wave abnormalities.
.
CXR, portable ([**12-23**]): No obvious pulmonary edema or
consolidating pulmonary infiltrates.
.
Echo ([**12-24**]):
1. The left atrium is mildly dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.There is no pericardial effusion.
.
Renal U/S with doppler ([**12-26**]):
1. Normal renal ultrasound study. No stones or hydronephrosis
on either side.
2. Normal Doppler evaluation bilaterally.
.
Prior studies -
.
ETT ([**2-5**]):
INTERPRETATION: This patient is a 44 year old man with a history
of
CABG and diabetes mellitus who was referred for atypical chest
pain.
The patient exercised for 10.5 minutes on a modified [**Doctor First Name **]
protocol and stopped for fatigue. This represents a good
physical capacity. There were 0.5 mm horizontal/upsloping ST
depressions beginning at peak exercise (0.0 minutes of recovery)
in leas V4-V5. At minute 1.0 of recovery there were 1.0 mm
horizontal/upsloping ST depressions in leads II, III, aVF, V4,
and V5. At minute 3.0 of recovery there were 1.[**Street Address(2) 27090**]
depressions in leads II, III, aVF, V4, V5, and lead I. The ST
deviations resolved at minute 15.0 of recovery. The rhythm was
sinus with no ectopy. The blood pressure response was good.
IMPRESSION: No anginal symptoms and borderline ischemic ECG
changes at the acheived workload. Nuclear report sent
separately.
Stress images show a moderate-to-severe perfusion defect of the
lateral wall.
.
MIBI ([**2-5**]):
Resting perfusion images show this defect to be predominantly
reversible. Ejection fraction calculated from gated wall motion
images obtained after exercise is 55%, with normal wall motion.
IMPRESSION: At the level of exercise achieved, a
moderate-to-severe,
predominantly reversible, lateral wall defect with EF 55%.
Brief Hospital Course:
46M h/o CAD s/p CABG, DM2, HTN, CRI presents with GI symptoms,
SOB, malaise x 1 day found to have symptomatic bradycardia,
hyperkalemia with ECG changes and anion-gap metabolic acidosis
in the setting of acute-on-chronic renal insufficiency s/p temp
pacemaker wire placement and intubation, transiently on dopamine
gtt, now extubated and hemodynamically stable.
.
1.) Rhythm:
Patient was admitted with symptomatic bradycardia with
ventricular escape rhythm and ECG changes suggestive of
bradycardia. ECG not suggestive of CHB. Patient's bradycardia
was thought likely secondary to his hyperkalemia in the setting
of acute renal failure and possibly further complicated by beta
blocker toxicity from atenolol (given renal clearance of
atenolol). Patient was initially placed on dopamine and
intubated, then had temporary pacemaker wire placed, and was
then weaned off dopamine drip and extubated as mental status and
rhythm improved. As hyperkalemia resolved, patient's HR somewhat
improved and patient had 100% native pacing. The temp wire was
discontinued one day after admission and patient's rhythm
remained stable for the duration of his admission.
.
2.) Ischemia:
Patient has a history of coronary artery disease s/p CABG.
Patient had elevations of CK with mildly elevated Troponin T,
thought likely secondary to his acute renal failure on
presentation. Patient had an episode of isolated rising CK with
stable CK-MB and Troponin T, thought likely secondary to
myositis. Patient's medication regimen upon discharge includes
aspirin, plavix, statin, beta blocker, imdur, hydralazine,
lisinopril, and hydrochlorothiazide. Patient was recommended to
discuss with his outpatient cardiologist the usefulness of
taking plavix as the patient has no clear indication.
.
3.) Pump:
Echo demonstrated a preserved EF of greater than 55% and
appeared slightly volume overloaded on initial exam. Upon
discharge, patient was stabilized on a regimen of beta blocker,
ACEI, imdur, and HCTZ for blood pressure control.
.
4.) Hyperkalemia:
Etiology of patient's hyperkalemia thought likely secondary to
acute renal failure. Etiology of acute renal failure thought
likely secondary to pre-renal etiology after patient's history
of diarrhea. Potassium peaked at 7.2 with ECG changes suggestive
of hyperkalemia. Patient was treated with calcium, bicarb,
insulin, and kayexalate on admission and potassium remained
stable throughout the admission.
.
5.) Anion-gap metabolic acidosis:
Patient with elevated lactate and serum glucose on admission
with trace urine ketones. Etiology of anion gap metabolic
acidosis thought likely secondary to elevated lactate, perhaps
secondary to metformin and renal failure.
.
6.) Type 2 Diabetes Mellitus
Patient hyperglycemic on admission and had been stabilized on
metformin and glyburide at home. Upon admission, patient was
converted to a regimen of glyburide and insulin with input from
[**Last Name (un) **]. Patient to be discharged with follow-up with [**Last Name (un) **].
.
7.) Anemia:
Patient with a normocytic anemia of unclear etiology. Baseline
hematocrit appears to be between 30-32 with iron studies
consistent with anemia of chronic disease. Patient had an
attempted transfusion which was discontinued due to a
transfusion reaction with fevers and rigors. Patient recommended
to follow-up with his primary care doctor regarding his anemia.
.
8.) Hematuria:
Patient had several episodes of hematuria during this
hospitalization thought most likely secondary to trauma from
Foley insertion. Hematuria had much improved during the
hospitalization, but patient recommended to follow-up with his
PCP and consider an outpatient urology consult if hematuria does
not improve.
.
9.) Respiratory: Intubated initially for airway protection,
successfully extubated [**12-24**]. Overnight CPAP stable settings. He
was encouraged to discuss with his primary physician pursuing [**Name Initial (PRE) **]
sleep study as an outpatient if he develops concerns.
.
10.) CRI: s/p biopsy [**2138**] c/w diabetic etiology. elevated Cre at
presentation, pre-renal ARF [**3-6**] diarrhea and osmotic diuresis
from hyperglycemia resolved. After his presentation with the
elevated creatinine, his creatinine had some mild daily
variation but none clearly out of his baseline. He should have
his chemitries repeated in outpatient follow-up.
.
11.) Myositis: mildly elevated CKs, possibly due to
immobilization or statin however on home regimen. no evidence
cardiac etiology. By time of discharge, his CK had resolved to
normal. He remained without symptom of muscle pain. Should the
elevations, persist or recurr there could be a consideration for
changing his statin dose or brand.
.
12.) FEN: cardiac/[**Doctor First Name **] diet, replete 'lytes prn
.
13.) PPX: heparin sc tid, PPI, bowel regimen
.
14.) Code: FULL
.
15.) Dispo: home with VNA for insulin teaching with PCP and
[**Name9 (PRE) **] [**Name9 (PRE) 702**]
Medications on Admission:
Aspirin
Plavix 75mg qd
Lisinopril 30mg [**Hospital1 **]
Atenolol 50mg qd
Verapamil SR 240mg [**Hospital1 **]
HCTZ 25mg qMWF
Metformin 1g [**Hospital1 **]
Glyburide 5mg [**Hospital1 **]
Meclizine 12.5mg q8h
Protonix 40mg qd
Cozaar 25mg qD
Crestor 20mg qD
Clonidine 0.1mg qD
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*45 Tablet(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
Disp:*270 Tablet(s)* Refills:*2*
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25)
Suspension Sig: as directed as directed Subcutaneous once a day:
As directed.
Disp:*1 vial* Refills:*2*
14. Insulin Syringe Ultrafine [**2-3**] mL 29 x [**2-3**] Syringe Sig: One
(1) ea Miscell. three times a day: as directed.
Disp:*200 ea* Refills:*2*
15. Humalog Pen 300 unit/3 mL Insulin Pen Sig: as directed units
Subcutaneous twice a day: see attached sliding scale for dosing.
Disp:*3 pens* Refills:*2*
16. One Touch Ultra Test Strip Sig: One (1) strip Miscell.
four times a day.
Disp:*120 strips* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Bradycardia
Hyperkalemia
Hyperglycemia
Acute on chronic renal failure
Discharge Condition:
Stable to be discharged home. stable vital signs. ambulating
unassisted. tolerating oral medications and nutrition.
Discharge Instructions:
Please follow up as below and take all medications as
prescribed.
.
New medications: metoprolol, imdur, hydralazine,
hydrochlorothiazide (dose change), insulin
Discontinued medications: atenolol, verapamil, cozaar,
metformin, clonidine
.
If you develop any chest pain, shortness of breath,
lightheadedness, passing out or fainting, or any other
concerning symptom, please call Dr. [**Last Name (STitle) 1147**] or report to the
nearest ER.
.
Please check your blood sugars at least 3 times per day and
record them in a notebook so you and your regular physicians can
adjust the insulin as needed.
Followup Instructions:
You have an appointment scheduled with Dr. [**Last Name (STitle) 1147**] on Monday
[**1-5**], at 3:30pm in the [**Location (un) 4628**] office. Please call
[**0-0-**] with questions.
.
Please discuss with your primary care physician regarding any
further work-up needed for your anemia. Also, please let your
primary care physician know if you continue to have hematuria
(blood in your urine).
.
You have an appointment with Dr. [**First Name (STitle) 10083**] at the [**Hospital **] Clinic on
[**1-28**] at 9am. Please call ([**Telephone/Fax (1) 3537**] with questions.
ICD9 Codes: 5849, 5859, 2767, 2762, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5280
}
|
Medical Text: Admission Date: [**2138-11-1**] Discharge Date: [**2138-11-12**]
Date of Birth: [**2076-5-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
CABGx4(LIMA->LAD,SVG->Diag,SVG->OM,SVG->PDA)
History of Present Illness:
Patient is a 62 year old male with PMH of DM II, HTN, and
hypercholesteremia who presented to an OSH with nausea and
vomiting. The nausea and vomiting started 3 days ago, brownish
in color, and it has been constant. He has been unable to eat
due to the nausea and has not taken his medications, including
his insulin, for the last 3 days. Denies
lightheadedness/dizziness, chest discomfort or pain, arm pain,
jaw pain, sweating, SOB, palpatations, orthopnea, PND, edema. No
history of recent travel, no sick contacts, and has not been out
to eat lately, only 'out to the supermarket.' He has had no
diarrhea but has not had a BM in 3 days. His last BM was normal
in color, no melena, no hematochezia. His urination has
decreased, he believes because of decreased PO intake, but no
dysuria or hesitancy. Mild increased thirst.
In the ED at [**Hospital6 33**] the patient was found to have
CK's of 1635, CK-MB of 34.3, trop 0.55, an elevated creatinine
of creatinine of 2.1 with BUN 54. EKG showed NSR with T wave
flattening and possible inversion in inferior leads per report,
and CXR was unremarkalbe. Additionally LFT's were slightly
elevated and he had a white count of 11.8. Amylase and lipase
normal. ABG with respiratory and metabolic alkalosis
(7.55/30/76/26.2). He was given fluids and antiemetics. Because
they felt the cardiac enzymes could not be explained by the ARF
alone, he was started on heparin gtt, asa, and lopressor.
ROS is o/w unremarkable for no weight gain/loss, no HA's, no
vision changes, no fevers, chills, or night sweats, no abdominal
pain, +constipation, no diarrhea, no muscle weakness or pain.
Past Medical History:
HTN
Hypercholesteremia
DM II
Social History:
Lives with wife at home, but she is currently at [**Hospital1 336**] receiving
chemotherapy.
Family History:
Noncontributory
Physical Exam:
GEN: NAD, WN, WD
HEENT: Clear OP, MMM
Neck: Supple, No LAD, No JVD
Lungs: CTA, BS BL, No W/R/C
Cardiac: RR, NL rate. NL S1S2. No murmurs
Abd: Soft, NT, ND. NL BS. No HSM.
Ext: No edema. 2+ DP pulses BL.
Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact. Sensation
decreased in bilateral LE to soft touch and pin prick. [**5-29**]
strength throughout in upper and LE's
Pertinent Results:
[**2138-11-1**] WBC-13.1 Hgb-13.5 Hct-39.2 Plt Ct-191
[**2138-11-6**] Hct-30.3
[**2138-11-7**] WBC-6.1 Hgb-8.6 Hct-24.8 Plt Ct-107
[**2138-11-12**] WBC-7.3 Hgb-8.9 Hct-26.2 Plt Ct-269
[**2138-11-1**] Gluc-240 BUN-54 Creat-1.9 Na-140 K-4.3 Cl-103 HCO3-25
[**2138-11-3**] Gluc-229 BUN-36 Creat-1.6 Na-139 K-3.3 Cl-102 HCO3-25
[**2138-11-7**] Gluc-155 BUN-15 Creat-1.1 Na-140 K-3.9 Cl-105 HCO3-25
[**2138-11-12**] Gluc-117 BUN-20 Creat-1.1 Na-138 K-4.0 Cl-100 HCO3-27
CARDIAC CATHETERIZATION:
1. Selective coronary angiography revealed a right dominant
system
with severe three vessel coronary artery disease. The LMCA had
mild
disease. The twin LAD system has a 90% stenosis at the origin of
the
septal component and a 79% stenosis prior to the bifurcation of
a large
diagonal branch. The LCA had a total occlusion after the OM1
with left
to left collaterals. The RCA had a proximal occlusion with left
to right
collaterals.
2. Limited resting hemodynamics demonstrated moderate systemic
hypertension and mildly elevated left sided pressures (LVEDP 18
mmHg)
with no gradient upon movement of the catheter from the
ventricle back
to the aorta.
3. Left ventriculography was deferred for renal insufficiency.
CAROTID SERIES COMPLETE
Mild atherosclerotic changes in the proximal internal carotid
arteries bilaterally with less than 40% stenosis on both sides.
CT
1. Small retroperitoneal hematoma.
2. Right renal obstruction with right-sided hydroureter and
hydronephrosis with marked soft tissue prominence at the right
ureterovesical junction, containing a punctate density. Findings
could indicate obstructing right UVJ stone, although the degree
of UVJ swelling is unusual and tumor cannot be excluded.
Alternatively the denisty could represent contrast in the
collecting system. A non contrast enhanced follow-up scan of the
pelvis would help to determine whether this density represents a
stone. If a stone is suspected, the soft tissue prominence at
the right UVJ has to be followed to complete resolution on CT.
Alternatively, this could be further evaluated with cystoscopy.
3. Small right pleural effusion and minimal bibasilar
atelectasis.
RENAL U/S:
Mild right hydronephrosis. Assymetric bladder wall thickening
at the right vesicoureteric junction. Although an echogenic
lesion here likely reflects calculus, the degree of thickening
is thought to be atypical for a calculus, even an impacted one,
and cystoscopic evaluation is recommended to rule out tumor.
[**2138-11-11**] CXR
Comparison is made to study performed one day prior. The patient
has undergone median sternotomy. There is stable cardiomegaly.
Pulmonary vasculature is not engorged. There are small bilateral
pleural effusions as well as bibasilar atelectasis. Osseous
structures are unremarkable.
[**2138-11-7**] EKG
Sinus rhythm. Probable inferior myocardial infarction. Minor
non-specific
ST-T wave abnormalities. Compared to [**2138-11-1**] tracing is not
suggestive of left ventricular hypertrophy.
Brief Hospital Course:
Mr. [**Known lastname 41776**] was admitted to the [**Hospital1 18**] on [**11-1**]/095 for further
management. Heparin and aspirin were continued given his
elevated cardiac enzymes.An echocardiogram was obtained which
revealed hypokinesis of his anterior septum. A cardiac
catheterization was performed which revealed severe three vessel
disease. Given the severity of his disease, the cardiac surgical
service was consulted and Mr. [**Known lastname 41776**] was worked-up in the usual
preoperative manner. As Mr. [**Known lastname 41776**] had hematuria, an abdominal
CT scan was obtained which revealed a small retroperitoneal
hematoma and a right renal obstruction with right-sided
hydroureter and hydronephrosis with marked soft tissue
prominence at the right ureterovesical junction, containing a
punctate density. The urology service was consulted and a
cystoscopy was recommended in the future. Urine cytology was
performed which was read as atypical cells.On [**2138-11-7**], Mr.
[**Known lastname 41776**] was taken to the operating room where he underwent
coronary artery bypass grafting to four vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit. On postoperative day one, Mr. [**Known lastname 41776**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Aspirin and beta
blockade were resumed. He was then transferred to the cardiac
surgical down unit for further recovery. He was gently diuresed
towards his preoperative weight. Ceftriaxone and levofloxacin
were started for presumed pneumonia. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. After obtaining a normal chest x-ray
prior to discharge, his antibiotics were discontinued. Some mild
erythema was noted at his incision and keflex was started. Mr.
[**Known lastname 41776**] continued to make steady progress and was discharged
home on postoperative day five. He will follow-up with Dr.
[**Last Name (STitle) **], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Procardia (unknown dose)
Lipitor (unknown dose, has been on for 15? years)
ASA 81 mg PO QD
NPH 40 units QAM, 20 QHS
Humalog 8 units in a.m. and 8 units at supper
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. 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*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 1 weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: NPH 40
Units QAM, 20 Units QPM Subcutaneous twice a day: Humolog 8
Units with breaksfast, 8 units with dinner.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
3 vessel Coronary Artery Disease
Diabetes, controlled
Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
Shower, wash incision with soap and water and pat dry. No baths,
lotions, creams or powders.
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Followup Instructions:
Please see your cardiologist 2 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 33129**] Follow-up
appointment should be in 2 weeks
Completed by:[**2138-12-1**]
ICD9 Codes: 5849, 4019, 2720, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5281
}
|
Medical Text: Admission Date: [**2186-12-24**] Discharge Date: [**2187-1-14**]
Date of Birth: [**2131-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
[**2186-12-24**] Head and Chest CT Scan
[**2186-12-24**], [**2186-12-26**] [**Month/Day/Year **]
[**2186-12-26**] Cardiac Catheterization
[**2187-1-8**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending; vein
grafts to posterior descending artery and obtuse marginal.
History of Present Illness:
Mr. [**Known lastname 66460**] is a pleasant 55 year old male with hypertension,
elevated cholesterol and smoking history who was lifting a harp
into the car when he started breathing heavy and collapsed.
Wife started CPR immediately. Paramedics initial rhythm was
ventricular fibrillation. He was shocked multiple times and
intubated in the field, and transferred to [**Location (un) **]. ECG with
wide complex tachycardia at rate of ~140. He was treated with
Amiodarone and Lidocaine, and subsequently med flighted to
[**Hospital1 18**]. While in the ED, found to be in atrial flutter at 150
with 2:1 block and BP 170/110. CXR revealed CHF. He was
admitted to the CCU, intubated and sedated.
Past Medical History:
Hypertension, Hypercholesterolemia, Subclinical Hyperthyroidism,
s/p Appendectomy, s/p Testicular Surgery, s/p Deviated Septum
Social History:
Active pipe smoker for >30 years. Denies excessive ETOH. He is
married and works as a chemist. He denies IVDA and recreational
drugs.
Family History:
Mother had MI at age 72, s/p CABG. Father died of osteosarcoma.
Physical Exam:
Vitals in CCU T100.8 HR 154, BP154/114, intubated
Gen: Middle aged male intubated in bed unresponsive to commands
HEENT: PERRL, MMM, JVP not assessed as pt intubated and lying
flat.
Chest: vented breath sounds, clear anteriorly
CVR: tachycardic, regular, nl s1, s2, +s4
Abdomen: soft, obese, nontender, +bs
Ext: 2+ femoral pulses, 1+ PT pulses bilaterally.
Neuro: pt intubated, pupilary reflexes intact
Pertinent Results:
[**2187-1-7**] 04:20PM BLOOD WBC-14.0* RBC-4.81 Hgb-14.5 Hct-42.9
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.4 Plt Ct-515*
[**2187-1-14**] 05:10AM BLOOD WBC-11.4* RBC-2.94* Hgb-9.1* Hct-25.5*
MCV-87 MCH-30.8 MCHC-35.6* RDW-13.9 Plt Ct-525*
[**2186-12-31**] 06:55AM BLOOD Neuts-56 Bands-7* Lymphs-23 Monos-8 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2187-1-14**] 05:10AM BLOOD Plt Ct-525*
[**2187-1-7**] 04:20PM BLOOD PT-11.9 INR(PT)-0.9
[**2187-1-7**] 04:20PM BLOOD Plt Ct-515*
[**2187-1-14**] 05:10AM BLOOD Glucose-97 UreaN-17 Creat-1.0 Na-136
K-4.7 Cl-102 HCO3-25 AnGap-14
[**2187-1-7**] 04:20PM BLOOD Glucose-131* UreaN-16 Creat-1.0 Na-138
K-4.9 Cl-103 HCO3-20* AnGap-20
[**2187-1-7**] 04:20PM BLOOD ALT-56* AST-21 LD(LDH)-271* AlkPhos-113
TotBili-0.2
[**2186-12-30**] 10:50AM BLOOD CK-MB-4 cTropnT-0.17*
[**2187-1-6**] 10:40AM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.7 Mg-1.9
[**2186-12-26**] 02:00PM BLOOD VitB12-613
[**2187-1-7**] 04:20PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2186-12-26**] 02:00PM BLOOD Triglyc-187* HDL-35 CHOL/HD-3.6
LDLcalc-53
[**2186-12-24**] 06:03PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
On admission to the CCU, an [**Month/Day/Year 461**] was notable for a
dilated left ventricle and severely depressed LVEF of around
20%. Chest and head CT scans were also obtained. The chest scan
revealed diffuse ground glass opacities and bilateral lower lobe
air space disease. There was no evidence of pulmonary embolism.
The head scan was remarkable for two foci of low attenuation,
one within the right subcortical temporal lobe white matter, and
one within the right medial temporal lobe. Both of these may
represent areas of lacunar infarction.
He was concomitantly noted to have a leukocytosis and spiked a
fever to 102.0. He was empirically started on broad spectrum
antibiotics. Pan cultures remained negative. He also experienced
a transient decline in renal function with creatinine peaking to
2.4. Within days, his renal function normalized and his
hypoxia/acidosis improved. He maintained stable hemodynamics and
was eventually extubated on hospital day two. No further
ventricular arrhythmias were noted on telemetry and he remained
pain free. His CK-MB and troponin peaked to 70 and 1.5
respectively.
On [**12-26**], cardiac catheterization revealed severe three
vessel coronary artery disease in a right dominant system. The
left main demonstrated mild diffuse disease. The LAD had a 70%
stenosis after the 1st Diagonal. The D1 was totally occluded and
filled via left to left collaterals. The LCX demonstrates a 40%
proximal lesion along with a totally occluded OM2 that filled
via left to left collaterals. The RCA demonstrated a 70%
proximal lesion along with a total occlusion
of the distal vessel that filled via left to right collaterals.
Repeat [**Month (only) 461**] again showed moderately to severely
depressed left ventricular systolic function of approximately
30-35%. Resting regional wall motion abnormalities included
inferior/inferolateral akinesis/hypokinesis and distal septal
and apical hypokinesis. There was only mild mitral regurgitation
and mild aortic insufficiency.
He was referred to Dr. [**Last Name (STitle) **] for CABG when he was medically
ready to go to the OR. He remained in the CCU prior to his
surgery initially and then was transferred to the floor. His
rising WBCs was an issue that prevented him from going to the OR
earlier. There was a question of an aspiration PNA and he
completed abx. Blood and urine cultures were negative. Heparin
turned off several days before surgery. He underwent CABG x3 on
[**1-8**]. He was seen on [**1-9**] by the EP service for evaluation for
possible ICD. It was determined he could see Dr. [**Last Name (STitle) **] in
one month as an outpatient. Swan and chest tubes were removed on
POD #1. He was extubated and was alert and oriented. He remained
on an amiodarone loading drip and the neo drip was weaned off on
POD #2. He was transferred to the floor in the afternoon.
On the floor he developed a rash on his RUE where the BP cuff
had been. He was given benadryl and lidex cream and had a
dermatology consult. He remained in SR and the amiodarone was
DCed. His leukocytosis was improving and he had no evidence of
active infection. Ibuprofen had been started for a pericardial
rub, but this was stopped the next day when his creatinine rose
to 1.6. This decreased to 1.0 the next day. He had a small
hematoma at the left thigh. Flomax was started for complaints of
difficulty urinating. Diuresis and beta blockade continued and
he was cleared for discharge to home with VNA on [**1-14**].
T 99.0 HR 80 SR 120/88 RR 16 sat 95% RA
Medications on Admission:
HCtz 25 qd, Lisinoprril 20 qd, Lipitor 20 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, Viagra
prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
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 1
weeks.
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. 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
CAD
HTN
hypercholesterolemia
s/p Vfib arrest
s/p cabg x3
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain greater then 2 pounds in 24 hours or 5
pounds in one week.
4) Take lasix as directed with potassium and stop in one week.
5) No lifting more then 10 pounds for 10 weeks.
6) No creams, lotions or powders to wounds until they have
healed. Steristrips will fall off on there own. If have not
fallen off in 2 weeks from discharge, please remove.
7) Call with any questions or concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2187-2-14**]
1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2187-2-14**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 3390**] [**Name11 (NameIs) **] appointment should be in 2 weeks
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] appointment should be in 2
weeks
Completed by:[**2187-1-25**]
ICD9 Codes: 4271, 4280, 5070, 5845, 5180, 4019, 2724, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5282
}
|
Medical Text: Admission Date: [**2140-8-25**] Discharge Date: [**2140-9-2**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Transfer from MICU, initially admitted for hypertensive
emergency
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 23 year old female with h/o SLE, lupus nephritis
and ESRD on HD, and poorly controlled HTN on multiple
medications presenting on [**8-25**] with unresponsiveness, bilateral
lower extremity weakness, and nausea/vomiting. She was in her
USOH until 2 days pta, when she developed n/v, and on the day of
admission, she was found lying on the floor unresponsive to
family members. Upon awakening she found that she could not
move either of her legs. She was taken to the EW, where she had
BP 260s/200s, had a non-contrast head CT showing left frontal
ICH, right parieto-occipital ICH, and edema throughout
bilaterally thought to be c/w PRES (posterior reversible
encephalopathy syndrome) with superimposed ICH, and had a
MRI/MRV to exclude venous thrombosis showing ICH in the
parieto-occipital lobes bilaterally and pons without venous
sinus thrombosis. She had a tonic-clonic seizure in the ED
terminated with 2 mg IV lorazepam. Neurosurgery was consulted
and felt that she should be managed non-surgically, a labetalol
drip was started with a target SBP of 160s-180s, and she was
admitted to the MICU.
.
In the MICU, she was initially maintained on the labetolol gtt.
She was also started on dilantin for seizure prophylaxis. She
was intubated to have an MRI of the head, as there was concern
for sinus venous thrombosis. MRI was negative for thrombosis.
She transiently required phenylepherine for BP maintenence while
she was on a propofol gtt for maintenence of sedation. She was
extubated on [**8-26**]. While in the ICU she was seen by nephrology
who did not think she needed acute HD. Hematology was also
consulted as the patient had thrombocytopenia and hemolytic
anemia. They did not think she had TTP and thought it was more
likely [**Last Name (un) 1724**] from hypertensive emergency. Additionally, she had
[**3-12**] sets of blood cultures from [**8-25**] grow oxacillan resistant
coagulase negative staph and was started on vancomycin. TTE was
done and negative for vegetation. Her PO BP meds were uptitrated
in the ICU and SBPs have been <180s in the past 24 hours. She
was transferred to the Medicine Team.
.
Upon transfer to Medicine team, the patient's SBPs were being
maintained between 150-160's and on po medications. She denied
fever, chills, nausea, vomiting, headache, chest pain, or
shortness of breath.
Past Medical History:
# Lupus - Diagnosed [**2134**] (16 years old)
- Diagnosed when she had swollen fingers, arm rash and
arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
# CKD/ESRD secondary to SLE - [**2135**]
# HTN - [**2137**]
- baseline BPs 180's/120's
- previous history of hypertensive crisis with seizures
# Uveitis secondary to SLE - [**4-15**]
- s/p left eye enucleation [**2139-4-20**] for fungal infection
# Thrombocytopenia - previous thrombocytopenia and hemolytic
anemia (TTP vs malignant HTN were considered on DDx)
# HOCM - per Echo in [**2137**]
# Anemia
# Vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera
injection requiring transfusion
# History of Coag negative Staph bacteremia and HD line
infection - [**6-15**] and [**5-16**]
# Previous history of SVC and UE clot, previously maintained on
coumadin
- SVC venogram performed [**2139**] s/p coumadin therapy revals patent
SVY and subclavian
- ?APLS but never has had positive anti-phospholipid antibody
Social History:
SH: Lives in [**Location 669**] with mother, who works at [**Hospital1 18**], and her 16
year old brother. She was able to graduated from high school but
unable to work since then secondary to her illness.
Drugs: ??????
Tob: ??????
Alc: ??????
Family History:
No family history of SLE
MGF: HTN, MI, stroke in 70s. No clotting disorders in family. No
history of autoimmune disease.
Physical Exam:
Vitals: T 97.6 HR 102 BP 176/100 RR 16 O2 sat 100% RA
General: Patient is a young African American female, sitting up,
talking on phone, NAD
HEENT: Left eye s/p enucleation. otherwise NCAT.
Neck: Supple
Pulmonary: CTA b/l
Cardio: Regular. +III/VI early systolic murmur throughout
precordium, loudest at LLSB.
Abdomen: SOft, non-tender, non-distended. NABS
Ext: No C/C/E
.
Neuro:
CN 2-12 intact, except EOMI and pupilary light reaction not
tested
Muscle strength intact in upper and lower extremities b/l
.
ON TRANSFER TO MEDICINE:
========================
Vitals: T 97.2 HR 92 BP 154/90 RR 16 O2 sat 100% RA
GEN: NAD, pleasant, sitting in bed.
HEENT: Left eye s/p enucleation. o/w NCAT, OP - no erythema, no
exudate, no LAD
PULM: CTAB, no w/r/r
CV: RRR. +III/VI early systolic murmur throughout precordium,
loudest at LLSB. No rubs/gallops
ABD: NABS, soft, NDNT
EXT: no c/c/e
Pertinent Results:
ADMISSION LABS:
===============
14.4
8.2 >------< 56 MCV 84
41.7
135 109 50
----|----|-----< 103
6.1 14 5.1
free Ca 1.14
.
PERTINENT LABS DURING HOSPITALIZATION:
======================================
Hct Trend: 41.7 - 40.2 - 39 - 30.4 - 26.9 - 25.1 - 23.2 - 21.7 -
25.4 - 25.8 - 27.0 - 28.6 - 25.7 - 27.9
Platelet Trend: 56 - 70 - 59 - 40 - 37 - 44 - 107 - 108 - 148 -
165 - 150 - 139 - 170 - 173
.
[**2140-8-25**] 10:51AM Glucose-94 Lactate-1.2 Na-136 K-6.3* Cl-114*
calHCO3-14*
[**2140-8-25**] 02:23PM Lactate-2.2*
[**2140-8-25**] 04:12PM Lactate-1.0 K-5.1
[**2140-8-25**] 10:51AM Type-[**Last Name (un) **] pH-7.19*
[**2140-8-25**] 01:48PM Type-ART pO2-117* pCO2-24* pH-7.27* calTCO2-12*
Base XS--13
[**2140-8-25**] 04:12PM Type-ART Temp-37.6 Rates-/22 pO2-106* pCO2-25*
pH-7.32* calTCO2-13* Base XS--11 Not Intubated
[**2140-8-25**] 07:47PM Type-ART Temp-36.9 Rates-16/ Tidal V-500 PEEP-5
FiO2-100 pO2-336* pCO2-29* pH-7.26* calTCO2-14* Base XS--12
AADO2-365 REQ O2-64 -ASSIST/CON Intubat-INTUBATED
[**2140-8-25**] 11:02PM Type-ART Temp-36.9 Rates-18/ Tidal V-500 PEEP-5
FiO2-40 pO2-208* pCO2-25* pH-7.30* calTCO2-13* Base XS--11
-ASSIST/CON Intubat-INTUBATED
[**2140-8-26**] 01:27AM Type-ART Temp-36.7 Rates-/20 Tidal V-450 PEEP-5
FiO2-40 pO2-207* pCO2-28* pH-7.30* calTCO2-14* Base XS--10
Intubat-INTUBATED Vent-SPONTANEOU
[**2140-8-26**] 03:59AM Type-ART Temp-36.7 pO2-108* pCO2-31* pH-7.35
calTCO2-18* Base XS--7 Intubat-NOT INTUBA
[**2140-8-26**] 08:25PM Type-[**Last Name (un) **] Temp-37.0 pO2-41* pCO2-36 pH-7.33*
calTCO2-20* Base XS--6 Intubat-NOT INTUBA
.
[**Doctor First Name **]-POSITIVE Titer-1:320
ACA IgG 11.4 ACA IgM 9.0
ESR 15
C3-55* C4-13
Haptoglobin trend: <20 - 69
LDH: 326 - 256 - 246
Retic Count: 1.8 - 2.0
[**Doctor Last Name 17012**] Negative
Urine 24 hr Creat-630
.
MICROBIOLOGY:
=============
[**8-25**] Blood Cultures from venipuncture: Staph, coag negative x 2,
susceptible only to rifampin, tetracycline, and vancomycin.
[**8-25**] Blood Cultures from arterial line: Staph, coag negative x
2, susceptible only to rifampin, tetracycline, and vancomycin.
[**8-27**] Blood Cultures x 2 NGTD
[**8-27**] Blood Cultures x 2 NGTD
[**8-27**] Blood Cultures from catheter tip: Staph, coag negative,
susceptible only to rifampin, tetracycline, and vancomycin.
[**8-28**] Blood Cultures x 2 from femoral NGTD
[**8-28**] Blood Culture from femoral: enterobacter>15
[**8-28**] Blood Cultures x 2 NGTD
[**8-31**] Blood Cultures pending
[**9-1**] Blood Cultures pending
.
STUDIES:
=========
CHEST (PORTABLE AP) [**2140-8-25**]
IMPRESSION: AP chest compared to 11:49 a.m.:
Tip of the new endotracheal tube, with the chin slightly flexed
is no more than 15 mm above the carina, 2 cm below optimal
placement, as reported to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2026**] on
[**8-25**]. An ascending caval catheter ends in the low right atrium.
Nasogastric tube ends in the stomach. There is no pneumothorax
or pleural effusion. Lungs are clear and heart size is normal.
No pneumothorax.
.
MRA BRAIN W/O CONTRAST [**2140-8-25**]
IMPRESSION:
1. Multifocal areas of cortical T2 signal hyperintensity, some
with foci of recent hemorrhage. The most affected areas are the
parietal and occipital lobes, as well as the pons. The
appearance may represent posterior reversible encephalopathy
syndrome. Hemorrhage and pontine involvement in this disorder is
somewhat unusual, but has been described in the literature.
.
2. No definite evidence of major venous sinus thrombosis.
Nevertheless, if further evaluation is felt necessary
clinically, axial and coronal-acquired 2D time-of-flight MR
venography sequences could be performed, allowing each of the
major venous sinuses to be imaged orthogonally, a procedure
which would minimize any in-plane flow artifacts simulating
thrombus. However, this diagnosis, even at present, is
considered highly unlikely.
.
CT HEAD W/O CONTRAST [**2140-8-25**]
IMPRESSION:
1. Acute intraparenchymal hemorrhages peripherally in the right
parietoccipital and left frontal lobes, with surrounding edema
and local mass effect.
.
2. Vasogenic and interstitial edema in a strikingly symmetric
and posterior distribution involving both [**Doctor Last Name 352**] and white matter
of the occipital lobes and frontalparietal regions, bilaterally.
.
COMMENT: These findings are highly suggestive of PRES
(hypertensive encephalopathy), with development of superimposed
hypertensive hemorrhages. However, given the history of SLE,
suspicion of underlying "lupus anticoagulant" and non-arterial
distribution of edema and hemorrhage, cerebral venous (including
dural venous sinus) thrombosis should be excluded, and urgent
MRI with MRV has been recommended, below.
.
The results were discussed with Dr. [**First Name8 (NamePattern2) 698**] [**Last Name (NamePattern1) **], EU
resident, at the time of study.
.
2. Right maxillary sinus mucus retention cyst.
.
CHEST (SINGLE VIEW) [**2140-8-25**]
IMPRESSION: Unremarkable chest radiograph.
.
EKG [**2140-8-25**]
Sinus tachycardia. Voltage criteria for left ventricular
hypertrophy. Diffuse ST-T wave abnormalities, most likely
related to left ventricular hypertrophy. Compared to the
previous tracing of [**2140-7-30**] lateral ST-T wave abnormalities have
improved.
TRACING #1
.
EKG [**2140-8-26**]
Sinus tachycardia. Compared to the previous tracing of [**2140-8-25**]
no significant diagnostic change.
TRACING #2
.
ECHO [**2140-8-26**]
Conclusions:
The left atrium is normal in size. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is a mild resting left ventricular outflow tract
obstruction. The gradient increased with the Valsalva manuever.
The findings are consistent with hypertrophic obstructive
cardiomyopathy (HOCM). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2140-5-20**], no
change.
.
IMPRESSION: No valvular vegetations seen.
Brief Hospital Course:
Ms. [**Known lastname **] is a 23 yo female with a h/o SLE with secondary lupus
nephritis, uveitis s/p left eye enucleation, question of APLS
and poorly controlled HTN who presented on [**8-25**] with N/V,
lethargy, fatigue and headaches, found to have hypertensive
emergency,who subsequently seized. CT head showed multiple
intraparenchymal hemorrhages.
.
# Hypertensive Emergency with ICH: Patient initially presented
with significantly elevated blood pressures resulting in end
organ damage causing seizure and intracranial hemorrhage. Her
intracranial bleed appears to be most consistent with PRES,
though septic emboli are on the differential. Goal SBP 150-160s.
Continued dilantin 100 mg tid for seizure prophylaxis, and pt
scheduled for follow up at neuro clinic in two weeks after
discharge. Continued po regimen of labetolol 1000 mg TID,
hydralazine 75 mg PO BID (the only change in home meds),
lisinopril 40 mg [**Hospital1 **], valsartan 320 mg PO daily, nicardapine 60
mg PO TID, as well as clonidine patch when transferred to the
floor. Pt achieved goal of SBPs in 150-160s on this regimen and
was discharged home.
.
# Bacteremia: She had high grade bacteremia with 6/6 bottles on
[**8-25**] growing oxacillan resistant coagulase negative staph. HD
cath was d/c'ed. A TTE was negative for vegetation. Blood
cultures from [**8-27**] and [**8-28**] showed NGTD. Pt started on
vancomycin. Levels were followed to achieve therapeutic goals.
Ideally, vancomycin would be continued for 14 days after first
negative blood cultures. Repeatedly, pt was told that
vancomycin was superior to linezolid for bacteremia, but she
still refused PICC. Thus, pt started on po linezolid and
discharged with linezolid. She will need close follow up for
bone marrow suppression secondary to linezolid.
.
# Thrombocytopenia: Patient has had previous episodes of
clinical illness with acute drop in platelets with question of
consumptive coagulopathy from thrombosis vs. secondary to
malignant hypertension. Received one unit platelets with
placement of R femoral line. Platelets slowly improved over
hospitalization. Evaluated by heme who did not think
thrombocytopenia was consistent with TTP, but more likely to be
due to malignant hypertension. Platelets counts improved with
improvement in blood pressures.
.
# SLE: The patient was previously treated with
Cytoxan/Prednisone and on admission was on low dose prednisone.
There had been concern in the past for anti-phospholipid
syndrome but her APA testing has been negative. Rheum consulted.
Pt on 15 mg prednisone during hospitalization and discharged
with this dose and follow up.
.
# CKD stage V - Patient most recently had not been to HD for 3
weeks because she did not like the way it made her feel. Some
residual kidney function and awaiting kidney transplantation
from a relative. HD catheter was pulled during this admission
due to high grade bacteremia. Per renal, not imperative that pt
needs acute HD. Electrolytes monitored. Sevelamer and daily
Kayexalate continued during hospitalization.
.
#. Anemia - Thought to be chronic and likely related to her CKD.
There was concern for hemolytic anemia during this admission,
likely caused by malignant hypertension. Hct trended up during
hospitalization. Continued Epogen 4000 u three times/wk per
renal.
.
# Code - Presumed Full
.
#. Communication: Mother - [**Telephone/Fax (1) 43497**]
.
#. Dispo: Home with services.
Medications on Admission:
Valsartan 320 mg QD
Clonidine patch weekly
Hydralazine 50 mg [**Hospital1 **]
Lisinopril 40 mg [**Hospital1 **]
Nicardipine 60 mg TID
Labetalol 1000 mg TID
Prednisone 20 mg QD
Neurontin 100 mg 3x/week
Sevelemer 800 mg TID
Allergies: PCNs -> rash
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO Q8H (every 8 hours).
Disp:*90 Capsule(s)* Refills:*2*
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
Disp:*450 Tablet(s)* Refills:*2*
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Nicardipine 30 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*2*
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
9. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive emergency
Seizures
Coagulase negative Staph bacteremia
Chronic kidney disease
Discharge Condition:
good
Discharge Instructions:
You were admitted for high blood pressure, seizures and head
bleeding.
.
Your blood pressure was controlled and you were evaluated by the
neurology, [**Location (un) **] and renal doctors. You should follow up
with all of them after you are discharged.
.
Please continue all your medications as prescribed.
.
You should continue taking your antibiotic as prescribed for 8
more days. Linezolid twice a day for 8 days.
.
If any fevers, shortness of breath, chest pain, headaches or any
other symptoms that may concern you please call your PCP or come
to the emergency department.
.
Followup Instructions:
Nephrology
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2140-9-5**] 4:00
.
Primary Care
Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 44538**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2140-9-6**] 3:00
.
Neurology:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] [**9-16**] 1 pm. Phone. [**Telephone/Fax (1) 40554**]
.
[**Telephone/Fax (1) 2225**]:
Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2140-10-5**] 3:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2140-9-5**]
ICD9 Codes: 7907
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5283
}
|
Medical Text: Admission Date: [**2183-7-10**] Discharge Date: [**2183-7-14**]
Date of Birth: [**2155-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 27yoM with history of depression with SI who presents
from psychiatric facility ([**Hospital 1680**] Hospital) with question of
unknown ingestion. Per report, took "something" from roommate.
Found with an empty plastic bag. No report of what he could have
taken. Brought to [**Hospital1 18**] for evaluation. Unclear if patient was
somnolent when found and if that's what prompted the suspicion
of ingestion.
In ED, initial VS were 97.7, 92, 135/83, 14, 97% 2L. Initial
evaluation was unremarkable. However, while in ED, patient
became more somnolent and was given narcan 0.4mg diagnostically
but did not improve mental status. ABG at that time was
7.31/72/87. Labs were otherwise unimpressive. Given somnolence,
patient was admitted to MICU further management. VS prior to
admission were: Temp: 98.3 ??????F (36.8 ??????C), Pulse: 62, RR: 14, BP:
108/67, O2Sat: 97% RA.
On arrival to the MICU, patient was conscious and speaking and
was breathing comfortably on room air. Vitals: 98.1, 86,
140/83, 31, 92% RA. The patient reported he does not recall
anything since lunch. He does recall being at [**Hospital 1680**] Hospital
and being admitted there after he threatened to commit suicide
by overdose of home medications. He does not recall taking an
overdose at [**Hospital 1680**] Hospital.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- hypothyroidism (TSH 5.09, T4 0.8 on [**7-9**])-- patient reports
compliance with home medication
- hepatitis C
- depression with suicidal ideation ([**3-20**] past suicide attempts,
1 cutting, [**2-16**] overdose with methadone, cocaine, or heroin)
- PTSD (sexually abused at age 7)
- IVDU w/ heroin, now on methadone, last used heroin on [**6-3**] (part of reason for recent admission was that he was afraid
he would relapse to illicit drug use)
- sleep apnea -- used CPAP in past, but hasn't used it in a
while
Social History:
smoker, homeless, IVDU as per PMH/HPI
Family History:
non-contributory
Physical Exam:
Admission Exam:
Vitals: 98.1, 86, 140/83, 31, 92% RA
General: somnolent, but arousable, falls asleep during
mid-conversation; when he does fall asleep his O2 sat drops to
low 90s/high 80s on RA; no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear, EOMI, PERRL (no
miosis or mydriasis)
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur 2nd
L intercostal space
Lungs: no wheezes or rhonchi, initially rales at B/L bases, but
they cleared after pt took a couple deep breaths
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
Discharge Exam:
VS: T97.6, HR 56, BP 96-135/68-78 RR 16, O2Sat 97% RA (96% on
CPAP with O2)
Gen: Awake, alert, oriented to self, place, and time
HEENT: PERRLA, sclera anicteric, MMM, OP clear
Neck: supple, no LAD
CV: RRR, soft systolic murmur at the LUSB
Lung: CTAB, no w/c/r
Abd: soft, NT, ND, BS+, no HSM
Ext: warm, dry, 2+ DP pulses, no c/c/e
Neuro: A&O, able to carry out a conversation, mental status much
improved and more alert compared to the initial presentation.
Pertinent Results:
Initial Labs:
[**2183-7-10**] 10:46PM URINE HOURS-RANDOM
[**2183-7-10**] 10:46PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2183-7-10**] 10:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2183-7-10**] 10:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2183-7-10**] 07:11PM TYPE-ART PO2-87 PCO2-72* PH-7.31* TOTAL
CO2-38* BASE XS-6 INTUBATED-NOT INTUBA
[**2183-7-10**] 07:11PM LACTATE-0.9
[**2183-7-10**] 07:11PM HGB-13.1* calcHCT-39 O2 SAT-94 CARBOXYHB-2
[**2183-7-10**] 05:20PM GLUCOSE-99 UREA N-13 CREAT-0.9 SODIUM-144
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-34* ANION GAP-10
[**2183-7-10**] 05:20PM estGFR-Using this
[**2183-7-10**] 05:20PM ALT(SGPT)-44* AST(SGOT)-27 ALK PHOS-68 TOT
BILI-0.3
[**2183-7-10**] 05:20PM ALBUMIN-3.9
[**2183-7-10**] 05:20PM TSH-1.2
[**2183-7-10**] 05:20PM T4-8.5
[**2183-7-10**] 05:20PM LITHIUM-0.8
[**2183-7-10**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-7-10**] 05:20PM WBC-8.1 RBC-4.50* HGB-13.6* HCT-40.5 MCV-90
MCH-30.2 MCHC-33.5 RDW-14.2
[**2183-7-10**] 05:20PM NEUTS-53.7 LYMPHS-36.5 MONOS-5.1 EOS-3.9
BASOS-0.8
[**2183-7-10**] 05:20PM PLT COUNT-227
Pertinent Labs:
[**2183-7-11**] RPR- non-reactive
Labs on Discharge:
[**2183-7-14**] 07:40AM BLOOD WBC-5.8 RBC-4.41* Hgb-13.2* Hct-39.5*
MCV-90 MCH-29.8 MCHC-33.3 RDW-13.8 Plt Ct-202
[**2183-7-14**] 07:40AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-143
K-3.7 Cl-103 HCO3-36* AnGap-8
[**2183-7-12**] 07:55AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2
[**2183-7-14**] 07:40AM BLOOD VitB12-PND Folate-PND
EKG [**7-10**]:
Normal sinus rhythm. Normal tracing. No previous tracing
available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 182 88 [**Telephone/Fax (2) 112370**] 22
Imaging:
[**2183-7-10**]
- CXR: low lung volumes, no acute cardiopulmonary process
[**2183-7-11**]
- CT head: There is no evidence of acute intracranial
hemorrhage, mass effect, or shift of normally midline
structures. There is no cerebral edema or loss of [**Doctor Last Name 352**]-white
matter differentiation to suggest an acute ischemic event. A 4
x 3 mm hyperattenuating focus is seen at the level of the
foramen of [**Last Name (un) 2044**]. There is no hydrocephalus. Basal cisterns
are patent. Globes are intact. Paranasal sinuses and mastoid
air cells are well aerated. No fracture.
IMPRESSION:
A 4 x 3 mm hyperattenuating focus at the level from foramen of
[**Last Name (un) 2044**] is most compatible with a colloid cyst. Further
assessments with MRI can be
considered, if indicated. No hydrocephalus.
Brief Hospital Course:
27M w/ hx of PTSD, depression w/ multiple suicide attempts, IVDU
now on methadone, hepC, and ?sleep apnea who presents from
psychiatric hospital somnolent after suspected ingestion with
unknown drug.
Patient was observed in the MICU overnight before transferring
to the medicine floor.
ACUTE ISSUES:
# Respiratory Acidosis [**1-16**] sleep apnea, NOS. Acute on chronic
based on ABG. Based on presentation, had evidence of
hypoventilation. There was a concern for drug overdose, but no
causative [**Doctor Last Name 360**] was found. His tox screen showed presence of
benzo and methadone which he normally takes. His lithium level
was normal. Patient denies ingesting substances. Patient was
thought to have central sleep apnea. Therefore, the psychiatry
service assisted with medication adjustment to prevent worsening
of his respiratory drive. Patient's mirtazepine and gabapentin
were held. He was given CPAP while in house at night given that
he was noted to have O2 sat in the 70% when he falls asleep. He
responded to the CPAP with O2 supplement, and his O2Sat came up
to the 90% when asleep. The sleep medicine service plans to see
patient in the outpatient setting for a sleep study. Patient
was given CPAP with O2 supplement so that he would continued to
get bridge therapy while in the psychiatric hospital, awaiting
for sleep study. One can consider decreasing Xanax to TID from
QID and use Vistaril 12.5-25 mg q6-8 hr while awake for
breakthrough anxiety/restlessness.
# Altered mental status: Somnolence. Possibly secondary to
alleged toxin ingestion, although none was found. Hypercapnea
may have contributed partly, but the degree of which is not the
sole cause of his mental status. Psychiatry assisted with
medication adjustment to prevent worsening of his somnolence.
His somnolence improved with holding mirtazepine and gabapentin
and with use of CPAP.
# ? toxic ingestion. None was found. This was alleged by the
outside hospital. His tox screen showed evidence of benzo and
methadone, which he was taking. Lithium level was normal. He
did not have metabolic derangement or EKG changes. He had
minimal LFT abnormalities, which is likely result of underlying
hepatitis C. TSH was normal. RPR was non-reactive. It was
unlikely narcotics given lack of response to narcan. Patient
takes methadone at baseline.
# Suicidality / Depression / PTSD. Patient was sectioned 12 by
the psychiatry service. His medication were adjusted with
discontinuation of mirtazepine and gabapentin. The psychiatry
team here does not think it would be safe for patient to restart
mirtazepine or gabapentin at this time, given the somnolence
that led to his admission. Patient had 1:1 sitter to monitor
for safety. Psychiatry suggested decreasing Xanax to TID from
QID and using Vistaril 12.5-25 mg q6-8 hrs while awake for
breakthrough restlessness and anxiety, but this can be done in
the psychiatry hospital. He was thought to be medically stable,
and the BEST teaem assisted with bed search.
CHRONIC ISSUES:
# Hypothyroidism. Patient had normal TSH and T4. He was
continued on levothyroxine.
# Hepatitis C. Not currently on treatment. ALT is mildly
elevate. This will need to be monitored in the outpatient
setting.
TRANSITIONAL ISSUES:
# Follow up: sleep medicine on [**8-13**], psychiatry, and PCP (after
discharge from the psychiatric hospital)
# Pending
- pending B12 and folate
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Hospital 1680**] Hospital records.
1. ALPRAZolam 0.5 mg PO QID
2. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN
2 puffs QID:PRN wheezing, SOB
3. Citalopram 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lithium Carbonate 600 mg PO BID
7. Methadone 80 mg PO DAILY
8. Mirtazapine 30 mg PO HS
9. Ibuprofen 400 mg PO Q6H:PRN pain
10. Gabapentin 600 mg PO TID mood
11. Prazosin 1 mg PO HS
Discharge Medications:
1. ALPRAZolam 0.5 mg PO QID
2. Citalopram 40 mg PO DAILY
3. Ibuprofen 400 mg PO Q6H:PRN pain
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lithium Carbonate 600 mg PO BID
6. Methadone 80 mg PO DAILY
7. Prazosin 1 mg PO HS
8. albuterol sulfate *NF* 90 mcg/actuation Inhalation QID:PRN
2 puffs QID:PRN wheezing, SOB
9. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
10. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch daily Disp #*28 Unit
Refills:*0
11. Docusate Sodium 100 mg PO BID
12. CPAP
8-15 cm H2O with heated humidifcation.
13. O2 supplement
2L of O2 supplement, titrate to CPAP.
Mass Health # [**Telephone/Fax (5) 112371**]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses:
- Acute on chronic respiratory acidosis
- Sleep apnea, NOS, now on CPAP
- Altered mental status, secondary to possible ingestion and
acute on chronic respiratory acidosis
Secondary diagnoses:
- Depression
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 112372**],
You were transferred to [**Hospital1 69**]
because you were found to be very sleepy at [**Hospital 1680**] Hospital.
While you were here, we found that your breathing becomes very
slowed and stops at times. This seemed to be a long standing
issue based on what you tell us. We checked with [**Hospital **], but
they said you did not have sleep study there. Based on some lab
tests, it also seems that some of your medications were making
your breathing worse. Therefore, the psychiatrists in the
hospital helped with medication adjustment and recommended
holding off on the Rameron and Neurontin. You were also given a
CPAP while you were in the hospital. Your breathing seemed to
improve with these changes.
Please note the following changes with your medications:
- STOP Rameron for now (check with psych)
- STOP Neurontin for now (check with psych)
- START acetaminophen for pain
- START nicotine patch for tobacco smoking
Please be sure to follow up with the Sleep Medicine doctor [**First Name (Titles) 3**] [**Last Name (Titles) 19379**]d so that you can get a sleep study to treat the sleep
apnea formally.
Followup Instructions:
You should also be sure to follow up with your primary care
doctor at the [**Telephone/Fax (1) 58547**], The Family HealthCare Center at
SSTAR, within 1 week of your discharge from the mental health
hospital.
Department: MEDICAL SPECIALTIES/SLEEP MEDICINE
When: WEDNESDAY [**2183-8-13**] at 8:40 AM
With: DR. [**First Name (STitle) **]/DR. [**First Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2183-7-14**]
ICD9 Codes: 2762, 311, 2449, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5284
}
|
Medical Text: Admission Date: [**2134-4-2**] Discharge Date: [**2134-4-16**]
Date of Birth: [**2066-10-28**] Sex: M
Service:
ADMITTING DIAGNOSIS: Sternal wound infection.
HISTORY OF PRESENT ILLNESS: This is a 67 year old man who is
status post living related kidney transplant performed in
[**2133-12-17**], admitted for post CABG sternotomy wound
infection. The patient underwent CABG times four on [**2134-3-25**]
and was subsequently discharged on the 15th. However, over
the next couple of days the patient noted increasing
discharge from the chest wound incision site and returned to
the hospital on [**2134-4-2**] for evaluation. At that time the
patient denied fever, chills, nausea, vomiting, abdominal
pain. He denied pain over the transplant site. He denied
diarrhea or urinary complications. The patient's weight was
also increased from his baseline, so he was also felt to be
slightly volume overloaded.
PAST MEDICAL HISTORY: Includes living related kidney
transplant on [**2134-1-13**], for end stage renal disease
secondary to diabetes. Osteoarthritis of the neck. Coronary
artery disease. Type 1 diabetes. Non-Q wave MI in [**2134-3-16**].
Status post episode of aortic regurgitation in [**2134-3-16**].
PAST SURGICAL HISTORY: Status post transplant. Status post
CABG times four.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Include CellCept [**Pager number **] mg p.o.
q.i.d., Rapamune 6 mg p.o. q.d., Reglan, Bactrim single
strength one p.o. q.d., atenolol 25 mg p.o. q.d., NPH
insulin.
PHYSICAL EXAMINATION: On physical examination the patient
was afebrile with temperature of 98.8, blood pressure 150/52,
heart rate 70, respiratory rate 16. He was in no acute
distress. Chest sternotomy scar had drainage of
serosanguineous fluid. Cardiovascular exam was regular rate
and rhythm. Abdomen had normal bowel sounds, soft, nontender
over the right lower quadrant renal graft site. Extremities
showed 2+ edema.
LABORATORY DATA: On admission white count was 6.8,
hematocrit 29, platelets 255. Chem-7 was significant for BUN
of 25, creatinine 1.3, glucose 250. Bilirubin at the time
was 0.3. Rapamune level was also checked.
HOSPITAL COURSE: The patient was admitted for intravenous
antibiotics, management of volume overload and further
treatment of his sternal wound infection. He was placed on
vancomycin and a renal consult was requested given his kidney
transplant. The patient was maintained on IV antibiotics,
however, he had persistent low grade fever and persistent
discharge from his incisional site. Cultures from the site
grew coag negative staph.
Given the fact that he was a transplant patient with a
sternal wound infection and persistent low grade fever, he
was taken back to the operating room on [**4-6**] for sternal
rewiring. During this procedure there was avulsion of the
right graft followed by revision of the vein graft to the
PDA. Postoperatively the patient did very well. His sternum
was stable. There was a small amount of bloody drainage from
the sternal incision. His rate remained regular. The
patient had Cipro added to his antibiotic regimen. He did
have a bump in his creatinine that was felt to be some acute
renal failure which had resolved by the time of discharge.
On discharge on [**4-16**] the patient was doing well. He had a
normal white count most recently of 10.8. He remained
afebrile. His incision was healing well. BUN and creatinine
renal function were good with BUN of 32 and creatinine of
1.3. The patient was discharged with the following
diagnoses.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post CABG.
2. Sternal wound infection status post rewiring.
3. Revision of PDA graft.
4. Status post living related kidney transplant for chronic
renal failure.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gm IV q.d.
2. Ciprofloxacin 500 mg p.o. q.d.
3. Tums two capsules p.o. q.d.
4. Neutra-Phos one capsule p.o. q.d.
5. Lopressor 50 mg p.o. b.i.d.
6. CellCept [**Pager number **] mg p.o. q.i.d.
7. NPH 18 units q.a.m. subcu, 4 units q.p.m. subcu.
8. Rocaltrol 0.25 mg p.o. q.d.
9. Vitamin E 500 mg q.d.
10. Rapamune 6 mg p.o. q.d.
11. Prilosec 20 mg p.o. q.d.
12. Reglan 5 mg p.o. q.d.
13. Lipitor 20 mg p.o. q.d.
14. Bactrim single strength one p.o. q.d.
15. Epogen 3000 units subcu q.Monday through Friday.
16. Prednisone 10 mg p.o. q.d.
17. Multivitamin one p.o. q.d.
18. Potassium chloride 20 mEq p.o. q.d.
19. Colace 100 mg p.o. q.d.
20. Aspirin 81 mg p.o. q.d.
21. Lasix 60 mg p.o. b.i.d.
FOLLOWUP: The patient has a PICC line for IV antibiotics.
He is tolerating a regular diet and is in good condition.
The patient is to have daily wound checks for a week,
continue IV antibiotics for a week and follow up in one week
with Dr. [**Last Name (STitle) 1537**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2134-4-16**] 09:14
T: [**2134-4-16**] 11:17
JOB#: [**Job Number 32898**]
ICD9 Codes: 4241, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5285
}
|
Medical Text: Admission Date: [**2125-1-27**] Discharge Date: [**2125-2-3**]
Date of Birth: [**2048-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Colitis
Major Surgical or Invasive Procedure:
arterial line placement
History of Present Illness:
M with h/o COPD, s/p left lobectomy, rheumatic heart disease,
PAF on coumadin, HTN who presented to OSH on [**1-21**] with bloody
diarrhea, found to have collitis, transfered to [**Hospital1 18**] for
potential surgical issues and hypoxia management.
.
Patient reports diarrhea beg [**1-15**] (6 days PTA). He was having
[**6-15**] bowel movement per day - liquid. No f/c, no nausea, no sick
contacts. BMs with occasional blood - 1-2 per day with 1-2 cc of
blood 2 days prior to presentation to OSH. Patient was recently
treated with ABX for bronchitis. CT scan at [**Location (un) **] showed
pancolitis, with low suspicious for ischemic colitis. Patient
was admited for hydration, Cipro/flagy were started. His INR was
4.2 upon admission. They had difficulty obtaining a stool sample
due to lack of BMs. Subsequently, patient subsequently had a
colonocopy on [**1-24**] which showed distal sigmoid with intense
areas of pathacy, hyperemic mucosa with moderate inflammatory
changes. Moderate diverticulosis was see in the sigmoid, no
diverticulitis. The involvement was atypical for ischemic
disease. There were not specific for C. Diff either. Patient's
gastric distention improved with suctioning of air, functional
stricture was appreciated at junction of sigmoid and distended
colon - ? Ogilvies. Biopsies were taken from involved sigmoid
colon/rectum. Patient was also evaluted for hemoptysis as he has
h/o RUL spiculated nodule and LLL lobectomy. Patient coughed up
1 spood of blood, with resolution of hemoptysis. HIs INR
continued to raise during his admission to 4.7. Patient waws
also given 5 mg of Vitamin K. His Hct remained stable, no FFP
was hgiven. It was felt that bronchoscopy was not indicated.
Patient was subsequently transfered to [**Hospital1 18**] for potential
surgical intervention, hypoxia/SOB, worsening liver, renal
failure and on levophed for hypotension.
.
Patient denies any fevers/chills, he reports minimal PO intake
with liquid diet, he also reports insertion of NGT on [**1-27**]
without relief of his symptoms. He denies any cp, no current
SOB, although overall has been more dyspnic x 3 days. He admits
to persistent hemoptysis x 3 days, last episode 3 days ago.
Minimal amount. He denies any current abdominal pain. Had a BM,
well formed nonbloody this AM. He has a foley catheter that was
inserted [**1-24**]. He also reports increased LE edema since
[**Month (only) **].
Past Medical History:
COPD - FEV 1.5 - 2.0 L
s/p Left lower lobectomy for benign tumor
h/o of resolved spiculated RUL nodule - evaluated by Dr. [**Last Name (STitle) **]
in [**Month (only) 216**], felt to be inflammatory with no follow up necessary.
Nl bronchoscopy in [**Month (only) 216**] at [**Location (un) **].
H/O rheumatic heart disease
MR (moderate) /Mitral stenosis - valve area 1.5 - 2.0
PAF on coumadin - patient had failed cardioversion in [**Month (only) **],
due to persistence of Afib, increase in weight, SOB and
worsening of NYHA class to IV. During OSH admission his HR was
difficult to control with HR to 140s on BB, Digoxin. Patient is
schedule for potential PVI in [**2125-2-6**] here at [**Hospital1 18**]. Has been
on amiodarone in the past.
CHF
2000Cardiac catherization w/o evidence of CAD
h/o TIA
HTN
Hyperlipidemia
Bilateral hernia repair
Appendectomy
Malignant tumor (?muscle) in his leg
Social History:
patient lives alone with his wife. Quit tobacco 16 years ago. 50
+ pack years. No daily EtOH, several a week
Family History:
nc
Physical Exam:
Vitals on MICU Tx: 96.1 90(Afib) 105/64 95%2LNC RR 14-19
Vitals on Floor: 96.6 100/60 90 20 96%2LNC
Gen: alert, though appears sleepy.
HEENT: toungue moist, white exudate on posterior oropharynx
NECK: Supple, No LAD, prominent V waves appreciated on exam,
marked JVP, pulsitile
CV: RR, NL rate. NL S1, S2. systolic murmur heard best @ apex
LUNGS: Faint crackles bilaterally at bases
ABD: Soft, NT, ND. NL BS. No HSM
EXT: 2+ grossly pitting edema. 2+ DP pulses BL
SKIN: No lesions
Pertinent Results:
[**2125-1-27**] 06:24PM BLOOD WBC-17.5*# RBC-4.12* Hgb-12.5* Hct-39.1*
MCV-95 MCH-30.2 MCHC-31.8 RDW-15.6* Plt Ct-404#
[**2125-1-28**] 03:39AM BLOOD WBC-16.4* RBC-4.19* Hgb-12.7* Hct-39.4*
MCV-94 MCH-30.3 MCHC-32.2 RDW-15.6* Plt Ct-436
[**2125-1-29**] 03:33AM BLOOD WBC-15.9* RBC-4.15* Hgb-12.4* Hct-38.0*
MCV-92 MCH-29.7 MCHC-32.5 RDW-15.5 Plt Ct-368
[**2125-1-30**] 06:10AM BLOOD WBC-17.4* RBC-4.64 Hgb-13.7* Hct-43.9
MCV-95 MCH-29.6 MCHC-31.3 RDW-15.7* Plt Ct-537*
[**2125-1-31**] 05:45AM BLOOD WBC-18.7* RBC-4.50* Hgb-13.5* Hct-41.3
MCV-92 MCH-29.9 MCHC-32.6 RDW-15.3 Plt Ct-430
[**2125-1-31**] 05:08PM BLOOD WBC-16.4* RBC-4.24* Hgb-12.8* Hct-39.6*
MCV-93 MCH-30.2 MCHC-32.3 RDW-15.9* Plt Ct-449*
[**2125-2-1**] 03:36AM BLOOD WBC-22.7* RBC-4.51* Hgb-13.4* Hct-40.7
MCV-90 MCH-29.7 MCHC-32.9 RDW-15.8* Plt Ct-375
[**2125-2-2**] 04:00AM BLOOD WBC-21.3* RBC-4.24* Hgb-12.8* Hct-38.6*
MCV-91 MCH-30.2 MCHC-33.2 RDW-16.1* Plt Ct-446*
[**2125-1-27**] 06:24PM BLOOD Neuts-84.5* Lymphs-7.9* Monos-7.2 Eos-0.1
Baso-0.3
[**2125-2-1**] 03:36AM BLOOD Neuts-90* Bands-0 Lymphs-1* Monos-9 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
[**2125-2-1**] 03:36AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**]
[**2125-1-27**] 06:24PM BLOOD PT-38.8* PTT-38.7* INR(PT)-4.2*
[**2125-1-28**] 03:39AM BLOOD PT-34.2* PTT-37.8* INR(PT)-3.6*
[**2125-1-31**] 05:45AM BLOOD PT-26.5* PTT-34.5 INR(PT)-2.6*
[**2125-2-2**] 04:00AM BLOOD PT-26.3* PTT-35.2* INR(PT)-2.6*
[**2125-1-27**] 06:24PM BLOOD Glucose-118* UreaN-71* Creat-3.4*# Na-134
K-4.9 Cl-100 HCO3-19* AnGap-20
[**2125-1-28**] 03:39AM BLOOD Glucose-121* UreaN-75* Creat-3.1* Na-132*
K-5.2* Cl-102 HCO3-17* AnGap-18
[**2125-1-29**] 03:33AM BLOOD Glucose-108* UreaN-87* Creat-3.0* Na-132*
K-5.3* Cl-100 HCO3-19* AnGap-18
[**2125-1-31**] 05:45AM BLOOD Glucose-104 UreaN-111* Creat-3.2* Na-133
K-6.0* Cl-99 HCO3-20* AnGap-20
[**2125-1-31**] 05:08PM BLOOD Glucose-240* UreaN-118* Creat-3.6*
Na-130* K-6.9* Cl-97 HCO3-20* AnGap-20
[**2125-2-1**] 03:36AM BLOOD Glucose-109* UreaN-119* Creat-3.2*
Na-132* K-4.6 Cl-99 HCO3-22 AnGap-16
[**2125-2-1**] 05:26PM BLOOD Glucose-139* UreaN-120* Creat-3.1* Na-134
K-4.4 Cl-96 HCO3-23 AnGap-19
[**2125-2-2**] 04:00AM BLOOD Glucose-131* UreaN-122* Creat-3.0*
Na-132* K-4.6 Cl-96 HCO3-24 AnGap-17
[**2125-1-27**] 06:24PM BLOOD ALT-190* AST-207* LD(LDH)-293*
AlkPhos-133* TotBili-1.1
[**2125-1-28**] 03:39AM BLOOD ALT-173* AST-148* LD(LDH)-282*
AlkPhos-124* TotBili-1.1
[**2125-1-30**] 06:10AM BLOOD ALT-172* AST-154* LD(LDH)-354*
AlkPhos-134* TotBili-2.0*
[**2125-1-31**] 05:08PM BLOOD LD(LDH)-613* CK(CPK)-104
[**2125-2-1**] 03:36AM BLOOD ALT-124* AST-88* CK(CPK)-88 AlkPhos-123*
TotBili-2.4*
[**2125-1-27**] 06:24PM BLOOD Lipase-28
[**2125-1-28**] 03:39AM BLOOD Lipase-26
[**2125-1-30**] 06:10AM BLOOD proBNP-[**Numeric Identifier 28195**]*
[**2125-1-31**] 05:45AM BLOOD proBNP-[**Numeric Identifier 28196**]*
[**2125-2-1**] 03:36AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2125-1-27**] 06:24PM BLOOD Calcium-8.0* Phos-6.4* Mg-2.4
[**2125-2-2**] 04:00AM BLOOD Albumin-2.7* Calcium-7.8* Phos-6.9*
Mg-2.7*
[**2125-1-30**] 06:10AM BLOOD TSH-5.9*
[**2125-1-31**] 05:45AM BLOOD T4-8.1
[**2125-1-27**] 06:24PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2125-1-27**] 06:24PM BLOOD Digoxin-2.4*
[**2125-2-2**] 04:00AM BLOOD Digoxin-1.2
[**2125-1-27**] 06:24PM BLOOD HCV Ab-NEGATIVE
[**2125-1-27**] 10:08PM BLOOD Type-ART Temp-37.6 Rates-/24 pO2-69*
pCO2-30* pH-7.34* calTCO2-17* Base XS--8 Intubat-NOT INTUBA
[**2125-1-31**] 05:48PM BLOOD Type-ART pO2-52* pCO2-41 pH-7.34*
calTCO2-23 Base XS--3 Intubat-NOT INTUBA
[**2125-2-1**] 09:07AM BLOOD Type-ART Temp-35 pO2-65* pCO2-33* pH-7.37
calTCO2-20* Base XS--4 Intubat-NOT INTUBA
[**2125-2-1**] 11:04AM BLOOD Type-ART Temp-38 FiO2-70 pO2-92 pCO2-42
pH-7.36 calTCO2-25 Base XS--1 Intubat-NOT INTUBA
[**2125-2-1**] 02:19PM BLOOD Type-ART Temp-38.8 pO2-78* pCO2-41
pH-7.36 calTCO2-24 Base XS--1
[**2125-2-1**] 05:55PM BLOOD Type-ART Temp-36.4 pO2-67* pCO2-41
pH-7.38 calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2125-1-27**] 08:28PM BLOOD Lactate-1.8
[**2125-1-31**] 06:50PM BLOOD Glucose-153* Lactate-1.8 Na-131* K-4.7
Cl-98* calHCO3-20*
.
.
STUDIES:
[**2125-1-27**] KUB:
This is a single frontal film of the abdomen, limited by motion
artifact. Gas is seen in some mildly distended loops of colon
with the cecum measuring up to 8.2 cm. This study is not
sufficient to completely assess the abdomen or bowel given the
motion artifact.
.
[**2125-1-27**] CXR:
There are no old films available for comparison. The heart is
enlarged with bulbous contour which could be due to pericardial
effusion
versus cardiomegaly. There is an NG tube with tip off the film,
at least in the stomach. There is a right IJ line with tip in
the SVC. There is a
moderate-sized right pleural effusion. There is probably also
left pleural effusion with volume loss at both bases. There is
hazy, ill-defined vasculature most marked in the right lower
lobe and it is unclear if this represents some asymmetric
pulmonary edema or an infectious infiltrate.
.
[**2125-1-27**] LIVER USN:
Sludge within the gallbladder, as well as gallbladder wall
edema. In light of the patient's fluid overloaded state
(including ascites and pleural effusion), gallbladder wall edema
is nonspecific. The lack of son[**Name (NI) 493**] [**Name2 (NI) 515**] sign makes
acute cholecystitis less likely. If there is continued clinical
concern, nuclear medicine imaging could be obtained to evaluate
for acute cholecystitis.
.
[**2125-1-29**] TTE:
The left atrium is markedly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. The
estimated right atrial pressure is 10-20mmHg. Left ventricular
wall thicknesses, cavity size and regional/global systolic
function are normal (LVEF>55%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal diastolic septal motion/position consistent
with right ventricular volume overload. The aortic root is
mildly dilated at the sinus level. 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
moderately thickened with characteristic rheumatic deformity.
There is mild mitral stenosis. There is moderate thickening of
the mitral valve chordae. Mild to moderate ([**2-8**]+) mitral
regurgitation is seen. The severity of mitral regurgitation may
be underestiated due to acoustic shadowing. The tricuspid valve
leaflets are mildly thickened and fail to fully coapt. Moderate
to severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a very small
circumferential pericardial effusion.
.
IMPRESSION: Rheumatic valvular disease with mild mitral
stenosis, mild-moderate mitral regurgitation, and moderate to
severe tricuspid regurgitation. Moderate to server tricuspid
regurgitation. Right ventricular cavity enlargement/free wall
hypokinesis. Pulmonary artery systolic hypertension.
.
.
[**2126-2-2**] CXR:
Since the recent radiograph, there has been little change in
congestive heart failure pattern superimposed upon severe upper
lobe predominant emphysema. Bilateral pleural effusions are also
not substantially changed. Slight improved aeration is noted
within the left retrocardiac region with otherwise overall
similar appearance to the recent exam.
.
Brief Hospital Course:
MICU COURSE:
pt admitted to [**Hospital1 18**] ICU [**2125-1-27**] after initially presenting to
OSH ICU [**1-21**]. CT showed evidence of pancolitis, colonic
dilation, and a functional stricture in the sigmoid colon just
distal to the dilated colon. He was startedon cipro/flagyl and
given IVF for hypotension. Colonoscopy showed diffuse
erythematous mucosa, diverticulosis without diverticulitis,
sigmoid biopsy was performed. He was given vitamin K for peak
INR 4.7. An NG tube was placed for decompression, but had
minimal output and was removed. He was then started on a clear
diet which he tolerated.
.
Pt was also noted to be grossly volume overloaded, felt [**3-10**] CHF
with AFib. He was also started on a lasix drip for total body
fluid overload pon [**1-28**]. He was approximately 1L negative for
length of stay. He was continued on coumadin. He was found to
be transiently hypotensive, though was found to have SBP 20 mmHg
higher on aline thannoninvasives in the MICU. On [**1-29**] he was
transfered to the general medical floor after he was
transitioned from lasix gtt to bolus dose lasix.
.
FLOOR COURSE:
patient was given bolus IV diuresis, but responded poorly, and
developed worsening renal failure and hypotension. On [**1-31**] pt
triggered for low UOP. CHF consult was obtained, which
recommended restarting lasix gtt for his decompnesated CHF in
the setting of TR. Pt was transferered to the cardiology
service, but noted to be hypotensive with O2 sat in 80s on 3L.
He received insulin, HCO3, and D50 for high potassium, was
started on the dopamine gtt and transferred to the CCU.
.
.
CCU COURSE:
76 M with h/o COPD, CHF (EF>55%) [**3-10**] TR, rheumatic heart
disease, paroxysmal atrial fibrillation, initially admitted to
the MICU [**3-10**] colitis, course c/b pulmonary fluid overload, acute
renal failure refractory to bolus lasix while on the general
medical service, transferred to the CCU in setting of
hypotension, hypoxia.
.
.
# hypotension: was felt [**3-10**] afib with RVR and poor atrial kick
exacerbating CHF with intravascular depletion [**3-10**] bolus lasix
dosing. Also, consider systolic dysfunction although recent echo
w EF 55%. Infectious etiology also felt possible given recent
colitis, though no elevation in temperature curve and WBC count
initially trending down from admissions WBC 17->15.9, though did
trend up to 22, thus pt switched to zosyn/vanco. pt was breifly
on peripheral dopamine gtt after admission to CCU on [**1-31**] for
<24hrs. His SBP remained in the 90s off dopamine gtt, and his
initial tachycardia improved somewhat and was felt exacerbated
by dopa gtt. Pt was then begun on lasix gtt as below to treat
anasarca, however, this was limited by low SBP. Attempts to
introduce beta blockade for HR in low 100s [**3-10**] AFIB even with
esmolol were limited by low SBPs.
.
Given ongoing low BP, and inability to diurese pt with lasix
gtt, discussion turned to placement of central lines for further
pressor use and consideration of initiating hemodialysis to
address volume overload. Pt and family were in agreement that
these aggressive measures were not compatible with goals of
care, and decision made to change goals of care to comfort
measures only on [**2-1**] PM. lasix gtt d/c'd and pt started on
prn iv morphine for air hunger. pt expird [**2-3**] AM.
.
.
# CHF: pt with profound right sided failure in setting of
rheumatic valvular disease. Pt remained profoundly volume
overloaded, despite bolus lasix dosing on medical service.
Lasix gtt was restarted upon arrival to CCU without improvement,
though efforts were limited by ongoing hypotension.
Consideration was given to initiating hemodialysis, though given
pt and family's goals of care as above, this was deferred.
.
.
# Acute Renal Failure: hyaline casts seen, ?muddy brown.
hypotension may have caused ATN exacerbated by volume overload
and heart failure. Cr trending down with lasix gtt initially
(3.6->3.0), though pt then became oliguring. given family
decision not to pursue hemodialysis, and inability to remove
fluid with lasix gtt, along with worsening hypoxia, decision
made to switch goals of care to comfort measures only as above.
pt was treated for hyperkalemia with inuslin, d50, hc03 prn.
.
.
# Atrial Fibrillation: pt with chronic and paroxysmal afib,
which was felt to be contributing to pt's hypotension as above.
coumadin was held initially given anticipation of central line
placement and possible hemodialysis, then deferred [**3-10**] goals of
care as above. pt failed DCCV recently at OSH. attempts to
control rate with beta blockade, including esmolol, were limited
by hypotension.
.
.
# Hypoxia: Poor PaO2 was consistent to pulmonary edema, though
given failure respond to lasix gtt and desire not to be started
on dialysis, treatment options severely limited. pt treated
with nebulizer treatments prn, and ultimately with morphine gtt
for air hunger once goals of care switched to focus on comfort.
.
.
# Colitis: upon arrival to CCU abd pain was resolving, pt was
passing flatus. Prior management desicions reflected belief of
infectious, non-ischemic colitis. Biopsy results from outside
hospital were pending and were to be faxed to CCU. pt was
initially continued on cipro/flagyl for planned [**11-19**] day
course, though switched empirically to zosyn/vanco on [**2-1**] [**3-10**]
ongoing hypotension and concern for ongoing leukocytosis (20s).
pt initially pt was NPO then advanced to clear liquid diet as
tolerated.
.
# UTI: pt found to have positive U/A on [**1-31**] (many bacteria,
21-50 WBC), he was already being covered with cipro as above,
then covered with zosyn/vanco as above.
.
# Transamintis: suspected [**3-10**] congestive hepatopathy given
evidence of cor pulmonale on echo. wide open TR and exam
findings with prominent V waves correlate. medication list
reviewed, no likely culprits. pt was treated for underlying CHF
as above.
.
# DISPO: given pt's significant fluid overload, and failure to
respond to lasix gtt, goals of care discussed extensively on
[**2125-2-1**] with pt and daughter [**Name (NI) **]. pt and daughter declined
aggressive intervention including dialysis, central lines, and
intubation/resuscitation. pt initially drowsy, but able to
A&Ox3, and able to describe consequences of declining dialysis,
specifically his likely death. decision made to pursue comfort
measures only [**2-1**] 5PM. plans made to pursue home discharge
with hospice.
.
pt started on morphine iv prn for air hunger. pt expired on
[**2125-2-3**] ~6AM.
.
# COMM: wife: [**Telephone/Fax (1) 28197**]. son [**Name (NI) **]: [**Telephone/Fax (1) 28198**].
Medications on Admission:
MEDS ON TRANSFER TO CCU:
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Maalox/Diphenhydramine/Lidocaine 15-30 ml PO QID:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN
MetRONIDAZOLE (FLagyl) 500 mg PO TID (since [**1-23**])
Ciprofloxacin HCl 500 mg PO Q24H (since [**1-23**])
Nystatin Oral Suspension 5 ml PO QID
Dopamine gtt at 5
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Tiotropium Bromide 1 CAP IH DAILY
.
MEDS AT HOME:
Coumadin 2.5 mg on Mon/Wed/Fri, 5 mg other days
Lasix 40 mg Daily
Digoxin 0.125 mg Daily
Iron 65 mg daily
Toprol XL 12.5 mg daily
ASA 81
Spiriva
Advair 100/50 one puff [**Hospital1 **]
Discharge Medications:
none (pt expired)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
pt expired
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
ICD9 Codes: 5849, 5990, 2767, 496, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5286
}
|
Medical Text: Admission Date: [**2185-10-25**] Discharge Date: [**2185-11-3**]
Date of Birth: [**2111-8-11**] Sex: M
Service:
The patient is a 74-year-old male with a 52 year history of
insulin dependent diabetes mellitus, status post myocardial
infarction 16 years ago who presented to the Emergency Room
following a two week history of diarrhea and a two day
history of emesis and fever. The patient reported that he
had been in his usual state of health until he received
influenza vaccine until about two days prior to admission.
At that point, he began to feel unwell, developed diarrhea
without blood. Following the onset of nausea and vomiting
two days prior to admission, the patient reported that he was
too tired and was unable to take his diabetic medications.
When he rechecked his blood sugar, he found the level to be
critically high. He had, at that point, decided to come to
the Emergency Room.
On arrival in the Emergency Department, the patient was found
to be in diabetic ketoacidosis with an ABG of 7.21/23/96, an
anion gap of 22 with a bicarbonate of 10. Potassium was 5.7.
His urinalysis showed positive ketones and glucose. At that
point treatment was initiated.
The patient was also ruled in for myocardial infarction while
in the Emergency Department. The patient's electrocardiogram
at the time showed sinus tachycardia to the 110s as well as Q
waves in leads 2, 3, AVF and V5 and V6. He had ST segment
pressure in leads V4 through V6.
Please refer to the section headed hospital course for
details on the patient's subsequent cardiac catheterization
as well as coronary artery bypass grafting.
PAST MEDICAL HISTORY:
1. Diabetes
2. Gastroesophageal reflux disease
3. Chronic pancreatitis
4. Malabsorption/bacterial overgrowth
5. Myocardial infarction x3 [**98**] years ago
6. Possible carotid stenosis
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Cardizem 19 mg tid
2. Lipitor 20 mg qd
3. Lasix 40 mg [**Hospital1 **]
4. Creon 10 capsules with meals
5. Ecotrin 325 mg po qd
6. Nitrostat 0.3 mg qd
7. Flomax 0.4 mg q hs
8. Insulin NPH 7 in the a.m. and 7 at bedtime
9. Regular insulin
SOCIAL HISTORY: The patient is a retired manager. He smoked
two packs per day for about 40 years before quitting 20 years
ago. The patient drinks occasional alcohol.
PHYSICAL EXAM:
VITAL SIGNS: 94.8??????, 105, 135/66, 16 and 98% on room air
GENERAL: The patient was well developed, well nourished male
in no apparent distress lying in bed asleep.
HEAD, EARS, EYES, NOSE AND THROAT: The patient had no
jugular venous distention and no lymphadenopathy. His
oromucosa was moist.
CARDIOVASCULAR: Normal S1, S2, with no murmurs.
PULMONARY: The patient had some crackles at the left base,
but otherwise clear to auscultation.
ABDOMEN: Soft, nontender with positive bowel sounds and old
surgical scar.
EXTREMITIES: The patient had 1+ pitting edema bilaterally.
RECTAL: The patient had some perirectal excoriations.
LABS: The patient had the following labs on admission: CBC
was 15.7 with 86% neutrophils, 2% bands, 6% lymphocytes.
Hematocrit was 45.9, platelets 357. Chem-7 was
130/5.0/83/11/51/2.3. Subsequent labs revealed a blood
glucose off 688 trending down to 382. His potassium trended
down to 4.7 then 3.7. Initial troponin was 10.5, later
increasing to greater than 50 with a second draw. MB was
17.3, then 18.4. The patient's urinalysis was negative.
HOSPITAL COURSE: As previously mentioned, the patient was
initially admitted through the Emergency Department where
treatment was initiated for his diabetic ketoacidosis. The
patient was also ruled in for a myocardial infarction and
later had a cardiac catheterization on [**2185-10-26**]. The cardiac
catheterization revealed the patient had severe left main
disease and right coronary artery disease.
Following the cardiac catheterization, the patient was seen
by the cardiothoracic service and plans made to take him to
the Operating Room for coronary artery bypass graft on
[**2185-10-28**]. On the day prior to his coronary artery bypass
graft, the patient had an episode of hypotension requiring
the placement of an IABP and transferred to the CCU.
The patient's coronary artery bypass graft was performed on
[**2185-10-28**] without complications and the patient thereafter
transferred to the CSRU. The patient's stay in the CSRU was
relatively uneventful. He had occasional periods of
confusion that had been noted since his admission to the
Emergency Department. These were believed to be associated
initially with is diabetic ketoacidosis and later with pain
medications. The patient was initially slow to diurese on
Lasix. He was later transferred to the cardiothoracic
surgery floor was diuresis continued.
The patient did have considerable lower extremity edema and
scrotal edema. On postoperative day #6, the patient's Lasix
was changed to an IV form in an attempt to increase the
effectiveness of the diuresis. By the date of discharge on
postoperative day #6, the patient was feeling better although
he continued to have considerable edema to the waist.
A Foley was briefly placed on postoperative day #5 when the
patient had some difficulty voiding probably secondary to the
scrotal and penile edema. The patient received daily
physical therapy while on the floor. It was felt that he
would benefit from a post discharge stay at a rehabilitation
facility.
The patient had a brief period of atrial fibrillation on
postoperative day #2 and returned to [**Location 213**] sinus rhythm on
amiodarone and Lopressor. The patient had also been noted to
develop some hematuria during his first day of admission. He
was seen by urology. Their recommendation was that the
patient receive an outpatient cystogram.
DISCHARGE CONDITION: Stable
DISCHARGE MEDICATIONS:
1. Lasix 80 mg intravenous [**Hospital1 **] on the date of discharge
which is [**2185-11-3**].
2. Lasix 80 mg po bid to start on [**2185-11-4**].
3. Amiodarone 400 mg po bid
4. Oxazepam 15 mg po q hs prn
5. Insulin on a sliding scale
6. Lantus insulin 18 units at bedtime
7. .............. 0.4 mg po q hs
8. Atorvastatin 20 mg po qd
9. Creon 3 capsules po tid with meals
10. Protonix 40 mg po q day
11. Enteric coated aspirin 325 mg po qd
12. Colace 100 mg po bid
13. Metoprolol 25 mg po bid
FOLLOW UP:
1. The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] six
weeks following discharge.
2. The patient is also to follow up with urology at some
point for a cystoscopy.
3. The patient is also to follow up with his primary care
physician within two to four weeks.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis
2. Hematuria
3. Myocardial infarction status post coronary artery bypass
graft
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2185-11-3**] 10:05
T: [**2185-11-3**] 10:24
JOB#: [**Job Number **]
ICD9 Codes: 5849
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5287
}
|
Medical Text: Admission Date: [**2187-5-22**] Discharge Date: [**2187-5-29**]
Service: KURLIN-MED
IDENTIFYING DATA: [**Age over 90 **] year old female admitted to the Medical
Intensive Care Unit with mental status changes, hypoxia,
bradycardia and now called out to the Medical Floor.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
Cantonese speaking only female immigrated to the United
States in [**2164**] with a past medical history significant for
end-stage renal disease on hemodialysis, history of seizure
disorder since [**2187-1-19**], and recent pneumonia, who
initially presented from hemodialysis unresponsive,
bradycardic and short of breath, and admitted to the Medical
Intensive Care Unit.
At the Medical Intensive Care Unit the patient was
hypotensive and unresponsive to fluid boluses and started on
Dopamine, now off since [**5-23**], a.m. Heart rate stable in
the 40s to 50s, no Telemetry events. Started on Ceftriaxone
and Azithromycin for a possible Pulmonary process. Chest
x-ray was clear. Lumbar puncture was negative. Change in
mental status improved to more alert. Stools showed positive
C. difficile and Flagyl was started. A right upper quadrant
ultrasound was negative and was done secondary to an increase
in GGT and alkaline phosphatase. The patient was started on
Vancomycin secondary to one out of four bottles Gram positive
cocci, possibly secondary to a central line infection with
central line now discontinued.
The oxygen by nasal cannula was being weaned to off. Chest
CT scan on [**5-23**] revealed possible reactivation
tuberculosis with right apex opacities and now on respiratory
precautions. The patient was now stable for call out to the
Medical Floor.
PAST MEDICAL HISTORY:
1. Hypertension.
2. End-stage renal disease on hemodialysis.
3. History of recent pneumonia in [**2187-4-18**].
4. Low back pain.
5. Upper gastrointestinal bleed in [**2187-1-19**]
secondary to ibuprofen.
6. Seizure disorder; first diagnosed with a seizure during
hemodialysis in [**2187-1-19**].
7. History of appendectomy.
8. Status post colon perforation during colonoscopy with
resection and temporary ostomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: (On transfer)
1. Flagyl 500 intravenous three times a day.
2. Vancomycin 1 gram intravenously.
3. Ceftriaxone one gram intravenously.
4. Azithromycin 250 mg intravenously.
5. Dilantin 100 mg intravenously twice a day.
6. Subcutaneous heparin.
7. Protonix 40 intravenously.
8. Calcium carbonate.
9. Nephrocaps.
10. Renagel.
SOCIAL HISTORY: Immigrated to the United States in [**2164**];
[**Hospital 2670**] nursing home. No smoking or alcohol use. Son is
[**Name (NI) 38412**] [**Name (NI) 38413**], [**Telephone/Fax (1) 38414**].
PHYSICAL EXAMINATION: (On transfer) Vital signs are
temperature 99.1 F., maximum temperature 100.4 F.; blood
pressure 132/68; heart rate 51; respiratory rate 14; O2
saturation 100% on two liters. General appearance: In no
acute distress. Somewhat alert and awake. Makes eye
contact. Responds to verbal stimuli; mumbles. HEENT: No
jugular venous distention, normocephalic, atraumatic. Supple
neck; oropharynx clear. Moist mucous membranes, minimally
reactive pupils bilaterally, small. Cardiovascular: Regular
rhythm, bradycardic. Normal S1 and S2. II/VI systolic
murmur throughout. Lungs clear anteriorly and laterally.
Abdomen soft, nontender, nondistended with hypoactive bowel
sounds. Extremities: No signs of clubbing or cyanosis. No
edema bilaterally. Lower extremities with good pulses.
Neurologic: Nonfocal. Cranial nerves II through XII intact
with slightly decreased alertness.
LABORATORY DATA: White blood cell count 13.6, hematocrit
32.9, platelets 189. Chem-7 remarkable for a BUN of 38 and a
creatinine of 4.4 (the patient on hemodialysis with end-stage
renal disease). Glucose of 118. Blood cultures one out of
four grew Gram positive cocci, in pairs and clusters which
grew out to be Vancomycin resistant enterococcus. All other
blood cultures were negative to date. Lumbar puncture was
negative. Cerebrospinal fluid culture: No growth to date.
CK MB and troponin negative. Dilantin level 4.9. Central
line tip culture with no significant growth. Urine cultures
negative to date. Stool cultures C. difficile positive.
Fecal culture and Campylobacter culture negative to date.
Chest CT scan on [**5-23**], showed previous granuloma infection
with cluster of calcified granulomas at the left apex and
right apex, opacities at the right lung apex, suspicious for
reactivation tuberculosis; no other studies documenting
stability. Small bilateral pleural effusions, esophageal
nodular thickening questionable for neoplasm. Atrophic
kidneys with two cysts, hepatic cysts and bilateral anterior
rib fractures.
SUMMARY OF HOSPITAL COURSE: The patient is a [**Age over 90 **] year old
female with a past medical history of end-stage renal
disease, hypertension, recent pneumonia, and seizure
disorder, presenting initially to the Medical Intensive Care
Unit with mental status changes, hypoxia, bradycardia,
hypotension, and uremia, with hyperkalemia, now stabilized
and improved for transfer to medical floor.
1. Neurologic: The patient's mental status changes were
thought to be secondary to toxic metabolic (uremia) and
possibly infection. The family now reports that the
patient's mental status is back to baseline when patient was
transferred to Medical Floor. Infectious causes were worked
up and antibiotics were given empirically which were now
discontinued upon transfer to the floor. The patient was
continued on Dilantin for a history of seizure disorder with
Dilantin level in the low end of therapeutic.
The patient, for the remainder of her hospital stay, was
stable neurologically.
2. Infectious Disease: The patient had some fevers since
admission but was afebrile for the remainder of her hospital
stay with a decreasing white blood cell count. The patient
had initially been covered empirically with Ceftriaxone and
Azithromycin with possible pulmonary process which has since
then been discontinued with a clear chest x-ray and a chest
CT scan clear of infiltrates. The patient had a negative
lumbar puncture as well as negative urinalysis and urine
culture.
The chest CT scan did reveal concern for possible
reactivation TB and the patient was placed in respiratory
isolation upon transfer to the floor. Three AFB smears were
obtained and were all negative. The patient did not have any
active cough. The patient did have Gram positive cocci that
grew out from her right femoral line blood culture, one out
of two bottles. Peripheral cultures were negative.
Vancomycin had initially been started but then discontinued
with surveillance cultures showing no growth to date.
Femoral line was discontinued in the Medical Intensive Care
Unit and the culture was tipped which showed no significant
growth.
The patient did have stool that was positive for Clostridium
difficile and was treated with Flagyl 500 mg p.o. twice a day
renal dosed, and will continue for a total of 14 day
treatment. While on the floor, the patient remained stable
from an Infectious Disease standpoint.
3. Pulmonary: The patient initially was found to be hypoxic
while in the Medical Intensive Care Unit. Eventually this
was thought to be secondary to fluid overload and improved
with dialysis upon admission to the Medical Intensive Care
Unit. While on the Floor, the patient was on nasal cannula
at two liters saturating 98 to 100% and eventually was weaned
to room air. The patient remained in respiratory isolation
until ruled out for tuberculosis times three and negative AFB
smears. Chest CT scan as above. While on the floor, the
patient remained in stable respiratory condition.
4. Renal: The patient received dialysis on her regular
scheduled Tuesday, Thursday and Saturday, while in the
hospital. Renal Service was following throughout. The
patient continued on her Nephrocaps, Renagel and TUMS. Her
initial uremia was resolved while in the Medical Intensive
Care Unit. No other acute renal issues during hospital stay.
5. Cardiovascular: The patient was hemodynamically stable
upon transfer to the floor, off Dopamine since the morning of
[**5-23**]. The patient had stable bradycardia during the
Medical Intensive Care Unit stay and during hospital stay
which eventually returned to [**Location 213**] sinus rhythm. The
patient had initially been on 100 of Atenolol per day, which
was discontinued on admission. No significant Telemetry
events were noted during hospital stay.
The patient has a history of hypertension and was eventually
restarted back on her Norvasc and a lower dose of Lopressor
as well as Captopril for good blood pressure control.
6. Gastrointestinal: The patient was treated and continued
on Flagyl for a total course of 14 days for positive C.
difficile in her stool. The patient reportedly had guaiac
positive stool initially during the Medical Intensive Care
Unit stay, but her hematocrits have remained stable. The
patient's right upper quadrant ultrasound was negative after
being obtained secondary to an increase in GGT and alkaline
phosphatase which, since then, have trended down. No other
gastrointestinal issues were encountered while on the Medical
Floor.
7. Hematology: The patient's hematocrit remained stable
throughout her stay on the medical floor.
8. Musculoskeletal: The patient has a history of lower back
pain since [**Month (only) 404**] of [**Month (only) 956**] of this year. The patient
will be empirically treated with a Pox II inhibitor upon
discharge. No further studies were obtained.
9. Fluids, Electrolytes and Nutrition: The patient's diet
was slowly advanced after a Speech and Swallow evaluation was
obtained which showed that the patient was swallowing
adequately. Aspiration precautions were used initially until
the patient's alertness returned to baseline. Upon
discharge, the patient was eating well.
10. Code Status: The patient remained a full code during
hospital stay.
DISPOSITION: The patient will return [**Hospital1 2670**] Facility.
DISCHARGE INSTRUCTIONS:
1. Physical Therapy and Occupational Therapy will evaluate
patient and the patient was safely discharged back to nursing
facility.
2. The patient will follow-up with her primary care doctor
as needed.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital1 2670**] Nursing facility.
DISCHARGE DIAGNOSES:
1. End-stage renal disease on hemodialysis.
2. Hypertension.
3. Low back pain.
4. Seizure disorder.
5. Clostridium difficile positive stool on Flagyl.
DISCHARGE MEDICATIONS:
1. Captopril 12.5 mg p.o. three times a day.
2. Lopressor 25 mg p.o. twice a day.
3. Norvasc 10 mg p.o. q. day.
4. Dilantin 100 mg p.o. twice a day.
5. Protonix 40 mg p.o. q. day.
6. Flagyl 500 mg p.o. twice a day until [**2187-6-5**].
7. Calcium carbonate 1000 mg p.o. three times a day.
8. Colace 100 mg p.o. twice a day.
9. Sevelamer 800 mg p.o. three times a day.
10. Nephrocaps one capsule p.o. q. day.
11. Vioxx 12.5 mg p.o. q. day.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 11283**]
Dictated By:[**Last Name (NamePattern1) 1183**]
MEDQUIST36
D: [**2187-5-29**] 13:48
T: [**2187-5-29**] 14:33
JOB#: [**Job Number 10187**]
ICD9 Codes: 2930, 2767
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5288
}
|
Medical Text: Admission Date: [**2190-3-15**] Discharge Date: [**2190-3-23**]
Date of Birth: [**2109-1-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**Known firstname 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2190-3-15**] - Coronary artery bypass grafting x3(LIMA-LAD,SVG-OM-PDA
sequentially)
History of Present Illness:
This 81 year old male recently presented with heart failure, an
indeterminate troponin check and a significant drop in his EF to
25% by nuclear study which also demononstrated an inferorapical
infarct with a small area of inferior apical ischemia. He states
he has been experiencing increasing shortness of breath with
minimal exertion. He was then referred for coronary angiogram.
He was found to have progression of left main disease and was
referred to cardiac surgery for revascularization.
He was admitted for elective operation.
Past Medical History:
coronary artery disease
s/p stent [**11-22**]
Ischemic Cardiomyopathy EF 34%
Peripheral vascular disease
Hypertension
Hyperlipidemia
Asthma
chronic obstructive pulmonary disease on home oxygenation
[**Company 1543**] pacemaker secondary to complete heart block
Noninsulin dependent Diabetes Mellitus
gastroesophageal refluxAnxiety
Arthritis in back
s/p Right lung resection for benign disease
Social History:
Last Dental Exam:edentulous
Lives with:wife, Partners nurse [**First Name (Titles) 2176**] [**Last Name (Titles) 20515**]
Contact: [**Name (NI) **] (wife) cell# [**Telephone/Fax (1) 108888**]
Occupation:retired Iron worker
Cigarettes: Smoked no [] yes [x] Hx:quit 14 years ago and smoked
[**1-15**] ppd x50 years
Other Tobacco use:occasional cigars years ago
ETOH: < 1 drink/week [x] [**1-19**] drinks/week [] >8 drinks/week []
Illicit drug use:Denies
Family History:
Premature coronary artery disease- Grandfather had multiple MI's
Physical Exam:
Pulse:85 Resp:18 O2 sat:95/RA
B/P Right:129/83 Left:134/94
Height:5'[**88**].5" Weight:202 lbs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2190-3-15**] 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. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with apical akinesis, and severe hypokinesis of the mid to
distal anterior, anterolateral, and anteroseptal walls. There is
mild to moderate global hypokinesis on top of that. Overall
ejection fraction is about 25%. No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is dilated with
mild global free wall hypokinesis and focal severe hypokinesis
of the apical free wall. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There are simple atheroma in the
ascending aorta. There are complex (>4mm) atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly to modertaely thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**12-14**]+) mitral regurgitation is seen. The mitral
regurgitation has a slight anterior lean to it suggesting
slightly worse poterior leaflet restriction. Moderate to severe
[3+] tricuspid regurgitation is seen. Significant pulmonic
regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS The patient is AV paced and receiving norepinephrine
and milrinone by infusion. Biventricular systolic function is
globally improved from the pre-bypass period. The apical right
ventricular free was is improved but mild global RV hypokineis
remains. The left ventricle has improvement in global function
but regional wall motion abnormalities noted pre-bypass persist.
EF is about 35%. The tricuspid regurgitation is somewhat
improved - now moderate. The rest of valvular function appears
unchanged from pre-bypass. The thoracic aorta is intact after
decannulation.
[**2190-3-22**] 03:13AM BLOOD WBC-4.9 RBC-3.60* Hgb-9.6* Hct-31.2*
MCV-87 MCH-26.8* MCHC-30.9* RDW-17.0* Plt Ct-145*
[**2190-3-15**] 11:39AM BLOOD WBC-9.2# RBC-3.28*# Hgb-8.4*# Hct-28.4*#
MCV-87 MCH-25.5* MCHC-29.4* RDW-16.5* Plt Ct-146*
[**2190-3-22**] 03:13AM BLOOD Glucose-89 UreaN-35* Creat-1.6* Na-131*
K-3.2* Cl-90* HCO3-32 AnGap-12
[**2190-3-19**] 02:25AM BLOOD Glucose-71 UreaN-32* Creat-1.7* Na-131*
K-3.6 Cl-94* HCO3-26 AnGap-15
[**2190-3-22**] 03:13AM BLOOD WBC-4.9 RBC-3.60* Hgb-9.6* Hct-31.2*
MCV-87 MCH-26.8* MCHC-30.9* RDW-17.0* Plt Ct-145*
[**2190-3-15**] 11:39AM BLOOD WBC-9.2# RBC-3.28*# Hgb-8.4*# Hct-28.4*#
MCV-87 MCH-25.5* MCHC-29.4* RDW-16.5* Plt Ct-146*
[**2190-3-20**] 02:55AM BLOOD PT-12.0 PTT-25.8 INR(PT)-1.1
[**2190-3-15**] 11:39AM BLOOD PT-15.1* PTT-29.9 INR(PT)-1.4*
[**2190-3-23**] 04:41AM BLOOD Glucose-78 UreaN-36* Creat-1.5* Na-132*
K-3.4 Cl-94* HCO3-31 AnGap-10
[**2190-3-15**] 12:45PM BLOOD UreaN-23* Creat-1.0 Na-138 K-4.5 Cl-111*
HCO3-21* AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 12303**] was admitted to the [**Hospital1 18**] on [**2190-3-15**] for surgical
management of his coronary artery disease. He was taken directly
to the Operating Room where he underwent coronary artery bypass
grafting x3(LIMA-LAD,SVG-OM-PDA sequentially)
with Dr.[**Last Name (STitle) **]. Cardiopulmonary Bypass time=78 minutes. Cross Clamp
time=63 minutes. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring.
He required several days of Milrinone and pressor support due to
left ventricular dysfunction. These were weaned over several
days and after load reductuion with hydralazine substituted.
Post operatively he awoke neurologically intact and was
extubated. He developed atrial fibrillation for which Amiodarone
was started, with restoration of sinus rhythm.
He was seen by Physical Therapy for mobility and strength and
he was transferred to the step down unit for further recovery.
He was aggressively diuresed and developed a contraction
alkalosis which was treated with potassium chloride and
acetazolamide.
Mr. [**Known lastname 12303**] continued to make steady progress. He desired to
return home as he has home oxygen, the VNA already sees him
twice a week and his sons will stay with him around the clock.
On POD# 8 he was cleared by Dr.[**Last Name (STitle) **] for discharge to home with
VNA. All follow up appointments were advised.
Medications on Admission:
ALBUTEROL SULFATE nebulizer PRN, PLAVIX 75',FLUTICASONE FUROATE
Dose uncertain,FUROSEMIDE 40', GLIPIZIDE 5', LORAZEPAM 0.5" PRN,
METFORMIN 500", METOPROLOL 25', NTG 0.4 prn, SIMVASTATIN 20',
SPIRIVA 18 mcg Cap daily, ASPIRIN 325', Prilosec dose unknown
[**Hospital1 **] (otc)
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg(two tablets) twice daily for two weeks, then
200mg(one tablet) twice daily for two weeks, then 200mg (one
tablet) daily until directed to discontinue.
Disp:*100 Tablet(s)* Refills:*2*
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO four times a
day.
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
12. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p coronary stent [**9-23**]
Ischemic Cardiomyopathy EF 34%
Peripheral vascular disease
Hypertension
Hyperlipidemia
Asthma
Chronic obstructive pulmonary disease- on home Oxygen
s/p pacemaker secondary to complete heart block
noninsulin dependent diabetes mellitus
gastroesophageal reflux
Anxiety
Arthritis in back
s/p [**Hospital1 **];ateral total knee replacements
hyperlipidemia
s/p Right lung resection for benign lesion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema : none
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 provided.
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.
5) No lifting more than 10 pounds for 10 weeks
6) 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) **] on ([**Telephone/Fax (1) 170**]) on [**2190-4-15**] at 1:15pm
Please call to schedule appointments with your:
Cardiologist: Dr. [**Last Name (STitle) 10543**]
Primary Care: Dr. [**Last Name (STitle) 29117**] ([**Telephone/Fax (1) 70698**]) in [**3-18**] 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:[**2190-3-23**]
ICD9 Codes: 2761, 4168, 2851, 4280, 412, 4019, 2724, 4439
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5289
}
|
Medical Text: Admission Date: [**2109-10-10**] Discharge Date: [**2109-10-19**]
Date of Birth: [**2059-8-19**] Sex: M
Service: ACOVE
CHIEF COMPLAINT: This is a 50 year old male who was a direct
admission for hemoptysis, blood tinged sputum and increasing
shortness of breath.
PAST MEDICAL HISTORY:
2. HIV, last CD4 count [**2109-9-25**], was 151 with a viral load
of 423.
3. History of anus squamous cell carcinoma, status post
chemotherapy and radiation therapy.
4. Chronic obstructive pulmonary disease.
5. Mitral valve replacement in [**2102**], with a porcine valve.
Echocardiogram in [**2-6**], showed some mitral regurgitation,
6. Peripheral neuropathy.
7. Mediastinal seminoma in [**2095**], that was treated with
radiation and chemotherapy.
8. Testicular hypofunction.
9. Hypothyroidism.
10. Depression.
11. Atrial flutter.
HISTORY OF PRESENT ILLNESS: The patient had increased
shortness of breath over more than the week. He was seen in
Dr.[**Name (NI) 7750**] office on [**2109-9-26**], for hemoptysis that was
half blood and half sputum. Initially, the chest x-ray may
have shown left pneumonia for which he was treated with ten
days of Levofloxacin 250 mg per day. The patient says that
during the course of antibiotics he had decreased hemoptysis.
CT on [**2109-10-8**], showed no evidence of pulmonary embolus but
did show increased pulmonary nodules with a ground glass
appearance. The patient denied any chest pain but did feel
that he had increased pulsations in the neck over the last
few days.
REVIEW OF SYSTEMS: He has positive constipation since
radiation therapy for his anal cancer. He also complains of
pain in his legs and scrotal area from lymphedema post
radiation therapy for his cancer that has lasted over the
last two months. He has not obtained good pain control. He
denies any fever, chills, sweats, diarrhea or dysuria.
MEDICATIONS ON ADMISSION:
1. Stavudine 30 mg twice a day.
2. Lamivudine 150 mg twice a day.
3. Abacavir 300 mg twice a day.
4. Advair 250 mcg twice a day.
5. Aquaphor/Hydrocortisone 2.5% cream once daily.
6. Cyanocobalamin 1000 mcg/ml q.month.
7. Dapsone 100 mg once daily.
8. Delatestryl 200 mg/ml, administered as 1 cc q2weeks.
9. Digoxin 0.125 mg once daily.
10. Furosemide 40 mg once daily.
11. Lac-Hydrin 12% skin cream twice a day.,
12. Levofloxacin 250 mg p.o. once daily.
13. Ativan 2 mg q.h.s. p.r.n.
14. Marinol 2.5 mg twice a day.
15. Mepron 750 mg/5 cc given as 5 cc twice a day.
16 Mycelex 10 mg four times a day p.r.n. for thrush.
17. Potassium 40 meq once daily.
18. Proventil 90 mcg two tablets q4hours p.r.n.
19. Selenium Sulfide 2.5% once daily times seven days.
20. Triamcinolone Acetamide once daily.
21. Ultrase MT 18-59-18-59 one tablet three times a day.
22. Unithroid 100 mcg once daily.
23. Wellbutrin SR 100 mg once daily.
24. Dilaudid 2 mg q4hours p.r.n.
25. Duragesic 25 mcg per hour q72hours.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: Alcohol occasionally and now less than one
pack per day of cigarettes. He smokes marijuana every day.
FAMILY HISTORY: Mother died of an inner ear cancer. Father
had diabetes mellitus, coronary artery disease and brother
has alcohol abuse.
PHYSICAL EXAMINATION: On examination, the patient was
afebrile at 98.4, blood pressure 106/72, respiratory rate 28,
pulse 120. Initially on presentation, he was only saturating
at 83% in room air. After giving him three liters nasal
cannula, he saturated to 92%. Head, eyes, ears, nose and
throat examination - He had moist mucous membranes. Jugular
venous pressure to the angle of the jaw. His skin had woody
lymphedema, left leg greater than the right with positive
scrotal edema. He has no Kaposi lesions. Respiratory- He
had good air entry bilaterally but he had bilateral fine
crackles at the bases and some bronchial breath sounds at the
right upper lobe. Cardiovascular examination - harsh III/VI
systolic ejection murmur at the base and left sternal border.
The abdomen has positive bowel sounds, nontender,
nondistended, no organomegaly. His extremities showed
nonpitting edema.
LABORATORY DATA: White blood cell count 8,7, platelet count
157,000. Electrolytes were essentially unremarkable.
Neutrophils 75%.
CT of the chest on [**2109-10-8**], showed multiple pulmonary
nodules, associated ground glass opacities, new lung nodules
at the bases compared to [**2109-7-30**], minor scarring at the
right apex. No evidence of pulmonary embolus.
HOSPITAL COURSE: The patient was put on respiratory
precautions for his increasing shortness of breath with
hemoptysis. He was ruled out for tuberculosis and multiple
induced sputum and bronchoalveolar lavage from his
bronchoscopy sent for cytology and bacterial and fungal viral
infection. Essentially, his bronchoalveolar lavage had
negative cytology for malignant cells. His cryptococcal
antigen was negative. Three sets of acid fast bacilli and
cultures were negative. Coccidiodes was still pending to
date. His still antigen is negative. His sputum culture
only grew sparse growth of yeast. Fungal cultures were
negative. Legionella was negative. PCP was tested for and
was negative. Nocardia negative. Urine culture times two
negative. Blood cultures and fungal cultures no growth to
date.
The patient obtained a transthoracic echocardiogram which
showed an ejection fraction of 50% and akinesis of the apex
and paradoxical motion of the interventricular septum. He
had some right ventricular hypertrophy with mild to moderate
aortic regurgitation, moderate to severe tricuspid
regurgitation and at least some mild pulmonary hypertension.
Because all his laboratories were essentially negative for an
infectious disease workup, the patient was scheduled for a
VATS procedure and a Transesophageal Echocardiogram while
under general anesthesia. The patient went for the VATS
procedure on [**2109-10-16**], and failed extubation with pCO2 in the
90s. The patient was reintubated and transferred from te
Post Anesthesia Care Unit to the SICU on Neo-Synephrine and
pressure support of [**11-9**]. The Neo-Synephrine was
discontinued after twelve hours and the patient was
successfully extubated. His last arterial blood gas on
[**2109-10-18**], was pH 7.35/57/85. The patient's VATS had
demonstrated metastatic squamous cell carcinoma. The
Transesophageal Echocardiogram demonstrated an ejection
fraction of greater than 55%, left atrial dilatation, 2+
aortic regurgitation, no mitral regurgitation, 2+ tricuspid
regurgitation and no pericardial effusion, and a prosthetic
mitral valve.
Dr. [**Last Name (STitle) 2148**] spoke with the patient about his diagnosis of
metastatic squamous cell carcinoma to the lung. It was
agreed with the patient that he would be discharged with
Hospice care and no further intervention was to be pursued.
The patient was discontinued on all his antiretroviral
treatments and was only continued on pain control management
anxiety control medications and his antidepressant medication
as well as supplemental oxygen.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: The patient is DNR/DNI.
MEDICATIONS ON DISCHARGE:
1. Fentanyl patch 50 mcg/hour q72hours.
2. Marinol 2 to 5 mg p.o. twice a day.
3. Ativan 1 to 2 mg p.o. q4-8hours p.r.n.
4. Wellbutrin SR 100 mg p.o. once daily.
5. Proventil 90 mcg two puffs q4hours p.r.n. for cough.
6. Home supplemental oxygen to titrate to comfort.
7. Dilaudid 2 to 4 mg p.o. q2-4hours p.r.n.
8. Neurontin 300 mg p.o. three times a day.
The patient is to be admitted to Hospice/Palliative Care at
[**Hospital 2188**].
DISCHARGE DIAGNOSES:
1. Metastatic squamous cell carcinoma to the lung.
2. AIDS.
3. Hepatitis C.
4. Chronic obstructive pulmonary disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. [**MD Number(1) 9562**]
Dictated By:[**Name8 (MD) 1020**]
MEDQUIST36
D: [**2109-10-19**] 10:27
T: [**2109-10-19**] 13:17
JOB#: [**Job Number 9563**]
ICD9 Codes: 486, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5290
}
|
Medical Text: Admission Date: [**2154-7-26**] Discharge Date: [**2154-8-1**]
Date of Birth: [**2085-1-17**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
[**2154-7-26**]: Right sided burr holes and evacuation of hematoma
History of Present Illness:
This is a 69 year old gentleman who was found in his apartment
by elder services after being unable to get out of bed for many
days. Upon finding him elder services stated that his home was
uninhabitable and that he was found in his own feces. He was
taken to [**Hospital 8**] hospital and upon work up and questioning he
reported that he felt dizzy and fell a few days ago and then
was unable to ambulate. He states he only drank water and had
not had food in many days as well. A head CT was done at
[**Hospital 8**] hospital which showed a large chronic SDH with
significant MLS. As a result he was trasnferred to [**Hospital1 18**] for
further management and consultation. He is examined throguh a
Korean Interpretor. He reports minor headache, he denies visual
changes, hearing
changes, nausea, vomiting.
Past Medical History:
Hernia repair, high cholesterol
Social History:
He lives alone, reports no family
Family History:
NC
Physical Exam:
On Admission:
O: T:98.5 BP: 136/82 HR:72 R:16 O2Sats:100%
$4L
Gen: WD/WN, comfortable, unkempt
HEENT: Pupils: PERRL EOMs intact without 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 through Korean
Interpretor.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors through Korean
Interpretor
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Strength 5-/5 throughout LUE except Finger Intrinsics
[**2-26**].
Otherwise full strength. Normal bulk and tone bilaterally. No
abnormal movements,tremors. slight left pronator drift
Sensation: Intact to light touch bilaterally
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
AT Discharge: Non focal
Pertinent Results:
[**2154-7-27**]: CT Head- IMPRESSION:
1. Marked interval reduction in a right-sided subdural hematoma
status post evacuation with drain placement. Some residual
low-attenuation material with a small focus of hyperdense
material compatible with small hemorrhage.
2. 9-mm leftward shift of normally midline structures, markedly
improved
since the prior examination. Improvement in parafalcine
herniation.
3. No intraventricular, or intraparenchymal hemorrhage.
[**2154-7-27**]: LENI's- IMPRESSION: No evidence of DVT in the right or
left lower extremity.
Brief Hospital Course:
Mr. [**Known lastname 1022**] was admitted to the Neuro ICU and had a pre-op work up.
He was started on dilantin for seizure prophylaxis. On the
evening of [**7-26**] he was taken to the operating room and underwent
burr holes and evacuation of his SDH. Surgery was without
complication and he returned to the ICU. On [**7-27**] he remained
neurologically stable and his CT head was improved therefore he
was cleared for transfer to the stepdown unit. On [**7-28**] his drain
was removed and his neurological exam was much improved. On [**7-29**]
he was cleared for transfer to the floor and PT/OT were
consulted for assistance with discharge planning. He was seen by
social work and case management as he will not be able to return
to independent living any time soon. He was transferred to rehab
on [**8-1**]. We will see him in one month for follow up and will also
follow up on his isolated [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] weakness.
Medications on Admission:
cholesterol med, MVI
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).
3. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: max 4g/24 hrs.
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair after staples are removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, do not
resume taking these until cleared by your surgeon.
?????? 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**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-2**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the PA. Please make
this appointment by calling [**Telephone/Fax (1) 1669**]. You can also have
these removed at rehab on [**2154-8-2**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2154-8-1**]
ICD9 Codes: 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5291
}
|
Medical Text: Admission Date: [**2145-6-5**] Discharge Date: [**2145-6-11**]
Service: MEDICINE
Allergies:
Apple / Lisinopril
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Elevated Digoxin level, bradycardia/tacchyarrythmia,
unresponsiveness
Major Surgical or Invasive Procedure:
IR Guided Dobhoff placement
History of Present Illness:
Mr. [**Known lastname 9220**] is an 85 year old male with a history of recent
admission [**Date range (1) 9221**] for bilateral SDH s/p burr holes [**4-23**],
atrial fibrillation now off Coumadin on Digoxin, hypertension,
and diastolic dysfunction who presents from [**Hospital **] Rehab with
possible digoxin toxicity leading to ventricular tachycardia and
unresponsiveness.
.
The patient was recently hospitalized from [**Date range (3) 9222**] after
a fall complicated by hesitant speech and some difficulty
ambulating, and head CT on admission showed acute on chronic
bilateral subdural hematomas with mass effect and evidence of
early downward transtentorial herniation. He had bilateral burr
holes placed by neurosurgery on [**4-23**]. CXR on [**4-24**] showed
increasing left basilar opacification, and he was thought to
have an aspiration PNA and CHF. He was transferred to medicine
and treated with a 10 day course of Cipro and Flagyl. He had
diarrhea and leukocytosis, but C. diff negative x3. He was kept
NPO and his Na rose to 150 on [**4-27**], and this was treated with
D5W. His atrial fibrillation was difficult to control, and
required uptitration of his Metoprolol. (Note: As an outpatient,
he was on Amiodarone). His home dose of Coumadin 2.5 mg daily
was restarted [**4-30**] (7 days post-op). He then developed atrial
fibrillation with RVR, hypotension, and hct drop and was
transferred to the MICU. Warfarin was discontinued. EP was
consulted and recommended Metoprolol and Digoxin. He continued
to have cough and was discharged on empiric Vanc/Zosyn for a 14
day course. At the time of discharge, his WBC was 15.1, Hct
26.1, Na 140, Cr 0.9, Dig level 1.3.
.
The following information was obtained from a nurse [**First Name (Titles) **] [**Last Name (Titles) **].
Upon discharge to [**Hospital1 **], his temperature was 102.3 on the
evening of admission, and he remained febrile until [**5-28**]. He had
continued to have diarrhea, and had a rectal tube in place until
2 days PTA. He developed renal failure over the past 1 week. The
physician there was concerned that the Vancomycin IV bid was
contributing to his renal failure, so it was changed to Vanco IV
daily. When the Vanc/Zosyn were completed, he was started on
Vanco and Flagyl PO for presumed C. diff. He had an NG tube
placed in order to get free water boluses, which was removed 2
days PTA. Over the past 2 days, the patient has had almost no PO
intake and very dry mouth. His Lasix was being held for the
renal failure. On the day PTA, his labs showed WBC 17.3, Na 149,
Cr 2.8, BNP 519. Because of the continued leukocytosis, he was
started on Ceftazidime 2 gm IV daily. His Dig level was found to
be 2.2, so his Digoxin was decreased to 125 mcg daily. There was
no Digibind in the facility. On the morning of admission, the
patient was found to have bradycardia to 32 on telemetry and
then went into a "torsades" rhythm. His bp was down to 92/52
(from a baseline of SBP 130-140, and a code was called as the
patient was more unresponsive. no meds were given as there was
no Magnesium was in the building, and the patient remained
arousable to stimuli. He was transferred to [**Hospital1 18**].
.
In the ED, vitals were temp 98.1, HR 40-90, bp 140/90, RR 20,
SaO2 100% on RA. His WBC was up to 15.7 (from 15.1 on discharge
[**5-25**]), Hct 35.3 (from 26.1), Na 157 (from 140), Cr 2.7 (from
0.9), Dig 2.8 (from 1.3). TropT 0.08, CK 20, MB not done. The
patient was awake and verbal, but moaning. EKG showed slow
atrial fibrillation, with bradycardia down to 30-50. CXR
Portable showed persistent left retrocardiac opacity likely due
to pleural effusion and atelectasis although underlying
consolidation cannot be excluded. CT Head showed stable
appearance of small bilateral subdural fluid collections and
small unchanged focus in the right frontal cortex, but no new
hemorrhage or infarct. He was given 1 L NS, Potassium 40 mEq per
1 L, and Digibind 50 mL, and Zofran 4 mg IV x1.
.
Unable to obtain ROS as patient not responding.
Past Medical History:
-Acute on Chronic Bilateral SDH L>R s/p fall on [**4-11**], s/p
bilateral burr holes [**4-23**]
-Bilateral cystic hygroma, found s/p fall on [**2-/2066**]
-Atrial Fibrillation, cardioverted 2 years ago, off Coumadin
given SDH, started rated control with Metoprolol and Digoxin
-Hypertension
-Diastolic Dysfunction on TTE [**5-4**]
-Aspiration Pneumonia [**2145-4-24**]
-Diabetes, diet controlled
-Tremor since childhood
-BPH s/p TURP [**9-/2131**]
-Bilateral hearing loss
-GERD
-Ventral Hernia repaired [**3-4**]
Social History:
Social history is significant for the absence of tobacco use.
There is no history of alcohol abuse. He formerly would drink
one glass of wine or Crown [**Male First Name (un) 4542**] every day, but has had no
alcohol since [**3-5**]. He previously worked as a supervisor for
[**Company 2318**] on the [**Location (un) 2452**] line. Prior to that he was in the Navy.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His mother died at age [**Age over 90 **]. His father had a
history of TB on one lung, and died at age 69 with a traumatic
injury to his other lung.
Physical Exam:
VS - temp 99, bp 149/62, HR 70, RR 18, SaO2 98% on 1L
Gen: Cachectic looking man in NAD. Moaning in bed. Briefly opens
eyes to voice. Squeezes hands bilaterally. Diffuse myoclonic
twitching.
HEENT: Sclera anicteric. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm
CV: Irregularly irregular. Normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, ND, tender to palpation of the umbilicus and right
quadrant. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
LABS:
[**2145-6-5**] 08:20AM BLOOD WBC-15.7* RBC-3.77*# Hgb-10.7*#
Hct-35.3*# MCV-94 MCH-28.3 MCHC-30.3* RDW-14.7 Plt Ct-578*
[**2145-6-11**] 04:11AM BLOOD WBC-19.3*# RBC-3.22* Hgb-9.2* Hct-30.1*
MCV-94 MCH-28.5 MCHC-30.5* RDW-15.3 Plt Ct-310
[**2145-6-5**] 08:20AM BLOOD Neuts-87.2* Lymphs-7.9* Monos-3.2 Eos-1.4
Baso-0.2
[**2145-6-10**] 10:58AM BLOOD Neuts-86* Bands-0 Lymphs-5* Monos-4 Eos-4
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2145-6-10**] 10:58AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL
Schisto-OCCASIONAL Envelop-OCCASIONAL Bite-OCCASIONAL
[**2145-6-5**] 08:20AM BLOOD PT-15.0* PTT-28.0 INR(PT)-1.3*
[**2145-6-5**] 08:20AM BLOOD Glucose-114* UreaN-45* Creat-2.7*#
Na-157* K-3.6 Cl-121* HCO3-24 AnGap-16
[**2145-6-11**] 04:11AM BLOOD Glucose-199* UreaN-29* Creat-1.8* Na-144
K-3.8 Cl-110* HCO3-27 AnGap-11
[**2145-6-7**] 04:29PM BLOOD ALT-15 AST-16 LD(LDH)-208 AlkPhos-105
TotBili-0.3
[**2145-6-5**] 08:20AM BLOOD CK(CPK)-20*
[**2145-6-5**] 08:20AM BLOOD cTropnT-0.08*
[**2145-6-5**] 08:20AM BLOOD Calcium-9.2 Phos-4.7*# Mg-2.7*
[**2145-6-9**] 06:00AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.7 Mg-2.1
[**2145-6-11**] 04:11AM BLOOD Calcium-8.0* Phos-3.9# Mg-2.0
[**2145-6-7**] 04:29PM BLOOD VitB12-1084*
[**2145-6-9**] 06:00AM BLOOD Folate-8.6
[**2145-6-7**] 04:29PM BLOOD TSH-0.29
[**2145-6-5**] 05:00PM BLOOD Osmolal-338*
[**2145-6-5**] 08:20AM BLOOD Digoxin-2.8*
[**2145-6-6**] 01:30PM BLOOD Digoxin-3.6*
[**2145-6-7**] 05:18AM BLOOD Digoxin-4.4*
[**2145-6-11**] 05:01AM BLOOD Type-ART pO2-80* pCO2-78* pH-7.17*
calTCO2-30 Base XS--2
[**2145-6-11**] 05:01AM BLOOD Lactate-1.1
[**2145-6-5**] 08:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2145-6-5**] 08:20AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2145-6-5**] 08:20AM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2 TransE-<1
[**2145-6-6**] 06:40PM URINE Eos-NEGATIVE
[**2145-6-9**] 06:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.005
[**2145-6-9**] 06:40PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2145-6-9**] 06:40PM URINE RBC-44* WBC-10* Bacteri-FEW Yeast-NONE
Epi-0
[**2145-6-9**] 06:40PM URINE Mucous-RARE
[**2145-6-5**] 05:55PM URINE Hours-RANDOM UreaN-585 Creat-68 Na-21
[**2145-6-6**] 06:40PM URINE Hours-RANDOM UreaN-440 Creat-48 Na-30
[**2145-6-7**] 11:56AM URINE Hours-RANDOM UreaN-357 Creat-41 Na-34
[**2145-6-5**] 05:55PM URINE Osmolal-360
[**2145-6-6**] 06:40PM URINE Osmolal-303
[**2145-6-7**] 11:56AM URINE Osmolal-297
.
MICRO:
Urine Cx ([**6-9**]): No growth
Blood Cx ([**6-11**]): No growth
.
IMAGING:
ECG ([**6-5**]): Atrial fibrillation with slow ventricular response
at a rate of 53. Early R wave progression. Question
counterclockwise rotation. Diffuse non-specific ST-T wave
abnormalities.
.
CXR Portable ([**6-5**]): The patient is status post removal of a
Dobbhoff tube. Again noted is left retrocardiac opacity which
likely represents pleural effusion and atelectasis although
underlying consolidation cannot be excluded; at least some of
this appearance is likely due to elevation of the left
hemidiaphragm, as was previously demonstrated. Otherwise the
right lung and the left upper lung appear clear. An irregular
density projecting over the lateral right mid lung is not
changed in appearance from prior studies, and may represent a
calcified granuloma or pleural plaque. The cardiomediastinal and
hilar contours are unchanged. The pulmonary vasculature is
unremarkable. There is no pneumothorax or right pleural
effusion. The bony thoracic cage appears intact.
IMPRESSION: Persistent left retrocardiac opacity, likely due to
pleural effusion and atelectasis although underlying
consolidation cannot be excluded.
.
CT Head ([**6-5**]): IMPRESSION: Stable appearance of small bilateral
subdural fluid collections and small unchanged focus in the
right frontal cortex. No new hemorrhage or infarct.
.
ECG ([**6-6**]): Artifact is present. Probable sinus bradycardia at a
rate of 34 with first degree A-V block and PR 368. Diffuse
non-specific ST-T wave changes.
.
CXR ([**6-6**]): SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: A right
internal jugular line terminates with the tip in the distal SVC.
Effusion and atelectasis of the left lung base has increased
since the prior study. In comparison to radiographs from a month
prior, there is no longer marked hyperelevation of the left
diaphragm, as well there is no bowel loops projecting over the
left lower lung aswas seen before . This may represent surgical
intervention or a change in the abdominal process occurring at
that time. However, this raises the possibility of a
significantly larger pulmonic pleural effusion lowering the left
hemidiaphragm.
IMPRESSION: Left pleural effusion and atelectasis, increased
since the prior day. If concern for a large subpulmonic pleural
effusion exists, left lateral decubitus or chest CT would allow
better evaluation.
.
CT Head ([**6-7**]): IMPRESSION: Resolving subdural hematomas without
evidence of extension. No new infarct. No evidence of brain
abscess.
.
Renal Ultrasound ([**6-7**]): IMPRESSION:
1. No evidence of hydronephrosis.
.
ECG ([**6-8**]): Atrial fibrillation at a rate of 69. QRS duration is
0.08 seconds. Non-specific inferolateral T wave flattening.
.
EEG ([**6-9**]): IMPRESSION: Abnormal EEG due to the slow and
disorganized background and due to the bursts of generalized
slowing. These findings indicate a widespread encephalopathy
affecting both cortical and subcortical structures. Medications,
metabolic disturbances, and infection are among the most common
causes. Occasional generalized bursts of slowing had sharp
features, but there were no overtly epileptiform abnormalities.
The cardiac monitor indicated atrial fibrillation.
.
CXR Portable ([**6-10**]): FINDINGS: In comparison with the study of
[**6-6**], there is some increasing opacification in the left lung
with involvement of the perihilar and suprahilar region as well
as the bases. Dobbhoff tube has been inserted, which extends at
least to the second portion of the duodenum. The right lung
remains essentially clear.
.
CXR Portable ([**6-11**]): IMPRESSION: Interval left lower lobe
collapse, possibly related to gaseous distention of the stomach.
If there is concern for intra-abdominal free air, left lateral
decubitus film would help to clarify.
Brief Hospital Course:
The patient presented with digoxin toxicity in the setting of
hypovolemia and dehydration causing ARF and increased digoxin
levels. This was likely potentiated by the fact that he was
previously on amiodarone, and he likely still had amiodarone in
his system given its long half life. He had a Digoxin level of
2.2 at [**Hospital1 **] on the day PTA, for which his Digoxin was
decreased from 250 mcg to 125 mcg daily. On the day of
admission, he had an episode of bradycardia to 32 followed by a
tachyarrythmia that may have been ventricular tachycardia vs.
artifact. He spontaneously returned to his baseline rhythm, but
became less responsive, so was sent to [**Hospital1 18**]. His Digoxin level
was 2.8 on admission. Toxicology was consulted and recommmended
giving 1 vial of Digibind in the ED. He continued to have
bradycardia and [**8-4**] second pauses overnight the first night of
admission but maintained his SBP. He was transferred to the CCU
briefly for dopamine to maintain his heart rate. Per pharmacy,
given the patient's digoxin level on admission, he should have
been given 2.3 vials of Digibind, so he received another 1.5
vials on [**6-6**]. The patient's heart rate responded to dopamine,
and he subsequently had fewer pauses. His Metoprolol (for atrial
fibrillation) was held in the setting of bradycardia, and EP
determined that there was no indication for permanent pacemaker
at this time.
.
The patient had a sodium of 157 on admission, and he appeared
hypovolemic to euvolemic on physical exam. This was likely due
to impaired access to free water especially since his NG tube
was removed 2 days PTA and he no longer has gotten free water
boluses. He also had poor PO intake per his rehab, only meeting
10% of his calorie counts. His free water deficit was 4.8L on
admission. His sodium improved to 144 with D5W administration
over several days.
.
He also presented with ARF and Cr up to 2.7, which was intially
thought to be secondary to hypovolemia and dehydration. He
received 1 L NS in the ED. Urine lytes on admission showed FeNa
0.5%, FeUrea 50.8%, urine Na 21, urine osm 360. His urine was
inappropriately not concentrated, but this was interpreted in
the setting of ARF. Renal ultrasound showed no evidence of
hydronephrosis. Urine eos were negative. The plan was to give
D5W continuous and NS x1 L to correct sodium and to give back
volume. He was transferred to the CCU for bradycardia and pauses
on telemetry, and started on dopamine. Renal was consulted, and
urine sediment showed muddy brown casts which suggested he may
have more likely had non-oliguric ATN from his low MAPs and
prolonged hypoperfusion. His Lasix was held, and renal indicated
that once his Na corrected, he did not need any more volume and
the Cr would slowly trend down on its own.
.
The patient continued to have altered mental status during this
admission, and would occasionally open his eyes when his name
was called, but would only occasionally say a word. He would
squeeze hands bilaterally, but would only moan in bed and was
not alert or oriented. He was recently admitted to [**Hospital1 18**] s/p
fall on [**4-11**] with bilateral SDH. Neurosurgery placed bilateral
burr holes on [**4-23**]. Head CT on this admission showed stable
appearance of the small bilateral subdural fluid collections and
small unchanged focus in the right frontal cortex; there was no
new hemorrhage or infarct. Neurosurgery and Neurology were
consulted on this admission, and indicated that he most likely
has a metabolic encephalopathy due to many reversible causes
such as dehydration, possible infection (given his persistent
leukocytosis), dig toxicity, renal failure, and heart failure.
LFTs were WNL, TSH low normal at 0.29, Vitamin B12 1084, folate
8.6. EEG showed widespread encephalopathy affecting both
cortical and subcortical structures. The patient was not able to
feed himself, and he had an IR guided Dobhoff placed for
supplemental nutrition.
.
The cardiology and neurology teams held a family meeting on
[**6-10**]. His daughters and son determined that the patient would
have wanted short term interventions (i.e. intubation), but not
long term (i.e. tracheostomy). The family was aware of need to
frequently rediscuss code status given his poor prognosis, but
determined he would remain full code at that time. CXR on [**6-10**]
showed increasing opacification in the left lung with
involvement of the perihilar and suprahilar region as well as
the bases. There was concern the patient may have developed
aspiration PNA or hospital acquired PNA, and he was started on
Vancomycin/Zosyn. Overnight on [**4-12**] the patient's
respiratory status decompensated, with tachypnea and the
appearance of severe dyspnea, and ABG showed 7.17/78/80/30. The
patient's family was called, and the initial decision was made
to transfer the patient to the ICU for intubation. However,
after further discussion among the family members, the patient's
daughter (who was the health care proxy) called back and decided
to make the patient DNR/DNI. He was started on a Scopolamine
patch and Morphine IV was administered to relieve his tachypnea
and dyspnea, and passed away on [**6-11**] with several of his
children at the bedside.
Medications on Admission:
Acetaminophen 650 mg Tablet PO q4 hr prn pain
Calcium Carbonate 1000 mg Tablet, Chewable PO BID
Multivitamin with Minerals Tablet PO DAILY
Potassium Chloride 20 mEq PO daily
Metoprolol Tartrate 25 mg PO TID
Digoxin 125 mcg PO DAILY
RISS
Hydrocortisone 1% cream qid prn to scalp incision
Lidocaine 2% Jelly q2 hr prn sore mucous membranes
Lorazepam 0.5 mg PO q8 hr prn agitation/spasticity
Saccharomyces boulardii 250 mg PO q12 hr
Omeprazole 20 mg PO daily
Sodium Bicarbonate 10 cc mixed with Omeprazole
Miconazole nitrate top q12 hr to sacrum/groin
Vancomycin 125 mg PO qid until [**6-8**]
Flagyl 500 mg PO tid until [**6-10**]
Ceftazidime 2 gm IV daily started [**6-4**]
Caspofungin 50 mg IV daily to be started [**6-5**]
Furosemide 40 mg PO DAILY (had been ON HOLD)
.
ALLERGIES: Apples-> Diarrhea
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY:
PNA
Respiratory Failure
Digoxin Toxicity
Bradycardia
Altered Mental Status
Acute Renal Failure/ATN
Hypernatremia
Leukocytosis
.
SECONDARY:
Diastolic Dysfunction
Atrial Fibrillation
Hypertension
Acute on Chronic Bilateral SDH
Diabetes
Discharge Condition:
Deceased
Discharge Instructions:
Patient decompensated overnight, was made CMO and passed on [**6-11**]
Followup Instructions:
None
ICD9 Codes: 5845, 486, 4019, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5292
}
|
Medical Text: Admission Date: [**2184-3-15**] Discharge Date: [**2184-4-5**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female with a past medical history of an extensive congenital
hemangioma from the forehead to the neck and to the chest and
to the liver. She received a tracheostomy 12 years ago. She
has critical aortic stenosis and mitral regurgitation. She
is here for aortic valve replacement on Wednesday. The
patient was most recently admitted on [**2-9**] for Lasix
adjustment secondary to congestive heart failure
exacerbation. She denies an increase in orthopnea, dyspnea
on exertion but has not been active beyond walking in her
apartment. She denies pedal edema. The patient had recent
enterococcal urinary tract infection, complatant to
Levofloxacin. The patient denies fever, cough, upper
respiratory infection, sore throat, dysphagia, chest pain,
abdominal pain, nausea, vomiting, gastrointestinal or
genitourinary symptoms.
PAST MEDICAL HISTORY: Clinical aortic stenosis, congenital
hemangioma, recent enterococcal urinary tract infection,
congestive heart failure, noninsulin dependent diabetes
mellitus, congenital telangiectasia syndrome,
thrombocytopenia, appendectomy, attempted removal of
hemangioma 30 years ago, tracheostomy, hypernatremia.
MEDICATIONS:
1. Glipizide 10 mg p.o. q day.
2. Glucophage 1000 mg p.o. twice a day.
3. Lasix 60 mg p.o. twice a day.
4. Potassium 20 mEq p.o. twice a day.
ALLERGIES: Penicillin which causes a rash. Latex which
causes bronchospasm.
SOCIAL HISTORY: The patient lives with her daughter, three
children and grandchildren. Denies tobacco or ethanol use.
PHYSICAL EXAMINATION: Temperature 98.9, blood pressure
106/58, heart rate 65, respirations 20. 94% on O2 sat on
room air. In general the patient is not in acute distress.
She is alert and oriented times three. Head, eyes, ears,
nose and throat: Pupils are equal, round, and reactive to
light and accommodation with right eye atrophy. Extraocular
movements intact. Oropharynx clear. Neck supple, unable to
assess jugular venous distention because of the hemangioma.
Trach is in place. Lungs clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2.
3/6 systolic ejection murmur best heard at the lower sternal
border. Abdomen is soft, nontender, nondistended, positive
bowel sounds. Back: No CVAT. Extremities: No cyanosis,
clubbing or edema.
HOSPITAL COURSE: The patient was admitted on [**2184-3-15**] in
preparation for her surgery. She is taken to the operating
room on [**2184-3-16**] where aortic valve replacement was performed.
The surgery was quite a difficult one, the patient lost an
excessive amount of blood secondary to hemangioma. The
patient required Epinephrine, Dobutamine and Levophed drip
postoperatively. She also required an excess of blood
products including packed red blood cells, platelets, fresh
frozen plasma, secondary to her anemia and dilution of other
factors through replacement. The patient also received an
excess in intravenous fluid in an attempt to maintain blood
pressure. Meanwhile the patient was sent to the
Cardiothoracic Surgery Intensive Care Unit, the patient
continued to slowly bleed through her chest tubes. The chest
tubes were elevated and allowed to coagulate within in an
attempt to tampanode the bleeding off to ensure that the
patient did not suffer from cardiac tampanode, a
transesophageal echocardiogram probe was left in her
esophagus to continually assess collection of fluid within
her mediastinum.
Postoperatively the patient did have chest tubes in place,
she also had pacing wires in place. In the evening of the
postoperative night after significant amount of blood
products and fluid have been given the patient experienced
severe right ventricular dysfunction secondary to congestive
heart failure. The renal team was consulted who initiated
CVVHD with citrate for volume removal. She was also
challenged with Lasix which did allow the patient to urinate
minimally but while on CVVHD the patient did not urinate
much. Over the course of the next few days the patient had
her drips altered to take care of her needs. Over the course
of the next few days included Neo-Synephrine, Epinephrine,
Pertussin, Esmolol and Sustacuriam. The patient remained
intubated and sedated for some time. The patient received
perioperative Vancomycin for anti-microbial prophylaxis.
Over the course of the next couple of days the patient was
slowly weaned from ventilator to CPAP. While in the
Intensive Care Unit the patient experienced atrial
fibrillation for which she was loaded on Amiodarone. Over
the course of the next few days the CVVHD was slowly weaned
and Lasix challenge was performed. After the CVVHD was
discontinued however, that her urine output picked up and
functioned well on her own. The patient's drips were slowly
weaned and the patient was slowly transferred to a
ventilatory mask over her trach. With Lasix treatment the
patient became hypocalcemic for which she required aggressive
potassium replacement. The patient's chest tube and pacing
wires were removed at the appropriate time although extreme
caution was taken as the chest tubes did infiltrate the chest
cavity at a location where hemangioma tissue was likely to be
found. However, removal was successful without complication.
While in the Intensive Care Unit the patient's tracheostomy
was changed in order to facilitate easier usage of different
ventilatory support system. After all was said and done the
patient complained of difficulty breathing through it as well
as difficulty secondary to it and trach was finally switched
to her usual trach that she had from home. While in the
Intensive Care Unit the patient also experienced
thrombocytopenia for which a number of platelet transfusions
were required. A HIT antibody was checked which turned out
negative. Speech and Swallow was consulted while the patient
was in house to evaluate the patient's swallowing ability
which showed to be very poor postoperatively. The patient
was consulted who assisted the surgical team and appropriate
tube feeding regimens to maintain the patient's nutritional
status.
The patient was finally discharged to the regular
cardiothoracic floor on postop day seven. Respiratory care
was consulted for aggressive chest physical therapy as well
as Mucomyst in an attempt to aid the patient in breathing and
loosen up her trach secretions. This improved both with the
Mucomyst and after her tracheostomy apparatus was replaced.
Physical therapy was also consulted who aided in the
patient's physical stamina and chest physical therapy. While
on the floor it was noted that her chest incision was leaking
fluid but that was mixed with tracheostomy secretions. For
that reason the site was aggressively washed in Betadine and
sealed shut with Dermabond and a plastic [**Doctor Last Name **] to keep the
secretions from contaminating the incision. While on the
floor the patient became hyponatremic. Lasix was temporarily
stopped.
On the floor the patient was seen by Psychiatry secondary to
mild cognitive dysfunction. On [**2184-3-31**] the patient secondary
to complaints of dyspnea and left pleural effusion on chest
x-ray the thoracic team was consulted who placed a pigtail
drain in the pleural space to aid in drainage of the
effusion. This did help the patient with her dyspnea issues.
When felt appropriate the pigtail was removed. On [**2184-4-5**]
the Thoracic Team again evaluated the patient and performed a
bronchoscopy to ensure there was no obstruction within her
bronchial tree which was confirmed as negative. Chest x-ray
post bronchoscopy was performed which continued to show a
loculated pleural effusion. It is our intention to take the
patient to Pulmonary Procedure Room and tap the loculated
effusion if all goes well which is intended to the patient
will likely be discharged to rehabilitation on the morning on
[**2184-4-6**]. The patient is currently in good condition. She
should not bath but may take showers. She should not drive
while on pain medication. The patient should avoid strenuous
activity. She should follow-up with her primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 23430**] in one to two weeks and Dr.
[**Last Name (STitle) **] in approximately four weeks. She should also
follow-up with her Cardiologist in approximately 2 to 3
weeks.
The patient will be discharged on
1. Calcium 20 mEq p.o. twice a day.
2. Lasix 80 mEq p.o. twice a day for seven days which will
be re-evaluated at that time by rehabilitation.
3. Albuterol one to two puffs q 6 p.r.n.
4. Lopressor 50 mg p.o. twice a day.
5. Miconazole powder 2% one application topically
Three times a day p.r.n. rash.
6. Metformin 1 gram p.o. twice a day.
7. Tylenol 3 one to two tabs p.o. q 4 hours p.r.n. pain.
8. Lansoprazole oral solution 30 mg per nasogastric
tube q day.
9. Betafloxacin 500 mg p.o. q 24
10. Lopressor 10 mg intravenous q 6.
11. Mucomyst 20% 3 to 5 mls nebulizer q 4 to 6 p.r.n.
12. Glipizide 5 mg p.o. twice a day.
13. Amiodarone 400 mg p.o. q day.
14. Entericoated aspirin 325 mg q day.
15. Docusate sodium 100 mg p.o. twice a day p.r.n.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2184-4-5**] 21:20
T: [**2184-4-5**] 21:29
JOB#: [**Job Number 44526**]
ICD9 Codes: 5119, 2761, 9971, 2851, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5293
}
|
Medical Text: Admission Date: [**2189-1-22**] Discharge Date: [**2189-1-28**]
Date of Birth: [**2110-5-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Altered mental status, suicidal ideation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History obtained from ER physician, [**Name10 (NameIs) **] nursing staff at [**Location (un) 22092**] on the [**Doctor Last Name **] as patient unable to provide history. Per
report, this is a 78F with PMH of DMII, COPD on 2L home O2, HTN,
depression and anxiety presenting with altered mental status and
suicidal ideation. Per nursing staff patient has been
progressively more confused over the past two months, with
particular worsening over the past two weeks. Patient is
re-directable, but oriented only to self and has periods of
confusion where she believes her husband is still alive. On the
day of admission she became acutely agitated, throwing herself
on the ground and stating that she was going to jump out the
window or hang herself because she was being kept against her
will. At that time she was transferred to the [**Hospital1 18**]. Nursing
staff denies recent fevers or change in respiratory status; by
report, urinalysis and CXR were negative for infection over the
past week.
ROS: Unable to be obtained as patient refuses to answer
questions. Pertinent positives as noted above.
Past Medical History:
(Per Medical Records, unable to be confirmed with patient)
Lung Cancer s/p chemotherapy and lobectomy (date unknown)
Type II Diabetes on insulin
Macular Degeneration (legally blind)
Hypertension
COPD
Breast Cancer s/p lumpectomy
Hypercholesterolemia
Diverticulosis
Obesity
Depression/Anxiety
Anemia
B12 deficiency
Colon Polyps s/p polypectomy [**2186**]
Social History:
Per medical records: Positive smoking history, quit at the time
of her diagnosis of lung cancer. No current smoking, alcohol or
illicit drug use.
Family History:
Per medical records: No history of lung disease
Physical Exam:
VS: T=97.3 BP=114/83 HR=88 RR=24 92% on 2L
Gen: Sleeping with tongue sticking out, difficult to arouse
HEENT: NCAT, EOMI, anicteric
CV: RR, no m/r/g
Pulm: CTA B, good inspiratory effort
Abd: Soft, no grimace to deep palpation
Ext: 1+ edema to knees bilaterally
Psych: Reluctant to open eyes, but able to when repeatedly asked
to; able to follow commands, states "I feel fine" but does not
provide additional information. Denies desire to hurt or kill
herself or anyone else.
Pertinent Results:
[**2189-1-22**] 07:10PM BLOOD PT-12.5 PTT-25.8 INR(PT)-1.0
[**2189-1-23**] 09:36AM BLOOD ALT-20 AST-27 LD(LDH)-281* AlkPhos-113*
TotBili-0.2
[**2189-1-22**] 07:10PM BLOOD cTropnT-0.08*
[**2189-1-23**] 06:00AM BLOOD CK-MB-3 cTropnT-0.06* proBNP-4382*
[**2189-1-23**] 03:30PM BLOOD CK-MB-3 cTropnT-0.09*
[**2189-1-23**] 06:00AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.2
[**2189-1-23**] 03:30PM BLOOD TSH-0.87
[**2189-1-23**] 03:30PM BLOOD Cortsol-18.3
[**2189-1-22**] 07:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-1-23**] 09:42AM BLOOD Type-ART pO2-121* pCO2-70* pH-7.35
calTCO2-40* Base XS-10 Intubat-NOT INTUBA
[**2189-1-23**] 10:11AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2189-1-25**] 03:02PM BLOOD Type-ART FiO2-70 pO2-151* pCO2-71*
pH-7.36 calTCO2-42* Base XS-11 Comment-SIMPLE FAC
[**2189-1-25**] 09:59PM BLOOD Type-ART pO2-62* pCO2-70* pH-7.35
calTCO2-40* Base XS-9
[**2189-1-27**] 07:42PM BLOOD Type-ART FiO2-96 pO2-72* pCO2-70* pH-7.35
calTCO2-40* Base XS-9 AADO2-560 REQ O2-90
[**2189-1-23**] 09:42AM BLOOD Glucose-109* Lactate-0.6 Na-144 K-4.5
Cl-97*
[**2189-1-23**] 09:42AM BLOOD freeCa-1.32
MICRO:
URINE Blood-NEG Nitrite-NEG Protein-150 Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2
[**2189-1-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
{CLOSTRIDIUM DIFFICILE} INPATIENT - POSITIVE FOR C. DIFF
[**2189-1-22**] URINE URINE CULTURE-FINAL {GRAM POSITIVE BACTERIA}
EMERGENCY [**Hospital1 **]
DISCHARGE:
[**2189-1-28**] 03:32AM BLOOD WBC-6.5 RBC-3.98* Hgb-9.5* Hct-32.1*
MCV-81* MCH-23.7* MCHC-29.5* RDW-16.4* Plt Ct-207
[**2189-1-24**] 03:31AM BLOOD Neuts-84.9* Lymphs-7.4* Monos-5.6 Eos-2.1
Baso-0.1
[**2189-1-28**] 03:32AM BLOOD PT-12.6 PTT-26.3 INR(PT)-1.1
[**2189-1-28**] 03:32AM BLOOD Glucose-162* UreaN-44* Creat-1.9* Na-140
K-4.8 Cl-98 HCO3-32 AnGap-15
[**2189-1-28**] 03:32AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0
REPORTS:
PA/LAT [**2189-1-22**]:
1. Moderate right pleural effusion and multifocal faint
opacities, could
represent infectious process.
2. Unchanged post-surgical changes in the right upper lobe.
Correlation with surgical history is recommended.
[**2189-1-23**] [**2189-1-23**]:
The left atrium is elongated. The right atrium is markedly
dilated. Left ventricular wall thicknesses and cavity size are
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
[3+] tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension.
IMPRESSION: Moderately dilated and mildly hypokinetic right
ventricle. Moderate to severe tricuspid regurgitation. Severe
pulmonary hypertension. Preserved left ventricular global
systolic function. Elevated estimated filling pressures.
RUQ U/S [**2189-1-23**]:
Direct son[**Name (NI) 493**] examinations were performed on the four
abdominal
quadrants. There is a small pocket of ascites in the right lower
quadrant,
measuring approximately 3.8 x 2.6 cm (AP x TRV). A trace amount
of fluid is noted in the deep pelvis. Limited views of the
kidneys demonstrate no
evidence of hydronephrosis.
IMPRESSION: Small pocket of ascites in the right lower quadrant.
[**2189-1-24**]:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Moderate right-sided pleural effusion, with partial collapse
of right
lower lobe, and hyperdense material within the atelectic lobe.
Concerning for aspiration versus pneumonia. Comparison with
outside hospital studies and correlation with clinical and
surgical history would be helpful.
3. Several left-sided pulmonary nodules and mild left hilar
lymphadenopathy. Although probably infectious or inflammatory,
chest CT follow-up is recommended in three months given the
history of malignancy.
4. Several rounded soft tissue lesions in the posterior
subcutaneous tissues. These lesions typically represent
sebaceous cysts. However, in the clinical context of breast
cancer, direct physical examination or son[**Name (NI) 493**] evaluation is
recommended to rule out malignancy.
5. Hypodense areas in the liver and spleen, incompletely
evaluated in the
current study. Metastatic disease is an important differential
consideration, although benign lesions are common in the liver
and spleen. Recommend follow-up with MRI or multiphasic CT for
further assessment.
CT HEAD [**2189-1-24**]:
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect or
major vascular territorial infarct. There is no shift of
normally midline
structures. The slightly prominent ventricles and sulci are
likely secondary to mild global atrophy. Moderate
periventricular and subcortical white matter hypodensity is
compatible with chronic microvascular ischemic disease. The
paranasal sinuses and mastoid air cells are clear. There is mild
vascular calcification at the cavernous portion of the internal
carotid arteries. No acute fracture is noted.
IMPRESSION: No acute intracranial process. Moderate chronic
microvascular
ischemic disease.
CXR [**2189-1-27**]:
IMPRESSION: Stable findings on portable chest examination
consistent with
marked cardiac enlargement and chronic CHF. No acute interval
change.
Brief Hospital Course:
# Delirium on dementia vs. worsening dementia: Appears to be an
acute change in setting of progressive decline over the past two
months, most notably over the past two weeks. Antibiotics were
started for possible hospital acquired pneumonia and respiratory
status was addressed as below. Psychiatry was consulted and
felt that she had delerium and could not evaluate underlying
mood disorder in the setting of delerium. She continued to wax
and wane with significant agitation at times. She removed
several PIVs and foley catheters. She did improve some with
standing olanzapine and PRN haldol. QTC remained within normal
range (~440). At time of discharge, she still becomes
intermittently agitated with requirement of soft restraints to
prevent pulling out IVs and with some concern for aggressive
behavior. In addition, she also had intermittent periods of
nonresponsiveness that are felt to be willful and/or psychiatric
in nature, and she spontaneously breaks out of these with
resumption of more aggrevated mood. After much discussion with
her HCP and outside providers, it was felt that her wishes would
be to minimize interventions that are uncomfortable to her and
focus now on comfort and treatments that she will allow. She
will be transferred to the MACU for continued IV antibiotics,
respiratory monitoring, intermittent lab monitoring, and
attempts at improving her CHF and respiratory distress, but with
plan not rehospitalize if status worsens.
# Respiratory distress. She was transferred to the ICU on
[**2189-1-21**] for hypercarbic and hypoxemic respiratory distress. The
cause was thought to be multifactorial, likely secondary to
acute on chronic diastoic CHF, PNA and COPD exacerbation (at
baseline patient is a CO2 retainer). The patient was given
vanc/cefepime for empiric coverage of HCAP for 8 day course
(start date [**2189-1-23**] until [**2189-1-31**]). Regarding her diureis, the
patient has been progressively intravascularly dry but
extravascularly wet and failing IV lasix boluses and drip with
elevation of her creatinine. Ace-I was held given elevated Cr.
No evidence of PE on CTA. Ideally she would be a candidate for
milrinone and more aggressive diuresis, however, this would not
be consistent with patient??????s goals of care. Would encourage the
use of morphine PRN dyspnea. With agitation patient still
becomes hypoxic to 80%, however, hypoxia improves spontaneously
or with medications to treat agitation.
****** PATIENT IS DNR/DNI/DNH (DO NOT HOSPITALIZE) *******
#. Diabetes mellitus, type 2, uncontrolled, with complications:
Report of low blood sugar on the morning of admission. Will
decrease morning dose of Lantus from 70u to 50u and follow on
HISS. Pt remained normoglycemic throughout the ICU admission.
#. Hypertension: Patient remained normotensive but occasionally
hypotensive to 80s systolic while sleeping and asymptomatic.
Diltiazem was continued and Lisinopril stopped due to acute
renal failure.
#. Depression/anxiety: Continued home regimen pending further
evaluation
# C diff colitis: Likely secondary to vancomycin and cefepime.
No significant diarrhea. She was started on IV flagyl for a
course of two weeks after she completes antibiotics for HAP on
[**2189-1-31**].
# Unresponsiveness: Ruled out hypercarbia. Seizure unlikely as
does eventually respond to tactile stimulus. Possibly secondary
to being hard of hearing and a deep sleeper exacerbated by IV
morphine. Consider volitional unresponsiveness given mental
illness. TSH wnl. Would continue to monitor mental status
without any aggressive interventions.
# Acute renal failure: likely from intravascular volume
depletion from lasix. Also received contrast for CTA. Held lasix
on [**2189-1-28**] given failure of diuresis and worsening renal
function. Would not give IVF as would likely lead to flash
pulmonary edema and respiratory distress. Recommend instead
allowing her to reequilibrate on her own.
# Urethral trauma s/p several self-removals of foley with
balloon inflation. Has pulled out her foley with the balloon
inflated 3 times. Will not replace foley.
# Hypertension:
- continued dilt
- held Lisinopril given ARF
- reduced asa from 325mg to 81mg PO Daily
# Right Breast Mass and skin changes - concerning for
inflammatory breast cancer vs breast cancer relapse. Did have
right cyst on [**Last Name (un) 3907**] from [**5-13**] with plan for 6 month follow-up.
Given comorbidities, no further work up indicated as would not
be consistent with goals of care.
# Troponin elevation: Mild and stable likely secondary to demand
ischemia. She was continued on aspirin 81 mg daily.
Medications on Admission:
Lantus 70u qAM
Venlafaxine XR 150 mg PO DAILY
Simvastatin 40 mg PO DAILY
Iron Polysaccharides Complex 150 mg PO DAILY
Diltiazem Extended-Release 120 mg PO DAILY
Trazodone 100 mg PO HS
Clonazepam 0.5 mg PO/NG QHS
Olanzapine 2.5 mg PO BID
Lisinopril 40 mg PO Daily
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze, SOB
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Vitamin D 800 UNIT PO DAILY
Calcium Carbonate 500 mg PO Q 8H
Lorazepam 0.5 mg PO/NG HS [**1-23**]
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, SOB
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for sob wheezing.
13. Haloperidol Lactate 5 mg/mL Solution Sig: Two (2) Injection
TID (3 times a day) as needed for Agitation.
14. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
15. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
16. Haloperidol 4 mg IV QID:PRN Agitation
Please use one or the other.
17. Morphine Sulfate 2-4 mg IV Q4H:PRN Pain/dyspnea
Hold for sedation or RR<12
18. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED): see sliding scale.
19. Cefepime 1 gram Recon Soln Sig: One (1) Intravenous every
twenty-four(24) hours: Last dose [**2189-1-31**].
20. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
Q48H: Last dose [**2189-1-31**].
21. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous every eight (8) hours: Last dose 2 weeks
after finishing your other antibiotics ([**2189-2-14**]).
22. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Delerium, Acute on chronic obstructive pulmonary
disorder, Pneumonia, Clostridium difficule colitis, Acute on
chronic diastolic congestive heart failure
Secondary: Hypertension, anemia
Discharge Condition:
Mental Status: Confused.
Level of Consciousness: Lethargic but arousable
Activity Status: Bedbound
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted with confusion. Your confusion was thought to be a
result of a pneumonia and and heart failure with underlying
dementia. We are treating you with antibiotics. We had
difficulty diuresing you. You will be discharged to the MACU at
[**Hospital **] rehab where they will focus on treating you to maximize
your comfort.
Followup Instructions:
You will be seen by your doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab.
Completed by:[**2189-1-29**]
ICD9 Codes: 486, 5849, 2930, 4280, 4019, 4168
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5294
}
|
Medical Text: Admission Date: [**2142-6-8**] Discharge Date: [**2142-6-13**]
Date of Birth: [**2088-1-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
occasional dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2142-6-8**]
1. Aortic valve replacement with size a 25-mm [**Last Name (un) 3843**]-
[**Doctor Last Name **] Magna Ease tissue valve.
2. Ascending aortic aneurysm resection with a size 28-mm
Gelweave graft.
History of Present Illness:
54 year old female who has a history of bicuspid aortic valve
stenosis. She states she has been feeling well with occasional
mild dyspnea after climbing [**1-26**] flights of stairs. She was
diagnosed in the [**2109**]'s and has been followed through the years
by serial echocardiograms. She underwent cardiac catheterization
in [**2137**] at [**Hospital6 **] after a syncopal event
and had an echo showing a valve area of 0.6cm2. At
catheterization, her peak aortic gradient only ended up being
42.5mmHG with a valve area of 1.0cm2. Her most recent echo from
[**2141-11-23**] revealed a peak aortic gradient of 101 mmHG, mean
of 59 mmHG, [**Location (un) 109**] of 0.7cm2 and [**12-25**]+ AI. She underwent a cardiac
catheterization in [**Month (only) 547**] which showed normal coronaries and an
aortic valve area of 1.04cm2.
Past Medical History:
Bicuspid Aortic valve/aortic stenosis
Aortic insuffiency
Osteopenia
Migraines
Left Wrist fracture
Remote anemia
Past Surgical History:
Appendectomy
Tonsillectomy/Adnoidectomy - Bleeding episode associated with
this surgery
Bilateral blepharoplasty
Social History:
Lives with:Husband
Contact:[**Last Name (NamePattern4) **] (Husband) Phone #[**Telephone/Fax (1) 77351**]
Occupation:dental hygienist
Cigarettes: Smoked no [] yes [x] Hx:quit at age 18
Other Tobacco use:denies
ETOH: 6 drinks/week
Illicit drug use: denies
Family History:
Premature coronary artery disease- Father with an
MI at age 40, subsequently had CABG. He passed away at age 69.
Physical Exam:
Pulse:75 Resp:16 O2 sat:99/RA
B/P Right:111/77 Left: 105/74
Height:5'8" Weight:158 lbs
General: WDWN in NAD
Skin: Warm, Dry and intact
HEENT: NCAT, PERRLA [x] EOMI [x], sclera anicteric, OP Benign.
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR, Nl S1-S2, Systolic Murmur grade III-IV/VI with I/VI
diastolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left:2
DP Right: 2 Left:2
PT [**Name (NI) 167**]: 2 Left:2
Radial Right: 2 Left:2
Carotid Bruit: radiating murmur, no bruit
Pertinent Results:
[**2142-6-8**] TEE:
Conclusions
PRE-CPB: 1. The left atrium and right atrium are normal in
cavity size. No thrombus is seen in the left atrial appendage.
2. A patent foramen ovale is present. A left-to-right shunt
across the interatrial septum is seen at rest.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated.
6. The aortic valve is bicuspid. The aortic valve leaflets are
severely thickened/deformed. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation
is seen.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation. The mitral valve leaflets are elongated.
8. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine briefly. AV pacing for
slow sinus rhythm. Well-seated bioprosthretic valve in the
aortic position with trivial paravalvular leak consistent with
stitch hole, not visible post protamine. Preserved biventricular
function. The aortic contour is normal post decannulation.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2142-6-8**] where
the patient underwent Aortic Valve Replacement, Ascending Aorta
Replacement with Dr. [**First Name (STitle) **]. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. She
had a brief episode of non-sustained V-Tac and was treated with
an amiodarone bolus.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Naproxen 220 mg PO PRN pain
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
if extubated
2. Furosemide 20 mg PO BID
RX *furosemide 20 mg daily Disp #*5 Tablet Refills:*0
3. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg twice a day Disp #*30 Tablet
Refills:*0
4. Potassium Chloride 20 mEq PO BID
Hold for K >4.5
RX *Klor-Con 20 mEq daily Disp #*5 Packet Refills:*0
5. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg every four (4) hours Disp #*40 Tablet
Refills:*0
6. Naproxen 220 mg PO PRN pain
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Bicuspid Aortic valve/aortic stenosis
Aortic insuffiency
Osteopenia
Migraines
Left Wrist fracture
Remote anemia
Past Surgical History:
Appendectomy
Tonsillectomy/Adnoidectomy - Bleeding episode associated with
this surgery
Bilateral blepharoplasty
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2142-6-21**]
10:15
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2142-7-17**] 1:15 [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2142-6-26**] at 10:15a
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8506**] in [**3-29**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-6-13**]
ICD9 Codes: 4271, 9971, 2875, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5295
}
|
Medical Text: Admission Date: [**2161-5-23**] Discharge Date: [**2161-6-12**]
Date of Birth: [**2078-10-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
1. Central venous line placement and removal
2. PICC line placement ([**2161-5-29**])
3. Craniotomy ([**2161-6-5**])
4. Intubation ([**2161-6-7**])
History of Present Illness:
82yo female with a PMH notable for anxiety and depression, HTN,
bilateral PE s/p IVC filter on coumadin, aortic stenosis (valve
area 0.8), CAD s/p BMS to LAD on [**2161-2-3**] presenting to an
outside s/p fall witnessed by her daughter. On CT from the
outside hospital, there was an acute on chronic subdural
hematoma. She was transferred to [**Hospital1 18**] for evaluation. She was
anticoagulated on Coumadin for a PE in the past and her
INR=2.97. The INR was reversed at the outside hospital. While in
the ER, she had a hypoxic episode and required intubation and
subsequently was admitted to the ICU.
Past Medical History:
1. CAD s/p stent placement, bare metal stent [**1-/2161**]
2. [**Location (un) 260**] filter
3. PE
4. MI
5. HTN
6. GERD
7. anemia
8. Anxiety
9. Aortic stenosis
Social History:
Patient walks with a cane. Lives with her daughter. [**Name (NI) **] drinking
or smoking history.
Family History:
Non-contributory
Physical Exam:
GCS 14. Limited due to pt cooperation
O: T:96.3 BP:168 /73 HR:81 R 20 O2Sats 93%
Gen: WD/WN, comfortable, NAD.
HEENT: Nasal fx with multiple facial lacerations. Pupils:4mm to
3mm EOMs: Full
Neck: Supple. No JVD
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Anxious & agitation is escalating. Alert,
cooperative with select portions of exam. Affect initially
normal. Through course of exam she has become extremely
agitated. She does not keep medical monitors or oxygen on and is
hypoxic with low Oxygent sat of 80%-82% on room air.
Orientation: Oriented to person,and place. Not to day,month or
year.
Language: Speech short. Requiring frequent reminders regarding
monitoring equipment.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally. Visual fields are full as pt follows examiner
around bed.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing decreased to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Pt would not comply.
XII: Tongue midline without fasciculations.
Motor: Pt does not cooperate fully with exam. Normal bulk and
tone bilaterally. No abnormal movements,tremors. Strength full
power [**3-31**] throughout. Moves all extremities symmetrically
without
difficulty
Sensation: Intact to light touch, pain bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: pt not cooperative with coordination exam.
Pertinent Results:
Labs on admission ([**2161-5-22**])
GLUCOSE-133* UREA N-25* CREAT-1.1 SODIUM-138 POTASSIUM-3.2*
CHLORIDE-99 TOTAL CO2-27 ANION GAP-15
WBC-13.4* RBC-3.13* HGB-9.2* HCT-27.2* MCV-87 MCH-29.3 MCHC-33.7
RDW-16.1* Plat count: 344 NEUTS-72.4* LYMPHS-21.1 MONOS-4.3
EOS-1.7 BASOS-0.4
PT-23.3* PTT-27.6 INR(PT)-2.2*
Labs on discharge ([**2161-6-11**])
WBC-12.6* RBC-2.72* Hgb-7.8* Hct-24.6* MCV-90 MCH-28.6 MCHC-31.7
RDW-15.7* Plt Ct-479*
PT-14.3* PTT-24.1 INR(PT)-1.2*
Glucose-132* UreaN-27* Creat-1.0 Na-140 K-4.1 Cl-102 HCO3-26
ALT-160* AST-159* LD(LDH)-301* AlkPhos-170* TotBili-0.3
Albumin-3.5 Calcium-9.2 Phos-3.5 Mg-1.4*
[**2161-6-10**] calTIBC-308 VitB12-727 Folate-7.2 Ferritn-299* TRF-237
[**2161-6-7**] TSH-0.84
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2161-6-10**]):
Feces negative for C.difficile toxin A & B by EIA.
URINE CULTURE (Final [**2161-5-26**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ([**2161-5-23**]):
Minimally displaced comminuted nasal bone fracture. No other
evidence of acute fracture.
NON-CONTRAST CT HEAD ([**2161-5-23**]): There is a large subdural
hematoma covering the entire right convexity, which measures up
to 2 cm from the inner table, which causes 6 mm shift of
normally midline structures, unchanged since [**2161-5-23**]. There is
mild compression of the right lateral ventricle without evidence
of subfalcine or uncal herniation. The bony calvarium is intact.
The paranasal sinuses and mastoid air cells are clear.
Non-contrast CT of the head ([**2161-6-3**]):
1. Increased leftward shift of midline structures, with
increased subfalcine and stable transtentorial herniation. There
is increased effacement of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle.
2. Stable appearance to right convexity subdural hematoma
without evidence for new foci of hemorrhage.
Non-contrast CT of the head ([**2161-6-5**]): Status post evacuation
of right frontal subdural hematoma with improvement in mass
effect with reduction in subfalcine herniation with an
improvement in leftward midline shift, now 9 mm. No evidence of
acute hemorrhage.
Non-contrast CT head ([**2161-6-8**]): Status post right craniotomy
for evacuation of right frontal subdural hematoma, now with
improvement of midline shift, now only 4 mm in leftward
direction. There is no evidence of an acute hemorrhage.
CHEST (PORTABLE AP) ([**2161-5-22**]): Vascular engorgement without
overt CHF.
Echocardiogram ([**2161-5-25**]): Severe/critical aortic stenosis(valve
area 0.6cm2). At least moderate mitral regurgitation. Pulmonary
artery systolic hypertension. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function.
CXR 2V ([**2161-6-8**]): Interval improvement in bibasilar atelectasis
or consolidation, and pleural fluid.
RUQ ultrasound ([**2161-6-9**]):
1. Normal Doppler study.
2. Small right pleural effusion.
3. Mild calcifications of the abdominal aorta, without
aneurysmal dilatation.
4. Calcified granuloma within the liver.
Brief Hospital Course:
82 year-old female with history of pulmonary embolism and atrial
fibrillation on coumadin admitted [**2161-5-23**] following fall. On
admission, she was found to have a subdural hematoma which was
evacuated. Hospital course was complicated by respiratory
distress requiring intubation, ventilator associated pneumonia,
and UTI. Brief hospital summary is as follows.
1. Sub-dural hematoma: Pt was admitted through the emergency
department after being brought in s/p fall. She was intubated in
the ED for respiratory distress and increasing agitation. Head
CT revealed acute on chronic SDH on the right. She had been on
aspirin, plavix and coumadin and her anticoagulation was
reversed and her labs were followed closely. She was admitted to
the trauma ICU and after being cleared from a trauma
standpoint, she was admitted to neurosurgery. Extubation was
considered on hospital day #2 however she went into pulmonary
edema and the extubation was not attempted. Her management
continued to be primarily medical. Extubation was again
considered [**5-26**] but CXR showed fluid and she remained intubated.
Her neurologic exam improved on this day - her eyes were open,
she attended examiner and followed commands with motors
appearing full. Extubation again considered on [**5-27**] and was
successful.
On [**5-28**] she was neurologically intact. She was transferred
to the medicine service. She continued to complain of a dull,
persistent headache. A head CT on [**2161-5-31**] showed progression of
SDH further from the previous CT scan. Neurosurgery evaluated
the patient and decided that surgery was indicated. Over the
next couple of days, the patient steadily became more lethargic
and often lost her concentration. Her mental status would
fluctuate. Another CT scan on [**2161-6-3**] showed increased midline
shift of the brain. During a meeting with the neurosurgeons,
cardiologist, and primary medicine team, the risks and benefits
of surgery were explained to the family and the family decided
to pursue a craniotomy. The patient tolerated the procedure well
and was monitored for 24 hours in the PACU before being
transferred to the neurosurgical floor. She was transferred back
the medical service. She was noted to have continued delirium
which is much improved on discharge. She will need follow-up
with neurosurgery in one month. She will also need a repeat head
CT in one month. If patient has any evidence of neurological
decline, her neurosurgeon should be [**Date Range 653**] immediately.
Patient will need to have sutures removed from craniotomy site
on [**2161-6-15**].
Neurological deficits on discharge: Minor parathesia in
left hand, non-dermatomal distribution. Sluggish pupil in right
eye (secondary to macular degeneration). Occasional involuntary
movement of left fingers (likely residual deficits of SDH).
Re: SDH evacuation, patient underwent cranitomy with bone
flap. Presently the bone flap moves in a pulsatile manner; this
will continue to do so until fusion.
2. Ventilator-associated pneumonia: While in the ICU, the
patient developed hospital acquired pneumonia. She was started
on a 10 day course of Vancomycin and Ceftazidime to cover
ventilator and hospital acquired pneumonia. A sputum culture was
not diagnostic. In the ICU, she had a central line which was
later discontinued on the floor after placement of a PICC line.
In addition, the patient received chest PT. The cough persisted,
but she remained afebrile. The 10 day course of antibiotics was
finished in the hospital. Patient is afebrile and without
productive cough on discharge.
3. Anticoagulation: Due to the SDH, the patient was stopped on
her Coumadin therapy. In addition, her Plavix for her bare metal
stent placed on [**2161-2-4**] was discontinued - Plavix is no longer
indicated. Cardiology recommended that she no longer needed
Plavix. After her craniotomy, neurosurgery recommended that the
patient should continue her daily aspirin.
4. Episode of rapid A. fib vs. A. flutter: Prior to extubation
in the ICU, the patient did have an episode of rapid a-fib which
she was given Diltiazem/Lopressor and converted back to sinus
rhythm. Following craniotomy, patient again had episode of
atrial fibrillation with RVR. With the guidance of cardiology,
patient was amiodarone-loaded. Patient was subsequently noted to
have a transaminitis (see above). On discharge, transaminitis is
improved. Patient should have repeat LFTs within 3-4 days of
discharge. If rising, patient's PCP should be [**Name (NI) 653**]. We are
currently hold statin as well; may be started once transaminitis
resolves.
5. UTI: The patient developed a complicated UTI. A culture
revealed E. coli which was sensitive to ceftazidime. The UTI
resolved after antibiotic treatment.
6. Hypertension: Given that the patient has severe aortic
stenosis and therefore preload dependent, the patient was
discontinued on Isordil. With this exception, the patient was
continued on lisinopril (increased) and metoprolol with adequate
BP control.
7. Asymptomatic aortic stenosis: The patient has severe aortic
stenosis with a valve area of 0.6 cm2, but does not have any
symptoms related to AS. Continuing Lasix per home regimen.
8. Hypokalemia: Continuing potassium supplement.
9. Diarrhea, now resolved: C. diff negative x2.
10. Seizure. Partial complex with secondary generalization, six
days post-craniotomy. Likely contributors were some mild trauma
to the brain upon falling, with the development of the subdural
hematoma and the subsequent craniotomy. Seizure prophylaxis was
not indicated initially, but has now been started after the
seizure on [**2161-6-11**]. The [**Doctor Last Name 360**] used is Keppra 500 mg [**Hospital1 **].
Medications on Admission:
Zocor 80mg QD,
KCL 20Meq QD,
Coumadin 4mg [**Last Name (LF) 244**],
[**First Name3 (LF) **] 325mg QD,
Plavix 75mg QD,
Iron 325mg QD,
Monopril 10mg QD,
Isordil 10mg [**Hospital1 **],
Ativan 0.5mg TID,
Metoprolol 50mg Q8Hr,
Zoloft 75mg QD,
Mg Sulfate
Discharge Medications:
[**2161-6-13**]
Please draw liver function tests, electrolytes (chem-10) to
assess for resolving transaminitis and stability of
electrolytes.
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID:PRN as
needed for anxiety.
2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
3. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
4. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for Possible fungal infection in
mouth.
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Primary diagnoses:
-Subdural hematoma, right-sided after fall that also resulted in
nasal fracture.
Secondary diagnoses:
UTI, now resolved
Atrial fibrilation with rapid ventricular rate
Pulmonary edema, now resolved
Pneumonia - ventilator associated, now resolved
Transaminitis, secondary to amiodarone; improved
Brief diarrhea, now resolved
Seizure, secondary to fall/sdh/craniotomy
Discharge Condition:
There are some minor neurological deficits at present: There is
some parathesia of the left hand, likely of cortical origin and
secondary to the subdural hematoma. The right pupil is
sluggish, but this is likely due to a relative sensory afferent
defect caused by macular degeneration. There was one seizure
while an inpatient (partial complex with secondary
generalization) which ended spontaneously with some post-ictal
confusion, amnesia, partial paralysis, hypertension, all of
which resolved over the ensuing minutes to hours. Seizure
prophylaxis is now in place.
The bone flap is slightly pulsatile. This is because the
subdural was evacuated with a bone flap craniotomy. The wound
is healing well.
Mrs. [**Known lastname 39602**] is capable of taking a full diet, but has had
reduced intake of food and water. This originates in her desire
to not urinate or get up to toilet too often. It would be great
if her diet could be progressed further while in rehabilitation.
She is able to walk and toilet with assistance.
Discharge Instructions:
You came to the hospital after hitting your head on the ground.
You were found to have a bleed inside of your head. Your blood
thinner, Coumadin, was stopped. You required a breathing tube
while in the ER and were sent to the ICU. In the ICU, you became
more stable. You no longer needed a tube. You were found to have
a urinary tract infection and pneumonia, so you needed
antibiotics. You finished your antibiotics while in the
hospital. You underwent a craniotomy on [**2161-6-5**] for the
bleeding around your brain and currently are doing well. While
recovering you developed an abnormal heart rhythm which was
treated. This was treated with amiodarone with which you
reacted with some liver inflammation. This drug was stopped and
your liver function is improving. There was also one day of
diarrhea which has now resolved. On the day of intended
discharge, you had a seizure. This seizure is sometimes a
consequence of subdural hematoma (the bleed that you had) as
well as craniotomy. You have been started on an anti-seizure
medication (Keppra). We have monitored you recovery and now see
that you are well enough for rehabilitation.
Your medication regimen has changed. Please see attached
medication list.
Please follow-up with your providers: Neurosurgery, cardiology
and your PCP, [**Name10 (NameIs) 3**] directed below.
If you develop weakness of an arm or leg, worsening abnormal
sensation in the left hand, involuntary movements, particularly
of the left hand or arm, seizure, difficulty with speech, fever,
inflammation of the wound site, headache, confusion, or any
other concerning symptom, please return to hosptial.
Followup Instructions:
SUTURES NEED TO BE REMOVED ON THE [**6-15**].
Neurosurgery:
After leaving the hospital, please call the office of Dr.
[**Last Name (STitle) **], your neurosurgeon, to schedule an appointment. They
will arrange for a follow-up CT scan of your head that will
occur prior to the appointment. His rooms can be [**Last Name (STitle) 653**] at
([**Telephone/Fax (1) 26566**]. Ideally, this appointment would be one month
after discharge from the hospital. Until this time, please
continue to take your anti-seizure medication.
.
Cardiologist:
Please follow-up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8573**].
We will give you a letter describing your care here that will be
helpful in his ongoing management of your arryhthmia and
medications. Again, please make this appointment when you are
discharged, so that you will not have to wait too long. It would
be good if you could make this appointment for one to two weeks
after discharge from rehabilitation.
.
PCP:
[**Name10 (NameIs) 357**] make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32683**].
Please give him a copy of your discharge summary, so that he can
manage your global care. This appointment can be made for a date
one to two weeks after your discharge from rehabilitation.
ICD9 Codes: 5849, 5990, 4241, 2859, 412, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5296
}
|
Medical Text: Admission Date: [**2120-10-15**] Discharge Date: [**2120-10-19**]
Date of Birth: [**2094-7-14**] Sex: F
Service: [**Company 191**] MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 26-year-old
French-Canadian female with a past medical history
significant for depression and anxiety, who presented status
post a suicide attempt via polysubstance overdose.
Apparently the patient was feeling more anxious and depressed
on the day of admission. This anxiety had been building up
for the past few weeks. Consequently, she called her
psychiatrist and asked for an emergent appointment, but
unfortunately was not able to be seen. She then wrote a
suicide note addressed to her boyfriend and afterwards, while
sober, took the contents of bottles containing Tylenol,
aspirin, Paxil, Risperdal, Valium, Motrin and Claritin. She
then took a few sips of whiskey and tried to hang herself
with a cord. This proved to be too painful, so she untied
the cord, drank some more whiskey, and eventually passed out.
Her boyfriend found her on the floor surrounded by the empty
bottles, called EMT and, as a result, the patient was taken
immediately to [**Hospital1 **] Center's
Emergency Department.
PAST MEDICAL HISTORY: Remarkable for depression and anxiety.
The patient is currently followed every other week by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45375**], a local psychiatrist. She has been seeing
him for the past 18 months. The patient does have a history
of a prior hospitalization for several hours following a
suicide attempt via wrist slashing.
MEDICATIONS ON ADMISSION: Paxil 20 mg a day, Risperdal dose
unknown, Valium 5 mg as needed for insomnia, and Claritin as
needed.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is the younger of two children
from Montreal. She claims her parents were both alcoholics
and psychologically abusive. Her parents underwent a divorce
when she was 19. She denies any history of physical or
sexual abuse. She admits to having problems with alcohol
abuse as a teenager, but now states that she remains sober.
She denies any intravenous drug or recreational drug use, and
says that she has never smoked before. She is currently
obtaining her master's degree in counseling at [**University/College 5130**]
[**Location (un) **], and has been in [**Location (un) 86**] for the past three years.
PHYSICAL EXAMINATION: Temperature 96.8, blood pressure
118/72, pulse 101, oxygen saturation 100% on 40% FIO2. In
general, this was a well-developed, well-nourished, young
Caucasian female, who was lethargic and obtunded on initial
presentation. Her speech was slurred. She was confused and
not oriented to person, place or time. Her [**Location (un) 2611**] coma
scale was noted to be 10 in the Emergency Department. She
was not following commands, but opening her eyes to voice.
Her pupils were noted to be 6 mm and reactive bilaterally.
Her nares and her airway were both patent. Her oropharynx
was without any lesions, and her mucous membranes were dry.
Her neck was supple, without any lymphadenopathy. The lungs
were clear bilaterally. Cardiovascular examination revealed
a tachycardic S1, S2, but no murmurs, gallops or rubs were
appreciated. Her abdomen was soft, nontender, nondistended,
with good bowel sounds and no palpable masses. Her skin was
warm and dry, without any unusual lesions or rashes. Her
extremities revealed good pulses and no cyanosis, clubbing or
edema.
LABORATORY DATA: On admission, these were notable for a
white count of 4.8, with a differential of 45 polys, 45
lymphs, 7 monos, and 1 eosinophil. Hematocrit 39.3. Sodium
142, potassium 4.3, chloride 106, bicarbonate 25, BUN 10,
creatinine 0.8, glucose 84, thereby making an anion gap of
15. Urinalysis was remarkable for occasional bacteria and
[**3-26**] epithelial cells, no white cells, and no leukocyte
esterase or nitrites. Toxicology screen revealed an aspirin
level of 28, acetaminophen level of 114, and positive
benzodiazepines. Chest x-ray on admission showed no acute
cardiopulmonary process. Coags were remarkable for an INR of
1.3.
HOSPITAL COURSE: The patient was immediately given activated
charcoal and a loading dose of ___________ 15 in the
Emergency Department. She was intubated for airway
protection, and sedated with Ativan and fentanyl. She
remained in the Intensive Care Unit for 48 hours, and was
extubated on hospital day number one without any
complications.
For her Tylenol overdose, she was given 4200 mg of __________
15 for a total of 17 doses every four hours per protocol.
Her Tylenol levels were checked daily until they returned to
0. Her liver function tests and her coags were also checked
daily until they normalized. Given her elevated aspirin
level, her urine was alkalinized with appropriate amounts of
bicarbonate and her drug levels were followed very closely.
Daily electrocardiograms were also checked to monitor for
signs of QT prolongation, given her Risperdal overdose.
Inpatient Psychiatry was consulted and followed the patient
on a daily basis. She was placed on Protonix and
subcutaneous heparin for appropriate prophylaxis. The
patient was transferred to the general medical floor on
hospital day number two. Later that night, her temperature
was found to be increased to 101.7 degrees, no acute distress
her white cell count increased to 14.1. As a result, blood
and urine cultures were sent off, and a repeat chest x-ray
was performed. This chest x-ray showed a new left lower lobe
opacity in the retrocardiac region, consistent with a focal
aspiration vs. early pneumonia that was not seen on the film
taken on the day of admission. The patient was thus started
on a one week course of Levaquin 500 mg once daily. She was
placed on maintenance intravenous fluids. Her diet was
advanced to regular as tolerated. Her cultures all remained
negative, and she defervesced appropriately on the Levaquin.
A one-to-one sitter was provided at all times for the
patient's safety. Her electrolytes were checked on a daily
basis, and repleted as needed. On the day of discharge, her
liver function tests were all found to be normal, and her INR
had decreased to 1.2.
DISCHARGE DIAGNOSIS:
1. Depression/anxiety
2. Attempted suicide via polysubstance overdose
3. Left lower lobe pneumonia
DISCHARGE MEDICATIONS:
1. Levaquin 500 mg by mouth once daily for a total of seven
days, last dose on [**10-23**]
2. Ativan 0.5 mg by mouth every six hours as needed for
anxiety
DISCHARGE STATUS: The patient is to be discharged in stable
condition to a psychiatric facility following the last dose
of her Mucomyst on the midnight of [**10-19**]. There, she
is to undergo appropriate psychiatric counseling. Her
psychiatric medications are currently all on hold, and will
need to be restarted as deemed appropriate. She is to
continue her seven day course of oral Levaquin for her
pneumonia, likely to be aspiration in nature. Since she is a
Canadian national without any American insurance to cover the
cost of her psychiatric hospitalization, the [**Location (un) 86**] Emergency
Service team was contact[**Name (NI) **] and served as a liaison to secure
her a bed in such a facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22604**], M.D. [**MD Number(1) 22605**]
Dictated By:[**Last Name (NamePattern4) 1198**]
MEDQUIST36
D: [**2120-10-18**] 21:20
T: [**2120-10-19**] 00:00
JOB#: [**Job Number 45376**]
ICD9 Codes: 5070
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5297
}
|
Medical Text: Admission Date: [**2152-12-7**] Discharge Date: [**2152-12-13**]
Service: ACOVE/MED
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 36976**] is an 88-year-old
resident of [**Hospital **] Rehabilitation Center for Aged with a
past medical history of dementia, bipolar disorder,
Parkinson's, urinary and fecal incontinence, who presents
from the Medical Intensive Care Unit with hypernatremia.
The patient was in her usual state of health until three days
prior to arrival, when she was noted to be febrile and lethargic.
Urine
culture was sent and she was started on levofloxacin 250 mg by
mouth
once daily. The next day, the patient was alert but with
intermittent fevers. One day prior to arrival, laboratories
glucose of 645, and a creatinine of 1.7. The patient also
had tachycardia, tachypnea, and an oxygen saturation of 91 to
92% on room air. She was transferred to [**Hospital1 36977**] for evaluation.
In the Emergency Department, the patient was given
intravenous fluids, normal saline, changed to half-normal
saline, and started on an insulin drip. Ceftriaxone was given,
and
the patient had a corrected sodium at this time of 179, with a
free water deficit calculated at 8 liters. The source
of the increased white count was unclear, with urine,
pancreas,and decubiti possible sources. The patient
continued on ceftriaxone, was made NPO, and was
transferred to the floor from the Medical Intensive Care Unit
after 24 hours.
At presentation on the floor, the patient had a sodium of 162,
platelets decreased to 61. Chest x-ray was consistent with
pneumonia. The patient had no complaints, but was aphasic,
answers
questions with shaking of head.
PAST MEDICAL HISTORY:
1. Bipolar disorder
2. Parkinson's disease
3. Dementia
4. Gastroesophageal reflux disease
5. Status post right hip open reduction and internal
fixation
6. Urinary/fecal incontinence
7. Bilateral cataract surgery
MEDICATIONS ON ADMISSION: Aspirin 81 mg by mouth once
daily, multivitamin one tablet by mouth once daily, Axid 150
mg by mouth once daily, calcium carbonate 650 mg by mouth
twice a day, Sorbitol 5 ml by mouth once daily, Sinemet
25/100 two tablets three times a day one hour before meals,
Tylenol 650 mg by mouth every four hours as needed,
Guaifenesin syrup 15 ml every four hours as needed for cough.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Resident of [**Hospital1 5595**]. Patient is a widow, has
two daughters, emigrated from [**Name (NI) 36978**] in [**2071**].
PHYSICAL EXAMINATION: On presentation to the floor,
temperature 98.3, blood pressure 132/60, pulse 90,
respiratory rate 22, pulse oxygenation 90% on 3 liters,
finger stick oxygen saturation 66. Head, eyes, ears, nose
and throat anicteric, clear. Regular rate and rhythm, S1,
S2, II/VI systolic murmur at left upper sternal border.
Pulmonary showed crackles of the right lung three-quarters of
the way up. The left lung was clear. The abdomen was soft,
nontender, nondistended, positive bowel sounds. Extremities:
Trace edema bilaterally. Neurological: Patient responds to
questions with head shakes. Normal affect.
LABORATORY DATA: On presentation to the floor, sodium 162,
potassium 4.1, chloride 132, CO2 22, BUN 37, creatinine 1.1,
glucose 289. On [**12-8**], white count 18.3, hematocrit 37.0,
platelets 61, MCV 85. INR 1.4, PT 14.3, PTT 3.09. On [**12-7**],
ALT 42, AST 37, alkaline phosphatase 84, amylase 255, total
bilirubin 0.5, lipase 450. CKs showed progression from 90 to
101 to 164 to 175. Troponin went from 1.7 to 0.9 at the
third troponin check. On [**12-7**], serum osmolality of 420. On
[**12-7**], urine sodium 16, potassium 67, chloride 20. On [**12-8**],
urine culture showed less than 10,000 organisms. On [**12-7**],
urinalysis yellow, clear, specific gravity of 1.025, large
blood, negative nitrates, 100 protein, 500 glucose, trace
ketones, [**12-5**] red blood cells, [**6-25**] white blood cells,
moderate bacteria, [**12-5**] epithelial cells. On [**12-8**], chest
x-ray left hilar opacity, acute aspiration pneumonia vs.
pneumonia, no congestive heart failure, central line intact.
HOSPITAL COURSE: This is an 88-year-old resident of [**Hospital1 5595**]
with a past medical history of bipolar disorder, Parkinson's,
dementia, gastroesophageal reflux disease, status post right
hip open reduction and internal fixation, urinary and fecal
incontinence, who presents with hypernatremia, pneumonia,
decreased platelets, troponin elevation, and laboratories
consistent with pancreatitis.
1. Hypernatremia: The etiology was thought to be
secondary to hyperglycemia combined with decreased thirst related
to dementia. Patient's calculated free water
deficit when originally on the floor of 4 liters. The
patient did appear mildly dry. The patient's fluids were
managed carefully, and the patient was slowly brought down to
a normal sodium of 141. The patient did not correct faster
than 0.5 mEq/hour while on the floor. The patient's mental
status improved with rehydration and correction of
hypernatremia, so that the patient would verbalize three or
four words at the time of discharge.
2. Infectious Disease: Patient with unclear source to
elevated white count. Throughout her hospital stay, the
patient's white count declined to a normal level and, on
[**12-12**], the patient's white count was 9.6. The patient's
urine cultures did not grow anything. The patient's chest
x-ray, which was originally consistent with possible
pneumonia, cleared the next day on subsequent chest x-ray.
This was thought to possibly represent aspiration
pneumonitis. The patient was continued on ceftriaxone for
six days, then switched to oral levofloxacin to finish a 14
day course for a probable pneumonia.
3. Hematology: The patient's platelets declined while an
inpatient. The patient had a nadir of platelets at 38.
Subcutaneous heparin was stopped. DIC panel was checked.
Fibrinogen was normal, however, D-Dimers and FDP were both
consistent with DIC. The patient's coags continued to
correct. On [**12-11**], the patient's INR was 1.1 with a PT of
12.7 and PTT of 26.6. It was thought that her
thrombocytopenia was secondary to DIC. The patient's
platelets increased and, on [**12-11**], they were 57 and on [**12-12**]
they were 68. The patient's platelets should be monitored as an
outpatient.
4. Gastrointestinal: Patient with laboratories consistent
with pancreatitis. The patient did have mild tenderness in
the epigastrium to deep palpation. This pain appeared to
resolve over the next several days. Triglycerides were
checked and came back at 216 and were not thought to be the
cause of her pancreatitis. The patient did not have an
obstructive picture. The patient's amylase and lipase
declined and, at the time of discharge, lipase was mildly
elevated and amylase normal for two days.
5. Endocrinology: Patient admitted with extremely high
blood sugar. The patient had a hemoglobin A1c sent, which
came back high at 10.8. The patient was covered with sliding
scale while an inpatient, however, the patient was nothing by
mouth throughout much of her hospital stay. There was
thought given to starting an oral hyperglycemic medication.
This was deferred to the outpatient setting, where her sugars
will be monitored.
6. Fluids, electrolytes and nutrition: The patient was
started on an oral diet on [**12-12**] after pancreatitis had
resolved. The patient tolerated thick liquids. The patient
was discharged with the plan to increase oral intake as an
outpatient.
7. Pulmonary: Patient with oxygen requirement on admission.
The patient continued to have oxygen requirement throughout
her hospital stay of 3 liters. It was unclear what the cause
of the hypoxemia and hypoxia was. Patient with question
pneumonia per chest x-ray. Patient was seen by Physical
Therapy, who performed vigorous chest physical therapy on the
patient. This seemed to clear a lot of yellowish secretions.
These did not show any PMNs, and Gram stain was not positive
for bacteria. There was a possible diagnosis of ongoing
aspiration. The patient's head of bed was kept up at 30 to
45 degrees throughout her hospital stay.
DISCHARGE CONDITION: Fair
DISCHARGE PLACE: The patient was discharged to [**Hospital **]
Rehabilitation Center for Aged.
CODE STATUS: The patient is Do Not Resuscitate/Do Not
Intubate.
DISCHARGE MEDICATIONS: As per admission medications, plus
sliding scale of regular insulin and levofloxacin 500 mg by
mouth once daily for eight days.
DISCHARGE DIAGNOSIS:
1. Type 2 diabetes
2. Hypernatremia
3. Pancreatitis
4. Mild DIC
5. Possible pneumonia
FOLLOW UP:
1. The patient needs checking of her blood sugars with
recent diagnosis of Type 2 diabetes. She may need to start
on an oral hyperglycemia medication.
2. The patient will need continued assessment of fluid
status to prevent future hypernatremia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 16137**] 12-154
Dictated By:[**Last Name (NamePattern1) 1324**]
MEDQUIST36
D: [**2152-12-12**] 23:41
T: [**2152-12-13**] 00:00
JOB#: [**Job Number 36979**]
ICD9 Codes: 5070, 2760, 2765
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5298
}
|
Medical Text: Admission Date: [**2176-6-30**] Discharge Date: [**2176-7-3**]
Date of Birth: [**2148-6-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
tylenol overdose
acute intoxication
Major Surgical or Invasive Procedure:
intubation, mechanical ventilation
History of Present Illness:
This 28 yo man with h/o depression presented to the ED s/p OD on
'blue pills with PM on them', thought to be excedrin PM. Tox.
screen positive for acetominphen (unknown time of ingestion-?
0100-0200), and etoh. He resides in CT but was in [**Location (un) 86**]
visiting his girlfriend. She left to return a shirt to a friend
approx 0100 and that is when this OD occured. Per his parents he
had an episode of binge drinking 2 months prior where he was
hospitalized for detox (3 days) and treated with benzos but no
noted withdrawl/seizures. He rec'd 1.5 days counceling but did
not follow-up for further treatment. Around that time his PCP
started him on Paxil and he seemed to improve initially but has
been worse over the past 6 weeks. He arrived in [**Location (un) 86**] 1 week
prior to visit his ex-girlfriend and things were going well
until [**6-26**] when he started to drink heavily. Per his parents the
ex-girlfriend called last night stating he was drunk and
difficult, shortly after which he told her he took 20 pills
(excedrin pm?). Per his parents no known close friends/family
memebers with completed suicide, though a peer in high school
died by hanging. His parents came from CT and brought him to the
ED.
.
On arrival to the ED VS: T 98.7 HR 120 BP 157/96 RR 18 Sat 95%
on RA. Sat fell to 92% on RA. He was noted to be
confused/lethargic so intubated for airway protection. He was
given activated charcoal PO. narcan 0.4mg given with no effect.
Toxicology was consulted and he was admitted to the ICU.
For tylenol overdose he was given acetylcysteine based on 80kg
wt, (IV) 9800 mg (140mg/kg load) with 5600mg (70mg/kg) q4 iv for
24 hours-rec'd at 1000, 1400 prior to transfer. Toxicology
following: 1-2 beats of clonus, no hyperreflexia noted. He rec'd
1.7 L NS then approx 500cc D51/2NS. UOP 600cc when foley placed,
then total 1160 for 9 hours.
Past Medical History:
OSA on home CPAP
Hypertension: not known to be on medications
Depression: on paroxitene, ?compliance, no previous suicide
attempts known
GERD
Recent L wrist fracture w/metal pins placed (2 weeks prior), in
splint
h/o tremor since childhood
Social History:
Works as a restaurant manager in CT, here visiting his
girlfriend. + EtOH (recent heavy use as above) and tobacco use
(1 PPD, had quit 5 years ago but restarted 6-8 months ago).
Possible MJ use, no other known drug use per parents.
Family History:
nc
Physical Exam:
ON ADMIT
VS: T 99.5 oral, 100.6 rectal BP 155/96 HR 101 AC
500(500)/16(23)/0.5/5 98%
General: Intubated, sedated but arouses, nods yes/no to
questions, follows commands, NAD, withdraws to pain
HEENT: OP with charcoal, otherwise clear, PERRL 5->3mm bilat
Neck: Wide, JVP 6cm, no LAD
Resp: CTAB, no wheezes, rales, rhonchi
CV: Tachycardic but regular rhythm, no m/r/g; 2+ radial/DP/PT
pulses B
Abdomen: soft, NT, ND, +BS, no masses or HSM
Ext: L wrist in splint; no c/c/e
Skin: Multiple tattoos, no rashes or erythema, warm and moist to
touch
Neuro: PERRL 5->3mm bilaterally, + horizontal nystagmus both
directions; DTR's 2+ biceps B, brachioradialis R; 3+ patellar
reflexes bilaterally, babinski down-going bilaterally, +[**3-28**]
beats of clonus in ankles bilaterally, no rigidity or tremor
Brief Hospital Course:
A/P: 28 yo man with depression presents with EtOH intoxication,
suicide attempt via acetaminophen/diphenhydramine/? paroxetine
overdose.
.
# Acetaminophen overdose: Pt given NAC in the ED. Toxicology
consulted. Initial LFTs normal. completed treatment with NAC.
LFTS remained normal.
.
# Diphenhydramine overdose: Likely contributing to confusion,
monitored for hyperthermia, cutaneous vasodilation,
decreased/absent bowel sounds, pupillary dilation, tachycardia,
prolonged QTc, seizures as signs of anticholinergic toxicity and
all were within the normal in the initial 24 hours.
.
# Possible paroxetine overdose: Per pharmacy did not get
prescription refilled after [**5-27**], has one pill remaining so
likely not strictly compliant. Patient had mild hyper-reflexia,
clonus on exam, also tachycardic and with low-grade fever, ?
serotonin syndrome given on paroxetine, toxicology was
reconsulted. received supportive care and no intervention
needed.
.
# Suicide attempt: Psychiatry consulted, and followed throughout
hospitalization. initially on 1:1 sitter which was discontinued.
Ultimately, intensive outpatient counseling and therapy was
recommended and was agreeable to the patient and family.
Social work and addiction counseling saw the patient and helped
arrange follow-up closer to home in CT.
.
# EtOH intoxication: monitored on CIWA q 4 hours for withdrawal,
no signs or symptoms. Complete abstinence recommended and AA was
rec'd by psych.
.
#DEPRESSION -psychiatry consulted, continued on Paxil 20mg qd,
psychiatry established plan for safe care and follow up with
patient and family. Social work will follow up to help arrange
outpatient follow-up.
Medications on Admission:
paxil 20mg qd
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Tylenol PM overdose
alcohol intoxication
depression
Discharge Condition:
improved
Discharge Instructions:
call or seek medical attention if any questions or concerns.
Followup Instructions:
follow up with outpatient counseling and your primary care
doctor.
social work will be in contact tomorrow to confirm follow-up for
counseling.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2176-7-5**]
ICD9 Codes: 5070, 311, 3051
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5299
}
|
Medical Text: Admission Date: [**2135-5-27**] Discharge Date: [**2135-6-8**]
Date of Birth: [**2075-12-27**] Sex: F
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Transfer from outside hospital for
evaluation and pericardiocentesis.
HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old
female with a recent diagnosis of nonischemic cardiomyopathy
with an EF of [**10-12**]% who was in her usual state of health
until [**2135-3-29**] when she presented to an outside hospital
with chest pain. She was ruled out for a myocardial infarct
at that time; however, developed shortness of breath and
bilateral pleural effusions, at which time she was
transferred to another outside hospital where cardiac
catheterization showed clean coronary arteries but increased
right-sided pressures. A transthoracic echocardiogram was
performed and showed an EF of [**10-17**]% and was transferred to
[**Hospital1 18**] CCU on a dobutamine drip for a heart transplant and
evaluation for her cardiac transplant here. She had a PA
catheter placed and was found to have a CVP of 9, PA pressure
of 42/22, cardiac output 4.5, and index of 2.5. She was
weaned from a dobutamine drip without any changes in her PA
catheter numbers. She was maintained on fluid restriction,
started on digoxin and Coumadin for her low EF.
The previous admission culminated and the feeling that she
did not need a cardiac transplant at that time. She was,
therefore, discharged to home with follow-up with Dr. [**Last Name (STitle) **].
She was admitted to [**Hospital 6691**] Hospital on [**2135-5-24**] for
fevers to 103-104, chills and rigors. She had reported 5/10
chest pain since admission to [**Hospital 6691**] Hospital. A
transthoracic echocardiogram was performed to evaluate for
endocarditis due to her persistent fevers and revealed a very
large pericardial effusion. Her blood pressure dropped to
84/53 and her oxygen saturations decreased to 88% on room air
and, therefore, she was transferred to [**Hospital1 18**] for
pericardiocentesis.
She describes her chest pain as "pressure" which was
nonradiating and not associated with food or shortness of
breath. It started spontaneously when she was at the outside
hospital and was worse with inspiration and unrelieved by
sublingual nitrogens. Also, during her outside hospital
course, she was started on antibiotics; however, she did not
defervesce with her fevers in the 101-103 range. Blood
cultures and urine cultures were performed and all found to
be negative. A CT of the chest was performed which showed
mediastinal lymphadenopathy, bilateral small pleural
effusions and a 1 by 3 cm infiltrate in the right middle lobe
which did not have an appearance of pneumonia.
She had the transthoracic echocardiogram which is as
described above which noted a 1.5 cm circumferential effusion
with some RA collapse but no RV collapse. Her EF was
calculated at 10-15%.
PAST MEDICAL HISTORY:
1. Cardiomyopathy, nonischemic, diagnosed in [**2135-3-29**]
with an EF 10-15%.
2. Status post CVA times two, last one occurring
approximately three years ago without any residual symptoms.
3. Hyperlipidemia.
4. History of alcohol abuse.
5. Cardiac catheterization on [**2135-4-6**] at outside hospital
showing clean coronary arteries, increased right-sided
pressure with RA pressure of 18, pulmonary capillary wedge
pressure 23-29, cardiac output 2.3 and index 1.37.
6. Hypothyroidism.
7. Anxiety.
8. Gout.
9. Transthoracic echocardiogram on [**2135-4-11**] at [**Hospital1 18**] showed
EF 10-15%, left ventricular hypokinesis, anterior septal
akinesis, small pericardial effusion.
ALLERGIES: The patient has an allergy to Bactrim.
MEDICATIONS ON TRANSFER: (Same as her home medications.)
1. Paxil 25 mg p.o. q.d.
2. Synthroid 88 mg p.o. q.d.
3. Allopurinol 300 mg p.o. q.d.
4. Digoxin 125 p.o. q.d.
5. Lasix 10 p.o. q.d.
6. Toprol XL 25 mg p.o. q.d.
7. Lisinopril p.o. q.d.
8. Coumadin 2.5 mg p.o. q.d.
9. Aspirin.
10. Mevacor 10 mg p.o. q.d.
SOCIAL HISTORY: The patient is a retired secretary, lives
with her husband who is very supportive and involved in her
care. Alcohol: She previously drank greater than five
glasses of wine per day but has had no alcohol since [**2135-3-29**]. She denied any current or remote history of tobacco
use.
FAMILY HISTORY: Mother died of a myocardial infarct at age
57. Maternal uncles all died of myocardial infarct. Her
cousin had idiopathic cardiomyopathy.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs:
Temperature 102.8, blood pressure 97/60 with inspiration
98/58, heart rate 118, respiratory rate 18, oxygen saturation
96% on 2 liters nasal cannula. General: The patient was in
no apparent distress. She was anxious and mildly
dishevelled. HEENT: Poor dentition. The extraocular
muscles were intact. The pupils were equal, round, and
reactive. The oropharynx was clear. Neck: Supple. No
lymphadenopathy. Increased jugular venous pulsation to the
angle of the mandible. Chest: Lungs were clear to
auscultation bilaterally except for decreased breath sounds
at the bilateral bases. Cardiovascular: Tachycardiac but
regular with muffled heart sounds. Abdomen: Soft, diffuse
mild tenderness to palpation. Normoactive bowel sounds.
Extremities: No lower extremity edema. There were no
[**Last Name (un) 1003**] lesions or Osler's nodes appreciated. Neurologic:
She was alert and oriented times three. Cranial nerves II
through XII were intact. Motor was [**5-2**], symmetric upper and
lower extremities.
LABORATORY/RADIOLOGIC DATA: White count 13.1 with normal
differential and no bandemia, hemoglobin 12.3, hematocrit
36.1, MCV 98, platelets 336,000. PT 15.8, PTT 29.5, INR 1.6.
ESR 116. Sodium 133, potassium 4.4, chloride 96, bicarbonate
24, BUN 12, creatinine 1.1, AST 13, ALT 6, LDH 198, alkaline
phosphatase 112, amylase 70, total bilirubin 0.5, total
protein 6.9, albumin 3.1, calcium 9.6, phosphorus 4.1,
magnesium 1.9. TSH 6.5, [**Doctor First Name **] negative, rheumatoid factor
negative. CRP 10.88, significantly elevated. SPEP and UPEP
negative. C3 and C4 levels were both within normal limits.
Digoxin 1.6 and normal. Blood cultures: No growth times
five sets.
EKG on admission showed sinus tachycardia at a rate of 104,
normal axis, normal intervals with nonspecific ST-T wave
abnormalities in V4-V6.
IMPRESSION: This is a 59-year-old female with a history of
nonischemic cardiomyopathy with an EF of [**10-12**]%,
hypertension, history of alcohol abuse who was transferred
from an outside hospital after being admitted for a three day
history of spiking temperatures, chills, and rigors, found to
have a large pericardial effusion. The patient was
transferred to [**Hospital1 18**] for evaluation of pericardial effusion
and possible pericardiocentesis.
HOSPITAL COURSE: 1. PERICARDIAL EFFUSION: Upon transfer
from the outside hospital, the patient was taken directly to
the Cardiac Catheterization Holding Area where she was found
to be hemodynamically stable. A transthoracic echocardiogram
was performed while in the Cardiac Catheterization Holding
Area which was found to show no echocardiographic evidence of
tamponade with anterior portions of pericardial fluid
loculated an echodense. The remainder of the pericardial
fluid is echolucent. The effusion was moderate in size. Her
blood pressure was checked and she was found to have no
evidence of pulsus paradoxus.
As she was stable at that point, the decision was made not to
proceed with pericardiocentesis and monitor the patient with
medical management.
She remained hemodynamically stable for the first three days
of her hospitalization with heart rate ranging from 90s to
low 110s with occasional tachycardia in the 130s to 140s.
Her blood pressure was in the 90-110/40-60 range which was
near her baseline. Her oxygenation remained well at 95% on
room air. On [**2135-5-30**], hospital day number three, she was
taken to the Cardiac Catheterization Laboratory and had a
right heart catheterization performed which showed cardiac
output of 4.5, cardiac index 2.5, PA pressure of 44/27, and
no evidence of equalization of pressures. The pulse was
measured in the Catheterization Laboratory to be 7 mmHg.
Therefore, it was felt that conservative management of the
effusion was appropriate at that time.
The following day, the patient became hypotensive with
systolic blood pressures in the 60s and was started on
dopamine on the floor. After initiation of 5 micrograms per
kilogram per minute of dopamine, her blood pressure increased
to approximately 85-90 and she was transferred to the Cardiac
Care Unit.
While in the CCU, a transthoracic echocardiogram was
performed which showed early unchanged pericardial effusion
which was moderate in size, measuring less than 1 cm inferior
to the left ventricle, 1-1.5 cm lateral to the left
ventricle, less than 0.5 cm around the LV apex and anterior
to the right ventricle and greater than 2 cm anterior to the
right atrium. The asymmetric nature of the effusion again
suggested loculation.
She was weaned off dopamine in the Cardiac Intensive Care
Unit after a Swan-Ganz catheter was placed. The Swan-Ganz
catheter measured her wedge pressure to be 20, RA pressure of
17, and SVR 730 with an elevated cardiac output of 7.4. This
was slightly different from numbers during right heart
catheterization the day before. She was off dopamine
approximately 12 hours of initiation with stable systolic
blood pressures in the 100-120 range.
She was transferred back to the Cardiology Floor in stable
condition on [**2135-6-2**] after a two day stay in the Intensive
Care Unit. On [**2135-6-3**], a CT-guided pericardiocentesis was
performed by Radiology, at which time 15 cc of fluid was
removed. Analysis of this fluid showed a total protein of
5.2 and an LDH of 648. There were 0 red blood cells and
3,100 white blood cells which showed 90% neutrophilic
predominance. Judging by the analysis of the pericardial
fluid, it appeared to be exudative in nature and cytology was
sent. Cytology showed no evidence of malignant cells. AFB
stain was performed on fluid as well as Gram's stain culture,
fungal culture, all were found to be negative.
The etiology of the pericardial effusion still remains
unclear at the time of this dictation. However, it is
suspected to be a viral pericarditis/myocarditis; however,
the [**Location (un) **], Adenovirus, Histoplasmosis serologies were all
pending at the time of this dictation. Her Lyme serology was
negative. A Mycoplasma IgM and IgG were both negative as
well.
On [**2135-6-4**], twenty-four hours after pericardiocentesis, a
repeat transthoracic echocardiogram was performed which
showed resolution of the pericardial effusion with stable EF
of less than 20%. She remained hemodynamically stable after
transfer out of the Cardiac Intensive Care Unit.
2. NONISCHEMIC CARDIOMYOPATHY: As described in the history
of the present illness, the patient was diagnosed with
nonischemic cardiomyopathy in [**2135-3-29**], approximately
two months prior to current admission. She was evaluated for
a cardiac transplant at that point and was found not to need
one at the current time. She has been managed with diuresis
at home and just prior to current admission had been doing
excellent. Cardiac enzymes were cycled during this
hospitalization and were negative times three sets. She had
some chest discomfort during this hospitalization which was
thought secondary to her large effusion rather than ischemia
given her normal coronary arteries per cardiac
catheterization two months prior.
Once hemodynamically stable, she was diuresed with 10 mg p.o.
Lasix with 10 mg IV Lasix p.r.n. For the three days prior to
discharge, she was felt to be volume overloaded and was run
negative with a decrease in her weight of approximately 2
kilograms. At the time of discharge, she was felt to be
mildly volume overloaded but back to her baseline. Her
oxygen saturations were 95% on room air and decreased to
90-91% with ambulation.
3. NSVT: While on the Cardiac Floor, she was seen by
Electrophysiology initially for evaluation for pacemaker
placement who felt that it was not necessary at this time.
They were reconsulted after she had two episodes of NSVT of
15 and 16 beats. She was asymptomatic and denied any
palpitations, lightheadedness or shortness of breath during
these episodes. Her digoxin level, TSH and chemistry panel
were checked following these episodes and were found to be
within normal limits except for mildly elevated TSH given her
hypothyroidism. She was started on Amiodarone 400 mg p.o.
b.i.d. for which she will complete three weeks of therapy and
then switched to 400 mg p.o. q.d. She is being sent out of
the hospital on a Holter monitor given her initiation of
Amiodarone. LFTs were checked prior to initiation of therapy
an were found to be within normal limits. She will follow-up
with Dr. [**Last Name (STitle) **] and possibly Electrophysiology once stable on a
dose of 400 mg q.d. of Amiodarone.
4. INFECTIOUS DISEASE: The patient had spiking temperatures
through the first three to four days of hospitalization to as
high as 102.8. She had blood cultures performed on five
different occasions and were found to all be no growth. A
urine culture was performed when a Foley was placed in the
Intensive Care Unit and was shown to be contaminated. As she
was asymptomatic from a genitourinary point of view, it was
not felt that her urine culture was the source of her spiking
fevers. The Infectious Disease team was consulted while she
was in the Intensive Care Unit given her Swan numbers of
increased cardiac output to 7.3 and a decreased SVR to around
700 for evaluation of infectious etiology of her pericardial
effusion and hemodynamic instability. She was not felt to be
septic and the Infectious Disease Team recommended viral
serologies for evaluation of the pericardial effusion. She
was found to have a negative IgG and IgM for Mycoplasma and a
negative Lyme titer as well. Urine Histoplasma antigen was
checked as well as [**Location (un) **] A and B and Adenovirus which is
pending at the time of this dictation.
As described above, once pericardiocentesis was performed,
pericardial fluid was Gram's stain negative, culture
negative, and AFB negative. Therefore, the leading theory
for the patient's pericardial effusion was from a viral
infection that had not been identified at this time.
With the exception of one fever to 100.0 on [**2135-6-3**], five
days prior to discharge. The patient remained afebrile for
the remainder of the hospitalization.
5. PULMONARY: During evaluation for fever of unknown origin,
she had a CT scan of her torso which showed enlarged right
tracheal lymph node measuring 1.8 by 2.1 cm and multiple
other prominent right paratracheal lymph nodes as well as
multiple subcentimeter prominent lymph nodes in the
perivascular space and the aorticopulmonary window. The
Pulmonary Team was consulted on possible mediastinoscopy and
biopsy of the larger right tracheal lymph node to evaluate
for lymphoma as an etiology of her pericardial effusion. It
was the feeling of the pulmonary team as well as the
congestive heart failure team that the lymph nodes were
secondary to congestive heart failure and a biopsy was not
indicated at this time. She will follow-up with a repeat
chest CT approximately two to three weeks after discharge for
regression of lymph nodes. If they are still present at that
time, she will follow-up with the Pulmonary Team, Dr. [**Last Name (STitle) **],
who will perform mediastinoscopy plus biopsy of lymph nodes.
She was also noted to have bilateral pleural effusions, right
greater than left and given her spiking fevers and unclear
etiology of pericardial effusion she was taken to the
Interventional Pulmonary Laboratory for possible
ultrasound-guided thoracentesis. Under ultrasound
evaluation, she was found to have less than 1 cm of pleural
fluid and, therefore, it was not felt that a thoracentesis
was indicated. She did not have the procedure performed and
it was felt that her effusions would regress with appropriate
diuresis.
7. RHEUMATOLOGY: In evaluation of her pericardial
effusions, an ESR was checked and was found to be 116 and on
repeat was 115. CRP was also checked and found to be
significantly elevated at 10.88. Through workup of systemic
rheumatologic disease as a cause of her effusion, she had [**First Name8 (NamePattern2) **]
[**Doctor First Name **] and RF checked which were both found to be negative.
Compliment levels were checked and also found to be negative.
A CH50 and an ACE level are pending at this time to evaluate
for sarcoidosis.
The Rheumatology Team was consulted and did not feel given
her clinical history and supportive laboratory tests that she
had any evidence of systemic rheumatologic disease.
Her gout remained well controlled on Allopurinol 300 mg q.d.
8. ENDOCRINOLOGY: TSH was checked and found to be elevated
on two separate occasions and, therefore, her Synthroid dose
was increased from 88 micrograms to 100 micrograms q.d. The
increase in her Synthroid dose also showed positive effects
on blood pressure and heart rate.
9. RIGHT SHOULDER PAIN: After pericardiocentesis, the
patient complained of right shoulder pain which was evaluated
by upper extremity ultrasound as this was the location of her
central venous catheter while in the Intensive Care Unit.
This was found to be negative for deep venous thrombosis. A
chest x-ray was performed as well and she had no evidence of
elevated hemidiaphragm, ruling out phrenic nerve injury as
the etiology of the pain. The pain resolved spontaneously
and it was felt that it was most likely positional given her
extended period of lying in a decubitus position while in
Radiology to have the effusion drained.
10. HEMATOLOGY: She was found to have anemia of chronic
disease by iron studies. Her crit remained stable throughout
the hospitalization and she was given 2 units of FFP for an
elevated INR. The increased INR was likely secondary to her
Coumadin which she was taking as an outpatient but was not
continued during the hospitalization. She was not sent out
on Coumadin as her only indication was for
cardiomyopathy/decreased EF and CVA times two. Instead, she
was placed on Aggrenox for CVA prevention and Coumadin will
not be continued.
DISPOSITION: The patient was evaluated by Physical Therapy
the day before discharge. It was found that she was safe for
discharge to home. She had minor desaturation with
ambulation, otherwise, did excellent.
DISCHARGE DIAGNOSIS:
1. Pericardial effusion, status post CT-guided drainage,
etiology unclear, however, suspect viral source.
2. Pleural effusions, likely secondary to congestive heart
failure.
3. History of nonischemic cardiomyopathy with ejection
fraction 10-14%.
4. Mediastinal lymphadenopathy.
5. Nonsustained ventricular tachycardia, recently started on
Amiodarone.
6. Hypotension, status post transient dopamine infusion and
Cardiac Intensive Care Unit admission.
7. Transient febrile illness of unclear etiology.
8. Hyperlipidemia.
9. Hyperthyroidism.
10. History of alcohol abuse.
11. Anxiety.
12. Gout.
DISCHARGE MEDICATIONS:
1. Paxil 20 mg p.o. q.d.
2. Digoxin 0.125 mg p.o. q.d.
3. Synthroid 100 micrograms p.o. q.d.
4. Allopurinol 300 mg p.o. q.d.
5. Lasix 10 mg p.o. q.d.
6. Toprol XL 25 mg p.o. q.a.m.
7. Lisinopril 2.5 mg p.o. q.h.s.
8. Aggrenox one tablet p.o. b.i.d.
9. Amiodarone 400 mg p.o. b.i.d. until [**2135-6-19**] and then 400
mg p.o. q.d. until instructed to change dose by cardiologist.
10. Mevacor 10 mg p.o. q.d.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with primary care physician,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**], in approximately one to two weeks after
discharge.
2. She will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2135-7-5**].
3. She will have a follow-up CT scan in two weeks for which
she will call for a specific appointment time.
4. She is being sent out on the [**Doctor Last Name **] of Hearts Monitor with
instructions provided prior to discharge.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2135-6-8**] 10:39
T: [**2135-6-11**] 11:36
JOB#: [**Job Number 8702**]
ICD9 Codes: 4254, 4280, 5119, 4168, 2449
|
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