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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5300
}
|
Medical Text: Admission Date: [**2206-1-17**] Discharge Date: [**2206-1-20**]
Date of Birth: [**2143-8-20**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin / Nsaids / Iodine / Versed / Ativan / Haldol
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Thoracentesis
Hemodialysis
History of Present Illness:
62 year old male with a history of DM1, ESRD on HD, and
bilateral chylothoraces without clear etiology who was referred
to the ED after his VNA checked his sat at home and found it to
be 84%. Patient was completely asymptomatic.
.
In the ED, CXR showed large L sided effusion. He underwent
left-sided thoracentesis in the ED, with 2.1L were removed. He
was then satting mid 90's on 2L NC. 90 minutes later he was
noted to have persistently low saturations to 70%s on RA and
systolic BP of 210. Responded to 100% on NRB, titrated down to
5L NC with sat of 93%. BP responded to home dose of labetalol.
Repeat CXR showed re-expansion pulmonary edema, and he was
admitted to the ICU for monitoring.
.
In the ICU, he used Bipap overnight. Oxygen requirement
improved to 92% on RA, 95% on 2L. BP has been well controlled
with outpatient antihypertensive regimen. Patient continued to
feel well, and tolerated HD well this AM. On transfer, patient
has no complaints. Denies SOB, CP, HA, cough, abdominal pain, or
diarrhea.
.
ROS: Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia.
Past Medical History:
1. DM I for 45 yrs, complicated by triopathy
2. ESRD on HD T/Th/Sa
3. h/o Tunneled cath infections
4. UGIB [**2-17**] PUD
5. VSE septic shoulder
6. Osteomyelitis
7. Left BKA
8. HTN w/ visual changes and AMS when SBP <150, must run
150-170/80s
9. Gastroparesis
10. Depression
11. Right femoral dorsalis pedis graft - [**2198-3-15**]
12. H/o gangrenous cholecystitis
13. H/O R pleural effusion
14. h/o frequent episodes of delerium while hospitalized and
infected, always negative work-up
15. Non-specific right and left exudative pleural effusion
(?chylothorax) status post right pleuroscopy, pleural biopsy,
pleurodesis and Pleurex catheter placement (removed on [**2205-10-18**]).
No
16. Hx of recurrent C.diff
Social History:
Lives in [**Location 701**] with wife [**Name (NI) **] [**Name (NI) 10653**] (Home:
[**Telephone/Fax (1) 22469**], cell: [**Telephone/Fax (1) 22470**]). No EtOH. Former remote
smoker. Used to work in retail 14 yrs ago.
Family History:
Noncontributory.
Physical Exam:
T: 97.6 BP: 120/57 HR: 75 RR: 18 02 sat: 95% on 2L
GENERAL: middle aged male, no respiratory distress
HEENT: NC/AT MMM
CARDIAC: RRR no m/r/g. HD tunneled cath R chest
LUNG: inspiratory crackles on L anteriorly and posteriorly, with
decreased BS at both bases. Expiratory wheezes on R side.
ABDOMEN: S/NT/ND + BS
EXT: L BKA. WWP, no c/c/e
NEURO: non-focal
.
Pertinent Results:
[**1-18**] CXR: IMPRESSION: Persistent and increased left effusion with
increased compressive atelectasis.
[**1-19**] CXR: IMPRESSION: Allowing for differences in projection, no
probable change in size of left effusion.
[**1-20**] CXR:
Consolidation in the left lung, now largely restricted to
lingula and medial lung base continues to clear. The earlier
component of upper lobe
consolidation on [**1-18**] was probably asymmetric pulmonary
edema. The
components in the lower lungs could be pneumonia or resolving
hemorrhage.
Interstitial pulmonary edema is new, and a small right pleural
effusion has increased slightly. Heart is partially obscured but
size is probably top normal unchanged. Dual channel right
supraclavicular central venous line ends in the right atrium, as
before. No pneumothorax.
1/2 Blood cultures x2 pending
[**1-17**] pleural cx: 2+ PMNs
[**1-19**] Blood cultures x2 pending
[**1-19**] C diff negative
[**2206-1-17**] 12:15PM BLOOD WBC-7.4 RBC-3.86* Hgb-11.4* Hct-35.0*
MCV-91 MCH-29.5 MCHC-32.6 RDW-14.8 Plt Ct-313
[**2206-1-19**] 08:20AM BLOOD WBC-6.1 RBC-3.67* Hgb-11.1* Hct-33.7*
MCV-92 MCH-30.2 MCHC-32.8 RDW-14.6 Plt Ct-248
[**2206-1-17**] 12:15PM BLOOD Neuts-81.8* Lymphs-7.2* Monos-5.1
Eos-4.3* Baso-1.5
[**2206-1-17**] 12:15PM BLOOD Glucose-315* UreaN-31* Creat-5.1* Na-141
K-4.1 Cl-95* HCO3-33* AnGap-17
[**2206-1-19**] 08:20AM BLOOD Glucose-107* UreaN-16 Creat-3.9*# Na-147*
K-4.4 Cl-108 HCO3-30 AnGap-13
Brief Hospital Course:
62M with history of nonspecific exudative pleural effusions,
called out from MICU [**2205-1-17**] with hypoxia and re-expansion
pulmonary edema after thoracentesis.
.
1. Hypoxia: Secondary to chronic accumulation of pleural
effusion with subsequent re-expansion pulmonary edema. Patient
has infiltrates on LLL. Per IP, expect to resolve within 72
hours. No antibiotics were started, given that patient was
afebrile, without a leukocytosis. Pleural studies were
consistent with an exudate. Pleural culture were unremarkable
on discharge, though not finailized. Patient at high risk of C
diff given prior history. He was kept on supplemental oxygen to
keep saturations above 92%. Serial chest x-rays showed
pulmonary edema, with improving infiltrates. Interventional
pulmonology evaluated the patient daily, and recommended
ultrafiltration. They will see him as an outpatient in [**2-18**]
weeks.
-Please follow up final pleural fluid culture and gram stain.
.
2. End stage renal disease on Hemodialysis: Patient was
evaluated by Nephrology daily as an inpatient. He received
ultrafiltration, and was continued on outpatient regimen of
nephrocaps and phoslo.
.
3. History of C. diff: Patient at high risk for recurrent C.
diff. Had 2 episodes of diarrhea as an inpatient, that were not
foul smelling. Stool C diff negative x1.
.
4. Type 1 diabetes: Complicated by retinopathy, nephropathy, and
neuropathy. Patient has a history of labile blood sugars.
Patient was continued on outpatient regimen of NPH and sliding
scale insulin only for sugars > 300.
.
5. Hypertension: History of labile blood pressures. Per medical
record, patient has visual changes and altered mental status
when SBP < 150. History of labile BPs. SBP of 210 in ED.
Overnight BPS from (119-219)/(55-90). He was continued on
outpatient regimen of Nifedipine, Minoxidil, Labetalol, and
Lisinopril, with goal SBP 150-170s.
.
Medications on Admission:
# Labetalol 200 mg PO daily
# Minoxidil 2.5 mg PO DAILY
# Nifedipine SR 60 mg PO DAILY
# Sertraline 150 mg PO DAILY
# Lisinopril 80 mg PO DAILY
# PhosLo 3 caps po tid with meals
# nephrocaps 1 cap daily
# insulin NPH 8 units in the AM, 4 units at bedtime
# vancomycin 250mg po started today when decided to come to
hospital
# Florastor 250 mg PO BID as needed for replacement of
intestinal flora.
Discharge Medications:
1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed.
5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
10. Saccharomyces boulardii 250 mg Capsule Sig: One (1) Capsule
PO bid ().
11. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: as directed units Subcutaneous see below: 8 units in AM, 4
units in PM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary diagnosis:
1. Left sided pleural effusion
2. Reexpansion pulmonary edema
3. Hypertension
4. Type 1 Diabetes Mellitus
Secondary diagnosis:
End stage renal disease on hemodialysis
Discharge Condition:
Hemodynamically stable. Hypertensive. Stable Left sided pleural
effusion.
Discharge Instructions:
You were admitted with a pleural effusion. This was drained, but
you developed pulmonary edema thereafter. Interventional
pulmonology evaluated and recommended ultrafiltration to remove
some of the fluid. You were kept on supplemental oxygen, but no
longer required this prior to discharge. Nephrology evaluated
you and you received dialysis. Your blood pressure was poorly
controlled. We continued you on your home regimen of blood
pressure medications.
We did not change any of your medications.
If you have shortness of breath, cough, fevers, chills, chest
pain, or any other symptoms that concern you, please call your
primary care doctor or go to the emergency room.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on [**1-31**] at 10am.
The clinic phone number is [**Telephone/Fax (1) 17398**] or [**Telephone/Fax (1) 22635**].
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2206-1-31**] 10:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2206-1-31**]
11:00
Completed by:[**2206-1-21**]
ICD9 Codes: 5119, 5856, 5180, 3572, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5301
}
|
Medical Text: Admission Date: [**2132-10-8**] Discharge Date: [**2132-10-13**]
Date of Birth: [**2065-10-27**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 67-year-old gentleman
with aortic insufficiency and left main coronary artery
disease. He presented with increasing fatigue and shortness
of breath. On [**10-1**], he underwent a cardiac catheterization
which showed a 60% left main stenosis and 3+ to 4+ aortic
insufficiency. The catheterization was complicated by a
groin hematoma. The decision was made that the patient
should undergo an aortic valve replacement, as well as a
coronary artery bypass graft.
BRIEF HOSPITAL COURSE: The patient was admitted on [**2132-10-8**] and underwent an uncomplicated aortic valve
replacement with a 25 mm Bovine pericardial valve, as well as
a coronary artery bypass grafting x2 with the left internal
mammary artery to the diagonal branch and the saphenous vein
graft to distal left anterior descending artery. The patient
tolerated the procedure well and was transferred to the CSRU
being atrially paced. The patient continued to do well
overnight, remaining hemodynamically stable and being
subsequently extubated that evening.
On postoperative day #1, his Neo-Synephrine was weaned and he
was started on Lopressor 25 b.i.d. as well as aspirin. His
diet was advanced. He began a Lasix diuresis and his central
venous line and peripheral artery lines were discontinued.
The patient was subsequently transferred to the floor in
stable condition where upon arrival his chest tubes were
removed.
On postoperative day #2, the patient remained pain free. He
was noted to have several episodes of rapid atrial
fibrillation with a heart rate above 150 beats per minute
with a spontaneous conversion back into sinus rhythm. The
patient was subsequently loaded on intravenous amiodarone.
On postoperative day #3, the patient remained hemodynamically
stable, however his activity level was only graded at level
3. He continued to have brief episodes of rapid atrial
fibrillation.
On postoperative day #4, he had spiked a fever to 101.6??????
overnight. Due to the presence of a bioprosthetic valve, it
was decided to send off urinalysis cultures and sputum which
all subsequently returned negative results. His amiodarone
drip was discontinued and he was converted to p.o., as well
as continuing his Lopressor. Physical therapy determined his
activity level to be a level 5 and so they signed off of the
case.
On hospital day #5, the patient had remained afebrile. His
lungs were clear. He was ambulating well, tolerating a full
diet and was requesting to be discharged to home. The
patient was subsequently discharged home in stable condition.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. x1 week
3. Potassium chloride 20 mg p.o. b.i.d. x1 week
4. Zantac 150 mg p.o. b.i.d.
5. ASA 81 mg q.d.
6. Amiodarone 400 mg t.i.d. x4 days, then 400 mg b.i.d. x7
days, then 400 mg q.d. x30 days
7. Percocet 1 to 2 tablets p.o. q 3 to 4 hours prn pain
8. Colace 100 mg p.o. b.i.d.
The patient was discharged home on [**10-13**] in stable
condition.
DISCHARGE DIAGNOSES:
1. Aortic insufficiency
2. Coronary artery disease
3. Congestive heart failure
4. Status post coronary artery bypass graft x2 with an
aortic valve replacement
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2132-10-13**] 11:51
T: [**2132-10-15**] 10:31
JOB#: [**Job Number **]
ICD9 Codes: 4241, 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5302
}
|
Medical Text: Admission Date: [**2165-6-14**] Discharge Date: [**2165-6-19**]
Date of Birth: [**2087-6-7**] Sex: F
Service: MEDICINE
Allergies:
Rapamune / Ativan
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Hypoxia, hypertensive urgency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 year old female with a PMH of PKD s/p DDRT in [**2155**], s/p
bilateral native nephrectomy, polycystic liver disease s/p liver
reduction, recent abdominal rectopexy for irreducible rectal
prolapse [**3-/2165**] and recent admission [**Date range (3) 106652**] for
pneumonia/CHF exacerbation requiring noninvasive positive
pressure ventilation, treated with levofloxacin represents with
worsening shortness of breath x 2 days. She reports worsening
swelling of her legs, orthopnea, and paroxysmal nocturnal
dyspnea. She reports chills, fatigue, and nonproductive cough;
denies fevers, chest pain. She also reports "abdominal
tightness" across her upper abdomen over this timeframe,
nonradiating, with occasional associated nausea, but denies
vomiting, diarrhea. She is passing flatus with last bowel
movement two days prior; denies melena/BRBPR. She denies any
difficulty urinating and reports taking furosemide 20 mg daily
at home. She denies any difficulty taking her immunosuppressive
medications. She reports that her blood pressures have been high
in the morning, but that she has taken all her blood pressure
medications. She denies dietary indiscretions. Denies sick
contacts. [**Name (NI) **] believes dry weight is 135 lb.
.
In the ED, VS: T: 98.9 BP: 173/65 -> 224/90 HR: 68 RR: 18 SaO2:
98% -> 83% RA. Patient complained of abdominal pain.
- Laboratories significant for BNP [**Numeric Identifier 106653**]
- Placed on [**Numeric Identifier 597**]
- Started on nitroglycerin gtt
- Given furosemide 100 mg IV -> 1100 cc UOP
- Given ceftriaxone 1 gm IV and azithromycin 500 mg IV
- Chest x-ray - multifocal PNA, worse from previous
- CT abdomen - report below
.
On arrival to the ICU, the patient states her SOB is improved.
She denies CP, cough. She states her abdominal pain is also
improved. Mild headache after initiation of nitroglycerin gtt.
Past Medical History:
1. Polycystic kidney disease, status post cadaveric renal
transplant in [**2155**], status post bilateral nephrectomy [**2148**], [**2152**]
2. Polycystic liver disease status post liver resection - left
hepatic trisegmentectomy and right lobe cyst reduction [**2157**]
3. Recurrent partial small bowel obstruction
4. Status post cholecystectomy
5. Status post appendectomy
6. Parathyroid adenoma status post excision of [**2158**]
7. Hypertension
8. Breast cancer status post left radical mastectomy [**2151**]
9. History of right elbow and humeral fracture
10. History of incarcerated hernias although per history
"reduced" nonsurgically in the past
11. Spinal stenosis
12. Irreducible rectal prolapse status post abdominal rectopexy
[**2165-3-27**]
13. Depression
14. Grade II diastolic dysfunction
Social History:
Lives with husband who recently fractured his hip, has two
children who live locally. Denies ever using tobacco. No alcohol
in years.
Family History:
Polycystic kidney disease.
Physical Exam:
VS: T: 96.9 BP: 190/93 HR: 60 RR: 15 SaO2: 100% [**Month/Day/Year 597**] -> 96% 2L NC
Weight: 60 kg
GEN: NAD, speaking full sentences
HEENT: NCAT, PERRLA, [**Last Name (LF) 3899**], [**First Name3 (LF) **] ED retinal vessel narrowing, no
papilledema, no conjuctival injection, anicteric, OP clear, MMM
NECK: Supple, no LAD, R EJ in place, unable to assess JVP
CV: RRR, nl s1, s2, 2/6 systolic murmur noted previously
PULM: Coarse BS bilaterally, egophony at bases bilaterally, dull
to percussion at the bases
ABD: NABS, soft, distended, hepatomegaly on the right, nontender
RLQ transplanted kidney
EXT: Venous stasis changes, R > L edema (discrepancy is
baseline), R forearm AV fistula with palpable thrill
NEURO: Alert & oriented x3, CN II-XII grossly intact, moving all
extremities well
Pertinent Results:
Labwork on admission:
[**2165-6-14**] 12:10PM WBC-8.9# RBC-3.99*# HGB-11.7*# HCT-37.7#
MCV-95 MCH-29.4 MCHC-31.1 RDW-16.2*
[**2165-6-14**] 12:10PM PLT COUNT-148*
[**2165-6-14**] 12:10PM NEUTS-89.3* LYMPHS-7.5* MONOS-2.4 EOS-0.5
BASOS-0.2
[**2165-6-14**] 12:10PM PT-14.7* PTT-29.7 INR(PT)-1.3*
[**2165-6-14**] 12:10PM GLUCOSE-89 UREA N-51* CREAT-2.0* SODIUM-140
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-20
[**2165-6-14**] 12:10PM ALT(SGPT)-32 AST(SGOT)-48* CK(CPK)-37 ALK
PHOS-184* TOT BILI-1.0
[**2165-6-14**] 12:10PM CK-MB-NotDone proBNP-[**Numeric Identifier 106653**]*
[**2165-6-14**] 12:10PM cTropnT-0.07*
[**2165-6-14**] 12:39PM LACTATE-1.8 K+-4.7
.
CHEST (PORTABLE AP) Study Date of [**2165-6-14**]
IMPRESSION:
Worsening multifocal pneumonia. Poorly defined lucency in the
retrocardiac region. Further evaluation with a lateral
radiograph or chest CT is recommended.
.
CT CHEST W/O CONTRAST Study Date of [**2165-6-14**]
IMPRESSION:
1. Significant improvement to multifocal pneumonia; however, a
more solid component medially adjacent to a slightly enlarged
right paratracheal node appears slightly progressed from prior
exam. Given the patient's history, a repeat CT examination in
approximately three months is recommended to exclude an
underlying lesion within this area after the pneumonia has been
appropriately treated.
2. Unchanged moderate right and small left pleural effusion.
Slightly
increased adjacent compression atelectasis involving the lower
lobes.
3. Mild atherosclerotic disease within the coronary circulation
and
intrathoracic aorta.
4. Partially visualized known multicystic liver disease and
abdominal
ascites.
.
CT ABDOMEN W/O CONTRAST Study Date of [**2165-6-14**]
Preliminary Report
IMPRESSION:
1. Bilateral pleural effusions and basilar atelectasis. Moderate
ascites, slightly larger than prior study.
2. Multiple low-attenuation liver and pancreatic lesions
consistent with patient's known history of autosomal polycystic
disease.
2. Status post nephrectomy. Transplanted kidney in the right
iliac fossa is unremarkable
3. Diverticulosis, without obvious diverticulitis, limited
evaluation in the absence of contrast.
4. Periampullary duodenal diverticulum is noted.
.
TTE [**2165-5-23**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2165-3-26**],
left ventricular diastolic function has worsened. The amounts of
mitral regurgitation, tricuspid regurgitation, and estimated
pumonary artery systolic pressure have increased.
ECHO [**2165-6-19**]:
The left atrium is mildly dilated. 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%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
77 year old with a PMH PKD s/p DDRT in [**2155**], s/p bilateral
native nephrectomy, polycystic liver disease s/p liver
reduction, recent admission [**Date range (3) 106652**] for pneumonia/CHF
exacerbation p/w hypoxia.
# Hypoxia/hypertensive urgency: The patient was admitted with
hypoxia, likely secondary to her hypertensive urgency. She
improved after diuresis - consistent with an episode of acute on
chronic diastolic CHF. Her BNP was elevated to 51,462, from
previous value of 49,966 with last CHF exacerbation. She was
ruled out for myocardial infarction. She did not appear
infected and was not re-treated for pneumonia. Her blood
pressure medications were titrated for a goal SBP of 140-160.
She was started on Irbesartan, with good results after
discontinuation of the nitro gtt. Her kidneys tolerated the [**Last Name (un) **]
without elevation from her baseline creatinine and her
electrolytes remained stable. She was also restarted on Lasix
40 mg daily with good urine output and stable kidney function.
The patient resumed her home medications including diltiazem and
atenolol at discharge.
# Abdominal pain: The patient had mild abdominal pain which
improved prior to her being admitted to the floor. LFTs,
amylase/lipase and CT abdomen were all unrevealing for a source.
On her prior admission, the patient was noted to have a dilated
common bile duct, with normal abdominal labs, which should also
be followed up as an outpatient.
# Pulmonary hypertension: This was noted on TTE [**4-/2165**] and is
most likely secondary to diastolic dysfunction/CHF. A repeat
ECHO demonstrated moderate pulmonary hypertension. The patient
will follow this up as an outpatient.
# Resolving pneumonia: The patient should have a repeat CT scan
in 6 to 8 weeks to ensure resolution of her pneumonia.
# PCKD s/p DRRT: The patient was continued on her
immunosuppression with prednisone and CellCept. Her creatinine
remained at baseline. She also received two doses of IV iron to
complete an eight dose regimen.
# Depression/body pain: The patient was continued on her home
regimen of sertraline, Neurontin and tramadol.
Medications on Admission:
1. Sertraline 50 mg DAILY
2. Tramadol SR 300 mg DAILY
3. Gabapentin 100 mg TID
4. Epoetin Alfa 4,000 unit/mL QMOWEFR
5. Diltiazem HCl 240 mg DAILY
6. Mycophenolate Mofetil 500 mg [**Hospital1 **]
7. Atenolol 50-75 mg DAILY (patient states she takes this on a
sliding scale, 50 mg if BP normal, 75 mg if high)
8. Bisacodyl 10 mg DAILY
9. Senna 8.6 mg [**Hospital1 **]
10. Lasix 20 mg DAILY
11. Prednisone 6 mg DAILY
12. Clonazepam 0.5 mg DAILY
13. Ambien 5 mg DAILY
14. Cholecalciferol 400 units DAILY
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please take a total of 6 mg daily.
3. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please take a total of 6 mg daily.
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for pain.
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*0*
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Cartia XT 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
16. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Hypertensive urgency
Acute on chronic diastolic heart failure
Secondary:
Polycystic Kidney Disease s/p transplant
Polycystic Liver Disease
Anemia
Spinal stenosis
Discharge Condition:
Stable with improved blood pressure control.
Discharge Instructions:
You were admitted to the hospital with elevated blood pressure
and shortness of breath. While you were in the hospital, your
blood pressure medications were changed. You were started on a
new medication, irbesartan. Please take this medication as
prescribed. Please take atenolol 75 mg daily as well. Please
take Lasix 40 mg daily.
Please call your doctor or come the emergency room with any
increasing shortness of breath, chest pain or any other symptoms
you find concerning.
Followup Instructions:
Please follow up at the following appointment:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2165-6-25**] 2:00
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 4280, 2859, 2875
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5303
}
|
Medical Text: Admission Date: [**2122-5-17**] Discharge Date: [**2122-5-21**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 yo WF with CHF, IPF, CAD, COPD who presents with increasing
dyspnea and dropping O2 sats. Pt. lives at [**Hospital 100**] Rehab which
reports that pt has been increasingly short of breath. She also
has a nonproductive cough that has been gradually worsening.
Denies CP, N/V, F/C. Pt has indwelling catheter but denies
pelvic pain. Her daughter states she has only one kidney. She
reports no MS changes. Pt had chinese food for dinner last night
and has not been watching salt intake. CXR terrible with fluffy
infiltrates. U/A shows UTI. O2 sats were 99% on 4L in ED. After
being transferred to floor pt began to become tachycardic with
HR=150's. O2 sats began to drop and pt required face mask to
keep sats up. ABG was 7.27/48/167/23.
Past Medical History:
CHF (EF 55% 12/03)
CAD
IPF
COPD
CRI
Freq UTI
urinary incontinence
hypercholesterolemia
depression
Social History:
Widowed for 30 years. 4 children. Smoked for many years but quit
"a long time ago"
Family History:
CVA's
Physical Exam:
In ED:
T: 97.9 HR 73 BP 106/53 RR: 28 O2 sat: 93%4L
Gen: breathing heavily but in NAD
HEENT: PERRL
Neck: no masses, no bruits, could not appreciate JVP.
CV: difficult to auscultate, regular rate, ?S3/S4
Abd: obese, S/NT/
Lungs: rales, crackles, [**Month (only) **] BS mid-bases bilaterally
Ext: 1+ B LE edema
Neuro: A&Ox3. Strength 5/5 throughout.
Pertinent Results:
[**2122-5-17**] 03:42PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2122-5-17**] 03:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2122-5-17**] 03:42PM URINE RBC-0-2 WBC-[**1-23**] BACTERIA-MANY YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2122-5-17**] 03:42PM URINE HYALINE-[**1-23**]*
[**2122-5-17**] 03:22PM GLUCOSE-228* UREA N-60* CREAT-2.6* SODIUM-139
POTASSIUM-5.5* CHLORIDE-105 TOTAL CO2-21* ANION GAP-19
[**2122-5-17**] 03:22PM CK(CPK)-55
[**2122-5-17**] 03:22PM CK-MB-NotDone cTropnT-0.05*
[**2122-5-17**] 03:22PM WBC-19.2* RBC-4.25 HGB-10.6* HCT-37.1 MCV-87
MCH-24.9* MCHC-28.5* RDW-17.4*
[**2122-5-17**] 03:22PM NEUTS-87* BANDS-6* LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-1*
[**2122-5-17**] 03:22PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+
OVALOCYT-1+
[**2122-5-17**] 03:22PM PLT COUNT-342
[**2122-5-17**] 03:22PM PT-12.6 PTT-27.3 INR(PT)-1.0
Brief Hospital Course:
The patient was admitted [**2122-5-17**] with increasing dyspnea and
decreased oxygen saturation with a worsening nonproductive
cough. The respiratory symptoms were thought be secondary to CHF
and COPD exacerbations with possible pneumonia. She was started
on ceftrixone & vancomycin for consideration of nosocomia
pneumonia and given supplemental oxygen.
On HD2 she became increasingly dyspneic and tachycardic. She was
given Lasix and her steroid dose was increased to 40mg. Her
rapid afib was controlled with parenteral diltiazem, and then
with digoxin.
On HD3 a family meeting was held to discuss the prognosis and
goals of care. It was decided to provide comfort measures and
keep them informed of her progression. Over the course of HD 4
the patient had increased work of breathing and falling urine
output. Housestaff was called to the bedside on 7/0/04 when the
patient was noted to be apneic and pulseless. She was pronounced
dead and the family was notified.
Medications on Admission:
Cardizem 180 qd
Lasix 20 qd
MVI
Prednisone 10 qd
Advair [**Hospital1 **]
Zocor 20 qd
Glyburide 2.5
Atrovent nebs q8
Ativan prn
Humibid DM
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
hypoxic respiratory failure
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
ICD9 Codes: 5070, 5845, 5990, 2767, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5304
}
|
Medical Text: Admission Date: [**2115-11-4**] Discharge Date: [**2115-11-10**]
Date of Birth: [**2086-6-26**] Sex: M
Service: MICU-ORANG
CHIEF COMPLAINT: The patient was transferred from outside
hospital for continued fevers, jaundice, pancytopenia and
splenomegaly.
HISTORY OF PRESENT ILLNESS: This is a 29 year old male with
a recent prolonged admission at [**Hospital3 35813**] Center in
[**Doctor Last Name 792**]with pancytopenia, fevers, liver failure, who
was discharged to home for approximately one day and returned
with persistent fevers, hypotension and poor urine output.
The patient was initially admitted to [**Hospital3 45967**] on
[**10-10**] with fevers, question suicidal ideation, stated heard
voices telling him to shoot himself. He was found to be
pancytopenic with splenomegaly.
At the outside hospital, the patient had extensive Infectious
Disease work-up because of persistent high fever, including
blood cultures which remained negative including fungal
cultures, a liver biopsy that showed a granulomatous
hepatitis, bone marrow biopsy that showed increasing
eosinophils, flow cytometry on the bone marrow biopsy showed
no acute leukemia or lymphoma. A CT scan of the abdomen
showed splenomegaly, hepatomegaly, prominent mediastinal
lymph nodes and a gallium scan that was negative. [**Doctor First Name **]/ASNA
were negative. An ACE showed to be elevated at 115.
The patient had no monoclonal gammopathy, and the EEG that
the patient had was negative. Pancytopenia was thought to be
due secondary to splenomegaly. The patient was started on
Prednisone 20 mg three times a day for a question of sarcoid
and defervesced given the granulomatous infiltrate in the
liver that was noted.
The patient had a total of ten units of platelets, two units
of packed red blood cells and two units of fresh frozen
plasma during that admission and the patient was discharged
on [**11-1**], but re-presented on [**11-2**] with increasing shortness
of breath and fever to 104.0 F.
At the outside hospital, the patient was started on Zosyn,
Diflucan, and Vancomycin for empiric treatment and the
patient also had significant hypotension and dopamine was
started prior to the transfer of the patient to the [**Hospital1 1444**] for further work-up.
On arrival to the [**Hospital1 69**] and
transfer to the Medical Intensive Care Unit, the patient was
hypotensive and immediately continued on the dopamine drip
and continued to be febrile. The patient also had a
worsening acidosis with an arterial blood gases of 7.30, pCO2
of 29, pO2 of 90, and an elevation of lactate to 3.0, and
given the worsening acidosis and patient's tachypneic
appearance, the patient was subsequently intubated for
compensation of his acidosis.
PAST MEDICAL HISTORY:
1. Pancytopenia.
2. Splenomegaly.
3. Granulomatous hepatitis.
4. Mild mitral regurgitation.
5. Depression.
6. Question history of alcohol use.
7. Question history of seizure disorder.
ALLERGIES: Question Prozac.
HOME MEDICATIONS:
1. Prednisone 20 three times a day.
2. Protonix 40 q. day.
3. Zyprexa 15 q. day.
4. Paxil 30 q. day.
5. Lexapro 10 q. day.
PHYSICAL EXAMINATION: Vital signs with heart rate of 124;
blood pressure 94/42; respiratory rate of 30; oxygen
saturation 93% on four liters nasal cannula and a weight of
91 kilograms. In general, the patient was jaundiced,
oriented to person and place. HEENT: The sclerae
bilaterally were icteric. Pupils are equal, round and
reactive to light. The patient had dried blood in the
oropharynx and around the nares. Neck was supple, without
rigidity, and with increased jugular venous distention, no
lymphadenopathy. Lungs with decreased breath sounds at the
bases; tachypnea, no stridor. Cardiovascular with regular rhythm,
tachycardia, no murmurs, rubs or gallops. Abdomen distended,
diffusely tender, no bowel sounds, positive hepatosplenomegaly.
Skin with no rashes. Extremities with two plus pitting edema,
two plus pedal pulses. Neurological: Moving all extremities
well. Cranial nerves II through XII intact. Five out of five in
upper and lower extremities strength bilaterally. No
asterixis, no pronator drift. Sensation intact bilaterally.
LABORATORY: Pertinent for a hematocrit of 26.9, white blood
cell count of 3.4, platelets of 36, INR of 1.6, fibrinogen
400, total bilirubin 15.7, albumin at 2.5, calcium of 6.6,
lactate of 3.0. Arterial blood gases 7.30, 29, and 90.
ALT 84, AST 140, alkaline phosphatase 192, lipase 18, amylase
19, bicarbonate 15. Potassium was 4.6, creatinine of 3.9,
BUN 86.
Urinalysis with 1.025, large blood, positive nitrites,
positive glucose, 100 protein, trace ketones, large
bilirubin, trace leukocyte esterase, 11 to 20 red blood
cells, 3 to 5 white blood cells.
HOSPITAL COURSE:
1. METABOLIC ACIDOSIS: The patient initially presented with
an anion gap metabolic acidosis. Unclear whether this
patient was hypoperfusing versus renal failure or liver
involvement or tumor lysis. The patient was initially
ventilated and was unable to correct despite maximum
ventilatory support. The patient was started on a sodium
bicarbonate drip on hospital day two for a bicarbonate of 9.
The bicarbonate drip was continued and the Renal Team was
consulted for further management of this patient.
The patient has been subsequently started on CVVH, with
bicarbonate exchange on hospital day three. With improvement
of his metabolic acidosis and maximal ventilatory support,
abdominal CT scan on hospital day three showed no
splenomegaly, no perforations or free air.
2. PANCYTOPENIA: Unclear etiology, thought to be likely due
to secondary splenomegaly and splenic sequestration versus an
infectious or hematology process, question Ehrlichia. Also,
component of DIC with elevation of his coagulations and low
fibrinogen. The patient was transfused with blood products
to support a hematocrit greater than 30 and INR less than
1.5, and platelets greater than 50 given his continued
bleeding during this hospital stay.
We are currently in the process of obtaining a bone marrow
biopsy from the outside hospital which is now at the
[**Hospital6 1129**] being examined by their
pathologists.
3. RESPIRATORY FAILURE: The patient was maximally vented
for supportive acidosis give poor respiratory compensation.
The patient appeared hypoxic secondary to volume overload and
possible pneumonia process at the right apex by CT scan.
4. FEVER AND SEPSIS: Etiology is still unclear. The
patient initially during the first two hospital days,
required pressor support with Levophed and was able to wean
with improvement of his hemodynamics. Elaborate work-up is
currently pending and the patient was initiated on broad
spectrum antibiotics with Vancomycin, Meropenem, doxycycline,
Levaquin, and Caspofungin for empirical broad coverage.
5. INFECTIOUS DISEASE: The Infectious Disease consultation
team assistance was requested in the management of this
patient and the patient had an elaborate work-up including
multiple serologies for CMV, EBV, as well as numerous
Zoonotic diseases that are currently pending at this time.
Cultures and serologies are negative to the date of this
dictation on [**2115-11-10**].
Hematology/Oncology was also consulted in the management of
this patient and there was initial consideration of
disseminated sarcoid and the patient was initially placed on
a maximum dose of steroids on hospital day one and two
without significant improvement of his clinical symptoms and
it was thus thought that this was less likely to be sarcoid
and the corticosteroids were decreased.
The Hepatology Team was also consulted regarding the
granulomatous process. Biopsies of the liver were sent to
[**Hospital6 1129**] pathology for further work-up
and with communication with these pathologists, it was
thought that this was not a primary liver process, but a
disseminated process.
At this time, bone marrow biopsy shows that this infiltrate
might be consistent with more a lymphoma, and the patient's
clinical course explained by question tumor lysis syndrome
given his elevation of uric acid. The liver team is
attempting to obtain liver biopsy slice from the outside
hospital. The patient is currently being maintained with
maximum support of his hemodynamics.
Empirical treatment of tumor lysis with allopurinol was
initiated.
6. HYPERBILIRUBINEMIA/HEPATITIS: Liver biopsy with
inflammatory cell infiltrate and granulomas, not suggestive
of tuberculosis or sarcoid by report but per [**Hospital6 2121**] pathologist, differential diagnosis includes
most likely Hodgkin's lymphoma versus leptospirosis versus
other Infectious Disease process. Abdominal ultrasound was
negative. The patient had an abdominal CT scan that was also
unrevealing for any primary process.
The patient got high dose steroids times two days without
improvement and decreased distress dose only.
7. HYPOCALCEMIA: The patient upon initiation of CVVH, had a
significant drop in his calcium, and a calcium drip was initiated
during this administration for improvement. The patient, upon
initiation of CVVH with citrate exchange on hospital day three,
precipitated severe tetany, hypotension, for which a calcium drip
was started. The patient's calcium was repleted with a drip as
well as total parenteral nutrition with improvement of his
calcium on the day of this dictation.
8. COAGULOPATHY: The patient had low platelets and abnormal
coagulations, attributed to DIC. The patient continued to bleed
from the nose and we were transfusing platelets and fresh frozen
plasma. ENT was consulted for epistaxis and recommended
supportive care only.
9. ACUTE RENAL FAILURE: The patient was essentially anuric
during this hospital course, likely attributed to acute
tubular necrosis, ATN. The patient was getting hemodialysis
with bicarbonate exchange as well as calcium drip.
10. PERICARDIAL EFFUSION: The patient had an echocardiogram
initially with mild to moderate pericardial effusion noted.
A repeat echocardiogram showed improvement of the fluid as
well; however, in the setting of decreased calcium, the
patient also was noted to have on the repeat echocardiogram
an ejection fraction of 30%. A follow-up echocardiogram will
be needed to reassess.
The patient was started on total parenteral nutrition on
hospital day four with calcium supplementation. The patient was
maintained on CVVH.
CODE STATUS: The patient was on full code.
COMMUNICATION: The patient's mother and father were updated
on a regular basis and have been involved with the care of
this patient. Social Work was consulted regarding family
coping.
DISPOSITION: To be determined by the next dictation by the
incoming intern taking care of this patient in the Medical
Intensive Care Unit.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 5227**]
MEDQUIST36
D: [**2115-11-10**] 14:05
T: [**2115-11-10**] 17:51
JOB#: [**Job Number 50725**]
ICD9 Codes: 4589, 5845, 0389
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5305
}
|
Medical Text: Admission Date: [**2102-12-22**] Discharge Date: [**2103-2-14**]
Date of Birth: [**2102-12-22**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS:
[**Known lastname 60252**] [**Known lastname 60253**] was born at 30 2/7 weeks gestation to a 40 year
old gravida 3, para 2, now 3 woman. Her prenatal screens are
blood type A positive, antibody negative, Rubella immune, RPR
nonreactive, hepatitis surface antigen negative and Group B
Streptococcus unknown. The pregnancy was complicated by
pregnancy-induced hypertension for three weeks prior to
delivery treated with Labetalol, and also complicated by
absent diastolic flow and oligohydramnios, and decreased
fetal growth. The delivery was by cesarean section for
persistent pregnancy-induced hypertension and breech
presentation. The mother received a complete course of
betamethasone on [**2102-12-4**]. The infant emerged with
spontaneous respirations. Apgars were 7 at one minute and 9
at five minutes.
PHYSICAL EXAMINATION: The birth weight was 1,090 gm. The
birth length was 37 cm. The birth head circumference was 27
cm.
The admission physical examination reveals an active preterm
infant. Anterior fontanelle soft and flat. Positive
bilateral red reflex. Lungs clear and equal. Mild subcostal
retractions. Heart was regular rate and rhythm, no murmur,
well perfused. Abdomen was soft, nontender and nondistended.
Small sacral dimple. Mild bruising over the region of the
ischial crest. Patent anus. Stable hip examination.
HOSPITAL COURSE: Respiratory status - She required
nasopharyngeal continuous positive airway pressure for the
first 24 hours of life and then weaned to room air where she
has remained. She was treated with caffeine citrate for
apnea of prematurity from day of life Number 2, until day of
life Number 28. Her last episode of apnea of prematurity
occurred on [**2103-1-30**]. On examination she has
intermittent mild subcostal retractions and an intermittent upper
airway congestion. Her lung bases are clear and equal and her
respiratory rate is 30 to 50 breaths per minute.
Cardiovascular status - [**Known lastname 60252**] has remained normotensive
throughout her Neonatal Intensive Care Unit stay. She has an
intermittent Grade I/VI systolic ejection murmur at the left
upper sternal border consistent with peripheral pulmonic
stenosis. On examination she is pink and well perfused.
Fluids, electrolytes and nutrition status - At the time of
discharge her weight is 2,325 gm, her length 43.5 cm and head
circumference 31.75 cm. Enteral feeds were begun on day of
life Number 2 and reached full volume feedings on day of life
Number 8. She was increased to the maximum calorie enhanced
feeding of 30 cal/oz of breastmilk or special preemie
formula. At the time of discharge, she was breastfeeding and
being supplemented with 24 cal/oz breastmilk or formula. Her
feedings have all be oral since day of life Number 47.
Gastrointestinal status - The infant was treated with
phototherapy for hyperbilirubinemia of prematurity from day
of life Number 1 until day of life Number 11. Her peak
bilirubin occurred on day of life Number 3 and was total of
6.5, direct 0.4. On [**2103-2-5**], a mass was palpated in
her left inguinal area on clinical examination. An
ultrasound on [**2103-2-7**], revealed a uterus in an
unusual position, traveling initially proximally under the
bladder, then turning left and then curving toward the left
inguinal region. The tip of the fundus is located
superficially in the left inguinal region as is what appears
to be the left ovary, roughly at the level of the pubic
symphysis superficially. An ovoid structure in the left groin
thought to represent a left ovary measures 1.2 cm by 5 mm.
There are at least two cystic structures associated with what
is thought to represent the right ovary both of which measure
approximately 1.9 cm by 0.9 cm. There is no free fluid in
the pelvis. Both kidneys are present and of normal size. On
[**2103-2-12**], she was transferred to [**Hospital3 1810**] for bilateral
hernia repair. She had spinal anesthesia. She recoverd from the
procedure well. She was back taking full feeds later the day of
surgery and she was having normal bowel activity.
Hematological status - She has never received a blood product
transfusion during her Neonatal Intensive Care Unit stay.
Her last hematocrit on [**2103-2-1**] was 31.4 with a
reticulocyte count of 7.9 percent.
Infectious disease status - [**Known lastname 60252**] was started on Ampicillin
and Gentamicin at the time of admission for sepsis risk
factors. The antibiotics were discontinued after 48 hours
when the blood cultures were negative and the infant was
clinically well.
Neurology - Head ultrasound on [**2102-12-29**], was within
normal limits. Head ultrasound on [**2103-1-24**] was
within normal limits, however, an 8 mm choroid plexus cyst
was noted at that time.
Sensory - Audiology, a hearing screen was performed with
automated auditory brain stem responses and the infant
referred in both ears. An outpatient testing is scheduled
for [**2103-2-28**].
Ophthalmology, her eyes were examined most recently on
[**2103-2-2**] and were mature. She never had any
retinopathy of prematurity.
Psychosocial - Parents have been very involved in the
infant's care throughout her Neonatal Intensive Care Unit
stay.
The infant is discharged in good condition.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) 60254**]
[**Last Name (NamePattern1) 56597**] of [**Hospital **] Pediatrics, [**Location (un) 8170**], [**Apartment Address(1) 50442**],
Brooklin [**Numeric Identifier 1415**]. Telephone Number [**Telephone/Fax (1) 43701**].
RECOMMENDATIONS AFTER DISCHARGE: Her feedings otherwise consist
of feeding on an ad lib schedule, breastfeeding or supplementing
with 24 cal/oz breastmilk or formula made with 4 cal/oz of
Similac powder.
Medications at discharge include Vi-Daylin one ml
p.o. daily and iron sulfate 25 mg per ml 0.3 ml p.o. daily.
She passed the carseat position screening test.
Her last state newborn screen was sent no [**2103-2-2**],
the previous state screens have been within normal limits.
She has received her first hepatitis C vaccine on [**2103-1-25**] and her first Synagis on [**2103-2-8**].
Recommended immunizations consist of Synagis respiratory
syncytial virus prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria: Born at less than 32 weeks; Born
between 32 and 35 weeks with two of the following, daycare
during respiratory syncytial virus season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; With chronic lung disease.
Influenza Immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life
immunization against influenza is recommended for household
contacts and out of home caregivers.
Follow up appointments for this infant include [**Hospital3 18242**] Infant Follow Up Clinic, [**Hospital6 407**],
and early intervention program. She will follow up at [**Hospital 60255**]
Hospital surgery program Dr. [**First Name8 (NamePattern2) 44092**] [**Name (STitle) 37080**] 2-4 weeks after
discharge
DISCHARGE DIAGNOSIS: Status post prematurity at 30 2/7 weeks
gestation.
Status post bilateral inguinal hernia repair
Status post transitional respiratory distress.
Sepsis, ruled out.
Status post hyperbilirubinemia of prematurity.
Anemia of prematurity.
Apnea of prematurity.
Left inguinal hernia.
Choroid plexus cyst.
Referred hearing examination.
Sacral dimple.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2103-2-11**] 02:49:22
T: [**2103-2-11**] 08:45:38
Job#: [**Job Number 60256**]
ICD9 Codes: V053, V290, 7742
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5306
}
|
Medical Text: Unit No: [**Numeric Identifier 70787**]
Admission Date: [**2150-2-10**]
Discharge Date: [**2150-2-28**]
Date of Birth: [**2150-2-10**]
Sex: M
Service: NB
HISTORY: The patient is a 2215 gram product of a 33 and [**7-16**]
week twin gestation pregnancy born to a 35 year old gravida
2, para [**2-10**] mother. Prenatal [**Name2 (NI) **] included blood type O
negative, antibodies negative, RPR nonreactive, rubella
immune, hepatitis B negative and GBS unknown. Pregnancy
notable for IVF assisted twin gestation with a concordant
growth noted throughout pregnancy. Pregnancy was
uncomplicated until mother experienced PROMs on [**2-10**].
Given relatively advanced gestational age, maternal history
of prior C-section and breech/breech positioning, decision
made to proceed with C-section delivery. Mother did not
receive antibiotics prior to delivery and no maternal fever
was noted. At delivery, twin 2 emerged with moderate tone
and respiratory effort responding well to stimulation and
brief blow-by O2. Apgars were 7 and 9 and infant was brought
to NICU.
PHYSICAL EXAMINATION: His weight on admission was 2215 grams
which was 50-75 percentile. Head circumference was 32 cm;
that was in the 50-75 percentile, and length was 40.5 cm, 75-
90 percentile. In general, he was a well developed premature
infant with mild tachypnea and work of breathing, active and
responsive. Skin was warm, dry, pink, no rash. Head, ears,
nose, throat: Fontanelle soft and flat, ears and nares
normal, platelet intact, had positive red reflex bilaterally.
Neck was supple, no lesions. Chest was coarse, moderately
aerated, mild retraction. Cardiac, rate was regular and the
rhythm was regular. No murmur, femoral pulses were 2+. GU,
normal premature male. Testes palpable bilaterally. Anus
patent. Extremities, hips, and back were normal. Neuro,
appropriate tone and activity.
SUMMARY OF HOSPITAL COURSE: Respiratory: Infant admitted to
NICU on [**2-10**] for prematurity with mild respiratory
insufficiency, not requiring supplemental oxygen. He has
remained in room air since birth. Has not had any episodes
of apnea of prematurity and is not on caffeine.
Cardiovascular: Infant has been cardiovascular stable with a
heart rate of 130-160 and with a blood pressure of 71/43 with
a mean of 53. No history of murmur. Rate is regular and the
rhythm is regular.
Fluids, electrolytes and nutrition: Birth weight was 2245
grams. The infant was initially started on 80/kg/day of 10W.
Enteral feeds were initiated on day of life 1, advanced to
full enteral feeds by day of life 6. He is currently
receiving 130 ml/kg/day of Similac 24 by p.o. Weight at time
of discharge is 2635 which is 50 percentile.
Gastrointestinal: Bilirubin of 9/0.3 requiring phototherapy
on day of life 3. He has been off phototherapy since day of
life 4. His follow up bilirubin was 6.6/0.2 on day of life
5.
Hematology: His hematocrit on admission was 44.6. He has
not required any blood transfusions.
Infectious disease: He had a CBC with diff and a blood
culture on admission. His initial white count was 12.7 with
a hematocrit or 44.6, 29 polys and 1 band with a platelet
count of 427. Antibiotics were not initiated. Blood culture
remained negative.
As a result of a potential nosocmial RSV exposure the pateint
recieved a single prophylactic dose of Synagis. There were no
symptoms consistent with RSV.
Neurologic: Infant has been appropriate for gestational age.
Infant does not meet criteria for head ultrasound.
Sensory: Audiology: Hearing screen was performed with
automatic auditory brain stem and results were normal
bilaterally. Ophthalmology: Infant does not meet criteria
for eye exam for ROP.
Psychosocial: [**Hospital1 69**] social
worker has been in contact with the family. There are no
active ongoing issues at this time. The social worker can be
reached at this phone number, [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He is in [**Location (un) 1439**],
[**State 350**]. His telephone number is [**Telephone/Fax (1) 45985**].
RECOMMENDATIONS: Feeding at discharge: Ad lib, Similar 24
calorie. Discharge weight once again was 2635, 50
percentile. Length and head circumference will be
determined. At this point, no medications. His car seat
position screening has been passed. State newborn screening
has been per protocol and results are pending. Infant has
received hepatitis B vaccine on [**2-21**]. He also received
Synagis on [**2-27**]. Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria:
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with 2 of the following:
Day care during RSV season, a smoker in the household, a
neuromuscular disease, airway abnormalities, or school
age siblings.
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
adequate general endotracheal anesthesia 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 appointment with pediatrician should be within 48
hours after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity. He was born at 33 and 6/7 weeks. He is
twin gestation.
2. Rule out sepsis, which has been resolved.
3. Indirect hyperbilirubinemia which has been resolved.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 67981**]
MEDQUIST36
D: [**2150-2-28**] 03:06:45
T: [**2150-2-28**] 07:01:47
Job#: [**Job Number 70788**]
ICD9 Codes: 769, 7742, V053, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5307
}
|
Medical Text: Admission Date: [**2165-12-20**] Discharge Date: [**2166-1-5**]
Date of Birth: [**2165-12-20**] Sex: M
Service: NEONATOLOGY
product of a 33 week gestation pregnancy born to a 43 year
old G6, P2 woman, whose pregnancy was complicated
only by maternal asthma treated with inhaled meds. Prenatal
screen is notable for hepatitis B surface antigen, negative;
presented for routine OB visit on the day of delivery. Noted
the [**Hospital6 256**] for Cesarean section
which was performed under general anesthesia. Infant emerged
with Apgar scores of 7 at 1 minute and 9 at 5 minutes.
Received blowby O2 and stimulation in the
Delivery Room. Was transferred to the Newborn Intensive Care
PHYSICAL EXAMINATION: On examination, pink, active,
receiving blow-by O2. Head, ears, nose and throat, within
normal limits. Palate, intact. Mild grunting, flaring and
retracting. Bilateral lung breath sounds, coarse and equal.
Regular rate and rhythm without murmurs. Pulse is normal.
Abdomen, benign. Normal preemie male genitalia. Anus,
patent. Hips, negative for click. Neurological, nonfocal
and age appropriate activity. Spine, intact. Was noted to
have episodes of heart rate down to 80s. Blood pressure and
sats maintained. Blood pressure, mean of 35 during episodes
with the heart rate rise into the low 100s with duress.
Appeared to be in sinus bradycardia on monitor.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory - The baby's respiratory distress increased.
He initially was started on CPAP of 6. Had an initial blood
gas of 7.31/ 53/50. Escalated on his O2 requirement and was
intubated. Received two doses of Surfactant and within 48 hours
was extubated to room air and has had no further
respiratory distress. He has exhibited occasional drifts in
his saturations that has responded to supplemental O2. These
have not been observed for several days.
2. Cardiovascular - The baby was noted to have prolonged
periods of bradycardia lasting sometimes up to ten minutes or
so with stable blood pressures and then prolonged periods of
heart rates in the 120s to 140. Blood pressure remained
stable with systolics in the 50s to 60s; diastolics in the
30s with means in the 40s to 50s. There was possibly a
junctional beat and beat subsided by day of life #2 into 3.
He then was noted continue to have arrhythmias, Cardiology
evaluated the infant. He was described to have frequent APC's,
some blocked and some with bigeminy.
An echocardiogram was done on [**2165-12-30**] and revealed a small
patent foramen with left to right flow and trivial flow
acceleration across left pulmonary artery. A murmur was
initially heard but dissappeared during his hospital course.
Cardiology would like to have Dr. [**Last Name (STitle) 1537**] of [**Location (un) 2274**] see him in 1
month for f/u witha 24 hour Holter recording.
3. Fluids, Electrolytes and Nutrition - The baby initially
had a peripheral intravenous and was NPO. Had an initial D
stick of 32 which he responded to a D10W bolus 2 cc per kilo
with subsequent D sticks greater than 50. Enteral feedings
were introduced on day of life #3 as his respiratory and
cardiac status stabilized. He advanced on enteral feedings
and is currently eating PE 2,450 cc per kilo per day, most
PG. The baby is voiding and stooling. Last electrolytes on
[**2165-12-23**], 142; 5.0; 106; 24. He had an ionized calcium on
day of life #1 of 1.02. His initial calcium on day of life
#0 was 9.5 with a magnesium of 1.1. Initial electrolytes on
day of life #0, 139; 4.3; 108; 26.
The baby's birth weight was 2,425 (90th percentile); length, 48
cm (90th percentile); head circumference, 32.75 (90th
percentile).On discharge he weighed 2.585kg and was feeding
Enfamil 20.
4. Gastrointestinal- The baby demonstrated some physiologic
jaundice with peak on day of life #4 of 12.3; 0.4. Was
started under phototherapy. Phototherapy was discontinued on
day of life #7 and he had a rebound bili on day of life #8 of
5.7/0.3, 5.4.
5. Hematology - The baby has not required any blood products
during this admission. Hematocrit on admission was 47.8.
6. Infectious Disease - The baby had an initial sepsis
evaluation on admission with a white count of 13.4; 17 polys;
0 bands. Platelets, 271,000. Hematocrit, 47.8. He had a
blood culture sent and was started on Ampicillin and
Gentamicin. At 48 hours, the baby was clinically improving.
Cultures were negative and the antibiotics were discontinued.
He has had no further issues with infection.
7. Sensory - Audiology screening has been done on [**1-4**] and was
WNL .
8. Psychosocial - Mom visits frequently. Has a 2 [**11-28**] year
male son, [**Name (NI) **], at home and a 17 year old son, [**Name (NI) **], at
home. She currently works within the [**University/College **] System
coordinating conferences at the [**Hospital **] Medical School and
her husband is currently unemployed. He was in the high tech
industry. They look forward to the baby transitioning [**Name2 (NI) **]
DISCHARGE DISPOSITION: Name of Primary
Pediatrician, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16472**] at [**Hospital1 **] in BTR within 5 days and Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) 1537**] cardiology
in 1 month.
CARE RECOMMENDATIONS: MEDICATIONS: None at this time.
CAR SEAT SCREENING: Passed.
STATE NEWBORN SCREENING STATUS: Initial State screen sent on
[**2165-12-23**]. Next one due on [**2166-1-3**].
IMMUNIZATIONS: Received hepatitis B vaccine on [**2165-12-24**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38370**]
Dictated By:[**First Name3 (LF) 46138**]
MEDQUIST36
D: [**2165-12-30**] 19:04
T: [**2165-12-30**] 19:06
JOB#: [**Job Number 46139**]
ICD9 Codes: 769, 7742, V053, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5308
}
|
Medical Text: Admission Date: [**2153-6-17**] Discharge Date: [**2153-6-20**]
Date of Birth: [**2106-11-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
assault
Major Surgical or Invasive Procedure:
Intubation for combative behavior in the ED
History of Present Illness:
40 year old male s/p assault w/ head and facial trauma presented
to the ER with ETOH level of 616. He was intubated in the ER for
combativeness and
airway protection.
Past Medical History:
Hypertension
EtOH abuse
Social History:
Lives alone
Denies tobacco
History of ETOH intake about 2-3 days per week, drinking large
amounts of alcohol since his mother's death.
Family History:
Noncontributory
Physical Exam:
GEN: Intubated and sedated
HEENT: Lip laceration, C-collar in place
Pulm: CTAB
CV: RRR
Abd: soft
MSK: no spinal deformity, no long bone deformity
Neuro: GCS 7
Pertinent Results:
[**2153-6-16**] 10:40PM WBC-4.7 RBC-3.68* HGB-11.5* HCT-33.9* MCV-92
MCH-31.1 MCHC-33.8 RDW-15.6*
[**2153-6-16**] 10:40PM ASA-NEG ETHANOL-616* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2153-6-16**] 10:40PM UREA N-15 CREAT-1.2
[**2153-6-16**] 10:56PM HGB-12.6* calcHCT-38 O2 SAT-88 CARBOXYHB-2.6
MET HGB-0
[**2153-6-16**] 10:56PM GLUCOSE-201* LACTATE-3.5* NA+-153* K+-3.3*
CL--99* TCO2-31*
[**2153-6-16**] 11:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2153-6-17**] 05:22AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2153-6-17**] 05:51AM PHENYTOIN-18.2
[**2153-6-17**] 05:20PM GLUCOSE-128* UREA N-9 CREAT-0.9 SODIUM-146*
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-23*
Radiology Report MRI ABDOMEN W/O & W/CONTRAST Study Date of
[**2153-6-18**] 8:12 PM IMPRESSION:
1. Left renal mass with an enhancing nodular component. Given
the high
signal intensity on T1-weighted imaging, the mass is likely
hemorrhagic. The differential diagnosis would include a renal
cell carcinoma (especially papillary) or a urothelial carcinoma
arising from the collecting system. Correlation with urine
cytology and retrograde ureteroscopy is recommended. A follow-up
MRI after the hemorrhage has a chance to resolve may be also
helpful for further characterization.
2. Hepatic steatosis.
3. Diffuse bladder wall thickening, perhaps due to prostatic
hypertrophy.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2153-6-16**]
11:08 PM
IMPRESSION: Multiple hyperattenuating, scattered foci
representing acute
subarachnoid hemorrhage as described above with a small focus in
the left
frontal subdural space.
Brief Hospital Course:
The pt was intubated and sedated in the ED, his lip laceration
was sutured and he was admitted to TSICU under Attending Dr.
[**Last Name (STitle) **]. The CT head was positive for diffuse small SAH. On CT
torso for trauma, there was an incidental finding of a renal
mass. The patient was extubated in the AM of HOD 2 and he was
transferred to the floor. He was tolerating po, but failed to
ambulate without [**Last Name (LF) 75669**], [**First Name3 (LF) **] PT consult. Neurosurgery consult
provided recs for f/u head CT in 6 wks. Urology was consulted
for the renal mass and a dedicated MRI was performed, showing
hemorrhage vs neoplasm (RCC or TCC). Urology recs were urine
cytology (sent, but results pending at time of discharge) and
f/u in their clinic. Pt did not qualify for Rehab, per Case
Management, and pt refused Detox. PT recommended home w/ VNA,
but pt does not have insurance to cover it. Will be discharged
to home, with recs to f/u in Trauma Clinic to remove sutures,
[**Hospital 159**] clinic and [**Hospital **] clinic. Pt sent with 7 days
dilantin, per Neurosurg recs.
Medications on Admission:
Unknown
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Lip laceration
Alcohol intoxication
Discharge Condition:
Stable, meets discharge criteria, eating regular diet, voiding
on own, pain controlled on oral medications
Discharge Instructions:
You have been seen for your injuries after your assault.
You need to take the medication Dilantin for 7 more days, three
times per day. It is used to prevent seizures. It is very
dangerous to drink alcohol while you are on this medication. Do
NOT drink alcohol.
Return to the hospital or call your doctor if you experience any
of the following:
* Prolonged nausea
* Vomiting
* Confusion, drowsiness, change in normal behavior
* Trouble walking, or speaking (slurred speech)
* Numbness or weakness of an arm or leg.
* Severe headache
* Convulsions or seizures
Followup Instructions:
You have an appointment with the [**Hospital 159**] Clinic with [**Name6 (MD) 275**] [**Name8 (MD) 75670**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2153-6-26**] 10:00am. Is
is very important that you keep this appointment because you
might have cancer in your kidney.
You can call Dr.[**Name (NI) 12389**] clinic ([**Telephone/Fax (1) 22750**] to have the
stitches removed frfom your lip next week.
You need to call to make an appointment with the [**Hospital 4695**]
Clinic, Dr. [**Last Name (STitle) 548**] ([**Telephone/Fax (1) 88**]. You need to have a CT scan of
your brain in 6 weeks.
Please call your primary care physician to make an appointment
to futher evaluate your recovery in the next week.
Completed by:[**2153-6-20**]
ICD9 Codes: 4019, 2859, 2875
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5309
}
|
Medical Text: Admission Date: [**2157-7-21**] Discharge Date: [**2157-7-29**]
Date of Birth: [**2087-3-27**] Sex: F
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
admitted for acute stroke
Major Surgical or Invasive Procedure:
s/p t-PA
History of Present Illness:
The patient is a 70 year old RH woman with a history of
hypertension, new afib, and arthritis now presenting with acute
onset weakness in the lower extremities. As per the patient's
daughter, the patient had been feeling more anxious and
depressed
over the last couple weeks. On the prior Saturday, she felt
palpitations in her chest. She was taken to an OSH ER who
diagnosed her with anxiety and gave her propanolol and xanax.
Since that time she had been intermittantly anxious with
palpitations.
On the day of admission, the patient states she felt her heart
racing. Her daughter who is a nurse took her pulse and noted it
to be fast (didn't remember exact rate). They waited about an
hour and the daughter rechecked her mother's pulse and it was
regular and slower. The daughter left for about 45 minutes and
returned to find the patient sitting in the kitchen, attempting
to speak but with slurred speech, and complaining "my legs won't
move". At that point the daughter called EMS. When the
ambulance arrived the patient was noted to be in afib and had a
left facial droop and greater weakness on her left side (she
states both sides were weak but the left was weaker). The
patient denied any headache or visual problems during the
episode.
She was brought to the ER and a emergent head CT was performed
which did not show any acute bleed. On evaluation, however the
patient appeared very lethargic, not alert and it was determined
she needed intubation for airway protection. The stroke team
was
notified and promptly administered TPA for a presumed ischemic
episode. NIHSS score>20. The patient was subsequently
transferred to the NICU
for closer monitoring.
ROS: no recent h/o GI, GU, or musculo-skeletal difficulties
Past Medical History:
htn
atrial fib - new diagnosis upon this admission
arthritis
Social History:
-married and lives with husband
-has 2 daughters
-husband recently had stroke
-no tobacco or etoh use
Family History:
-father with CAD
-no history of seizures or strokes
Physical Exam:
INITIAL PE: T-afeb BP-177/70 HR-72 RR-16
Gen: lying in bed intubated, sedated
Neck: supple, no carotid bruits
Chest: clear to auscultation b/l
CV:regular rate, normal s1s2, no m/r/g
Ext: no c/c/e, 2+ dorsalis pedis
Neurologic Exam:
MS:
Sedated on propfol. Does not respond to voice or sternal rub,
not arousable. Does not follow axial or midline commands.
Nonverbal with ET tube.
CN:
perrl 4mm->2mm, sluggish. No Doll's. Positive corneals and gag
refelx. Face grossly symmetric with ET tube in place.
Motor/Sensory
Patient is sedated and has no movement to deep painful stimulus
in all extremities. There is no posturing. Tone and bulk are
symmetric b/l. Patient has equivocal plantar reflex on left,
extensor on right.
Coordination/ Gait:
Unable to test
NEXT DAY PHYSICAL EXMA:
Vitals: 98.4 150/70 72 22 100% on FM
General: Quiet elderly woman in no acute distress
Neck: supple, no carotid bruit
Lungs: decreased breath sounds at the bases, otherwise clear
CV: RR, no murmurs
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema, good pulses; ononcomycosis of toes
Neurologic Examination:
Mental Status: Awake and alert, cooperative with exam, blunted
affect. Oriented to person, place, month and president
Attention: Can say months of year backward and forward
Language: Fluent, no dysarthria, no paraphasic errors, naming
intact. Fund of knowledge normal
Registration: [**3-9**] items, Recall [**3-9**] items at 3 minutes with
prompting. No apraxia, No neglect. [**Location (un) **] and writing intact
Cranial Nerves: Visual fields are full to confrontation. Pupils
equally round and reactive to light, 3 to 2 mm bilaterally.
Extraocular movements intact, no nystagmus. Facial sensation and
decreased NLF. Hearing intact to finger rub bilaterally. Tongue
midline, no fasciculations. Sternocleidomastoid and trapezius
normal bilaterally.
Motor:
Normal bulk and tone bilaterally
No tremor.
Motor strength about 4+/5 bilaterally in the upper extremities
and may secondary to poor effort; the lower extremites were 4+/5
bilaterally
No pronator drift
Sensation was intact to Light touch, pin prick, temperature
(cold), vibration, and proprioception
Reflexes: B T Br Pa Pl
Right 2 2 2+ 2- 1
Left 2 2 2+ 2- 1
Grasp reflex absent
Toes were downgoing bilaterally
Coordination: FNF is mildy ataxic but symmetric; heel to shin
performed normally
Pertinent Results:
WBC: 8.4-> 11.5 (peak)
Hct: 41->33
Plt: 197-291
ALT: peaked at 3493, trended down
AST: peaked at 2654, trended down
Amylase, lipase, Total bili WNL
INR peaked at 1.7, trended down
Head ct [**7-20**], [**7-23**]: IMPRESSION: No acute intracranial
hemorrhage or mass effect. No change since the prior study six
hours earlier.
MRI/A [**7-20**]:
1. No evidence of diffusion abnormality to suggest the presence
of an acute stroke.
2. Confluent areas of high T2 signal seen on the FLAIR images as
well as several high T2 signal spots in the periventricular
white matter. This is nonspecific, but most likely relates to
chronic microvascular infarction.
3. Old lacunar infarctions in the inferior cerebellum
bilaterally.
4. Normal circle of [**Location (un) 431**] MRA.
Carotid duplex [**7-21**]:
FINDINGS: Duplex evaluation was performed in both carotid and
vertebral arteries. Minimal plaque was identified on the left.
On the right, peak systolic velocities are 80, 61, 90 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3.
This is consistent with no stenosis.
On the left, peak systolic velocities are 101, 64, 123, in the
ICA, CCA, ECA respectively. This is consistent with a less than
40% stenosis.
There is antegrade flow in both vertebral arteries.
RUQ US + doppler [**7-22**]:
IMPRESSION: Limited exam, but no evidence of venous or arterial
thrombosis. Cholelithiasis without acute cholecystitis.
TTE [**7-22**]: 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 hard to
assess given the rhythm but is probably low normal (LVEF
50-55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. The aortic valve leaflets
are mildly
thickened.
5.The mitral valve leaflets are mildly thickened.
6. There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Brief Hospital Course:
1. s/p Stroke - the patient presented with exam findings c/w a
basilar artery occlusion, NIHSS score>20, and thus was given
t-[**MD Number(3) 58459**] head CT showed no bleed. Subsequent MRI showed no
evidence of acute stroke, so it is possible that the t-[**MD Number(3) 58460**]
the clot. Her symptoms neurologic draumatically improved - no
weakness or numbness, able to eat and swallow without
difficulty. It is likely the source of embolus was from her new
onset afib. Carotid US showed <40% stenosis on left carotid
artery, o/w normal. TTE showed EF 50-55%, 1+ MR, no wall
motionabnormalities. Her SBP was maintained in the 140-160
range. A cholesterol panel was checked - chol 183, ldl 107, hdl
55, tg 105. We considered starting a statin, however her LFTs
prohibited this.
AST and ALT were checked and were found to be 500/700. Upon
recheck, these values were in the 3000 range with normal Tbili.
Liver service was consulted. The most likely etiology is some
kind of ischemia/shock liver. There is no clear documentation
of a hypotensive event that would cause shock liver, however it
is possible that she thru a clot to her liver which then lysed
after recieving t-PA. Tox screen (serum and urine) negative.
The transplant service was consulted as well. Her LFTs improved
to near [**Doctor First Name **] ranged over the next couple days with her INR
peaking at 1.7 but then returning to normal. Hepatotoxins
should be avoided. There is a battery of tests currently pending
to investigate the cause of the altered LFTs including hepatitis
panel, CMV, EBV, HSV, etc. RUQ US with doppler was performed -
+ for gallstones but no clot, no hematoma, no cholecystitis.
For her new onset afib, she was rate controlled with IV, then PO
metoprolol. When her rate is controlled, she goes into NSR.
TSH was WNL. Etiology unclear. She was started on IV heparin
(no bolus) for the afib, and also started on coumadin after her
liver issues resolved. She will need outpatient cardiology
followup. Additionally her EKG shows some old ST depressions
V4-V6 (seen on OSH EKG on [**7-16**] as well), these may be rate
related given her rapid afib. She may need an outpatient stress
test.
On the day of her liver failure she became acutely aggitated,
delerious with paranoia, visual hallucinations, suicidal
ideations (but no plan), pulled all her IVs, refused medical
care. Psychiatry was consulted. She was given a total of 6mg
IM/IV haldol for the acute state. Then transitioned to po prn
zyprexa. A head CT was performed to ensure no edema or
hydrocephalus - it was normal. Likely secondary to acute liver
failure.
Respiratory wise she was extubated the day after admission on
[**7-21**], inspiration spriometer at bedside.
While on the floor the patient did well, her neurologic exam
improved and she was less weak on the left side. We titrated
her metoprolol and added on verapamil to get her rate controlled
with regards to her afib.
Medications on Admission:
norvasc
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
2. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Ciprofloxacin HCl 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
5. Verapamil HCl 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. stroke
2. afib
Discharge Condition:
Stable, very little residual weakness on neuro exam.
Discharge Instructions:
Please return to the nearest ER if symptoms of dizziness,
weakness, or confusion occur. Please take medications as
prescribed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in Neurology in 4 weeks, call
[**Telephone/Fax (1) 2574**] to schedule a convenient time.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2157-7-28**]
ICD9 Codes: 2851, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5310
}
|
Medical Text: Admission Date: [**2202-1-8**] Discharge Date: [**2202-2-1**]
Date of Birth: [**2163-9-18**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Orencia / Remicade
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
L leg pain and erythema
Major Surgical or Invasive Procedure:
IR guided fluid drainage
Incision and drainage
Muscle biopsy
History of Present Illness:
Mr. [**Known lastname 17385**] is a 38 y.o. male with a history of psoriatic
arthritis on immunosuppresive therapy, HTN, HL, DM, cervicogenic
headaches who was recently discharged on [**1-8**] for left leg pain.
Pt reprots that he presented to the ED on [**2202-1-3**] for L heel pain
radiating to knees. He was initially treated with vanc and cipro
for question of septic left knee; the aspirate showed [**Numeric Identifier **] WBC
and 94% PMN but neg gram stain and culture and no crystals so
abx discontinued. LENI was negative for DVT or [**Hospital Ward Name **] cyst. No
fx on x-ray. This was thought to be a psoriatic arthritis flare,
so his prednisone was increased from his home dose of 30mg to
60mg daily with improvement in his inflammation. His pain
subsequently reutrned and repeat LENI was negative. Pt was
started on gabapentin for presumed fibromyalgia and discharged
yesterday on a stable pain regimen of MS contin with prn
dilaudid. He saw Rheum today who referred him to Derm for
evaluation of a superficial erythematous plaque, questioned
erythema nodosum. Derm did not think this was consistent but was
concerned about compartment syndrome so referred pt to ED.
.
In the ER, vitals were: T 98.2, P 79, BP 145/77, RR 17, O2sat
98. LENI neg for DVT but pt was noted to have an extensive left
posterior calf subcutaneous complex fluid collection. Ortho did
not see evidence of compartment syndrome and recommended
vascular c/s to rule out necrotizing fasciitis given the fluid
collection. Vascular did not think this was consistent with
necrotizing fasciitis. An MRI of the LE was done per Rads recs,
and this showed small fluid collections concerning for abscess
in his gastrocnemius that were too small to be drained with no
evidence of osteomyelitis. He was given vancomycin, zosyn, and
clindaycin. He also received his home meds of gabapentin, MS
contin, and po dilaudid. He was admitted to medicine with VS on
transfer: T 98.5, P 76, BP 136/68, RR 15, O2sat 98RA.
.
On evaluation on the floor, patient complains of persistent LE
pain and tenderness which is controlled on his pain regimen. His
LLE knee effusion has improved markedly since his recent
admission. He denies any fevers, chills, or night sweats.
.
ROS: Mild constipation d/t pain meds. Review of systems
otherwise negative.
.
Past Medical History:
-Psoriatic arthritis: Dx in early [**2198**] when pt presented with a
few lesions of psoriasis and symmetric polyarticular swelling of
MCPs, PIPs, MTPs, and dactylitis. Has failed trials of enbrel
and methotrexate due to lack of response. Failed Arava due to
Arava-induced polyneuropathy. Failed remicade and orencia due to
infusion reactions. Imuran was re-initiated in [**2201-2-25**].
Started Simponi in [**2201-8-27**].
-Morbid obesity
-OSA on CPAP
-IBD vs IBS: never diagnosed as UC or Crohns
-HTN: prednisone-induced
-DM2: prednisone-induced, followed by the [**Last Name (un) **]
-Hyperlipidemia
-Peripheral neuropathy
-NAFLD, felt to be secondary to methotrexate
-Cervicogenic migraine/dystonic muscle spasm/occipital
neuralgia:
Followed by pain clinic. s/p intermittent trigger point
injections, greater occipital and auriculotemporal nerve blocks
combined with Botox chemodenervation therapy
-Keratoconus s/p bilateral corneal transplant: 1st in 95, 2nd in
99
-s/p 4 anal fistulotomies
-s/p tonsillectomy x2 and adenoidectomy
-DJD s/p L4/L5 diskectomy
-Patello-femoral syndrome s/p arthroscopic surgery for both
knees
x 3 each
.
Social History:
Patient has never smoked. Admits to 1 beer per month. Admits to
1 x use of LSD in college. Patient is married with 4 children.
Only recent travel to [**Location (un) 6408**]and [**Last Name (un) 3625**] World. Has only
ever been sexually active with wife.
Family History:
Mother has [**Name2 (NI) **], HTN, hypercholesterolemia and bipolar disorder.
Father has non-smoking induced COPD and hypertension. Brother
has dermatologic psoriasis and UC. Sister with HTN and
hypercholesterolemia. Paternal Aunt with Crohn's and
sarcoidosis.
Physical Exam:
Vitals: T 98.5, BP 135/87, P 78, RR 17, O2sat 99RA, Height 6'1",
Weight 153 kg
General: Well-appearing, pleasant, obese man in NAD
HEENT: NCAT, oropharynx clear
Neck: Supple, no LAD
Pulm: CTA b/l
CV: RRR, S1-S nl
Abd: BS+, soft, obese, NT, ND
Extrem: Left knee perhaps mildly larger than right; erythema,
warmth, and tenderness over medial left calf, excoriations over
anteriolateral left calf. Pitting edema b/l. DP/PT pulses 2+
b/l.
Neuro: AAOx3, strength 5/5 in LE.
Pertinent Results:
rtPCR RNA study NEG
URINE culture NGTD
Wound culture NGTD
Blood culture NGTD after [**1-8**]
[**1-8**] BLOOD CULTURE GRAM POSITIVE COCCUS(COCCI) IN CLUSTERS -
pan-sensitive
[**2202-1-9**] JOINT FLUID: Stain NEG; BACT/FUNGAL/ACID FAST CULTURE
NEG
[**2202-1-8**] LYME SEROLOGY NEG
[**2202-1-11**] HBsAg: NEG HBs-Ab: NEG HAV-Ab: NEG HCV-Ab: NEG
[**2202-1-11**] ABSCESS Fluid - Fungal/GS NEG
.
Imaging:
[**2202-1-20**] US: No significant change in size of fluid collection
in the left popliteal fossa extending into the left posterior
calf, which contains small foci of gas.
.
[**2202-1-16**] US: 1. No evidence of left lower extremity DVT between
the left popliteal and common femoral veins. 2. Left popliteal
fossa collection extending into the calf, again seen.
.
[**2202-1-12**] CT of LLE - 1. Redemonstration of two loculated fluid
collections in the left calf. Slightly increased inferior extent
of the collection along the anteromedial edge of the medial head
of the gastrocnemius muscle. Otherwise no significant change. 2.
Subcutaneous edema along the anterior left leg, in keeping with
cellulitis, unchanged. 3. Small loculates of air within the
lower collection is attributed to recent aspiration procedure.
No other evidence of soft tissue emphysema identified.
.
[**2202-1-12**] TTE - The right atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. No mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No obvious
echocardiographic evidence of endocarditis. Mild symmetric left
ventricular hypertrophy with preserved global LV systolic
function. Mild pulmonary hypertension.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
[**2202-1-22**]
MRI calf
1. Persisted popliteus muscle collection and collection at the
anteromedial aspect of the medial head of the gastrocnemius
muscle.
2. Post-surgical findings following incision and drainage is a
new collection posterior to the medial head of the gastrocnemius
muscle, contiguous with the medial open skin defect and contains
low signal intensity foci, which may be due to air or possibly
packing.
3. Muscle edema in the medial head of the gastrocnemius muscle
and vastus
medialis obliquus muscle, likely postoperative.
4. A small knee joint effusion and mild synovitis without
definite findings of septic arthritis. As previously noted, the
popliteus tendon sheath can communicate with the knee joint.
Cartilage thinning and subchondral cysts along patella may be
degenerative. Clinical correlation is requested.
.
[**2202-1-12**] Radiology UNILAT LOWER EXT VEINS -1. Large complex
fluid collection tracking from the left popliteal fossa along
the medial left calf to the proximal mid calf region. Since it
is difficult to fully assess the extent and geography of this
collection on ultrasound, an MRI is suggested for further
characterization. 2. Smaller fluid collection at the left
anterior knee measuring 3.5 cm. 3. No evidence of deep vein
thrombosis in the left leg.
.
[**1-8**] LENIS: No left lower extremity DVT. Extensive left
posterior calf subcutaneous complex fluid collection.
.
[**1-8**] MRI calf: 1. Two loculated fluid collections concerning
for abcess collections, one in the substance of the popliteus
muscle, and the other along the anteromedial edge of the medial
gastrocnemius muscle.
2. Subcutaneous edema likely represents cellulitis in this
setting.
3. No evidence of osteomyelitis.
4. Limited assessment of knee joint -- please see comment (No
obvious direct communication between these collections and the
knee joint effusion is identified, but the popliteus abscess
does extend along the popliteus tendon, which can communicate
with the knee in some patients. Full assessment of the
relationship between the knee joint and popliteus is limited on
these views.)
Labs on admission:
[**2202-1-8**] 01:35PM GLUCOSE-152* UREA N-28* CREAT-1.2 SODIUM-136
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17
[**2202-1-8**] 01:35PM WBC-13.7* RBC-4.37* HGB-12.2* HCT-37.4*
MCV-86 MCH-27.9 MCHC-32.5 RDW-13.4
[**2202-1-8**] 01:35PM NEUTS-87.6* LYMPHS-8.4* MONOS-3.8 EOS-0.1
BASOS-0.1
[**2202-1-8**] 01:35PM PLT COUNT-354
[**2202-1-8**] 01:35PM PT-14.3* PTT-21.7* INR(PT)-1.2*
Brief Hospital Course:
38 years old male with psoriatic arthritis on immunosuppression,
DM, HTN, HL p/w LLE erythema, swelling and pain, found to have
gastrocnemius abscesses and overlying cellulitis.
.
# Acute renal failure: Patient noted to have acutely elevated
creatinine after I&D by surgery. All urine lytes testing
indicated pre-renal etiology. Resolved after fluid challenge. He
again had acute renal failure on [**2202-1-27**] in the setting of having
received increased doses of pain medications and resultant
hypoperfusion. His peak creatinine was 3.0, and resolved to his
baseline of 0.8-0.9 by the time of discharge.
.
# Left calf fluid collection with overlying cellulitis: No DVT
or [**Hospital Ward Name 4675**] cyst on multiple imaging studies. No compartment
syndrome per Orthopedic evaluation. No osteomyelitis on MRI and
not consistent with necrotizing fascitis per Vascular surgery.
It was noted on imaging that he had gastroceminis fluid
collection and overlying cellulitis. No signs of septic joint
from evaluation of knee aspiration. He had one positive blood
culture with pan-sensitive staph. He was placed on zosyn, later
narrowed to nafcillin. All other microbiology data were
negative. IR and vascular surgery helped drained the fluid
collection. Leg incision is to heal via secondary intention.
He developed a body rash that was determined to be folliculitis.
He completed the 2 week course IV antibiotics in house. His
major issue remained to be pain management. He required a large
amount of narcotics to control his pain, but after overdose (see
below) he was switched to a very conservative regimen. It was
determined that the swelling/fluid collection is from psoriatic
arthritis versus idiopathic spondylarthropathy. He was
discharged in stable condition. Muscle biospy showed necrotic
muscle with granulation tissue.
.
# Medication overdose: On [**2202-1-26**], on recommendation from the
pain service, patient's MS Contin dose was increased to 160 mg
TID from 130 mg TID, in addition to being ordered for PRN
Dilaudid. Later that night, Pt fell while ambulating. He had a
CT scan which was negative for acute intracranial pathologu.
Morning after the fall, Pt was noted to be somnolent and
hypotensive. He was given Naloxone 0.4 mg X3 and would arouse
briefly after each dose. He continued to be hypotensive after a
bolus of 1L of NS. He was transferred to the MICU for further
monitoring. In the MICU he was monitored closely and his
hypotension and mental status gradually improved. He was called
out back to the floor on [**2202-1-28**]. He never required intubation.
After being called out, he was normotensive and alert and
oriented X 3. It was believed his hypotension and altered mental
status were caused by medication overdose in the setting of
acute kidney injury. He was discharged on oxycodone 5mg Q4
hours, which he did well on for the 3 days prior to his
discharge. He will follow up with the pain clinic as an
outpatient.
.
# Psoriatic arthritis: On Golimumab every month, azathioprine,
prednisone. Rheumatology was consulted and suggested to decrease
prednison level to 20mg from 30 mg. He continued on PCP [**Name9 (PRE) **]
with Bactrim. Indomethacin was held due to renal failure but
restarted on discharge. He will continue to follow with
rhematology as an outpatient.
.
# DM: Continued on Lantus 8u qAM, 10u qPM with sliding scale
dictated by patient based on carbohydrate counting. [**Last Name (un) **] was
consulted and followed.
.
# HTN: Continued on HCTZ 25mg, lisinopril 40mg, metoprolol
succinate 100mg [**Hospital1 **]. Held HCTZ and lisinopril due to
ARF/hypotension and was restarted afterwards.
.
# Anemia: Patient found to be iron deficient and started on
supplementation. Patient informed he will need oupatient
evaluation to determine cause of this by his PCP. (PCP informed
by letter).
# HL: Continued pravastatin
.
# OSA: Continued CPAP qhs
.
# GERD: Continued Donnatal prn
.
Code: FULL
Comm: With pt. HCP is wife [**Name (NI) 5321**] [**Name (NI) 17385**] ([**Telephone/Fax (1) 35617**] H,
[**Telephone/Fax (1) 35618**] C)
Medications on Admission:
Prednisone 60mg PO daily
Golimumab (Simponi) 50mg SQ monthly
Azathioprine 150mg PO qAM, 100mg PO qPM
Indomethacin 50mg PO TID
MS contin 60mg [**Hospital1 **]
Gabapentin 300mg tid
Dilaudid 4-8mg q8h prn pain
Donnatal 16.2mg 1-2 tabs PO QID prn for dyspepsia
Alendronate 35mg PO qSunday
Calcium 500mg daily
Vitamin D2 50,000 unit capsule PO 3x per week (T/Th/F)
Bactrim DS 1 tab 3x per week (M/W/F)
Clobetasol 0.05% to scalp [**Hospital1 **] on weekends
Levemir 8u qAM, 10u qPM
Aspart based on carb counting
ASA 81mg PO daily
HCTZ 25mg PO daily
Lisinopril 40mg PO daily
Metoprolol succinate 100mg PO BID
Pravastatin 80mg PO daily
Montelukast 4mg PO daily
Discharge Medications:
1. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
2. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
3. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Golimumab 50 mg/0.5 mL Pen Injector Sig: Fifty (50) mg
Subcutaneous once a month.
6. Phenobarb-Hyoscy-Atropine-Scop 16.2-0.1037 -0.0194 mg Tablet
Sig: 1-2 Tablets PO every six (6) hours as needed for heartburn.
7. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QSUN (every
Sunday).
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. INSULIN
Please resume as you were taking before hospitalization:
Levemir 8u qAM, 10u qPM
Aspart based on carb counting
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QTUTHFRI ().
14. Clobetasol 0.05 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): on weekends.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain: Never drink alcohol, drive, or operate
heavy machinery with this medicine.
Disp:*30 Tablet(s)* Refills:*0*
16. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Montelukast 4 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
18. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours: Do not exceed 4 grams in 24 hours.
20. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for loose stools.
Disp:*60 Capsule(s)* Refills:*0*
22. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itchiness: Can apply to back
of calf or other regions of itchy skin. Avoid open wound -
please cover wound before application. .
Disp:*1 tube* Refills:*0*
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
Disp:*60 Tablet(s)* Refills:*0*
24. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
25. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*0*
26. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Idiopathic spondylarthropathy
Cellulitis
Hypotension in the setting of narcotic overdose
Psoriatic arthritis
Acute renal failure
GERD
OSA
DM
HTN
HL
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].
You were admitted because your left knee was swollen, red and
painful and you also had a pain on your left leg and foot. The
rheumatology team evaluated and took fluid from your knee. You
were initially treated with antibiotic for possible infection
and pain medications. The fluid was cultured for infection but
this was negative. You did have a blood culture that was
positive and we provided you with a two week course of
antibiotics. We also had interventional radiology and vascular
surgery to help drain the fluids from your leg. This helped
your swelling. You required a lot of pain medications to
control the pain, and at one point went to the ICU because your
system did not clear the medicines adequately. You are now on a
much more conservative pain regimen. You will follow up with
pain doctors as [**Name5 (PTitle) **] outpatient. We determined that the fluid
collection is not due to infection, and more likely a
rheumatological problem. [**Name (NI) **] will follow up with the
rheumatologists as an outpatient.
Please note we made the following changes to your medications.
1. Decrease prednisone from 60mg to 20mg
2. Stop MSContin
3. Stop gabapentin
4. Stop dilaudid
5. Start oxycodone every four hours for pain control. Never
drink alcohol, drive, or operate heavy machinery with this
medication.
6. Start iron supplementation
7. Start Sarna lotion and mupirocin cream for your rash and
follow up with your PCP for resolution
8. Start tylenol 1 gram every six hours as needed for pain. Do
not exceed 4 grams in one day.
9. Start omeprazole daily to protect your stomach lining while
you are taking prednisone and indomethacin (which can cause
irritation)
10. Start colace and senna to ensure you have having bowel
movements while on oxycodone and iron supplementation. Don't
take these medicines when you are having loose stools.
Follow up with your PCP and Dr. [**Last Name (STitle) **] for the results from your
muscle biopsy, which are still pending.
A visiting nurse will be coming to your home to help with your
wound vac. Follow up with Dr. [**Last Name (STitle) **] (vascular) as listed
below.
Followup Instructions:
You have the following appointments in place.
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2202-2-1**]
8:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2202-2-11**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2202-3-29**] 9:40
Department: INFECTIOUS DISEASE
When: TUESDAY [**2202-2-2**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -Primary Care
Address: [**Location (un) 35619**], [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 23661**]
Phone: [**Telephone/Fax (1) 35614**]
Appt: [**2-8**] at 2pm
Department: PAIN MANAGEMENT CENTER
When: WEDNESDAY [**2202-2-17**] at 10:20 AM
With: [**Name6 (MD) 8673**] [**Last Name (NamePattern4) 8674**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
You have been placed on an urgent patient cancellation list and
they will call you if there is an earlier appointment as well.
ICD9 Codes: 5849, 7907, 2760, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5311
}
|
Medical Text: Admission Date: [**2177-9-8**] Discharge Date: [**2177-9-13**]
Date of Birth: [**2100-3-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Septic Shock
Pericarditis
Pericardial effusion
Major Surgical or Invasive Procedure:
Right Heart Catheterization
Left Heart Catheterization
Intubation
Pericardiocentesis
History of Present Illness:
This is a 77 year old woman with a history of ESRD (HD MWF),
diabetic nephropathy, and dementia found at her nursing home to
be more lethargic than baseline since AM when she woke up for
HD. Her temp was 100.2 but no other symptoms of infection per
[**Hospital3 **] report or daughter. [**Name (NI) **] was transfered to
[**Hospital1 18**] for further evaluation. On arrival she was found to be in
altered mental status (but her baseline was poor) and she was
intubated for ? airway protection. Her EKG showed ST elevation
in I, II , aVF, V4-6 with STD in V1. She was taken to the cath
lab. She was started on dopamine 15/min for blood pressure
support. She received [**Hospital1 **] 325 but no plavix given lack of OGT
and no IIb/IIIa inhibitor given renal failure. Cath showed
80-90% LCx lesion and 90% prox RCA and received BMS.
She was transfered to CCU care intubated and on dopamine of
5/min.
Past Medical History:
Past Medical History:
1. End-stage renal disease. Anuric. On HD MWF with new L AV
graft.
2. Diabetic nephropathy.
3. Noninsulin-dependent diabetes mellitus.
4. Hypertension.
5. Cholecystectomy.
6. S/p Nephrectomy.
7. Mixed vascular and alzheimer's dementia.
8. Anemia.
9. Infected AVG LUE, I&D [**2176-12-20**].
Social History:
There is no history of alcohol abuse. Denies drug use,
smoking.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Has lived at [**Hospital3 2558**] since [**12-5**].
Physical Exam:
VS: T 97.1, BP 102/47 , HR 74, RR 17, pO2 293 on 100%,
(difficult to check sats) on 5 of dopamine
Gen: Intubated, in NAD, tracking with eyelids but not following
commands. Exam limited by intubation, mental status/dementia
and post cath position.
HEENT: NCAT. PERRL, EOMI.
Neck: Unable to properly assess JVP.
CV: RR, normal S1, S2. ? S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Soft NTND. No mass.
Ext: No c/c/e. Sheath still in.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2177-9-8**] 07:12AM BLOOD WBC-15.9*# RBC-2.83*# Hgb-8.3*#
Hct-27.1*# MCV-96 MCH-29.4 MCHC-30.7* RDW-15.1 Plt Ct-228#
[**2177-9-8**] 07:26PM BLOOD Hct-28.9*
[**2177-9-8**] 08:00AM BLOOD Glucose-308* UreaN-68* Creat-9.0*#
Na-149* K-5.3* Cl-109* HCO3-19* AnGap-26*
[**2177-9-8**] 07:12AM BLOOD CK-MB-3 cTropnT-0.13*
[**2177-9-8**] 11:10AM BLOOD calTIBC-104* Hapto-411* Ferritn-GREATER
TH TRF-80*
[**2177-9-8**] 04:25PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-112* pCO2-36
pH-7.39 calTCO2-23 Base XS--2 Intubat-INTUBATED
[**2177-9-8**] 12:42PM URINE RBC-21-50* WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2177-9-8**] Blood Culture, Routine (Preliminary):
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R
Catheterization [**2177-9-8**]
COMMENTS:
1. Selective coronary angiography of this right-dominant system
revealed two-vessel coronary artery disease. The LMCA was
heavily
calcific but without flow-limiting stenoses. The LAD had mild
diffuse
disease and heavy calcification throughout. The Ramus was
diffusely
diseased. The LCX was non-dominant with an 80-90% hazy lesion
at its
origen with preserved flow. The RCA was dominant and heavily
calcified
and had a 90% lesion at its origin.
2. Limited resting hemodynamics demonstrated high-normal right-
and
left-sided filling pressures with an RVEDP of 10 mmHg and an
PCWP a-wave
of 13 mmHg.
3. Successful PTCA and stenting of the ostial LCX with a 3.5x16
mm
Vision BMS and the ostial RCA with a 4.0x18 mm Vision BMS. Final
angiography of both vessels revealed 0% residual stenosis and
TIMI III
flow without angiographically-apparent dissection or distal
emboli.
FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
2. Successful stenting of the ostium LCX and ostium RCA with
bare metal
stents.
ECHO [**2177-9-8**]
The left atrium and right atrium are normal in cavity size.
There is moderate symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function (LVEF
>55%). The estimated cardiac index is borderline low
(2.0-2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The abdominal aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a small pericardial effusion.
IMPRESSION: Prominent symmetric left ventricular hypertrophy
with normal cavity size and preserved global/regional
biventricular systolic function. Increased LVEDP. Mild mitral
regurgitation. Dilated aorta.
Compared with her prior study (images reviewed) of [**2174-11-29**], the
estimated pulmonary artery systolic pressure is lower.
Biventricular systolic function is similar.
[**2177-9-9**] U/S R arm
FINDINGS: Limited study of the right jugular and subclavian line
only were
performed. Complete upper extremity study could not be completed
as the
clinical team requested early termination of the study. The
right jugular
vein appears patent demonstrating normal compressibility.
Echogenic thrombus
identified within the right subclavian vein, without evidence of
Doppler flow.
IMPRESSION: Limited study demonstrating thrombus within the
right subclavian
vein.
[**2177-9-10**] TTE
Left ventricular systolic function is hyperdynamic (EF>75%). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. The effusion appears loculated. No
right ventricular diastolic collapse is seen.
Compared to the prior study dated [**2177-9-8**], the pericardial
effusion appears slightly larger (this may be due to differing
imaging angles) with a more echodense effusion.
[**2177-9-10**] CT ABd
Provisional Findings Impression: KNw WED [**2177-9-10**] 5:09 PM
1 No evidence of infection identifed. No colitis or
intra-abdominal abcess.
Brief Hospital Course:
77 lady with ESRD/HD and dementia was admitted with changes in
mental status and STE in EKG. Status post cath and BMS to prox
80-90% LCX and 90 % prox RCA.
.
# CAD/Ischemia: Admission EKG was concerning for STEMI and she
underwent catheterization w/placement of 2 BMS to the LCx and
RCA. However, given the diffuse nature of the STE, pericarditis
remained on the differential, although the lack of preceding
infectious sx, lack of fever and ST depressions on V1 made that
dx less likely. She was loaded with Plavix and maintained on
that along with [**Year (4 digits) **] and high dose lipitor. Repeat CE showed
stable CE. EKGs continued to show diffuse STE concerning for
bacterial pericarditis given positive BlCx for MSSA.
.
# Pump: The patient appeared euvolemic but her BP was in the low
80s, requiring a dopamine drip of 5mcg/kg/min. Given the
relatively good function of the heart seen on RHC, the
possibility of sepsis was entertained, especially since her
temperature dropped to 95 and her WBC was 20 and a NL SVR in the
setting of using a pressor. We gave her 1500cc bolus and 1 unit
of RBC for a low Hct and we were then able to stop the dopamine
and her BPs remained in the 110s. TTE showed an EF of 65% w/NL
LV systolic function and symmetric LVH. Antihypertensives were
held initially. CXR showed no pulmonary edema.
.
# Rhythm: She remained on telemetry and was NSR initially. On
[**2177-9-9**], had episode of AF w/RVR Tx with diltiazem drip and
return to NSR; BP dropped to 90s (from 110s) and dilt stopped at
this point. Remained on and off of AF w/o changes in BP due to
RVR.
.
# Respiratory: Pt was initially quickly weaned from CMV to PS of
[**10-5**] on 40% FIO2 and she maintained paO2 greater than 100; we
were unable to maintain sat monitor on her. Given the potential
for sepsis, we kept her intubated. Her BP didn't tolerate
sedation well and she became apneic; she was switched back to
CMV on 40% FIO2. ABGs c/w good oxygenation. She remained
intubated throughout her stay until her Code (read below).
.
# Anemia and drop in HCT: Pt was admitted with a Hct of 27.9 and
s/p cath, repeat Hct was 23.9; guiaic was negative and hemolysis
labs were unremarkable. There were no clear signs of bleed and
iron studies were c/w anemia of chronic dz. She was given 1 Unit
of RBCs which maintained her Hct at 28.9. Of note, the cath was
uncomplicated and w/o significant blood loss.
.
# HTN: Initially, we held of antihypertensive as she was
requiring dopamine and eventually levophed given her sepsis.
.
# DM: Her initial glucose levels were in the 300s which then
leveled b/n 190 and 240. She was maintained on RISS and NPH 4U
[**Hospital1 **].
# ID: Pt reportedly had a temp to 100.2 and initially, had a WBC
of 20. This became more concerning when her temp dropped to 95
and her RHC showed an SVR of 800 although in the setting of a
high pressor requirement. The possibility of sepsis was
entertained and she was pan-Cx and empirically started on
renally dosed Cefepime and Vancomycin. BlCx grew coag positive
staph and UCx alpha hemolytic strep and lactobacillus; she was
maintained on vanco and added PO vanc/IV flagyl as her WBC rose
to 31 for potential C.diff. All her access lines were changed
and a new L femoral vein was placed for HD; central access in
RIJ/SC failed [**2-1**] venous thrombus and failure to advance the
guide wire. Abd CT sent and showed no abscess. TTE re-sent which
showed echodense, loculated effusion. BlCx grew MSSA and
switched to Nafcillin on [**9-11**]; she was C.diff negative.
.
# ESRD/HD: Renal was notified of her admission and HD was
deferred on Day 1 given her HoTN and stable potassium level. She
was maintained on her baseline ESRD Rx. CVVH was started on
[**2177-9-11**] given concern for rising lytes.
# FEN: Tube Feeds were started on [**9-11**].
.
# Prophylaxis: SC heparin, PPI
.
# Code: We had a discussion with her daughter, who is the
health care proxy, on [**9-11**] and she wished to continue with the
full code status. We explained that although her WBC count and
fever were decreasing, her direction was unclear. On the morning
of [**9-13**] she developed agonal respirations and went into PEA
arrest. A code was called. She received multiple doses of
epinephrine and electrical shocks during the code which lasted
over one hour. Pericardiocentesis was performed during the code
as her arrest was believed due to tamponade; serosanguinous
fluid was removed. She eventually returned into VT for which she
was shocked and cardioverted into NSR. By this time the family
had arrived at the hospital. After discussion with her daughter
and family, she was made DNR/DNI; her pressors were
discontinued. Her BP and HR slowly dropped and she passed away
shortly thereafter, moments after being extubated.
Medications on Admission:
[**Date Range **] 81 mg daily
Losartan 50 [**Hospital1 **]
Amlodipine 10 daily
Hydralazine 75 [**Hospital1 **] (hold on dialysis day)
Humulin R SS
Glipizide 5 mg (3 tabs PO QAM)
Renegel 800 mg TID
[**Hospital1 **] 30 mg daily
Calcium carbonate 500 mg (2 tabs TID)
Ativan 0.5 mg PRN up to 3x/day
Ranitidine 150 mg daily
Colace
Nephrocaps 1 capsule QD
Fluoxetine 10mg QD
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Completed by:[**2177-9-15**]
ICD9 Codes: 5856, 4275
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5312
}
|
Medical Text: Admission Date: [**2108-2-10**] Discharge Date: [**2108-2-17**]
Date of Birth: [**2048-1-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Thoracic tracheoplasty with mesh, right main stem bronchus and
bronchus intermedius bronchoplasty with mesh, left main stem
bronchus bronchoplasty with mesh.
History of Present Illness:
Mrs. [**Known lastname **] [**Known lastname **], is a 59 year-old female with severe
tracheobronchomalacia, she has undergone placement of metal
stents to the trachea and left mainstem bronchus with subsequent
improvement in symptoms. After stent removal the patient had
recurrence of symptoms. She is seen today to be evaluated for
possible tracheobronchoplasty. A BRAVO probe was performed
demonstrating no evidence of significant [**Last Name (LF) 84478**], [**First Name3 (LF) **] overall
[**Last Name (un) **] scores of 9.9 and 4.6 over 48 hours.
Past Medical History:
Crohn's disease s/p resection, last flare ~20 years ago
Arthritis
Hypertension
Tracheomalacia s/p stent placement in [**9-10**], removed [**10-11**],
scheduled for 2nd attempt with Dr. [**Last Name (STitle) **] on Monday
Social History:
Married, has 3 grown children. Works as an adherence officer in
the Court system x 20 years.
Tobacco: [**11-21**] pack year history, quit in [**2098**]
EtOH: 1-2 drinks a few nights a week
Illicits: None
Family History:
Mother w/HTN, father w/DM, 2 sisters; 1 with
mantle cell lymphoma, the 2nd with obesity & DM
Physical Exam:
AVSS
Gen: NAD
CV: RRR
Chest: CTAB, incision c/d/i
Abd: soft, nontender, nondistended
Ext: WWP
Pertinent Results:
[**2108-2-10**] 04:28PM GLUCOSE-168* UREA N-20 CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2108-2-10**] 04:28PM estGFR-Using this
[**2108-2-10**] 04:28PM CK(CPK)-1334*
[**2108-2-10**] 04:28PM CALCIUM-8.3* PHOSPHATE-4.2 MAGNESIUM-1.6
[**2108-2-10**] 04:28PM WBC-12.1*# RBC-4.24 HGB-13.3 HCT-39.9 MCV-94
MCH-31.5 MCHC-33.4 RDW-14.2
[**2108-2-10**] 04:28PM NEUTS-93.3* LYMPHS-4.0* MONOS-2.2 EOS-0.2
BASOS-0.3
[**2108-2-10**] 04:28PM PLT COUNT-204
[**2108-2-10**] 04:28PM PT-12.3 PTT-20.9* INR(PT)-1.0
[**2108-2-10**] 11:33AM TYPE-ART PO2-195* PCO2-51* PH-7.32* TOTAL
CO2-27 BASE XS-0
[**2108-2-10**] 11:33AM GLUCOSE-160* LACTATE-1.5 NA+-136 K+-3.8
CL--100
[**2108-2-10**] 11:33AM HGB-14.2 calcHCT-43 O2 SAT-99
[**2108-2-10**] 11:33AM freeCa-1.13
Brief Hospital Course:
Ms. [**Last Name (un) 84479**] was admitted to the SICU after surgery on
[**2108-2-10**]; she was transferred to the surgical floor on [**2108-2-14**]
and discharged home in good condition on [**2108-2-17**]. The following
summarizes her hospital course by system:
Neuro: Pain control with epidural per acute pain service
immediately postop, transitioned to dilaudid PCA with
bupivacaine epidural on POD #0. Epidural removed on POD 3 and
pain control was managed with a dilaudid PCA, however the
patient did not achieve sufficient pain control and was
transitioned to PO oxycodone and tylenol. Again Ms. [**Last Name (un) 84479**]
did not feel her pain was sufficiently controlled and her
regimen was changed to include toradol, PO morphine, gabapentin,
tylenol, and baclofen, which did provide better pain control for
her.
CV: Home valsartan/HCTZ was started on POD #1. The patient
remained hemodynamically stable throughout the hospitalization
and did not require pressors or additional antihypertensives.
Resp: A right-sided chest tube was kept to suction overnight on
POD #0 and transitioned to waterseal on POD #1 with no evidence
of leak or pneumothorax. On POD #3 the chest tube was removed
and CXR remained stable. Pulmonary toilet was initiated
immediately postop with encouraged deep breathing and incentive
spirometry. She was out of bed to a chair on POD #1 and
ambulating on POD #2. She initially required supplemental O2 by
nasal cannula, which was weaned over the hospital course and she
was discharged to home in good condition without a requirement
for supplemental O2.
GI: She was started on a clear liquid diet postoperatively and
transitioned to a regular diet as tolerated. She received stool
softeners and did have a bowel movement prior to discharge.
GU: Foley catheter was placed intra-operatively and removed at
the time the epidural was removed. She voided without
difficulty.
Heme: She remained hemodynamically stable throughout the
admission and did not require transfusions of any blood
products.
ID: She received perioperative ancef and did not demonstrate
evidence of infection while hospitalized; no further antibiotics
were required.
Endo: Fingersticks were stable.
Medications on Admission:
ACETYLCYSTEINE - 10 % (100 mg/mL) Solution - nebulize three
times
a day
BENZONATATE [TESSALON PERLE] - (Prescribed by Other Provider;
Pt
reports taking.) - 100 mg Capsule - 1 (One) Capsule(s) by mouth
as needed for cough
BUDESONIDE [PULMICORT] - (Prescribed by Other Provider; Pt
reports taking.) - Dosage uncertain
CELECOXIB [CELEBREX] - (Prescribed by Other Provider; Pt
reports
taking.) - 200 mg Capsule - 1 (One) Capsule(s) by mouth once a
day
CYANOCOBALAMIN - (Prescribed by Other Provider) - 1,000 mcg/mL
Solution - once a month
MESALAMINE [ASACOL] - (Prescribed by Other Provider; Pt reports
taking.) - 400 mg Tablet, Delayed Release (E.C.) - 4 (Four)
Tablet(s) by mouth once a day
TRAZODONE - (Prescribed by Other Provider; Pt reports taking.)
-
50 mg Tablet - 1 (One) Tablet(s) by mouth as needed
VALSARTAN [DIOVAN] - (Prescribed by Other Provider; Pt reports
taking.) - Dosage uncertain
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - (Prescribed by
Other Provider) - 80 mg-12.5 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] -
(Prescribed by Other Provider; Pt reports taking.) - 600 mg-400
unit Tablet - 2 (Two) Tablet(s) by mouth once a day
GUAIFENESIN [MUCINEX] - 1,200 mg Tab, Multiphasic Release 12 hr
-
1 Tab(s) by mouth twice a day
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Diovan HCT 80-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
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. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
scoop
scoop PO DAILY (Daily).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Baclofen 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day):
while taking narcotics.
11. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: Two
(2) Tablet PO once a day.
12. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day.
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
VNA & Hospice of [**Hospital3 **]
Discharge Diagnosis:
tracheobronchomalacia
Crohn's disease
arthritis
hypertension
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] with questions or
concerns
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**2108-3-6**] 9:30 AM in the [**Hospital Ward Name 121**]
Building Chest Disease Center [**Hospital1 **] I
Chest X-Ray [**2108-3-6**] 9:00 AM in the [**Hospital Ward Name 517**] Clinical Center
[**Location (un) **] Radiology Department
Follow-up with Dr. [**First Name (STitle) 5586**] [**2108-3-6**] 10:00 am
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5313
}
|
Medical Text: Admission Date: [**2117-3-25**] Discharge Date: [**2117-4-20**]
Date of Birth: [**2041-10-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Quinine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
fevers and lethargy
Major Surgical or Invasive Procedure:
[**2117-3-26**]
Bronchoscopy
.
[**2117-3-27**]
Right pleural pigtail catheter placement
.
[**2117-3-29**]
Bronchoscopy, and right thoracotomy, right middle lobectomy with
intercostal muscle flap buttress, decortication.
.
[**2117-4-14**]
Left IJ tunnelled dialysis catheter
History of Present Illness:
This is a 75yo M with a recent history of a VATS right lower
lobectomy performed on [**2117-3-17**] with a postoperative course
requiring bronchoscopy due to persistent hypoxia and inability
to
clear secretions. He subsequently continued to recover and was
discharged home with VNA, home physical therapy, and home O2 on
[**2117-3-23**]. Yesterday the patient was reportedly lethargic at home
with a low grade temperature. Today the patient's daughter
called to report that he had a temperature of 102.1 and hence
the
patient was directed to come to the emergency room for
evaluation.
Upon evaluation, the patient reports that he has had some
lethargy for the past day. He also reports some continuing SOB,
and does get short of breath with exertion. His cough is
productive of sputum, some of it rust tinged.
Past Medical History:
PAST MEDICAL HISTORY:
1. DM2
2. HL
3. HTN
4. PE ([**2094**])
5. Knee surgery ([**2094**])
6. Appendectomy as a child
7. Rigid Esophagus
PAST SURGICAL HISTORY:
1. [**2117-3-12**] Cervical mediastinoscopy
2. VATS RLLobectomy [**2117-3-17**]
Social History:
Cigarettes: [ ] never [x] ex-smoker [ ] current Pack-yrs:_50_
quit: _2008__
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [x] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation:
Marital Status: [ ] Married [x] Single
Lives: [x] Alone [ ] w/ family [ ] Other:
Family History:
non contributory
Physical Exam:
ON ADMISSION:
Temp: 98.1 HR:112 BP:114/56 RR:16 O2 Sat:94%2L
GENERAL [ ] All findings normal
[ ] WN/WD [x] NAD [x ] AAO [ ] abnormal findings: Some SOB,
appears mildly ill
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings: Diminished breath sounds at right base,
some coarse crackles on right, left side is clear
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
.
ON DISCHARGE:
-------------
Vitals:
T: 99.0 P: 71 BP: 133/61 RR: 15 O2sat:
General: slow to arouse, dobhoff in place
HEENT: NCAT, MMM
Heart: RRR
Lungs: bilateral rhonchi improving
Abdomen: soft, NT, ND, (+) BS
Extremities: WWP, no CCE, moves all
radial DP PT
R palp palp palp
L palp palp palp
Pertinent Results:
LABS ON ADMISSION:
------------------
[**2117-3-25**] 04:59PM WBC-21.0*# RBC-3.92* HGB-12.0* HCT-34.1*
MCV-87 MCH-30.6 MCHC-35.1* RDW-12.6
[**2117-3-25**] 04:59PM PLT COUNT-427
[**2117-3-25**] 04:59PM PT-12.5 PTT-27.8 INR(PT)-1.2*
[**2117-3-25**] 04:59PM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-1.9
[**2117-3-25**] 04:59PM GLUCOSE-181* UREA N-13 CREAT-1.0 SODIUM-133
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
.
[**2117-3-25**] Chest CT :
1. Overall growth and progressive gaseous contents of a large
right infrahilar phlegmon, probably an abscess, and larger air
and fluid loculations in the dependent right pleural space, are
indirect but strong indications of active connections between
the lungs or airway and the pleurae, even though a discrete
connection from the lower lobe bronchial stump is not visible.
The findings of peripheral alveolitis in the left lung conform
to 'spillover' pneumonitis seen in such circumstances. Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7343**] was paged to discuss these findings, at the time
of dictation.
2. Right middle lobe bronchus is still obliterated.
3. Severe coronary artery calcification and possible aortic
valvular
stenosis.
.
[**2117-3-27**] CT guided drainage :
CT-guided placement of 10 French pigtail catheter into the right
complex
pleural air/fluid collection. Requested laboratory analysis
pending
.
[**2117-3-30**] Cardiac echo :
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is normal (LVEF
55-65%). The number of aortic valve leaflets cannot be
determined. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
[**2117-4-14**] Fluoro for HD catheter:
Successful placement of a tunneled hemodialysis access catheter
through the left internal jugular vein approach. The distal tip
is located in the right atrium and the proximal lumen at the
SVC/right atrial junction. The catheter is ready for use.
.
[**2117-4-15**] CXR:
: Compared to the previous radiograph, the patient has received
a new
hemodialysis catheter over a left-sided approach. The course of
the catheter is unremarkable, the tip of the catheter projects
over the right atrium. Otherwise, there is no relevant change.
Unchanged size of the cardiac silhouette. Unchanged mild fluid
overload. Unchanged elevation of the right hemidiaphragm with a
mild-to-moderate right pleural effusion. Focal parenchymal
opacities have newly occurred.
.
[**2117-4-19**] CXR:
FINDINGS: Monitoring and supporting devices are in standard
position.
Moderate right pleural effusion and small left pleural effusions
associated with adjacent lung atelectasis and bilateral
pulmonary vascular congestions is unchanged. Cardiomediastinal
silhouette is stable. No new interval changes in the lung.
.
[**2117-4-19**] LENIs:
IMPRESSION:
No right or left lower extremity DVT.
.
[**2117-3-26**] 8:42 am BRONCHOALVEOLAR LAVAGE RIGHT BRONCHIAL
ASPIRATE.
GRAM STAIN (Final [**2117-3-26**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2117-3-31**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ACID FAST SMEAR (Final [**2117-3-29**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2117-4-9**]):
YEAST.
.
[**2117-3-27**] 11:09 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2117-3-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2117-3-30**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2117-4-2**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
UAs
---
[**2117-3-30**] 12:33PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2117-4-2**] 03:02PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2117-4-15**] 11:11AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
.
LABS ON DISCHARGE:
------------------
[**2117-4-20**] 04:14AM BLOOD WBC-12.3* RBC-2.70* Hgb-8.3* Hct-25.4*
MCV-94 MCH-30.7 MCHC-32.6 RDW-14.7 Plt Ct-164
[**2117-4-20**] 04:14AM BLOOD Neuts-71.8* Lymphs-19.9 Monos-3.9 Eos-3.7
Baso-0.8
[**2117-4-20**] 04:14AM BLOOD Plt Ct-164
[**2117-4-20**] 04:14AM BLOOD Glucose-135* UreaN-52* Creat-4.2*# Na-140
K-4.3 Cl-103 HCO3-27 AnGap-14
[**2117-4-20**] 04:14AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 91948**] was evaluated by the Thoracic Surgery service in
the Emergency Room and scans were reviewed. His chest CT showed
a large collection of fluid and air in the right pleural space
along with pneumonitis and his WBC was 21K. He was admitted to
the hospital and placed on broad spectrum antibiotics.
.
On [**2117-3-26**] he underwent a bronchoscopy to R/O bronchopleural
fistula. There was no visualization of a BPF but the stump was
poorly visualized. He subsequently had a pigtail catheter
placed in his right pleural space for drainage but did not
improve. His oxygen requirements increased and he eventually
was intubated and transferred to the ICU. He was taken to the
Operating Room on [**2117-3-29**] and underwent a Bronchoscopy, and
right thoracotomy, right middle lobectomy with intercostal
muscle flap buttress and decortication for a bronchopleural
fistula and empyema. He tolerated the procedure well but
required aggressive fluid resuscitation and pressors to maintain
stable hemodynamics.
.
His post op course was complicated by prolonged intubation and
acute kidney injury requiring CVVH on [**2117-4-2**] with a high
creatinine of 6.4 and eventually hemodialysis. His kidney
function recovered a bit after 4 days to a creatinine of 2.5 but
unfortunately it was short lived and hemodialysis was restarted
and continues. He had a tunnelled line placed on [**2117-4-14**] via
the left IJ and undergoes dialysis every Monday, Wednesday and
Friday.
.
From a pulmonary standpoint, he was finally weaned and extubated
on [**2117-4-12**] and currently undergoes vigorous pulmonary toilet and
is able to cough up his secretions. His chest tubes were
removed 10 days post op and all of his intraop cultures were
negative. His incision sites are healing well. He still uses
1.5-2L nasal cannula oxygen to maintain saturations > 90%.
.
The Speech and Swallow service assessed him on multiple
occasions and felt that he was a high aspiration risk due to his
occasional lethargy. His nutrition requirements are currently
given thru an NG tube (dobhoff) as well as through oral thin
liquid and puree solid feeds. Tube feeds will be stopped when
nutrition requirements are met solely via an oral route.
.
The patient continues on hemodialysis for improvement of the
acute kidney injury he sustained as above. Creatinine is
downtrending nicely.
.
The patient will receive 6 days of ciprofloxacin to cover a
possible urinary tract infection, although to date, urine
culture remains NGTD, the patient is afebrile, and white count
continues downtrending.
Medications on Admission:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY.
2. aspirin 81 mg Tablet, Chewable Sig 1 tab PO DAILY
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO QHS PRN
Constipation
7. Colace 100 mg Capsule Sig: One (1) Capsule PO BID
8. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO BID
9. Oxygen at 2 liters/min via nasal cannula, continuous
Discharge Medications:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 doses.
2. heparin (porcine) 1,000 unit/mL Solution Sig: 1000 (1000)
units/mL Injection PRN (as needed) as needed for dialysis.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for fever or pain: Do not exceed 4 grams in 24
hours.
8. Nasal cannula oxygen
Patient on 1.5-2L via nasal cannula.
9. insulin glargine 100 unit/mL Solution Sig: Forty (40) Units
Subcutaneous QAM.
10. insulin regular human 100 unit/mL Solution Sig: refer to
sliding scale sliding scale Injection four times a day: Please
refer to sliding scale attached with discharge papers in
addition to standing AM Lantus dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Bronchopleural fistula with empyema formation.
Sepsis.
Acute kidney injury.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 91948**],
You were admitted to the hospital with fevers, shortness of
breath, and lethargy due to an infection in your lung. You
underwent an operation to remove the middle lobe of your right
lung and clean out this infection. You were very sick, and
unfortunately suffered an acute kidney injury for which you are
still receiving hemodialysis.
.
* You have improved daily, and are now breathing on your own
without difficulty or assistance. When you are stronger you
will be able to eat a full and regular diet, but for now, you
are being fed through a feeding tube in your nose as well as
with a liquid and puree diet by mouth in order to give you
adequate nutrition.
.
* You are being transferred to a rehab facility to help build up
your strength and endurance before returning home.
.
* You will still need to follow-up with Dr. [**Last Name (STitle) **] in his
clinic on Tuesday, [**2117-4-27**] @ 2PM.
.
YOUR MEDS ON ADMISSION:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
2. aspirin 81 mg Tablet, Chewable Sig 1 tab PO DAILY
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO QHS PRN
7. Colace 100 mg Capsule Sig: One (1) Capsule PO BID
8. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO BID
9. Oxygen at 2 liters/min via nasal cannula, continuous
.
MEDS ON DISCHARGE:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 doses.
2. heparin (porcine) 1,000 unit/mL Solution Sig: 1000 (1000)
units/mL Injection PRN (as needed) as needed for dialysis.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for fever or pain: Do not exceed 4 grams in 24
hours.
8. Insulin 40 Lantus QAM and insulin sliding scale.
9. Nasal cannula oxygen Patient on 1.5-2L via nasal cannula.
.
Simvastatin and Metformin should be restarted when patient
stabilized on oral nutrition regimen alone and acute kidney
injury resolved.
Followup Instructions:
You have the following follow-up appointments:
.
When: TUESDAY [**2117-4-27**] at 2:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PODIATRY
When: TUESDAY [**2117-5-11**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2117-4-20**]
ICD9 Codes: 486, 0389, 5845, 2762, 5990, 2767, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5314
}
|
Medical Text: Unit No: [**Numeric Identifier 72994**]
Admission Date: [**2177-5-21**]
Discharge Date: [**2177-6-9**]
Date of Birth: [**2177-5-21**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: The patient was the 1.39 kg
product of a 33 and 0/7 week gestation born to a 33-year-old,
primip. Prenatal screens A+, antibody negative, RPR
nonreactive, rubella immune, hepatis surface antigen
negative, GBS unknown. Pregnancy was complicated by
hypertension, leading to transfer from [**Hospital1 6687**] to [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. The mother received betamethasone x
1 and then the infant was noted to be less responsive and
delivered by emergent cesarean section under general
anesthesia. No maternal fever. Fetal tachycardia. No
intrapartum antibiotic prophylaxis. Rupture of
membranes for clear fluid at delivery. Infant emerged with
spontaneous cry and required only blow-by oxygen and required
routine care in the delivery room. Apgar scores were 8 and 9.
Weight on admission was 1390, 10th percentile. Length was 37.5
cm, less than 10th percentile. Head circumference was 28 cm, 10th
percentile.
DISCHARGE PHYSICAL EXAM: Awake and alert. Anterior fontanel
open and flat. Breath sounds clear and equal on room air with
mild retractions and comfortable respiratory effort. No
audible murmur. Well perfused with normal pulses. Abdomen
soft and rounded with active bowel sounds. Hemangioma
approximately 2 cm around on left abdomen. Mild redness in
diaper area. Normal genitalia.
HOSPITAL COURSE: Respiratory: The patient was admitted to
the newborn intensive care unit with mild grunting, flaring
and retracting treated with CPAP for a total of 12 hours at
which time he transitioned to room air. He has remained
stable in room air since that time. He has not required
methylxanthine therapy and has had no episodes of apnea or
bradycardia.
Cardiovascular: He has been cardiovascularly stable without
issues.
Fluids and electrolytes: Birth weight was 1390 g. Discharge
weight was 1830 g. Discharge length was 43.5 cm. Discharge
head circumference was 29 cm. Infant was initially started on
80 cc/kg of D10W. Enteral feedings were initiated on day of
life #1. Achieved full enteral feedings by day of life #8.
Maximum caloric intake was 150 cc of Special Care 26 calorie.
He has been on all p.o. feedings since [**2177-6-7**].
Discharge formula is with NeoSure powder concentrated to 26
calories to support his weight gain. He is taking in adequate
amounts.
GI: Peak bilirubin was 12/0.4. He was treated with
phototherapy and the issue resolved.
Hematology: Hematocrit on admission was 59. The infant has
not required any blood transfusions.
Infectious disease: Routine results were benign and
ampicillin and gentamicin were discontinued at 48 hours with
negative blood culture. He has had no further issues of
sepsis.
Neurologic: The infant has been appropriate for gestational
age.
Sensory: Hearing screen was performed with automated auditory
brain stem response and the infant passed both ears.
Ophthalmology: The infant was seen on [**6-2**] with immature
retinal vessels to zone 3. Recommended follow-up in 3 weeks.
Psychosocial: Mother has been involved. Limited English.
Mother is mostly [**Name (NI) 8003**] speaking and are staying with family
in [**Hospital1 189**] while she is off island.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 38832**] at [**Hospital 189**] Community Health
Center, [**Telephone/Fax (1) 30953**]. Name of pediatrician in [**Hospital1 6687**] is
Dr. [**Last Name (STitle) 45938**], [**Telephone/Fax (1) 45939**].
CARE RECOMMENDATIONS: Continue ad lib feeding, NeoSure 26
calorie by concentration.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREENING: The infant was sent home on car
bed as the infant was too small for his car seat.
STATE NEWBORN SCREENS: Have been sent per protocol and have
been within normal limits. Hepatitis B vaccine was given on
[**2177-6-9**].
DISCHARGE DIAGNOSIS: Infant born at 33 weeks, mild
respiratory distress, strawberry hemangioma, mild
hyperbilirubinemia.
Reviewed BY: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 72995**]
MEDQUIST36
D: [**2177-6-9**] 21:42:31
T: [**2177-6-9**] 22:36:53
Job#: [**Job Number 72996**]
ICD9 Codes: 769, 7742, V053, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5315
}
|
Medical Text: Admission Date: [**2173-7-14**] Discharge Date: [**2173-7-24**]
Service: Vascular Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
gentleman, well known to the vascular service, who was
recently discharged after evaluation of a right foot ulcer.
He returned on [**2173-7-14**] with an episode of a fall early
that morning. The patient felt dizzy and fell on the floor.
He had some pain in both eyes. The patient does have a
history of a cerebrovascular accident and transient ischemic
attacks and was scheduled for a right carotid endarterectomy.
The patient denies any changes in speech, numbness, tingling
or loss of sensation anywhere in his body. His symptoms
disappeared in a few minutes.
PAST MEDICAL HISTORY: 1. Coronary artery disease, old Q
wave myocardial infarction in [**2172-3-12**]. 2. Congestive
heart failure, left ventricular ejection fraction 25% to 30%.
3. Diabetes mellitus. 4. Chronic obstructive pulmonary
disease. 5. End-stage renal disease, on hemodialysis on
Monday, Wednesday and Friday. 6. Gout. 7. Anemia. 8.
Pneumonia in [**2173-3-12**]. 9. Epididymitis. 10. Right foot
gangrene.
PAST SURGICAL HISTORY: 1. Percutaneous transluminal
coronary angioplasty in [**2173-6-12**] (left anterior descending
artery plus stent, left coronary artery plus stent). 2.
Left femoral-peroneal bypass graft in [**2172-3-12**]. 3. Left
arteriovenous fistula. 4. Left transmetatarsal amputation.
5. Left inguinal hernia repair in [**2114**]. 6. Radiocephalic
fistula in [**2172-12-12**]. 7. Left brachiocephalic fistula
in [**2173-1-12**].
MEDICATIONS ON ADMISSION: Glucotrol 2.5 mg p.o.q.d.,
Lopressor 12.5 mg p.o.b.i.d., Lipitor 10 mg p.o.q.d., Zestril
5 mg p.o.q.d., allopurinol 100 mg p.o.q.d., Tums 500 mg
p.o.t.i.d., aspirin 325 mg p.o.q.d., Flomax 0.4 mg
p.o.q.h.s., Protonix 40 mg p.o.q.d., Atrovent one to two
puffs q.12h., albuterol one to two puffs q.4-6h.p.r.n.,
Flovent one to two puffs b.i.d., Epogen 4,000 units with
hemodialysis, Plavix 75 mg p.o.q.d., levofloxacin 250 mg
p.o.q.48h., Flagyl 500 mg p.o.t.i.d.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 97.3, pulse 72, blood
pressure 100/60, respiratory rate 16 and oxygen saturation
94% in room air. Head, eyes, ears, nose and throat: Pupils
equal, round, and reactive to light, no erythema, no
exudates. Cardiovascular: Regular rate and rhythm. Lungs:
Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended. Extremities: Right dry gangrene
over lateral aspect of right foot, gangrenous toes #2 and 3
on the right foot, left transmetatarsal amputation, incision
site clean, dry and intact, 1+ ankle edema bilaterally.
Pulses: Carotids 1+ with bruits heard on right, femoral 2+
bilaterally, popliteal not palpable, dorsalis pedis
Dopplerable right and left, and posterior tibialis
Dopplerable on left, nonpalpable and non-Dopplerable on
right. Neurologic examination: Alert and oriented times
three, cranial nerves II through XII intact, sensory intact,
motor intact, deep tendon reflexes 1+ bilaterally.
LABORATORY DATA: Admission hematocrit was 32.9, sodium 139,
potassium 4.5, chloride 99, bicarbonate 27, BUN 54,
creatinine 3.6 and blood sugar 82.
HOSPITAL COURSE: The patient was admitted to the vascular
service and placed on a heparin drip for anticoagulation. A
cardiology consult was obtained and a recommendation was made
for the patient to remain on Plavix due to his recent cardiac
procedure.
On [**2173-7-18**], on recommendation from cardiology, the
Plavix was stopped because it was felt that the patient had
had an adequate amount of time on this medication. The
patient remained asymptomatic until [**2173-7-21**], when he
was taken to the Operating Room for a right carotid
endarterectomy.
At the end of the case, during suturing, the patient
developed severe hypotension with a systolic blood pressure
dropping down to 50 and heart rate in the 40s and 50s. The
patient was supported on epinephrine. A Swan-Ganz catheter
was placed showing a central venous pressure of 14, pulmonary
artery pressure of 60/22, cardiac output 3.4. A
transesophageal echocardiogram was performed in the Operating
Room, which showed a left ventricular ejection fraction of
35%, distal anterior septal hypokinesis, and mild tricuspid
regurgitation.
The patient responded well to pressors and was transported to
the Post Anesthesia Care Unit with a blood pressure of 120/70
and electrocardiogram showing no significant changes at that
time. The patient was transferred to the Surgical Intensive
Care Unit, where he remained completely asymptomatic. He was
ruled out for a myocardial infarction by cardiac enzymes and
electrocardiograms. The patient was transferred to a regular
floor on [**2173-7-23**].
Laboratory data on discharge: Hematocrit 27, white blood
cell count 8.2, platelet count 199,000, sodium 140, potassium
3.8, chloride 105, bicarbonate 23, BUN 35, creatinine 3.8,
blood sugar 135, prothrombin time 12.7, partial
thromboplastin time 29.5, INR 1.1, calcium 7.3, magnesium
1.6, phosphorous 4.3.
DISPOSITION: The patient continued to be asymptomatic and
was discharged home on [**2173-7-24**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home with
VNA services.
DISCHARGE MEDICATIONS:
Glucotrol 2.5 mg p.o.q.d.
Lopressor 12.5 mg p.o.b.i.d.
Lipitor 10 mg p.o.q.d.
Zestril 5 mg p.o.q.d.
Allopurinol 100 mg p.o.q.d.
Tums 500 mg p.o.t.i.d.
Aspirin 325 mg p.o.q.d.
Flomax 0.4 mg p.o.q.h.s.
Protonix 40 mg p.o.q.d.
Atrovent one to two puffs q.12h.
Albuterol one to two puffs q.4-6h.p.r.n.
Flovent one to two puffs t.i.d.
Epogen 4,000 units with hemodialysis.
Levofloxacin 250 mg p.o.q.48h. times ten days.
Flagyl 500 mg p.o.t.i.d. times ten days.
Percocet one to two tablets p.o.q.4-6h.p.r.n.
Dakin's solution one-quarter strength for dressing changes
b.i.d.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) 1391**] in ten to 14 days, at which time staples will be
removed. At that time, the patient can discuss further
management of his right foot ulcer with Dr. [**Last Name (STitle) 1391**].
DISCHARGE DIAGNOSES:
1. Right carotid stenosis, status post right carotid
endarterectomy.
2. Episode of hypotension, ruled out for myocardial
infarction, etiology unknown.
SECONDARY DIAGNOSES:
1. Coronary artery disease.
2. Congestive heart failure.
3. Diabetes mellitus.
4. Chronic obstructive pulmonary disease.
5. End-stage renal disease, on hemodialysis.
6. Gout.
7. Anemia.
8. Epididymitis.
9. Right foot ulcer.
10. Right leg ischemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern4) 22171**]
MEDQUIST36
D: [**2173-7-25**] 16:02
T: [**2173-7-25**] 16:26
JOB#: [**Job Number 22172**]
ICD9 Codes: 4280, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5316
}
|
Medical Text: Admission Date: [**2134-6-15**] Discharge Date: [**2134-7-5**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
CC:[**Last Name (STitle) 102394**]
Major Surgical or Invasive Procedure:
Temp R HD cath
History of Present Illness:
48 YO M with sarcoidosis with ESRD s/p failed transplant, h/o
hep B/C/?D, h/o paf on coumadin, h/o pulmonary aspergillosis,
presented from NH to OSH with neck stiffness, was found to be
hypotensive to the 80s, was started on vancomycin and
transferred to the [**Hospital1 18**]
.
In the field T101.8 108 111/66, in ED BP 79/53. was given
ceftazidine, gentamicin, transplant was consulted for possible
line removal, and renal were consulted. In addition his INR was
5 and was given FFP. He was given 250cc NS and transferred to
the ICU.
.
In the ICU, he states he's had an aching neck pain [**11-10**] and
stiffness for the past day, he denies trauma, or headache, light
sensitivity or rash, this pain is new onset. He otherwise
denied f/c, cough/sob, cp, diarrhea, n/v, no urine output on
baseline. no recent travel.
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-4**] now on HD- L
groin line
IVC stent
Sarcoidosis
Pulmonary aspergillosis
DM
Chronic HCV
Hypertension
Sinusitis,
Paroxysmal atrial fibrillation, C. difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity DVT ([**2132**])
Pancreatitis
Bilateral BKA
Right index finger amputation
Social History:
Patient currently living at rehab facility. Smoked 1 ppd X 30
years but quit one year ago. No alcohol. Previous drug use
(IVDU). Girlfriend is involved in his care.
Family History:
Mother, brother with diabetes.
Physical Exam:
PE: VS 96.3 93/59 106 20 94% 2L
Gen: lethargic, AAOx3, speaking in full sentences
HEENT: EOMI, PERRLA, neck unable to touch chin to chest,
OP dry,
Chest: crackles at the bases bilaterally
CV: RRR nl s1 s2 no mrg appreciated
Abd: soft, NT, ND +BS no guarding or rebound
Ext: R BKA, L BK (dark skin around sutures, otherwise clean,
dry)
R index finger amputation, wound CDI, no erythema fluctuance
Neuro: moves all 4, AAOx3
Pertinent Results:
[**2134-6-15**] 12:40PM BLOOD WBC-20.6*# RBC-4.05* Hgb-11.9* Hct-38.7*
MCV-96 MCH-29.5 MCHC-30.9* RDW-16.8* Plt Ct-385
[**2134-6-15**] 12:40PM BLOOD Neuts-71* Bands-0 Lymphs-13* Monos-16*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2134-6-15**] 12:40PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2134-6-15**] 12:40PM BLOOD PT-61.9* PTT-68.8* INR(PT)-7.7*
[**2134-6-15**] 12:40PM BLOOD Glucose-64* UreaN-84* Creat-11.3*#
Na-130* K-5.2* Cl-93* HCO3-13* AnGap-29*
[**2134-6-16**] 02:14AM BLOOD Calcium-8.4 Phos-5.0*# Mg-2.2
[**2134-6-16**] 02:14AM BLOOD Vanco-14.8
.
EKG SR 106bpm NA, peak P waves. no ST-T changed, no change from
previous.
.
CXR:
Suspicion of diffuse process in lungs possibly reoccurrence of
aspergillosis. As translation of findings on plain chest
examination into findings observed on previous CT may be
difficult, consider the possibility to ascertain these new
findings by renewed CT examination of this patient known to have
rather advanced sarcoidosis. Stat report delivered to emergency
room board.
Brief Hospital Course:
Assessment/Plan: 48M with sarocoidosis, amyloidosis-->ESRD on HD
with hx mult line infections, who p/w MRSA bacteremia,
endocarditis, pre-vertebral cervical abscess.
.
# MRSA bacteremia/Pre-vertebral abscess/Endocarditis: Pt
presented with neck pain/stiffness. Found to have prevertebral
(c3-4) abscess with associated discitis/osteomyelitis on CT &
MRI. Source likely MRSA bacteremia from infected HD catheter
(in L groin). Blood cx's from [**6-15**] grew MRSA in [**8-8**] bottles;
cx's from [**6-17**] grew MRSA in [**2-2**] bottles. Surveillance cultures,
following initiation of antibiotics, from [**6-18**] thru [**6-22**] were no
growth. TTE showed moderate-sized
mobile vegetation on mitral valve, which will be treated with
antibiotics only. Pt was treated with both vancomycin and
gentamicin. Gentamicin was discontinued on [**2134-6-25**], and the
patient was continued on vancomycin. He went for a washout of
cervical abscess w/ neurosurgery on [**2134-6-24**]. Abscess grew MRSA
as well. He is to continue on vancomycin 8wks from [**6-24**], which
was the date of his prevertebral abscess washout. Pt
defervesced following initiation of antibiotics. A tunnelled
catheter was replaced in the groin on [**2134-7-5**].
Neurosurgery does not feel that there is a need for follow up
imaging and he will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2134-7-26**].
.
# ESRD: Thought to be due to amyloidosis. He is status post
failed renal transplant. He is maintained on chronic HD on a
Tues-Thurs-Sat schedule.
.
# Right index finger pain: likely due to progressive dry
gangrene. He is status post amputation of distal portion on
[**2134-6-7**] by plastic surgery and given progression of gangrene, the
rest of the digit to the MCP was removed with flap revision on
[**2134-6-30**].
.
# Anemia: likely multi-factorial--related to CKD/anemia of
chronic disease & operative loses. He receives Epo at HD, was
stable during this admission.
.
# H/o asperg infxn: Itraconazole was continued for prophylaxis.
.
# H/o adrenal insufficiency: related to chronic steroid use (for
possible renal transplant or amyloid). He received stress dose
steroids for surgery and by the time of discharge had been
tapered down to his outpatient regimen of prednisone 5mg
alternating with 2.5mg daily.
.
# Delirium: CT head w/ contrast unremarkable. Altered mental
status attributed to infection exacerbated by pain medication.
By the time of discharge, patient was back to baseline.
.
# DM: well controlled on insulin sliding scale.
.
# Afib: The patient was in NSR throughout the admission. His
metoprolol was continued, but given his multiple procedures and
also given that his INR was supratherapeutic on admission, his
coumadin was held. It was restarted on the day of discharge,
with a goal of [**3-6**] which will have to be monitored upon
discharge.
.
# Psych: celexa was continued.
.
# FEN: Please maintain patient on a renal, diabetic, fluid
restricted (to 1.5L/day) diet.
.
# PPx: subcut heparin, ppi
.
# Comm: HCP [**Name (NI) 102395**] [**Name (NI) 10664**] (girlfriend) [**Telephone/Fax (1) 102392**]
.
# Code: Full (discussed with pt & HCP).
Medications on Admission:
Prednisone 5MG QD, 2.5mg QD
Provigil 100mg QD
Nephrocaps QD
Sensipar 60mg QD
Itraconazole 200mg [**Hospital1 **]
Fosrenol 50mg TID
Renagel 2400mg TID
Citalopram 30mg QD
Folic Acid 1mg QD
Metoprolol 12.5mg QD
Vicodin ES TID
MOM 30ml [**Hospital1 **] PRN
Tramadol 50mg [**Hospital1 **] PRN
Tylenol PRN
Dulcolax 10mg PRN
Coumadin 1mg QHS
Discharge Medications:
1. Outpatient Lab Work
Please check CBC/diff, ESR, CRP every week and fax to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of Infectious Diseases ([**Telephone/Fax (1) 16411**].
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
15. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
18. Vancomycin 1000 mg IV HD PROTOCOL
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
20. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please check INR, goal [**3-6**].
21. Outpatient Lab Work
Please check INR daily, patient just being restarted on coumadin
on [**2134-7-5**] after tunnelled line placement. Goal INR is [**3-6**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary:
MRSA bacteremia
Endocarditis
Pre-vertebral cervical abscess
Gangrene of right index finger
.
Secondary:
ESRD on HD likely secondary to amyloidosis
Anemia
History of aspergillus infection
Diabetes Mellitus
Atrial Fibrillation on coumadin
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted for infection of the heart valves and the
space around your spinal cord. You have been on intravenous
antibiotics during this admission and will continue on these
antibiotics for a total of 8 weeks. You also had further
amputation of the right index finger secondary to progressive
gangrene.
.
If you experience fevers or chills, nausea/vomiting, chest pain
or shortness of breath, please seek medical attention.
Followup Instructions:
With Dr [**First Name (STitle) **] in Infectious Diseases (ID) Clinic on [**7-26**] at
9:30am.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5856, 4280, 2930, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5317
}
|
Medical Text: Admission Date: [**2167-1-22**] Discharge Date: [**2167-1-30**]
Date of Birth: [**2091-7-12**] Sex: F
Service: MEDICINE
Allergies:
Enalapril / Shellfish
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
Balloon Angioplasty of AV fistula
History of Present Illness:
75F dm, esrd, chf presents with nausea, vomiting, and GI upset
for x2 days. Pt called PCP [**1-21**], day before admit, with
complaints of "feeling sick" for previous 4 days with gi upset.
At that time, denied vomiting, cough, irregular bowel movement.
She then related the symptoms to eating a hot dog and jelly
beans. PCP thought she sounded quite miserable and not herself,
plan was for ED evaluation if worsened.
Pt also complains of fatigue during this time period. Denies
vision changes, sore throat, dysphagia, epigastric discomfort,
diarrhea or bloody stools. Denies MSK cramps.
In [**Hospital1 18**] ED, vital signs stable, sbp 160/80, hr 120, rr 18,
satting 97% ra, afebrile. Abd soft, mildly tender lower
quadrants. Glucose elevated at 346, given insulin. EKG showed
st-depressions v5-v6, cxr normal, ct scan abd showed mild
diverticulitis. Cards consulted for troponin bump with
tachycardia. Given 2.5l IVF, given aspirin 325mg once,
initiated on flagyl and cipro, which caused a rash, then
switched to zosyn. Lactate initially 4.0, resolved to 2.6 with
IVF. Transferred to MICU for persistent tachycardia and
troponin bump, in stable condition.
Past Medical History:
1. TII diabetes mellitus - insulin-dependent - diag [**2130**].
2. Chronic kidney disease - stage 5 - followed by Dr.
[**Last Name (STitle) 7473**]. Left av-fistula in place with question of proximal
narrowing, pending surgical evaluation. Has not been
hemodialyzed as of yet.
3. CHF - [**2160**] EF 20-30%, [**2-/2166**] ECHO persistent LVH, likely [**1-10**]
hypertensive heart disease, with mild MR, mild-to-moderate TR.
Followed by [**Hospital 1902**] clinic, cardiomyopathy thought [**1-10**] htn dm.
4. Sensory neuropathy.
5. Onychodystrophy
6. Hyperkeratotic lesions plantar aspects feet
7. Ischemic colitis - [**4-/2166**]
8. LGIB - [**4-/2166**] - thought possible [**1-10**] to ischemic colitis
9. Diverticulosis
10. Breast cancer (invasive ductal, dx [**2156**]). diagnosed [**9-/2157**]
with a 1.5 cm grade II infiltrating ductal cancer of the right
breast, clean lymph nodes, ER positive, HER-2/neu negative.
Presumed remission now s/p five years on tamoxifen.
11. Renal osteodystrophy
12. Hypercholesterolemia
13. TB @ 21 yo, s/p lobectomy
14. Fibroids, s/p hysterectomy
Social History:
She is living with her daughter, grandson, his
wife and great granddaughter who is two months old. She is
finding that to be quite acceptable to her. She does not smoke.
She does not drink alcohol.
Family History:
Mother -- breast cancer
[**Name (NI) **] -- breast cancer
Brother -- melanoma
Physical Exam:
T 98 BP 160/80 HR 134 RR 20 98%ra
Gen - NAD, A/Ox3, sitting in bed, vomiting (yellow-brownish
fluid, no blood identified). conversant, cooperative, not able
to finish all sentences due to vomiting..
HEENT - no conjunctival pallor, no scleral icterus appreciated,
mildly dry membranes. no posterior pharyngeal erythema
appreciated.
NECK - no posterior/anterior LAD, +JVD 2cm superior to clavicle
bil in upright position.
CV - RRR, S1+S2+S3-S4-, 3/6 sem lsb with radiation to the back
LUNGS - CTAB, good air movement bilaterally, no crackles
appreciated, no wheezes appreciated
ABD - NABS, soft, non-tender, non-distended. No organomegaly
appreciated.
EXT - trace lower extremity edema. 2+ palpable pulses
bilaterally dorsalis pedis, posterior tibial, radial, ulnar, all
2+.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy. Preserved sensation throughout. MSK 4+/5
bilaterally, upper extremities and lower extremities. 1+
reflexes L4 bilaterally.
PSYCH - Listens and responds to questions appropriately
.
T 97.2 BP 122/60 HR 74 RR 18 98%ra
Gen - NAD, A/Ox3, sitting in bed in NAD
HEENT - no JVD, no lympadenopathy
CV - RRR, S1+S2+S3-S4-, [**2-12**] murmur (refered from AV fistula)
LUNGS - CTAB, good air movement bilaterally, no crackles
appreciated, no wheezes appreciated
ABD - NABS, soft, non-tender, non-distended. No organomegaly
appreciated.
EXT - no lower extremity edema. AV fistula in left arm w/o
bleeding or bruising, in tact.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact,
strength 5/5
Pertinent Results:
CBC
[**2167-1-22**] 06:00AM BLOOD WBC-13.4* RBC-4.44 Hgb-12.0 Hct-35.6*
MCV-80* MCH-26.9* MCHC-33.6 RDW-15.2 Plt Ct-289
[**2167-1-22**] 06:00AM BLOOD Neuts-86.5* Lymphs-8.3* Monos-5.0 Eos-0.1
Baso-0.1
[**2167-1-24**] 03:54AM BLOOD WBC-12.0* RBC-4.11* Hgb-10.9* Hct-34.5*
MCV-84 MCH-26.4* MCHC-31.5 RDW-15.1 Plt Ct-253
[**2167-1-25**] 06:50AM BLOOD WBC-11.1* RBC-3.78* Hgb-9.8* Hct-31.1*
MCV-82 MCH-25.9* MCHC-31.5 RDW-15.2 Plt Ct-263
[**2167-1-26**] 09:45AM BLOOD WBC-10.5 RBC-3.86* Hgb-10.0* Hct-32.5*
MCV-84 MCH-26.0* MCHC-30.8* RDW-15.5 Plt Ct-269
.
Chem 7
[**2167-1-22**] 06:00AM BLOOD Glucose-375* UreaN-65* Creat-4.6* Na-140
K-5.0 Cl-98 HCO3-22 AnGap-25*
[**2167-1-23**] 12:07AM BLOOD Glucose-120* UreaN-70* Creat-5.2* Na-144
K-4.6 Cl-111* HCO3-21* AnGap-17
[**2167-1-25**] 06:50AM BLOOD Glucose-75 UreaN-67* Creat-5.5* Na-140
K-4.1 Cl-103 HCO3-23 AnGap-18
[**2167-1-27**] 06:40AM BLOOD Glucose-126* UreaN-50* Creat-4.8*# Na-138
K-4.0 Cl-98 HCO3-23 AnGap-21*
[**2167-1-29**] 06:15AM BLOOD Glucose-107* UreaN-35* Creat-4.5*# Na-139
K-4.0 Cl-100 HCO3-28 AnGap-15
.
Cardiac Enzymes
[**2167-1-22**] 06:00AM BLOOD cTropnT-0.18*
[**2167-1-22**] 11:00AM BLOOD cTropnT-0.17*
[**2167-1-23**] 12:07AM BLOOD cTropnT-0.22*
[**2167-1-24**] 03:54AM BLOOD cTropnT-0.14*
[**2167-1-22**] 11:00AM BLOOD CK(CPK)-62
[**2167-1-23**] 12:07AM BLOOD CK(CPK)-76
.
Misc
[**2167-1-22**] 06:49AM Lactate-4.0*
[**2167-1-22**] 11:03AM Lactate-2.3*
[**2167-1-22**] 04:17PM Lactate-1.9
[**2167-1-25**] 11:16AM Lactate-1.7
[**2167-1-29**] 06:15AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.0
[**2167-1-22**] 06:00AM BLOOD ALT-11 AST-28 CK(CPK)-95 AlkPhos-86
TotBili-1.0
[**2167-1-22**] 06:00AM BLOOD Lipase-16
.
Echo
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate to severe global left ventricular hypokinesis with
akinesis of the mid inferior and mid inferolateral walls and
hypokinesis of remaining segments (LVEF = 30 %). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-10**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate to severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-2-12**],
there has been global deterioration of left ventricular systolic
function. The estimated pulmonary artery systolic pressure is
greater and right ventricular free wall hypokinesis is now
present..
.
Exercise MIBI
Excercise: In the presence of 0.[**Street Address(2) 107513**] depression and
T wave inversions inferiorly and in leads V3-6, there were no
significant ST segment changes throughout the study. The rhythm
was sinus with one apb during infusion. The patient was
hypertensive at baseline with an appropriate response to the
infusion; heart rate response was flat. No signficant EKG
changes in the presence of baseline abnormalities. No anginal
type symptoms.
Nuclear report: Inferior wall perfusion cannot be evaluated due
to subdiaphragmatic activity. Decreased LVEF of 39% and
moderately increased left ventricular cavity size.
.
CXR [**1-23**]: Worsening, mild-to-moderate fluid overload and
persistent cardiomegaly.
.
AV fistulagram: Stenosis at arterial anastomosis site of left
upper extremity AV fistula. Successful balloon dilatation with
6-mm balloons and with improvement of flow.
Brief Hospital Course:
75F dm, esrd, chf presents with nausea, vomiting, and GI upset
for x2 days, found to have mild diverticulitis and NSTEMI in
setting of tachycardia. She was briefly admitted to MICU for
tachycardia and diverticulitis w/ a concern for impending sepsis
with low BP with an elevated lactate. She received fluids and
Zosyn. She was observed in the MICU for 2 days with resoving
lactate and leukocytosis and then transfered to the floor.
.
# Diverticulitis - Pt's primary symptoms over the three days
prior to admission were gastrointestinal in origin with nausea,
vomiting, and overall "GI upset." She has a history of ischemic
vs. infectious colitis in [**2165**] in tranverse and descending
colon, which has resolved on CT scan. CT scan did reveal new
diverticulitis which was thought to be the etiology of her
symptoms. She received cipro and flagyl in the ED and developed
a rash. In the MICU she was swithed to Zosyn. Initially, there
was a concern for impending sepsis with blood pressures in the
90's and an elevated lactate to 4.0. She was given fluids and
Zosyn for two days. Her symptoms and blood pressure improved. In
addition, her lactate level come down to normal. She was then
transfered to the floor where she was switched to Augmentin to
complete a 10 day course of abx. She remained afebrile with
decreasing leukocytosis (13->6) and resolving symptoms. She was
discarged with no abdominal pain, nausea or vomiting.
.
# NSTEMI - On admission, she had several EKGs with TWI in
lateral leads and I/II, not concordant with any coronary
distribution. Her troponins were found to be mildly elevated,
with flat CK: troponin 0.18->0.22, CK 95->53. A cardiology
consult was called for assistance with EKG changes and mild
troponin elevation. They determined that these changes were
likely due to demand ischemia and recomended against heparin or
cardiac catheterization. She was continued on ASA, BB and
statin.
.
# CHF- The patient has history of non-ischemic cardiomyopathy
with depressed EF (30%) which then recovered to 55%. Pt had
echocardiogram done on this admission to further evaluate
cardiac status. The echo showed moderate to severe global left
ventricular hypokinesis with akinesis of the mid inferior and
mid inferolateral walls and hypokinesis of remaining segments
(LVEF = 30 %). The regional areas of hypokinesis in the
inferior/inferiorlateral walls raised the possibility of new
ischemic cardiomyopathy. A pMIBI was performed which was unable
to assess the inferior walls and vessels due to subdiaphragmatic
activity. The remainder of the walls were without perfusion
defects. This study may need to be repeated in the future to
assess the inferior walls and reasses her EF. She will follow up
with her cardiologist, Dr. [**First Name (STitle) 437**]. While in house, she became
slightly volume overload from IVF in the MICU. She had mild
symptoms of orthopnea, but no SOB or hypoxia. She was dialized
with resolution of her symptoms. Lasix was discontinued as she
is now on HD.
.
# Hypertension - The patient was continued on amlodipine and
metoprolol after her blood pressure returned to [**Location 213**].
Clonidine was discontinued. As she became hypertensive, she was
started on Valsartan with an improvement in blood pressure.
.
# ESRD - Stage 5 CKD, likely [**1-10**] diabetes and hypertension
followed by Dr. [**Last Name (STitle) 7473**]. She has been on oral iron
supplementation and procrit for associated anemia. The fistula
had been in place in anticipation of starting HD. There was
previous concern for a proximal narrowing of the fistula with a
loud bruit. She received an AV fistulogram which showed proximal
stenosis. The stenosis was sucessfully dilated via balloon
angioplasty by IR. She was started on dialysis for the first
time, and received HD several times. She did have one episode of
symptomatic orthostatic hypotension after her third HD where 1.5
kg was removed. This episode occured in conjuntion with
receiving her BP meds just after HD. She had no further episodes
of orthostatic hypotension, and her blood pressure remained
stable even with her anti-hypertensives. She was discharged with
a plan for HD MWF at Da Vita Dialysis Center. She will follow up
with her nephrologist Dr. [**Last Name (STitle) 4883**]. Her last dialysis session
was [**2167-1-29**] in the PM.
Medications on Admission:
ASPIRIN 81 mg qd
Amlodipine 10 mg qd
Clonidine 0.2 mg [**Hospital1 **]
FERROUS GLUCONATE 325 mg qd
FUROSEMIDE 80 mg qam 40mg qpm
HECTOROL 2.5 mcg--1 capsule(s) by mouth qMWF
LOVASTATIN 20MG qhs
Mastectomy Bra --right side diagnosis cancer of the right breast
NPH (HUMAN) --26 units qam [**First Name8 (NamePattern2) **] [**Last Name (un) 387**]
OMEPRAZOLE 40mg qd
PROCRIT 20,000 unit/mL--inject 6000 units q10 days
RENAGEL 400 mg tid
TOPROL XL 300mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed
for constipation.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
8. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
10. Insulin
Take NPH and humalog sliding scale as previously prescribed by
[**Last Name (un) **].
11. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO once a
day for 1 days: Last day [**1-31**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Diverticulitis
Non-ST segment Elevation Myocoardial Infarction
Renal Failure
Discharge Condition:
improved
Discharge Instructions:
You were admitted for diverticulitis (a colon infection) and a
small heart attack. You were put on antibiotics which helped
heal the infection. Your heart function was also monitored. You
will need to follow up with your cardiologist. You were also
started on hemodialysis and will need to continue going to
hemodialysis from now on.
.
The follow medication changes were made. Take all the rest of
medications a previously directed:
1. Stop taking Clonidine.
2. Start taking Valsartan
3. Stop taking lasix( furosemide).
4. Stop taking iron (ferrous glucontate), hectorol and procrit.
These medications will be given to you at hemodialysis.
5. Lovastatin was changed to Atorvastatin.
6. Take Augmentin (antibiotic)for 1 more day, to complete a 10
day course of antibiotics. Last day [**1-31**].
Followup Instructions:
Please call your cardiologist [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], MD [**Telephone/Fax (1) 3512**] to
make a follow up appointment in the next two weeks.
.
Dialysis on Monday [**2167-2-1**] at 2:30pm at [**Location (un) **] [**Location (un) **]
Dialysis [**Telephone/Fax (1) 5972**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3766**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time: [**2167-2-4**] at 4:00pm
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Date/Time:[**2167-2-2**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2167-2-18**] 10:30
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2167-5-26**] 10:10
ICD9 Codes: 5856, 4280, 5849, 2762, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5318
}
|
Medical Text: Admission Date: [**2134-11-3**] Discharge Date: [**2134-11-5**]
Date of Birth: [**2134-11-3**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the former
3.49 kg product of a 38-2/7 weeks gestation pregnancy born to
a 26-year-old G5, P2, now 3 woman. Prenatal screens were
blood type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
strep status unknown. The pregnancy was uncomplicated. The
mother presented for repeat elective cesarean section.
Previous OB history was notable for 2 cesarean sections. The
infant was born at 1540 hours on [**2134-11-3**]. He was
noted to have retractions after birth and was transferred to
the neonatal intensive care unit for observation and
monitoring. He required blow-by oxygen. Apgars were 8 at 1
minute and 8 at 5 minutes.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit, weight was 3.49 kg, length 51 cm, head
circumference 35 cm, all 75th to 90th percentile for
gestational age. GENERAL: The infant appears consistent with
a gestational age of 38 weeks, pink and nasal cannula O2,
well-perfused, responsive. HEAD, EARS, EYES, NOSE AND THROAT:
Normocephalic, anterior fontanelle soft and flat. Ears are
normal. Palate is intact. NECK: Normal. CHEST: Clavicles
normal, breath sounds equal bilaterally with grunting,
intercostal retractions. CARDIOVASCULAR: Normal heart sounds,
no murmur. Peripheral pulses are normal. ABDOMEN: Soft,
nondistended, nontender, no masses, no hepatosplenomegaly.
GU: Normal male, anus patent. SPINE: Normal. EXTREMITIES:
Normal. SKIN: Normal without lesions. NEURO: Mildly decreased
tone with intact reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: RESPIRATORY: [**Known lastname **] was initially on nasal cannula O2
due to his increased work of breathing. He was changed to
continuous positive airway pressure. He remained on the
continuous positive airway pressure until 8 p.m. on [**2134-11-3**] when he transitioned to room air. He remained stable
in room air with oxygen saturations greater than 95% with
minimal work of breathing. Chest x-ray was consistent with
retained fetal lung fluid on day of life #1. Repeat chest x-
ray on day of life #2 showed improvement. There was no
concern for pneumonia and the antibiotic course was
discontinued at 48 hours.
CARDIOVASCULAR: [**Known lastname **] has maintained normal heart rates and
blood pressures. No murmurs have been noted.
FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] was initially NPO
on intravenous fluids. After the discontinuation of the
continuous positive airway pressure, enteral feeds were
started. He has been breastfeeding ad lib and maintaining
normal glucoses. The mother's choice is to exclusively
breastfeed with no formula. Weight on the day of transfer is
3.44 kg. Serum electrolytes at 24 hours of life were within
normal limits.
INFECTIOUS DISEASE: Due to the unknown etiology and severity
of the respiratory distress, [**Known lastname **] was evaluated for sepsis
upon admission to the neonatal intensive care unit. A
complete blood count had a white count of 25,100 with a
differential of 39% neutrophils, 20% band neutrophils and
normal platelets. Intravenous ampicillin and gentamicin were
started. A repeat complete blood count on day of life #2 had
a white blood cell count of 29,400 with a differential of 77%
polymorphic neutrophils and 7% band neutrophils. Blood
culture obtained prior to starting antibiotics was no growth
and the antibiotics were discontinued at 48 hours as the
respiratory symptoms had resolved.
GASTROINTESTINAL: Serum bilirubin on day of life #1 was a
total of 5.7 mg/dL. A recheck bilirubin is to be drawn along
with the state screen on the morning of [**2134-11-6**].
HEMATOLOGICAL: Hematocrit was birth was 47.8%.
NEUROLOGICAL: [**Known lastname 49225**] neurological exam improved with his
improvement in respiratory status. He has maintained a normal
neurological exam and there are no neurological concerns at
the time of discharge.
SENSORY: Audiology hearing screening has not yet been
performed.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transferred to the newborn nursery
under the care of the [**Doctor Last Name 46742**] Newborn Service.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location 48056**] Center, phone number [**Telephone/Fax (1) 6951**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Ad lib breastfeeding.
2. No medications.
3. Car seat position screening not recommended.
4. State newborn screen to be drawn on [**2134-11-6**].
5. No immunizations administered to date.
DISCHARGE DIAGNOSES:
1. Near term infant.
2. Respiratory distress secondary to retained fetal lung
fluid.
3. Suspicion for sepsis ruled out.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2134-11-5**] 23:03:48
T: [**2134-11-6**] 07:39:05
Job#: [**Job Number 68497**]
ICD9 Codes: V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5319
}
|
Medical Text: Unit No: [**Numeric Identifier 71142**]
Admission Date: [**2112-12-28**]
Discharge Date: [**2113-1-4**]
Date of Birth: [**2112-12-28**]
Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname 71143**] is the 2990 gram product of a
term. EDC was [**2112-12-28**], gestation to a 40-year-old
gravida 1, now para 1 mom, with prenatal labs blood type B-
positive, antibody negative, RPR nonreactive, rubella immune,
hepatitis-B negative and GBS unknown. The pregnancy was
uncomplicated. Mom has history of HSV, advanced maternal age
and anemia. This infant was born by elective scheduled C-
section with Apgars 8 at 1 minute and 8 at 5 minutes. Infant
admitted to NICU with respiratory distress after C-section.
PHYSICAL EXAMINATION: Active infant with retractions and
increased work of breathing. Weight was 2990 grams, 25th
percentile, head circumference was 33 cm, 25th percentile,
and the length was 50 cm, 50th percentile. Head, ears, eyes,
nose and throat: Normocephalic, anterior fontanelle is open
and soft, palate was intact, red reflex present bilaterally.
Neck: Supple. Respiratory: Lungs are clear but with
intercostal retractions and increased work of breathing.
Cardiac: Regular rate and rhythm, no murmur. Femoral pulses
2+ bilaterally. GI: Abdomen is soft with active bowel sounds.
No masses or distention. GU: Normal male testes, palpable in
canal bilaterally. Anus patent. Spine midline, no dimple.
Hips stable. Clavicles intact. Neurologic: Good tone. Normal
suck. Normal gag.
HOSPITAL COURSE:
Respiratory: Infant initially on nasal cannula O2 for
increased work of breathing. Weaned to room air early on a.m.
of day of life 1. In p.m. of day of life 1, increased work of
breathing with respiratory rate in the 80s with desaturations
down to the 80s. Chest x-ray revealed right pneumothorax. ABG
at that time was 7.39, 41, 74. Pneumothorax was treated with
100% oxygen. On day of life number 3, infant transitioned to
nasal cannula O2 and, on day of life 5, infant weaned to room
air. Chest x-ray on [**1-3**], day of life 6, revealed the
pneumothorax has resolved.
Cardiovascular: The infant has been cardiovascular stable
with heart rate 120s to 160s with BP 89/47 with a mean of 63.
Fluid, electrolytes and nutrition: Birth weight was 2990.
Current weight is 2800, which is 10th percentile, with a head
circumference of 33 cm, which is 25th percentile, and length
of 50 cm, which is 50th percentile. Initially started on 50
mL/kg/day of D10W. Ad.lib. enteral feeds of breast milk began
on day of life 1 then stopped on day of life 1. Infant made
NPO, started back on 80 per kg/day of D10W with 2 mEq of
sodium chloride and 1 mEq of KCl per 100 mL. Enteral feeds of
breast milk restarted on day of life 4. On day of life 5,
reached ad.lib. of enteral feeds of breast milk.
GI: Peak bilirubin of 11.1, 0.4 on day of life 5. Infant did
not required phototherapy.
Hematology: Initial hematocrit on admission was 44. Has not
required any blood transfusions.
Infectious disease: CBC with diff and blood culture obtained
on admission. Initial white count was 2,200, hematocrit 44,
polys 70, bands 0, lymphs 23, and a platelet count of
316,000. Antibiotics of ampicillin and gentamicin initiated.
Infant treated for 7 days due to respiratory status. LP
obtained, results were normal.
Neurology: Infant does not meet criteria for head ultrasound.
Audiology: Hearing screen was performed with automatic
auditory brain stem response. Result - passed.
Ophthalmology: Infant does not meet the criteria for eye
exam.
Psychosocial: [**Hospital1 18**] social worker saw the family, with no
current concerns. Social worker can be reached at [**Telephone/Fax (1) 55529**].
CONDITION AT DISCHARGE: Age-appropriate full term infant,
stable.
DISPOSITION: To home.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66546**], which is [**Hospital3 47775**], phone #[**Telephone/Fax (1) 43701**], fax #[**Telephone/Fax (1) 43702**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge are ad.lib.feeds of breast milk.
2. Medication is Tri-Vi-[**Male First Name (un) **] 1 ml daily and
ferrous sulfate 0.3 ml of a 25 mg/mL concentration solution
daily.
3. Car seat position screening passed.
4. State newborn screening status has been sent per protocol,
results are pending.
5. Immunizations received is the hepatitis-B vaccine on
[**1-2**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) Born at less than 32
weeks; (2) born between 32 and 35 weeks with 2 of the
following - day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school-age siblings; (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 child's life, immunization against
influenza is recommended for household contacts and out-of-
home caregivers. Followup appointment should be scheduled
with the pediatrician 48 hours after discharge.
DISCHARGE DIAGNOSES:
1. Respiratory distress - mild hyaline membrane disease
versus neonatal pneumonia
2. Pneumothorax, resolved.
3. Presumed sepsis/pneumonia, resolved.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 71144**]
MEDQUIST36
D: [**2113-1-4**] 03:44:47
T: [**2113-1-4**] 07:20:24
Job#: [**Job Number 71145**]
ICD9 Codes: V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5320
}
|
Medical Text: Admission Date: [**2182-12-4**] Discharge Date: [**2182-12-10**]
Date of Birth: [**2151-12-6**] Sex: F
Service: MEDICINE
Allergies:
Lamictal
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Pericardial Effusion
Major Surgical or Invasive Procedure:
Pericardial Window
Right Heart Catheterization and attempted Pericardiocentesis
History of Present Illness:
This is a 30 y/o F with h/o Depression, PTSD, bipolar disorder
who is admitted after Echo showed early sings of tamponade.
.
Patient was seen on [**2182-11-29**] at [**Hospital 191**] clinic with multiple
complains, including disphagia, dysuria and abdominal pain. A Ct
scan was done on [**2182-12-2**] that did not reveal any intraabdominal
pathologies, but it showed a large pericardial effusion. She had
an Echocardiogram on [**2181-12-4**] that showed + RA collapse, pulses
in clinic 15-20. BP 100/60, HR 100 so she was refered for
pericardiocentesis.
.
She reports that over last 6 weeks, she had join aches, fatigue,
sore thorat, + dry ocugh and low grade fevers. Over last 2
weeks, she had worsening shortness of breath on exertion,
feeling more fatigue while walking or going up stairs. Also
reports, increase orthopnea going from 2 to 5 pillows. She also
had ongoing episodic abdominal pain over last month. Diffusse,
not nausea of vomit. Intermittent loose stools.
.
In the cath lab, multiple attempts to acces fluid by subxiphoid
approach failed. Pressures RA 7, RV 18/1/6, PA 14/7/10, PCW 3.
Echo post procedure showed a moderate to large sized pericardial
effusion with brief right atrial diastolic collapse. There was
also intermittent, localized (inferior RV free wall) RV
compression suggestive of elevated intrapericardial pressure
and/or early, focal tamponade.
.
Patient was transfer to CCU for monitoring.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. No urinary symptoms.
.
*** Cardiac review of systems is notable for + chest thitgness,
dyspnea on exertion, orthopnea. No ankle edema.
Past Medical History:
Depression
Post traumatic disorder
Border line personality disorder
Dissociative identity disorder
Sexual aversion disorder
Conversion disorder
Anorexia
h/o self harm and suicidal ideation
GERD
Premature ovarian failure
Migraines
Chornic fatigue syndrome
CKD likely secondary to lithium
Inflammatory arthorpathy - likely psoriatic arthritis
Fibromyalgia
Osteopenia
Mitral valve prolapse
Pituitary adenoma
.
Cardiac Risk Factors: Diabetes (-), Dyslipidemia (-),
Hypertension (-
Social History:
Lives in a group home. Cambrige.
works partime as pharmacy technician. NO smoking, alcohol or
illicit drug use.
Family History:
Mother, grand mother, and grand grand mother with breast cancer.
Physical Exam:
VS: T 97.3, BP 118/75 , HR 68 , RR17 , O2 %100 2L
Pulses: 4mmHg
Gen: non apparent distress, pale
HEENT: Sclera anicteric. Pale conjuctiva. dry oral mucose.
Neck: JVP flat.
CV: RRR, s1-s2 normal,no murmurs, rubs or gallops appreciated.
Chest: Clear to auscultation anteriorly
Abd: soft, mild diffuse tenderness, no rebound
Ext: No edema. distal pulses preserved.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: strong distally
Skin: no hematoma on groin site. subxiphoid incision clean.
Pertinent Results:
EKG: NSR, her 83, normal axis, normal intervals, no t wave or st
changes
[**2182-12-4**] 12:45PM WBC-5.1 RBC-3.68* HGB-12.1 HCT-34.2* MCV-93
MCH-32.8* MCHC-35.4* RDW-12.6
[**2182-12-4**] 12:45PM PLT COUNT-178
[**2182-12-4**] 12:45PM GLUCOSE-115* UREA N-22* CREAT-1.6* SODIUM-142
POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-24 ANION GAP-15
[**2182-12-4**] 05:52PM WBC-4.6 RBC-3.73* HGB-11.7* HCT-35.3* MCV-95
MCH-31.2 MCHC-33.0 RDW-12.6
[**2182-12-4**] 05:52PM NEUTS-81.2* LYMPHS-14.4* MONOS-3.2 EOS-0.9
BASOS-0.3
[**2182-12-4**] 05:52PM TSH-1.3
[**2182-12-4**] 05:52PM GLUCOSE-151* UREA N-20 CREAT-1.5* SODIUM-142
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12
[**2182-12-4**] 05:52PM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.3
[**2182-12-7**] 09:22AM BLOOD WBC-2.5* RBC-3.39* Hgb-10.8* Hct-32.3*
MCV-95 MCH-31.9 MCHC-33.5 RDW-12.4 Plt Ct-137*
[**2182-12-10**] 06:10AM BLOOD WBC-4.3 RBC-3.68* Hgb-11.8* Hct-35.7*
MCV-97 MCH-32.2* MCHC-33.2 RDW-13.0 Plt Ct-220
[**2182-12-10**] 06:10AM BLOOD Glucose-98 UreaN-17 Creat-1.5* Na-142
K-3.8 Cl-111* HCO3-24 AnGap-11
[**2182-12-7**] 09:22AM BLOOD TotProt-4.9* Calcium-8.5 Phos-2.9 Mg-1.8
[**2182-12-7**] 09:22AM BLOOD LD(LDH)-124
[**2182-12-6**] 06:59AM BLOOD Cryoglb-NO CRYOGLO
[**2182-12-4**] 05:52PM BLOOD TSH-1.3
[**2182-12-6**] 06:59AM BLOOD ANCA-NEGATIVE B
[**2182-12-6**] 06:59AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2182-12-6**] 06:59AM BLOOD RheuFac-6 CRP-1.0
[**2182-12-6**] 06:59AM BLOOD C3-88* C4-27
[**2182-12-9**] 04:40AM BLOOD HIV Ab-NEGATIVE
[**2182-12-9**] 03:55AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND
[**2182-12-7**] 01:21PM BLOOD DNA AUTOANTIBODIES, SS-Test
[**2182-12-7**] 01:21PM BLOOD SM ANTIBODY-Test
[**2182-12-7**] 01:21PM BLOOD RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]
[**2182-12-7**] 01:21PM BLOOD RNP ANTIBODY-Test
[**2182-12-7**] 01:21PM BLOOD ANTI-HISTONE ANTIBODY-Test
[**2182-12-6**] 06:59AM BLOOD SCLERODERMA ANTIBODY-Test
[**2182-12-6**] 06:59AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-Test
[**12-7**] Pericardial Fluid:
[**2182-12-7**] 12:02 pm FLUID,OTHER
GRAM STAIN (Final [**2182-12-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2182-12-10**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2182-12-9**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2182-12-7**] 12:02PM
Report Comment:
PERICARDIAL FLUID
ANALYSIS
WBC, Other Fluid 130* #/uL 0 - 0
RBC, Other Fluid 7760* #/uL 0 - 0
Polys 0 % 0 - 0
Lymphocytes 58* % 0 - 0
Monos 7* % 0 - 0
Macrophage 33* % 0 - 0
Other Cell 2* % 0 - 0
Pericardial Fluid Adenosine Deaminase - negative
[**2182-12-9**] TTE: Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2182-12-6**], the
pericardial effusion has resolved.
.
[**2182-12-6**] TTE: There is a moderate to large sized pericardial
effusion. The effusion appears circumferential. There is
sustained right atrial collapse, consistent with low filling
pressures or early tamponade. There is mild right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology.
Compared with the findings of the prior study (images reviewed)
of [**2181-12-4**], the pericardial effusion is similar in size;
however, left atrial chamber invagination is now present. In
addition, the right ventricvle appears somewhat more compressed
.
[**2182-12-4**] Cath: . Pericadial effusion without clinical signs of
tamponade
and with normal RA pressure.
2. Unsuccesful pericardiocentesis. Multiple attempts to access
the
pericardial space using a subxiphoid approach were unsuccesful.
TTE
obtained during the procedure showed anterior collection but not
at apex
and beneath liver edge. Despite echo guidance, the operator was
still
unable to enter the pericardial space. The patient developed
left
shoulder pain during the procedure attempts that resolved with
removal
of the needle.
FINAL DIAGNOSIS:
1. No clinical signs of tamponade, normal RA pressure.
2. Unsuccesful pericardiocentesis
Brief Hospital Course:
# Pericardial effusion: On admission the patient was taken to
cath lab for pericardiocentesis. During the procedure
pericardial fluid was failed to be obtained. Hemodynamics
inconsistent with tamponade physiology. The patient was admitted
to the CCU for continued monitoring. Repeat TTE [**12-7**] demonstrated
new LA and RV invagination. CT surgery was consulted and the
patient was taken for pericardial window. She tolerated the
procedure well with no complications. Drain and chest tube
placed during procedure. Removed on [**12-10**] after repeat TTE on [**12-10**]
demonstrated a normal left ventricular wall thickness, cavity
size, and normal systolic function and a resolution of
pericardial fluid. Her pericardial fluid was of unclear
etiology. Rheumatology was consulted and her sulfasalazine was
discontinued for concern of drug induced lupus given effusion
and decreasing WBC. WBC did stabalize after stopping medication.
Also concern for collagen vascular disease. Panel of autoimmune
antibodies pending at time of discharge. Cytology and
pericardial biopsy also pending at time of discharge. [**Doctor First Name **] to
evaluate for TB as cause pending. The patient did report recent
URI symptoms, can consider pericarditis as cause of effusion.
EBV, CMV pending. HIV negative. She also reports a family
history of breast CA - recent mamogram WNL. The patient was
discharged home in good condition to follow up with her PCP and
rheumatology for further management.
.
# Hypotension - Pt BP range 80s-110 systolic. The patient does
have low BP at baseline. Reported recent poor po intake and
history of eating disorder. She received intermittent fluid
bolus, likely due to increased insensible losses. She also has a
history of increased urine output with lithium induced CRI.
.
# Psych: continued on home medications Abilify, Quetiapine
.
# Question of Psoriatic arthiritis: continued prednisone per
Rheumatology recommendation. Sulfasalazine DC'd due to concern
for drug induced lupus
.
# Vaginal Bleeding - During her hospitalization the patient
reported scant vaginal bleeding. She has been post-menopausal
for many years. She was advised to undergo further workup for
this bleeding as outpatient. Given her past history of sexual
abuse she has reported refusing previous pelvic examination.
.
# Fibromyalgia: continued tizanidine and Ultram
# CKD: creatinine at baseline.
.
The patient is scheduled to follow up with Cardiology, CT
surgery, Rheumatology and her PCP for further management. Also
to follow up on outstanding pericardial fluid cytology and
biopsy, as well as pending Autoimmune workup.
Medications on Admission:
Ativan 1 mg [**Hospital1 **]
Ativan 2 mg qhs
Colace
Correctol 2 tab once a day (not taken over last 3 days
Cymbalta 120 qhs
Desmopresin 0,3mg qhs
fioricet 100-650 PRH
MVI
Naproxen 250 q4h prn
Prednisone 10 mg/daily
Proair HFA 2 puffs inh 4-6h
seroquel 400 TID and 800 qhs
Sulfasalazine 1500 [**Hospital1 **]
Synthroid 50 mcg/daily
Topamax 75 [**Hospital1 **] 100 mg qhs
Ultram EF 300/daily
Vistaril 50mg QID PRN
Zanaflex 4mg qhs
Prilosec 40 [**Hospital1 **]
Ranitidine 150 qhs
Abilify 30 mg/qhs
Hydroxizine
prazosin
Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4)
Capsule, Delayed Release(E.C.) PO HS (at bedtime).
4. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-4**]
Tablets PO DAILY (Daily) as needed.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
9. Quetiapine 200 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Topiramate 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
12. Topiramate 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day) as needed.
14. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Prazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. Aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
20. Ultram ER 300 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
21. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours as needed.
22. Correctol 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Pericardial Effusion
2. Pericarditis - Post Viral
Secondary:
1. Chronic Renal Insufficiency
2. Inflammatory Arthropathy
Discharge Condition:
Good, Clinically Improved
Discharge Instructions:
You were admitted with a fluid collection around your heart
called a pericardial effusion. You underwent a catheterizaton to
attempt drainage of this effusion however no fluid could be
obtained. You then underwent a pericardial window by
cardiothoracic surgery to open your pericardial space to drain
the fluid.
.
Your workup from your pericardial effusion has been negative to
date. The cytology and biopsy from your procedure are still
pending as well as viral studies. You will follow up with
Cardiology and Rheumatology for further workup.
.
Your medication Sulfasalazine has been discontinued. You should
continue to take your medication Prednisone 10mg daily until
follow up with Dr. [**Last Name (STitle) **] in Rheumatology.
.
You continue to have a high urine output related to your kidney
disease. Please continue to drink plenty of caffeine free fluids
at home. If you develop lightheadedness please return or call
your primary care physician.
.
You have complained of occassional vaginal spotting during your
hospital stay. You should follow up with your primary care
physician for further workup.
.
If any chest pain, shortness of breath, fevers or any other
sympotms that may concern you, plaease call your PCP or come to
the emergency department
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] regarding your pericardial
effusion, in the cardiology clinic. An appointment has been made
for you on [**2183-1-1**] @ 10AM, in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. Please call [**Telephone/Fax (1) **] if you have any questions or
concerns about this appointment.
.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 5808**] Date/Time:[**2182-12-26**] 10:20
.
Please follow-up with your Rheumatologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2182-12-19**] 8:30
.
Please follow up with Cardiothoracic Surgery with Dr. [**Last Name (STitle) 72103**]
[**Name (STitle) 914**] in the [**Hospital Unit Name **], [**Location (un) **] CARDIAC SURGERY LMOB 2A
Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2182-12-25**] 2:00
ICD9 Codes: 5859, 4240
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5321
}
|
Medical Text: Admission Date: [**2102-1-13**] Discharge Date: [**2102-1-15**]
Date of Birth: [**2017-10-29**] Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / gabapentin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Need for peritoneal dialysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 4135**] is an 84 yo M with AF on warfarin, CAD s/p CAB, ESRD
on peritoneal dialysis, polyneuropathy, and other medical issues
transferred from [**Hospital **] Hospital for peritoneal dialysis and
recent intraventricular hemorrhage [**3-16**] fall.
.
Patient states frequent falls, every other week since back
surgery in [**2096**]. He reports a fall about 10 days ago and caused
posterior scalp laceration s/p stapling. His INR was not
checked and he had not had Coumadin dose changed for the past
several months. He states taking warfarin 4 mg daily except for
Friday when he takes 7 mg. About 4 days prior to admission,
staples were removed, but has been oozing. He noticed that his
pillow was stained with [**Last Name (LF) **], [**First Name3 (LF) **] he went to [**Hospital **] Hospital to
get suture where his INR was found to be 9.2 and 10 point Hct
drop compared to about 1 week prior. Per report, he received
FFP and vitamin K there. However, since [**Location (un) **] does not do PD
and his wife has not been able to help him with it due to recent
hospitalization (d/c'ed home yesterday), he is transferred to
[**Hospital1 18**].
.
In the ED, initial VS were: 98.4 60 139/60 16 98% 2L Nasal
Cannula. Guaiac negative. He received 1 unit of pRBC, 10 mg IV
vitamin K, and about 500 cc NS. Labs were drawn right after the
pRBC with Hct 22 and INR of 2.2. CT head showed a small left
intraventricular bleed in the posterior [**Doctor Last Name 534**]. Neurosurgery felt
that patient did not require any surgical intervention. Per ED,
neurology thought patient was stable. Renal was contact[**Name (NI) **] and
felt that he could get PD tomorrow. Has 18G x2 IV on the right
arm. VS upon transfer were 98.2, 77, 140/63, 18, 95% RA.
.
On arrival to the MICU, currently feeling well. He states that
he falls at least once but no more than 5 times a month. He
thinks it is a balance problem, but would lose consciousness and
find himself on the ground. He denies prodrome or post-ictal
symptoms.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes. He denies tingling, numbness, diplopia.
Past Medical History:
- CAD s/p CABG
- Afib on Coumadin
- HTN
- HLD
- ESRD on peritoneal dialysis
- Chronic LBP s/p discectomy in [**2096**]
- Chronic anemia
- h/o strokes
- BPH s/p TURP
- psoriasis
- carotid stenosis, most recent carotid ultrasound in [**12/2101**]
- h/o GIB
- T2DM
- anxiety
Social History:
Lives at home with wife who is the HCP and next of [**Doctor First Name **].
Retired engineer.
No smoking hx.
Rare alcohol use
Family History:
No premature CAD, brother and sister with DM.
DM in aunt, sisters, and brother
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T98.8 HR 76, BP 132/51, RR 21, O2Sat 94% RA
General: Alert, oriented, no acute distress
HEENT: + hematoma in the posterior occipital scalp, s/p suture,
sclera anicteric, PERRLA, MMM, OP clear
Neck: supple, JVP not elevated, no LAD, + carotid bruits L>R
CV: irregularly irregular, normal S1 and S2, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, dialysis line in place, area clean without
erythema or drainage
GU: no foley
Ext: warm, well perfused, 1+ pulses, no edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
diminished sensation to light touch in the left foot, gait
deferred
.
Pertinent Results:
ADMISSION LABS:
[**2102-1-13**] 08:45PM [**Month/Day/Year 3143**] WBC-9.2 RBC-2.32*# Hgb-7.3*# Hct-22.5*#
MCV-97# MCH-31.2# MCHC-32.2 RDW-14.3 Plt Ct-290
[**2102-1-13**] 08:45PM [**Month/Day/Year 3143**] Neuts-75.0* Lymphs-16.0* Monos-4.7
Eos-4.1* Baso-0.2
[**2102-1-13**] 08:45PM [**Month/Day/Year 3143**] PT-23.4* PTT-31.6 INR(PT)-2.2*
[**2102-1-13**] 08:45PM [**Month/Day/Year 3143**] Glucose-192* UreaN-52* Creat-5.4*# Na-144
K-3.7 Cl-100 HCO3-33* AnGap-15
[**2102-1-14**] 06:25AM [**Month/Day/Year 3143**] Calcium-8.0* Phos-3.6 Mg-1.8
[**2102-1-14**] 11:38AM [**Month/Day/Year 3143**] Type-ART pO2-81* pCO2-46* pH-7.48*
calTCO2-35* Base XS-9 Intubat-NOT INTUBA
.
IMAGING:
[**1-13**] CT HEAD: FINDINGS: A small amount of intraventricular
hemorrhage layers posteriorly in the occipital [**Doctor Last Name 534**] of the left
lateral ventricle. No additional intra- or extra-axial
hemorrhage is identified. Ventricular dilatation is unchanged
since [**2096**], with prominence of the sulci, likely due to atrophy.
Focal hypodensities in the right thalamus and left lentiform
nucleus are unchanged since [**2096**], and likely reflect lacunes.
Confluent periventricular and subcortical white matter
hypoattenuation is compatible with the sequela of chronic
microvascular infarction. A large posterior parietal subgaleal
hematoma is present. No fractures are seen. Visualized paranasal
sinuses and mastoid air cells are well aerated. Calcification of
the cavernous carotid arteries is present.
IMPRESSION: Small amount of intraventricular hemorrhage in the
occipital [**Doctor Last Name 534**] of left lateral ventricle. Large posterior
parietal subgaleal hematoma.
.
[**1-14**] CXR: IMPRESSION:
1. Status post median sternotomy for CABG with stable cardiac
enlargement and calcification of the aorta consistent with
atherosclerosis. Relatively lower lung volumes with no focal
airspace consolidation appreciated. Crowding of the pulmonary
vasculature with possible minimal perihilar edema, but no overt
pulmonary edema. No pleural effusions or pneumothoraces.
Brief Hospital Course:
Mr. [**Known lastname 4135**] is an 84 year old male with end-stage renal disease
(ESRD) on peritoneal dialysis (PD), atrial fibrillation (AFib)
on warfarin, coronary artery disease (CAD) status post bypass
surgery who presented with intraventricular bleed transferred to
MICU for neurological monitoring.
.
ACTIVE ISSUES BY PROBLEM:
# Intraventricular bleed was secondary to recent fall in the
setting of being on warfarin and with supratherapeutic INR.
Based on CT head without contrast. [**Month (only) 116**] have some mild sensation
deficit in the LE L>R, could be chronic given underlying
diabetes. Currently asymptomatic and stable from
intraventicular bleed. He did recieve one unit packed RBCs
before transfer and his hematocrit was maintained above 25. His
warfarin was held and he was given vitamin K which brought his
INR to therapeutic levels quickly. Neurosurgery was consulted
and they recommended that he be closely monitored.
He was discharged with instructions to continue antiepileptic,
dilantin x 10days and to follow up with neurosurgery clinic in
[**5-18**] weeks with repeat head imaging. Given multiple falls, would
not recommend restarting anticoagulation.
.
# Anemia: Likely chronic in nature with acute intraventricular
bleed as mentioned above. Recieved one unit packed RBCs and
warfarin was held.
.
# Falls/Syncope: Based on history, concerning for cardiogenic
arrhythmia given no prodrome with drop attacks in the setting of
underlying CAD requiring CABG. Also could be due to gait
instability from peripheral neuropathy from T2DM. Also, patient
had history of CVA and has carotid stenosis, although symptoms
unlikely from TIA. Monitored on tele with no significant
arrhythmias. PT saw patient and felt that he could safely be
discharged home with services.
.
# ESRD on PD: Creatinine at 5.4. No significant electrolyte
derangement at this time. He did continue on PD while an
inpatient. Continued renal cap and calcitriol. He gets epo
20,000 unit every other week. Followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
[**Hospital1 **], [**Telephone/Fax (1) **] as an outpatient
.
# Chronic AF: High risk for bleed given frequency of
falls/syncopes; however, with CHADS 5 is also at high risk of
stroke. Given ICH, warfarin was stopped and coagulopathy was
aggressively reversed in the ED. At time of discharge, INR was
1.0. Decision whether to resume anticoagulation was deferred to
cardiologist but is strongly not recommended given frequent
falls. at this time.
.
# CAD s/p CABG/HTN/HLD (hypertension and hyperlipidemia):
Continued home Diovan, isosorbide, furosemide, amlodipine.
Would recommend switching simvastatin to atorvastatin 40 mg
given higher risk of rhabdo with simvastatin on amlodipine.
.
# Diabetes mellitus type 2 (T2DM): On insulin, continued home
regimen.
.
# Anxiety: continued citalopram 20 mg as at home
.
TRANSITONAL ISSUES:
ICH: antiepileptic x 10 days, follow up with head imaging in
neurosurgery clinic in [**5-18**] weeks
afib: stopped coumadin given recent ICH, will need to discuss
possible initiation of antiplatelts
Medications on Admission:
- Diovan 160 mg [**Hospital1 **]
- isosorbid 30 mg daily
- furosemide 40 mg [**Hospital1 **]
- simvastatin 80 mg daily
- amlodipine 10 mg daily
- calcitriol 0.25 every other day
- renal cap daily
- folic acid daily
- B6 100 mg daily
- vitamin D 1000 IU daily
- 20 mg citalopram
- ISS with Humalog
- 12 units of Lantus qHS
- tums 1 TID
- Epo 20,000 unit every other week
- Ferrex without food daily
- warfarin 4 mg every day except Friday, 6 mg on Friday
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. insulin aspart 100 unit/mL Solution Sig: per sliding scale
Subcutaneous per sliding scale.
13. phenytoin 125 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) for 9 days.
Disp:*27 tablets* Refills:*0*
14. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
16. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Vna
Discharge Diagnosis:
Primary Diagnosis:
intraventricular hemorrhage
supratherapeutic INR
mechanical fall
Secondary Diagnosis:
atrial fibrillation
end stage renal disease on peritoneal dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 4135**],
You were admitted to the hospital after a fall with [**Known lastname **] in
your brain. You were seen by the neurosurgeons, your coumadin
was stopped and you were given products to reverse your [**Known lastname **]
thinning. The bleeding in your head stopped but you will need
to take medications to prevent seizure for the next 9 days. You
will also need to follow up with the neurosurgery team with a
repeat CT scan of your head in the next 4 -6 weeks.
Please make the following changes to your medication regimen:
STOP coumadin. Do NOT restart this medication. Talk to your
cardiologist about other options, like aspirin, for your atrial
fibrillation
START dilantin 100mg three times daily for the next 9 days (end
date [**2102-1-24**])
Please take all of your other medications as previously
prescribed
Followup Instructions:
Follow up in [**Hospital 4695**] clinic in [**5-18**] weeks with a repeat
head CT at that time and appointment with Dr. [**Last Name (STitle) **]. Call
[**Telephone/Fax (1) 1669**] to schedule.
Follow up with cardiologist on Monday, [**1-16**] as previously
scheduled
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], in
the next 1-2 weeks. Call [**Telephone/Fax (1) 41459**] to schedule an
appointment
ICD9 Codes: 5856, 2851, 2724, 3572
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5322
}
|
Medical Text: Admission Date: [**2179-7-20**] Discharge Date: [**2179-7-30**]
Date of Birth: [**2121-2-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Motorcycle accident
Major Surgical or Invasive Procedure:
Tracheostomy
Percutaneous Gastrostomy
Incision and Drainage L scapular hematoma
Thoracic epidural catheter
History of Present Illness:
58 yo M med-flighted to [**Hospital1 18**] from [**Location (un) 3844**] following an
unhelmuted, over the handlebar, motorcycle accident. Pt
reportedly intoxicated, but was awake and alert at the accident
scene, talking with paramedics, but became increasingly
combative, and then less responsive and was intubated prior to
transfer.
Past Medical History:
bullous emphysema, COPD, HTN, anxiety, EtOH dependence
Social History:
Non-contributory
Family History:
Non-Contribultory
Physical Exam:
T 97.8 BP 132/87 HR 100 BP 132/87 RR 28 O2 98%
Gen: AOx3
HEENT: PERRLA
CVS: RRR
Resp: coarsh breathsounds bilaterally
Ab: soft, non-tender, non distended, + BS
ext: 1+ edema bilaterally
Pertinent Results:
[**7-21**] Echo: Hyperdynamic left ventricle suggestive of hypovolemia
with hyperdynamic left ventricular systolic function. No
evidence of traumatic valvular dysfunction or cardiac contusion.
There is a trivial/physiologic pericardial effusion.
Films:
[**7-20**] cxr: Small left sided pneumothorax. Left-sided chest tube
courses apically. Distal left clavicle fracture and left glenoid
fracture. Displaced left-sided rib fractures involving the left
third through seventh ribs posterolaterally.
[**7-20**] CT c/a/p
1. Moderate sized left lung pneumothorax with chest tube in good
position.
Extensive surrounding subcutaneous emphysema tracking into the
left neck and
extending into the posterior soft tissues through to the pelvis.
2. Fractures involving the left second through ninth posterior
ribs. Fracture
of the posterior [**Doctor First Name 362**] of the left scapula as well as a fracture
involving the
left glenoid. Comminuted fracture of the left distal clavicle.
4. Nondisplaced fracture of the left transverse process of the
T6 vertebral
body. Otherwise, the thoracic and lumbar spines are without
fracture or
malalignment.
5. Severe centrilobular emphysema. 9 mm right apical spiculated
nodule.
While this may represent scar, followup dedicated chest CT is
recommended in
[**3-2**] months to confirm stability.
[**7-21**] CXR Increased density at the right lung base and in the
left
perihilar region which may represent evolving infiltrates.
Evidence for
interval decrease in small left pneumothorax. Extensive
subcutaneous
emphysema unchanged. Left rib fractures and left clavicular
fracture.
[**7-20**] CT head/C-spine
1. Diffuse subarachnoid hemorrhage overlying the left temporal
lobe with a
few foci of intraparenchymal hemorrhage, likely representing
hemorrhagic
contusions. Tiny subdural hematoma layering along the temporal
bone convexity.
No significant associated mass effect aside from local edema.
2. No skull fracture identified. Left orbital fracture better
delineated on
the CT of the facial bones performed on the same date.
3. High-density material within the left maxillary sinus. Occult
fracture suspected.
4. Large left temporoparietal subgaleal hematoma.
[**7-20**] CT Max/fac
1. Minimally displaced, comminuted left zygoma fracture which
extends to
involve the inferolateral orbital wall and zygomaticosphenoid
suture on the left.
2. Non-displaced left inferior orbital rim fracture.
3. Left lamina papyracea fracture.
4. Bilateral periorbital hematomas. No intraconal abnormalities
identified.
[**7-21**] head CT - unchanged
Brief Hospital Course:
58 yo M med-flighted to [**Hospital1 18**] from [**Location (un) 3844**] following an
unhelmeted, over the handlebar, motorcycle accident. Accident
was head-first, with no LOC Pt reportedly intoxicated, but was
awake and alert at the accident scene, talking with paramedics,
but became increasingly combative, and then less responsive and
was intubated prior to transfer.
Neuro: SAH and left parietal hemorrhagic contusion. no midline
shift
Loaded with 1g dilantin and continued until [**7-31**]. recieved neuro
checks q4hr, and was sedated with propfol and fentanyl.
Neurosurgery was c/s and believed no surgical managment was
needed.
HEENT: minimally displaced comminuted L zygoma fracute with
involvment of inferolateral orbital wall on left. Left lamina
papyracea fracture. Bilateral perioribal hematomas.
c/s plastics for above injuries. Head of bed remained elevated
at 30 degrees
Head CT repeated on [**7-21**] with no significant change
Per plastics, injuries non-operatative
Chest: comminuted fx of L proximal clavical. Fracture of L
scapula in the post [**Doctor First Name 362**] and glenoid with minimal displacement.
fracture of posterior L ribs [**2-5**] with extensive SQ emphasema
small non displaced fx of post T6 vertebral body
Clavicle fracture believed to be open, and was taken to the OR
[**7-29**] for I and D.
CV: was placed on levophed for BP support, eventually weened
HCT decreased and recieved 2 u RBC on [**7-24**], with appropriate
response
TEE to r/o tamponade - echo was normal
PICC line was inserted [**7-29**] for access
resp: Intubated on arrival, confirmed by CXR
L tension pneumothorax on arrival - needle decompressed with 30
cc air, then 14 g chest tube inserted. CT replaced at [**Hospital1 18**]
[**7-27**] tracheostomy
[**7-27**] sputum showed gram negative rods, Levoquin started [**7-28**]
CT removed [**7-28**]
Patient weaned from vent. Given his significant pulmonary
history of bronchitis, COPD and asthma, he remaine tachypnic
throughout hospitalization with respiratory rates in high 20's
to 30's. He was weaned to pressure support ventilation and
trach mask with adequate ABGs for his baseline disease.
GI: NG tube was placed and pt was given tube feeds
nutrition was consulted and set goal of tube feeds for 1800 cal
with 25 g beneprotein
[**7-27**] percutaneous-gastrostomy for continuing nutritional needs.
Prophylaxis with H2 blocker, heparin SC and pneumoboots
Pain was controled by acute pain survice. They placed an
epidural catheter [**7-22**] to give an IV fentanyl infusion.
Epidural removed [**7-27**], subsequently pain was controlled with
percocet elixir.
Endocrine: given hydrocort to maintain steroid response and
subsequently weaned.
ID: on Ancef for open clavicle fracture x3 doses. Subsequently
stopped.
Levoquine for total of 7 days for positive sputum culture.
PT/OT
Medications on Admission:
Zoloft 100 mg qday
albuterol inhaler 2 puffs qid
spiriva 1 puff qid
Nexium 40 mg qday
Luesta 2 mg qday
Vicadin 7.5/750 qid
klonipin 1mg [**Hospital1 **]
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. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lorazepam 0.5-1 mg IV Q4H:PRN anxiety
7. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q2-3H (every 2-3 hours) as needed.
8. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1)
Intravenous ASDIR (AS DIRECTED).
9. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day:
prn.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO every 6-8 hours as needed: PRN pain.
11. Insulin
[**Known lastname **],[**Known firstname **] H. [**Numeric Identifier 74196**]
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Fingerstick QACHSInsulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-80 mg/dL [**12-29**] amp D50 [**12-29**] amp D50 [**12-29**] amp D50 [**12-29**] amp D50
81-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-200 mg/dL 4 Units 4 Units 4 Units 4 Units
201-240 mg/dL 6 Units 6 Units 6 Units 6 Units
241-280 mg/dL 8 Units 8 Units 8 Units 8 Units
12. Tube Feeding
Tubefeeding: Nutren Pulmonary 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 >= : 100 ml
Flush w/ 200 ml water q6h
Adjust free water flushes as needed to treat hypernatremia.
13. Outpatient Lab Work
[**Hospital1 **] electrolytes. Replete prn.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
16. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO PRN (as needed) as needed for Phos < 3.0.
17. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN
(as needed): PRN Mag < 2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
L-SAH/IPH/SDH (temporal)
Large L-temporoparietal subgaleal hematoma
Grade 4 L scapula fracture
L clavicle fx
Pneumothorax
Small HemoPTX
Multiple L-sided rib fx ([**2-6**])
L orbital wall fx
Discharge Condition:
Stable to rehabilitation facility
Discharge Instructions:
Continue Levoquin for 7 days
Remove sutures on chest in [**10-10**] days
Continue Oxygen to trach collar at 10-15 L/min
Continue trach and peg care
Continue tube feeds to goal of 1800 Kcal per day with 25 g of
beneprotein
Ativan as needed for agitation
Followup Instructions:
Remove sutures in [**10-10**] days
Completed by:[**2179-7-30**]
ICD9 Codes: 496, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5323
}
|
Medical Text: Admission Date: [**2170-9-18**] Discharge Date: [**2170-9-26**]
Date of Birth: [**2107-5-20**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Back and bilateral leg pain
Major Surgical or Invasive Procedure:
1. Posterior spinal fusion L4-5 with instrumentation.
2. L3-4 to L5-S1 lumbar decompression, medial facetectomy and
foraminotomy bilaterally.
3. Bilateral laminotomy of L3 with medial facetectomy and
foraminotomy.
4. Application of local autograft, allograft and demineralized
bone matrix.
History of Present Illness:
I had the pleasure of seeing this patient for evaluation and
treatment of her chief complaint, which is back and bilateral
leg pain. She has been treated massage therapy and epidural
injections. The epidural injections gave her short-term relief.
A [**7-10**] at rest and [**11-9**] with activity. She had a MRI done at
the [**Doctor Last Name **] [**Location (un) **], which shows multilevel lumbar stenosis
with an L4-L5 grade 1 spondylolisthesis and facet arthropathy.
X-rays confirm this. There may be a, grade 1, listhesis at L2-3
as well. No spondylolisthesis was noted. It is certainly worse
with walking and she has trouble walking approximately [**11-14**]
feet. When asked what is bothering her when she walks she
points to her buttock and posterior thighs.
Past Medical History:
Her past medical history of hypertension. She does not have
diabetes.
Social History:
French speaking. Does not smoke.
Family History:
None
Physical Exam:
On physical examination, this is a 5 feet 5 inches, 216 pound
female, blood pressure is quite high with a pulse of 74. She is
alert and oriented. Affect is within normal limits. She is
talking to her daughter who serves as interpreter. Her affect
is within normal limits. She is obese. Her gait is in a flexed
posture unable to stand in upright position. She has no
specific
tenderness along her spinous processes. She has no pain with
internal rotation of hips. Negative straight leg raise
bilaterally. She has good strength in bilateral lower
extremities and [**Last Name (un) 938**], anterior to gastroc, quads, hamstrings and
hip flexors, abductors and adductors. Her calves are soft.
Distal pulses are intact. No skin changes. Greater trochanter
is nontender to palpation. There is no hyperreflexia.
Sensation grossly intact to light touch throughout.
Pertinent Results:
[**2170-9-20**] 05:15AM BLOOD WBC-11.7* RBC-3.29* Hgb-9.4* Hct-27.9*
MCV-85 MCH-28.6 MCHC-33.7 RDW-13.1 Plt Ct-273
[**2170-9-20**] 08:23PM BLOOD WBC-13.5* RBC-3.25* Hgb-9.1* Hct-28.0*
MCV-86 MCH-28.0 MCHC-32.5 RDW-12.7 Plt Ct-262
[**2170-9-21**] 12:28AM BLOOD WBC-13.1* RBC-3.52* Hgb-9.5* Hct-30.2*
MCV-86 MCH-26.9* MCHC-31.5 RDW-12.6 Plt Ct-273
[**2170-9-22**] 03:14AM BLOOD WBC-10.8 RBC-3.24* Hgb-9.3* Hct-27.0*
MCV-83 MCH-28.6 MCHC-34.4 RDW-12.8 Plt Ct-303
[**2170-9-23**] 06:30AM BLOOD WBC-8.8 RBC-3.34* Hgb-9.4* Hct-27.8*
MCV-83 MCH-28.0 MCHC-33.6 RDW-12.9 Plt Ct-351
[**2170-9-21**] 12:28AM BLOOD ALT-16 AST-18 LD(LDH)-165 AlkPhos-76
TotBili-0.8
[**2170-9-18**] 02:20PM BLOOD Type-ART pO2-252* pCO2-45 pH-7.39
calTCO2-28 Base XS-2 Intubat-INTUBATED
[**2170-9-18**] 04:23PM BLOOD Type-ART pO2-230* pCO2-43 pH-7.40
calTCO2-28 Base XS-1 Intubat-INTUBATED
[**2170-9-20**] 08:37PM BLOOD Type-ART Temp-36.5 Rates-/16 pO2-265*
pCO2-51* pH-7.39 calTCO2-32* Base XS-5 Intubat-NOT INTUBA
[**2170-9-21**] 12:32PM BLOOD Type-ART pO2-73* pCO2-44 pH-7.45
calTCO2-32* Base XS-5
CT abdomen/pelvis [**2170-9-23**]
IMPRESSION:
1. Small subcutaneous fluid and gas collection at the surgical
site in the
lower back.
2. Dilatation of the common bile duct and pancreatic duct.
Further
evaluation with MRCP would be helpful.
Brief Hospital Course:
Ms. [**Known lastname 78866**] was seen in clinic by Dr. [**Last Name (STitle) 1352**] for her low back and
bilateral leg pain. She concented to undergo elective lumbar
decompression and fusion. She was identified in the holding
area and questions were answered. She was brought back to the
OR for her procedure, which she tolerated well. After her
procedure, Ms. [**Known firstname 70030**] was brought to the PACU and then moved to
the general floor. On post op day number 2, Ms. [**Known firstname 70030**] was
triggered for decreased O2 saturation and changes in menatal
status. It was thought that she had decreased respirations
secondary to narcotics. She was given Narcan 0.2mg and
transfered to the MICU when she did not respond to second dose.
She was in the MICU overnight where she was monitored. She
remained stable in MICU. She was transfered back to the general
floor after three days in the MICU. It was felt that
desaturation may be combination of narcotics and obstructive
sleep apnea. Pulmonary embolus was ruled out with increased
saturation after narcan administration. Ms. [**Known firstname 70030**] did have
episodes of abdominal pain. She was evaluated by the general
surgery team who felt that it was not an acute surgical issue.
Her abdominal pain decrease once Ms. [**Known firstname 70030**] had a bowel
movement. Ms. [**Known firstname 70030**] continued to work with physical therapy
who okayed her for discharge to home. The rest of her course
was unremarkable.
Medications on Admission:
Verapamil SR 180mg [**Hospital1 **]
Percocet
Multi Vitamin
Discharge Medications:
1. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
2. Zaditor Ophthalmic
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Lumbar spondylolisthesis L4 on 5.
2. L4-5 lumbar stenosis.
3. L3-4 and L5-S1 moderate stenosis.
4. Neurogenic claudication
5. Morbid obesity.
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **]
have been given additional medication to control pain. Please
allow 72 hours for refills of this medication. Please plan
accordingly. You can either have this prescription mailed to
your home or you may pick this up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for
narcotics to the pharmacy. If you have questions concerning
activity, please refer to the activity sheet.
Followup Instructions:
Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3648**] PA-C on [**2170-10-2**] at 12:40pm.
If you have any questions, please call [**Telephone/Fax (1) **].
Completed by:[**2170-10-3**]
ICD9 Codes: 2851, 2762, 4019, 4439
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5324
}
|
Medical Text: Admission Date: [**2186-3-9**] Discharge Date: [**2186-3-11**]
Date of Birth: [**2109-9-23**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Called by Emergency Department to evaluate
left leg numbness and weakness s/p IV tPA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 39318**] is a 76-year-old right-handed woman with a
history of cardiac arrhythmia s/p PPM on Coumadin who presents
with acute onset left leg numbness and weakness. This morning
she
was in her USOH standing at the kitchen sink. She tried to turn
to use the microwave, and felt that her left leg was heavy and
did not turn as quickly as she wanted. She walked to the bedroom
and lay down on the couch. She felt heart palpitations and a
general feeling of weakness, and said to her husband, "I need to
go to the hospital." They called 911, and EMS brought her to
[**Location (un) 620**].
There, her initial NIHSS score was 4, as recorded by the ED
physicians. This included 2 for weakness in her left leg and 2
for what they felt was subtle ataxia in her left arm and leg.
The
decision was made to thrombolyse, and IV tPA was begun at 9:05.
After tPA was delivered, the Stroke team at [**Hospital1 18**] was then
called, who agreed with transfer to [**Hospital1 18**]. She now feels that
her
leg is better, but still not back to normal. She had no other
weakness and no speech or language difficulty.
Of note, she was scheduled for a colonoscopy and thus had
stopped
her Coumadin 1 week ago. The colonoscopy got delayed and she
restarted her Coumadin 2 days ago. She reports pitch black stool
this morning, but was Guaiac negative in the [**Location (un) 620**] ED prior to
tPA. INR was 1.3 at [**Location (un) 620**].
On neuro ROS, Ms. [**Known lastname 39318**] reports a mild bifrontal headache.
She
denies loss of vision, blurred vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal numbness, parasthesiae. No bowel or
bladder incontinence or retention. Denies difficulty with gait.
On general review of systems, she denies recent fever or chills.
No night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
Paryoxysmal atrial fibrillation on Coumadin
Sinus node dysfunction s/p PPM
Hyperlipidemia
RUQ breast mass
Lightheadedness in the past, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 46062**] in
neurology and evaluated by EEG, which was normal, and symptoms
have been attributed to a fib.
Social History:
Denies history of smoking. Drinks wine with dinner.
Lives with husband at home in [**Name (NI) 620**] and volunteers at
[**Hospital1 **].
Family History:
Father died of MI at age 57. Sister died of emphysema
and PE at age 50. Mother died of cancer at advanced age.
Physical Exam:
Vitals: T: 98.0 P: 79 R: 16 BP: 119/74 SaO2: 97%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Contracture of right elbow with scar on medial
aspect.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5- 5- 5 5 5 5 5- 5 4 5- 5 5 5
R 5- 5- 5 5 5 5 4+ 5 4+ 5 5 5 4+
-Sensory: Decreased pinprick over small strip of lateral left
foot. Decreased vibration at left great toe. No deficits to
light
touch, cold sensation, proprioception throughout. No extinction
to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
(Subcutaneous tissue at the knees interferes with reflex
testing)
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem with some difficulty. Romberg
absent.
Pertinent Results:
[**2186-3-10**] 09:55AM BLOOD WBC-6.6 RBC-4.15* Hgb-13.8 Hct-38.0
MCV-92 MCH-33.3* MCHC-36.3* RDW-13.0 Plt Ct-193
[**2186-3-9**] 12:10PM BLOOD WBC-8.7 RBC-4.25 Hgb-13.6 Hct-38.9 MCV-91
MCH-32.0 MCHC-35.0 RDW-13.6 Plt Ct-194
[**2186-3-9**] 12:10PM BLOOD Neuts-79.5* Lymphs-16.0* Monos-3.0
Eos-1.2 Baso-0.3
[**2186-3-10**] 09:55AM BLOOD PT-17.2* PTT-24.4 INR(PT)-1.6*
[**2186-3-9**] 12:10PM BLOOD PT-18.9* PTT-26.8 INR(PT)-1.7*
[**2186-3-10**] 09:55AM BLOOD Glucose-152* UreaN-12 Creat-0.6 Na-141
K-3.9 Cl-109* HCO3-24 AnGap-12
[**2186-3-9**] 12:10PM BLOOD Glucose-118* UreaN-16 Creat-0.7 Na-142
K-4.8 Cl-108 HCO3-25 AnGap-14
[**2186-3-10**] 09:55AM BLOOD CK(CPK)-47
[**2186-3-9**] 12:10PM BLOOD CK(CPK)-69
[**2186-3-10**] 09:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2186-3-9**] 12:10PM BLOOD cTropnT-<0.01
[**2186-3-10**] 09:55AM BLOOD Calcium-9.3 Phos-2.8 Mg-1.9 Cholest-PND
NCHCT [**2186-3-10**]: (prelim)
no intracranial hemorrhage
[**2186-3-11**] 07:05AM BLOOD PT-16.1* PTT-29.8 INR(PT)-1.4*
Brief Hospital Course:
This 76 yo F was transferred from [**Hospital1 **] [**Location (un) 620**] after IV tPA for a
suspected stroke presenting as LLE weakness/heaviness as
described in the HPI. Twenty four hours after the onset of her
symptoms, she felt that her LLE strength had returned to
baseline. Her NCHCT post tPA showed no hemorrhage and she was
restarted on her coumadin, with a lovenox bridge. She was
transferred to the neurology floor. She did well on the floor
and was discharged with home services to help with Lovenox while
coumadin becomes therapeutic.
Medications on Admission:
Coumadin 2.5 mg po Sun/Wed; 5 mg po other days
Clonazepam 0.5 mg po daily
Digoxin 250 mcg po daily
Omeprazoel 20 mg po bid
Sotalol 80 mg po bid
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for temp > 100.4 or pain.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*14 syringe* Refills:*2*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Stroke v. TIA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of some weakness in your leg. This
may have been due to a stroke. We did not see any evidence on
the CT of an acute stroke. You should return to the ER if you
have any new weakness, nubmness, dizziness or slurred speech.
You will need to take coumadin to prevent future strokes
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2186-5-19**] 2:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2040**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2186-5-19**] 3:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2040**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2186-8-21**] 11:20
F/U with Dr. [**Last Name (STitle) **] - please call
You will need to follow-up with your PMD on monday for INR
checks
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5325
}
|
Medical Text: Admission Date: [**2193-11-18**] Discharge Date: [**2193-11-21**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Altered Mental Status, Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, this is a 60 yoM with ESRD on peritoneal dialysis, DM2,
HTN, diastolic CHF, anemia, wheelchair-bound state who presented
from home with agitation and dyspnea after his wife was unable
to successfully complete his PD sessions at home. The catheter
had been flipped up into his abdomen and was not successfully
pulling back. He also became dyspneic at home - likely from
volume overload with inability to remove the dwelling fluid. The
catheter has since been fixed and he has had successful dialysis
while here. Importantly, the patient also had a recent admission
for C.diff diarrhea (+ by PCR) and is to complete a PO Vanc
course until [**2193-11-25**]. On initial presentation the patient was
extremely agitated, K was 6.9, lactate 0.8. CXR was performed
and pneumonia could not be excluded, thus patient was given 750
mg IV levofloxacin, also got doses of vanco and flagyl.
Kayexelate, insulin were given and K improved to 4.7 today.
.
Currently, the patient's VS are 99.8 80 138/67 18 99% on RA. He
is conversant and appropriate. He states that he feels well and
wants to go home. He denies SOB though his lungs have diffused
rhonchi and crackles. He abdomen is non-tender. He reports that
he was having [**1-5**] bowel movements at home. He currently has a
flexiseal in place.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**], then PD since
[**9-9**]
2. HTN
3. Chronic low back pain [**2-5**] herniated discs
4. diastiolic CHF- TTE [**12-9**] EF 75%, LVH
5. Peripheral neuropathy
6. Anemia
7. h/o nephrolithiasis
8. s/p cervical laminectomy; ?osteo in past
9. h/o depression
10. h/o MSSA bacteremia ([**3-9**]-infected HD catheter), E. coli
bacteremia
11. s/p L AV graft: [**7-7**]
12. h/o [**12-7**] of L4-5 diskitis, osteo, epidural abscess
13. MRSA cath tip infection
14. MSSA peritonitis [**6-10**]
15. thyroid nodule on u/s [**6-10**], recommended f/u 1 yr
16. wheelchair bound due to knee/muscle contraction since had a
PNA and ICU admission in [**2187**]
17. h/o IJ clot
18. Right third digit abscess through the entire finger
including flexor sheath s/p amputation 9/[**2193**].
Social History:
Lives in [**Location 2268**] with wife, who takes care of him at home, she
also takes care of his peritoneal dialysis. He uses a wheel
chair to move around at home which has been more difficult for
him and wife has had difficulties with transfers. Has two sons.
One of his sons lives in [**Name (NI) 3908**] and the other lives in [**Location 86**].
TOBACCO: 1-2 packs per day for the past 40 years.
ETOH: Last drinking 8 years ago
ILLICITS: Denies
Family History:
No family history of high blood pressure or heart attack. Two of
his grandparents, his aunt, and his father had diabetes, but he
is not sure which type. Both his father and mother passed away
from lung cancer. No fam hx of renal disease.
Physical Exam:
On admission:
VS: 99.8 80 138/67 18 99% on RA
GEN: alert and oriented, appropriate, lying on back in NAD
HEENT: PERRL, EOMI, red eyes and mildly icteric sclerae
NECK: Supple, no LAD, distended neck vein
PULM: Bilateral rhonchi and expiratory wheezing, patient with
abdominally augmented expiration, crackles heard throughout
CARD: RR, 2/6 systolic murmur at RUSB, nl S2, no R/G
ABD: BS+, soft, NT, ND, PD catheter site without tenderness or
erythema, no exudates
EXT: WWP, diminished peripheral pulses
NEURO: sensation intact; CNII-XII intact, Full strength in bil
UE/LE, able to lift both legs off bed
.
On discharge:
pulmonary exam had improved with only scattered crackles heard
and with transmitted upper airway noises
Pertinent Results:
Labs/Studies:
.
CBC:
[**2193-11-18**] 03:00AM BLOOD WBC-10.4# RBC-2.57* Hgb-7.5* Hct-24.2*
MCV-94 MCH-29.2 MCHC-31.0 RDW-21.3* Plt Ct-429
[**2193-11-21**] 05:37AM BLOOD WBC-8.0 RBC-2.93* Hgb-8.8* Hct-27.5*
MCV-94 MCH-29.9 MCHC-31.8 RDW-20.0* Plt Ct-383
.
[**2193-11-18**] 03:00AM BLOOD Glucose-77 UreaN-46* Creat-9.9*# Na-135
K-6.9* Cl-106 HCO3-20* AnGap-16
[**2193-11-21**] 05:37AM BLOOD Glucose-102* UreaN-36* Creat-9.9* Na-142
K-3.8 Cl-104 HCO3-25 AnGap-17
[**2193-11-18**] 10:54AM BLOOD ALT-53* AST-40 LD(LDH)-291* CK(CPK)-374*
AlkPhos-111 TotBili-0.1
.
[**2193-11-18**] 05:02PM BLOOD CK-MB-15* MB Indx-4.6 cTropnT-0.73*
[**2193-11-19**] 12:43AM BLOOD CK-MB-11* MB Indx-4.0 cTropnT-0.81*
[**2193-11-19**] 04:40AM BLOOD CK-MB-11* MB Indx-3.8
.
[**11-20**] CXR:
Cardiomediastinal silhouette is unchanged, slightly shifted
towards the left
side. Bibasilar consolidations have improved on the right side
due to
improvement of the component of atelectasis. Vascular congestion
has markedly
improved. There is pneumothorax or large pleural effusions.
Spinal hardware
is present.
.
AbXrays: initially showed peritoneal dialysis catheter flipped
into upper quadrant (wrong location) and then showed resolution
with catheter coiled in RLQ
.
11/5 Blood and peritoneal fluid cultures: NGTD
Brief Hospital Course:
60 yo M with ESRD on peritoneal dialysis, presented from home
with altered mental status and dyspnea in setting of receiving
no peritoneal dialysis since recent discharge from [**Hospital1 18**] on
[**2193-11-14**]. In ED, was combative and refusing treatment, had
hyperkalemia on laboratory evaluation.
.
#. Altered Mental Status:
Patient with single day of confusion and agitation. AMS most
likely secondary to metabolic derangements (hyperkalemia) given
recent limitations in dialysis. Pt was alert and oriented x 3
at the time of discharge. Blood cultures were negative at the
time of discharge. Restarted home mirtazapine and paroxetine at
home doses.
.
#. ESRD / Hyperkalemia:
Likely due to insufficient peritoneal dialysis in last 4 days
due to shift in location of dialysis catheter and in setting of
patient being discharged from hospital newly on lisinopril and
with instructions to take 20 mEq supplemental potassium daily.
(Patient was recently started on potassium supplements and
lisinopril because of chronically low K). The catheter shifted
back into proper location and multiple rounds of successful
peritoneal dialysis were performed. The patient was discharged
to have labs drawn the following week in case his potassium
again became low. Continued calcitriol and nephrocaps.
.
#. Dyspnea:
Likely due to volume overload from ineffective dialysis. He was
initially covered with antibiotics, however these were stopped
when the patient's dyspnea improved with successful dialysis. He
did have crackles on pulmonary exam at the time of discharge,
however, CXR was improved and he did not have fevers. He did
have URI symptoms but broad-spectrum antibiotics were not
continued as the patient was breathing comfortably on room air.
.
#. Diarrhea:
Presumably related to c diff colitis as evidenced by +PCR during
prior admission.
Continued oral Vancomycin for until [**2193-11-25**] as previously
planned. Restarted loperamide and Diphenoxylate-Atropine and
uptitrated medications to help slow the diarrhea. The patient
was to have GI follow-up the following week. He had no
tenderness on abdominal exam.
.
#. Troponin elevation:
Likely slightly elevated in setting of ineffective dialysis.
CK-MB values were flat. Continued aspirin and simvastatin.
.
#. Hypertension:
BP elevated to 170s systolic at presentation, no periods of
relative hypotension in [**Name (NI) **]. Continued home metoprolol and
nifedipine. Held lisinopril though this may need restarted as an
outpatient if potassium again becomes low.
.
#Anemia: Hct stable but low at 23; likely [**2-5**] renal disease.
Transfused 1 unit PRBCs with adequate response.
.
Access: The patient had a R femoral line during admission.
.
# DVT prophylaxis was with subQ heparin. The patient remained
full code during this admission. Communication was with [**Name (NI) 3408**]
[**Name (NI) 103960**] (Wife and HCP) - (h)[**Telephone/Fax (1) 103965**] , (c)[**Telephone/Fax (1) 104066**].
Medications on Admission:
1) Omeprazole 20 mg PO DAILY
2) Paroxetine HCl 20 mg PO DAILY
3) Mirtazapine 30 mg PO HS
4) Nifedipine 60 mg PO DAILY
5) Simvastatin 20 mg PO DAILY
6) Aspirin 325 mg PO DAILY
7) Calcitriol 0.25 mcg PO DAILY
8) Metoprolol tartrate 12.5 mg PO BID
9) Gabapentin 600 mg PO HS
10) Gabapentin 300 mg PO AM
11) Epoetin alfa 10,000 unit/mL MWF
12) Potassium chloride 20 mEq PO once a day
13) Oxycodone 5 mg PO Q6H:PRN pain
14) Nephrocaps 1 mg DAILY
15) Loperamide 4 mg PO TID
16) Diphenoxylate-atropine 2.5-0.025 mg PO BID:PRN loose stools
17) Vancomycin 125 mg PO Q6H until [**2193-11-25**]
18) Lisinopril 5 mg PO HS
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO at bedtime.
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a
day.
11. Epogen 10,000 unit/mL Solution Sig: One (1) injection
Injection qMon,Wed,Fri.
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
13. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) puff Inhalation every six (6) hours as
needed for dyspnea or wheezing.
16. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day) as needed for diarrhea.
17. loperamide 2 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day) as needed for diarrhea.
18. Outpatient Lab Work
Please have bloodwork checked next Tuesday [**2193-11-26**]. Check
Chem10 panel. Please fax results to Dr. [**Last Name (STitle) 1366**] at [**Telephone/Fax (1) 721**].
19. Outpatient Lab Work
Please have bloodwork checked on Friday, [**2193-11-22**]. Check Chem10
panel. Please fax results to Dr. [**Last Name (STitle) 1366**] at [**Telephone/Fax (1) 721**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Hyperkalemia
C. difficile diarrhea
Pulmonary edema
Anemia of chronic disease
.
Secondary:
ESRD on peritoneal dialysis
Hypertension
Chronic lower back pain
Diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 103960**],
You were admitted to the hospital because you were short of
breath and you were agitated. These symptoms were from
inadequate dialysis at home as your dialysis catheter was in the
wrong location - your potassium was very high as a result. This
problem resolved on its own and you have had successful dialysis
during this admission. You have also had problems with diarrhea
- you will need to complete a course of vancomycin and you
should continue to take loperamide and lomotil to help slow down
the diarrhea. You will see a GI physician next Tuesday who will
address your diarrhea if it has not slowed down. Your shortness
of breath improved your chest x-ray looked much better before
discharge. We believe that the mass on your L hip is a lipoma
-this is not a concerning finding but can be surgically excised
if you have pain or discomfort at the site.
.
We made the following changes to your medications:
We STOPPED potassium supplemention
We STOPPED lisinopril
We stopped these agents because they can increase your
potassium. Depending on your values next week. They may be
restarted if your potassium again becomes low.
You should continue dialysis per your home regimen.
.
Your follow-up appointments are listed below.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2193-11-22**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2193-11-26**] at 2:30 PM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], 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
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 2767, 5856, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5326
}
|
Medical Text: Admission Date: [**2143-8-27**] Discharge Date: [**2143-9-6**]
Date of Birth: [**2096-10-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
colonoscopy [**2143-8-28**]
thoracentesis [**2143-9-5**]
History of Present Illness:
46M s/p liver transplant [**2143-7-26**] presents to the ED from
[**Hospital **] Rehab after having [**5-16**] bloody bowel movements overnight
accompanied with hallucinations. He bright red blood per rectum
mixed with stool/on the toilet paper/in the toilet bowl
intermittently over the past week though it wasn't obvious or
severe until last night when he had [**5-16**] bloody bowel movements,
initially "almost entirely" clot with some solid material in it
and transitioning to mostly brown liquid stool with some blood
in
it. He reports that he has otherwise been having [**2-12**] normal,
formed bowel movements daily, no diarrhea or constipation.
He also reports hallucinations last night, confirmed by his RN
who accompanies him from [**Hospital1 **]. He reports that he felt as
though his cat was following him and that there was someone
speaking to him in a low voice. He readily acknowledges that he
was aware the entire time as he is now that these were, in fact,
hallucinations and not real. He denies hallucinations currently
but does feel slightly "foggy...like it's hard to pay
attention".
Of note, his post-operative course was significant for
persistent
hyperkalemia for which he was started on fludricortisone with
good results. This was discontinued in clinic followup.
ROS: As per HPI, otherwise denies fevers, chills, nausea,
vomiting.
Past Medical History:
- Alcohol cirrhosis c/b esophageal varices (grade III) with
bleed s/p banding in [**7-/2142**], ascites/SBP ([**5-/2142**]),
encephalopathy, rectal varices
- Alcoholic hepatitis [**2-/2141**]
- Recurrent hepatic hydrothorax
- Hemolytic anemia on prednisone
- Type 2 diabetes mellitus
- Hypertension
- Hyperlipidemia
- Strep viridans and MSSA bacteremia s/p Vancomycin X 2 weeks
[**5-/2142**]
- Alcohol abuse (last drink [**2142-3-13**])
- GERD
- Depression/anxiety
- OSA on CPAP
- h/o Atrial fibrillation s/p cardioversion not on
anticoagulation
Social History:
Currently lives at a rehab facility, where per documentation he
requires assistance with most ADLs (bathing, ambulating,
dressing) though he can eat independently. He has never smoked
and denies IVDU, but used cocaine, ecstasy and special K prior
to [**2122**]. He is close to a brother and sister both live in the
area. He is currently unemployed. He denies current tobacco or
alcohol use, states last EtOH was [**2142**].
Family History:
Patient states that father and mother likely both had EtOH
abuse. His father died of an infection, his mother passed away
of complications from CVA 2 years ago.
Physical Exam:
Vitals: 97.6 106 108/68 18 100 RA
NAD, AAOx3 and appropriate in conversation but admits difficulty
with concentration
mild tachycardia
RRR, unlabored respiration
abdomen soft, non-tender, non-distended, midline xiphoid portion
of [**Last Name (un) **]-[**Last Name (un) **] incision open and midly wet with
fibrinoupurulent fluid at base
DRE: liquid brown stool with small amount of gross blood, no
hemorrhoids immediately visible or palpable on exam
ext no edema
11.9 > 27.1 < 115
128 | 97 | 22
--------------< 110
5.6 | 22 | 0.9
ALT 21 AST 19 AP 70 Tb 0.9 Alb 3.4
INR 1.3
UA negative
Pertinent Results:
[**2143-8-27**] 01:00PM BLOOD WBC-11.9*# RBC-2.91* Hgb-9.2* Hct-27.1*
MCV-93# MCH-31.6 MCHC-33.9 RDW-17.1* Plt Ct-115*
[**2143-8-27**] 07:35PM BLOOD WBC-9.1 RBC-2.53* Hgb-8.1* Hct-24.2*
MCV-94 MCH-31.8 MCHC-33.7 RDW-17.0* Plt Ct-93*
[**2143-8-28**] 01:48PM BLOOD WBC-10.3 RBC-3.19* Hgb-10.0* Hct-29.3*
MCV-92 MCH-31.5 MCHC-34.3 RDW-17.2* Plt Ct-84*
[**2143-9-6**] 06:09AM BLOOD WBC-6.0 RBC-3.45* Hgb-10.8* Hct-32.1*
MCV-93 MCH-31.3 MCHC-33.6 RDW-17.0* Plt Ct-137*
[**2143-9-2**] 12:23AM BLOOD PT-13.0* PTT-32.9 INR(PT)-1.2*
[**2143-9-6**] 06:09AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-137
K-4.1 Cl-107 HCO3-23 AnGap-11
[**2143-8-27**] 01:00PM BLOOD ALT-21 AST-19 AlkPhos-70 TotBili-0.9
[**2143-9-6**] 06:09AM BLOOD ALT-16 AST-16 AlkPhos-61 TotBili-0.6
[**2143-9-6**] 06:09AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8
[**2143-9-1**] 09:00AM BLOOD TSH-2.2
[**2143-9-6**] 06:09AM BLOOD tacroFK-8.6
[**2143-9-5**] 5:31 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2143-9-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
46M s/p liver transplant [**2143-7-26**] presents to the ED from [**Hospital **]
Rehab with bloody stools and hallucinations. On admission, hct
was 27.1. He was transferred to the SICU where a colonoscopy was
performed. This demonstrated a small polyp in the distal colon
that was not removed. There was an irregular, bumpy, friable
mucosa in the rectum that was biopsied. Large non-bleeding
hemorrhoids were seen. Otherwise, normal colonoscopy to cecum.
He was transfused with 3 units of PRBC with hct increase to 29.
Hct remained stable. Rectal mucosal biopsies demonstrated
colonic mucosa with surface hyperplastic change; otherwise,
within normal limits. He was started on iron. EGD was not done
at that time, but will be arranged as an outpatient.
Liver duplex was unremarkable. LFTs were stable.
Immunosuppression continued with daily adjustment to Prograf
based on trough levels.
He developed SVT/afib which was treated with Lopressor and
diltiazem. He continued to have intermittent brief episodes of
tachycardia with rates up to 200. Lopressor and Diltiazem doses
were adjusted. He was ruled out for MI. Once stable, he was
transferred out of SICU. However, he went back to the SICU on
[**9-1**] for non-sustained Vtach which responded to diltiazem doses
and lopressor adjustment. Once stable again, he was transferred
back to Med-[**Doctor First Name **] unit again.
On [**9-4**], he complained of SOB. Breath sounds were diminished [**2-11**]
way up on right lung. CXR showed a small pleural effusion. This
was also noted on liver duplex. A repeat CXR was done on [**9-5**],
showing stable RLL and possibly RML collapse. IP was consulted
and a 1400ml thoracentesis was performed. Post thoracentesis CXR
revealed significantly improved right pleural effusion, to near
resolution and no pneumothorax. Pleural effusion was
unremarkable. Culture was negative. Follow up CXR on [**9-6**]
demonstrated small re accumulation of right pleural effusion.
His mental status was notable for confusion and a delirium.
Oxycodone, Wellbutrin,and Lidocaine patch were stopped.
Prednisone was decreased to 10mg daily. Mental status became
more alert/oriented and improved, however, he continues to be
slow to answer and disorganized in his thought process/answers.
Blood sugars were well controlled.
Abdominal incision wound VAC continued to be changed every 3
days. Output/drainage was minimal.
PT evaluated and recommended rehab. He feels weak during
ambulation and has decreased endurance. SBP runs on the low side
and fall precautions were implemented. SBP ranged between
99-114/73 with HR in 80s. O2 was mid 90s to 100 on room air.
[**Hospital **] Rehab was approved and he will transfer there today.
Medications on Admission:
bupropion 75', fluconazole 400', folic acid 1', lasix 20',
lantus 18', lispro SS, MMF 1000'', protonix 40', prednisone
17.5', bactrim SS', tacrolimus 3'', valcyte 900', venlafaxine XR
150', colace, vit D2, iron sulfate, thiamine
All: NKDA
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Bacitracin Ointment 1 Appl TP ASDIR
Daily to left 1st toe
3. Dextrose 50% 25 gm IV PRN hypoglycemia
4. Diltiazem Extended-Release 240 mg PO DAILY
Start once daily dosing with ER dosing on [**9-5**]
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluconazole 400 mg PO Q24H
7. FoLIC Acid 1 mg PO DAILY
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. NPH 18 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
10. Metoprolol Tartrate 25 mg PO TID
hold for HR <60
11. Mycophenolate Mofetil 1000 mg PO BID
12. Pantoprazole 40 mg PO Q24H
13. PredniSONE 10 mg PO DAILY
Decrease on [**9-4**]
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. ValGANCIclovir 900 mg PO DAILY
16. Venlafaxine XR 150 mg PO DAILY
17. Tacrolimus 3 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Melena
colon polyp
Afib
abdominal incision wound
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 will be transferring to [**Hospital **] Rehab in [**Location (un) 701**]
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following:
temperature of 101 or greater, chills, nausea, vomiting,
jaundice, confusion, dizziness, shortness of breath, abdominal
pain, incision wound has pus or foul odor, bloody bowel
movements or any concerns
-you will need to have blood work drawn twice weekly for lab
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-9-11**] 10:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-9-18**] 10:00
Completed by:[**2143-9-6**]
ICD9 Codes: 4168, 5789, 4271, 5119, 2767, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5327
}
|
Medical Text: Admission Date: [**2142-10-29**] Discharge Date: [**2142-11-6**]
Date of Birth: [**2069-5-15**] Sex: M
Service: HEPATOBILIARY SURGERY SERVICE
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male, with a history of peripheral vascular disease, elevated
PSA, history of benign prostatic hypertrophy, who went for a
routine physical exam and was noted to have elevated liver
function tests. This prompted to obtain an ultrasound of the
abdomen which was performed on [**2142-9-25**],
demonstrating a lobular slight hypoechoic mass in the region
of the pancreatic head that measured roughly 3-cm in diameter
and was associated with prominent abnormal dilatation of the
pancreatic duct which measured 10 to 11-mm in diameter. There
was also dilatation of the common bile duct which measured 11
to 12-mm in diameter and was associated with slight
intrahepatic ductal dilatation. The remainder of the exam was
unremarkable. A CT of the abdomen was performed on [**2142-9-25**] which demonstrated a mild to moderate intrahepatic
biliary duct dilatation, as well as dilatation of the common
bile duct which measured 1.1-cm at the level of the
pancreatic head. There was diffuse dilatation of the
pancreatic duct which measured 0.8-cm. There was normal
enhancement of the superior mesenteric artery and vein
without involvement of the tumor. There was adenopathy noted
inferior to the head of the pancreas measuring 1.7 x 1.9-cm.
A necrotic mass was seen in the small bowel mesentery on the
left at the level of the head of the pancreas measuring 1.6 x
2.9-cm.
Patient is completely asymptomatic. Patient is able to
tolerate a regular diet, has normal bowel movements. Patient
is fully active. He denies any fevers, chills, nausea,
vomiting, diarrhea, any weight loss or steatorrhea.
PAST MEDICAL HISTORY: Patient has a history of peripheral
vascular disease, elevated PSA, benign prostatic hypertrophy,
history of bilateral inguinal hernia repair in the [**2106**],
status post appendectomy in [**2086**].
ALLERGIES: Allergic to penicillin.
MEDICATIONS ON ADMISSION: Flomax 0.4 mg p.o. once daily.
SOCIAL HISTORY: He is married and has 3 children. He is a
retired managerial psychologist who has a doctorate in
psychology, currently working in the service department for
the [**Company 65042**] organization.
PHYSICAL EXAM: Temperature 97.2, BP 160/80, heart rate 68,
respirations 16, height 5-feet 9-1/2-inches, weight 152-
pounds. Patient is a well-nourished, well-developed male in
no acute distress. Skin normal. HEENT: Pupils equal, round,
reactive to light. EOMIs are full. No scleral icterus. MOUTH:
Oropharynx clear. Neck supple, no lymphadenopathy, no
thyromegaly, carotids 2-plus/4-plus without bruits. Lungs
clear to auscultation bilaterally. CV regular rate and
rhythm, normal S1, S2, without rub, but he does have a II/VI
systolic ejection murmur that is present along the left
sternal border. ABDOMEN: Positive bowel sounds, soft,
nontender, no hepatosplenomegaly, masses. EXTREMITIES: No
C/C/E. Neurologically grossly intact.
LABS PRIOR TO ADMISSION FROM [**2142-10-25**]: WBC of 7.3,
hematocrit 42.2, PT 12.3, PTT 22.2, INR 1.0, sodium 137, 4.5,
101, 25, BUN and creatinine 16 and 1.2, glucose 122, ALT 125,
AST 108, alkaline phosphatase 525, amylase 139, total
bilirubin 1.0, lipase 90, total protein 6.9, CEA on [**2142-10-25**], 2.9, AFP 6.1, and CA19-19, 170.
HOSPITAL COURSE: On [**2142-10-29**], the patient had
surgery in which a pylorus-sparing pancreaticoduodenectomy,
cholecystectomy, small bowel resection was performed by
Doctors [**Name5 (PTitle) **] and [**Name5 (PTitle) **]. Please see operative note for more
details. Patient received 6000-cc of crystalloid, made 485-cc
of urine, estimated blood loss was 500-cc. The skin was
closed using staples after irrigating the subcutaneous
tissue. JP drain was placed posteriorly to the pancreatic
anastomosis.
Postoperatively, patient went to the SICU. Patient had
epidural catheter for pain control. Postop day 1 labs: WBC of
11.7, hematocrit of 32.9. Coags were unremarkable.
Electrolytes were unremarkable except for a blood sugar of
202. LFTs: ALT 228, AST 75, alkaline phosphatase 233, total
bilirubin 1.1. On [**2142-10-31**], epidural was removed. NG
was clamped. JP drain put out 20-cc. Patient was started on
IV pain medications. Patient continued to be afebrile, vital
signs stable. Diet was advanced. Foley was removed on
[**2142-11-2**]. Continued to be n.p.o. until [**11-2**],
at which time patient started on sips and was advanced on the
17 to a regular diet. Oncology was consulted on [**2142-11-2**], and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] saw the patient. Path report came
back as 1) adenocarcinoma of the pancreas, 2) extensive
pancreatic intraepithelial neoplasm with high-grade dysplasia
(PanIN III). 3) There were permanent sections. The permanent
sections of the pancreatic neck margin showed no dysplasia or
carcinoma. 4) Chronic pancreatitis with atrophy and fibrosis.
5) Dilatation of common bile duct without tumor. 6) Duodenal
segment within normal limits. Gallbladder demonstrated
cholecystic duct lymph node, no tumor, gallbladder within
normal limits. Small bowel segment within normal limits.
Lymph node superior pancreatic demonstrated metastatic
adenocarcinoma.
Physical therapy saw patient and felt that he would be able
to be discharged to home without services. On postop day 5,
the patient had a low-grade fever of 100.9, otherwise doing
well. Vital signs were stable. The output of the JP was 60-
cc. The patient was ambulating fine without difficulty.
Patient had increased stool output which was loose. So, stool
culture was sent on [**2142-11-4**] demonstrating positive
C. difficile toxin. Patient was started on Flagyl 500 t.i.d.
On [**2142-11-6**], JP drain was removed, and a U-stitch
was placed. On [**2142-10-29**], he was afebrile, vital
signs stable. The dressing was clean, dry and intact. JP
drain was removed. Staples intact. Labs on [**2142-11-6**],
WBC of 8.3, hematocrit of 26.6 which was repeated which
demonstrated 29.5, platelets 531, sodium 142, 3.8, 106, 28,
BUN and creatinine of 12 and 1.1, with glucose 106, ALT 58,
AST 26, alkaline phosphatase 188.
So, patient was discharged from the hospital, in which the
patient does live in [**State 108**] and will be residing in a nearby
hotel for 1-week.
DISCHARGE MEDICATIONS: Tylenol [**11-19**] p.o. q 4-6 h p.r.n.,
tamsulosin 0.4 mg 1 tab once daily, Percocet [**11-19**] p.o. q. [**2-21**]
h p.r.n., Flagyl 500 mg t.i.d. x14 days.
Patient is to follow-up with Dr. [**Last Name (STitle) **] on [**2142-11-14**]
at 9:40 a.m. Please call [**Telephone/Fax (1) 673**] if there are any
questions about the appointment. Patient is to call
transplant surgery immediately at [**Telephone/Fax (1) 673**] for any
fevers, chills, nausea, vomiting, abdominal pain, any
increased redness to incision, sustained decreased appetite,
increased bowel movements, or any problems with urination.
FINAL DIAGNOSES: Pancreatic carcinoma.
SECONDARY DIAGNOSIS: Clostridium difficile, peripheral
vascular disease, elevated prostate-specific antigen/benign
prostatic hypertrophy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2142-11-7**] 11:38:35
T: [**2142-11-7**] 12:33:21
Job#: [**Job Number 65043**]
ICD9 Codes: 4439
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5328
}
|
Medical Text: Admission Date: [**2173-11-16**] Discharge Date: [**2173-11-19**]
Date of Birth: [**2113-9-27**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old
woman who noticed tearing of her left eye with puffiness of
the skin under the left eye for the last six months with no
other symptoms.
PHYSICAL EXAMINATION: Speech and affect within normal
limits. There is a clear cut mild exophthalmus of the left
eye with some puffing of the lower eyelid. Full range of
motion of the eye. Visual fields are full to confrontation.
Cranial nerves examination shows normal sensation of the face
include the cornea. Normal motor function. Hearing normal
to finger sounds and lower cranial nerve intact. Otherwise
neurological examination is intact. A CT and MRI scan of the
brain shows a left retro-orbital tumor. The patient was
prepped for a craniotomy for removal of the tumor. On
[**2173-11-16**] she had a left pterional craniotomy for resection
of sphenoid [**Doctor First Name 362**] orbital question meningioma. There were no
intraoperative complications. Postop vital signs were
stable. The patient was awake and alert. Extraocular
muscles were full. Tongue was midline. No pronator drift.
IPs 5 out of 5. The patient had severe swelling of the left
eye. Her vital signs were otherwise stable. She was
afebrile. Pupils 3 down to 1 on the right and 2 down to 1 on
the left. The patient's incision was clean, dry and intact.
She has no drainage from her incision. Her vital signs had
been stable. She was afebrile.
The patient will be discharged to home with follow up with
staple removal on [**11-26**] at 1:00 p.m. with [**Doctor Last Name 6910**].
MEDICATIONS ON DISCHARGE: Percocet one to two tabs po q 4
hours prn, Synthroid .15 mg po q.d., Zantac 150 mg po b.i.d.,
Metoprolol 12.5 mg po b.i.d.
The patient was in stable condition at the time of discharge.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2173-11-19**] 10:33
T: [**2173-11-21**] 10:00
JOB#: [**Job Number 33098**]
ICD9 Codes: 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5329
}
|
Medical Text: Admission Date: [**2155-1-29**] Discharge Date: [**2155-2-16**]
Date of Birth: [**2091-3-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2155-2-3**]
Coronary artery bypass grafting x4 with left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein graft from aorta to first diagonal coronary
artery; reverse saphenous vein graft from aorta to first obtuse
marginal coronary artery; as
well as reverse saphenous vein graft from aorta to posterior
left ventricular coronary artery
History of Present Illness:
63 year old male who presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with chest
pain/shortness of breath for the last 2-3 days. The patient
stated that three days ago he developed sudden onset of
midsternal chest pain as a dull pain. He had intermittent pain;
the longest one lasted around 2-3 hours. Next day woke up with
shortness of breath and continued to have chest pain. Unable to
catch his breath and EMS was activated on [**2154-11-20**]. Peak trop
0.52 [**2155-1-20**], trending down 0.42. Patient has
bilateral Rales, he has been receiving IV bumex with good
diuresis. Patient had an episode of chest pain this am, mid
sternum, while at rest relived with one sublingual ntg. He was
transferred to [**Hospital1 18**] for cardiac cath.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Chronic kidney disease
DVT (no PE)
Past Surgical History:
s/p Left hip replacement
s/p multiple knee surgeries in past Left and right
Social History:
Race:Caucadian
Last Dental Exam:edentulous
Lives with:wife
Occupation:retired
Tobacco:quit 25 years ago
ETOH:occasionally
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:83 Resp:24 O2 sat:97/2L
B/P Right:189/94 Left:171/86
Height: 6'1" Weight:280 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [] chronic venous stasis +
Edema +2 Varicosities: None []
Neuro: Grossly intact
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2155-2-12**] 03:19AM BLOOD WBC-10.9 RBC-3.06* Hgb-9.5* Hct-28.7*
MCV-94 MCH-30.9 MCHC-33.0 RDW-14.8 Plt Ct-386
[**2155-2-11**] 03:32AM BLOOD WBC-10.3 RBC-3.03* Hgb-9.1* Hct-27.6*
MCV-91 MCH-30.1 MCHC-33.0 RDW-15.0 Plt Ct-382
[**2155-2-12**] 03:19AM BLOOD Glucose-87 UreaN-88* Creat-3.1* Na-142
K-3.8 Cl-100 HCO3-27 AnGap-19
[**2155-2-11**] 03:32AM BLOOD Glucose-113* UreaN-84* Creat-2.9* Na-142
K-4.0 Cl-102 HCO3-29 AnGap-15
[**2155-2-10**] 03:07AM BLOOD Glucose-138* UreaN-80* Creat-3.0* Na-145
K-4.2 Cl-102 HCO3-28 AnGap-19
[**2155-2-9**] 03:20AM BLOOD Glucose-80 UreaN-74* Creat-3.3* Na-148*
K-3.7 Cl-107 HCO3-28 AnGap-17
[**2155-2-8**] 02:39AM BLOOD Glucose-112* UreaN-73* Creat-3.8* Na-144
K-4.0 Cl-104 HCO3-28 AnGap-16
[**2155-2-3**] Intraop TEE
PRE-CPB: 1. The left atrium is mildly dilated. A patent foramen
ovale is present.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. There is moderate
regional left ventricular systolic dysfunction with inferoapical
and anteroapical hypokinesis. Overall left ventricular systolic
function is moderately depressed (LVEF= 30-35 %). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. with mild global free wall
hypokinesis.
3. There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
4. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
6. There is a very small pericardial effusion. The pericardium
may be thickened.
POST-CPB: On infusion of epi and milrinone briefly. A-paced for
bigeminy briefly. Improved biventricular systolic function after
CPB with the LVEF = 40-45%. The anterior and inferior walls are
improved. The MR is now trace. The aortic contour is normal post
decannulation.
[**2155-2-14**] 04:51AM BLOOD WBC-8.2 RBC-2.88* Hgb-8.9* Hct-26.8*
MCV-93 MCH-30.9 MCHC-33.1 RDW-14.7 Plt Ct-331
[**2155-2-15**] 05:45AM BLOOD WBC-8.4 RBC-2.90* Hgb-9.1* Hct-26.5*
MCV-92 MCH-31.4 MCHC-34.3 RDW-14.6 Plt Ct-400
[**2155-2-10**] 03:07AM BLOOD PT-18.0* PTT-29.7 INR(PT)-1.6*
[**2155-2-16**] 04:56AM BLOOD Glucose-161* UreaN-112* Creat-4.1* Na-138
K-4.7 Cl-98 HCO3-27 AnGap-18
[**2155-2-14**] 04:51AM BLOOD Calcium-7.0* Phos-6.3* Mg-2.5
Brief Hospital Course:
63 yo male history of Diabetes Mellitus 2, Hypertension,
Hyperlipidemia, Coronary artery disease s/p recent cath at
[**Hospital1 18**] on [**2155-1-22**] after NSTEMI found to have three vessel
disease with CABG planned on [**2155-2-7**] that presented with chest
pain and shortness of breath consistent with unstable angina,
acute on chronic heart failure exacerbation, and acute on
chronic renal failure. On [**2155-2-3**] he was taken to the operating
room and underwent coronary artery bypass grafting x four with
left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein graft from aorta to
first diagonal coronary artery; reverse saphenous vein graft
from aorta to first obtuse marginal coronary artery; as well as
reverse saphenous vein graft from aorta to posterior left
ventricular coronary artery with Dr.[**Last Name (STitle) 914**]. Cross clamp time=
83 minutes. Cardiopulmonary Bypass Time=110 minutes. [**2155-2-4**] he
awoke neurologically intact and was weaned to extubation. The
following day he was reintubated secondary to hypercapnea. All
lines and drains were discontinued in a timely fashion. POD#4 he
was weaned to extubation successfully.
Beta-blocker/Statin/Aspirin/ and diuresis were initiated. All
narcotics were discontinued due to postoperative delerium and
confusion.Renal was consulted for acute on chronic renal
failure. He continued to progress, mental status improved and on
POD#7 he was transferred to the step down unit for further
monitoring. Physical Therapy was consulted for strength and
mobility. Pt was recommended to go to rehab, but refused. Pt
decided to sign out against medical advice His BUN and cratinine
remain high. He is making good urine. BUN 112 / Creatine 4.1.
Renal recommended laasi and zaroxalyn. All follow up
appointments were advised.
Medications on Admission:
Pro-air inhaler 2 puffs every 2 hours
Simvastatin 40mg QD
Lasix 40mg Daily
Lostartan/potassium 50mg Daily
MVI
Vit. C 500mg Daily
Vitamin D 50,000 units daily
Allergies:Morphine/Diluadid (Confusion)
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. 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*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Neurontin 400 mg Capsule Sig: One (1) Capsule PO once a day.
5. Lopid 600 mg Tablet Sig: One (1) Tablet PO once a day.
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): prn for pain.
Disp:*240 Tablet(s)* Refills:*2*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): untill follow up.
Disp:*30 Tablet(s)* Refills:*0*
10. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. insulin
Insulin SC Fixed Dose Orders
Breakfast Bedtime
Glargine 50 Units Glargine 40 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 6 Units 6 Units 6 Units 3 Units
200-239 mg/dL 10 Units 10 Units 10 Units 5 Units
240-280 mg/dL 14 Units 14 Units 14 Units 7 Units
> 280 mg/dL Notify M.D.
13. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day: 120
mg [**Hospital1 **].
Disp:*180 Tablet(s)* Refills:*2*
14. Zaroxolyn 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Daily chem 10, please fax the results to Dr [**Last Name (STitle) **] at ([**Telephone/Fax (1) 93163**] and Dr [**First Name (STitle) **] at ([**Telephone/Fax (1) 93164**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
1+ 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 [**Last Name (STitle) 914**] on [**2155-2-25**] at 2:30
Cardiologist:[**Last Name (LF) 10543**], [**First Name3 (LF) **]
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 19961**] in [**4-1**] weeks [**Telephone/Fax (1) 33016**]
**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:[**2155-2-16**]
ICD9 Codes: 5845, 2760, 2930, 5990, 5859, 4280, 3572
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5330
}
|
Medical Text: Admission Date: [**2153-9-4**] Discharge Date: [**2153-9-14**]
Service: NSU
PRESENT ILLNESS: [**Known firstname **] [**Known lastname 66572**] was an 81 year old female who
complains of bilateral hand pain and numbness for
approximately two months. She also has some posterior neck
discomfort. She denies any neck or radicular arm pain. She
does complain of balance problems and states she "sways as if
she is drunk." She does drop objects with both hands. She
cannot write or sign checks. She denies any bowel or bladder
disfunction other than urgency. She has not had physical
therapy or epidural steroid injections.
PAST MEDICAL HISTORY: Is remarkable for diabetes,
osteoporosis, hypertension, rheumatoid arthritis.
PAST SURGICAL HISTORY: Is remarkable for mastectomy and
bilateral knee arthroscopies.
MEDICATIONS ON ADMISSION: Were Norvasc, gemfibrozil,
Clarinex, Zoloft, Ambien, Flonase and Bextra. She has no
known drug allergies. She is not a smoker.
PHYSICAL EXAMINATION: Her height was 5 feet 3 inches.
Weight is 138 pounds. Vital signs at the time of admission
were stable. On examination she did have a spastic gait.
Motor examination in the upper extremities on the left were 3
plus and the deltoid, biceps, triceps, brachial radialis,
wrist flexors, wrist extensors and intrinsics. The lower
extremities were [**4-4**] bilaterally. Deep tendon reflexes were
3 plus bilaterally at brachial radialis, biceps, triceps, 3
plus at the right knee, absent at the left knee, 2 plus at
the ankles. She had no [**Doctor Last Name 937**] and clonus bilaterally.
She did have an MRI done on [**2153-8-11**] that did show
a peri-odontoid C2 pannus with significant compression of the
cervical medullary junction with an increased T2 cord signal.
X-rays with flexion and extension did show a C1-2 instability
with hypermobility of C1 on C2.
HOSPITAL COURSE: She was admitted and brought to the
operating room on [**2153-9-5**] where she underwent a
transoral odontoidectomy and posterior occipital cervical
fusion. She also had placement of a Delta feeding tube
placed intraoperatively. Postoperatively she was transferred
to the post anesthesia care unit where she remained intubated
and sedated. She was kept there overnight for close
observation. When she was lightened off the propofol she was
moving all four extremities briskly. She was also on
Decadron 6 mg every six hours. On [**9-6**], the first
postoperative day her vital signs were stable. She was
afebrile. She could open her eyes to voice and continued to
move all four extremities spontaneously as well as on
command. She was kept intubated. She was also followed by
Medicine as they saw her preoperatively as well. She was
transferred to the Intensive Care Unit for close
neurosurgical neurological monitoring. She continued
extubated and once the swelling in her airway was decreased
she was able to be extubated which did occur on [**9-8**].
Her posterior incision was clean, dry and intact. She
received aggressive chest physical therapy. She was started
on Kefzol. She was stable enough to be transferred to the
floor on [**9-10**]. She was started on Physical Therapy and
Occupational Therapy. She was on total parenteral nutrition
for nutrition but then on [**9-13**] she did start on clear
fluids which was quickly advanced. She tolerated this well.
She had received intravenous Lasix on several occasions for
diuresis. She also received blood products while in the
Intensive Care Unit and was treated for fluid volume overload
with intravenous Lasix. She was also started on total
parenteral nutrition for malnutrition while she was n.p.o.
Her Decadron was weaned to 2 B.I.D She did have some mild
erythema at the inferior aspect of the posterior cervical
wound and started on Keflex 500 mg 4 times a day for ten
days. She will be discharged to home on [**2153-9-14**]
with home physical therapy to assist with her ambulation.
She is scheduled to follow up with Dr. [**Last Name (STitle) 1906**] in six weeks
and Dr. [**Last Name (STitle) 1327**] for staple removal on next Wednesday, [**2153-9-19**] for staple removal.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2153-9-14**] 12:22:22
T: [**2153-9-14**] 13:24:14
Job#: [**Job Number 37246**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5331
}
|
Medical Text: Admission Date: [**2195-3-18**] Discharge Date: [**2195-3-31**]
Date of Birth: [**2118-3-16**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
woman with a history of right upper extremity tremor. She
had an MRI scan which showed a 7 mm right posterior
communicating artery fetal PCA aneurysm. She was seen by Dr.
[**Last Name (STitle) 1132**] and admitted for angio and possible coil embolization
of this aneurysm. She was admitted status post arteriogram
which showed evidence of this right PCA aneurysm which was
not amenable to coiling; therefore, the patient was scheduled
for clipping of this aneurysm. She remained in the hospital,
was seen by cardiology and cleared for surgery.
PAST MEDICAL HISTORY: 1) Migraines, 2) Palpitations, 3)
Hepatitis A.
ALLERGIES: 1) codeine, 2) sulfa, 3) penicillin.
PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy as a
child.
HOSPITAL COURSE: She was taken to the OR on [**2195-3-24**] for
clipping of this right fetal PCA aneurysm without intraop
complication. Postop, the patient was in the Intensive Care
Unit. She was extubated on postop day #1. She was awake,
alert, oriented, following commands, moving all extremities
with no drift. She was weaned to 2 liters nasal cannula.
She was ruled out for an MI per protocol per cardiology,
which she did rule out for. Her vital signs remained stable.
She was afebrile, and she was transferred to the floor on
postop day #2. She remained neurologically awake, alert,
oriented x 3 with a slight left drift on postop day #3.
Repeat head CT showed no new evidence of hemorrhaging or
stroke. She had an upper extremity Doppler due to some left
upper extremity weakness and swelling which was also
negative. She was seen by physical therapy and occupational
therapy and found to require rehab. Her left upper extremity
weakness did improve greatly before discharge. Her vital
signs remained stable. Her incision was clean, dry and
intact.
DISCHARGE MEDICATIONS: 1) hydrocodone 1-2 tabs po q 4 h prn,
2) aspirin 81 mg po qd, 3) famotidine 20 mg po bid, 4)
albuterol inhaler 1 puff q 6 h prn, 5) Dilantin 100 mg po
tid, 6) heparin 5,000 units subcu q 12 h, 7) fexofenadine 60
mg po bid, 8) metoprolol 100 mg po bid, 9) alprazolam 0.25 mg
po bid prn, 10) albuterol 1-2 puffs q 6 h prn.
DISCHARGE CONDITION: Stable at the time of discharge.
FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 1132**] in one month.
Staples should be removed on postop day #10.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2195-3-30**] 14:19
T: [**2195-3-30**] 13:28
JOB#: [**Job Number 49053**]/[**Numeric Identifier 49054**]
ICD9 Codes: 2762, 5990, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5332
}
|
Medical Text: Admission Date: [**2110-7-11**] Discharge Date: [**2110-7-22**]
Date of Birth: [**2039-10-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**7-18**] Coronary artery bypass grafting x3 with left internal
mammary artery to the left anterior descending artery; reverse
saphenous vein single graft from the aorta to the posterior
descending artery; as well as reverse saphenous vein graft from
the aorta to obtuse marginal 1, Repair of aortovenous fistula in
the right groin by vascular (this will be dictated by vascular
surgery
History of Present Illness:
70 year old male with no PMH who presented to OSH with confusion
in setting of NSTEMI. All head imaging negative. Transferred for
cardiac cath.
Past Medical History:
none
Social History:
Occupation: Former professional baseball player. Works in
sporting goods store.
Last Dental Exam:>1 yr ago
Lives with:sister and nephew
[**Name (NI) **]:Caucasian
Tobacco:Denies
ETOH:4 drinks/week
Family History:
1 brother and 1 sister/14 siblings with CAD s/p stenting
Physical Exam:
Pulse:79 Resp:13 O2 sat: 98% RA
B/P Right:144/75 Left:140/68
Height:5'[**11**]" Weight:188 LBS
General:ALert & oriented x 3
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 [] No Murmur or gallops.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:+2 Left:+2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**7-14**] Cardiac cath: 1. Coronary angiography in this right
dominant system demonstrated three vessel disease. The LMCA had
a distal 60% stenosis. The LAD was diffusely disease with a 20%
stenosis proximally and 80% stenosis in the mid vessel. The
diagonals were small and diffusely diseased. The Cx had a 90%
stenosis at the origin with a thrombotic subtotal occlusion at
the mid Cx where the OM1 came off. The RCA was diffusely
diseased with a 90% stenosis in the proximal vessel. The mid RCA
had a 60% stenosis. The distal vessels of the RCA fill via left
to right collaterals. 2. Central aortic pressure was 130/70
mmHg.
[**7-18**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. There
is sclerosis of the aortic valve with decreased mobility of the
non-coronary cusp. ([**Location (un) 109**]~ 2.1 cm2) No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. POSTBYPASS: There is preserved
biventricular systolic function. The exam is unchanged from
prebypass
[**7-16**] Femoral U/S: Grayscale and color Doppler son[**Name (NI) 1417**] were
performed in the right groin at the puncture site. Color flow is
identified within both the common femoral artery and vein.
Proximal to the puncture site in the common femoral vein, there
are elevated velocities of approximately 260 cm/sec. This
waveform demonstrated pulsatility and turbulence. There is a
normal arterial waveform in the adjacent femoral artery. Distal
to the puncture site in the common femoral vein, there were
appropriate waveforms with a velocity of approximately 20
cm/sec. Surrounding small hematoma was identified. A fistulous
connection between the common femoral artery and common femoral
vein is possibly seen.
[**2110-7-11**] 09:15PM BLOOD WBC-8.6 RBC-4.97 Hgb-15.3 Hct-44.6 MCV-90
MCH-30.9 MCHC-34.3 RDW-13.9 Plt Ct-283
[**2110-7-21**] 05:10AM BLOOD WBC-14.7* RBC-2.88* Hgb-9.1* Hct-26.3*
MCV-91 MCH-31.5 MCHC-34.6 RDW-13.9 Plt Ct-248
[**2110-7-11**] 09:15PM BLOOD PT-12.7 PTT-25.2 INR(PT)-1.1
[**2110-7-19**] 03:50PM BLOOD PT-15.1* PTT-30.2 INR(PT)-1.3*
[**2110-7-11**] 09:15PM BLOOD Glucose-102 UreaN-24* Creat-0.9 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
[**2110-7-21**] 05:10AM BLOOD Glucose-128* UreaN-29* Creat-0.9 Na-135
K-4.7 Cl-100 HCO3-29 AnGap-11
[**2110-7-18**] 06:10AM BLOOD ALT-33 AST-26 AlkPhos-70 TotBili-1.1
Brief Hospital Course:
Mr. [**Known lastname 82924**] was transferred from OSH with a myocardial
infarction. Upon admission he underwent a cardiac cath which
revealed severe three vessel and 60% left main disease. After
cath he was admitted for cardiac surgery work-up and Plavix
washout. On [**7-18**] he was brought to the operating room where he
underwent a coronary artery bypass graft x 3(Left internal
Mammary Artery grafted to Left Anterior Descending/Saphenous
Vein Grafted to Obtuse Marginal/Posterior Descending Artery) and
repair of Right Groin aortovenous fistula.Cross Clamp Time= 90
minutes. Cardiopulmonary Bypass Time=111 minutes. Please see
Dr[**Last Name (STitle) 5305**] operative report for further details. He tolerated
the procedure well and was transferred in critical but stable
condition to the CVICU. He weaned from sedation, awoke
neurologically intact and extubated on POD#1. All lines and
drains were discontinued when criteria was met.Chest tubes
remained in to POD#3 due to drainage/Plavix preop. Beta-Blocker,
Plavix, and diuresis was initiated when tolerated. He continued
to progress and was transferred to the step down Floor for
further monitoring. Physical Therapy was consulted for
evaluation/mobility. POD#3 on exam, bloody sternal drainage was
noted and antibiotics were initiated. CXR was reviewed by
DR.[**Last Name (STitle) 914**] and DR.[**Last Name (STitle) **] from radiology. The remainder of his
postoperative course was essentially uneventful. He continued to
progress and was cleared by Dr.[**Last Name (STitle) 914**] for discharge to home
with VNA on POD#4. All follow up appointments were advised.
Medications on Admission:
ASA 81 mg daily
Discharge Medications:
1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take 400mg (two 200mg pills)daily for one week, then
decrease to 200mg daily for one week.
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for poor targets.
Disp:*60 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 14
days.
Disp:*28 Tablet(s)* Refills:*0*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Myocardial Infarction
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. In the event that you have drainage
from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital Ward Name 121**] 6 for wound check in 1 week, call for appointment
[**Telephone/Fax (1) 3071**]
Dr. [**Last Name (STitle) 914**] in 4 weeks, [**Telephone/Fax (1) **], please call for
appointment
Dr. [**Last Name (STitle) 12167**] in [**1-28**] weeks
PCP [**Last Name (NamePattern4) **] [**12-27**] weeks
Completed by:[**2110-7-22**]
ICD9 Codes: 2930, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5333
}
|
Medical Text: Admission Date: [**2201-2-12**] Discharge Date: [**2201-2-16**]
Date of Birth: [**2126-7-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Mevacor / Lipitor / Tricor / Zocor / Pravachol / statins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pressure and dyspnea
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-DIAG, SVG-OM, SVG-PDA)
[**2201-2-12**]
History of Present Illness:
This is a 74 year old gentleman with
known coronary artery disease status post PTCA and stenting in
the past who presented to his cardiologist with increasing
episodes of exertional chest pressure and dyspnea. He underwent
a
stress test which when compared to his previous study in [**2199-8-16**] showed a decreased ejection fraction, wall abnormalities
which were more pronounced and new, more extensive inferior and
anterior ischemia. He underwent a cardiac cath on [**2201-1-1**] which
showed severe three vessel coronary artery disease and was thus
referred for surgical revascularization.
Past Medical History:
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- Prior asbestos exposure
- Hx of prostate cancer
- Chronic Venous Stasis with some varicose veins
Past Surgical History:
- LAD stenting [**3-/2186**]/RCA stenting in 12/97/PLV stenting in [**5-19**].
- Radical prostatectomy c/b bowel injury requiring diverting
colostomy which was eventually reversed
- Umbilical Hernia Repair
Social History:
Lives: Alone
Occupation: Marine Distributor
Cigarettes: Denies
ETOH: < 1 drink/week [] [**12-23**] drinks/week [x] >8 drinks/week []
Illicit drug use: Denies
Family History:
Brother with PTCA in his 50's. Father also
underwent CABG in his 60's
Physical Exam:
Pulse: 88 Resp: 16 O2 sat: 100% room air
B/P Right: 185/100 Left: 178/100
General: WDWN male in no acute distress. Appears younger than
stated age of 74. Very anxious and appeared stressed.
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 - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x] - multiple, well healed scars
Extremities: warm, chronic venous statis changes noted
Edema: Trace
Varicosities: anterior varicosities noted. right leg appeared to
have more varicosed areas compared to left. left greater
saphenous appeared suitable from ankle to groin. right greater
saphenous appeared suitable from just below knee to groin.
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2 ** right femoral bruit noted **
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Pertinent Results:
[**2201-2-12**] Intra-op Echo:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. There are simple 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 thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of surgery.
POST-BYPASS: The patient is atrial paced, systolic function is
unchanged, no new regional wall motion abnormalities. No new
valvular abnormalities. No sign of ascending aorta dissection.
[**2201-2-16**] 04:45AM BLOOD WBC-10.8 RBC-3.30* Hgb-10.1* Hct-31.6*
MCV-96 MCH-30.6 MCHC-31.9 RDW-13.3 Plt Ct-193
[**2201-2-16**] 04:45AM BLOOD Plt Ct-193
[**2201-2-16**] 04:45AM BLOOD Plt Ct-193
[**2201-2-16**] 04:45AM BLOOD PT-13.4* INR(PT)-1.2*
[**2201-2-15**] 05:51AM BLOOD Plt Ct-171
[**2201-2-15**] 05:51AM BLOOD PT-12.7* INR(PT)-1.2*
[**2201-2-16**] 04:45AM BLOOD Glucose-122* UreaN-40* Creat-1.3* Na-140
K-4.0 Cl-106 HCO3-27 AnGap-11
[**2201-2-16**] 04:45AM BLOOD Mg-2.5
Brief Hospital Course:
The patient was brought to the Operating Room on [**2-12**]/12where
the patient underwent CABG x 4 with Dr. [**Last Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. 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. He
had several bouts of atrial fibrillation. He converted to sinus
rhythm with amiodarone and titration of beta blocker. He was
started on coumadin and Coumadin follow up was arranged with Dr.
[**Last Name (STitle) 7389**]. 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 #4 the patient was ambulating freely, he was
hemodynamically stable in sinus rhythm, his wounds were healing
and pain was controlled with oral analgesics. The patient was
discharged in good condition with appropriate follow up
instructions. His creatinine was elevated from baseline at
discharge will need to be monitored over the next few days.
Medications on Admission:
Medications - Prescription
CHOLESTYRAMINE-ASPARTAME [CHOLESTYRAMINE LIGHT] - (Prescribed
by
Other Provider) - 4 gram Packet - 4 gms by mouth twice a day
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - (Prescribed by
Other Provider) - 320 mg-25 mg [**Last Name (STitle) 8426**] - 1 [**Last Name (STitle) 8426**](s) by mouth
once
a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg [**Last Name (STitle) 8426**],
Delayed
Release (E.C.) - 1 [**Last Name (STitle) 8426**](s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit [**Last Name (STitle) 8426**], Chewable - 1 [**Last Name (STitle) 8426**](s) by mouth once a day
COENZYME Q10 - (Prescribed by Other Provider) - 100 mg Capsule
-
1 Capsule(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider)
-
1,000 mcg [**Last Name (STitle) 8426**] - 1 [**Last Name (STitle) 8426**](s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 0.8 mg [**Last Name (STitle) 8426**] - 1
[**Last Name (STitle) 8426**](s) by mouth once a day
OMEGA 3-DHA-EPA-FISH OIL [OMEGA-3 FISH OIL] - (Prescribed by
Other Provider) - 910 mg (308 mg-448 mg-154 mg)-1,400 mg Capsule
- 1 Capsule(s) by mouth once a day
Discharge Medications:
1. potassium chloride 10 mEq [**Last Name (STitle) 8426**] Extended Release Sig: Two
(2) [**Last Name (STitle) 8426**] Extended Release PO once a day for 7 days.
Disp:*14 [**Last Name (STitle) 8426**] Extended Release(s)* Refills:*0*
2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
PO BID (2 times a day).
Disp:*60 Packet(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
6. metoprolol tartrate 50 mg [**Last Name (STitle) 8426**] Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 [**Last Name (STitle) 8426**](s)* Refills:*2*
7. warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM.
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2*
8. tramadol 50 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*40 [**Last Name (Titles) 8426**](s)* Refills:*0*
9. amiodarone 200 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO BID (2 times
a day): then 200mg po bid x 7days then 200mg po daily until seen
by cardiologist.
Disp:*120 [**Last Name (Titles) 8426**](s)* Refills:*2*
10. Lasix 40 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once a day for 7
days.
Disp:*7 [**Last Name (Titles) 8426**](s)* Refills:*0*
11. Vitamin D3 1,000 unit [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once a
day.
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
12. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
13. cyanocobalamin (vitamin B-12) 1,000 mcg [**Last Name (Titles) 8426**] Sig: One (1)
[**Last Name (Titles) 8426**] PO once a day.
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
14. folic acid 1 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once a day.
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] [**Location (un) 5087**]
Discharge Diagnosis:
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- Prior asbestos exposure
- Hx of prostate cancer
- Chronic Venous Stasis with some varicose veins
Past Surgical History:
- LAD stenting [**3-/2186**]/RCA stenting in 12/97/PLV stenting in [**5-19**].
- Radical prostatectomy c/b bowel injury requiring diverting
colostomy which was eventually reversed
- Umbilical Hernia Repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
1+ edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2201-2-24**] at
10:30 AM
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2201-3-25**] at 1:30p
PCP/Cardiologist Dr. [**Last Name (STitle) 7389**], [**Telephone/Fax (1) 14525**] on [**2201-3-4**] at 11:15a
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for AFib
Goal INR 2-2.5
First draw day after discharge [**2201-2-17**] - please check INR and
crea
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 7389**]
Results to phone [**Telephone/Fax (1) 14525**]
Completed by:[**2201-2-16**]
ICD9 Codes: 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5334
}
|
Medical Text: Admission Date: [**2157-4-13**] Discharge Date: [**2157-4-16**]
Service: ACOVE
CHIEF COMPLAINT: Chest pain.
HISTORY OF THE PRESENT ILLNESS: The patient is an
86-year-old male, Russian-speaking only, with history of
Parkinson's disease, depression, and colon cancer presenting
with new-onset left sided pleuritic chest pain, shortness of
breath, and new atrial fibrillation. The patient presented
to the emergency department with concern for pulmonary
embolism. He was started on heparin infusion. CT angiogram
was performed, which was negative. The patient was admitted
to the Cardiology Service, where the patient was found to be
in rapid ventricular rate and given 25 mg of Metoprolol. The
patient, shortly, thereafter, became hypotensive and
unresponsive. The patient was started on pressors and a head
CT was ordered. The head CT showed no evidence of
intracranial hemorrhage. The patient's mental status
improved while at the CT scan. The patient was rapidly
weaned off pressors and continued to do well in the ICU. He
was initially treated with antibiotics for presumed sepsis.
However, the patient's hypotension was thought to be more
likely secondary to Metoprolol with exaggerated response,
The patient also had an echocardiogram that revealed a
pericardial effusion. He was started on NSAIDS. There was
no evidence of tamponade physiology.
PAST MEDICAL HISTORY:
1. Parkinson's disease.
2. Benign prostatic hypertrophy
3. Depression with psychosis.
4. Gastroesophageal reflux disease.
5. Colon cancer status post hemicolectomy two years ago.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Sinemet 20/100, one p.o.q.i.d. and q.h.s.
2. Cardura 2 mg p.o.q.h.s.
3. Neurontin 600 mg p.o.t.i.d.
4. Flomax 0.4 mg p.o.q.h.s.
5. Seroquel 150 mg p.o.b.i.d.
SOCIAL HISTORY: The patient is Russian-speaking only. He is
a resident of [**Hospital1 5595**]. He ambulates with a walker. He is a
retired dentist. The patient notes remote cigarette smoking
approximately for twenty years.
FAMILY HISTORY: History is noncontributory.
PHYSICAL EXAMINATION: Examination revealed the temperature
of 96.6, blood pressure of 110/70, pulse 82, respiratory rate
20, and oxygen saturation of 97% on three liters. The
patient was then placed on room air, where he was saturating
95%. There was no evidence of pulsus paradoxus. GENERAL:
The patient was a fairly well appearing elderly male in no
acute distress. HEENT: Examination revealed EOMI, PERRLA,
slightly dry mucous membranes. NECK: Examination revealed
CVP of approximately 7 cm of water. There was no
lymphadenopathy. CARDIAC: Examination revealed irregularly
irregular rhythm with normal S1 and S2, no murmurs, rubs, or
gallops. PULMONARY: Examination revealed lung clear to
auscultation bilaterally. ABDOMEN: Examination revealed
belly soft, nontender, nondistended with normal bowel sounds.
EXTREMITY: Examination revealed no edema. Vascular
examination revealed good capillary refill. RECTAL:
Examination revealed good anal tone and guaiac negative.
LABORATORY DATA: Pertinent laboratory findings revealed the
following: The patient had a WBC of 7.4, hematocrit 28.4,
and platelet count of 172,000. Creatinine was 1.0. The
patient has a TSH of 0.36. Magnesium was 2.3 and phosphate
3.0. INR was 1.4. Urinalysis was unremarkable, except for
trace blood. The patient had initial CK of 50 with the
second CK of 135, third CK of 111, fourth CK of 134 with
negative indices. The patient did have troponin of 1.1 and
1.2.
Chest x-ray revealed no failure and left basilar atelectasis
that was improving.
Head CT: No acute intracranial pathologic process.
Chest CT: Bilateral small pleural effusions, pericardial
effusion, left lower lobe atelectasis, no PE.
On [**2157-4-14**], echocardiogram revealed left atrial
enlargement, right atrial enlargement, concentric LVH, EF
greater than 55%, RVH trace AR and trace MR, moderate
loculated pericardial effusion and no echocardiogram evidence
of tamponade.
HOSPITAL COURSE: The patient is an 86-year-old man with
history of depression, colon cancer, who presented with
new-onset chest pain and hypotension. The patient was found
to have pericardial effusion.
#1. CARDIOVASCULAR: The patient presented with chest pain
and hypotension. He was found to have a pericardial effusion
without evidence of tamponade. Apparently, the episode of
hypotension was felt to be secondary to an exaggerated
response to Metoprolol. The patient responded quickly to IV
fluids and pressors. The patient was easily weaned. He
ruled out for myocardial infarction. The patient developed
new atrial fibrillation thought to be secondary to his
pericarditis. He was not anticoagulated because of the
presence of a pericardial effusion. TSH was done and it was
on the low end of normal. He was started on NSAIDS for his
pericarditis. He was continued on aspirin. The patient's
atrial fibrillation with rapid ventricular response was
initially stable, but then he developed a rate into the 140s
to 160s. He was given 5 mg of Diltiazem IV push and 30 mg
p.o. Diltiazem with good response in his rate control. He
stabilized in the 80s to 90s. Repeat EKG was done, which
revealed atrial fibrillation in the 70s, leftward axis,
normal [**Doctor Last Name 1754**], intervals. ST segment elevation of 1-mm in
lead 2, biphasic T in V2, and T wave flattening in lead 3.
When compared to an earlier [**2157-4-14**] EKG, there were no
significant changes.
#2. GASTROESOPHAGEAL REFLUX DISEASE: The patient was
maintained on Protonix.
#3. GENITOURINARY: The patient has history of benign
prostatic hypertrophy, maintained on Flomax and Cardura.
#4. NEUROLOGIC: The patient has history of Parkinson's
disease maintained on Sinemet.
#5. PSYCHIATRIC: The patient has a history of depression
with psychosis, maintained on Seroquel.
#6. GASTROINTESTINAL: The patient has history of
constipation treated with Senna, Dulcolax, Fleet, and Colace.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged on the
following medications:
1. Aspirin 81 mg p.o.q.d.
2. Colace 100 mg p.o.b.i.d.
3. Sinemet 25/100, one p.o.q.i.d. and q.h.s.
4. Flomax 0.4 mg p.o.q.h.s.
5. Multivitamin, one p.o.q.d.
6. Seroquel 150 mg p.o.b.i.d.
7. Neurontin 600 mg p.o.t.i.d.
8. Motrin 600 mg p.o.t.i.d. with meals.
9. Heparin 7500 units subcutaneously b.i.d. until
ambulatory.
10. Senna, two tablets p.o.q.h.s.
11. Diltiazem 30 mg p.o.q.i.d. hold for SVP less than 90 or
heart rate less than 55.
12. Protonix 40 mg p.o.q.d.
13. Dulcolax 10 mg p.o.pr, q.d. p.r.n.
14. Fleet one pr, q.4h.p.r.n. constipation.
15. Tylenol 650 mg p.o.q.4h. to 6h p.r.n. pain.
The patient was discharged back to [**Hospital3 **]
Center.
DISCHARGE DIAGNOSES:
1. Pericardial effusion.
2. Atrial fibrillation with RVR.
3. Hypotension.
4. Parkinson's disease.
5. Benign prostatic hypertrophy.
6. Depression with psychosis.
7. Gastroesophageal reflux disease.
8. Colon cancer status post hemicolectomy two years ago.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], M.D. [**MD Number(1) 16133**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2157-4-15**] 13:22
T: [**2157-4-15**] 14:16
JOB#: [**Job Number 21682**]
cc:[**Last Name (STitle) 21683**]
ICD9 Codes: 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5335
}
|
Medical Text: Admission Date: [**2138-9-17**] Discharge Date: [**2138-9-21**]
Date of Birth: [**2056-10-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
acute onset chest tightening, dizziness, diaphoresis, and
shortness of breath
Major Surgical or Invasive Procedure:
coronary catherterization
History of Present Illness:
81 y old male with hx of dyslipidemia, HTN, CAD s/p NQWMI in '[**32**]
s/p bare metal stenting of proximal and mid LAD as well as OM1
presented to ED by ambulance with acute onset chest tightening,
dizziness, diaphoresis, and shortness of breath, was found to
have STE >5mm in II, III, aVF, V4-V6 along with 3-4mm ST
depression in I and aVL. Hr was in the 40s. Code STEMI was
called, pt was given ASA 325mg, plavix 600mg (although takes
plavix at home), Heparin 5000 units x 1, Integrillin 17mg IVx1
and then transferred to cath lab. In cath lab pt had
successfull bare metal stenting to proximal RCA and was also
found to have new diffuse aneurysmla dilatation of his vessels.
Pt became bardycardic intermittently in the cath lab and
required atropine x2. Temporary pacer placed prior to the
transfer to the floor.
When pt seen on on the floor he denied any chets pain, sob,
diaphoresis, nausea. States onset of chest pain was in the
setting of the culmination of a 16 day editing project he had as
a composer. Pt quickly realized the urgency of the situation as
the sx's very similar to his prior MI and therefore asked his
friend to [**Name2 (NI) **] 911.
Of note, pt states he was on ASA 325mg up until about 2 years
ago when he was noted to have "blood from below". Per pt he was
told to stop taking the ASA and never had a GI w/u for the
bleeding as he states "it was assumed that the bleeding was due
to apirin". His last colonoscopy was 7-8 years ago and was
normal. he has never had an EGD.
At home pt exercises by "speed-walking" on a treadmill for 30
minutes almost every day and never experiences any anginal sx's
or SOB. He has never smoked, drinks occasionally and tries to
adhere to a fairly low fat diet.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis,
recent black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems when seen on the floor is notable for
absence of chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
# CAD s/p NQWMI in '[**32**] s/p bare metal stenting of proximal and
mid LAD as well as OM1
# HTN
# Dyslipidemia
# Hx of ulcers on feet bilaterally
# R eye blind after traumatic injury at age 11
Social History:
Social history is significant for the absence of tobacco use.
Occasional alcohol.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 96.4, BP 98/69, HR 62, RR 19, SaO2 100% on 2L
Gen: male appearing younger than stated age in NAD. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: No JVD
CV: RR, normal S1, S2. No S4, no S3.
Chest: Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: Both feet with toes in dorsiflexion appearing like
contractures. Also with superficila fungal infections of toes
and nails. Both legs with brown discoloration of feet up to
mid-calf.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: Femoral 2+ without bruit bil; 1+ DP bil.
Pertinent Results:
[**2138-9-17**] 08:45PM GLUCOSE-126* UREA N-20 CREAT-1.2 SODIUM-140
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-16
[**2138-9-17**] 08:45PM estGFR-Using this
[**2138-9-17**] 08:45PM CK(CPK)-115
[**2138-9-17**] 08:45PM cTropnT-<0.01
[**2138-9-17**] 08:45PM CK-MB-5
[**2138-9-17**] 08:45PM WBC-7.9 RBC-5.18 HGB-16.4 HCT-49.4 MCV-95
MCH-31.7 MCHC-33.2 RDW-14.5
[**2138-9-17**] 08:45PM NEUTS-39.3* LYMPHS-51.5* MONOS-6.8 EOS-2.0
BASOS-0.4
[**2138-9-17**] 08:45PM PLT COUNT-189
[**2138-9-17**] 08:45PM PT-13.7* PTT-27.3 INR(PT)-1.2*
.
Echo ([**9-19**]):
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
inferolateral wall. The remaining segments contract normally
(LVEF = 45-50 %). The aortic root is moderately dilated at the
sinus level. The ascending aorta is moderately dilated. The
aortic arch is mildly dilated. The aortic valve leaflets are
mildly thickened. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD. Mild aortic regurgitation. Mild mitral regurgitation.
Dilated thoracic aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2130-12-21**], the regional left ventricular wall
motion abnormality is new and the ascending aorta and arch are
now identified as dilated.
CLINICAL IMPLICATIONS:
Based on [**2137**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Pt with presentation to [**Hospital1 18**] as mentioned above, taken to cath;
in cath lab pt had successfull bare metal stenting to proximal
RCA and was also found to have new diffuse aneurysmal dilatation
of his vessels. Pt became bardycardic intermittently in the
cath lab and required atropine x2. Temporary pacer placed prior
to the transfer to the CCU. In the CCU where pt was placed on
tele. On the second day the pace was briefly needed but then
heart rate remained in to 60-s and 70s, therefore the pacer was
removed after 48hrs, lopressor was again started after 72 hrs
without a drop in the heart rate (bradycardia improved as
expected since RCA reperfused)
Enzymes were negative in the emergency room, but second set came
back VERY elevated at CK 2713, Trop T 11.23, CK-MB 363 and MB
index of 13.4. Ezymes thereafter trended down. Medically,
plavix 75 mg was continued, atorvastatin 80mg was started (for
pleotropic effects, i.e. anti-inflammatory ect, and for
mortality benefits), ASA 325 mg was restarted in hosp on
admission. The reason for pt not taking it the past 2 years
prior to presentation was cleared up with PCP who stated this
was b/c pt had nose bleeds during his performances, and
therefore elected not to take ASA anymore. PCP agrees pt needs
to be on lifelong ASA and plavix and will follow up closely in
the case of another bleed. ACEI was held on presentation due to
concern of droing BP with bradycardia but restarted on HOD#2. An
echo was done to r/o wall motion abnormalities determine EF
demonstrating mild symmetric left ventricular hypertrophy with
regional systolic dysfunction, and LVEF = 45-50 % c/w CAD.
Pt was evaluated by PT who found patient fit to go home since pt
ambulated for 15 minutes at a fast rate without any CP or SOB.
Upon discharge pt was asymptomatic, and ambulating, voiding,
taking good po on own, and saturating well off oxygen.
Medications on Admission:
Altace (ramipril) 5mg qday
Toprol XL 25 mg qday
Isosorbide Mononitrate 30 mg qday
Lipitor 10mg qday
Plavix 75 mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial infarction (Inferior STEMI)
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with an ST elevation myocardial
infarction.
Please take your previous medications as prescribed. The
following changes has been made to your medications:
- please start taking aspirin 325mg daily for secondary
cardiovascular prevention (to prevent another heart attack) and
atorvastatin 80mg daily for your heart and for your cholesterol.
- please stop taking isosorbide mononitrate
If you develop chest pain, jaw pain, or chest pressure with pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
Followup Instructions:
Please call your PCP for an appointment within 1-2 weeks.
ICD9 Codes: 9971, 4240, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5336
}
|
Medical Text: Admission Date: [**2116-7-25**] Discharge Date: [**2116-7-28**]
Date of Birth: [**2053-3-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 year old man with HTN, DM, elevated cholesterol,
who presents with acute onset of slurred speech. He was in his
usual state of health, when he noticed slurred speech while
driving and talking to a friend at ~9am today. Just prior to
this, he loaded several heavy boxes (40-50lbs) into his car. He
pulled over, and his friend drove him to the hospital (Pt
insisted on driving back to [**Location (un) 86**] from [**Location (un) 3844**]). Pt felt
that his comprehension was not impaired; his friend was able to
understand what he was saying. He also noted transient numbness
around the right side of his mouth and of the right arm. He
describes it as similar to a novocaine injection. Also noted
mildly unsteady gait, but no falls.
Upon arrival to the [**Hospital 1474**] Hospital ED, slurred speech
remained, and BP was elevated to 209/119. Head CT revealed small
left basal ganglia hemorrhage; Pt was transferred to [**Hospital1 18**] for
further evaluation. Received Labetalol prior to transfer with
good response (SBP 150s).
BP again increased to 200s/100s upon arrival to the [**Hospital1 18**] ED.
Received Labetalol 20mg IV x2, BP decreased to 132/78, but BP
again increased to 200s/100s. Labetalol gtt started.
ROS: No history of similar symptoms; numbness has resolved.
Denies recent fever, chills, nausea, vomiting, rash, diarrhea,
bloody stools, abd pain, CP, palpitations, cough, or SOB. Also
denies change in vision or hearing, tinnitus, vertigo, weakness,
abnormal gait, incontinence, or difficulty with swallowing. No
recent head trauma.
He has remained stable in the ICU, with repeat NCHCT unchanged
from prior. BP has been well controlled on labetalol drip and he
is now transferred to the floor on oral antihypertensives for
observation of bp control prior to discharge.
Past Medical History:
* Hypertension - Has been on medication for the past 10 years.
Baseline BP 170s-180s. Approximately PCP prescribed increase in
anti-hypertensive med to [**Hospital1 **]. Pt was non-compliant and continued
to take the medication daily.
DM2
Hyperlipidemia
Pilonidal cyst s/p repair
Social History:
SHx: Previously in the air force, then worked as a truck driver
for the [**Location (un) 86**] Globe. Quit smoking many years ago. +[**5-9**] shots of
whiskey per day. No illicit drug use.
Family History:
FHx: Paternal grandmother - brain aneurysm
Physical Exam:
98.4 75 130/59-178/108 26 97%ra 113-154fsg
GEN well appearing
HEENT NCAT, MMM, OP clear
Neck supple, no thyromegaly, no [**Doctor First Name **], no carotid bruits
Chest CTAB
CVS RRR, no m/r/g
ABD soft, NT, ND, +BS
EXT no c/c/e, distal pulses strong, +petechiae around ankle on
L
foot. Splinter hemorrhages on R big toenail
Neuro
MS - Alert, Ox3, appropriately interactive, provides history
without difficulty. States days of the week backwards without
difficulty
Speech - slurred, but fluent w/o paraphasic errors; repetition,
naming, [**Location (un) 1131**] intact. Dysarthria worse for dentals than
labials, guttarals.
CN: II,III--PERRLA 2 to 1mm bilaterally, VFF, optic discs sharp;
III,IV,VI--EOMI w/o nystagmus, no ptosis; V--sensation intact to
LT/PP; VII--full facial movement w/o asymmetry; VIII--hears
finger rub bilaterally; IX,X--palate elevates symmetrically;
[**Doctor First Name 81**]--SCM/trapezii [**5-8**]; XII--tongue protrudes midline
Motor: normal bulk and tone; no tremor, or rigidity. +right
pronator drift.
D T B WE WF FF FE IP Q H DF PF
L 5 5 5 5 5 5 5 5 5 5 5 5
Coord: slowed rapid movements on the right on finger tapping and
rapid suppination/pronation. FTN and HTS intact b/l.
Reflex:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2+ | 2+ | 2+ | 2 | 1 |down|
R | 2+ | 2+ | 2+ | 2 | 1 |down|
[**Last Name (un) **]: LT, PP, and joint position intact. No evidence of
extinction.
Pertinent Results:
[**2116-7-25**] 09:13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Brief Hospital Course:
The patient was admitted to the ICU for q1 hour neurochecks. His
dysarthria improved over the course of his stay and repeat NCHCT
showed no expansion of the bleed (which was less than 30cc's in
volume). BP was kept below sbp 140 with a labetolol drip and on
HD#3, the patient was transferred to the floor on oral
antihypertensives. His exam now shows only mild dysarthria and a
very slight R pronator drift.
Outstanding issues include stroke prevention. The patient should
cut down on alcohol use. In addition, and of primary importance
in the case of an ICH, is blood pressure control (the patient
had been non-compliant and now understands the necessity). He
will be discharged on a beta blocker and ACEI, with outpatient
PCP [**Name9 (PRE) 702**] this Thursday. He is also on lipitor 10 for
cholesterol lowering. He should maintain tight glycemic control
as well (HbA1c 6.7).
The most likely etiology of the bleed was uncontrolled
hypertension. However, an underlying AVM or mass cannot
completely be ruled out. The patient should have outpatient MRI
once the blood has resolved. This should be arranged as per Dr.
[**First Name (STitle) **], who will follow the patient as an outpatient.
Medications on Admission:
Lipitor 5mg QD
Glyburide 5mg [**Hospital1 **]
Lunesta
[**Name (NI) 69792**] [**Hospital1 **] (pt taking only once a day)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left basal ganglia intracerebral hemorrhage
Hypertension
Hyperlipidemia
Diabetes mellitus type 2
Discharge Condition:
Improved
Discharge Instructions:
Please continue to take all medications. Return to ER with any
recurrent or new neurologic symptoms (slurred speech, double
vision, dizziness, weakness, numbness, severe headache, etc)
Followup Instructions:
Please followup with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Thurs [**2116-7-30**] at
11:30 am.
Schedule appointment with Dr. [**First Name (STitle) **] by calling [**Telephone/Fax (1) 2574**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2116-8-11**]
ICD9 Codes: 431, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5337
}
|
Medical Text: Admission Date: [**2178-12-23**] Discharge Date: [**2178-12-29**]
Date of Birth: [**2100-10-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20224**]
Chief Complaint:
hypotension, hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 78 y.o female with h.o COPD (no home o2), HTN with
recent MVA
right distal fibula, talus, and navicular fx with talonavicular
dislocation, newly dx RLL-PNA, started on levaquin at rehab,
found to have sat "<90% on RA", HR >100, weak and with decreased
coordination sent from [**Hospital3 2558**] for further eval.
vitals prior to transfer to ED, BP 91/68, T 97.4, HR 104, RR 18,
sat 93% on 2L.
Pt reports that she had been feeling in her USOH (mild chronic
dyspnea) until Monday night when she developed dry cough. She
then developed mildly worsening dyspnea. She reports CXR was
taken and she was started on levaquin. She does denies headache,
LH, blurred vision, ST/rhinorrhea, orthopnea, CP, palp, abd
pain/n/v/d/constipation/melena/brbpr/dysuria/joint pain/skin
rash/
paresthesias. She denies that she is on home O2 and states she
did receive both flu and H1N1 vaccinations. She states she
currently feels better after being given "medications" since Mon
night for her PNA.
.
In the ED,
Time Pain Temp HR BP RR Pox
- 14:43 0 97.3 116 110/60 24 100
pt reported to have BP 80's-90's, s/p 2 L IVF. Pt noted to be
guaiac negative. Given 1gm tylenol for T 100.4, vanco/zosyn for
presumed PNA, solumedrol for ?COPD flare and heparin started as
cannot r/o PE.
.
Medications
Today 16:23 MethylPREDNISolone Sodium Succ 125mg Vial 1 [**Doctor Last Name 10132**],
Shamus
Today 16:23 Vancomycin 1g Frozen Bag 1 [**Doctor Last Name 10132**], Shamus
Today 16:24 Albuterol 0.083% Neb Soln 0.083%;3mL Vial 2 [**Doctor Last Name 10132**],
Shamus
Today 16:24 Ipratropium Bromide Neb 2.5mL Vial 2 [**Doctor Last Name 10132**], Shamus
Today 16:32 Acetaminophen 500mg Tablet 2 [**Doctor Last Name 10132**], Shamus
Today 16:39 &&Piperacillin-Tazob (Mini Bag +) [[**Numeric Identifier 103888**]] 1
[**Doctor Last Name 10132**], Shamus
Today 17:03 Heparin Sodium 5000 Units / mL- 1mL Vial 1 [**Doctor Last Name 10132**],
Shamus
Today 17:03 Aspirin 81mg Tab 4 [**Doctor Last Name 10132**], Shamus
Today 17:03 Heparin Sodium 25,000 unit Premix Bag 1 [**Doctor Last Name 10132**],
Shamus
Past Medical History:
COPD, chronic back pain
PSH: b/l knee replacement (few yrs ago), ex-lap (distant)
Social History:
Lives alone
2 daughters who help out. Quit smoking 10yrs ago former
1ppdxmany years. 2 glasses of wine nightly, denies drug use
Family History:
mother with uterine and breast ca. Father with MI
Physical Exam:
T 98.7, HR 103, BP 112/48, RR 16, sat 95% on 2L
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing, NAD, answers questions in [**3-1**]
word sentences.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
NECK: L.side with linear, ecchymoses-healing.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=not elevated.
LUNGS: b/l ae, +expiratory wheezes through, Rhonchi RUL
anteriorly, crackles, LLL posteriorly.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: 1+ edema, no calf pain, 2+ dorsalis pedis/
posterior tibial pulses on L.leg. R.leg with cast up to knee. no
thigh asymmetry.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout, Gait assessment
deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admit labs:
PT-14.6* PTT-38.8* INR(PT)-1.3*
PLT COUNT-510*
WBC-25.5* (NEUTS-93.0* LYMPHS-4.5* MONOS-1.9* EOS-0.5
BASOS-0.1)->improved to 13.9 but increased to 19.0 on [**2178-12-29**]
RBC-3.80* HGB-10.8* HCT-33.5* MCV-88 MCH-28.6 MCHC-32.3 RDW-13.4
calTIBC-212* FERRITIN-245* TRF-163*
ALBUMIN-3.4* IRON-10*
CK-MB-31* MB INDX-2.4 cTropnT-0.10* proBNP-994*
LIPASE-11
ALT(SGPT)-36 AST(SGOT)-49* LD(LDH)-215 CK(CPK)-1302* ALK
PHOS-136* TOT BILI-0.2
GLUCOSE-131* UREA N-47* CREAT-2.6*->improved to 0.6, SODIUM-135
POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-31
LACTATE-2.1
UA: RBC-[**1-29**]* WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 BLOOD-LG
NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-NEG
Micro: blood cx ngtd [**12-23**]; respiratory viral screen [**12-24**]
negative
CHEST, AP UPRIGHT PORTABLE VIEW: Left basilar opacity may
represent
atelectasis, although infection/pneumonia cannot be excluded.
Heart size is normal. Mediastinal contours are normal. Dense
calcifications of the aortic arch are unchanged. Osseous
structures are unchanged.
IMPRESSION: Left lower lobe opacity, infection/pneumonia cannot
be excluded.
AP SUPINE CHEST RADIOGRAPH: There is patchy left lower lobe
opacity which
silhouettes the diaphragm and has increased since [**2178-12-23**]. The
upper lungs
are clear. There is a small left pleural effusion. There is no
pneumothorax. Moderate degenerative changes in the
thoracolumbar spine are unchanged.
IMPRESSION: Worsening left lower lobe pneumonia.
LENIs: No evidence of bilateral lower extremity DVT
Urine, blood, respiratory viral screen pending
Brief Hospital Course:
Pt is a 78 y.o female with h.o COPD, HTN, recent MVA with
R.ankle/foot fx who presented with hypoxia and LLL infiltrate.
1. [**Hospital 25730**] Healthcare associated pneumonia/[**Name (NI) 15305**]
Pt was admitted from rehab with hypoxia and tachycardia, and was
found to have LLL infiltrate concerning for HAP. She also had
leukocytosis, cough, hypotension (fluid responsive), and
low-grade temperature.
Pt was managed in the ICU with broad-spectrum antibiotics, with
Vanc and Cefepime, and these were continued on the floor for
ongoing treatment. Pt's respiratory status gradually improved to
near baseline. She will continue on vancomycin and cefepime for
HAP for 8 day course. Oxygen should be weaned at rehab (on
discharge was mid 90's on RA, 98% on 2L). Additionally her WBC
generally improved with treatment, however increased to 19 on
day of discharge. Clinically she appeared well with all VS and
exam improving and no new signs or symptoms of infection so she
was felt stable for discharge but her CBC should be monitored on
[**12-31**] to ensure it is falling.
2. COPD: provided nebulizers to treat possible superimposed COPD
flare. Steroids were not provided considering pneumonia. She
was continued on advair as well.
3. Hypertension, benign: Initially her bp meds were held given
her sepsis, they were restarted and actually uptitrated given
hypertension so lisinopril increased from home dose of 5mg daily
to 10mg dialy, also continued on lasix.
4. Acute renal failure: Cr 2.6 on admission, returned to
baseline. Likely due to sepsis/hypovolemia. Given the change her
vanco trough was monitored and dose adjusted accordingly.
5. Anemia: likey due to operative losses (from foot repair),
iron deficiency, ACD, and critical illness. No e/o bleed. She
was started on iron supplements with bowel regimen for
constipation.
6. Depression, NOS: she was continued on fluoxetine.
7. Ankle fracture: on Lovenox DVT ppx per Ortho for 30 days
(starting [**12-10**]); continue through [**1-10**]. Given hospitalization
she missed her scheduled follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 7376**]. Repeat
appointment was attempted to be scheduled for her
unsuccessfully, so this will need to be scheduled within 1 week
of discharge.
8. Chronic pain: neurontin restarted on discharge.
Full code
Medications on Admission:
1. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q 24H (Every 24 Hours) for 30 days.
Disp:*30 doses* Refills:*0*
8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety: hold for oversedation.
colace [**Hospital1 **]
senna
lovenox 40mg SQ x30 days.
duonebs.
levoquin 250mgx7 days
Discharge Medications:
1. Miralax 17 gram Powder in Packet Sig: One (1) unit PO once a
day as needed for constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit Inhalation Q6H (every 6 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
10. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 11 days.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Lisinopril 5 mg Tablet Sig: Ten (10) Tablet PO DAILY
(Daily).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for sob/wheeze.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
16. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
18. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 2 doses.
19. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 5 doses.
20. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times
a day.
21. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
22. Outpatient Lab Work
Please check CBC with differential to ensure WBC is dropping on
[**2178-12-31**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
# [**Hospital 7502**] healthcare associated
# Sepsis due to pneumonia
# Hypertension, with period of malignant hypertension
# COPD
# Recent ankle fracture
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital and treated for pneumonia.
You were treated with and will complete a course of antibiotics.
Your linisopril was increased from 5mg daily to 10mg daily.
You were admitted to the hospital and treated for pneumonia.
You were treated with and will complete a course of antibiotics.
Your linisopril was increased from 5mg daily to 10mg daily.
Followup Instructions:
Recommend DriveWise Assessment
Please call [**Telephone/Fax (1) 103889**].
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15312**] upon
discharge from rehab. Please call [**Telephone/Fax (1) 15313**] for this
appointment.
Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 7376**] of orthopedic surgery
within 1 week of discharge. Please call ([**Telephone/Fax (1) 2007**] for this
appointment.
ICD9 Codes: 0389, 5849, 486, 496, 2859, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5338
}
|
Medical Text: Admission Date: [**2176-5-19**] Discharge Date: [**2176-5-25**]
Date of Birth: [**2176-5-19**] Sex: M
Service: Neonatology
HISTORY: [**First Name8 (NamePattern2) 20069**] [**Known lastname **], boy #2, was born at 32 and 3/7 weeks
gestation by cesarean section for unstoppable preterm labor.
The mother is a 31-year-old gravida III, para I, now III,
woman. Her prenatal screens are blood type B positive,
antibody negative, rubella immune, RPR nonreactive, hepatitis
surface antigen negative and group B strep unknown. This was
a spontaneous twin pregnancy of monochorionic/diamniotic
twins. This pregnancy was also complicated by maternal [**Doctor Last Name 933**]
disease treated with Levoxyl. The mother had normal thyroid
function tests during pregnancy. This infant emerged in a
breech position and he had Apgars of 8 at one minute and 9 at
five minutes.
His birth weight was 1895 grams (75th percentile), his birth
length 48 cm (greater than 90th percentile) and head
circumference 29.5 cm (25th to 50th percentile).
PHYSICAL EXAMINATION: His physical exam at the time of
discharge, his discharge weight 1805 grams. He is a vigorous
nondysmorphic preterm infant. Anterior fontanelle open and
flat. Sutures approximated. Positive bilateral red reflux.
Eyes without drainage. Palate intact. Neck supple and without
masses. Clavicles intact. Minimal subcostal retractions in
room air. Lung sounds clear and equal. Heart was regular rate
and rhythm, no murmur. Abdomen soft, nontender, nondistended,
with active bowel sounds, cord dry. Testes in canal
bilaterally. No sacral anomalies. Stable hip exam--yet very lax
(no clicks or clunks). Normal creases and digits. Age appropriate
and symmetric tone and reflexes.
HOSPITAL COURSE:
By systems:
Respiratory status: The infant has remained in room air
throughout his NICU stay. He had some initial grunting,
flaring and retracting which resolved within a few hours of
age. He has 1-4 episodes of apnea and bradycardia in a 24
hour period. Most are resolved with mild stimulation. He was
never received caffeine treatment. On exam, his respirations
are comfortable. Lung sounds are clear and equal.
Cardiovascular status: He has remained normotensive
throughout his NICU stay. He has had no heart murmur and no
active cardiovascular issues.
Fluid, electrolytes and nutrition status: Enteral feeds were
begun on day of life #1 and advanced without difficulty to
full volume feedings by day of life #5. At the time of
transfer, total fluids are 150 mL/kg/day. He is eating
Similac special care formula 20 calories per ounce by gavage
every 4 hours. Except for an initial low glucose requiring a
dextrose bolus to resolve, he has remained euglycemic
throughout his NICU stay. His electrolytes at 24 hours of age
were sodium 142, potassium 5.1, chloride 109, and bicarbonate
26.
Gastrointestinal status: He was treated with phototherapy for
hyperbilirubinemia of prematurity from day of life #2 until
day of life #3. His peak bilirubin on day of life #2 was
total 8.6, direct 0.3. His rebound bilirubin on day of life
#4 was total 5.4, direct 0.3 with a 2nd rebound bilirubin today
of 5.5/0.3 . He was passing transitional stool.
Hematology status: He has never received a blood product
transfusion during his NICU stay. His hematocrit at the time
of admission was 55.3 and repeated at 24 hours and it was
48.5. His platelets at admission were 298,000 and repeated at
24 hours were 267,000.
Infectious disease status: The infant was started on
ampicillin and gentamicin at the time of admission for sepsis
risk factors. The antibiotics were discontinued after 48
hours when the blood cultures remained negative and the
infant was clinically well. At admission, his white blood
cell count was 5.2 with a differential of 8 polys and zero
bands with an ANC of 416. That was repeated at 24 hours of age
when he had a white blood cell count of 10.2 with a differential
of 46 polys and 1 band.
Neurology: There are no active issues.
Sensory: Audiology screening is recommended prior to
discharge.
Psychosocial: The parents have been very involved in the
infant's care throughout his NICU stay. The infant's last
name after discharge will be [**Last Name (un) 32687**]. The father is [**Name (NI) **]
[**Name (NI) 32687**]. The parents live together in [**Hospital1 1474**].
CONDITION ON DISCHARGE: The infant is discharged in good
condition.
DISPOSITION: He is transferred to [**Hospital 1474**] Hospital Special
Care Nursery for continuing care.
PRIMARY PEDIATRIC CARE PROVIDER: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45820**] of
[**Hospital 1475**] Pediatrics, [**Street Address(2) **], [**Location (un) 1475**],
[**Numeric Identifier 36089**]. Telephone number [**Telephone/Fax (1) 38348**].
CARE AND RECOMMENDATIONS: After discharge:
1. Feedings: Similac Special Care 20 calories per ounce with
additional calories as needed for consistent weight gain
at 150 mL/kg/day.
2. Medications: The infant is discharged on no medications.
3. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months of age.
4. Infant will need a car seat position screening test prior
to discharge.
5. A State newborn screen was sent on [**5-22**], and again on
[**5-25**], prior to transfer. Thyroid tests will need to be
monitored in setting of maternal [**Doctor Last Name 933**] disease.
6. The infant has received no immunizations to date.
7. Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of
the following 4 criteria: 1. Born at less than 32
weeks, 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 sibling, 3. With chronic
lung disease or 4. Hemodynamically significant
congenital heart 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.
3. 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 APPOINTMENTS:
1. The family does have a history of developmental dysplasia
of the hips and this infant was born in breech
positioning so should have ultrasound of the hips at
approximately 6 weeks of age or after discharge.
2. The parents desired this infant to have a circumcision
prior to discharge.
3. There are no follow up appointments scheduled.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 weeks.
2. Twin #2.
3. Status post transitional respiratory distress due to
retained fetal lung fluid.
4. Status post hypoglycemia.
5. Status post hyperbilirubinemia of prematurity.
6. Sepsis ruled out.
7. Infant born in breech positioning.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2176-5-25**] 00:16:28
T: [**2176-5-25**] 10:31:39
Job#: [**Job Number 72642**]
ICD9 Codes: 7742, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5339
}
|
Medical Text: Admission Date: [**2117-8-16**] Discharge Date: [**2117-8-23**]
Date of Birth: [**2064-12-23**] Sex: M
HISTORY OF PRESENT ILLNESS: The patient is a 52 year old
male with a history of diabetes mellitus, hypertension,
hypercholesterolemia, peripheral vascular disease and known
three-vessel coronary artery disease on diagnostic
elective coronary artery bypass graft on [**2117-8-18**],
presenting with substernal chest pain and abdominal pain
three days prior to admission. The patient had multiple
sublingual Nitroglycerin without relief of pain and presented
to outside hospital three days prior to admission, was placed
on heparin and Integrilin, Nitroglycerin drip, aspirin, beta
blocker, with relief of pain. The patient also had relief of
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for elective coronary artery
bypass graft.
On hospital day number two, he developed abdominal pain and
was given Maalox with minimal relief. He had the onset of
mild chest pain. An ECG done at that time showed precordial
Q waves with poor R wave progression suggestive of old
anterior infarction with ST elevations in V1 through V3,
minimally changed compared to previous electrocardiograms,
but with flipped T's in I and AVL.
The patient was taken emergently to Cardiac catheterization
which revealed a left dominant system with a calcified left
main coronary artery, left anterior descending occluded to
left main, left circumflex with diffuse disease, with 70%
lesions at the obtuse marginal to patent ductus arteriosus
and right coronary artery occluded. No intervention was
performed at this time. The patient was scheduled for
elective coronary artery bypass graft.
Of note, the patient is a Jehovah's Witness who strongly
refuses blood products.
Currently, at the time of admission, the patient was
experiencing mild abdominal pain, three out of ten, and
minimal chest pain, one out of ten, with no radiation.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Hypertension.
3. Coronary artery disease as documented above.
4. Previous history of transient ischemic attacks for which
the patient is on Coumadin. Last one was two to three years
ago.
5. Obesity.
6. Leg ulcers.
MEDICATIONS ON TRANSFER:
1. Heparin drip.
2. Nitroglycerin drip.
3. Atenolol 100 p.o. q. day.
4. Lasix 40 p.o. q. day.
5. Integrilin drip.
6. Aspirin.
7. Protonix 40 q. day.
8. Regular insulin sliding scale.
ALLERGIES: The patient is allergic to penicillin and
statins.
SOCIAL HISTORY: The patient's social history is remarkable
for, as mentioned above, the patient is a Jehovah's Witness
with strong belief that prevents him from receiving blood
products. He lives with his mother and has no smoking. Only
occasional alcohol use.
FAMILY HISTORY: Family history is positive for both father
and mother with coronary artery disease in their seventies.
PHYSICAL EXAMINATION: On admission, the patient had a
temperature of 98.2 F.; blood pressure of 114/56; pulse of
90; breathing 15; saturating 94% on room air. He has central
venous pressure of 11. Heparin drips were going at 100 Units
per hour, Nitroglycerin gtt. Generally, the patient was
alert and oriented, comfortable, in no apparent distress.
The patient's neck was plethoric, thus it was difficult to
assess jugular venous distention. The patient had no carotid
bruits. Lungs were clear to auscultation bilaterally.
Cardiovascular: The patient had a regular rate; normal S1,
S2, no murmurs were appreciated. Abdomen was obese, soft,
with mild diffuse tenderness and normoactive bowel sounds.
Extremities: The patient had warm extremities without edema.
He had Doppler-able dorsalis pedis and posterior tibialis
pulses bilaterally. The site of his balloon pump was
without ecchymosis or oozing.
LABORATORY: On admission, the patient's white count was
13.5, hematocrit 35.3, platelets 242, PT 13.1, INR 1.2.
Electrolytes were all within normal limits. Notably, his BUN
and creatinine were 17 and 0.7 respectively. The patient's
liver function tests were all within normal limits.
The patient had a total CK of 331 which proceeded to 472; CK
MB was 34 and 41 respectively and troponins were 10 and 31.3
respectively.
Cardiac catheterization is as discussed in the HPI.
EKG post-catheterization showed normal sinus rhythm with a
rate of 90, normal QRS axis, and question of left atrial
enlargement, Q waves in V1 through V3. ST segment elevations
V1 through V3 with T wave inversions in I and AVL. No change
from the EKG prior to intervention.
In short, this is a 52 gentleman with multiple cardiac risk
factors and known three-vessel disease presenting with
breakthrough pain while on nitrates and heparin drip awaiting
elective coronary artery bypass graft. The patient underwent
diagnostic catheterization again without intervention and an
intra-aortic balloon pump was placed.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Coronary artery disease - The patient
was maintained on aspirin. Plavix held secondary to
increased risk of bleeding with potential for surgery in the
near future. The patient was on heparin drip, Nitroglycerin
drip as well as an intra-aortic balloon pump. The patient
had recurrent chest pain requiring intra-aortic balloon pump
and Nitroglycerin drip.
Initially, it was felt that the patient would go to coronary
artery bypass graft within the next few days following
admission, but due to the patient's falling hematocrit and
strong desire not to receive blood products, CT Surgery
declined to intervene on him surgically at this time. Thus,
the patient was maintained on a balloon pump and nitrates
until such time as he could be taken to Cardiac
Catheterization Laboratory, where he underwent successful
percutaneous intervention with rotational atherectomy to his l
eft
anterior descending and stents times two to his left anterior
descending with no residual stenosis.
Following catheterization intervention, the patient was able
to be weaned from the balloon pump and nitrates and was pain
free at the time of discharge on a long-acting nitrate.
Shortly prior to acticipated discharge, the patient suffered a
cardiac arrest and could not be resuscitated.
Pump: The patient had poor ejection fraction secondary to
ongoing ischemia. The patient was maintained on intra-aortic
balloon pump to increase afterload reduction until after his
catheterization, at which time he was weaned from the balloon
pump. A beta blocker and ACE inhibitors were titrated as
tolerated and the patient was diuresed as necessary.
Rhythm: The patient had no acute rhythmic issues during the
course of his stay on Telemetry prior to his arrest.
2. Hematology: The patient had a baseline anemia on
admission of unclear etiology. He refused transfusion
secondary to religious beliefs. The patient's hematocrit on
admission was 35.3. Following his cardiac catheterization
interventions, his hematocrit decreased to a nadir of 28.0.
The patient was started on Epogen subcutaneously 300 units
three times a week, in hopes of boosting his hematocrit to
the point where he would be able to undergo cardiac surgery
at some point in the near future.
3. Endocrine: The patient was a known diabetic and was
maintained on Regular insulin sliding scale during the course
of his admission.
4. Gastrointestinal: The patient had multiple episodes of
epigastric and right upper quadrant pain, associated with
eating, occurring about 30 minutes after eating. The pain
was colicky in nature. The patient's abdominal examination
remained benign with no evidence of [**Doctor Last Name 515**] sign. His liver
function tests were all normal. Nevertheless, the patient
was arranged to have a right upper quadrant ultrasound to
assess his gallbladder and his liver, and that study was
still pending at the time of death.
5. Infectious Disease: The patient spiked fevers several
days after admission to a temperature maximum of 101.5 F. He
was pan-cultured and started on empiric antibiotics of
Vancomycin and Levofloxacin. The patient's cultures remained
negative throughout the course of his stay. No source of
infection was localized, nevertheless, it was decided to
treat the patient with Levofloxacin 500 mg p.o. for a ten day
course. The patient's white count was decreasing at the time
of discharge and he remained afebrile.
6. CODE: The patient was a Full Code throughout the course
of his stay.
DISPOSITION: The patient died following angioplasty.
DISCHARGE DIAGNOSES:
1. Coronary artery disease with unstable angina.
2. Status post intervention to the left anterior descending
coronary artery with stent placement times two.
3. Diabetes mellitus.
4. Hypercholesterolemia.
5. Anemia.
6. Likely bronchitis.
7. Death following coronary angioplasty.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 02-229
Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36
D: [**2117-8-21**] 16:14
T: [**2117-8-21**] 20:05
JOB#: [**Job Number **]
1
1
1
DR
ICD9 Codes: 9971, 4271, 4275, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5340
}
|
Medical Text: Admission Date: [**2168-7-23**] Discharge Date: [**2168-8-4**]
Date of Birth: [**2101-10-22**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p brady arrest
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Mr. [**Known lastname 73649**] was a 66 year old male with h/o CAD s/p CABG
(atatomy not known) as well as PCI with stent in [**12/2167**] in [**Location (un) 7349**]
who was in his USOH until 4 pm on [**7-22**] when the patient
collapsed after lifting heavy boxes. By report, CPR was
initiated immediately and 911 called with rapid EMS response.
Per report, EMS found pt in WCT likely VT and pulseless. Pt
received a total of 9 shocks and lidocaine push during the
transport to OSH ED. On arrival in the ED the patient was
unreponsive and without a pulse, s/p two more shocks and
intubated for airway protection. EKG with WCT and he was given
amio bolus x 2 and started on a drip. The patient also was given
epi and atropine during the code. The patient remained
hypotensive and was started on dopamine/levophed for pressure
support. The patient was then transferred to [**Hospital1 **] for ongoing
care. Echo at OSH by report demonstrated an EF of 40% with
global hypokinesis, no focal wall motion abnormalities, but was
a limited study. CT of the head showed no acute changes. Meds on
transfer included amio gtt and plavix.
Past Medical History:
- CABG [**76**] yrs ago, ANATOMY: LIMA to LAD, SVG to High Lateral
- PCI [**2167-12-2**] w/two DES to mid and distal RCA
- PCI [**2167-12-16**] w/DES to SVG
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
Social History:
Lives in [**Location 7349**], was here in the [**Name (NI) 73650**], [**First Name3 (LF) **] in area.
Family History:
not obtained
Physical Exam:
per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:
VS: T 99 BP 118/63 HR 70 RR 20 O2 100% on AC 500/15
Gen: Intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Bleeding gums.
Neck: Supple with JVP flat
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Intubated, b/l coarse crackles, ?rib fracture
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Pertinent Results:
admission labs:
145 112 38
--------------< 174
4.0 19 1.5
CK: 9097 MB: >500 Trop-T: 9.87
Ca: 10.1 Mg: 2.8 P: 4.0
.
15
20.1 >----< 319
44.2
[**2168-7-24**] 09:29AM BLOOD WBC-11.7* RBC-3.11* Hgb-10.0* Hct-28.4*
MCV-91 MCH-32.1* MCHC-35.1* RDW-14.6 Plt Ct-189
[**2168-7-25**] 04:21PM BLOOD WBC-10.1 RBC-3.10* Hgb-10.1* Hct-28.2*
MCV-91 MCH-32.7* MCHC-35.9* RDW-14.5 Plt Ct-135*
[**2168-8-3**] 05:39AM BLOOD WBC-17.8* RBC-1.47*# Hgb-4.6*# Hct-14.9*#
MCV-101* MCH-31.6 MCHC-31.1 RDW-14.4 Plt Ct-269
[**2168-7-25**] 04:45AM BLOOD Fibrino-822*
[**2168-7-25**] 04:21PM BLOOD Glucose-126* UreaN-26* Creat-0.9 Na-143
K-3.7 Cl-114* HCO3-23 AnGap-10
[**2168-8-2**] 05:56AM BLOOD Glucose-112* UreaN-27* Creat-0.9 Na-150*
K-3.2* Cl-112* HCO3-26 AnGap-15
[**2168-7-24**] 08:02AM BLOOD ALT-143* AST-216* LD(LDH)-839* AlkPhos-39
TotBili-0.6
[**2168-7-25**] 04:45AM BLOOD ALT-111* AST-165* LD(LDH)-799*
AlkPhos-36* TotBili-0.7
[**2168-7-27**] 05:44AM BLOOD ALT-74* AST-96* CK(CPK)-694* AlkPhos-40
TotBili-0.6
[**2168-7-23**] 01:40AM BLOOD CK-MB-GREATER TH cTropnT-9.87*
[**2168-7-23**] 02:25PM BLOOD CK-MB-282* MB Indx-3.1
[**2168-7-25**] 09:14AM BLOOD CK-MB-13* MB Indx-0.6
[**2168-7-26**] 05:31AM BLOOD CK-MB-13* MB Indx-0.8
[**2168-7-27**] 05:44AM BLOOD CK-MB-5
[**2168-7-25**] 09:14AM BLOOD Hapto-143
[**2168-7-23**] 02:29AM BLOOD Type-ART pO2-445* pCO2-39 pH-7.39
calTCO2-24 Base XS-0
[**2168-7-23**] 01:53PM BLOOD Type-ART pO2-72* pCO2-30* pH-7.48*
calTCO2-23 Base XS-0
[**2168-7-30**] 05:27AM BLOOD Type-ART Temp-38.7 Tidal V-500 PEEP-5
pO2-138* pCO2-35 pH-7.46* calTCO2-26 Base XS-2 Intubat-INTUBATED
[**2168-7-23**] 12:43PM BLOOD Lactate-1.6
.
[**2168-8-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-neg
[**2168-7-31**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-neg
[**2168-7-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-neg
[**2168-7-28**] URINE URINE CULTURE-NG
[**2168-7-28**] URINE URINE CULTURE-NG
[**2168-7-28**] SPUTUM GRAM STAIN (Final [**2168-7-28**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2168-8-3**]):
RARE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
232-0962F
([**2168-7-27**]).
[**2168-7-28**] BLOOD CULTURE NG
[**2168-7-28**] BLOOD CULTURE NG
[**2168-7-27**] SPUTUM GRAM STAIN (Final [**2168-7-27**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2168-7-29**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
[**2168-7-26**] CATHETER TIP-IV NG
[**2168-7-26**] URINE URINE CULTURE-NG
[**2168-7-26**] BLOOD CULTURE NG
[**2168-7-26**] BLOOD CULTURE NG
[**2168-7-25**] SPUTUM GRAM STAIN (Final [**2168-7-25**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2168-7-27**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
[**2168-7-25**] BLOOD CULTURE NG
[**2168-7-25**] URINE URINE CULTURE-NG
[**2168-7-25**] BLOOD CULTURE NG
[**2168-7-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{KLEBSIELLA PNEUMONIAE} INPATIENT
[**2168-7-23**] BLOOD CULTURE NG
[**2168-7-23**] BLOOD CULTURE NG
[**2168-7-23**] URINE NG
.
CHEST (PORTABLE AP) [**2168-7-23**] 11:10 AM
TWO PORTABLE VIEWS. Comparison with the previous study done
earlier the same day. There is streaky density at the lung bases
consistent with subsegmental atelectasis as before. The patient
is status post median sternotomy and CABG. Mediastinal
structures are unchanged. An endotracheal tube and nasogastric
tube remain in place.
IMPRESSION: Subsegmental atelectasis.
.
PORTABLE SEMI-UPRIGHT CHEST 7:56 A.M. [**8-3**]
Compared with [**2168-8-2**] at 10:44 p.m., no obvious interval change
in the pulmonary vascular engorgement centrally.
The patchy streaky opacities at the right lung base are slightly
more prominent and confluent suggesting pneumonia.
.
Cardiology Report ECG Study Date of [**2168-7-23**] 1:59:54 AM
Sinus rhythm, rate 76. Technical artifacts are seen. An
indeterminate axis is
noted. Right bundle-branch block pattern is seen. Ther is likely
an
anteroseptal myocardial infarction of undetermined age. No
previous tracing
available for comparison.
.
ECHO [**8-22**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.5 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 20% (nl >=55%)
Aorta - Valve Level: *4.0 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
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: 174 msec
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum.
No ASD by 2D or color Doppler. Dilated IVC (>2.5cm) with <50%
decrease during
respiration (estimated RAP 16-20 mmHg).
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. No LV
mass/thrombus. Severely depressed LVEF. No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.
Paradoxic septal
motion consistent with conduction abnormality/ventricular
pacing.
AORTA: Moderately dilated aortic sinus. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Trivial MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
Indeterminate PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Echocardiographic results were reviewed by telephone with the MD
caring for
the patient.
Conclusions:
The left atrium is mildly dilated. There is an echodensity
associated with the
left atrial of the posterior mitral annulus ([**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] vs
artifact/tissue?).
No atrial septal defect is seen by 2D or color Doppler. The
estimated right
atrial pressure is 16-20 mmHg. Left ventricular wall thicknesses
are normal.
The left ventricular cavity is moderately dilated. No masses or
thrombi are
seen in the left ventricle. Overall left ventricular systolic
function is
severely depressed with severe global hypokinesis and akinesis
(thinned) of
the basal inferior and lateral walls. There is very apical
dyskinesis. There
is no ventricular septal defect. There is focal hypokinesis of
the apical free
wall of the right ventricle. The aortic root is moderately
dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal.
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: Severely depressed LVEF with regionality c/w CAD.
Possible [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 2966**] vs artifact. If clinically indicated, a TEE may better
characterize
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 73651**].
.
MR HEAD W/O CONTRAST [**2168-7-25**] 9:33 PM
MR HEAD W/O CONTRAST
Reason: Please assess for bleed, please asses for thromboembolic
cva
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with brady arrest requiring 11 shocks by
DC-cardioversion.
REASON FOR THIS EXAMINATION:
Please assess for bleed, please asses for thromboembolic cva,
please assess neck for cord compression and soft tissue injury.
INDICATION: Cardiac arrest, requiring shocks by cardiac
conversion.
TECHNIQUE: Multiplanar T1- and T2-weighted sequences were
obtained through the brain with diffusion-weighted imaging.
FINDINGS: Evaluation of the ADC map demonstrates diffuse
cortical low signal. This corresponds to increased signal on the
diffusion-weighted sequence within the cortex. These findings
represent diffuse cortical slow diffusion. This would represent
diffuse cortical injury from anoxia. There is a tiny focus of
abnormal magnetic susceptibility at the [**Doctor Last Name 352**]-white matter
junction in the posterior right frontal lobe consistent with
petechial hemorrhage. There is no midline shift, mass effect, or
hydrocephalus. The normal vascular flow voids are present. There
is paranasal sinus disease due to the patient's intubated
status.
IMPRESSION: Findings are consistent with diffuse anoxic brain
injury.
.
MR CERVICAL SPINE W/O CONTRAST [**2168-7-25**] 9:33 PM
MR CERVICAL SPINE W/O CONTRAST
Reason: Now patient with c-collar needs to be cleared.
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p brady arrest and fall.
REASON FOR THIS EXAMINATION:
Now patient with c-collar needs to be cleared.
INDICATION: Brady arrest and fall.
The patient with C collar needs to be cleared.
TECHNIQUE: Multiplanar T1- and T2-weighted sequences were
obtained through the cervical spine with sagittal STIR sequence.
FINDINGS: The alignment of the cervical spine appears normal.
There is no abnormal bone marrow edema. The intrinsic cord
signal appears generally normal although it is poorly evaluated
due to some motion. At the level of [**6-12**], there is a small focus
of abnormal magnetic susceptibility within the left-sided cord.
This is suspicious for an intramedullary hemorrhage.
There are multilevel posterior osteophytes causing mild spinal
canal narrowing. There are areas of moderate bilateral neural
foraminal narrowing associated with these osteophytes.
Given the patient's history and the presence of abnormal
susceptibility within the cord, the concern is for a cord
injury.
IMPRESSION: Small area of abnormal magnetic susceptibility
within the cord at the level of C5-6 is concerning for a
petechial hemorrhage. This could be a secondary finding
associated with cord injury. The intrinsic cord signal is poorly
evaluated due to patient motion artifact on the STIR sequence.
There however is no bone marrow edema.
.
OBJECT: BEDSIDE SIDE EEG WITH VIEDO, [**Date range (1) 73652**]. THE HEART WAS
MONITORED BECAUSE DISORDERS OF HEART RHYTHMS [**Month (only) **] PRODUCE
NEUROLOGICAL
COMPLAINTS AS DESCRIBED ABOVE OR NEUROLOGICAL DISORDERS SUCH AS
SEIZURES, WHEN SYMPTOMATIC, [**Month (only) **] PRODUCE CARDIAC ARRHYTHMIAS.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
FINDINGS:
ROUTINE SAMPLING: A low voltage [**3-12**] Hz disorganized posterior
background rhythm is seen with frequent electrode artifacts seen
at the
bilateral temporal leads with a very rhythmic alpha frequency
quality
that is limited to these leads; however, at other times, it is
also seen
in the right central region. There was also electrode artifact
seen in
the left central leads. When these artifacts were at their
lowest, a
very slow [**4-10**] Hz low voltage rhythm was noted with no clear
regions of
focal slowing and no clear epileptiform discharges noted.
SLEEP: There were no normal sleep/wake transitions seen.
CARDIAC MONITOR: A generally regular rhythm was noted with an
average
rate of 96 bpm. However, frequent premature ventricular
contractions
were seen.
AUTOMATIC SPIKE DETECTION FILES: There were 259. These consisted
primarily of electrode artifact, particularly at the bilateral
temporal
leads. There also seemed to be superimposed electrical artifact
of low
voltage and high frequency. No true epileptiform features were
noted.
AUTOMATIC SEIZURE DETECTION FILES: There were 43. These
consisted of
the above-noted electrode or electrical artifact seen in the
bilateral
temporal leads as well as multiple other leads. No true
electrographic
seizures were recorded, however.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This is an abnormal 24-hour video EEG telemetry in
the
waking and sleeping states due to the low voltage suppressed
slow and
disorganized background rhythm with much superimposed electrical
artifact. Nonetheless, no true electrographic seizures or
epileptiform
features were noted. There were no pushbutton activations. This
slow
low voltage and disorganized background is suggestive of a
severe
encephalopathy which may be seen with medication effect, toxic
metabolic
abnormalities, or infections as well as global ischemic disease.
Of
note, there were frequent premature ventricular contractions
noted
throughout the tracing.
.
Neurophysiology Report EP Study Date of [**2168-7-28**]
OBJECT: CARDIAC ARREST. ASSESS NEUROLOGIC FUNCTION.
REFERRING DOCTOR: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 489**]
FINDINGS:
BRAIN STEM AUDITORY EVOKED POTENTIAL (07-085): After stimulation
of the
right ear there was no discernible evoked potential at any
position.
This can often come from lesions in the VIIIth cranial nerve.
The
patient was reported to have an earlier and severe hearing loss
on
the right.
After stimulation of the left ear there was a very poorly
formed and faint peak at position I and another poorly formed
peak at
position V with a normal latency. This suggests some conduction
from
the periphery to the mid-brain, and with a normal latency.
MEDIAN NERVE SOMATOSENSORY EVOKED POTENTIAL (07-086): After
stimulation
of the right median nerve there was an evoked potential peak at
Erb's
point with a normal latency. Subsequent peaks were not
discernible.
This suggests a defect in the large fiber somatosensory
conducting
system after right median stimulation, with the defect proximal
to the
brachialplexus. This can be at the root level or centrally.
After left median nerve stimulation there were no discernible
evoked potential peaks at any position. There was no peak at
Erb's
point. This suggests a defect in the large fiber somatosensory
conducting system peripherally. This can be due to peripheral
neuropathies, body habitus, and sometimes to technical factors.
Brief Hospital Course:
66 M with h/o CAD s/p CABG and PCI who presented from OSH s/p
cardiac arrest, reportedly down for ~10 hrs, pulseless, s/p
multiple shocks, intubated & sedated on amiodarone and heparin
gtt's. Hospital course by problem:
.
#) CAD: Pt was s/p CABG with unknown anatomy (done in [**Location (un) 7349**]), also
with recent PCI in [**12-13**]. AMI per EKG. Due to an unkown etiology
for his arrest, thought seconsary to scar rather than acute MI,
in combination with his tenuous clinical status and questionable
nuerologic recovery - an acute cardiac catheterization was not
performed.
.
#) Rhythm: His amiodarone drip was continued for several days.
He had only small runs of NSVT and a malignant arhythmia did not
return. His amiodarone drip was discontinued. He remained in
sinus rhythym while monitored on telemetry.
.
#) Pump: EF was reportedly 40% at OSH with global HK. A repeat
echo here showed an EF of 20%.
.
#) Resp: He remained intubated up until the point he was made
comfort measures only at which point he was taken off the
ventilator.
.
#) Neuro: Neurology was involved in this patient's care and an
MRI was obtained. The MRI showed diffuse cortical injury. He did
not recover meaningful cortical activity. He developed
epileptiform partialis continuium is his right arm and was
initially started on a dilantin load. This was discontinued
after EEG showed no epileptiform activity. A family meeting was
held to discuss the neurologic prognosis and ultimately the
family decided that given his poor prognosis, they would change
his care to comfort measures only.
.
#) Febrile Illness - unclear source. Infectious vs. central
fever. The patient appeared septic early in the course of his
hospitalization and was broadly covered with Vanc and Zosyn.
This was changed to levoquin for 2 days, but high spiking fevers
to 102 returned and he was re-started on Vanc/Zosyn. Sputum
cultures were not initially definitive for a source, though
eventually grew klebsiella (cukture data above.
.
#) Dispo: The patient was made comfort measures only and expired
on [**2168-8-4**].
Medications on Admission:
Diovan 120 mg daily
ASA 325
Plavix 75
Lipitor 30
Folic Acid
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Anoxic brain injury following cardiac arrest.
Discharge Condition:
expired.
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
Completed by:[**2168-9-23**]
ICD9 Codes: 0389, 5849, 5990, 4280, 2720, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5341
}
|
Medical Text: Admission Date: [**2160-12-6**] Discharge Date: [**2160-12-9**]
Service: MED
CHIEF COMPLAINT: Cough, rhinorrhea, dehydration.
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
female with breast cancer, status post lumpectomy/radiation
therapy/Tamoxifen ([**2155**]), hypertension, hyperlipidemia,
multiple urinary tract infections who presents with a four
day prodrome of dry cough, rhinorrhea, coryza, malaise,
chills, headache, decreased p.o. intake, loose bowel
movements with diarrhea and no blood, decreased urine output,
no sick contacts, had flu shot this year. In the Emergency
Department, she had labile blood pressure with systolic blood
pressure in the 80s. Her usual is systolic blood pressure in
the 120s, this was despite two liters of intravenous fluids
and she was transferred to the Medical Intensive Care Unit
for closer monitoring for possible early sepsis. The
Intensive Care Unit course was notable for initially
receiving broad spectrum antibiotics as well as a white blood
cell count of 11.0 with 15 bands. She was ultimately changed
to Levaquin for a possible early pneumonia pending cultures.
The Intensive Care Unit course was also notable for negative
chest x-ray, two units of packed red blood cells for a
hematocrit of 24.0 with appropriate bump in her hematocrit
and no evidence of bleeding, stable blood pressure despite a
net fluid balance of negative 2.5 liters. No central access
was needed. The sepsis protocol was aborted. Also of note,
her liver function tests had been normal. Random cortisol
was 17 and her DFA was positive for influenzae A with a viral
culture pending at the time of discharge. Blood and urine
cultures were no growth at the time of discharge as well.
She also had a right lower extremity noninvasive ultrasound
that was negative for deep venous thrombosis.
PAST MEDICAL HISTORY: Breast cancer diagnosed in [**2154**], Stage
I, status post left lumpectomy, on [**2156-4-20**], and repeat
surgery with sentinel node dissection on [**2156-5-18**].
Invasive mucinous carcinoma with estrogen receptor positivity
and HER2/NEU negative. Left chest radiation, on Tamoxifen
therapy. She is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19**].
Question of vertebral basilar cerebrovascular accident in
[**2160-7-30**], with associated limb ataxia. Magnetic
resonance imaging was negative except for some microvascular
cerebral white matter changes.
Question peripheral vertigo, takes Meclizine p.r.n.
Hypothyroidism.
Hypertension.
Hypercholesterolemia.
Glaucoma.
Cataract.
Osteopenia.
Left hip arthritis.
History of urinary tract infections.
Anemia, with a baseline hematocrit of 31.0, with a TIBC that
was low and a high ferritin.
Echocardiogram in [**2160-8-29**], with preserved ejection
fraction of 60 percent with trivial mitral regurgitation and
mild left atrial enlargement.
Cardiac stress test in [**2160-2-28**], that was negative for
inducible ischemia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Evista 60 mg p.o. daily.
2. Tamoxifen 20 mg p.o. daily.
3. Lisinopril 5 mg p.o. daily.
4. Triamterene/Hydrochlorothiazide 37.5/25 mg p.o. daily.
5. Enteric Coated Aspirin 325 mg p.o. daily.
6. Meclizine 25 mg q8hours p.r.n.
7. Aggrenox twice a day, the dose was not known.
8. Synthroid 125 mcg daily.
SOCIAL HISTORY: She denies tobacco and alcohol abuse. She
is a professional bowler. She lives alone though her family
is in the area.
FAMILY HISTORY: Breast cancer in multiple female relatives.
PHYSICAL EXAMINATION: At the time of presentation,
temperature 100.8, heart rate 89, blood pressure 106
systolic, respiratory rate 18, oxygen saturation 97 percent
in room air. Physical examination is read off the admitting
note from the Intensive Care Unit team and is not reflective
of the examination by this dictator. General - The patient
appears stated age, found lying flat in bed, in no acute
distress. Head, eyes, ears, nose and throat - Sclera
anicteric, conjunctiva injected, the pupils are equal, round
and reactive to light and accommodation, the mucous membranes
are dry, oropharynx clear. Neck - No jugular venous
distention, no lymphadenopathy. Cardiac regular rate and
rhythm, normal S1 and S2, I/VI holosystolic murmur at the
apex. Chest clear to percussion and auscultation. Abdomen
is soft, nontender, nondistended, no hepatosplenomegaly.
Extremities - No calf tenderness, no edema. Neurologically,
mental status examination is normal. Cranial nerves II
through XII are intact.
LABORATORY DATA: On admission, chest x-ray with no acute
cardiopulmonary process. Electrocardiogram notable for sinus
tachycardia with a rate of 104 beats per minute, normal axis,
normal intervals, new T wave inversion in III and old T wave
inversions in aVL and V1. This was not significantly changed
from comparison with [**2160-2-28**].
On admission, white blood cell count 7.3, 73 percent
neutrophils, 15 percent bands, 6 percent lymphocytes,
hematocrit 30.4, platelet count 228,000. Sodium 136,
potassium 3.5, chloride 98, bicarbonate 23, blood urea
nitrogen 16, creatinine 0.8, glucose 142.
HOSPITAL COURSE: This is an 80 year old female with a
history of Stage I breast cancer, hypertension,
hyperlipidemia, who presents with a leukocytosis/bandemia,
hypotension in the setting of dehydration and influenza.
After a short Medical Intensive Care Unit course where she
remained hemodynamically stable, she was transferred to the
floor. [**Last Name **] problem list is as follows:
Hypotension - This was likely secondary to volume depletion
in the setting of a diarrheal and viral respiratory syndrome.
Her blood pressure was stable after three liters of normal
saline. She was clinically euvolemic after that. She did
receive two units of packed red blood cells. There is no
evidence of gastrointestinal bleed or adrenal insufficiency
during the course of her evaluation. Her antihypertensives
were initially held and reinstated upon discharge.
Influenza A - DFA confirmed, the viral cultures were pending
at the time of discharge. The initial bandemia would not
have been consistent with a typical influenza presentation,
so she was continued on a fourteen day course of Levaquin to
eliminate any possibility of a bacterial superinfection or
early pneumonia.
Loose bowel movements - This problem was resolved and had
been a viral syndrome on presentation. There was no evidence
of diarrhea during medical [**Hospital1 **] stay.
Anemia - This is a chronic problem. She has known iron
deficiency. There was no evidence of bleeding. She was
guaiac negative and the Hemophilus panel was negative. She
was reinstated on iron at discharge and her hematocrit was
stable.
Hypothyroid - She was continued on her Synthroid.
Osteopenia - She was continued on Evista.
Fluids, electrolytes and nutrition - She was tolerating a
house diet upon discharge.
FOLLOW UP: She is a patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] and
will follow-up with her in one to two weeks.
MEDICATIONS ON DISCHARGE:
1. Evista 60 mg p.o. daily.
2. Tamoxifen 20 mg p.o. daily.
3. Lisinopril 5 mg p.o. daily.
4. Triamterene/Hydrochlorothiazide 37.5/25 mg p.o. daily.
5. Enteric Coated Aspirin 325 mg p.o. daily.
6. Meclizine 25 mg q8hours p.r.n.
7. Aggrenox twice a day, the dose was not known.
8. Synthroid 125 mcg daily.
9. Levofloxacin 250 mg p.o. daily to complete a fourteen day
course. She was given a prescription for ten more days.
DISCHARGE DIAGNOSES: Influenza A.
Hypotension secondary to volume depletion.
Anemia.
Hypothyroidism.
CONDITION ON DISCHARGE: The patient was breathing
comfortably in room air. She was normotensive and her
hematocrit was stable at her baseline upon discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**]
Dictated By:[**Doctor Last Name 31781**]
MEDQUIST36
D: [**2160-12-10**] 16:25:42
T: [**2160-12-10**] 20:11:26
Job#: [**Job Number 31782**]
ICD9 Codes: 2765, 2449, 2724, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5342
}
|
Medical Text: Admission Date: [**2181-1-1**] Discharge Date: [**2181-1-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
89 year old woman with past medical history significant for
chronic anemia, lung cancer s/p RFA, recent UTI treated at
[**Hospital3 5365**] and discharged to rehab [**12-28**], presenting with
upper GI bleed.
.
Patient has been having nausea since last Saturday, and per
history it is unclear if she has been having blood in her
vomitus since then. Patient however was noted to have coffee
ground emesis on the day of admission and she was sent from
rehab back to [**Hospital3 5365**] for evaluation. Per report, she
was going to be admitted but due to lack of telemetry beds she
was transferred to [**Hospital1 18**] for further management.
.
In the ED, vital signs were initially: 97.3 86 132/66 18 97,
Patient received 1L NS and underwent NG lavage with positive
coffee grounds. Per report, she initially had a well formed
stool that was guaiac negative, however during her evaluation
has a large, loose guaiac positive stool and associated
hypotension down to 70's systolic. Patient was type and crossed
x 4 units PRBC, GI consult was obtained and patient was admitted
for further management.
Past Medical History:
Chronic anemia
Lung ca s/p RFA
Spinal stenosis
s/p Small bowel obstruction
-- Per daughter in setting of [**Name (NI) 28303**] overuse (does not like to
go the bathroom)
s/p hysterectomy 80's
s/p cholecystectomy
hx of UTIs ([**1-25**] in the last year)
Social History:
Very hard of hearing, Lives with daughter, uses [**Name2 (NI) **] for
ambulation
Family History:
NC
Physical Exam:
VS: 96.9, 178/60, 49, 18, 100% 3L NC
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST: Lungs are clear with occasional rhonchi at right base
CARDIAC: irregular, bradycardic, soft S1 S2, no murmurs, rubs,
or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: no peripheral edema, warm without cyanosis
NEUROLOGIC: alert, oriented to name/year/location. CN II-XII
grossly intact. BUE 4+/5, and BLE 4+/5 both proximally and
distally. No pronator drift. Reflexes were symmetric.
Pertinent Results:
LABS ON ADMISSION:
[**2181-1-1**] 07:30PM BLOOD WBC-9.3 RBC-3.57* Hgb-10.9* Hct-33.3*
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.5 Plt Ct-272
[**2181-1-1**] 07:30PM BLOOD Neuts-88.7* Lymphs-8.2* Monos-3.1 Eos-0
Baso-0.1
[**2181-1-1**] 07:30PM BLOOD PT-10.9 PTT-19.5* INR(PT)-0.9
[**2181-1-1**] 07:30PM BLOOD Glucose-160* UreaN-60* Creat-1.4* Na-148*
K-4.2 Cl-105 HCO3-32 AnGap-15
[**2181-1-1**] 07:30PM BLOOD CK(CPK)-41
[**2181-1-1**] 07:30PM BLOOD cTropnT-<0.01
[**2181-1-1**] 07:30PM BLOOD Calcium-9.8 Phos-5.0* Mg-2.7*
[**2181-1-3**] 03:41AM BLOOD TSH-0.59
[**2181-1-2**] 12:48AM BLOOD Lactate-1.6
.
LABS ON DISCHARGE:
[**2181-1-5**] 07:00AM BLOOD WBC-7.6 RBC-3.51* Hgb-10.9* Hct-32.8*
MCV-93 MCH-31.0 MCHC-33.1 RDW-14.5 Plt Ct-233
[**2181-1-5**] 07:00AM BLOOD Plt Ct-233
[**2181-1-5**] 07:00AM BLOOD Glucose-87 UreaN-29* Creat-1.1 Na-141
K-4.0 Cl-105 HCO3-29 AnGap-11
[**2181-1-5**] 07:00AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.9
.
Endoscopy: Large hiatal hernia Granularity and nodularity in the
antrum compatible with gastritis (biopsy taken). No blood was
seen in the stomach or intestine. Abnormal esophageal motility
consistent with presbyesophagus
.
Upper GI Final Read: FINDINGS: The study was limited due to the
inability of the patient to be in a standing position. Thin
liquid barium was administered to the patient in RPO and LPO
positions and images were obtained. The images demonstrate a
small axial hiatal hernia with the GE junction positioned above
the diaphragm. Also seen is a large paraesophageal hernia, with
the entire stomach including
the proximal portion of the antrum, positioned above the
diaphragm. The distal portion of the antrum exits below the
diaphragm. Stomach empties normally and there is no evidence of
gastric outlet obstruction. IMPRESSION: Large mixed hiatal
hernia with nearly the entire stomach positioned above the
diaphragm.
Brief Hospital Course:
89 year old woman with past history of lung cancer s/p RFA,
recurrent UTI's, presenting from rehab with upper GI bleeding.
.
# UPPER GI BLEED: Unclear etiology, however in light of vomiting
worrisome for esophageal tear (boorhave's). Differential
diagnosis included peptic ulcer disease, variceal bleed
(although no history of esophageal varices), gastritis, avm,
etc. Patient was given 2 units of pRBC, started on IV PPI.
Scoped by GI with EGD showing gastritis, no active
bleeding/ulcers/or tears, and small axial hiatal hernia and a
large para esophageal hernia. Source of bleeding felt to be
gastritis. Patient's H. pylori serology also returned positive.
The UGIB had resolved on discharge, as evidenced by stable Hct
and vital signs for over 24 hours. She had no further episodes
of bloody emesis or melena. On discharge, patient will continue
[**Hospital1 **] PPI and will be treated with triple therapy for H pylori
with PPI [**Hospital1 **], amoxicillin, clarithromycin.
.
# SINUS BRADYCARDIA WITH PAUSES: on 12 lead EKG, appears to be
sinus bradycardia with PVCs. Also has some 1st degree block as
well as pauses < 2 seconds. Likey has underlying sick sinus. DDx
also included elevated vagal activity, infiltrative diseases,
collagen vascular diseases, carotid sinus hypersensitivity. She
does not appear to be on any medications which may be
contributing. Electrolytes have been within normal limits and
TSH was normal. Of note, option for PPM was discussed with
patient and HCP [**Name (NI) **], as documented in [**Name (NI) **] note. Both
understand the risks and benefits, and PPM was strongly opposed
and would not be in line with patient's wishes.
.
# HIATAL HERNIA: small axial hiatal hernia and a large para
esophageal hernia noted on EGD. Patient does have mild symptoms
of reflux, without regurgitation; however, patient and HCP [**Name (NI) **]
felt that these symptoms were mild and did not warrant surgical
intervention.
.
# ACUTE ON CHRONIC RENAL FAILURE: resolved and back to baseline
on discharge. Patients baseline creatinine 1.1 after obtaining
OSH records. In setting of GI Bleeding most likely pre-renal
azotemia. Nephrotoxins were avoided. Urine was negative for
eosinophil smear. After GIB resolved and after volume
resuscitation, BUN and Cr were at baseline. Discharge Cr 1.1
.
# HX of UTI: Per D/C Summary culture with Citrobacter sensitive
to cipro. Denies urinary sx currently. Urine culture on [**2181-1-2**]
was negative.
.
# HYPERTENSION: Initially held BP meds due to prior GI bleed and
hypotension. Resumed on low dose lisinopril and amlodine on
discharge. These may be titrated as needed at rehab facility.
.
# Dispo: discharge to rehab facility, follow-up appt with PCP
Medications on Admission:
Bisacodyl
Lidocaine patch
Colace 100mg PO BID
Omeprazole 20mg PO daily
Cipro 250mg PO BID
Prinivil 30mg PO BID
Norvasc 10mg PO daily
Compazine 25mg PO BID PRN
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
8. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Continuing Care Center - [**Hospital1 392**]
Discharge Diagnosis:
1) upper GI bleed
2) Gastritis
3) acute blood loss anemia
4) Hiatal hernia
Discharge Condition:
Mental status: Alert and oriented to self and date, with
intermittent confusion as to location and reason for
hospitalization.
Ambulatory status: with [**Hospital1 **]
Discharge Instructions:
It was a pleasure taking care of you at the [**Hospital1 771**]. You were transferred here from [**Hospital1 **] after vomiting blood. You received a blood transfusion
to replace the blood you had lost, and pantoprazole to decrease
acid production in your stomach. You had an endoscopy that
showed gastritis, which was thought to be the source of your
bleeding. Your bleeding has now stopped and your blood counts
have stabilized. You should continue to take pantoprazole 40 mg
twice a day by mouth.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- START Pantoprazole 40 mg by mouth, twice a day
- START amoxicillin 1 gram by mouth twice daily for only 10 days
- START clarithromycin 500 mg twice daily for only 10 days
.
In addition, your endoscopy showed a hiatal hernia, which you
have had before, and for which you had previously declined
surgery.
.
Please seek medical attention for any renewed vomiting, dark
stools, blood in your stools, difficulty eating, or any other
concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], within 1 week. His phone number is [**Telephone/Fax (1) 86541**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2181-1-5**]
ICD9 Codes: 5849, 2760, 2859, 5859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5343
}
|
Medical Text: Admission Date: [**2163-11-24**] Discharge Date: [**2163-11-26**]
Date of Birth: [**2104-11-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Percocet / Doxycycline / Penicillins / Latex / Banana
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dark red blood per rectum
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
Cauterization of GI bleed
Blood transfusions.
History of Present Illness:
This is a 58 year-old female with a history of chronic
pancreatitis who presents with dark red blood per rectum 2 days
s/p [**First Name3 (LF) **]. She had her first episode of pancreatitis in [**December 2162**]. At that time, endoscopic ultrasound revealed biliary
sludge. No stones were noted. She is not a drinker. She
underwent cholecystectomy in [**February 2163**]. In [**Month (only) 359**], she
developed similar pain to her first episode of pancreatitis but
even more severe. She was hospitalized at an OSH for this. Two
weeks later, she suffered a third episode, but chose to get
herself through it at home. Since then she continued to have
mild abdominal discomfort. She was evaluated by Dr. [**First Name4 (NamePattern1) 10168**]
[**Last Name (NamePattern1) 174**] (pancreas) approximately 4 weeks ago and he recommended
that she undergo [**Last Name (NamePattern1) **] for sphincterotomy. Pt had [**Last Name (NamePattern1) **] on [**11-22**]
which was only notable for mimimal diffuse dilation of the
common bile duct suggestive of ampullary stenosis.
Sphincterotomy was performed and she was admitted for overnight
observation. Pt reports that she developed severe nausea after
receiving dilaudid for pain and vomited 6-7 times that evening.
By the following day, she was tolerating clears and was
discharged to home. At home, she ate chicken for dinner and then
developed severe RUQ pain with radiation to her R chest. She
subsequently had a large, loose, dark-colored stool and reports
that the abdominal pain resolved. On the morning of admission
she had 2 more loose, dark bowel movements. After the third, she
reports that she realized the stool was grossly bloody and
called Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] recommended that she come to the
ED for evaluation.
In the ED, her BP was initially 82/60 at triage and she had a
witnessed syncopal episode. Her BP subsequently improved to
115/70 by the time she got back to her room without any
intervention. Otherwise vitals remained within normal limits.
Bedside ultrasound revealed no free fluid in the abdomen. CXR
was clear. Hct was noted to be 31.5 from 38.5 prior to the
procedure. Received 3L IVF. Two large bore IV's were placed. She
was admitted to the [**Hospital Unit Name 153**] for close monitoring.
On arrival to the [**Hospital Unit Name 153**], the patient complains of headache and
lightheadedness. Denies chest pain or SOB. No further episodes
of bleeding per rectum.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, constipation, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, gait unsteadiness, focal weakness,
vision changes, headache, rash or skin changes.
Past Medical History:
Chronic pancreatitis
Pancreatic serous cyst
h/o MGUS
Fibromyalgia
Social History:
Formerly worked in a dermatologist's office, now takes care of
her grandchildren a few days per week. Denies tobacco or EtOH
use.
Family History:
No history of pancreatitis.
Physical Exam:
Vitals: T: 97.5 BP: 109/64 HR: 62 RR: 12 O2Sat: 98% RA
GEN: Pale middle-aged female, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
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.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2163-11-24**] 04:45PM GLUCOSE-124* UREA N-20 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2163-11-24**] 04:45PM ALT(SGPT)-87* AST(SGOT)-66* ALK PHOS-98 TOT
BILI-0.3
[**2163-11-24**] 04:45PM LIPASE-85*
.
[**2163-11-24**] 04:45PM WBC-8.4 RBC-3.55* HGB-11.0* HCT-31.5* MCV-89
MCH-31.0 MCHC-34.9 RDW-12.6
[**2163-11-24**] 04:45PM NEUTS-55.8 LYMPHS-38.9 MONOS-3.9 EOS-0.9
BASOS-0.5
[**2163-11-24**] 04:45PM PLT COUNT-254
.
[**2163-11-24**] 11:00PM HCT-25.8*
.
[**2163-11-24**] 04:45PM PT-14.7* PTT-27.5 INR(PT)-1.3*
.
EKG: Sinus rhythm. Non-diagnostic inferior Q waves.
Non-diagnostic Q waves are also in leads V5-V6. Non-specific T
wave flattening in lead aVL with
T wave inversion in lead V1 and biphasic T wave in lead V2.
Compared to the previous tracing of [**2163-11-22**] the T wave changes
in leads V1 and V2 are new.
.
CXR:
Mild borderline cardiomegaly as above. No acute pulmonary
process.
.
[**Date Range **] 12/5
Blood clot at the apex of the prior sphincterotomy site.
Successful hemostasis with Bicap probe at apex of
sphincterotomy.
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized.
Successful placement of a 10Fr x 5cm double pigtail stent into
the right hepatic system to protect against biliary obstruction
s/p bicap.
Brief Hospital Course:
.
# Gastrointestinal bleed with acute blood loss anemia: She was
admitted with blood per rectum 2 days s/p sphincterotomy for
chronic pancreatitis, and underwent repeat [**Date Range **] with
cauterization of oozing sphincterotomy site and stent placement.
She required 2 units of blood. She continued to have maroon
stools throughout the day after her [**Date Range **], but subsequently had
no further bleeding. She was transferred out of the [**Hospital Unit Name 153**] on the
day prior to discharge. Her hematocrit remained overall stable
after transfusion, and was 31.5 at the time of discharge. She
will require repeat [**Hospital Unit Name **] in 4 weeks for stent removal. She will
also follow up with Dr. [**Last Name (STitle) 174**] as needed.
.
# Hypotension/Syncope: Transient event likely [**1-22**] acute blood
loss. With transfusion and fluids, this resolvedd. She did have
an EKG that showed a TW inversion in V1, and biphasic T wave in
V2, but had no cardiac symptoms.
.
# Transaminitis: AST and ALT were mildly elevated on admission
after her recent [**Month/Day (2) **], but trended down. These should be
rechecked by her PCP [**Last Name (NamePattern4) **] [**12-22**] weeks to verify resolution.
.
Medications on Admission:
Flonase
Multivitamin
Vitamin D
Glucosamine-chondroitin
Calcitrate
[**Doctor First Name **] prn
Restasis eye gtts
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO ONCE (Once)
as needed for pain: Up to 4 g/day.
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Glucosamine-Chondroitin Oral
5. Restasis 0.05 % Dropperette Sig: One (1) drop Ophthalmic
twice a day.
6. [**Doctor First Name **] 180 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO three times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute blood loss anemia
Gastrointestinal bleed
Chronic pancreatitis
Fibromyalgia
Discharge Condition:
Stable, tolerating liquids, no further bleeding.
Discharge Instructions:
You were admitted after an [**Doctor First Name **] with bleeding. The bleeding
stopped after Dr. [**Last Name (STitle) **] was able to find the source and stop
it. You received 2 units of blood, and your blood count is
stable this morning.
.
Continue to take in liquids today, and then try a bland diet in
the next few days, low fat preferably.
.
Please return to the ED for continued bright red blood per
rectum or syncope. Please return for fevers, chest pain,
shortness of breath, night sweats, dizziness, vertigo, burning
on urination, unresolving cough, or any other concerning
symptom.
.
Please follow-up with your providors below. You have 3 (three)
appointments, each of which is critical to your post-hospital
course. You will need to return to have your stent removed in 4
weeks; Dr.[**Name (NI) 12202**] office will contact you to set this up.
.
We have not made any changes to your medications.
.
It has been a pleasure caring for you and we wish you the best
in the future.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2163-12-19**] 9:45
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2164-1-6**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2164-1-6**] 11:30
.
Call Dr. [**Last Name (STitle) 53107**], PCP, [**Name10 (NameIs) **] an appointment in [**12-22**] weeks.
ICD9 Codes: 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5344
}
|
Medical Text: Admission Date: [**2155-10-28**] Discharge Date: [**2155-11-11**]
Date of Birth: [**2098-5-26**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: Change in mental status.
HISTORY OF PRESENT ILLNESS: This is a 57-year-old gentleman
with a complicated past medical history including end-stage
renal disease on hemodialysis, insulin-dependent diabetes
mellitus, chronic MRSA infection of an aorto-aortic graft,
aortic dissection status post repair in [**2143**], coronary artery
disease status post coronary artery bypass grafting, who
presented with a three-week history of increased confusion
and somnolence.
According to the patient's family, the patient had a slowly
declining mental status over the past three months; however,
during the three weeks prior to this admission, decline in
mental status was much more rapid.
One week prior to admission, the patient had increased
mumbling and has been speaking to people who were not
present. On the night prior to admission, the patient's wife
reported that his head and eyes started twitching. During
this time, the patient was intermittently communicative
versus nonsensical mumbling.
He had no history of bowel or bladder incontinence. No
history of seizures or tongue biting.
On the day of admission, the twitching resolved following
hemodialysis; however, at hemodialysis, the patient continued
to be agitated and was sent to the Emergency Department.
In the Emergency Department, the patient's blood pressure was
increased to 230/120. At that time, he was given 100 mg IV
Labetalol and 1 in Nitropaste with a decrease in his blood
pressure to the systolic 170s.
On further review of systems, the patient's wife reported
that he was "hot" last night but denied any chills, cough,
abdominal pain, diarrhea, constipation, bright red blood per
rectum, melena, chest pain or shortness of breath.
The patient had decreased p.o. intake one week prior to
admission. The patient also complained of feeling heavy
times one week.
PAST MEDICAL HISTORY: 1. End-stage renal disease on
hemodialysis Tuesday, Thursday and Saturday since [**2151**]. 2.
History of chronic MRSA infection of his aortic graft. 3.
History of aortic dissection with repair in [**2143**]. 4.
Hypertension. 5. Adult onset diabetes mellitus. 6. Status
post cardiac arrest in [**2151**] in the setting of hyperkalemia.
7. History of gastrointestinal bleed in [**2151**]. 8. History
of endocarditis of the mitral leaflets in [**2152**]. 9. Coronary
artery disease status post coronary artery bypass grafting in
[**2148**]. 10. Left rotator cuff tear. 11. Sleep apnea. 12.
History of multiple cerebrovascular accidents. 13.
Gastroesophageal reflux disease.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Nephrocaps 1 cap p.o. q.d.,
Labetalol 200 mg p.o. t.i.d., Zantac 150 mg p.o. q.p.m.,
Lentes 8 U q.h.s., Epogen 8000 U three times per week,
Seroquel 25 mg p.o. q.h.s., Lisinopril 10 mg p.o. b.i.d.,
Ativan 0.5 mg p.o. b.i.d., Vancomycin dosed at hemodialysis.
SOCIAL HISTORY: The patient is a retired school principal
who lives with his wife. [**Name (NI) **] is an immigrant from [**Country 2045**]. He
is former smoker. No intravenous drug use. The patient is
DNR/DNI.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.7??????, blood
pressure 177/87, pulse 86, respirations 15, oxygen saturation
90% on room air. General: The patient was an elderly man
lying comfortably in bed, mumbling incoherently. HEENT:
Pupils equal, round and reactive to light. Sclera muddy.
Semi-dry mucous membranes. Fundus not visualized. Neck:
Supple. No lymphadenopathy. Cardiovascular: Regular, rate
and rhythm. S1 and S2. No murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally. Abdomen:
Soft. Positive bowel sounds. Nontender, nondistended.
Extremities: No clubbing, cyanosis, or edema. Right femoral
groin line in place. Right AV fistula thrill. Neurological:
The patient was alert and oriented times three.
LABORATORY DATA: On admission white count was 6.8,
hematocrit 38.7, platelet count 239; INR 1.1; sodium 140,
potassium 4.8, chloride 97, bicarb 33, BUN 20, creatinine
5.7, glucose 126, iron 44, total iron binding capacity 240,
ferratin 792, hemoglobin A1C 7.7, CK 54.
CT of the head showed no evidence of acute intracranial
hemorrhage, no shift of normally midline structures or mass
affect. There was a stable appearance of low attenuation
area within the right frontal lobe. There was chronic
bilateral microvascular infarctions in the periventricular
white matter. There was a stable appearing bilateral lacunar
infarct. There was moderate brain atrophy.
Chest x-ray showed stable moderate cardiomegaly. Aorta
>................... There was no pulmonary vascular
congestion, pleural effusion, local infiltrate or
pneumothorax. There were degenerative changes in the left
shoulder.
Electrocardiogram was normal sinus rhythm at 84 beats per
minute. Left anterior descending. Normal intervals. T-wave
inversion in I, AVL, V5-V6, unchanged from previous studies.
HOSPITAL COURSE: 1. Hypertension: The patient was admitted
with hypertensive urgency. On admission he had no
electrocardiogram changes and a poorly visualized
.................. exam.
Initially the patient's blood pressure decreased with
Labetalol and an ACE inhibitor. Initially the patient was
admitted to the Medical Intensive Care Unit where he was
started on a Labetalol drip for blood pressure control. At
that time, he was also continued on his home ACE inhibitor.
By [**2155-11-1**], the patient was able to be transferred
to the floor with oral control of his blood pressure.
Hypertension continued to be an active issue throughout the
hospitalization with the patient having frequent systolic
blood pressures in the 200s.
A final medication regimen of Labetalol 400 mg p.o. b.i.d.,
Amlodipine 5 mg p.o. q.d., Lisinopril 40 mg p.o. q.d. has
provided the best blood pressure control in this patient. In
addition, fluid is being removed in hemodialysis to decrease
the patient's dry weight in hopes of improving his
hypertension. His blood pressure has been fairly well
controlled over the past 3-4 days with systolic blood
pressures most commonly in the 160-170s.
2. Altered mental status: In speaking with the patient's
family, he has had a declining mental status over the three
months prior to admission; however, this decline was
occurring more sharply in the three weeks prior to admission.
In addition, he had acute changes including mumbling and
hallucinations in the one week prior to admission.
During this admission, an extensive work-up was done to
evaluate the patient's mental status. In addition to the CT
obtained on admission, the patient had an MRI of his head on
[**2155-10-29**]. This revealed no evidence of abnormal
diffusion on diffusion weighted imaging to suggest a major or
minor vascular territorial infarct.
The exam was unchanged when compared to a previous exam from
[**2155-10-15**], with diffuse abnormal signal in the
periventricular white matter and pons consistent with chronic
microvascular infarct, diffuse atrophy, and scattered tiny
foci of abnormal signal on ................. imaging
suggestive of remote hemorrhagic infarct and amyloid
angiopathy.
In addition, the patient had an EEG on [**2155-10-30**],
which showed slow rhythm throughout along with generalized
.................. delta slowing superimposed. During this
study, the patient would talk "nonsense," and there were no
correlating EEG abnormalities to indicate seizure activity.
No focal or epileptiform features were seen. The EEG was
considered most consistent with encephalopathy.
In addition, the patient had a negative toxicology screen,
normal TSH, normal Vitamin B12, and normal folic acid during
this admission.
Although there was a very low suspicion, a lumbar puncture
was attempted on [**2155-11-7**]. This was unsuccessful.
Throughout the admission, the patient's mental status
continued to wax and wane. It is most likely multifactorial
due to his TIAs, CVAs, hypercalcemia, chronic infection, and
end-stage renal disease. The patient's hyperkalemia is being
corrected at hemodialysis. He is receiving Vancomycin for
his chronic aortic graft infection.
3. End-stage renal disease: The patient was continued on
his schedule of Saturday, Tuesday, Thursday hemodialysis
throughout the admission. The patient was dosed with
Vancomycin at hemodialysis. He was also continued on his
Nephrocaps 1 cap p.o. q.d. throughout the admission.
4. Infectious disease: The patient has a chronic infection
of his aortic graft with intermittent bacteremia. His last
positive blood culture, which grew Methicillin resistant
Staphylococcus aureus, was from [**2155-11-2**].
Throughout the admission, he continued to receive Vancomycin
at hemodialysis.
5. Diabetes mellitus: The patient was continued on Glargine
and sliding scale Insulin throughout the admission and q.i.d.
fingersticks. Overall the patient had good blood sugar
control, although he did have multiple sugars in the low
200s.
6. Gastrointestinal: The patient was continued on Zantac
throughout the admission for symptoms of gastroesophageal
reflux disease.
7. Fluids, electrolytes and nutrition: The patient
continued on the Americana Diabetic Association, 2 g sodium,
cardiac diet throughout the admission.
On [**2155-11-8**], the patient had an episode of choking
while taking his medications. Following this episode, the
patient was made NPO. His risk of aspiration due to his
waxing and [**Doctor Last Name 688**] mental status was discussed with the family
at a family meeting on [**2155-10-21**]. They have decided
that he would wish to be fed despite the risk of aspiration.
They are in agreement with this.
On [**2155-11-10**], the patient had a swallowing study,
which he passed without difficulty while alert. At this
time, the patient will be continued on a regular diet with
the family understanding the possible risk of aspiration. He
should maintained on aspiration precautions. The patient has
made previously known his desire to not have a feeding tube.
8. Prophylaxis: The patient continued on subcue Heparin for
DVT prophylaxis throughout the admission. He continued on a
bowel regimen.
9. Code status: The patient is DNR/DNI.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to
[**Hospital **] Health Center for further care.
DISCHARGE DIAGNOSIS:
1. End-stage renal disease on chronic hemodialysis.
2. Hypertension.
3. Transient ischemic attack.
4. Cerebrovascular accident.
5. Chronically infected aortic graft on Vancomycin.
6. Dementia.
7. Delirium.
8. Hypercalcemia.
9. Diabetes mellitus.
10. Coronary artery disease status post coronary artery
bypass grafting in [**2148**].
11. History of gastrointestinal bleed in [**2151**].
DISCHARGE MEDICATIONS: Nephrocaps 1 cap p.o. q.d., Docusate
Sodium 100 mg p.o. b.i.d., Senna 1 tab b.i.d. p.r.n.,
Pantoprazole 40 mg p.o. q.d., Labetalol 400 mg p.o. b.i.d.,
Amlodipine 5 mg p.o. q.d., Lisinopril 40 mg p.o. q.d.,
Vancomycin 1000 mg IV to be dosed at hemodialysis, sliding
scale Insulin, Glargine 8 U subcutaneous q.h.s., subcue
Heparin 5000 U q.12 hours.
FOLLOW-UP: 1. The patient will follow-up for hemodialysis
at .................. [**Location (un) **] on Tuesday, Thursday,
Saturday. 2. The patient will be seen by physicians at
[**Hospital3 4262**] Group while the patient is at [**Hospital **]
Healthcare.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2155-11-11**] 13:28
T: [**2155-11-11**] 13:42
JOB#: [**Job Number 4264**]
ICD9 Codes: 7907, 2930
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5345
}
|
Medical Text: Admission Date: [**2125-2-13**] Discharge Date: [**2125-2-22**]
Date of Birth: [**2062-5-2**] Sex: M
Service:
DISCHARGE DIAGNOSIS: Right temporal and putaminal hemorrhage
secondary to amyloid angiopathy.
CHIEF COMPLAINT: Left-sided weakness for 2?????? hours.
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
ambidextrous man with a history of hypertension,
gastrointestinal bleed, sleep apnea, and recent mild memory
problems. [**Name (NI) **] was last seen in his usual state of health at 9
p.m. by his daughter. At approximately 10 p.m. he awoke on
the floor and realized that he had left leg and arm weakness.
He tried to get up and get back into his bed, but he could
not get off the floor.
The neighbor heard him cry out and found him on the floor and
then called EMS. He arrived at the [**Hospital6 649**] Emergency Department at approximately 11:30
p.m. He was vomiting at that time but denied headache or
change in vision. He was noted at that time to have slurred
speech, inability to stand and left-sided weakness.
PAST MEDICAL HISTORY: Significant gastrointestinal bleed.
Sleep apnea for which he is on CPAP. Peptic ulcer disease.
Memory problems. Hypertension. [**Name2 (NI) 650**] Raynaud's phenomena,
currently undergoing work-up.
MEDICATIONS ON ADMISSION: Aspirin 40 mg p.o. q.d., Vitamin E
400 mg p.o. q.d., Mirapex 0.125 mg p.o. q.d., Beconase 2
puffs q.h.s., Lactulose p.r.n., Rhinocort p.r.n.,
................... 10 mg q.h.s., Protonix 40 mg p.o. q.d.,
Prilosec 40 mg p.o. q.d., Robitussin p.r.n., Nifedipine CR 30
mg p.r.n. for Raynaud's phenomena.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He is a nonsmoker. He does not drink
alcohol. He moved to the U.S. at age 7 from [**Country 651**]. He is a
physician and researcher at [**Hospital3 328**]. He is married, and
his wife is also a physician who at the time of his admission
was in [**Location 652**]. His primary care physician is [**Name Initial (PRE) **]
.................. He has three children, all of whom are
healthy.
FAMILY HISTORY: No history of stroke or clotting problems.
His father lives to age [**Age over 90 **] and his mother to age 88 and never
had any strokes.
REVIEW OF SYSTEMS: Difficult to obtain from the patient
secondary to dysarthria.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.6??????, pulse
72, blood pressure 142/80, respirations 20, oxygen saturation
99% on room air. Head: Normocephalic. He had a small left
.................. laceration. Moist mucous membranes. He
had evidence of recent vomiting. Neck: Supple. No carotid
bruits. Lungs: Clear to auscultation bilaterally.
Cardiovascular: Normal S1 and S2. Regular rhythm. No
murmurs, rubs, or gallops. Abdomen: Soft and nontender.
Extremities: No edema. Neurological: He was awake, alert,
oriented to self, age, month, year, place. He had severe
dysarthria but with normal naming, repetition and
comprehension. He had marked neglect of the left
initially and only limited insight into his weakness. Cranial
nerves: His pupils were equally
reactive from 4-2 mm bilaterally. No relative ABT.
Extraocular movements full. Visual fields were intact to
confrontation. He had a severe left central facial droop.
Sensation was decreased in V1, V2, and V3. His palate moved
symmetrically. His shoulder shrug was 5 out of 5. Tongue
was midline. Motor: Left arm was flat and 0 out of 5 motor
strength. His left leg exhibited 2 out of 5 motor strength.
His right arm and leg were both 5 out of 5 strength. He had
increased tone in the left upper extremity. Sensory: No
response on the left arm, face and leg. The right side was
normal. Deep tendon reflexes were brisk on the left, 2+ on
the right. The left toe was upgoing. The right toe was
downgoing. Coordination testing was intact to
finger-to-nose-to-finger on the right. He was unable to be
tested on the left. Gait testing was deferred.
LABORATORY DATA: Admission labs included a CBC with a white
count of 8.9, hematocrit 41, platelet count 240; INR 1.1, PTT
26.4; sodium 135, BUN 18, creatinine 1.1, glucose 113, CK
256, troponin less than 0.3, MB 3.
Labs from [**1-25**] showed [**First Name8 (NamePattern2) **] [**Doctor First Name **] positive at 1-180 with a
speckled pattern; double-stranded DNA was pending; Rheumatory
factor was negative.
HOSPITAL COURSE: The patient was admitted to the
Neuromedicine Service. The stroke attending was called and
was present within 15 min of the patient's arrival to the
Emergency Department. TPA was prepared but not given, as the
patient seemed to have a hemorrhage while in MR scanning.
MRI was reviewed with the stroke attending and discussed with
the Neurosurgery resident on call.
Dr. ..................., his primary care physician, [**Name10 (NameIs) **]
[**Name (NI) 653**], as well as the patient's son and his wife.
The MR [**First Name (Titles) 654**] [**Last Name (Titles) 655**] hemorrhage in the temporal lobe
on the right side with ventricular
extension into the right frontal lobe. There was no evidence
of a mass or aneurysm on MRA. The patient was admitted to
the Neuromedicine Intensive Care Unit for further management
at that time.
On [**2-13**], angiogram was performed which showed no
evidence of arterial venous malformation or fistula. A
repeat CT showed increased signs of the area affected by the
hemorrhage which was likely due to redistribution of the
bleed, but there was no new blood seen on the scan. The
bleed extended further into the right frontal cortex. The
patient was started on Dilantin for prevention of seizures.
On [**2-14**], Speech and Swallow evaluation was performed,
and it was suggested that the patient have only honey-thick
liquids; however, he did not tolerate this well in the
Intensive Care Unit, as he was choking on these at the
bedside, and he was kept NPO from then on.
On [**2-15**], ................... returned showing
.................. .................... At this point, it
was considered most likely that his bleed was secondary to
amyloid angiopathy. Speech and Swallow evaluation was
repeated at the bedside on [**2125-2-16**], which showed
him to have decrease in his ability to swallow at this time.
The patient was transferred from the Intensive Care Unit to
the floor of Far Five on [**2125-2-16**]. There was very
little change in his exam over the next two days; however, on
the 24th, it was noted that he had small contractions with
effort in his left hamstring and abductor, as well as
response to cold on that side. He was also better able to
form sounds, "ga, ma and la" with less dysarthria.
Repeat swallow study was performed which showed remarkable
improvement with him having difficulty only with swallowing
pills. He was therefore placed back on a soft diet with
clear liquids and crushed pills and apple sauce.
His left-sided neglect continually was improving with much
effort from both the patient and his wife, reminding him pay
more attention to his right side.
On [**2-20**], bilateral lower extremity Dopplers were
obtained and showed no evidence of deep venous thrombosis.
DISCHARGE MEDICATIONS: .................. 2 mg IV q.6 hours
p.r.n., ................ 0.125 mg p.o. t.i.d., Bisacodyl 10
mg rectal suppository b.i.d. p.r.n., Tylenol 325-650 mg p.o.
q.[**4-1**] p.r.n., Docusate 100 mg p.o. b.i.d., Metoprolol 25 mg
p.o. b.i.d., Levofloxacin 500 mg p.o. q.d., Phenytoin 350 mg
p.o. q.d., Protonix 40 mg p.o. q.d.
FOLLOW-UP: With Dr. [**Last Name (STitle) 656**] and to call at [**Telephone/Fax (1) 657**] for
an appointment.
DISPOSITION: He will be discharged to [**Hospital1 **] for acute
rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. [**MD Number(1) 659**]
Dictated By:[**Last Name (NamePattern1) 660**]
MEDQUIST36
D: [**2125-2-20**] 20:09
T: [**2125-2-20**] 20:12
JOB#: [**Job Number 661**]
ICD9 Codes: 431, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5346
}
|
Medical Text: Admission Date: [**2183-7-17**] Discharge Date: [**2183-8-3**]
Date of Birth: [**2183-7-17**] Sex: F
Service: NEONATAL
HISTORY: Baby Girl [**Known lastname **] [**Known lastname 15499**], twin #1, delivered at 33
and 4/7 weeks gestation with birth weight of [**2120**] grams was
admitted to the Intensive Care Nursery for management of
prematurity.
Mother is a 40 year old Gravida 2, para 1, mother with an
estimated date of delivery of [**2183-8-31**]. Prenatal screens
included blood type O positive, antibody screen negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, and Group B Streptococcus unknown.
Obstetrical history is notable for a previous delivery at 32
weeks.
This pregnancy was conceived on Clomid, resulting in a
di-chorionic, di-amniotic twin gestation The pregnancy was
complicated by preterm labor, treated with a course of
betamethasone, magnesium and terbutaline.
The mother presents on day of delivery 4 centimeters dilated
and was delivered by repeat cesarean section. Membranes were
ruptured at delivery.
Twin emerged with spontaneous cry requiring only free flow O2
in the Delivery Room. Apgar scores were 8 and 9 at one and
five minutes respectively.
PHYSICAL EXAMINATION: On admission, weight was [**2120**] grams
which was the 25th to 50th percentile; length 42.5
centimeters which is 25th percentile; head circumference 30.5
centimeters which is 25th to 50th percentile. Anterior
fontanel soft, open, flat. Red reflex present bilaterally.
Palate intact. No increased work of breathing. Breath
sounds clear and equal. Regular rate and rhythm without
murmur. Peripheral pulses two plus including femorals,
abdomen, benign without hepatosplenomegaly. No masses.
Normal female external genitalia for gestational age. Normal
back and extremities with stable hips. Skin pink and well
perfused. Normal tone and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: No respiratory distress; has been in room
air since admission. Respiratory rate in the 40s to 50s with
easy work of breathing. Has had apnea of prematurity not
requiring Xanthine therapy. Last bradycardia on [**2183-7-28**].
2. CARDIOVASCULAR: He has been hemodynamically stable
throughout hospitalization. Recent blood pressure was 65/46
with a mean of 57; no heart murmur.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Did not require
intravenous fluids on admission. Was started on feeds with
premature Enfamil formula or expressed breast milk on day of
delivery, working up to full volume feeds on day of life
five. Calories were increased 24 calories per ounce with
good weight gain.
At discharge, is taking breast milk enhanced with Enfamil
Powder to equal 24 calories per ounce or Enfamil 24 calories
per ounce ad lib.
Discharge weight is 2170 grams. Length 43cm and head
circumference is 31cm
4. GASTROINTESTINAL: Peak bilirubin total 5.5 and direct of
0.2 on day of life five. Did not require phototherapy.
5. HEMATOLOGY: Hematocrit at birth was 47.5%. Has not
required any blood products during this admission.
6. INFECTIOUS DISEASE: A CBC and blood culture was drawn on
admission due to preterm labor. The CBC was benign. Blood
cultures was negative. Did not receive antibiotics.
7. NEUROLOGY: Head ultrasound not indicated as greater than
32 weeks gestation and examination age appropriate.
8. SENSORY: Hearing screening was performed with automated
auditory brain stem response and passed both ears.
9. OPHTHALMOLOGY: Eye examination not indicated due to
gestational age greater than 32 weeks.
CONDITION ON DISCHARGE: Stable preterm infant now 36 weeks
corrected age.
DISCHARGE DISPOSITION: Discharged home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at telephone number
[**Telephone/Fax (1) 51546**]. Fax number is [**Telephone/Fax (1) 38715**].
CARE AND RECOMMENDATIONS:
1. Feeds: Breast feeding or taking breast milk enhanced
with Enfamil Powder to equal 24 calories per ounce ad lib;
follow weight gain.
2. Medications: Poly-Vi-[**Male First Name (un) **], 1 cc p.o. daily; ferrous
sulfate 25 mg per cc, taking 0.15 cc p.o. once a day.
3. Car Seat Position testing performed and passed.
4. State Newborn Screen was sent on [**7-22**], and drawn again
at two weeks of age on [**7-31**] and is expected to be sent to
State laboratory on [**2183-8-4**].
5. Immunizations received were hepatitis B immunization on
[**2183-7-29**].
6. Follow-up appointment with pediatrician recommended
within three to five days of discharge.
7. Visiting Nurses Association referral was made.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age 33-3/7 weeks preterm
female.
2. Twin Number one.
3. Apnea of prematurity, resolved.
4. Physiologic jaundice resolved.
5. Sepsis, ruled out.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 51547**]
MEDQUIST36
D: [**2183-8-2**] 17:54
T: [**2183-8-2**] 18:40
JOB#: [**Job Number 51548**]
ICD9 Codes: 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5347
}
|
Medical Text: Admission Date: [**2162-7-25**] Discharge Date: [**2162-8-13**]
Date of Birth: [**2095-5-11**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Severe back pain, fever
Major Surgical or Invasive Procedure:
Sugical Incision and Drainage of the Left Elbow -twice
L2-S1 Laminectomy and Washout
PICC Line Insertion
History of Present Illness:
67 M w/ recent ulnar nerve surgery at OSH p/w severe lower back
pain and fever. Of note, patient is a very difficult historian.
He states that he has had chronic back pain for several years
due to spinal stenosis. Approximately one year ago he had a
lumbar laminectomy. He has chronic pain that he reports began
to get severe about one week ago. His pain medication regimen
is unclear - he states that he only takes what he has with him.
His regimen used to include celebrex and colchicine, but has
recently run out of these medications and has been taking
oxycodone at times and roxicet at times. He denies recent
trauma. He states that one time last week he lost control of
his bowel and bladder. He denies changes in his sensation. He
has difficulty ambulating - uses a cane at home.
.
He had surgery on his left elbow (for ulnar nerve entrapment)
approximately three weeks ago ([**2162-7-8**]) at NEBH by Dr. [**Last Name (STitle) 92623**].
He states that surgery was fine without any complications. He
has noted some drainage and redness from the surgical site, but
no overt pain.
.
He has also had fevers, chills, HA, diarrhea over the past few
days.
.
ED course: He presented with fever and otherwise normal vital
signs. There was concern for spinal epidural abscess, and an MR
L spine was done which revealed his spinal stenosis and no e/o
infection. He was given vancomycin for his UE cellulitis. For
his pain he was given IV dilaudid and tylenol.
.
He currently is complaining of lots of back pain. He states
that he took 4 of his own Roxicet in the ED without telling
anyone.
.
Review of Systems: He has been nauseous for the past several
days with decreased PO intake. He has been a bit more SOB
recently.
.
Past Medical History:
Past Medical History:
Inferior MI ([**2156**]) w/ stent to RCA and ICU stay at OSH
s/p Cardiac arrest (pulseless VTach)
Diastolic CHF (EF 60% in [**2156**])
Diverticulitis
HTN
Hyperlipidemia
Depression
Esophageal varicies
s/p L spine laminectomy / spinal stenosis / chronic LBP
Ulnar entrapment
Insomnia
Asthma
BPH
.
Social History:
.
Social History: He is a retired registered nurse, has a long
smoking history but quit about one year ago. He has not had
alcohol in about one year as well. Denies any illicit drugs.
He lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], never been married.
.
Family History:
.
Noncontributory
.
Physical Exam:
.
PHYSICAL EXAM~
Vs- 101.0 122/64 84 20 94% RA 196 lbs
Gen- Uncomfortable, disheveled male lying still in bed,
tremulous, but in NAD
Heent- MMdry, edentulous, anicteric, pupils 3mm, reactive to
light, EOMI no oral lesions
Neck- supple, no LAD
Cor- RRR, distant heart sounds, no murmur appreciated, no S4 or
S3 heard
Chest- Poor effort, but clear bilaterally
Abd- soft, NT, ND, obese, pos BS, no organomegaly
Ext- no c/c/e. Dark discolored toe nail.
Neuro- AAO x 3. Poor attention span but easily arousable. [**3-25**]
strength in all 4 extremities. Decreased sensation to light
touch on LE, but equal bilaterally. 2+ DTR let [**Name2 (NI) 15219**], 3+ DTR
right [**Name2 (NI) 15219**]. Atrophy noted (L>R) in intrinsic hand muscles.
Skin- Pale, warm.
Msk- Left elbow with surgical wound incision draining purulent
material that is easily expressible. Limited ROM at the left
elbow in full flexion and full extension, both active and
passive. Back exam limited by pain. Pain with palpation
directly over L4 spinous process.
.
Pertinent Results:
MRI L spine [**2162-7-25**]: No definite pathologic enhancement, though
there is extensive postsurgical change in the posterior soft
tissues of the lower back, related to lower lumbar laminectomy.
.
MRI Spine [**2162-8-3**]:
1. Marked short-term interval progression of spinal stenosis at
L2-L3, with complete effacement of the CSF space and likely
compression of all of the descending nerve roots.
2. Markedly enhancing tissue in the anterior epidural space at
the same level. A distinct posterior disc herniation is not well
visualized on this study, compared to before, although
comparison of the anterior epidural soft tissue is difficult
because the timing of contrast enhancement may be different.
3. New bone marrow edema in the L2 vertebral body, and probably
increased edema signal within the L2-L3 intervertebral disc with
partial enhancement. In addition to the findings above, this
appearance raises strong suspicion for infection superimposed on
post-operative changes.
.
TAGGED WBC [**2162-8-5**]:
IMPRESSION: 1. No definite evidence of epidural abscess,
however, sensitivity of study is decreased as patient has been
on antibiotic therapy.
2. Increased tracer activity seen in region of left elbow,
consistent with
known infection.
.
MRI SPINE [**2162-8-7**]:
1. Findings at L2-3 disc indicate discitis and osteomyelitis.
2. Anterior epidural phlegmon from L1-2 and L3 level with a
small focus of epidural abscess.
3. Phlegmon and enhancement in the left neural foramen and also
involving the medial portion of both psoas muscles and also in
the posterior soft tissues.
4. Subtle increase of signal indicating fluid in the
prevertebral region from C1-C4 level. No evidence of discitis or
osteomyelitis in the cervical region. The prevertebral area is
not fully evaluated on this study and a followup focused
cervical spine MRI is recommended for better evaluation.
.
TEE ECHO [**2162-7-30**]:
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%). There
are simple
atheroma in the aortic arch and descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is mild focal
thickening of the noncoronary cusp of the aortic valve. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
.
LEFT FOOT THREE VIEWS: [**2162-8-10**]
1. Mild soft tissue swelling about the left fifth digit without
evidence of osteomyelitis at this time.
2. Mild degenerative changes about the mid foot and small
plantar calcaneal enthesophyte.
.
ABDOMINAL ULTRASOUND [**2162-7-31**]
1. Echogenic liver likely representing fatty metamorphosis.
However, more advanced liver diseases including hepatic
fibrosis/cirrhosis cannot be excluded in this study.
2. Small right posterior hepatic lobe cyst, unchanged as
compared to the prior MR examination dated [**2155-8-21**].
3. Moderate amount of gallbladder sludge, with no evidence for
cholecystitis.
4. No renal calculus or evidence for obstruction.
.
CXR [**2162-8-2**] COMPARISON: [**2162-7-25**].
Right PICC line has been placed with distal tip of radiodense
wire terminating in the proximal right atrium. This finding has
been communicated by telephone to the venous access nurse caring
for the patient on [**2162-8-2**].
Heart size is normal. Pulmonary vascularity is engorged, and
there is new bilateral interstitial pulmonary edema.
.
CXR [**2162-8-8**]:
A single portable image of the chest was obtained and compared
to the prior examination dated [**2162-8-6**]. There is no significant
interval change. A stable retrocardiac opacity is noted likely
reflects underlying small pleural effusion with atelectasis,
difficult to exclude pneumonia. There is mild perihilar fullness
associated with loss of definition of the pulmonary
bronchovasculature as well as vascular redistribution suggesting
mild underlying pulmonary venous congestion. No new focal
opacities are seen. The cardiomediastinal silhouette is stable.
The bony thorax is grossly unremarkable.
.
ON ADMISSION:
[**2162-7-25**] 04:50PM PT-12.6 PTT-29.5 INR(PT)-1.1
[**2162-7-25**] 04:50PM PLT COUNT-327
[**2162-7-25**] 04:50PM NEUTS-94.0* LYMPHS-2.4* MONOS-3.0 EOS-0.1
BASOS-0.5
[**2162-7-25**] 04:50PM WBC-14.1*# RBC-3.89* HGB-12.7* HCT-35.7*
MCV-92 MCH-32.5* MCHC-35.5* RDW-14.3
[**2162-7-25**] 04:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-8.3
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2162-7-25**] 04:50PM calTIBC-203* FERRITIN-662* TRF-156*
[**2162-7-25**] 04:50PM ALBUMIN-3.8 CALCIUM-9.5 PHOSPHATE-2.4*
MAGNESIUM-2.4 IRON-17*
[**2162-7-25**] 04:50PM CK-MB-NotDone
[**2162-7-25**] 04:50PM cTropnT-<0.01
[**2162-7-25**] 04:50PM ALT(SGPT)-37 AST(SGOT)-31 LD(LDH)-240
CK(CPK)-73 ALK PHOS-132* TOT BILI-1.2
[**2162-7-25**] 04:50PM estGFR-Using this
[**2162-7-25**] 04:50PM GLUCOSE-136* UREA N-31* CREAT-1.3* SODIUM-138
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-18* ANION GAP-21*
[**2162-7-25**] 05:05PM LACTATE-1.3
.
ON DISCHARGE:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2162-8-13**] 07:15AM 4.4 3.05* 9.2* 27.3* 90 30.1 33.6 15.2
400
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2162-8-13**] 07:15AM 72.9* 16.5* 4.1 5.4* 1.1
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy Burr
[**2162-8-12**] 07:35AM NORMAL 1+ NORMAL NORMAL NORMAL NORMAL
1+
Source: Line-picc
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2162-8-13**] 07:15AM 400
[**2162-8-13**] 07:15AM 13.9* 33.9 1.2*
Brief Hospital Course:
67 male with history of coronary artery disease, lower back
pain, hypertension, and recent elbow surgery who presents with
bacteremia, elbow joint abscess, and soft tissue infection
involving lumbar spine (? cauda equina syndrome).
.
1) MSSA bacteremia: On arrival the patient was febrile and
rigoring. He was given IVF with stabilization of SBP in 90s-low
100s. He was given Vancomycin IV. Demerol was given for
rigoring. He was transferred from the ED to the ICU for
hypotension and desaturation. The next AM orthopedics brought
the patient to the OR for washout of his elbow. Blood cultures
grew MSSA and vancomycin was changed to nafcillin. This
bacteremia is likely due to septic arthritis of left elbow
causing bacteremia and seeding of lumbar disc space fluid
collection based on findings of cauda equina syndrome and
enhancement at L2/L3 on MR spine. Blood cultures from 8/5/6/7
all grew MSSA. All blood cultures from 8/8,9,10,15,18,19 are
0/22 with negative cultures. Patient afebrile at discharge.
- Continue nafcillin IV 2g Q4H, antibiotic course of 8 weeks
ending [**2162-10-2**]
- Check weekly labs while on nafcillin (CBC, LFTs, BUN/Cr)to be
faxed to Infectious Disease
- Follow-up with Infectious Disease
- PICC Line Care needed until patient finished antibiotic
course. The PICC line will be pulled by infectious disease
nursing at [**Hospital1 18**]. Length of PICC: 53cm.
.
2) Septic arthritis (L elbow): Patient had two washouts
performed on the left elbow [**7-26**] and [**8-5**]. After the first
washout patient had a brief ICU stay for hypotension, but was
quickly stabilized with fluids and transferred to the floor
hemodynamically stable. Patients clinical exam stable with range
of motion 70-180 degrees, [**3-30**] pain on active/passive movement,
and 4+/5 strength. Erythema, swelling and warmth of elbow
resolving with minimal residual swelling. Orthopedics has stated
the patient may be discharged from their service. The patient
has a wound VAC which was last changed on [**8-12**] and will need
change again on [**2081-8-13**].
- Change wound VAC on [**8-14**] or 26, then continue to change wound
VAC every three days until a wound VAC is no longer needed, then
change to wet to dry dressings.
- Orthopedic follow-up at [**Hospital6 2910**]
.
3) Soft tissue infection of lumbar spine: Soft tissue infection
around lumbar spine consistent with possible cauda equina
syndrome with multiple MR [**Name13 (STitle) **] over course of the patient's
hospitalization. The most recent on [**8-7**] (performed with
intubation for better image quality) showing progressive L2/L3
discitis/osteomyelitis, epidural phlegmon/abscess at L2/L3.
Patient had L2-S1 laminectomy with drainage on [**8-7**]. Findings
of cauda equina markedly improved since surgery now with 4+/5
hip flexion/extension, improved vibratory sense at L/R hip,
unchanged sphincter tone and resolving bowel/bladder
incontinence. Patient slowly defervesced after his L2-S1
laminectomy with washout. Patient reports "markedly improved"
back pain [**3-30**] at the time of discharge. Patient afebrile on
discharge.
- Physical and Occupational Therapy in Intensive [**Hospital 1739**]
Rehabilitation
- Follow-up with Orthopedic Surgery for repeat MRI Lumbar Spine
with and without contrast, CRP, ESR and appointment
- Staples out [**2162-8-19**]
- Wound Care: change dressings daily and as needed if soiled
.
4) Paranoia, hallucinations and subtle delirium: In the
immediate post-operative period following his laminectomy the
patient reported hallucinations, paranoia and was intermittently
confused. As soon as able patient was weaned from the Dilaudid
PCA which was started post-operatively. Most likely delirium is
a drug reaction to hydromorphone as patient has documented
reaction of formication to morphine and delirium temporally
related to its administration. Infection was considered as a
cause, but work-up of lung, urine, wound were negative and
patient's fever curve trended downward. Delirium has resolved
with in two days on discontinuation of the Dilaudid. Patient
currently stabilized on a pain regimen of oxycodone SR
(Oxycontin) 60 mg PO Q12H and oxycodone 5mg PO Q4H:PRN.
.
5) Hypoxia/Chronic Obstructive Pulmonary Disease: Patient has
had intermittent oxygen requirements after his ICU stay and
after his surgeries. These have resolved with diuresis for
pulmonary edema and treatment of his Chronic Obstructive
Pulmonary Disease with albuterol and ipratropium nebulizers.
Patient encouraged to use incentive spirometry to improve lung
volumes while mostly bed bound. Patient baseline oxygen
saturation is 91-92% on room air.
- Patient has follow-up with his Primary Care Physician and it
is recommended that he have outpatient pulmonary function tests.
.
6) Acute Renal Failure: After the patient's episode of
hypotension in the ICU and his transition from Vancomycin to
Nafcillin the patient developed acute on chronic renal failure.
The patient has chronic kidney disease with a baseline Cr
1.1-1.3; however, during this time period the patient's Cr
increased to 2. Initial fractional excretion of sodium indicated
the patient had prerenal failure. With fluid rehydration the
patient's creatinine improved to 1.7. A renal ultrasound was
performed that ruled out obstruction. Renal was consulted about
the concern for acute interstitial nephritis due to Nafcillin.
Over the next two weeks the patient's renal function continued
to improve and Renal consult did not feel the acute renal
failure was due to acute interstitial nephritis. It is felt
that the patient's episode of hypotension due to bacteremia
resulted in prerenal renal failure with subsequent damage to the
kidney due to this low flow state. As discharge the patient's
creatinine has improved to 1.3 which is at the upper limit of
his baseline. The patient's medications were renally dosed
during this hospitalization.
- Weekly BUN/Cr monitoring for Nafcillin renal toxicity
- Follow-up with [**Hospital1 18**] Renal for Chronic Kidney Disease
.
7) Shock Liver: The patient developed a coagulopathy with
elevated transaminases and t. bilirubin after his hypotensive
episode. The patient required vitamin K to treat his
coagulopathy. Suspect likely due to shock liver; however, poor
PO intake and patient's history of Hepatitis B may have
contributed to this episode. Patient currently Hepatitis B
immune, with a negative Hepatitis B viral load. Patient liver
ultrasound concerning for developing fibrosis. Patient's LFTs
have normalized and patient INR was 1.2 at the time of
discharge.
- Follow-up to establish care with [**Hospital1 18**] Liver Center
.
8) Multiple loose stools: Likely due to aggressive bowel regimen
and patient's spinal infection. Clostridium Difficile was
negative. Patient's bowel regimen was changed to as needed.
Patient's bowel frequency has decreased and he has two loose
bowel movements per day.
.
9) Swollen left second toe: Patient has history of gout,
although his uric acid was not elevated on this admission. Toe
has slowly improved and is currently non-tender with small
amount of soft tissue swelling. X-ray of L foot showed no
evidence of osteomyelitis with mild degenerative changes about
mid foot and small plantar calcaneal enthesophyte. Patient has
not been on his colchicine due to his renal failure.
- Monitor for resolution
- [**Month (only) 116**] restart low dose colchicine as needed
.
10) Normocytic Anemia/Declining Hematocrit: Patient's hematocrit
has declined over the course of the hospitalization due to
hemodilution, losses from JP drain, phlebotomy and surgical
losses in setting of anemia of chronic disease per iron studies
with inadequate hematopoiesis. Recent hematocrit was 40 at NEBH
three weeks ago, 35 on admission. Status post initial elbow
washout the hematocrit declined from 35 to 28 and remained
stable for three days. Hematocrit decreased from 28 to 25 while
patient received multiple blood draws, including blood cultures
and fluids. The patient's hematocrit declined further after
this second elbow wash out to 22. Patient received 2 units of
blood 8/18 during back surgery with repeat hematocrit of 23.
Patient has received a total of 4 units of packed red blood
cells and 2 units of fresh frozen plasma. Negative stool guiac.
Patient hematocrit has stabilized at 25-28 for the past 4 days.
- Primary Care Physician should [**Name9 (PRE) 702**] patient hematocrit
- Weekly CBC will be checked and faxed to Infectious Disease
.
11) Crusted vesicles on left flank - Small 1*2cm region with
vesicles which are now resolving. Does not follow clear
dermatomal distribution and is non-painful. Skin DFA for VZV
testing personally delivered to the laboratory, but the
laboratory does not have the sample. No further work-up or
treatment is indicated.
.
12) Hypertension: Hypotensive episode in ICU led to holding of
blood pressure medications. As the patient's pressure have
improved her blood pressure medications have been slowly added
back on. Patient currently on metoprolol 25 mg PO BID, and
lisinopril 10 mg daily.
- Please titrate Lisinopril as needed for blood pressure control
(patient was previously on 40 mg daily)
.
13) Low Back Pain: Patient has chronic low back pain which has
been exacerbated by his soft tissue spine infection. In the
hospital setting with the patient's renal function both his
Celebrex was held. Patient was continued on his narcotics which
were increased to provide adequate pain control.
- Taper narcotics as patient's acute pain resolves. Anticipate
patient will have chronic narcotic requirements.
- [**Month (only) 116**] add back Celebrex after consideration of patient's renal
function
.
14) Gastritis/Food Retention: patient has gastroesophageal
reflux disease. He was treated aggressively while in the
hospital with proton pump inhibitor twice a day. He will be
discharged on a proton pump inhibitor daily. Retained food was
found in his esophagus; therefore, he was scheduled for
outpatient manometry and gastrointestinal follow-up.
- Follow-up with GI and have the manometry study
.
15) Coronary Artery Disease: Cardiac enzymes negative. Continue
aspirin, Statin, metoprolol and recently added back his ACE-I.
.
16) Depression: Continued home Effexor
.
17) FEN: pneumatic boots, patient required occasional repletion
of potassium, regular cardiac diet
.
18) PPx: Pantoprazole 40mg PO daily, bowel regimen prn,
incentive spirometry
.
19) Code: DNR/DNI, confirmed with patient
.
20) Communication: [**Name (NI) 717**] [**Name (NI) 92624**] (sister) [**Telephone/Fax (1) 92625**].
.
21) Disposition: To [**Hospital **] Rehab for intensive rehabilitation.
Medications on Admission:
Allergies: Morphine (itching)
Medications (he brought in a shopping bag with these pills):
aspirin 81 daily
Atenolol 25 daily
Roxicet q4 prn (given by surgeon [**7-9**])
Effexor 150 [**Hospital1 **] (by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**])
Lisinopril 40 daily
Oxybutynin 5 daily
Lipitor 40 dailiy
Terazosin 1mg daily
Celebrex 200mg daily (by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 53718**])
Colchicine 0.6 daily (by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 92626**])
Protonix 40 [**Hospital1 **] (by Dr. [**First Name4 (NamePattern1) 22917**] [**Last Name (NamePattern1) 92627**])
Vitamin D 50,000 units q week
MVI daily
Docusate prn
Atrovent
Combivent
Vitamin C
.
Prescriptions that were old:
Norvasc (not currently taking) (by Dr. [**First Name (STitle) **] [**Name (STitle) **])
Lasix (not currently taking)
Discharge Medications:
1. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO QDAILY
().
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours) for 8 weeks: STARTED [**2162-8-7**]
STOP [**2162-10-2**].
Disp:*672 grams* Refills:*0*
11. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation three times a day.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Outpatient Lab Work
Please check weekly liver function tests (AST, ALT, ALK PHOS, T.
BILI), BUN, Creatinine, CBC. Please fax the results to ([**Telephone/Fax (1) 10739**] ATTN: [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**], [**Hospital1 18**] Infectious Disease Clinic
START: [**8-16**], END: [**10-2**]
19. Wound Care
Please evaluate and treat the patient.
The patient has a wound vaccuum on his left elbow that needs to
be changed [**Last Name (LF) 1017**], [**8-15**], and then changed every three
days thereafter until a wound vaccuum is not longer indicated.
At that time please change to wet to dry dressings daily.
The patient also has healing wound on his back from his
laminectomy which are at risk for skin breakdown, please monitor
and treat.
20. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
21. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Methacillin Sensitive Staphlococcus Aureus Bacteremia
Septic Arthritis
Cauda Equina Syndrome
Chronic Obstructive Pulmonary Disease
Chronic Kidney Disease
Acute Renal Failure
Surgical Wound Infection at Site of Previous Back
Surgery
Shock Liver
Anemia
Hypoxia
Secondary: Coronary Artery Disease
Depression
Benign Prostatic Hyperplasia
Discharge Condition:
Afebrile, Vital Signs Stable, Oxygen Saturation at baseline
91-92%.
Discharge Instructions:
You were admitted for an infection in your elbow joint. This
infection had spread to your blood and your back. After
antibiotics, back surgery and several elbow surgeries you are
much improved and ready to begin your rehabilitation.
.
Please take your medications as directed. Please complete the
full course of your antibiotics. Please make sure to have your
blood drawn once a week for laboratory testing. Please keep all
of your follow-up appointments.
.
If you experience any fevers, chills, nausea, vomiting, chest
pain/pressure, shortness of breath, diarrhea please report it to
your primary care provider or the current physician caring for
you at the Extended Care Facility
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39008**], [**Hospital6 **] Date/Time: [**8-16**] [**2161**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2165**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2162-8-17**] 8:00
Fpr gastroenterology follow-up
Provider: [**Name10 (NameIs) 2166**] ROOM GI ROOMS Date/Time:[**2162-8-17**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**]
Date/Time:[**2162-8-24**] 10:00 For Infectious Disease Follow-up
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 92623**] Orthopedics [**Hospital6 2910**]
Date/Time: [**8-26**] 2:10pm
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4090**] [**Hospital1 18**] Renal Date/Time: Thursday [**9-2**] at 1pm [**Hospital Ward Name 23**] [**Location (un) 436**]
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Date/Time: [**11-3**] 9:20am [**Hospital1 18**] Liver
Center.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Hospital1 18**] West 110 [**Doctor First Name **] 3rd Fl, 3B.
Date/Time: [**2162-9-22**].
ICD9 Codes: 7907, 5849, 5859, 4589, 2724, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5348
}
|
Medical Text: Admission Date: [**2145-10-24**] Discharge Date: [**2145-10-31**]
Date of Birth: [**2090-5-14**] Sex: M
Service: SURGERY
Allergies:
Pollen Extracts
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Chills, RLQ pain, low grade temps
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
55 yo M w/ h/o sarcoidosis, HTN, DM, recently dx rectal
adenocarcinoma s/p laparoscopic low anterior resection w/
coloanal anastamosis and ileostomy on [**2145-10-11**], p/w pain at the
ostomy site, chills and low grade temps x 3 days.
Pt recently underwent laparoscopic anterior resection w/
coloanal anastamosis and ileostomy placement [**10-11**]. He tolerated
procedure well and was discharged [**10-14**] with a foley catheter
due to voiding difficulties and started on flomax. Pt was seen
in colorectal [**Month/Year (2) **] [**10-21**]. At that time failed voiding trial.
He had urine cx that were positive for two strains of
pan-sensitive pseudomonas. Per patient day of [**Month/Year (2) **] visit he
was feeling well, had walked ~2miles. On Friday, 3 days prior
to admission, patient began to develop RLQ pain below his
ileostomy site. His temp at home was 100 taken by visiting
nurse. He has not taken any antibiotics for the positive urine
cultures. The day prior to admission his abdominal pain was
[**7-13**], but currently it has subsided.
In the ED: initial VS were T 98.2, HR 103, BP 96/46, RR 16, O2
100% RA. His BP dropped to 70s, received 7L NS and was briefly
on levophed. His SBP improved to low 100s. His Tmax in the ED
was 101.3. His exam was notable for drowsiness, but
alert/oriented, and mildly distended but soft abdomen. Labs
were notable for WBC 55.2, 9% bands, lactate 2.8, hct 19.6,cr
2.5 (baseline 1.1), Na 126. Urine notable for few bact, wbc,
mod leuks. He received pyridium, cipro, flagyl, and cefepime.
CT abd/pelvis notable for LLL spiculated opacity slightly
increased from prior, increased ground glass opacity in the
lingula, increased mediastinal/hilar lad, gall bladder sludge,
no abdominal abcess.
Currently, patient denies any abdominal pain. He denies
nausea/vomiting, cough, shortness of breath, chest pain. He has
his usual lower back pain, not worse than before. He has been
having chronic loose stools, that are brown and non-bloody.
Past Medical History:
#. Sarcoidosis
- CT torso [**2145-8-31**] showed hilar/mediastinal lymphadenopathy and
a dense area of spiculated consolidation in the left lower lobe.
Underwent EBUS on [**9-17**] that revealed non-caseating
granulomas.
- His LLL nodule was not appropriately sampled. He was started
on prednisone, with resulting response in lymphadenopathy and
nodule seen on ct scan [**10-1**].
#. Rectal adenocarcinoma
- Found to be anemic [**6-/2145**], colonoscopy/EGD performed on
[**2145-8-20**] and notable for a small proximal ascending colon
adenomoatous polyp, and a mobile rectal polyp that showed high
grade dysplasia and areas of likely intramucosal adenocarcinoma.
- CT torso [**2145-8-31**] poorly visualized the rectal mass, but did
not show
perirectal or inguinal adenopathy. The CT chest component
revealed mediastinal and hilar lymphadenopathy and a dense area
of spiculated consolidation in the left lower lobe. Rectal MRI
on [**2145-9-1**] which showed a sessile lesion 6.7cm from the anal
verge.
- [**2145-9-10**] underwent TRUS showed along the left rectal wall full
thickness through the mucosa, submucosa, and into the muscularis
propria with no concerning adenopathy and overall T2N0 stage.
- s/p laparoscopic low anterior resection w/ coloanal
anastamosis and ileostomy on [**2145-10-11**]
# Diabetes
# Hypertension
# Hyperlipidemia
# H/o ?nerve tumor s/p exploratory spine surgery at NWH with no
concerning findings
Social History:
Married, lives with his wife. [**Name (NI) **] one adult son. Manages the
international terminal at [**Location (un) 6692**] airport.
EtOH: [**2-4**] drinks/week
Tobacco: Quit 30yrs ago, 15 pack year history
Illicits: denies
Family History:
Mother: Died in 70s of CHF, had DM. Father: Died in 70s of CVA
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 102.2 BP: 115/53 HR: 113 RR: 22 100% O2sat on 2L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachycardic, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly,
ileostomy bag in place
GU: + foley
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
=========
LAB
=========
[**2145-10-24**]
- CBC with differentials: WBC-55.2*# RBC-3.37* Hgb-10.3*
Hct-29.6* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.2 Plt Ct-642*#
Neuts-83* Bands-9* Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0
Metas-1* Myelos-0
- CHEM 7: Glucose-300* UreaN-35* Creat-2.5*# Na-126* K-4.7
Cl-92* HCO3-18*
- LFTs: ALT-29 AST-15 AlkPhos-193* TotBili-0.7
- PM Cortsol-21.3*
- @ 10:09AM Lactate-2.8*
- UA @ 8:50AM: Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.028 Blood-LG
Nitrite-NEG Protein-75 Glucose-TR Ketone-TR Bilirub-SM
Urobiln-NEG pH-5.0 Leuks-MOD RBC-[**2-5**]* WBC-[**5-13**]* Bacteri-FEW
Yeast-NONE Epi-0-2
- UA @ 11:55AM: URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.029
Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-SM
Urobiln-NEG pH-5.0 Leuks-MOD RBC-[**10-23**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2145-10-25**]
- Urine electrolytes: UreaN-359 Creat-61 Na-63 K-12 Cl-80
Osmolal-342
[**2145-10-26**]
- CBC: WBC-28.5* RBC-2.66* Hgb-8.2* Hct-22.6* MCV-85 MCH-30.7
MCHC-36.1* RDW-14.1 Plt Ct-506*
- CHEM 7: Glucose-133* UreaN-12 Creat-1.4* Na-134 K-4.2 Cl-107
HCO3-17*
===================
MICROBIOLOGY
===================
[**2145-10-24**]
- Blood cultures [**1-5**]: -------
- Urine cx: Negative
- MRSA screen: -------
[**2145-10-25**]
- Blood cx [**12-4**]: -------
- C. diff: negative
[**2145-10-26**]
- Blood cx [**12-4**]: -----
- C. diff: negative
===================
IMAGING
===================
[**2145-10-24**]
- CXR: The cardiac, mediastinal and hilar contours are unchanged
since [**2145-9-17**]. There are bilateral low lung volumes,
but no pleural effusion or pneumothorax. Left basilar linear
opacity is most compatible with atelectasis, less likely
sequelae of aspiration. Bones appear intact.
IMPRESSION: Left basilar linear opacity, likely atelectasis.
- CT OF THE ABDOMEN: Evaluation is limited due to the lack of IV
contrast. The spleen measures up to 13.8 cm which is slightly
elevated in size and appears increased since the previous study.
Non-contrast appearance of the kidneys is within normal limits.
The adrenal glands, liver, pancreas, and stomach are within
normal limits. Slightly hyperdense material noted within the
gallbladder may represent sludge or tiny gallstones. The
gallbladder is not distended. The retroperitoneal and mesenteric
fat demonstrates prominent stranding, although this may be due
to third-space fluid distribution. The stranding includes the
peripancreatic region, so early pancreatitis is not excluded,
though the changes are not centered about the pancreas. Small
retroperitoneal and mesenteric lymph nodes are noted, although
none meet CT criteria for pathologic enlargement. The
intra-abdominal loops of bowel are within normal limits. There
is no
obstruction. Patient is status post colectomy with loop
ileostomy in the right lower quadrant. There is no evidence of
hernia or obstruction. At the lung bases, again seen is an area
of spiculated-appearing opacity in
the peribronchiolar distribution at the left lung base (2:7).
This appears
slightly more prominent than on previous study of [**2145-8-31**]. A small area of subpleural septal thickening is seen (2;5)
in the right middle lobe. This may be post inflammatory, but a
small area of interstitial fibrosis is possible. Minor scarring
or atelectasis is noted within the lingula. Hilar and
mediastinal lymphadenopathy is again seen, although incompletely
visualized on this study. The visualized lymphadenopathy also
appears to have increased in size since the previous study with
a node inferior to right bronchus now measuring 1.4cm in short
axis versus 1cm on prior study. There is no pleural effusion.
The heart size is normal.
- CT OF THE PELVIS: Suture material is noted from prior
colectomy in the rectum. A Foley catheter is noted within a
decompressed bladder. No free fluid is noted within the pelvis.
There is no inguinal or pelvic lymphadenopathy.
- BONE WINDOWS: No concerning osseous lesions are identified.
IMPRESSION:
1. Similar basal chest findings, with slight increased
prominence of left lower lobe spiculated opacity. Minimal
possible right middle lobe subpleural interstitial abnormality.
Splenomegaly. As previously described, these findings could be
seen in sarcoidosis, though neoplasm is not excluded at the left
lung base.
2. Increased size of visualized portion of mediastinal
lymphadenopathy.
3. Hyperdense material within the gallbladder, which is new
since the previous study and may represent sludge.
4. Stranding throughout the mesenteric fat and retroperitoneal
fat which may be due to patient's fluid status. This includes
the peripancreatic region so early pancreatitis is difficult to
exclude - clinical correlation is advised.
5 Status post colectomy with ileostomy in the right lower
quadrant. No evidence of hernia or obstruction.
Scrotal US [**2145-10-30**]
1. Findings suggestive of right-sided orchitis and epididymitis;
of note there
is a surrounding thin rim of hyperechoic material but without
mobility of
echotexture likely to represent liquefaction; this may represent
phlegmonous
change in the scrotal sac, however.
2. Left testicular microlithiasis. Recommend clinical followup
and ultrasound
in 1 year to document stability, as this may be associated with
increased
testicular neoplasm.
Brief Hospital Course:
Spiculated LLL lung mass had increased in size compared to
previous imaging. Pt requires follow up for further evaluation
of this lung mass as it may be independent process of hilar
lymphadenopathy. Pt was notified on [**2145-10-26**] that the mass had
increased in size and it is unclear as to its etiology, but it
is an unusual presentation for sarcoid. He said that he and his
physicians planned to work this mass up further, but his
surgical intervention was a priority. Please make sure the
patient follows up for further evaluation in the future.
55 yo M w/ h/o sarcoidosis, HTN, DM, recently dx rectal
adenocarcinoma s/p laparoscopic low anterior resection w/
coloanal anastamosis and ileostomy on [**2145-10-11**], p/w pain at the
ostomy site, chills, low grade temps x 3 days, urine cx from
[**10-21**] positive for pseudomonas transferred to [**Hospital Unit Name 153**] for sepsis.
# Septic Shock, supported by hypotension, leukocytosis with
bandemia, and elevated lactate. Unclear source. Initial
thought of the infectious source is the urine given prior
positive pan-sensitive pseudomonas, however, Ucx was negative.
Less likely from pneumonia given lack of clinical symptoms and
negative abscess on abdominal scan. Unlikely a biliary source
given normal LFTs despite some evidence of biliary sludge.
Blood cultures also have been NGTD????. Unlikely adrenal
insufficient from the brief prednisone course 7-10 days in
[**Month (only) 359**] and cortisol level was normal. Patient was started on
cefepime, ciprofloxacin, Flagyl, vancomycin ([**2145-10-24**]). The
cefepime and ciprofloxacin for double coverage of the
Pseudomona, Flagyl for the loose stools, and vancomycin for the
Gram positive coverage. Oral vancomycin was discontinued as
recommended by ID. He received more than 6 L of fluid in in ED,
home antihypertensives were held, and was subsequently getting
diuresed in the [**Hospital Unit Name 153**] as his hemodynamics improved.
- Will need to narrow antibiotics coverage as cultures return
# LLL consolidation on CXR and speculated mass on CT: Pt had
lymph node biopsy proven non-necrotizing granulomas; however,
LLL mass was not adequately biopsied. Pt was tried on steroids
for 7-10 days and lymphadenopathy and LLL mass were noted to
have decreased in size and so it was assumed that they are both
from the same underlying etiology. However, on re-evaluation at
this admission the appearance of the speculated mass is not
consistent with sarcoidosis. Would consider re-evaluation at a
later date and possible biopsy for further evaluation as the
patient has a long history of smoking as well as asbestos
exposure. This was possibibility was discussed with patient and
his family.
# Acute Kidney Insufficiency. Likely pre-renal in the setting
of sepsis. He had adequate urine output with the foley catheter
in place. There was no evidence of hydronephrosis on the CT,
making obstructive process less likely. ATN is also possible
given episodes of hypotension. He was also autodiuresing post
the multiple liters of fluid resuscitation in the ED.
Electrolytes were checked twice a day given autodiuresis.
# Hyponatremia. Likely secondary to dehydration. As he got
rehydrated, his sodium improved. He did not present any
symptoms of hypernatremia.
# Urinary retention. It was noted that patient failed a voiding
trial in the outpatient setting. He had a Foley in place while
in the [**Hospital Unit Name 153**] and also was started on Flomax as well as
antibiotics for the UTI/urosepsis The original plan was to have
the foley catheter removed on [**2145-10-27**].
# Anion Gap Acidosis, likely from lactic acidosis. Resolved.
He also likely has a superimposed non-gap acidosis given
delta-delta ration was less than 1 [**1-5**] extra-renal losses from
dirrhea and loose stools.
# Rectal adenocarcinoma. S/p laparoscopic low anterior
resection w/ coloanal anastamosis and ileostomy on [**2145-10-11**].
Patient was followed by surgery while in the [**Hospital Unit Name 153**].
# Sarcoid, diagnosed in 10/[**2144**]. He completed a course of
prednisone for 7-10 days with improved imaging. Repeat CT does
show slightly increased opacification in the LLL, which was not
biopsied. He was asymptomatic and maintained adequate O2Sat
while in the [**Hospital Unit Name 153**]. This finding was discussed with patient in
details (see above for LLL consolidation and spiculated mass on
CT). This will need to be followed by his primary care
provider.
# HTN. His antihypertensives were held while in the [**Hospital Unit Name 153**] given
hypotensive episodes.
# HLD. He continued with rosuvastatin.
# Diabetes mellitus. Patient's oral medication was held and he
was switched to insulin sliding scale
FEN: IVFs, Diabetic diet, Replete Lytes
Access: 3pivs
PPx: Tylenol, hold stool softners
Comm: [**Name (NI) **]
Emergency Contact: Wife - [**Name (NI) **] (HCP), cell [**Telephone/Fax (1) 14118**],
home [**Telephone/Fax (1) 14119**]
Code: Full (confirmed)
DISPO: floor
Pt transferred to floor in stable condition and was continued on
IV antibiotics. He was tolerating a regular diet and having
bowel movements. He remained afebrile but had a persistently
elevated WBC count althought his was trending downwards.
Subsequent urine cultures were negative for any growth. He
denied any abdominal pain but began conplaining of right sided
scrotal pain. His right testicle and scrotum was noted to be
swollen and tender and an ultrasound was performed which was
consistent with orchitis/epidydimytis. An ID and urology consult
was requested at this time. The recommmendation was to continue
antibiotics as the ultrasound showed no no evidence of a
drainable fluid collection. Pt was discharged on a [**2-4**] week
course of oral antibiotics as per recommendations made by the
infectious disease team. Because he had trouble voiding when the
foley catheter was removed earlier in the hospital course, he
was discharged with the foley catheter and a leg bag as per the
urology team to follow up with them in 2 weeks.
Medications on Admission:
Oxycodone 5 mg prn
Metformin 1000 mg [**Hospital1 **]
Simvastatin 20 mg daily
Aspirin 81 mg daily
Amlodipine 5 mg daily
Valsartan 160 mg daily
Flomax 0.4 mg daily
Acetaminophen 500 mg prn
Glimepiride 1 mg daily
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
4. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4
weeks.
Disp:*56 Tablet(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Orchitis, Epidydimytis
Discharge Condition:
Stable.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1120**]/[**Doctor Last Name **] this week. Please call
([**Telephone/Fax (1) 3378**] to make an appointment.
Please follow up with Dr. [**Last Name (STitle) 770**] in 2 weeks. Please call ([**Telephone/Fax (1) 9444**] to make an appointment.
ICD9 Codes: 0389, 5990, 5849, 2761, 2762, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5349
}
|
Medical Text: Admission Date: [**2100-11-9**] Discharge Date: [**2100-11-14**]
Date of Birth: [**2037-1-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Burning across chest
Major Surgical or Invasive Procedure:
[**2100-11-10**]
1. Emergency coronary artery bypass graft x4: Left
internal mammary artery to left anterior descending
artery and saphenous vein graft to ramus intermedius and
a saphenous vein sequential graft to obtuse marginal 1
and 2.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
63F with history htn and hyperlipidemia p/t OSH ED c/o chest
burning while mowing the lawn. She was admitted to [**Hospital **]
Hospital on [**11-6**] and had a NSTEMI with a peak troponin of 1.45.
Workup included cardiac cath which revealed three vessel
disease.
She also had an elevated creatinine when she presented (1.6)
which was new for her. A CXR revealed a 6-7 cm pulmonary nodule
in the RUL. She is transferred for surgical consideration.
Past Medical History:
Past Medical History:
hypertension
h/o hypertensive urgency [**2097**]- stress echo was negative for
ischemia at this time
hyperlipidemia
anxiety
s/p NSTEMI [**2100-11-6**]
Past Surgical History: s/p C section
Social History:
Lives with: husband
Occupation: retired
Tobacco: 1 1/2 packs per week
ETOH: denies
Family History:
mother with a-fib
sister with a-fib
Physical Exam:
Pulse: 65 Resp:18 O2 sat: 97% on RA
B/P Right: 136/77 Left:
Height: 65" Weight: 153lb
General:
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [] Edema
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: no Left: no
Pertinent Results:
[**2100-11-13**] 04:56AM BLOOD WBC-9.1 RBC-3.42* Hgb-10.3* Hct-28.8*
MCV-84 MCH-30.3 MCHC-35.9* RDW-14.4 Plt Ct-101*
[**2100-11-12**] 03:59AM BLOOD PT-14.3* PTT-26.9 INR(PT)-1.2*
[**2100-11-13**] 04:56AM BLOOD Glucose-120* UreaN-18 Creat-1.0 Na-140
K-4.0 Cl-106 HCO3-23 AnGap-15
[**2100-11-10**] Intra-op TEE
PRE-BYPASS No spontaneous echo contrast is seen in the body of
the left atrium. No atrial septal defect is seen by 2D or color
Doppler. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is mild mitral valve
prolapse. Physiologic mitral regurgitation is seen (within
normal limits). The intra-aortic balloon tip is about 6 cm below
the distal aortic arch. 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 atrially paced. There is normal
biventricular systolic function. The thoracic aorta appears
intact after decannulation. No other significant changes from
the pre-bypass study
Brief Hospital Course:
The patient was transferred from an outside hospital where she
ruled in for NSTEMI on [**2100-11-6**]. She had ongoing chest pain,
received a balloon pump and was brought to the operating room on
[**2100-11-10**] where the patient underwent emergent CABG x 4 with Dr.
[**First Name (STitle) **]. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. 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. Hydralazine was
started for hypertension and beta blocker titrated as tolerated.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. ACE inhibitor was not
started, as it was felt more important to titrate her beta
blocker for tachycardia. This can be initiated outpatient by
her cardiologist when appropriate. By the time of discharge on
POD 4 the patient was ambulating freely, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged to home in good condition with appropriate follow up
instructions.
Medications on Admission:
triamterene/HCTZ 37.5/25mg daily
lopressor 100mg daily
simvastatin 40mg hs
diltiazem CD 240mg daily
Diovan 80mg daily
alprazolam 0.25mg hs
lisinopril recently discontinued
Plavix - last dose: she received: [**11-7**]: 300 mg, [**11-8**]: 225 mg,
[**11-9**]: 75 mg
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
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. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
coronary artery disease
PMH:
hypertension
h/o hypertensive urgency [**2097**]- stress echo was negative for
ischemia at this time
hyperlipidemia
anxiety
s/p NSTEMI [**2100-11-6**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 1+ edema bilateral LEs
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:
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2100-12-6**] 1:00
Cardiologist Dr [**Last Name (STitle) 8579**] [**Telephone/Fax (1) 23882**] on [**12-7**] at 10:30am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1575**] S. [**Telephone/Fax (1) 13350**] 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:[**2100-11-14**]
ICD9 Codes: 4271, 2724, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5350
}
|
Medical Text: Admission Date: [**2175-7-20**] Discharge Date: [**2175-7-26**]
Date of Birth: [**2115-11-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
fatigue, imbalance
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Ms. [**Known lastname 21051**] is a 59 year-old woman with a history of type 1
diabetes who has been fatigued and developed a sense of
imbalance in the past two weeks.
*
Ms. [**Known lastname 21051**] was in her usual state of health until two weeks ago
when she began to feel fatigued. She would start yawning at 5pm
which is unusual for her and would go to sleep early. One week
ago, she noticed difficulty in controlling her glucose levels
and she began to feel malaise and some nausea. She was eating
less and administering more insulin but was still measuring high
glucose levels. She attributed her fatigue, nausea, and malaise
to her diabetes. She also noticed that she was waking up every
hour during the night to urinate. Six days ago ([**7-17**]), she
visited her PCP who worked her up for a urinary tract infection.
*
Five days ago, she noticed that when she drove, the car was
veering off to left. She sidescraped two cars while coming out
of a parking lot and hit the rocks on the side of her driveway
resulting in two flat tires. She has been feeling "off-balance"
- a friend noted that she was not walking straight - and nearly
fell out of a chair.
*
Four days ago, she called her PCP who recommended that she come
into the ED. She planned to come in the next day, but when she
fell asleep at 4:30 in the afternoon, which is unusual for her,
her fourteen-year old daughter became concerned and asked a
friend to bring her into the [**Name (NI) **].
*
While in the ED, she was found to have a fever to 101.3F;
however she did not know she had one. She does recall now that
she had chills at night in the week prior to coming to the ED
and wore a heavy jacket and robe to the ED in 90 degree heat on
her night of admission. Since admission, Ms. [**Known lastname 21051**] has
developed fevers and night sweats. She has felt fatigued and
spends most of the day sleeping.
*
On review of symptoms, she denies any chest pain, shortness of
breath, neck stiffness, abdominal pain, dysuria, hematuria,
diarrhea, blood in her stool, or any numbness, burning, or
tingling sensations in her arms or legs. A travel history is
significant for a visit to [**Hospital1 6687**] a week and a half ago
(after her symptoms of fatigue began). She lives in a wooded
area but does not go into the [**Doctor Last Name 6641**]. She reports decreased
appetite and 15 lb wt loss since
[**1-30**] when her husband died. She has had some chills recently,
but no fevers at home. She also reports that she was noted to
have a "rash" on her legs, but is unsure of how long she has had
this rash and did not notice it before.
.
In the ED, VS on arrival T 101.3, BP 148/61, HR 74, RR 12, SaO2
97%/RA. Blood cx x 2 and urine cx were drawn. Pt was given 2 gm
Rocephin x 1 and 1 gm Vanc x 1. She was also given 2 L NS and
D5NS. 4 units of regular insulin was also given for BS 275.
Past Medical History:
IDDM (since age 16); A1C usually in 8 range - on NPH and RISS
Hyperlipidemia
Seasonal allergies
Breast masses (diabetic mastopathy) [**2166**]; mammogram [**2175-7-3**]
Colonoscopy [**2170**] nl
Nl bone density [**4-29**]
Some depression, anxiety after death of husband
Mild mitral valve regurg (murmur per old notes)
Borderline glaucoma
Social History:
She lives with her fourteen year-old daughter. [**Name (NI) **] husband
passed away in [**Month (only) 116**] from metastatic melanoma. She is active -
plays tennis daily. She has a remote tobacco history and
usually drinks a drink or two of wine or vodka a night (CAGE
negative). She has no elicit drug use. She is independent with
all activities of daily living.
Family History:
No h/o cancer, strokes, seizures, CAD in family.
Physical Exam:
T 101.3 HR 74 BP 148/61 RR 12 97%RA
General: well appearing white female, NAD, though
appears fatigued
HEENT: NC/AT, PERRL, EOMI. No sinus tenderness. MM dry, OP
clear.
Neck: supple, no bruits or LAD
Heart: RRR s1 s2 normal, II/VI SEM loudest at apex
Lungs: CTA-B, no w/r/r
Abdomen: soft, NT/ND, NABD, no HSM
Extremities: no c/c/e, pulses 2+ b/l
Skin: palpable fine purpuric rash over lateral LE mid-shin b/l
Neuro: AO x 3, but sleepy. Good recall, intact language without
slurring. CN II-XII intact grossly, intact visual fields. Motor
strength 5/5 throughout with normal muscle tone and bulk.
Sensation to light touch and pin prick intact throughout. DTR's
2+ in UE and LE b/l (absent ankles), downgoing babinksi's.
Slight R>L ataxia with FTN, HTS normal. Gait not tested.
Pertinent Results:
[**2175-7-26**] 06:25AM BLOOD WBC-3.5* RBC-3.06* Hgb-9.9* Hct-28.5*
MCV-93 MCH-32.3* MCHC-34.7 RDW-15.0 Plt Ct-198
[**2175-7-20**] 01:15AM BLOOD WBC-3.1* RBC-3.10* Hgb-10.1*# Hct-28.5*#
MCV-92# MCH-32.6* MCHC-35.5* RDW-14.4 Plt Ct-79*#
[**2175-7-25**] 06:15AM BLOOD Neuts-54 Bands-2 Lymphs-32 Monos-10 Eos-1
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2175-7-20**] 01:15AM BLOOD Neuts-59 Bands-2 Lymphs-24 Monos-12*
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2175-7-26**] 06:25AM BLOOD Plt Ct-198
[**2175-7-26**] 06:25AM BLOOD PT-12.3 PTT-22.7 INR(PT)-1.1
[**2175-7-20**] 01:15AM BLOOD Plt Ct-79*#
[**2175-7-20**] 07:00AM BLOOD Fibrino-367 D-Dimer-1215*
[**2175-7-20**] 07:00AM BLOOD ESR-50*
[**2175-7-26**] 06:25AM BLOOD Glucose-226* UreaN-11 Creat-0.6 Na-136
K-4.9 Cl-101 HCO3-30 AnGap-10
[**2175-7-20**] 01:15AM BLOOD Glucose-163* UreaN-10 Creat-0.8 Na-125*
K-3.9 Cl-90* HCO3-27 AnGap-12
[**2175-7-26**] 06:25AM BLOOD ALT-40 AST-36 AlkPhos-91 Amylase-39
TotBili-0.6
[**2175-7-20**] 07:00AM BLOOD ALT-32 AST-38 LD(LDH)-361* AlkPhos-80
TotBili-1.6* DirBili-0.4* IndBili-1.2
[**2175-7-26**] 06:25AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.4 Mg-2.4
[**2175-7-20**] 07:00AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.1 UricAcd-3.0
Iron-21*
[**2175-7-20**] 07:00AM BLOOD calTIBC-164* VitB12-1405* Folate-18.9
Hapto-<20* Ferritn-1536* TRF-126*
[**2175-7-20**] 07:00AM BLOOD Osmolal-269*
[**2175-7-20**] 07:00AM BLOOD TSH-1.7
[**2175-7-20**] 07:00AM BLOOD CRP-66.3*
[**2175-7-20**] 02:56PM BLOOD HIV Ab-NEGATIVE
[**2175-7-20**] 01:20AM BLOOD Lactate-0.6
[**2175-7-20**] 06:03PM BLOOD EHRLICHIA ANTIBODY PANEL (HME AND HGE)-
TEST
*
CXR - [**2175-7-20**]:
No acute cardiopulmonary process.
*
Head CT w/o contrast:
Small left basal ganglia intraparenchymal hemorrhage with small
amount of surrounding edema and no shift of normally midline
structures. Calcification in the choroid plexus of the left
temporal [**Doctor Last Name 534**], a normal finding.
*
MR HEAD W & W/O CONTRAST [**2175-7-20**] 7:26 AM
FINDINGS: There is no slow diffusion to indicate an acute
infarct.
.
There is an area of focal hemorrhage within the left putamen as
noted on the prior CT. This has high T1 and T2 signal indicating
late subacute stage blood products. A small hemosiderin rim is
present corresponding to the hyperdensity on the CT at the
periphery of the hemorrhage. There is only a tiny amount of
adjacent T2 signal abnormality, which could be due to vasogenic
edema. There are no enhancing abnormalities or areas of flow
void to indicate an AVM or neoplasm. There is no evidence of an
infection or abscess. These findings could be due to a
hypertensive hemorrhage. Please correlate with the patient's
history.
.
There is no midline shift, mass effect or hydrocephalus. The
normal vascular flow voids are present. Incidental note is made
of a subcutaneous 1.2 cm well defined lesion, which is low on T1
and T2 signal overlying the right parietal skull vertex, likely
due to an old sebaceous cyst. Please correlate with the physical
examination findings.
.
The paranasal sinuses are well pneumatized.
.
There are several T2 hyperintense foci within the centrum
semiovale and subcortical white matter of both cerebral
hemispheres consistent with chronic microvascular infarct.
.
IMPRESSION: No evidence of an acute infarct. There is a late
subacute hemorrhage within the left putamen and no acute blood
is identified. There is no evidence of AVM or neoplasm. No
significant mass effect.
.
MRA:
TECHNIQUE: 3D time-of-flight MRA of the circle of [**Location (un) 431**].
FINDINGS: The circle of [**Location (un) 431**] is normal with no evidence of an
aneurysm or significant intracranial atherosclerotic disease.
The anterior and posterior circulation appear normal.
IMPRESSION: Normal circle of [**Location (un) 431**] MRA.
.
Cytology SPINAL FLUID
Pending
Brief Hospital Course:
59 yo female with type I DM who presented with malaise and gait
instability, found to have babesiosis and sub acute basal
ganglia hemorrhagic stroke. Initially admitted to the medicine
ICU for close monitoring. Patient was hemodynamically stable but
had mild memory deficits and gait instability. Below is her
medical course by problems:
.
1. Babesiosis - Babesiosis was diagnosed by visualization of
intraerythrocytic parasites on peripheral blood smear.
Babesiosis is distinguishable from Plasmodium falciparum malaria
by the following features: (a) The absence of pigment granules
in infected erythrocytes, (b) the presence of exoerythrocytic
parasites, (c) pathognomonic tetrads of merozoites forming
"maltese crosses." Following diagnosis, Ms. [**Known lastname 21051**] was started
on accepted first-line combination therapy of quinine and
clindamycin; however, she reported a sensation of hearing loss,
a rare but terrible side-effect of quinine. The quinine and
clindamycin combination was discontinued out of concern for
hearing loss. She was started on [**7-22**] on an alternate
combination of azithromycin and atovaquone which has been
suggested to be an effective therapy in both animal and human
studies. (A comparison of the two regimens has shown them to be
of similar efficacy, but azithromycin/atovaquone is generally
better tolerated.) Finally, it is recommended that in areas
endemic for Lyme disease and ehrlichiosis, doxycycline may also
be given because of the high frequency of coinfection. The
diagnosis of babesiosis offers an explanation for her
presentation with pancytopenia, malaise, and hemolysis. LP not
suggestive of CNS infection. Patient will continue these
antibiotics at discharge:
-- Doxycycline (day 4 of 28 at discharge), per ID recommendation
to cover empirically for erlichosis
-- Atovaquone (day 4 of 7 at discharge)
-- Azithromycin (day 4 of 7 at discharge)
Her CSF lyme and HSV PCR results are pending and will be
followed up outpatient.
.
2. Left putamen hemorrhage:
Ms. [**Known lastname 21051**] [**Last Name (Titles) 21052**] status has improved and currently has
no neurologic deficits to correspond to area of injury seen on
imaging. It is possible that the etiology of her hemorrhage was
thrombocytopenia vs. Babesiosis-related vasculitis vs. CNS
involvement of Lyme disease. She was ruled out for an
atriovenous malformation or neoplasm by CT and there was no
evidence of acute hemorrhage. There is a question of whether she
could have neuroborelliosis, as Lyme disease and babesiosis can
be co-transmitted. Her serum Lyme titers are negative which can
remain negative in early disease, but a CSF concentration of
antibody to Borellia burdorferi is a more specific and sensitive
test for CSF Lyme than serum antibody titers. PCR can also be
used to identify the organism within the CSF.
.
ID was consulted and recommended an LP given her platelet count
of 76 to check for pleiocytosis. Pt's brain imaging findings did
not correlate with symptoms of ataxia, memory loss, and fatigue.
Incidence of CNS babesiosis infection has not been described in
humans. An LP would be able to better evaluate the etiology of
her [**Last Name (Titles) 21052**] symptoms. If CSF fluid analysis reveals
pleiocytosis, her treatment regimen would need to be changed
from doxycycline 100 mg [**Hospital1 **] to ceftriaxone 2g QD for 2-4 weeks,
which is the recommended treatment for CNS Lyme.
.
Neurology was called to ask about contraindications of doing an
LP with a platelet count of 76. They pointed out that her
platelet count is above the cut-off for contraindication for LP,
which is a platelet count of below 50.
.
Upon discharge, she did not have any residual [**Hospital1 21052**]
findings on exam, out of bed and ambulating without need for
assistance, mental status intact
.
3. Pancytopenia: Although the precise mechanism is unknown, it
is well documented that merazoite invasion of the RBC leads to
red cell lysis and hemolytic anemia. RBC, WBC, and platelet
counts (198 from 59 on admission) are trending up. It will
likely take some time for cell counts to return to normal.
.
4. Hyponatremia - Thought to be due to SIADH secondary to the
basal ganglia hemorrhage. She has been fluid restricted and her
sodium has come up to 137 on morning labs. Patient was switched
to regular PO intake and electrolytes were within normal.
.
5. Unsteadiness - Pt's gait has improved, without unsteadiness
or sizziness. PT worked with patient daily and was able to
assist her with walking. According to a neurology consult on
[**7-20**], her lack of balance and unsteadiness is not consistent
with the basal ganglia hemorrhage seen on CT. At discharge, she
was no longer unsteady, walking without difficulty.
.
6. Type I DM: Continue [**Hospital1 **] NPH plus SSI. QACHS fingersticks.
Patient has had intermittent episodes of hypoglycemia down to
50s, but has otherwise been hyperglycemic with sugars above
150s. Discussed patient's home insulin regimen to confirm
inpatient fixed dose. Her recent infection and stress
responsible for hyperglycemia. Levels should stabilize as
infection is treated and we will not modify therapy too much. We
will schedule her with [**Hospital **] clinic for outpatient followup.
Upon discussion with team, her evening NPH was increased from 6
to 8, patient had generally received 10U regular insulin per SSI
regimen daily. She will be discharged on sliding scale along
with fixed insulin dosage for better control of blood sugars.
.
7. Hyperlipidemia: continued Lipitor, LFTs within normal
.
8. FEN: diabetic/cardiac diet. Fluid restriction of 1.5 L in the
setting of resolving hyponatremia. Goal K>4, Mg>2.
.
9. Prophylaxis: Pneumoboots; hold heparin in setting of
thrombocytopenia.
.
10. Code status: full code.
.
11. Followup: Infectious disease clinic on [**8-14**] at 10:30
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] located on [**Last Name (NamePattern1) **]; [**Last Name (un) **]
Diabetes center appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21053**] on [**8-10**] at 2:30pm.
Medications on Admission:
Lipitor 20 mg once a day
Celexa 20 mg once a day (since [**Month (only) 116**])
Insulin NPH 17 units qam, 6 units
Ativan 0.5 mg once a day PRN
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 24 days.
Disp:*48 Capsule(s)* Refills:*0*
3. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day) for 3 days.
Disp:*1 * Refills:*0*
4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Capsule(s)* Refills:*0*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1) Subcutaneous twice a day: 17 units in AM, 8 in PM.
Disp:*1 * Refills:*2*
7. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
4 Subcutaneous before dinner: and as needed.
Disp:*1 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Babesiosis
.
Other diagnosis:
1. Type I Diabetes - Diagnosed at 16 years. Insulin-dependent.
No end organ disease. Followed by Dr. [**Last Name (STitle) **] at [**Last Name (un) **]. HBA1c
in [**7-2**]% range. Most recent HBA1c was 8.0 on [**2175-7-17**]. Mild
asymmetric background retinopathy.
2. Ovarian cyst and oopherectomy - 20 years old.
3. Mitral Regurgitation - Dianosed in [**2172-5-24**]. Flow murmur.
Echo-->mild MR, otherwise nl.
4. Hyperlipidemia - [**3-28**] homocysteine 13.6 (0-10.3).
5. Borderline hypertension
6. Depression/anxiety - since the death of her husband last [**Name2 (NI) 116**]
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications. Do not perform strenuous
activities. Avoid driving alone.
Followup Instructions:
You have an appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9671**] at the
[**Hospital **] clinic on [**8-10**] at 2:30 pm.
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2175-8-14**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2175-9-4**] 11:10
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2175-9-7**] 10:15
ICD9 Codes: 431, 2761, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5351
}
|
Medical Text: Admission Date: [**2127-12-12**] Discharge Date: [**2128-1-13**]
Date of Birth: [**2046-10-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
Acute Exacerbation of Congestive Heart Failure
Major Surgical or Invasive Procedure:
central line placement
hemodialsys catheter placement
CVVH
History of Present Illness:
PCP: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. ([**Telephone/Fax (1) 103326**], [**Hospital3 103327**], Suite #202,
Briefly, 81 yo male with Hx of ischemic cardiomnypothy s/p CABG,
CHF (EF 30%), DM, and peripheral vascular disease s/p bipass
with graft on left femoral artery in [**Month (only) **]. Since discharge
from [**Hospital1 18**] in [**Month (only) 359**], he did not take any of his CHF meds, and
now returns increased swelling in his abdomen, legs. Orthopnea,
+DOE (can only walk to the bathroom, can not climb a flight of
stairs [**1-31**] to dyspnea) as well as 50lbs weight gain specially
over the last week. He finally came back to ED on [**12-15**] b/c
groin abscess and was initially admitted to vascular service.
The abcess was drained and he was started on nafcillin on [**12-15**].
He was then transferred to [**Hospital1 1516**] for diuresis on [**12-18**].
On the floor, he was started on a lasix gtt (5 -> 10 mg/hr) with
50-100cc output in 24hrs. He was given one dose of chlorthiazide
and loaded with digoxin. Creatinine was increased to 3.9 from
baseline of 1.5. Renal consulted for further eval of oliguria.
Urology also following because he was having urinary retention.
Foley placed (and then replaced) by urology but still not
draining adequately. He was given one dose of hyoscyamine
ungoing bladder spasm and per urology giving but can exacerbate
tachycardia (only recived one dose)
Given the poor response to lasix gtt, the CHF service has
requested transfer to CCU for pressors (milrinone) to see if he
will autodiurese with improved cardiac output.
Past Medical History:
# CAD: MI [**2106**]; s/p CABG 2 vessels [**2097**], s/p redo CABG 5 vessels
# CHF: ischemic cardiomyopathy, LVEF 35% by PMIBI [**8-1**]
# atrial fibrillation on coumadin
# DM type 2: c/b peripheral neuropathy
# hyperlipidemia
# HTN
# Anemia: baseline HCT 26-30
# COPD: no PFTs recently, started advair 1 month ago
# PVD: s/p redo fem-fem right to AK-popliteal with
8-mm PFT and right 2nd toe amputation on [**2123-7-30**]; s/p right
femoral BK-popliteal bypass with PTFE on [**2125-5-30**]. L Fem-[**Doctor Last Name **] w/
PTFE and 3rd L toe amputation [**9-5**]
# s/p Aortobifemoral bypass graft for abdominal aortic
aneurysm [**2118**]
# colon polyps s/p polypectomy
# internal hemorrhoids
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
Social History:
Social history is significant for the absence of current tobacco
use but significant past tobacco use. There is no history of
alcohol abuse. There is no family history of premature coronary
artery disease or sudden death. He worked as a bookeeper. Lives
with his wife.
Family History:
Non-contributory
Physical Exam:
T 96.3, Bp 84/37, RR 16 Hr 82 Afib , Sat 100%
General: non apparent distress,
HEENt: dry oral mucose, NO LAD. JVD up to the earlobe at 45
degrees
Lungs: few crackles in the bases.
CV: irregularly irregular. s1-s2 normal, ? s3. holosytolic
murmur RLSB
Abdomen: Distended, BS decreased, + ascitis. Non tender.
Extremities 3+ edema up to the thigh. 2nd and 3rd toe amputated
L and R. Distal pulses difficult to palpate given extensive
fluid accumulation. extremities warm.
L groin wound- gauze in place. no secretions. mild erythema.
L thigh wound- no secretion either.
R arm: mild erythmea forearm.
Neuro: Alert, oriented. responding appropiately to all
questions.
Pertinent Results:
[**2128-1-13**] 07:40AM BLOOD WBC-9.8 RBC-3.46* Hgb-9.5* Hct-29.7*
MCV-86 MCH-27.5 MCHC-32.1 RDW-15.6* Plt Ct-332
[**2128-1-6**] 07:50AM BLOOD WBC-14.0* RBC-2.60* Hgb-6.9* Hct-21.8*
MCV-84 MCH-26.7* MCHC-31.8 RDW-17.8* Plt Ct-377
[**2127-12-12**] 11:35PM BLOOD WBC-11.0 RBC-3.84* Hgb-10.5* Hct-31.7*
MCV-83 MCH-27.2 MCHC-32.9 RDW-16.5* Plt Ct-373#
[**2128-1-6**] 04:00PM BLOOD Neuts-84.3* Lymphs-8.6* Monos-5.7 Eos-0.8
Baso-0.5
[**2128-1-9**] 06:28AM BLOOD PT-15.7* PTT-35.2* INR(PT)-1.4*
[**2127-12-20**] 05:51AM BLOOD PT-35.9* PTT-53.7* INR(PT)-3.8*
[**2127-12-12**] 11:35PM BLOOD PT-19.8* PTT-40.1* INR(PT)-1.8*
[**2128-1-5**] 04:50PM BLOOD ESR-50*
[**2128-1-9**] 11:30AM BLOOD Ret Aut-2.6
[**2128-1-13**] 07:40AM BLOOD Glucose-85 UreaN-48* Creat-1.6* Na-142
K-3.9 Cl-103 HCO3-28 AnGap-15
[**2127-12-22**] 05:11AM BLOOD Glucose-44* UreaN-83* Creat-5.4* Na-134
K-5.1 Cl-94* HCO3-27 AnGap-18
[**2127-12-12**] 11:35PM BLOOD Glucose-119* UreaN-52* Creat-1.7* Na-138
K-2.8* Cl-96 HCO3-32 AnGap-13
[**2128-1-11**] 05:40AM BLOOD ALT-10 AST-27 AlkPhos-129* Amylase-44
TotBili-1.0 DirBili-0.6* IndBili-0.4
[**2128-1-10**] 05:42AM BLOOD ALT-9 AST-26 LD(LDH)-184 AlkPhos-121*
TotBili-1.9*
[**2128-1-8**] 03:17AM BLOOD CK(CPK)-334*
[**2128-1-7**] 09:04PM BLOOD CK(CPK)-404*
[**2128-1-11**] 05:40AM BLOOD Lipase-38
[**2128-1-7**] 02:45PM BLOOD Lipase-34
[**2128-1-8**] 03:17AM BLOOD CK-MB-3 cTropnT-0.19*
[**2128-1-7**] 09:04PM BLOOD CK-MB-3 cTropnT-0.20*
[**2128-1-7**] 02:45PM BLOOD CK-MB-4 cTropnT-0.20*
[**2128-1-7**] 11:37AM BLOOD CK-MB-3 cTropnT-0.23*
[**2128-1-13**] 07:40AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
[**2128-1-10**] 05:42AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.6 Mg-2.2
[**2128-1-10**] 05:42AM BLOOD Hapto-136
[**2127-12-21**] 04:22AM BLOOD Hapto-271*
[**2127-12-20**] 06:28PM BLOOD calTIBC-169* Ferritn-393 TRF-130*
[**2127-12-19**] 06:30AM BLOOD calTIBC-160* VitB12-904* Folate-18.4
Ferritn-343 TRF-123*
[**2127-12-18**] 08:11PM BLOOD %HbA1c-5.8
[**2127-12-19**] 06:30AM BLOOD Triglyc-52 HDL-29 CHOL/HD-2.8 LDLcalc-41
[**2127-12-21**] 01:16PM BLOOD TSH-11*
[**2128-1-5**] 04:50PM BLOOD T3-74* Free T4-1.1
ERYTHROPOIETIN 12.3 4.1-19.5 MU/ML
[**2128-1-10**] 02:37PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2128-1-10**] 02:37PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2128-1-10**] 02:37PM URINE RBC-<1 /HPF WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1 /HPF
[**2128-1-10**] 02:37PM URINE RBC-<1 /HPF WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1 /HPF
CULTURE DATA:
URINE CULTURE (Final [**2128-1-9**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
Blood Culture, Routine (Final [**2128-1-13**]): NO GROWTH.
Blood Culture, Routine (Final [**2128-1-10**]): NO GROWTH.
URINE CULTURE (Final [**2128-1-5**]): NO GROWTH.
URINE CULTURE (Final [**2127-12-27**]):
PSEUDOMONAS AERUGINOSA.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
GRAM STAIN (Final [**2127-12-13**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2127-12-15**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
81 M h/o ischemic CHF (EF=25%), 1+MR, 3+TR, DM, PVD, admitted to
vascular service for left groin abcess s/p [**9-5**] fem-[**Doctor Last Name **] bypass,
transferred to CCU for management of CHF, with acute renal
failure with CVVH for volume removal then transferred to the
floor for further management.
Cardiovascular
1.Pump: The patient has Acute on chronic systolic CHF - he has
ischemic cardiomyopathy. His Last Echo [**12-17**] showed EF 20%-25%.
His most recent cath [**2127-9-25**] showed patent grafts, no
interventions done. He had a Lasix drip which was attempted
prior to transfer to CCU with no significant response. On
transfer to the CCU, he was given low dose milrinone x3 days,
with gross anasarca and oliguric renal failure, likely secondary
to CHF per renal, though he did have proteinuria. He had a swan
placed on [**12-21**], milrinone was stopped, and his CI and SVR [**12-22**]
initially concerning for septic shock 8h after milrinone was
stopped, though SBPs stablized off milrinone at SBP 120s and on
CVVH. The pt received CVVH [**Date range (1) 25254**] with net 27L removed.
Lasix drip was then started on [**12-29**] with low urine output.
Diuril was added Q12H hr with improved urine output. Renal
continued to follow the patient and he never required
hemodialysis. The patient was continued on a lasix gtt on the
floor with a net negative goal of approximately 2L a day, which
he maintained on the lasix gtt and the diuril IV BID. He
continued to have good diuresis, and he was eventually switched
to Lasix IV TID, then [**Hospital1 **]. He was transitioned to PO lasix
prior to discharge to rehab. His edema had markedly improved,
and his pulmonary exam was improved as well. His O2 sats were
>95% on room air. On [**2128-1-7**], the patient became hypotensive
with systolics in the 60s-70s. His WBC count had increased to
14, but he remained afebrile without any clear source of
infection. A CT abdomen/pelvis was done for a slowly decreasing
HCT which showed bilateral, but right greater than left psoas
hematoma. It was unclear whether there was active bleeding
since the scan was done without contrast given his renal
failure. He was transferred to the CCU for hypotension and
workup of possible sepsis/cardiogenic shock. In the CCU, the had
him on levophen shortly for shock. It was unclear whether this
was cardiogenic vs septic, but he was started and maintained on
Zosyn with improvement in his leukocytosis and his blood
pressure. He was weaned off the pressors, and his metoprolol
was up-titrated with good response. He was transferred back to
the floor where he remained stable, with normal BP, afebrile,
and improving leukocytosis. He will need to continue lasix PO,
as well as Toprol for his heart failure. He will also continue
low dose ACE-I with uptitration as tolerated by his creatinine.
At the time of discharge, he had mild crackles at the lower
bases and will likely need continue his lasix for a goal of even
to net negative 500 cc a day.
# Cardiac - ischemia: The patient has a history of CAD. He is
s/p CABG [**10-5**], no evidence of ischemia currently. He will need
to continue ASA 325 mg daily, Toprol, Rosuvastatin, and
Lisinopril.
# cardiac - rhythm: The patient initially in afib with HR in the
90s-130s. He received a dig load but then the digoxin was
stopped. He had a subtherapeutic INR, which then became
supratherapeutic, and the warfarin was held. His metoprolol was
up-titrated for improved HR control. In the beginning of
[**Month (only) 404**], the patient developed bilateral, spontaneous, psoas
hematomas with a decreasing HCT. The heparin drip was stopped,
and the warfarin was stopped as well. This is presumed
anti-coagulation failure with spontanous life threatening
bleeding, and given his high risk for fall as well, he should
not be on anti-coagulation unless later, his PCP or [**Name9 (PRE) 31931**]
feels another trial of anticoagulation should be initiated to
decrease his risk of stroke (high given age, DM, CHF). He will
need to continue the Toprol and ASA 325 mg daily.
# Acute renal failure - The patient's baseline creaitnine per
OMR was 1.0-1.2. During this hospitalization, he increaed up to
5.2 with oliguria thought to be due to poor forward flow from
his heart faliure. He had a foley placed, and had blood clots
so he had bladder irrigation as well. He was followed by urology
initially for the hematuria which grossly resolved. The patient
had CVVH for a few days while in the CCU for volume removal
given the poor UOP and elevated creatinine. Renal followed
closely, and he was initially on phosphate binders. At the time
of discharge, his creatinine had improved to 1.6. He will have
followup with Dr. [**Last Name (STitle) 118**] in [**Hospital 2793**] Clinic. He also developed a
UTI with pseudomonas which was treated with Cipro for 14 days.
His repeat urine cultures only grew yeast, but no UTI on UA. The
patient will be discharged with a foley, and while at rehab
should have bladder training to eventually remove the foley.
# Left groin abcess and recent RUE cellulitis. The patient had
a Cefazolin course which was completed on [**12-26**]. Vascular
surgery followed the patient, and his left groin abscess
improved. He was followed by wound care with their
recommendations. He should continue to have wound care while he
is in rehab. Also, he will follow up with Dr. [**Last Name (STitle) 1391**] after
discharge to evaluate his progress. He was afebrile at the time
of discharge with improvement in his abscess
# DM2: The patient's last HbA1c on [**2127-9-10**] was 6.9. He should
continue sliding scale insulin at rehab. His PCP should
followup whether any other agents should be used in the future.
# Anemia - The patient's baseline HCT is approx 30. He
initially had a decrease of his HCT, and CT scans did not show
evidence of RP bleed. It was thought to be likely dilutional.
He received multiple blood tranfusions during this
hospitalizaiton. Prior to inital planned discharge to rehab, he
developed bilateral psoas hematomas with a decreasing
hematocrit. His anticoagulation was stopped due to the
decreased HCT and hypotension, and he was given a unit of blood
in the CCU. His HCT stablized, and prior to discharge was at
his baseline. He also developed blood clots in the urine
earlier in his hospitalization. He had bladder irrigation with
improvement. At the time of discharge, he had no active
bleeding in his urine. He was guaiac negative during his
hospitalization.
# Peripheral Arterial Disease: The patient was admitted for
[**12-12**] for left groin abcess x 2 s/p fem-[**Doctor Last Name **] bypass [**2127-9-25**]. He
had an I&D, and received antibiotics during this
hospitalization. He received a 14 day course of Cefazolin with
improvement. At discharge, he was afebrile, and his groin
looked good. He will need continued wound care and followup
with Dr. [**Last Name (STitle) 1391**].
# Hematuria - The patient had difficulty urinating initially.
The bladder scan showed elevated PVR, though likely [**1-31**]
anasarca. Urology placed a foley [**12-17**] secondary to massive
edema. There were clots noted [**12-20**], and foley was replaced and
he was started on CBI, with resolution of clots. Now that he is
off anticoagulation, his hematuria has resolved. He will be
discharged with a foley, and that should eventually be removed
while in rheab.
# Hyperlipidemia: The patient will continue rosuvastatin. His
lipid panel showed HDL 29 and LDL 41.
#. CODE: DNR/DNI confirmed with patient and wife/HCP
#. Communication: wife and [**Name (NI) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 103328**]
#. Dispo: The patient will be transferred to [**Hospital **]
rehabilitation. He will be discharged with a foley catheter
which should be removed after bladder training. He will need
twice weekly electrolyte monitoring to evaluate his kidney
function and potassium levels. He should also have twice weekly
hematocrit checks. His goal I/O should be even to negative 500
cc daily and lasix titration accordingly.
Medications on Admission:
(on transfer from rehab):
albuterol nebulizer
Morphine [**2-2**] IV Q6H
Doccusate [**Hospital1 **]
Pantoprozole 40 daily
Fluticasone Salmeterol 100/50 [**Hospital1 **]
Rosuvastatin 10 mg
Hydralazine 25 Q8H
Spirolactone 25 PO daily
Insulin lantus 10 units +ss
Nafcillin 2 g IV Q6H
Ipratropium bromide neb
Metoprolol 50 [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis: Left Femoral Abscess
Acute on Chronic Systolic Heart Failure
Urinary Tract Infection
Acute Kidney Injury
Anemia
Bilateral Psoas Hematomas
Secondary Diagnosis:
Diabetes Type 2
Hypertension
Atrial Fibrillation
Coronary Artery Disease
Peripheral Arterial Disease
Discharge Condition:
stable, hematocrit stable, blood pressure stable, rate
controlled, on room air
Discharge Instructions:
You were admitted to the hospital for a left groin abscess. You
were found to be severely fluid overloaded because you had not
been taking your lasix. You were in the ICU to have
hemodialysis to remove fluid. You had approximately 30-40
liters of fluid removal while you were in the hospital. You
also developed a urinary tract infection for which you were
treated with antibiotics. You had a prolonged hospital course,
with complications, but at the time of discharge, you were felt
safe to go to rehab for aggressive, inpatient rehabilitation.
You will no longer be on anticoagulation for your atrial
fibrillation given your spontanenous bleeding into your abdomen.
You will only continue aspirin.
Please take all medications as prescribed. Please keep all
scheduled appointments.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: Fevers, chills, chest pain,
shortness of breath, worsening leg swelling, blood in the stool.
Followup Instructions:
Please call your PCP Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 87110**] to make a followup
appointment in the next 1-2 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2128-1-28**] 3:00
Please call Dr.[**Name (NI) 1392**] office to confirm your appointment
[**Telephone/Fax (1) 1393**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
ICD9 Codes: 5990, 5849, 4280, 2859, 4019, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5352
}
|
Medical Text: Admission Date: [**2101-4-10**] Discharge Date: [**2101-4-21**]
Date of Birth: [**2041-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
52M with no significant PMH who was transferred to [**Hospital1 18**] from
OSH after Cardiac Arrest reportedly during sexual activity.
.
On the evening prior to admission, the patient was noted to be
unresponsive during sexual activity and had reportedly taken
sildenafil that evening. After the patient became unresponsive,
EMS was called and arrived to the scene soon thereafter starting
CPR. It is estimated the patient had 10-15 minutes of Chest
compressions and was Shocked x 4 times, after multiple rounds of
epinephrine.
.
On arrival to OSH, the patient was noted to be in Ventricular
trigeminy there, and was started on Amio and Heparin gtt. The
patient was started on cooling protocol and was
sedated/intubated on Propofol.
.
The patient was transferred to [**Hospital1 18**] for further management. The
patient arrived in NSR was continued on Amiodarone 1mg/minute
gtt and Heparin gtt. Sedation was lightened to perform a neuro
exam and the patient was noted to be shivering and overbreathing
the ventilator.
Past Medical History:
Hypertension
Social History:
-Tobacco history: Remote, > 25 years ago
-ETOH: Occasional
-Illicit drugs: None
Family History:
Brother s/p two MIs in 40s, Mother deceased from MI at age 62
Physical Exam:
Vitals: T: 33.2 P:75 R: 16 BP:140/74 SaO2:
General: Intubated and sedated, on cooling protocol
HEENT: NC/AT, in c-collar
Neck: neck in collar, unable to assess
Pulmonary: mechanical breath sounds bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: all extremities cool, no edema.
Neurologic:
II: small 2->1.5, doesn't blink to threat
III, IV, VI: cannot asses dolls as in c-collar
V,VII: corneal present
IX, X: no gag noted
Pertinent Results:
Labs on Admission:
[**2101-4-10**] 05:01PM TYPE-ART TEMP-32.4 RATES-20/ TIDAL VOL-450
PEEP-5 O2-50 PO2-123* PCO2-35 PH-7.44 TOTAL CO2-25 BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
[**2101-4-10**] 04:47PM GLUCOSE-199* UREA N-29* CREAT-0.7 SODIUM-139
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14
[**2101-4-10**] 04:47PM AST(SGOT)-92* CK(CPK)-1073*
[**2101-4-10**] 04:47PM CK-MB-79* MB INDX-7.4* cTropnT-0.20*
[**2101-4-10**] 04:47PM MAGNESIUM-1.9
[**2101-4-10**] 01:35PM TYPE-ART PO2-193* PCO2-36 PH-7.39 TOTAL
CO2-23 BASE XS--2
[**2101-4-10**] 11:22AM URINE HOURS-RANDOM
[**2101-4-10**] 11:22AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2101-4-10**] 11:08AM TYPE-ART TEMP-32.4 RATES-20/ TIDAL VOL-600
PEEP-5 O2-60 PO2-117* PCO2-25* PH-7.49* TOTAL CO2-20* BASE XS--1
INTUBATED-INTUBATED
[**2101-4-10**] 11:08AM GLUCOSE-200*
[**2101-4-10**] 08:58AM TYPE-ART PO2-269* PCO2-48* PH-7.29* TOTAL
CO2-24 BASE XS--3
[**2101-4-10**] 08:58AM LACTATE-1.7
[**2101-4-10**] 08:38AM GLUCOSE-158* UREA N-33* CREAT-0.9 SODIUM-139
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2101-4-10**] 08:38AM ALT(SGPT)-82* LD(LDH)-558* CK(CPK)-1089* ALK
PHOS-60 TOT BILI-0.9
[**2101-4-10**] 08:38AM CK-MB-61* MB INDX-5.6 cTropnT-0.36*
[**2101-4-10**] 08:38AM CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-2.0
CHOLEST-165
[**2101-4-10**] 08:38AM TRIGLYCER-57 HDL CHOL-51 CHOL/HDL-3.2
LDL(CALC)-103
[**2101-4-10**] 08:38AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-4-10**] 08:38AM WBC-17.7* RBC-4.75 HGB-15.6 HCT-42.2 MCV-89
MCH-32.8* MCHC-36.8* RDW-13.5
[**2101-4-10**] 08:38AM PLT COUNT-158
[**2101-4-10**] 04:54AM TYPE-ART TEMP-37 RATES-16/11 TIDAL VOL-550
PEEP-5 O2-100 PO2-134* PCO2-47* PH-7.33* TOTAL CO2-26 BASE XS--1
AADO2-544 REQ O2-89 -ASSIST/CON INTUBATED-INTUBATED
[**2101-4-10**] 04:54AM HGB-15.5 calcHCT-47 O2 SAT-98
[**2101-4-10**] 04:00AM GLUCOSE-132* UREA N-30* CREAT-1.2 SODIUM-142
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-17
[**2101-4-10**] 04:00AM estGFR-Using this
[**2101-4-10**] 04:00AM CK(CPK)-657*
[**2101-4-10**] 04:00AM CK-MB-39* MB INDX-5.9 cTropnT-0.44*
[**2101-4-10**] 04:00AM WBC-17.4* RBC-4.92 HGB-16.0 HCT-44.5 MCV-91
MCH-32.6* MCHC-36.0* RDW-13.3
[**2101-4-10**] 04:00AM NEUTS-82* BANDS-3 LYMPHS-11* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2101-4-10**] 04:00AM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2101-4-10**] 04:00AM PLT COUNT-223
[**2101-4-10**] 04:00AM PT-13.9* PTT-40.0* INR(PT)-1.2*
Labs on Discharge:
[**2101-4-20**] 03:42AM BLOOD WBC-10.5 RBC-3.21* Hgb-10.6* Hct-30.3*
MCV-94 MCH-32.9* MCHC-34.9 RDW-15.1 Plt Ct-200
[**2101-4-20**] 03:42AM BLOOD PT-12.7 PTT-25.1 INR(PT)-1.1
[**2101-4-20**] 03:42AM BLOOD Glucose-107* UreaN-21* Creat-0.6 Na-143
K-4.0 Cl-112* HCO3-25 AnGap-10
[**2101-4-10**] 04:47PM BLOOD CK-MB-79* MB Indx-7.4* cTropnT-0.20*
[**2101-4-10**] 08:38AM BLOOD CK-MB-61* MB Indx-5.6 cTropnT-0.36*
[**2101-4-10**] 04:00AM BLOOD CK-MB-39* MB Indx-5.9 cTropnT-0.44*
[**2101-4-20**] 03:42AM BLOOD Albumin-2.6* Calcium-7.5* Phos-2.5*
Mg-1.9
[**2101-4-20**] 09:34AM BLOOD Type-ART Tidal V-450 PEEP-8 FiO2-40
pO2-89 pCO2-38 pH-7.43 calTCO2-26 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
Microbiology:
[**2101-4-10**] MRSA SCREEN MRSA SCREEN- No MRSA Isolated
[**4-12**] Urine Cx FINAL NEGATIVE
[**4-13**] Blood cx x2 FINAL NEGATIVE
[**2101-4-13**] 6:10 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2101-4-16**]**
GRAM STAIN (Final [**2101-4-15**]):
THIS IS A CORRECTED REPORT ([**2101-4-15**]).
Reported to and read back by DR. [**Last Name (STitle) 17081**], N ([**Numeric Identifier **]) ON
[**2101-4-15**] AT
14:47 PM.
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
PREVIOUSLY REPORTED ([**2101-4-13**]) AS;.
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2101-4-16**]):
SPARSE GROWTH Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.
MODERATE GROWTH.
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2101-4-17**] 7:00 am URINE Source: Catheter.
**FINAL REPORT [**2101-4-19**]**
URINE CULTURE (Final [**2101-4-19**]):
KLEBSIELLA PNEUMONIAE. ~[**2089**]/ML.
Further workup requested by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 88642**]).
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2101-4-20**] Urine Culture negative FINAL
[**4-18**], [**4-17**] Blood cultures PENDING
Imaging:
- CT HEAD W/O CONTRAST Study Date of [**2101-4-10**] 3:15 AM
IMPRESSION:
1. No acute intracranial process. If there is clinical concern,
MR can be
ordered.
2. Paranasal sinus disease.
NOTE ADDED AT ATTENDING REVIEW: The sulci are small and there is
poor
grey/white differentiation. These findings are suspicious for
global
hypoperfusion and infarction. This revised interpretation was
discussed by
telephone with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] at 4:52pm on [**2101-4-10**] by [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
- CHEST (PORTABLE AP) Study Date of [**2101-4-10**] 3:15 AM
IMPRESSION: Cardiogenic pulmonary edema.
- ABDOMEN (SUPINE & ERECT) Study Date of [**2101-4-10**] 10:25 AM
FINDINGS: Frontal view of the chest demonstrates nasogastric
tube with the tip at the pylorus or duodenum. Air is present in
the stomach. Additional leads project over the abdomen.
- Portable TTE (Complete) Done [**2101-4-11**] at 11:24:57 AM
FINAL
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. 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 estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No definite valvular pathology identified. Mildly
dilated aortic sinus.
- CHEST (PORTABLE AP) Study Date of [**2101-4-11**] 1:09 PM
FINDINGS:
Frontal view of the chest is compared to prior study from
[**2101-4-10**]. There
are low lung volumes. There is hazy density and crowding of the
pulmonary
vasculature, but there is also concern for mild-to-moderate
congestive
failure. Lines and tubes remain unchanged in position. Heart and
mediastinum are unchanged. \
- RENAL U.S. PORT Study Date of [**2101-4-12**] 7:15 AM
IMPRESSION: No hydronephrosis.
- CHEST (PORTABLE AP) Study Date of [**2101-4-12**] 7:51 AM
IMPRESSION: Left small effusion and basilar atelectasis.
Peripherally
inserted central catheter tip projects over the right atrium and
could be
retracted. There is prominence of perihilar vascularity which
may reflect
pulmonary venous congestion.
- EEG Study Date of [**2101-4-12**]
CONTINUOUS EEG: The record consists of nearly continuous [**12-26**] Hz
generalized periodic epileptiform discharges (GPEDs) activity.
At
approximately 10:30 a.m., the GPEDs become slightly less
regular,
decreased in amplitude and periods of suppression appear with
variable
duration, lasting between one to five seconds. However, over the
next
few hours, the periods of suppression gradually shorten until
the GPEDs
become more continuous again. At 2 p.m., there is a decrease in
regularity and amplitude of GPEDs activity and with the
reappearance of
brief periods of suppression lasting between one to eight
seconds.
However, with time, the periods of suppression shorten and the
record is
dominated by rather continuous GPEDs.
SPIKE DETECTION PROGRAMS: There were numerous entries in these
files
which show generalized high amplitude spike and polyspike and
wave
discharges.
SEIZURE DETECTION PROGRAMS: There are numerous entries in these
files
which consist of [**12-26**] Hz generalized periodic epileptiform
discharges
(GPEDS) but no electrographic seizures seen.
PUSHBUTTON ACTIVATIONS: There were no entries in these files.
QUANTITATIVE EEG: The review of the rhythmic run detection and
display
panel demonstrated a clear decrease in power across multiple
frequencies
in both left and right hemispheres occurring at 10:30 a.m. and 2
p.m.
In addition, there was an increase in the burst suppression
index also
occurring at 10:30 a.m. and 2 p.m. This corresponded with a
decrease in
regularity and amplitude of GPEDs activity and apearance of
brief but
variable periods of suppression in the raw EEG as described
under
"Continuous EEG."
SLEEP: There was no evidence of normal sleep architecture seen.
CARDIAC MONITOR: Showed a generally regular rhythm between
90-100 bpm.
IMPRESSION: This is an abnormal continuous video EEG telemetry
due to
the presence of frequent and often continuous generalized
periodic
epileptiform discharges at 1-2 Hz (GPEDs). There were two time
periods
during which the discharges were more suppressed in amplitude
and
occurred in a burst suppression pattern, at approximately 10:30
a.m. and
2:30 p.m. These time periods likely corresponded to the
administration
of sedative or antiepileptic medications. However, these
slightly more
suppressed discharges did become more continuous GPEDs toward
the latter
half of the recording. There were no electrographic seizures
seen.
Overall, compared to the previous day's recording there was no
significant change. In the context of diffuse hypoxic injury,
the
presence of GPEDs portends a poor prognosis.
- MR HEAD W/O CONTRAST Study Date of [**2101-4-13**] 11:05 AM
IMPRESSION:
Diffusion abnormality involving bilateral occipital and parietal
cortex and
bilateral thalami. These findings are concerning for global
hypoxia/hypoperfusion injury. Posterior reversible
encephalopathy syndrome is
a differential in consideration; however, less likely, given the
lack of white
matter involvement. Alternatively, these findings may represent
transient
changes related to recent seizure activity.
- MR CERVICAL SPINE W/O CONTRAST Study Date of [**2101-4-13**] 11:10 AM
IMPRESSION:
No evidence of malalignment or abnormal cord signal. In the
setting of
trauma, CT spine should be obtained to assess for possible
underlying
fractures.
- BILAT LOWER EXT VEINS PORT Study Date of [**2101-4-18**] 8:15 AM
IMPRESSION: No evidence of deep vein thrombosis in either lower
extremity.
- CHEST (PORTABLE AP) Study Date of [**2101-4-20**] 7:25 AM
FINDINGS: As compared to the previous radiograph, the
endotracheal tube, the
nasogastric tube, and the right subclavian line are in unchanged
position.
Unchanged mild cardiomegaly with bilateral areas of atelectasis.
The signs
indicative of fluid overload have minimally improved. Minimal
bilateral
pleural effusion. No pneumothorax.
-EEG Study Date of [**2101-4-21**]
IMPRESSION: This is an abnormal extended routine EEG due to the
presence of frequent and prolonged bursts of [**2-1**] Hz GPEDs
separated by
brief periods of generalized suppression. After 6:30 a.m., the
GPEDs
appear to be nearly continuous. The decrease in burst
suppression
compared to the previous day's recording may represent a
lightening of
pharmacologic sedation.
- EEG Study Date of [**2101-4-20**]
IMPRESSION: This is an abnormal continuous EEG due to the
presence of a
burst suppression pattern. The bursts consist of variable
frequency [**1-31**]
Hz GPEDs lasting between two and eight seconds separated by
periods of
suppression lasting between two and ten seconds. While the
duration and
frequency of the GPEDs is variable, overall, the bursting
periods appear
to be more prolonged compared to the previous day's recording.
Burst
suppression pattern is most commonly seen during pharmacologic
sedation
but after diffuse hypoxic brain injury portends a poor
prognosis.
- EEG Study Date of [**2101-4-19**]
IMPRESSION: This is an abnormal continuous EEG due to the
presence of a
burst suppression pattern where the burst consisted of a [**3-29**] Hz
frequency of generalized periodic epileptiform discharges
(GPEDs)
lasting between one and five seconds with periods of generalized
suppression lasting between one and ten seconds. There were
several
periods during the tracing during which the periods of bursting
appeared
to be more prolonged, e.g. at 9 a.m., 11 a.m., and 11 p.m.
Overall,
however, the quality of the record does not change significantly
throughout the record and does not represent a significant
change
compared to the previous day's recording. A burst suppression
pattern
is most commonly seen in pharmacologic sedation but after
diffuse anoxic
injury, portends a poor prognosis.
- EEG Study Date of [**2101-4-18**]
IMPRESSION: This is an abnormal continuous EEG due to the
presence of a
burst suppression pattern where the burst consisted of a [**1-28**] Hz
frequency of generalized periodic epileptiform discharges
(GPEDs),
lasting between one and four seconds, with periods of
generalized
suppression, lasting between one and ten seconds. Overall,
compared to
the previous tracing, there was no significant change. A burst
suppression pattern is most commonly seen in pharmacologic
sedation but
after diffuse anoxic injury portends a poor prognosis.
Brief Hospital Course:
52M with no significant PMH who was transferred to [**Hospital1 18**] from
OSH after Cardiac Arrest post sexual activity with seizure-like
activity.
# s/p Cardiac Arrest: The patient was transferred to the CCU
from OSH for Arctic Sun cooling protocol in the setting of
recent cardiac arrest and poor neurologic status. He was cooled
for 3 days per protocol, and then rewarmed. His cardiac markers
were only slightly elevated on admission with TropT 0.44 and CK
MB 39, with the tropinin trending downwards, attributed to the
patient's receiving CPR as well as shocks. The patient was noted
at OSH to have runs of VT, for which he was started on
amiodarine; on arrival to [**Hospital1 18**], he was not noted to have these
runs, so his amiodarione gtt was discontinued. Heparin gtt was
similarly discontinued given no active signs of ischemia.
cardiac cath was deferred secondary to poor outcome secondary to
neurologic status. His ECHO showed normal biventricular cavity
sizes with preserved global biventricular systolic function
without any evidence of focal wall motion abnormality. Patient
was monitored on telemetry and noted to remain in a normal sinus
rhythm.
# Possible Seizures: Upon arrival to CCU, patient had brief [**1-27**]
second sustained jerking movements of his extremities,
associated with horizontal nystagmus. Neurology was consulted,
and the patient was started on 24 hour EEG monitoring. Final
read from Head CT in house showed small sulci and poor
grey/white differentiation, suspicious for global hypoperfusion
and infarction. An MRI showed diffusion abnormality involving
bilateral occipital and parietal cortex and bilateral thalami,
concerning for global hypoxia/hypoperfusion injury. On EEG, the
patient was initially shown nearly continuous generalized
periodic epileptiform discharges (GPEDs) occurring most at 0.5-1
Hz, but occasionally reaching up to 2 Hz, with infrequent
periods of suppression lasting between one and four seconds. Per
Neurology, the patient was started on propofol, midazolam,
keppra, pheytoin, and valproate, but despite this regimen
continued to have the presence of frequent and prolonged bursts
of [**2-1**] Hz GPEDs separated by brief periods of generalized
suppression. During hospitalization, an attempt was made to wean
the patient's anti-epileptic medications, but with only the
weaning of the propofol the patient was noted to have small
clonic motions of his head and arms, and propofol therapy was
re-instituted. The family was made aware of the patient's
prognosis, and the NEOB was notified.
# Acute Hypoxic Respiratory Failure: Presumed secondary cardiac
arrest; there was concern initally for [**Doctor Last Name **] given the P/F ratio
less than 300, which the patient continued to have during his
hospitalization; his ventilator settings were titrated to
maintain low tidal volumes. His sputum at one pointed ended up
growing Klebsiella, which was pan-snesitive, for which he
initally received broad spectrum abx therapy with vancomycin and
cefepime, ultimately weaned down to [**Doctor Last Name 88643**].
# UTI: The patient was noted to have a Klebseilla species
growing in his urine; this was already appropriately being
treated by [**Last Name (LF) 88643**], [**First Name3 (LF) **] no additional antibiotics were
changed or added.
# Central DI: Near the end of the patient's hospitalization, he
was noted to start having urine output nearing 400 cc urine/hr.
Urine lytes were checked and were consistent with central
diabetes insipitus; the patient was started on ddAVP to help
control urine output, as well as to help control the climbing
hypernatremia which was resulting from his DI.
# Goals of Care: Several family discussions were held, with
neurology present, to discuss the patient's poor prognosis in
the setting of re-warming, as well as the patients generalized
seizure activity not controlled on multi-drug anti-epileptic
regimen. The family elected to withdraw care on [**2101-4-21**], and
requested an autopsy.
Medications on Admission:
Viagra PRN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis: cardiac arrest
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
ICD9 Codes: 4275, 5990, 4271, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5353
}
|
Medical Text: Admission Date: [**2198-2-8**] Discharge Date: [**2198-2-15**]
Date of Birth: [**2125-1-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
[**Location (un) **] tracheal canula change and debridement of granulation
tissue
History of Present Illness:
This is a 73 year old gentleman with a PMH significant for
tracheobronchomalacia and severe central OSA s/p trach placed in
[**5-26**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] button in [**11-27**], obesity hypoventilation
syndrome s/p, asthma, c-spine injury with left diaphragmatic
paralysis, pulmonary HTN, diastolic CHF, followed by Dr.
[**Last Name (STitle) **], who is transferred from the PACU s/p trach revision
with post-operative hypoxia with oxygen saturations to the
60-70% range.
.
Patient underwent flexible bronchoscopy on [**2197-10-27**] demonstrating
supraglottic tissues which were collapsing over the epiglottis
creating obstruction with mild degree of granulation tissue
around the [**Location (un) **] tube. This afternoon, he underwent
[**Location (un) **] tracheal canula change and debridement of granulation
tissue. In the PACU, his oxygen saturations were in the 60-70%
range on room air. Patient was awake, alert, and without
acute complaints. Patient was transferred to the MICU for
monitoring of oxygenation status overnight.
.
Upon transfer to the MICU, patient appears comfortable and is
breathing comfortably with oxygen saturations of 87% on RA. He
has no acute complaints at this time.
Past Medical History:
1. OSA s/p trach [**5-26**], [**Location (un) **] button [**11-27**]
2. Asthma
3. HTN
4. DM2
5. Hyperlipidemia
6. PUD
7. CHF - diastolic heart failure (documented on Echo in [**2192**])
8. Pulmonary hypertension
9. History of PEA arrest
10. Obesity hypoventilation syndrome
Social History:
Lives with his wife, used to work in Demolition,
Never smoked, no EtOh, no IVDU.
Family History:
Father had an MI at 49, Mother with MI at 44,
Brother with MI at 75.
Physical Exam:
VS: Temp: 96.7, BP: 139/76 HR: 76 RR: O2sat: 87% RA
GEN: pleasant, NAD
HEENT: PERRL, EOMI, anicteric, dry mucous membranes
RESP: expiratory wheezes bilaterally
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no pedal edema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. 5/5 strength throughout
Pertinent Results:
[**2198-2-8**] 09:41PM GLUCOSE-151* UREA N-17 CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-38* ANION GAP-11
[**2198-2-8**] 09:41PM CALCIUM-9.1 PHOSPHATE-4.8*# MAGNESIUM-1.7
[**2198-2-8**] 09:41PM WBC-7.6 RBC-5.75 HGB-17.0 HCT-53.1* MCV-93
MCH-29.7 MCHC-32.1 RDW-13.5
[**2198-2-8**] 09:41PM PLT COUNT-121*
.
[**2198-2-15**] 04:42AM BLOOD WBC-4.8 RBC-5.24 Hgb-15.6 Hct-46.2 MCV-88
MCH-29.8 MCHC-33.7 RDW-12.9 Plt Ct-134*
[**2198-2-15**] 04:42AM BLOOD Glucose-172* UreaN-24* Creat-0.8 Na-133
K-4.1 Cl-91* HCO3-38* AnGap-8
[**2198-2-15**] 04:42AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8
[**2198-2-14**] 04:00AM BLOOD Type-ART Temp-36.7 Rates-/16 Tidal V-250
PEEP-5 FiO2-30 pO2-79* pCO2-63* pH-7.38 calTCO2-39* Base XS-8
Intubat-INTUBATED
EKG: [**2198-2-6**]: Sinus rhythm. A-V conduction delay. Non-specific
lateral ST-T wave changes as recorded [**2197-7-7**]. Otherwise, no
diagnostic interim change.
.
Imaging:
Chest radiograph ([**2197-2-6**]): FINDINGS: The lung volumes are
relatively low. There is unchanged marked cardiomegaly with
large diameter pulmonary vessels, suggesting mild-to-moderate
overhydration. No pleural effusions. No focal parenchymal
opacity suggesting pneumonia. Normal appearance of the
mediastinal and hilar contours.
Brief Hospital Course:
In regards to vent settings: [**Location (un) 7188**] with bag attachement,
current setting (1 liter oxygen) and an oxygen flow rate up to 6
liters/minute. We didn't test higher flow rates. [**Location (un) 7188**] with
vent settings PS 5, PEEP 5, and the minimal FiO2 needed to get
sats 90-94%. We can't set a BUR as we would on BiPAP ST, but if
the low MV alarm sounds, the ventilator will switch to SIMV
mode.
.
To Do: Needs teaching about trach care and vent management prior
to safe return to home.
.
Hospital Course:
#. Hypoxia: Likely multifactorial as patient with known
tracheobronchomalacia and severe OSA, asthma, pulmonary
hypertension, and diastolic CHF. Lack of fever, leukocytosis,
symptoms, or chest radiographic evidence of opacities argues
against PNA. With evidence of mild volume overload on chest
radiograph was given some lasix in attempt to diuresis with mild
improvement in hypoxia and increase in bicarb. IP recommended a
sleep study to assess for central sleep apnea after a witnessed
episode of apnea while in the ICU.
He had a tracheostomy tube placed on the monring of [**2-10**]. He
required mechanical ventilation for a short time afterwards
while the sedating medications wore off. He underwent the sleep
study the night of [**2-10**] which was inconclusive. Vent settings
were titrated with multiple sleep studies and he ultimately did
well on trach colalr during the day and PSV 5/5 FiO2 30% on
[**Location (un) 7188**] ventilator at nighttime. He should continue on these
vent settings while sleeping and will need teaching about how to
suction, deflate and inflate cuff and use ventilator. Goal PCO2
at nighttime remained around 60.
#. Asthma: Continued albuterol nebs.
.
#. Diastolic CHF: On last echo in [**2194**], patient found to have
severe symmetric left ventricular hypertrophy. With evidence of
volume overload on chest radiograph was diuresed until
bicarbonate increased and then discontinued diuresis.
#. HTN: Stable, continued home hydrochlorothiazide, metoprolol,
nifedipine, and lisinopril.
#. DM: Stable, held home oral antiglycemic medications and
covered with insulin sliding scale overnight. Restarted home
regimen on discharge.
#. Hyperlipidemia: Continued lovastatin 20mg PO daily.
#. PUD: Stable, on PPi.
Comm: patient
[**Name2 (NI) 7092**]: FULL code
Medications on Admission:
- ALBUTEROL SULFATE - 2.5 mg/0.5 mL Solution for Nebulization -
1
(One) ampoule inhaled via nebulizaiton every eight (8) hours
- ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**1-21**] puffs
Q4-6
prn
- FREESTYLE GLUCOMETER - - as directed for blood sugar
monitoring dx code 250.00
- GLIPIZIDE [GLUCOTROL XL] - 5 mg Tablet Extended Rel 24 hr - 1
Tab(s) by mouth once a day
- HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once
a
day
- LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
- LOVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
take
in the evening
- METFORMIN - 500 mg Tablet Sustained Release 24 hr - 1 (One)
Tablet(s) by mouth once a day Take in the morning with Glipizide
- METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet Sustained
Release 24 hr - 1 Tablet Sustained Release 24 hr(s) by mouth
once
a day
- NIFEDIPINE - 90 mg Tablet Sustained Release - 1 Tablet(s) by
mouth once a day
Discharge Medications:
1. [**Location (un) 7188**] Ventilator
Pressure support 5
PEEP 5
Back up rate 10
Oxygen 30%
Diagnosis: Tracheobronchomalacia, obstructive sleep apnea
2. albuterol sulfate 2.5 mg/0.5 mL Solution for Nebulization
Sig: One (1) amp Inhalation every 6-8 hours as needed for
shortness of breath or wheezing.
3. Glucotrol XL 5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Tracheomalacia
Central sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU for low oxygen levels after a
tracheostomy revision. You were followed by the sleep doctors
and had a sleep study. Weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight goes up more than 3 lbs. You will have teaching about
your ventilator and how to manage your trahheostomy at the
facility you are being discharged to.
There were no changes made to your medication regimen other
thanthe addition of heparin SC while you are at a rehab facility
to prevent blood clots.
It was a pleasure taking part in your care.
Please follow up as below and call the doctor if you have any
issues with your breathing or tracheostomy.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2198-5-11**] at 9:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3300**] RRT/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
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2198-5-11**] at 9:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3300**] RRT/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
ICD9 Codes: 4168, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5354
}
|
Medical Text: Admission Date: [**2154-7-14**] Discharge Date:
Date of Birth: [**2078-5-1**] Sex: M
Service: CCU
NOTE: For discharge date, please see Addendum. Please see
Addendum to Discharge Summary for hospital course starting on
[**2154-7-18**] until the time of discharge.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
male who presented to [**Hospital6 33**] with chest pain on
[**2154-7-14**] and was transferred to the [**Hospital1 346**] for management of an acute
myocardial infarction.
He has a history of atrial fibrillation since [**2143**], deep
venous thrombosis, and colon cancer. His cardiac risk
factors include a remote smoking history,
hypercholesterolemia, and a family history of myocardial
infarctions.
He was in his usual state of health until the morning of
[**7-14**] when he developed acute chest pain when getting up at
4 a.m. The pain appeared localized mostly to his back
without any radiation. He did not have symptoms of dyspnea.
No nausea, and no diaphoresis. He was able to go back to
sleep and woke up again at 5 a.m. with severe squeezing chest
pain localized to the anterior chest. He rated the pain
[**10-31**]; again no radiation, no dyspnea, no nausea, and no
diaphoresis were noted. He had never had this type of chest
pain before. He also had not experienced any recent changes
in exercise tolerance of being able to walk about one flight
of stairs (limited by dyspnea and not limited by pain). He
did not give any history of orthopnea or paroxysmal nocturnal
dyspnea. He does have chronic leg edema which has not
changed recently.
He was brought to [**Hospital6 33**] where he received four
doses of sublingual nitroglycerin which relieved the chest
pain temporarily. An electrocardiogram at [**Hospital6 3426**] showed ST elevations in V2 to V6. His cardiologist
is Dr. [**Last Name (STitle) 11378**] at [**Hospital6 1708**], but due to an
unavailability of beds he was transferred to [**Hospital1 346**] for cardiac catheterization.
The initial electrocardiogram at [**Hospital1 190**] showed marked ST elevations in leads I, aVL,
and V2 to V6, with reciprocal depressions over the inferior
leads, as well as a right bundle-branch block pattern, and
left axis deviation.
Cardiac catheterization at [**Hospital1 188**] showed total occlusion of the left anterior descending
artery after first heart sound, diffuse irregularities in the
right coronary artery, but no significant disease in the left
main coronary artery and left circumflex. The left anterior
descending artery occlusion was successfully stented;
however, no reflow resulted.
He was admitted to the Coronary Care Unit for management of
his acute myocardial infarction.
PAST MEDICAL HISTORY:
1. Atrial fibrillation since [**2143**].
2. Congestive heart failure in the setting of atrial
fibrillation.
3. Deep venous thrombosis in [**2134**] and [**2150**] (the latter in
the setting of colectomy).
4. Colon cancer, status post colectomy with colostomy in
[**2150**].
5. Arthritis.
6. Hypercholesterolemia.
7. One past episode of hematuria of unclear etiology.
8. Depression.
9. Benign prostatic hyperplasia with transurethral resection
of prostate a little more than five years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Medications at home included
digoxin 0.25 mg p.o. q.d., Zestril 20 mg p.o. b.i.d.,
furosemide 40 mg p.o. q.d., Celexa 20 mg p.o. q.d.,
Lipitor 10 mg p.o. q.d., metoprolol 50 mg p.o. b.i.d.,
verapamil 240 mg p.o. q.d., naproxen 500 mg p.o. q.d.
SOCIAL HISTORY: He is a retired police officer. He lives
with his wife in [**Name (NI) 11379**]. He smoked four packs per day
for over 10 years, but he quit 40 years ago. He occasionally
drinks alcohol.
FAMILY HISTORY: His brother died from a myocardial
infarction at the age of 56. His father died from "heart
disease" at the age of 40.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Coronary Care Unit revealed vital signs
with a temperature of 97, blood pressure of 110/60, heart
rate of 77, respiratory rate of 16, pulse oximetry 90% on 3
liters nasal cannula. General appearance revealed the
patient was tired-appearing but in no acute distress. Head,
eyes, ears, nose, and throat revealed pupils were equal,
round, and reactive to light. Extraocular movements were
intact. His sclerae were anicteric. He had moist mucous
membranes, and no appreciable oral lesions. Neck revealed
jugular venous pressure was difficult to assess due to the
supine position. No carotid bruits were appreciated.
Cardiovascular examination revealed an irregularly irregular
rhythm with a [**3-27**] holosystolic murmur at the apex, radiating
to the axilla. The lungs had mild diffuse wheezes
throughout. The abdomen was soft, nontender, and
nondistended, with active bowel sounds. A well-healed
midline scar, and a colostomy bag in place on the left side.
Extremities revealed 1 to 2+ pitting edema on both legs and
chronic venous stasis changes. Good distal pulses. The
catheterization site in the right groin were remarkable for
dressing soaked with blood. No hematoma or bruits were
evident. Neurologic examination revealed the patient was
alert and oriented. Cranial nerves II through XII were
intact. No drift. Full grip strength. Plantar flexion
strength was [**5-26**]. His reflexes were symmetric. His toes
were equivocal.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
at the time of admission to the Coronary Care Unit, his
hematocrit was 43.4, white blood cell count was 7.9, platelet
count was 161. His PT was 16.9, INR of 2, PTT of 23.2.
Sodium of 140, potassium of 4.9, chloride of 106, bicarbonate
of 22, blood urea nitrogen of 29, creatinine of 0.9, blood
glucose of 203. The initial creatine kinase was 114, and the
CK/MB was 7, troponin I was less than 0.3.
RADIOLOGY/IMAGING: Electrocardiogram performed status post
catheterization showed atrial fibrillation with an average
ventricular response of 69, marked ST elevations were noted
in leads I, aVL, and V2 through V6; suggesting an acute
myocardial infarction. There was also a right bundle-branch
block pattern and left axis deviation.
A chest x-ray from [**Hospital6 33**] showed evidence of
congestive heart failure as well as small right-sided pleural
effusion.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: Following catheterization, he was
admitted to the [**Hospital1 69**] Coronary
Care Unit with a diagnosis of acute myocardial infarction.
He was started on aspirin, Plavix, and an 18-hour course
Integrilin following catheterization, and metoprolol and
nitroglycerin drip for management of chest pain and blood
pressure. His Coumadin had been held for catheterization,
and he was started on heparin for anticoagulation in the
setting of atrial fibrillation. His digoxin, verapamil,
Lasix, and Zestril were initially held.
He was initially not given an intravenous fluids as his
physical examination and outside chest x-ray suggested
possible mild fluid overload.
An echocardiogram was planned for the next day. Over the
course of the first night he had three short episodes of
chest pain and nausea which were relieved by nitroglycerin.
One of them required 1 mg of morphine. Electrocardiograms at
that time with chest pain showed developing Q waves, but no
new ST elevations. Serial creatine kinases were drawn which
peaked at the second creatine kinase at 5856, the CK/MB
was 482, and the MB index was 8.3. The third creatine kinase
was 3586, CK/MB of 258, MB index of 7.2.
In the morning of [**7-15**], he became hypotensive to a blood
pressure of 80/40. He had not yet given consent for a
central line. He was given two fluid boluses of 250 cc of
normal saline which stabilized his blood pressure. However,
over the next few hours he developed considerable respiratory
distress requiring increasing concentrations of oxygen and a
brief course of BiPAP. A chest x-ray showed evidence of
congestive heart failure. He now gave consent for central
line, and a right internal jugular line was put in place. He
was given a total of 160 mg of intravenous Lasix with great
improvement in his respiratory status, and he was able to
breathe comfortably on nasal cannula again. His blood
pressure remained stable except for one further episode of
hypotension in the evening of [**7-15**], for which he was
briefly placed on a Levophed drip which was discontinued
after two hours. He did not require management with
intravenous pressors.
An echocardiogram done on [**7-15**] showed extensive left
ventricular systolic dysfunction including akinesis of the
distal third of the inferior, lateral, and anterior walls as
well as the apex, and additional areas of hypokinesis. There
was evidence of torn mitral cordis with moderate (2+)
eccentric jet of mitral regurgitation directed
inferolaterally. Moderate tricuspid regurgitation was also
seen. His ejection fraction was 20% to 25%.
Note: Based on the American Heart Association
recommendations, these findings recommend endocarditis
prophylaxis in the future.
His blood pressure remained stable, but he still was
repeatedly tachycardia into the 100 to 120 range. Over the
next two days his metoprolol dose was increased. Captopril
and eventually digoxin were added to the regimen for improved
blood pressure and rate control. Please see addendum to this
Discharge Summary for further cardiovascular course and
details on the medications on discharge.
2. PULMONARY: As noted above, the patient developed
respiratory distress on [**7-15**], likely secondary to
congestive heart failure. He initially required BiPAP but
was quickly able to switch back to nasal cannula with
improved oxygenation following 160 mg of intravenous Lasix.
His respiratory status continued to improve over the next two
days. He was given daily intravenous Lasix for continued
diuresis and will likely be switched back to his home oral
regimen of daily Lasix prior to discharge. Please see
addendum for details of his pulmonary course.
3. GENITOURINARY: As noted above, the patient has a history
of hematuria even though a full workup has never been
initiated. During the initial night of [**7-14**], he developed
significant hematuria with clotting in the Foley catheter bag
as well as leakage of blood and urine around the Foley
catheter. His urine output dropped to 0 secondary to
clotting. An attempt was made with a larger Foley which was
only briefly successful.
Due to the hematuria, the post catheterization Integrilin was
stopped after a total of 15 hours instead of the normal 18
hours.
The Urology Service was consulted and were able irrigate
copious clots with a larger Foley catheter. He was started
on continuous bladder irrigation which was stopped after 24
hours, as he had no further hematuria.
The Urology Service recommended outpatient workup of the
hematuria when he was stable including outpatient cystoscopy.
For this, the patient should follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**]
(telephone number [**Telephone/Fax (1) 2906**]).
4. ENDOCRINOLOGY: The patient's initial blood glucose on
admission was 203. He did not have a known diagnosis of
diabetes, but was placed on fingerstick checks and an insulin
sliding-scale. He did require an average of 2 units of
regular insulin per day. Most of his blood sugars were in
the 150 to 170 range. His hemoglobin A1c was checked which
was 6.7. This suggested he does potentially recent onset
diabetes. Given his cardiac history, he would benefit from
glucose control and should probably be started on an oral
hypoglycemic [**Doctor Last Name 360**] such as metformin on discharge. Please
see details in the addendum.
NOTE: Please see addendum to this Discharge Summary for the
hospital course beginning on [**2154-7-18**] until the time of
discharge for further events of hospital stay; including
discharge diagnosis, medications, and followup instructions.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 423**]
MEDQUIST36
D: [**2154-7-18**] 18:16
T: [**2154-7-20**] 04:53
JOB#: [**Job Number 11380**]
ICD9 Codes: 4280, 5185, 4271, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5355
}
|
Medical Text: Admission Date: [**2188-1-8**] Discharge Date: [**2188-1-17**]
Date of Birth: [**2118-8-18**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 69-year-old white
male who has a history of coronary artery disease,
hypertension, and noninsulin-dependent diabetes, who
presented to [**Hospital6 33**] on [**2188-1-4**] with jaw pain
on exertion. He did not have shortness of breath,
diaphoresis, or nausea and vomiting. He did rule in for an
MI with a peak CK of 498, troponin of 1.21, and MB of 52.3.
he underwent cardiac catheterization which revealed a 90-95%
left main stenosis, an occluded left circumflex and was
transferred for CABG. He has a normal RCA and LV aneurysm.
He had an echocardiogram in [**12-6**] which showed an EF of
35-40%.
PAST MEDICAL HISTORY:
1. History of coronary artery disease, status post MI times
two 15 years ago and in [**2182**].
2. History of noninsulin-dependent diabetes.
3. History of LV aneurysm with thrombus.
4. Status post right leg embolectomy in [**2183**].
5. Status post left knee arthroplasty.
6. History of AAA, 3.5 cm.
7. History of chronic renal insufficiency with a baseline of
1.4.
ADMISSION MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Metformin 1,000 mg p.o. b.i.d.
3. Lasix, question of the dose.
4. Zantac, question of the dose.
5. Coumadin 5 mg p.o. q.d., the last dose on [**2188-1-4**].
6. Plavix 75 mg p.o. q.d. which was started at the outside
hospital.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Significant for coronary artery disease.
SOCIAL HISTORY: He has a 40 pack year smoking history and
quit four years ago. He does not drink alcohol. He lives
alone and works as a security guard.
REVIEW OF SYSTEMS: Significant for slight vision loss in the
right eye.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient is a
well-developed, well-nourished white male in no apparent
distress. Vital signs: Temperature 97.8, pulse 99,
respirations 14, blood pressure 125/72. HEENT:
Normocephalic, atraumatic. The extraocular movements were
intact. The pupils were equal and reactive to light and
accommodation. The oropharynx was benign. Poor dentition,
upper dentures. Neck: Supple, full range of motion. No
lymphadenopathy or thyromegaly. Carotids 2+ and equal
bilaterally without bruits. Lungs: Clear to auscultation
and percussion. Cardiovascular: Regular rate and rhythm.
Normal S1 and S2 without rubs, murmurs, or gallops. Abdomen:
Soft, nontender, with positive bowel sounds, no masses or
hepatosplenomegaly. Extremities: He had an intra-aortic
balloon pump in the left groin and was without clubbing,
cyanosis or edema. Pulses were 2+ and equal bilaterally
except for 1+ bilaterally in the DP and PT. Neurologic:
Nonfocal.
HOSPITAL COURSE: He was admitted to the CRSU after he was
transferred from [**Hospital6 33**] and he had an
intra-aortic balloon pump placed. He also had carotid
studies which revealed no significant hemodynamic lesion in
either right or left bifurcation. He also had a cardiac
echocardiogram preoperatively which revealed that there were
LV wall abnormalities, basal inferolateral hypokinesis,
midinferolateral hypokinesis, anterior apex was akinetic.
The septal apex was akinetic, inferior apex was akinetic, and
the lateral apex was hypokinetic. The right ventricular wall
motion was normal. There was a mild apical aneurysm of the
left ventricle. There were no masses or thrombi seen. His
ejection fraction was 35%.
On [**2188-1-9**], he underwent a CABG times three with LIMA to the
LAD, reverse saphenous vein graft to the distal RCA and the
diagonal and he had a repair of an ASD. His cross-clamp time
was 81 minutes, total bypass time 119 minutes. He tolerated
the procedure well and was transferred to the CRSU on
milrinone and propofol. He was extubated on his
postoperative night.
On postoperative day number one, he had his intra-aortic
balloon pump discontinued without incident. On postoperative
day number three, he was weaned off his milrinone and Neo and
his chest tubes were discontinued. He also went into atrial
fibrillation and was converted to sinus with Diltiazem but
this was also weaned off.
On postoperative day number four, he was transferred to the
floor in stable condition. He did have another episode of
atrial fibrillation and was started on Amiodarone and
remained in sinus rhythm. He continued to progress. His
creatinine baseline was 1.4 and it increased to 1.9. On
postoperative day number eight, he was discharged to home in
stable condition.
LABORATORY/RADIOLOGIC DATA: On discharge, his laboratories
revealed a hematocrit of 34.5, white count 10,900, platelets
229,000. Chemistries are pending and will be on the
addendum.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Ecotrin 325 mg p.o. q.d.
3. Percocet one to two p.o. q. four to six hours p.r.n.
pain.
4. Lopressor 25 mg p.o. t.i.d.
5. Glucophage 1,000 mg p.o. b.i.d.
6. Amiodarone 400 mg p.o. b.i.d. times one week and then
decrease to 400 mg p.o. q.d. for a week and then decrease to
200 mg p.o. q.d.
7. Zantac 150 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Atrial septal defect.
3. Postoperative atrial fibrillation.
4. Noninsulin-dependent diabetes.
FOLLOW-UP: The patient will be seen by Dr.
.................... in one to two weeks and by Dr. [**Last Name (STitle) 1537**] in
four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2188-1-16**] 05:00
T: [**2188-1-16**] 17:16
JOB#: [**Job Number 34295**]
ICD9 Codes: 9971
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5356
}
|
Medical Text: Admission Date: [**2201-3-21**] Discharge Date: [**2201-3-31**]
Date of Birth: [**2127-8-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
s/p fall with significant right sided subdural hemorrhage
Major Surgical or Invasive Procedure:
[**3-21**]: Right Craniotomy for SDH
[**3-29**]: PEG
History of Present Illness:
7M on coumadin for an embolic stroke in [**2190**] and fell at 0500 on
[**3-21**] while he was getting out of bed. This fall was
unwitnessed, however his wife heard him fall and went
immediately to the bedroom to his side. He was brought to [**Hospital 28941**] ED and then was transferred to [**Hospital1 18**] for further
evaluation. Upon arrival to the ED his INR was 5.6 he was
reversed with Vitamin K, profiline, and FFP.
Past Medical History:
embolic stroke [**2190**], HTN
Social History:
resides at home with wife.
Family History:
non-contributory
Physical Exam:
On Admission:
en: lethargic, but arousable, comfortable, NAD.
HEENT: Pupils:3-2.5 on right and 2.5 to 2 on the left EOMs pt
not cooperative with exam.
Neuro:
Mental status: Awake to voice-lethargic, inconsistently
following
simple commands only
Orientation: Oriented to person, place "rehab", and date is
correct with prompting.
Recall:unable to perform at this time.
Language: slow to respond, answers with one word after much
prompting.
Cranial Nerves:
I: Not tested
II: Pupils round and reactive to light, 3-2.5 on right and 2.5
to
2 on the left. Visual fields cut on left.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength- left facial droop
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal on right, decreased
on left.
XII: Tongue midline without fasciculations.
Motor: Strength full power [**4-14**] on right, plegia on left-
contracted left arm. Unable to perform pronator drift secondary
to long standing left sided paresis
Sensation: Intact to light touch bilaterally.
Toes upgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam on Discharge:
Oriented x 2. PERRL. Dysarthric. Moves right side strongly. Left
arm plegic. Left leg withdraws to pain.
Pertinent Results:
Labs on Admission:
[**2201-3-21**] 02:30PM BLOOD WBC-9.9 RBC-2.04* Hgb-5.0* Hct-16.2*
MCV-79* MCH-24.5* MCHC-31.2 RDW-17.2* Plt Ct-354
[**2201-3-21**] 02:30PM BLOOD Neuts-76.5* Lymphs-13.5* Monos-9.6 Eos-0
Baso-0.3
[**2201-3-21**] 02:30PM BLOOD PT-49.3* PTT-32.4 INR(PT)-5.6*
[**2201-3-21**] 02:30PM BLOOD Glucose-138* UreaN-29* Creat-1.2 Na-137
K-4.2 Cl-105 HCO3-19* AnGap-17
[**2201-3-21**] 02:30PM BLOOD CK(CPK)-386*
[**2201-3-21**] 02:30PM BLOOD cTropnT-<0.01
Imaging:
CT Head [**3-21**]:
unchanged large 4.3cm right temporo/parietal/occipital acute on
chronic SHD with no shift of midline or herniation. severe right
frontal encephalomalacia with dilation of the right frontal [**Doctor Last Name 534**]
of lateral ventricle. compression of right lateral ventricle
temporal [**Doctor Last Name 534**]. stable left frontal parenchymal hemorrhagic
contusion.
CT Torso [**3-21**]:
No traumatic injury to the torso.
CXR [**2201-3-26**]:
FINDINGS: In comparison with the study of [**3-23**], there is little
change.
Nasogastric tube again extends well into the stomach. There may
be mild
atelectatic changes at the left base, but no evidence of acute
focal
pneumonia.
Brief Hospital Course:
Patient transferred to [**Hospital1 18**] following a fall while at home on
the morning of [**3-21**]. Of significance, patient was on coumadin
therapy for a prior embolic CVA in [**2190**]. Upon admission to
[**Hospital1 18**], he received FFP, Vitamin K, and profiline to reverse
effects of anticoagulation. Because of the size of the right
subdural hematoma, and his neurologic examination, he was
emergently taken to the OR for evacuation. Post-operatively, he
was returned to the ICU. The patient was stable enough to be
transferred to the neurosurgical floor afterwards. He was
lethargic but able to open his eyes to voice and follow some
commands when he was first transferred. On [**3-26**] he was observed
to have a mild amount of respiratory effort. Chest x-ray was
performed for the concern of a developing pneumonia, and was
read as negative by radiology. He was prophylactically started
on a course of antibiotics.
General surgery was contact[**Name (NI) **] on [**3-25**] for consideration of PEG
placement due to persistantly poor performance during speech and
swallow examinations. This was placed on [**3-29**] without incident.
The patient was also given a course of nystatin for oral thrush.
He was seen by physical and occupational therapy who determined
he would be an appropriate candidate for rehab. He was
discharged to an appropriate facility on [**2201-3-31**].
Medications on Admission:
diovan, tramadol, coumadin, ceplex, tylenol
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral thrush for 7 days: stop on
[**4-6**].
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] - [**Hospital1 **] NH
Discharge Diagnosis:
4.3cm right temporo/pariteal/occipital acute on chronic SDH
Dysphagia requiring feeding tube placement
Discharge Condition:
Neurologically Improved
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.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You may NOT resume your Coumadin(warfarin) until 1 month from
discharge.
?????? 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:
Follow-Up Appointment Instructions
??????Please return to the office in 7 days for a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
-Follow-up with neurology for discussion of restarting coumadin.
Completed by:[**2201-3-31**]
ICD9 Codes: 2859
|
{
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5357
}
|
Medical Text: Admission Date: [**2132-9-18**] Discharge Date: [**2132-9-21**]
Date of Birth: [**2060-9-5**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
[**2132-9-19**]: PICC Placement
History of Present Illness:
72-year-old female with a history of hypertension, [**Month/Day/Year **], and
multiple presentations concerning for
TIAs with dysarthria and various weaknesses, all found to be
DKA, who presents with altered mental status and hyperglycemia.
Patient was last seen in her usual state of health yesterday.
Today, her son found her walking around her house, confused and
dysarthric. He pressed the life line, and she was brought to the
[**Hospital1 18**] ED. Her glucose at home was found to be critically high.
In the ED, initial VS: 99.2 96 140/66 16 100%. Initial labs
significant for Sodium 128, Potassium 9.2 (hemolyzed), Bicarb
18, creatinine 1.2, and glucose 650. WBC count 12.5. ABG
revealed pH 7.21 pCO2 46 pO2 51 HCO3 19. CT head negative for
acute process. The patient was evaluated by neurology for
altered mental status, dysarthria, and a twitching episode noted
while in the ED. The patient underwent CTA to evaluate for
vascular event (poorly timed - incomplete study). An LP was
attempted to rule out meningitis, but was unable to be
performed. Due to concern for focal seizures, the patient was
loaded with IV keppra.
For her diabetic ketoacidosis, she was started on insulin at 7
units/hr and received 2L NS. Anion gap improved to 17 prior to
transfer. VS prior to transfer: 101.9 116 138/56 18 100%.
On arrival to the MICU, the patient was obtunded with minimal
response to sternal rub.
On the floor, patient reports never missing a dose of Insulin.
Taking SSI everyday and Lantus at night. On day of admission,
she was feeling poorly and lying in bed, however, she still took
her insulin. She reports the day before feeling fine. Denied any
other symptoms. The only differing dietary history is that she
had chicken mcnuggets the day prior to admission and she reports
not usually eating fried foods. She didn't have any soda/sweet
tea, just diet soda.
Review of systems: Unable to be performed due to altered mental
status.
Past Medical History:
Significant MVA in [**2092**], s/p facial reconstruction
Left eye prosthesis
Right Eye glaucoma
HTN
hyperlipidemia
type 2 DM
CAD
Breast mass (unclear etiology or diagnosis)
Question of TIAs and multiple admissions and evaluations by
neurology:
[**2124**]: Dysarthria. negative MRI/MRA and EEG.
[**2128**]: Dysarthria, left sided weakness. DKA. negative stroke work
up.
[**2131**]: Dysarthria. Hyperglycemia. negative CT/CTA.
Social History:
Lives with her husband who is sick. and she takes care of him.
Her son recently moved with them. Per OMR, no history of
smoking. She used to drink alcohol daily but has not done so in
many years.
Family History:
Family history is negative for strokes, seizures, or peripheral
nerve palsies. [**Year (4 digits) 982**] is present in her sister and aunt. [**Name (NI) **]
sister also had stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 99.7 BP: 157/73 P: 116 R: 26 O2: 96%
Fingerstick 253
General: Appears mildly comfortable; withdraws to pain and
sternal rub; does not open eyes on command or verbally answer
questions
HEENT: Left prosthetic glob; right Sclera anicteric, MM dry,
oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: feet cool bilaterally 1+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
VS - Temp 97.9/98.0F, 140-178/60-89BP , 58-84HR , 18R , O2-sat
99% RA
GENERAL - NAD, comfortable
HEENT - NC/AT, Left eye glass, Right EOMI, sclerae anicteric,
MMM, OP clear. [**Hospital1 **]-temporal wasting
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no w/r/r
HEART - RRR, 2/6 SEM in ULSB no rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - 2+ distal pulses. No lower extremity edema. 1mm
lentigo on her R small toe
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-24**] throughout, sensation grossly intact throughout,
Pertinent Results:
ADMISSION
[**2132-9-18**] 11:40PM TYPE-[**Last Name (un) **] PO2-131* PCO2-29* PH-7.34* TOTAL
CO2-16* BASE XS--8
[**2132-9-18**] 11:40PM LACTATE-2.0
[**2132-9-18**] 11:34PM GLUCOSE-332* UREA N-20 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-16* ANION GAP-21*
[**2132-9-18**] 11:34PM estGFR-Using this
[**2132-9-18**] 09:55PM GLUCOSE-499* K+-4.7
[**2132-9-18**] 09:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2132-9-18**] 09:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-9-18**] 08:23PM PO2-51* PCO2-46* PH-7.21* TOTAL CO2-19* BASE
XS--9 COMMENTS-GREEN TOP
[**2132-9-18**] 08:23PM K+-7.0*
[**2132-9-18**] 08:00PM GLUCOSE-650* UREA N-24* CREAT-1.2*
SODIUM-128* POTASSIUM-9.2* CHLORIDE-92* TOTAL CO2-18* ANION
GAP-27*
[**2132-9-18**] 08:00PM WBC-12.5*# RBC-4.65 HGB-13.0 HCT-41.3# MCV-89
MCH-27.8 MCHC-31.3 RDW-13.6
[**2132-9-18**] 08:00PM NEUTS-87.1* LYMPHS-9.7* MONOS-2.7 EOS-0.4
BASOS-0.2
[**2132-9-18**] 08:00PM PLT COUNT-252
[**2132-9-18**] 08:00PM PT-11.6 PTT-20.3* INR(PT)-1.1
[**2132-9-18**] 08:23PM BLOOD pO2-51* pCO2-46* pH-7.21* calTCO2-19*
Base XS--9 Comment-GREEN TOP
[**2132-9-19**] 09:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE:
[**2132-9-21**] 05:27AM BLOOD WBC-6.7 RBC-4.21 Hgb-11.8* Hct-36.1
MCV-86 MCH-28.1 MCHC-32.7 RDW-13.5 Plt Ct-184
[**2132-9-20**] 05:58AM BLOOD Neuts-61.7 Lymphs-29.4 Monos-7.4 Eos-1.3
Baso-0.2
[**2132-9-21**] 05:27AM BLOOD Glucose-118* UreaN-13 Creat-0.6 Na-142
K-4.0 Cl-106 HCO3-31 AnGap-9
[**2132-9-21**] 05:27AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
ABG:
[**2132-9-18**] 08:23PM BLOOD pO2-51* pCO2-46* pH-7.21* calTCO2-19*
Base XS--9 Comment-GREEN TOP
[**2132-9-18**] 11:40PM BLOOD Type-[**Last Name (un) **] pO2-131* pCO2-29* pH-7.34*
calTCO2-16* Base XS--8
[**2132-9-19**] 09:59AM BLOOD Type-[**Last Name (un) **] pO2-240* pCO2-28* pH-7.45
calTCO2-20* Base XS--2
MICRO:
UCx [**9-18**]: URINE CULTURE (Final [**2132-9-21**]):
PRESUMPTIVE GARDNERELLA VAGINALIS. 10,000-100,000
ORGANISMS/ML..
BCx [**9-18**]: No growth to date, pending final
IMAGING:
ECG [**9-18**]: Sinus tachycardia. Vertical axis. Early R wave
progression. Consider right ventricular hypertrophy and
pulmonary disease. Since the previous tracing of [**2131-9-23**] no
significant change.
CT Head [**9-18**]: IMPRESSION: No acute intracranial process.
CXR [**9-18**]: IMPRESSION: No acute cardiopulmonary process
CTA Head and Neck w/ and w/o contrast [**9-19**]: FINDINGS: There has
been only minimal opacification of the arterial system due to
poor timing of image acquisition in relation to the contrast
bolus. Although there is no obvious large occlusion, further
assessment cannot be performed on this study. A repeat study
with more optimized bolus timing is recommended for evaluation.
Brief Hospital Course:
72-year-old female with a history of hypertension, [**Month/Day (4) **], and
multiple episodes of DKA, who presents with altered mental
status, fevers, and DKA.
ACTIVE ISSUES:
1. Diabetic ketoacidosis: Pt presented with glucose in the 600s
and ketones in her urine with anion gap. There was no triggering
cause established. Likely secondary to infection, given fevers
and leukocytosis. Glucose improved and gap closed on insulin gtt
and she was transitioned over to her home insulin regimen
without difficulty. Infectious workup included U/A, BCx
(negative to date) and CXR which were negative. LP was
attempted and unsuccessful in ED; again considered in MICU but
deferred as pt's mental status improved. She was discharged with
stable blood sugars for 48+ hours after deminstrating her
ability to draw up her own insulin and give the correct amount
depending on her blood sugar without any impairment. [**Last Name (un) **]
recommended we increase her Lantus to 17units qhs. We also
slightly increased her HSSI to start at 200 at bedtime instead
of 250.
2. Altered Mental status: Likely secondary her DKA (similar
symptoms previously) which could have been due to infection
given fevers to 101 and elevated WBC count however no clear
source of infection on workup. CXR without evidence of
pneumonia, U/A negative for UTI. The patient was unable to
undergo LP, but received a dose of vancomycin and ceftriaxone to
cover for meningitis which was stopped on day #2 due to clinical
improvement with low suspicion for meningitis. The neurology
stroke service evaluated her. A CTA was inconclusive due to
inappropriate timing of sequences. She was briefly keppra loaded
with concern for epileptic activity. Her mental status returned
to baseline on hospital day #2 and further workup of her AMS was
stopped. Per records she has a history of severe AMS in the
setting of DKA in the past. An EEG can be considered on an
outpatient basis if felt to be clinically indicated.
3. Hypoxia on Presentation: Patient's ABG on presentation showed
hypoxia with pO2:56 and pCO2:46. With her metabolic acidosis,
you would expect a lower pCO2 and she should not be hypoxic only
from this. Patient denies any respiratory symptoms. CXR with
chronic changes, no acute process. Pulmonary vasculature
prominent. Received empiric antibiotics for possible meningitis
coverage initially, which could have suppressed a respiratory
infection. She could have mucous plugging as well. She
potentially will need follow up for any lung pathology.
4. Hypertension: Chronic. Antihypertensives had been held in
MICU due to being normotensive. When she was transferred to the
floor, they were readded in a step-wise fashion with first
metoprolol, and then lisinopril/amlodipine restarted at home
dose. On discharge, her Isosorbide mononitrate was being held
and this can be started as an outpatient.
CHRONIC ISSUES:
1. CAD: Patient was continued on aspirin, plavix, statin, and
metoprolol at home doses.
TRANSITIONAL ISSUES:
-[**Last Name (un) **] and PCP f/u after DKA event and to assess to see if any
etiology is found to trigger this event. She was told to
schedule with PCP [**Name Initial (PRE) 176**] 1 week and [**Last Name (un) **] within a couple
weeks.
-BCx's pending on discharge
-BP: Patient restarted on all home BP meds except Isosorbide
Mononitrate. After f/u with PCP, [**Name10 (NameIs) **] as clinically
indicated
-Potential lung follow up if hypoxia seems to have been an
inciting event
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 16 Units Bedtime
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Glargine 16 Units Bedtime
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Diabetic Ketoacidosis
Secondary Diagnosis:
Altered Mental Status
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 102927**],
It was a pleasure taking care of you while you were at the [**Hospital1 1535**]. When you came to the hospital,
you were confused and had a very high blood sugar (Diabetic
Ketoacidosis). CT scan of your head did not show any new
problems causing your confusion, and your symptoms resolved when
your blood sugar corrected. After to talking with the [**Last Name (un) **]
on-call doctor, we increased your night time Lantus to 17 units
and slightly increased your insulin sliding scale to try to
prevent this from happening again.
We initially held some of your blood pressure medications
because your pressure was low. We restarted your Metoprolol,
Lisinopril, and Amlodipine, but did not give you your Isosorbide
Mononitrate. This can be restarted by your Primary Care
Physician.
Your appointment with Dr. [**Last Name (STitle) **] is currently for [**10-13**] but we would like you to call the office to move your
appointment to within 7 days of you being discharged. Also, you
should call your [**Last Name (un) **] doctor, Dr. [**First Name (STitle) **], to schedule an
appointment within a few weeks. Both of these numbers are listed
below.
The following medications were STOPPED during your admission:
Amlodipine
The following medications were CHANGED:
Lantus (Glargine)
Humalog Sliding Scale
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2132-10-13**] at 11:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Endocrinology
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
[**First Name (Titles) **] [**Last Name (Titles) 982**] Center
One [**Last Name (un) **] Place
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Fax: [**Telephone/Fax (1) 26643**]
Department: PODIATRY
When: WEDNESDAY [**2132-11-12**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5358
}
|
Medical Text: Admission Date: [**2105-4-6**] Discharge Date: [**2105-4-10**]
Date of Birth: [**2035-9-2**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
[**4-5**] intubation
History of Present Illness:
The pt is a 69 year-old man with PMHx of afib (not on
anticoagulation) s/p pacemaker, HTN, COPD, CAD s/p cardiac
bypass
in [**2104-1-19**], DM2 and adrenal insufficiency (on chronic steroids)
who presents from an OSH after 5 reported seizures. Per pt's
wife, the pt had been c/o "not feeling well" for 3 days, but did
not have any specific sx like runny nose, cough, sore throat
etc.
and did not have any fevers/chills. Then on [**4-5**], pt's wife
reports that he pt was on the phone with their granddaughter,
and
she thought he had hung up the phone (she was in the next room),
but then the phone rang again and he didn't pick it up, so she
went to check on him and found him on the bed with his arms and
legs shaking and her eyes rolled back. This lasted about a
minute
and so his wife called 911. [**Name2 (NI) **] then had 2 more before EMS
showed
up. EMS noted that he had urinated on himself. He was taken to
[**Hospital3 **], but in the ambulance and while in the ED he was
given
6mg of ativan, intubated, sedated (on propofol) and given
fosphenytoin 1200mg x1. He then began bucking the vent so was
given 2mg of additional ativan. As the pt is on chronic
steroids, there was concern for an infectious source of the
seizures, so at the OSH he was given vancomycin and zosyn, as
well as hydrocortisone 100mg IV x1.
He was then sent to [**Hospital1 18**] for further management. In the ED, he
was minimally responsive, not following commands. He had an LP
which showed 0 WBCs and 8 RBCs, with protein of 35 and glucose
of
165. He was noted to be afebrile. He was admitted to the neuro
ICU for further monitoring.
.
Pt is unable to complete the Neuro or General ROS as he is
intubated and sedated.
Past Medical History:
- afib not on anticoagulation
- s/p pacemaker
- HTN
- COPD
- CAD s/p cardiac bypass [**2104-1-19**]
- DM2
- hx of GIB
- LBB
- adrenal insuffiency
Social History:
- smoked 20 yrs 1ppd, quit 25 years ago, drinks 5 beers per day,
but did not suddenly stop recently (however, his ethanol level
was undetectable), no substance abuse, lives
with wife, retired from being a truck driver
Family History:
unknown
Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 97.8 P: 100 R: 18 BP:129/74 SaO2: 100% on ETT
General: intubated, not sedated, unresponsive
HEENT: ETT in place
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Pt unresponsive to voice or sternal rub, did not
follow commands, would occ. spontaneously open eyes and look
straight ahead.
-Cranial Nerves:
I: Olfaction not tested.
II: L pupil 2->1mm, R pupil 1.5->1mm, both reactive. Pt does
not
blink to threat. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages. Pt does not have corneal reflexes
bilaterally
III, IV, VI: Unable to test [**Name (NI) 3899**], pt unable to follow commands
V: Unable to test
VII: No facial droop (although ETT in place, therefore difficult
to assess), facial musculature appears symmetric.
VIII: Unable to test
IX, X: Per nursing, gag intact
[**Doctor First Name 81**]: Unable to test
XII: Unable to test
-Motor: Normal bulk, tone throughout. No asterixis noted. Pt
withdraws briskly in all 4 ext to noxious stim, but is unable to
cooperate more fully with strength testing.
-Sensory: Withdraws to noxious stim as above
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was withdrawal bilaterally.
-Coordination/Gait: Unable to test
------
Pertinent Results:
Admission Labs:
[**2105-4-5**] 11:44PM WBC-13.6* RBC-3.51* HGB-13.3* HCT-42.1
MCV-120* MCH-38.0* MCHC-31.7 RDW-14.7
[**2105-4-5**] 11:44PM PLT COUNT-178
[**2105-4-5**] 11:44PM PT-10.6 PTT-24.8* INR(PT)-1.0
[**2105-4-5**] 11:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
[**2105-4-5**] 11:44PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2105-4-6**] 12:43AM TYPE-ART PO2-175* PCO2-31* PH-7.22* TOTAL
CO2-13* BASE XS--13 INTUBATED-INTUBATED
[**2105-4-6**] 01:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-35
GLUCOSE-162
[**2105-4-6**] 01:30AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-8* POLYS-4
LYMPHS-58 MONOS-38
[**2105-4-6**] 08:24AM PHENYTOIN-2.8*
[**2105-4-6**] 08:24AM %HbA1c-5.8 eAG-120
[**2105-4-6**] 08:24AM ALBUMIN-3.1* CALCIUM-7.4* PHOSPHATE-3.4
MAGNESIUM-2.0
[**2105-4-6**] 08:24AM ALT(SGPT)-22 AST(SGOT)-51* ALK PHOS-85 TOT
BILI-0.4
[**2105-4-6**] 08:24AM GLUCOSE-209* UREA N-10 CREAT-1.0 SODIUM-142
POTASSIUM-3.7 CHLORIDE-117* TOTAL CO2-15* ANION GAP-14
NCHCT [**2105-4-6**]: No acute intracranial process. If there is
ongoing concern of the cause of seizures, then an MR may be far
more helpful than this non contrast CT.
LENIs [**2105-4-6**]: No deep venous thrombosis in right or left
lower extremity.
KUB [**2105-4-7**]: An image of the abdomen centered at the
umbilicus shows a
nasogastric tube coiled in the stomach and may end just below
the
gastroesophageal junction. There is no particular distention of
intestinal
tract in the upper abdomen.
NCHCT [**2105-4-6**]: There is no evidence of hemorrhage, edema,
mass, mass effect, or infarction. The ventricles and sulci are
normal in size and configuration. The basal cisterns appear
patent and there is preservation of [**Doctor Last Name 352**]-white differentiation.
No fracture is identified. Bilateral sclerosis of mastoid air
cells, right greater than left, suggest chronic inflammation.
Bilateral retention cysts are noted in the maxillary sinuses.
The visualized ethmoid and frontal sinuses are clear.
Chest Film [**2105-4-7**]: As compared to the previous radiograph,
the patient has been extubated and the nasogastric tube was
removed. Lung volumes have slightly decreased. The signs
suggesting fluid overload have slightly increased. The size of
the cardiac silhouette is still above the normal range. No
larger pleural effusions. No focal parenchymal opacity
suggesting pneumonia.
Brief Hospital Course:
69M w/ AF (not on AC) s/p PPM, HTN, COPD, CAD (s/p CABG), DM2,
adrenal insufficiency presented s/p five seizures. Intubated for
airway protection/respiratory support initially in ICU. The
patient initially was admitted for control of a cluster of
seizures which did not recur. He was treated with Fosphenytoin
which his liver appeared to metabolize quickly, resulting in
initial subtherapeutic levels. Fosphenytoin was subsequently
bolused and titrated up. He had a 20 min EEG performed to
exclude the possbility of status epilepticus which showed
encephalopathy but no epileptiform discharges or electrographic
seizures. When he was tapered from Propofol and extubated, his
mental status returned to his normal baseline.
In terms of the possible etiologies, he could then report that
he had no prior history of seizures. There were no toxic
metabolic abnormalities on his laboratory studies including on
measures of electrolytes, given his history of adrenal
insufficiency. He does, however, drink ETOH daily (at least five
beers) which although reporting consistent drinking during the
prior three days when he felt ill he also had an ETOH level of 0
upon arrival to our ED. He was treated with an MVI, thiamine,
and folate. He will be maintained on Dilantin mono-therapy (PO)
for 4 weeks after discharge before discontinuation.
In the days prior to his discharge, he remained at times
noncooperative with RN staff and PT staff on the floor. He
refused PT evaluations. At times, he would become tearful, and
at other times, he would make open advances to female nursing
staff. His wife arrived on his discharge day and confirmed his
sedentary lifestyle. He was extensively counseled by myself and
others about the importance reducing or discontinuing his
alcohol intake, and replacing his EtOH with diet and exercise.
He was prescribed thiamine/folate repletion. On discharge, he
had a nonfocal neurological examination.
Medications on Admission:
- ASA 81mg QD
- motrin 800mg Q8H PRN
- omeprazole 40mg QD
- percocet 1tab Q6H PRN
- insulin lispro (75/25) 14 units QAM and 6 units QPM
- hydrocortisone 15mg QAM and 5mg QPM
- florinef 0.1mg QD
- levothyroxine 150mcg QD
- K-Dur 40mEQ TID
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
4. insulin lispro 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous QAM: Take as prior to admission.
5. insulin lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous QPM: Take as prior to admission.
6. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
7. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
8. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. phenytoin sodium extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day): To be taken @ 8AM and 8PM.
Disp:*120 Capsule(s)* Refills:*0*
15. phenytoin sodium extended 100 mg Capsule Sig: 1.5 Capsules
PO once a day for 1 months: Take 1.5 tabs daily at 2 PM in
addition to 2 tabs daily at 8 AM and 8 PM.
Disp:*45 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care
Discharge Diagnosis:
Alcohol withdrawal seizure
Atrial fibrillation
Diabetes mellitus
Coronary artery disease
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 7739**],
It was a pleasure taking care of you during this
hospitalization. You were admitted to the Neuro-Intensive Care
unit and the Neurology wards of the [**Hospital1 827**] following several seizures. These seizures were
likely related to your alcohol use. We started you on a
medication called Phenytoin (dilantin) to decrease the chance of
having another seizure. Please continue this for one month. As
we discussed, it is very important that you stop drinking as
this likely caused your seizure, and could cause further
injuries and health problems if you continue to drink.
.
Physical therapy saw you, and recommended continued physical
therapy within your home after discharge.
.
According to [**State 350**] State law, you cannot drive until you
are seizure-free for six months after your event.
.
Please continue your medications as prescribed. In addition to
your anti-seizure medication, we added a medication (Atenolol)
for your blood pressure and a multivitamin, thiamine, and folate
to take daily with your home medications.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1693**], your primary care physician.
[**Name10 (NameIs) 6**] appointment has been made for you on Tuesday [**2105-4-14**]
at 1:00PM. The phone number is [**Telephone/Fax (1) 75799**], and their address
is 237A [**Street Address(1) **], [**Location **],[**Numeric Identifier 21478**].
Please also follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital1 771**]. An appointment has been scheduled for
you on Tuesday, [**6-16**] at 4 PM. His office can be reached at
[**Telephone/Fax (1) 2574**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2105-4-10**]
ICD9 Codes: 4019, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5359
}
|
Medical Text: Admission Date: [**2134-12-23**] Discharge Date: [**2134-12-29**]
Date of Birth: [**2076-4-21**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Bladder cancer
Major Surgical or Invasive Procedure:
Radical cystectomy and hysterectomy
History of Present Illness:
58 year old female with history of invasive bladder cancer s/p
TURBT in 9/[**2133**]. Now with a CT [**9-/2134**] showing left bladder
thickened wall with enhancement adjacent fat stranding.
Past Medical History:
PMH: HTN, TB exposure, hyperchol, lbp
PSH: TURBT
Social History:
unremarkable
Family History:
unknown
Physical Exam:
vital signs: T 97.8 HR 67 RR 20 BP 133/66 O2Sat 97% on RA
Gen: no acute distres
Lung: Clear to ausculation bilaterally
CV: RRR
Abdomen: soft, nontender, nondistended
Brief Hospital Course:
58yF with irritative LUTS, gross hematuria -> BT near L u/o
seen. TURBT [**8-18**] invasive hgTCC ?mp invasion. Patient underwent
radical cystectomy and ileal conduit; uncomplicated; please see
op note for full details. Her hospital course was uncomplicated.
Per system, neuro: initially managed with epidural, M-pca +
toradol and eventually changed to PO's with excellent pain
control; she did complain of some LBP, anesthesia evaluated,
likely musculoskeletal; she did have some tape blisters. POD1
her vag pack was removed. Short ICU course in which she was
extubaged POD1 and HD stabilized before transfer to floor.
Post-op CXR were clear. She was cardiovascularily stable
throughout. She was maintained npo/ngt until flatus occurring
POD2-3 with PPI; NGT was removed and her diet was advanced; POD6
she had a BM. She was given periop ancef/flagyl and remained
afebrile; 1 dose gent intraop.
DVT prophylaxis with venodynes and early ambulation. She has 2
ureteral stents which will stay in for 2-3 weeks, final duration
per Dr. [**Last Name (STitle) **]. She has 2 JPs were were removed late in her
hospital course after minimal output. She had a stoma consult
and was appropriately taught stoma management which VNA will
assist will. Her wound was C/D/I on discharge and her stoma as
pink, slightly flat; her staples will be removed this upcoming
Monday with Dr. [**Last Name (STitle) **].
Medications on Admission:
asa, ditropan, flonase prn, fosamax 70 qwk, hctz 25mg qd, lopid
600mg qd, loratadine 10 qd, ca/vitd
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO Q 24H (Every
24 Hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day as needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
5. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week.
6. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Bladder Cancer
Discharge Condition:
stable
Discharge Instructions:
* Increasing pain or persistent pain that is not relieved by
pain medications
*Inability to urinate
* Fever (>101.5 F)
*Nausea or Vomiting that last longer than 24 hours
* Inability to pass gas or stool
* Other symptoms concerning to you
Home with VNA services for stoma care/wound check.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] [**Last Name (STitle) 3726**] at [**Telephone/Fax (1) 15124**] to confirm follow-up
appt; tentatively scheduled for [**1-3**] for staple removal. Will
plan for stent removal in [**1-15**] weeks per Dr. [**Last Name (STitle) **].
Completed by:[**2134-12-29**]
ICD9 Codes: 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5360
}
|
Medical Text: Admission Date: [**2139-6-1**] Discharge Date: [**2139-6-10**]
Date of Birth: [**2057-10-19**] Sex: F
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Altered mental status (lethargy), bradycardia, hypercalemia
Major Surgical or Invasive Procedure:
Placement of left sided subclavian central venous line
PLacement of arterial line
History of Present Illness:
This is an 81 year old female with past medical history of
diastolic CHF, anemia, HTN, HL, who presnted today from home
with an unclear period of suffering from lethargy and altered
mental status. Apparently, the patient's daughter noted she was
very lethargic and thus brought her in to be evlaluated. It is
unclear when the daughter left but none of her insights are
available and she was not interviewed by either the ED resident
giving sign out or this writer. The patient apparently
complained of productive cough of an unclear duration but denied
fever or dyspnea.
In the ED initial VS 98.3 52 130/48 18 100%. She complained of
productive cough but denied fever, chest pain, or dyspnea. She
denied abdominal pain, nausea, or dysuria. Exam notable for
encephalopathy without focal findings. Labs revealed [**Last Name (un) **],
elevated troponin to 0.2, notably benign UA. CXR w/ ?
retrocardiac opacity and EKG not acutely ischemic. She was
given ceftriaxone/azithromycin for empiric treatment of CAP.
Trop was 0.2 so she was started on a heparin drip. PLans were
made to admit to the floor but then the patient was noted to
have sinus brady to the 40s without change in BP and then to the
20's with SBP's dropping into the 60s. Each of these episodes
resolved with a dose of atropine. Cards was consulted and said
they would see the patient on the floor, and tox was consulted
and recommended glucagon for treatment of a possible beta
blocker overdose. Glucagon administered without significant
change in HR. She was admitted to the ICU.
On arrival to floor pt continued to report productive sputum
without fever and deny other localizing symtpoms. Speaking very
slowly in short, difficult to understand sentences and not
always replying appropriately. Soon after arrival she dropped
her rate into mid 20's with decreased pressures with SBP's in
70s. Initially, HR and SBP improved with atropine but then only
HR with persistent low BPs. She was started on peripheral
dopamine with little improvement and then had another event
where she became barely responsive with SBP's in 60s but still
breathing and protecting airway. Anesthesia stat was called but
received one dose of epinephrine prior to intubation and this
increased SBPs into 110's with HR 100 and she became more
responsive so intubation deferred. Left subclavian CVL placed.
ROS: Unobtainable due to mental status.
Past Medical History:
-NIDDM
-Dyslipidemia,
-Hypertension
-Diastolic heart failure
-Anemia
-Low DLCO
-Osteoporosis
-ARF
-Gout
-Syrinx
-Renal cyst
Social History:
She does not smoke though has a distant history. No alcohol or
illicits. Lives with her husband, independent for ADLs.
Family History:
Father died young of cerbral hemorrhaage. Mother also died
young of complications of pneumona. CAD and vascular disease in
various other members.
aneurysm and a third with an MI.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 96.6, BP: 129/47, P 76, RR 16, O2 sat: 100% on 2L NC
General: Alert, no acute distress
HEENT: Sclera anicteric, MM exceedingly dry with white plaque
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally,but limited by poor
inspiratory effort
CV: bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Physical Exam on Discharge:
VS: 98.0, 122/82, 64, 20, 99% RA
General: AOX3, no acute distress
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, mild
nonpitting edema in lower extremities
Pertinent Results:
ADMISSION LABS
[**2139-6-1**] 12:25PM CALCIUM-23.3* PHOSPHATE-3.4 MAGNESIUM-2.8*
[**2139-6-1**] 12:25PM PTH-13*
[**2139-6-1**] 12:25PM WBC-22.0*# RBC-3.23* HGB-10.2* HCT-31.8*
MCV-98 MCH-31.5 MCHC-32.0 RDW-17.5*
[**2139-6-1**] 12:25PM NEUTS-90.1* LYMPHS-7.1* MONOS-1.9* EOS-0.7
BASOS-0.2
[**2139-6-1**] 12:25PM cTropnT-0.20*
[**2139-6-1**] 12:29PM LACTATE-1.5 K+-3.6
DISCHARGE LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2139-6-10**] 05:45 8.2 2.57* 8.3* 26.3* 102* 32.4* 31.7 19.5*
183
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2139-6-10**] 05:45 116*1 24* 1.3* 141 3.5 112* 21* 12
PERTINENT IMAGING
#[**2139-6-1**] CHEST (PA & LAT)
FINDINGS: AP upright and lateral views of the chest are
obtained. There is
mild elevation of the right hemidiaphragm with blunted right CP
angle which
could reflect a small effusion. Evaluation is overall limited
given the low
lung volumes, though there is no focal consolidation of overt
CHF. Bony
structures appear grossly intact. Degenerative spurring in the
mid thoracic
spine noted.
IMPRESSION: Possible small right pleural effusion. No overt
abnormalities
including no definite pneumonia.
#[**2139-6-1**] CT head
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect or
major vascular territorial infarction. Ventricles and sulci are
slightly
prominent, compatible with central atrophy. Mild periventricular
and
subcortical white matter hypodensities suggest chronic small
vessel ischemic
disease. There is no shift of normally midline structures. There
is no
fracture. Visualized paranasal sinuses and mastoid air cells are
well
aerated.
IMPRESSION: No acute intracranial process.
#[**2139-6-3**] CT ABD & PELVIS WITH CO
FINDINGS:
CONTRAST-ENHANCED CT OF THE CHEST:
There are small bilateral pleural effusions, right greater than
left, along
with bibasilar atelectasis. The heart size is mildly enlarged.
There are
coronary artery calcifications. There is no pericardial
effusion. Central
airways appear patent. There is some calcification noted along
the aortic
arch. There is no mediastinal, hilar, or axillary
lymphadenopathy.
CONTRAST-ENHANCED CT OF THE ABDOMEN:
Scattered hepatic cysts are identified. The gallbladder is
unremarkable.
There is no intra- or extra-hepatic biliary duct dilation. The
spleen,
pancreas, and adrenals are normal in appearance. Extensive cysts
and
low-density lesions likely representing cysts are noted in the
bilateral
kidneys. There is no hydronephrosis or hydroureter. There is no
abdominal
ascites. There is no mesenteric or retroperitoneal
lymphadenopathy. There is
no abdominal ascites. Extensive calcified plaque is noted
involving the
abdominal aorta along with the origin of the celiac artery, SMA,
and the
bilateral renal arteries. In particular, the SMA origin appears
to be
significantly narrowed.
CONTRAST-ENHANCED CT OF THE PELVIS:
A large amount of retained stool is noted in the rectosigmoid
colon.
Calcified uterine fibroids are present. A Foley catheter is
noted in the
bladder. Trace amount of free fluid is seen the right hemipelvis
(2:94). The
left-sided colon is narrowing, which may be in part to
underdistension. There
is no pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES:
Multilevel degenerative changes are noted. There is no
concerning lytic or
sclerotic lesion.
IMPRESSION:
1. No findings to suggest primary malignancy, as questioned.
2. Bilateral pleural effusions along with bibasilar atelectasis.
3. Numerous renal and hepatic cysts.
4. Extensive atherosclerosis of the abdominal aorta and branch
vessels
including the celiac trunk and the SMA.
5. Large amount of retained stool within the rectosigmoid colon.
# [**2139-6-2**] RENAL U.S. PORT
The left kidney measures 9.6 cm in length and shows no evidence
of hydronephrosis, stones, or solid masses. There is an
interpolar cyst measuring 2.1 cm, with no worrisome features.
The right kidney measures 10.1 cm in length and is largely
replaced by numerous cortical and parapelvic cysts. One of these
has a thin septation and measures 3.9 x 3.7 x 5.0 cm. This is
slightly larger than on the prior scan. The parapelvic cyst
measures 3.3 x 3.7 x 4.0 cm, similar in size to the prior.
However, there is suggestion of hydrocalix involving the upper
pole collecting system which was not seen on the prior study.
Views are somewhat limited in this portable scan due to
patient's difficulty in positioning.
CONCLUSION: Relatively normal-sized kidneys with multiple cysts,
particularly on the right side. There may be new hydrocalicosis
of the upper pole of the right kidney, but the appearance is
otherwise stable. There are no stones seen.
Brief Hospital Course:
81 y.o. female with history of hypertension, presenting with
altered mental status, and was found to have bradycardia,
hypercalcemia and leukocytosis.
ACTIVE ISSUES
# Hypercalcemia
Patient presented to the ED with Ca 23.6, with last normal Ca in
[**2139-5-8**]. Patient received Calcitonin and aggressive IV
fluid / lasix cycling in the ICU. Her Ca normalized gradually.
We suspect the cause is secondary to calcium supplements intake
in the setting of recent increase of losartan dose, although
patient explicitly denied overdosing. Of note, patient had
negative work up of PTH, TSH, SPEP, and no lytic lesions on
Chest X-ray, CT head/chest/abdomen/pelvis. Positive findings
include pan-hypoglobinemia, and occasional stipple cells on
peripheral smear. At the time of discharge, vitamin D level,
PTHrP, b2-microglobin, IgG kappa, Lamda are still pending.
-Pending issues
-- follow up on vitamin D, PTHrP, IgG kappa, Lamda
-- potential bone marrow biopsy as an outpatient for complete
melignancy work-up
# Bradycardia
Shortly after presenting to ED, patient developed bradycardia to
40s. She was admitted to MICU and received atropine there. The
etiology of bradycardia was thought to be related with
beta-blocker overdose vs idiosyncratic response to
hypercalcemia. Cardiology was consulted who felt bradycardia was
likely secondary to metabolic derangments. With improvement in
calcium bradycardia resolved. The heart rate has remained within
normal range in the past a couple of days prior to discharge.
# Leukocytosis
Patient presented to the ED with WBC of 22 (90% neutrophil).
Etiology: stress response vs infection. Infectious work-up
demonstrated [**12-8**] blood culture positive with coag-neg staph
(thought to be a contaminant); admission CXR also with findings
of ? early pneumonia. Patient received a total of 5 days of
treatment with ceftriaxone and doxycycline. Antibiotics were
discontinued due to low clinical suspicion of infection. In days
preceding discharge patient remained afebrile with normal WBC
without signs or symptoms of localized infection.
# Acute renal failure
Patient presented with a Cr 4.4 (baseline 1.5). The
cause-effect of acute renal failure and hypercalcemia is unclear
- ie whether [**Name (NI) **] resulted in hypercalcemia or vice versa.
Patient was aggressively hydrated. Creatinine nadired at 1.1. In
days preciding discharge noted to elevated to 1.2 - 1.3. Patient
continued on Lasix 40mg daily.
OUTPATIENT ISSUES:
-- Please check creatinine in 2-3d after discharge.
CHRONIC ISSUES
Ms. [**Known lastname 96383**] has a documented history of hypertension. Her blood
pressure medication were withheld temporarily in concern of
hemodynamic instability/bradycardia. At the time of discharge,
she was back on all her home blood pressure medication, which
she tolerated well. Her diabetes was controlled by sliding
scale insulin. [**Known lastname 96383**] appears to have baseline macrocytic
anemia, and developed mild thrombocytopenia, both of which
remained stable during this hospitalization.
TRANSITIONAL ISSUES
-- We have discontinued losartan, since we suspect that losartan
could have caused her acute renal failure.
-- Patient is switched to a lower dose furosemide 40 mg daily
(from 60 mg daily). Please follow up accordingly for possible
dose adjustment.
-- Patient is switched to a lower dose of allopurinol 100 mg
daily (from 300 mg daily) based on her current renal function
status.
-- Patient will need a cardiology appointment for follow up.
The appointment has not been made at the time of discharge.
-- Ms. [**Known lastname 96383**] is arranged to have hematology followup.
-- patients calcium/vitamin D on hold until seen in follow-up
Medications on Admission:
ALENDRONATE 70 mg by mouth once weekly
ALLOPURINOL 300 mg by mouth once a day
DARBEPOETIN ALFA 100 mcg sc Q3wks
FLUTICASONE 50 mcg - 2 sprays daily in both nostrils
FUROSEMIDE 60 mg by mouth daily
GABAPENTIN 300 mg by mouth twice a day
HYDRALAZINE 200 mg by mouth 3 times a day
LACTULOSE daily as needed for bowel movements
LOSARTAN 50 mg by mouth daily
METOPROLOL SUCCINATE 25 mg by mouth once daily
SIMVASTATIN 40 mg by mouth once a day
SITAGLIPTIN 50 mg by mouth daily
ASPIRIN 325 mg once a day
CALCIUM CARBONATE-VITAMIN D3 by mouth once a day
FERROUS GLUCONATE 325 mg daily on an empty
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) as needed for foot pain.
3. lactulose 10 gram/15 mL Solution Sig: 15-30 PO once a day as
needed for constipation.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. hydralazine 100 mg Tablet Sig: Two (2) Tablet PO three times
a day.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
11. darbepoetin alfa in polysorbat 100 mcg/mL Solution Sig: One
(1) Injection q3wks (every 3 weeks).
12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Outpatient Lab Work
Please have chemistry panel checked in 2-3days
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation and Nursing Center - [**Location (un) 701**]
Discharge Diagnosis:
Primary
Hypercalcemia
Acute renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 96383**],
You came to our hospital because on [**6-1**], and was found to
have acute kidney failure and very high calcium level in your
blood. Your heart rate later became too slow that requied
admission in our medical intensive care unit for treatment. We
stabilized your situation, and treated you with antibiotics for
a possible pneumonia. Your kidney function recovered in the
meantime. We still do not have a good explanation for the cause
of your elevated calcium level. Some of the studies are still
pending. We have set up several follow up appointments for you,
and our doctors [**Name5 (PTitle) **] discuss the remaining results with you.
CHANGES TO YOUR MEDICATION
-- Please stop taking Losartan until you discuss your physician
[**Name9 (PRE) **] [**Name10 (NameIs) 357**] take a lower dose of furosemide at 40 mg daily
Please see Dr. [**Last Name (STitle) **] on [**6-18**], Dr. [**Last Name (STitle) 3638**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
[**6-24**]. You will also need to call the [**Hospital 18**] [**Hospital **] at [**Telephone/Fax (1) 96384**]-9600 to make an appointment with your
primary care doctor for follow up. Please see below for more
information.
Please weigh yourself every morning, and call your doctor if
weight goes up more than 3 lbs.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2139-6-18**] at 10:30 AM
With: PADDY [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2139-6-24**] at 1 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2139-6-24**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 486, 2760, 4280, 2724, 2749, 2875, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5361
}
|
Medical Text: Admission Date: [**2187-5-5**] Discharge Date: [**2187-5-22**]
Date of Birth: [**2131-6-2**] Sex: M
Service: MEDICINE
Allergies:
Chlorhexidine
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Liver Biopsy - [**2187-5-8**]
EGD - [**2187-5-10**] and [**2187-5-16**]
History of Present Illness:
55 year old male with alcohol abuse and chronic pain on Vicodin
for the last 10 years who presents with jaundice and fatigue.
Patient reports he typically drinks two alcoholic drinks per
night (brandy) but his wife recently hospitalized and went on a
binge with friends over the weekend. He drank several liters of
rum in a two day period. He also continued to take tylenol and
vicoden (about [**4-10**] grams per day). When his wife came home from
the hospital she noted that he appeared yellow. He noted
abdomen distended and he felt fatigued. Denies BRBPR, melena,
nausea, vomiting, abdominal pain, fever, chills. He also denies
confusion. Notes his last drink was 3AM on [**5-4**].
.
He went to [**Hospital 1562**] hospital where labs notable for: WBC 32.5,
HCT 30, ALT/AST: 164/492 T. Bili 15.5, INR 1.4, ETOH level 91.
He was loaded with NAC, tylenol level 2.7 there.
.
In the [**Hospital1 18**] ED initial vital signs were 98.8 130 114/79 18 97%.
Persistently tachycardic. EKG showed sinus tach. Exam notable
for diffuse jaundice, abdomen non-tender and + asterixis. Has
peripheral edema. Labs notable for T. Bili 16.1, ALT/AST:
168/481, Phos 0.7 serum and urine tox negative. INR 1.7,
platelets >500. U/A negative. Patient received 4 hour NAC gtt
and lactulose and PO phos. Liver consulted as discriminate
function is 49, but they did not feel steroids were indicated.
VS on transfer: 118/76 HR :125 RR:23 97% on RA
Past Medical History:
- Rotator cuff injury
- Alcoholism
- Multiple orthopedic surgeries right knee, right shoulder and
both feet
Social History:
- Tobacco: denies
- etOH: [**3-9**] alcoholic drinks/night, denies history of withdrawls
- Illicits: denies
Family History:
His father was a smoker and DM. No one has liver disease
Physical Exam:
Exam on Admission:
VS: afebrile HR 125
GEN: AOx3, NAD, jaundice
HEENT: MMM, no JVD, neck supple,
Cards: tachycardic, no audible murmur
Pulm: dullness at the bases
Abd: distended, tympanic, no fluid wave. BS+, NT
Limbs: 2+ edema in the legs,
Skin: No rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, gait deferred
.
Exam on Discharge:
VS: HR low 100s
Skin: Jaundice
Abd: Distended, non-tender, no fluid wave
Ext: [**2-8**]+ pitting edema in lower extremities
Pertinent Results:
[**2187-5-5**]
06:10PM BLOOD WBC-22.3* RBC-2.35* Hgb-10.5* Hct-29.9* MCV-127*
MCH-44.6* MCHC-35.1* RDW-18.2* Plt Ct-512*
[**2187-5-5**] 06:10PM BLOOD WBC-22.3* RBC-2.35* Hgb-10.5* Hct-29.9*
MCV-127* MCH-44.6* MCHC-35.1* RDW-18.2* Plt Ct-512*
[**2187-5-5**] 06:10PM BLOOD Neuts-84.5* Lymphs-11.6* Monos-3.3
Eos-0.1 Baso-0.4
[**2187-5-5**] 06:10PM BLOOD PT-19.0* PTT-30.9 INR(PT)-1.7*
[**2187-5-7**] 04:13AM BLOOD Fibrino-411*
[**2187-5-5**] 06:10PM BLOOD Glucose-175* UreaN-20 Creat-0.8 Na-126*
K-3.3 Cl-85* HCO3-27 AnGap-17
[**2187-5-5**] 06:10PM BLOOD ALT-168* AST-481* AlkPhos-295*
TotBili-16.0* DirBili-11.8* IndBili-4.2
[**2187-5-7**] 04:13AM BLOOD ALT-159* AST-383* LD(LDH)-310*
AlkPhos-259* TotBili-19.9*
[**2187-5-5**] 06:10PM BLOOD Albumin-2.5* Calcium-7.8* Phos-0.7*
Mg-2.1
[**2187-5-6**] 03:28AM BLOOD calTIBC-96* VitB12-796 Folate-13.8
Ferritn-3044* TRF-74*
[**2187-5-6**] 03:28AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND
[**2187-5-5**] 10:43PM BLOOD Lactate-3.7*
.
LABS ON DISCHARGE:
WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2187-5-22**] 04:15 25.9* 2.40* 9.2* 28.2* 118* 38.3* 32.5 21.0*
422
Glu UreaN Creat Na K Cl HCO3 AnGap
[**2187-5-22**] 04:15 149*1 39* 1.0 135 4.8 104 25 11
ALT AST AlkPhos TotBili
[**2187-5-22**] 04:15 156* 208* 281* 11.5*
.
MICROBIOLOGY:
BLOOD CULTURE:
Blood Culture, Routine (Final [**2187-5-12**]):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS.
NO GROWTH DUE TO NONVIABILITY.
GRAM NEGATIVE ROD(S). NO GROWTH DUE TO NONVIABILITY.
Anaerobic Bottle Gram Stain (Final [**2187-5-6**]):
Reported to and read back by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] @ 3:20 PM ON
[**2187-5-6**].
GRAM POSITIVE COCCI IN PAIRS.
GRAM NEGATIVE ROD(S).
.
Remaining surveillance blood cultures were negative.
.
Urine Culture: negative
.
Stool Culture:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2187-5-21**]):
CLOSTRIDIUM DIFFICILE: FECES POSITIVE FOR C. DIFFICILE
TOXIN BY EIA.
.
IMAGING:
CT OF THE ABDOMEN WITH IV CONTRAST:
The liver is diffusely enlarged and heterogeneous with massive
enlargement of the caudate lobe. There are multiple large
nodular lesions in the liver most prominently in segment III
measuring measuring 2.5 cm (3:49), Segment IVB (2.1 and 1.7 cm)
and a large lesion in the caudate lobe which splays the adjacent
vessels (3:178 4.7 x 4.7 cm). All lesions are hypoattenuating
compared to liver parenchyma and show no enhancement on the post
contrast
phases.
.
The spleen is normal in size. There is a small hiatal hernia.
The portal and hepatic veins are patent. The hepatic arteries
are patent as well. No focal lesions are noted within the liver.
The gallbladder is unremarkable although a small stone is
noted.. Pills are noted in the stomach. Both adrenals, pancreas,
and both kidneys (with the exception for simple cysts) are
unremarkable. There is small amount of simple fluid ascites with
a little bit of stranding and wall thickening of the jejunum,
which is likely related to collapse. No abdominal free air is
present. No abdominal, retroperitoneal or mesenteric
lymphadenopathy by CT size criteria is present.
.
IMPRESSION:
1. Massively enlarged liver with multiple nodular lesions that
show no
post-contrast enhancement. These are indeterminate in nature but
are amenable to percutaneous biopsy (especially the nodules in
segment III, IVB). The portal vein, hepatic vein, and hepatic
arteries are patent.
2. Small amount of ascites without splenomegaly.
3. Small hiatal hernia.
.
ECHO:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No vegetations or clinically-significant valvular
disease seen.
.
LIVER ULTRASOUND ([**2187-5-13**]):
Technically difficult study. Patent main hepatic artery. The
left portal
vein was not definitely visualized. No mass lesions were noted.
However,
evaluation for these lesions is limited due to the factors
described above. A CT or MR is recommended for further
evaluation of the hepatic vessels as well as for focal lesions.
.
LIVER BIOPSY:
Liver, core needle biopsy:
1. Cirrhosis on trichrome stain with a prominent component of
sinusoidal fibrosis. Reticulin stain also evaluated.
2. Marked fatty change with extensive balloon degeneration,
prominent hyalin, and neutrophils surrounding degenerating
hepatocytes.
3. Mixed inflammation and bile duct proliferation in portal
areas/fibrous tract with a component of neutrophils.
4. Immunostain for cytomegalovirus is negative with appropriate
positive control.
5. Immunostain for glypican is negative with appropriate
positive control.
6. No increase in iron on iron stain.
.
EGD ([**2187-5-10**]):
Grade 4 esophagitis in the gastroesophageal junction and lower
third of the esophagus compatible with erosive esophagitis.
Mosaic appearance in the stomach body and fundus compatible with
mild gastropathy. Normal mucosa in the whole duodenum (biopsy).
No esophageal or gastric varices seen.
.
ESOPHAGEAL BIOPSY:
- Active esophagitis, neutrophilic, with ulceration.
- Special stains for fungi is pending.
.
Brief Hospital Course:
# Acute Hepatitis: On presentation, the patient had acute onset
of jaundice and labs were notable for MELD of 21 and
discriminant function of 49. His presentation and laboratory
values were believed to be consistent with alcoholic hepatitis.
Liver was consulted and recommended against steroids;
pentoxyphiline was initiated. The patient LFTs and liver
synthetic function trended down initially, then reached a
plataeu, suggesting inadequate response. He was ultimately
started on a course of prednisone 40 mg, for a presumed 28 day
course (to be completed on [**6-13**]). A feeding tube was placed in
order to bolster his nutritional intake. Serum studies for viral
hepatitis, wilson's disease, hemochromatosis, alpha-1
antitrypsin, autoimmune hepatitis were negative. AFP was
normal. Of note his anti-smooth muscle antibody was positive,
but the titre was weakly positive at 1:20. In the setting of
negative [**Doctor First Name **], it was felt that his presentation was unlikely due
to autoimmune hepatitis. With prednisone initiation, the
patient's bilirubin began steadily trending downwards by the
time of discharge. Please monitor bilirubin, WBC for evidence of
continued improvement.
.
# Upper GI bleeding: On HD 5, the patient was noted to have
coffee ground emesis, gastroccult positive. He was transferred
to the intensive care unit and NG lavage showed about 300cc of
coffee ground. He was also started on octreotide and
pantoprazole gtt. The patient's VS remained stable and EGD was
performed; EGD revealed severe esophagitis, presumed to be the
source of the bleed. There was no evidence of active bleeding or
esophageal varices. The patient's octreotide was stopped. He
was started on a oral PPI and sucralfate. His HCT remained
stable after transfer to the floor, with no further episodes of
bleeding.
.
# C.Diff: C.diff toxin returned positive on [**2187-5-21**] in the
setting of rising WBC count and worsening diarrhea. He was
treated with PO flagyl to complete a ten day course (continue
through [**2187-5-30**]).
.
# Tachycardia: Patient presented with sinus tachycardia to the
100-120s. This tachycardia persisted in the low 100s throughout
the course of his hospital stay. This tachycardia was believed
to be secondary to hepatic decompensation, and subsequent
peripheral vasodilation. Also considered the contribution of
infection (c.diff). He was given fluid boluses with mild
improvement in heart rate. ECHO showed normal global and
regional biventricular systolic function, without vegetations or
clinically-significant valvular disease seen. No hypoxia or
right-heart strain to suggest pulmonary embolism.
.
# BRBPR: Patient had small volume bleeding per rectum following
defecation. It is believed to be secondary to internal
hemmoroids. HCT and hemodynamics remained stable throughout
admission.
.
#. Positive blood culture: The patient had one blood culture
that grew GPCs and GNRs, however all subsequent surveillance
cultures returned with no growth. He was started on Vancomycin
and Zosyn empirically, but this was discontinued shortly
thereafter as he remained afebrile, HD stable, and with
re-peated negative blood cultures.
.
# Liver Lesions: Initially visualized on liver U/S. Subsequent
CT abdomen showed multiple nodular lesions that show no
post-contrast enhancement. AFP was normal. Biopsy of these
lesions was conducted by IR; biopsy showed evidence of bile duct
proliferation with neutrophils, consistent with alcoholic
hepatitis.
.
# Cirrhosis: No prior history of liver disease. Ultrasound and
CT revealed cirrhotic liver with small amount of ascites. He was
started on furosemide and spironolactone given significant edema
in the setting of his hepatic decompensation. Please monitor
patient's creatinine and electrolytes. No varices on EGD. No
evidence of encephalopathy or SBP during hospital course.
.
#. Macrocytic Anemia: Likely due to alcohol. HCT remained
stable. B12 and folic acid were normal.
.
# Hyponatremia: Remained stable. Likley related to cirrhosis.
.
#. Alcohol abuse: No evidence of withdrawal during hospital
stay. Started on PO thiamine, folate, MVI.
.
# Transitions of Care:
- Will follow-up with Dr. [**Last Name (STitle) 497**] in outpatient liver clinic
- Check the following labs on [**2187-5-24**], and three times weekly
thereafter: LFTs, bilirubin, INR, albumin, CBC, chemistry panel.
- Continue prednisone through [**6-13**]
- Continue flagyl through [**5-30**]
- Monitor HCT daily given small volume bright-red blood per
rectum (likely hemmoroids)
Medications on Admission:
Vitamin daily
Vicodin 5 mg-500 mg 2 Tablet(s) every three hours per day
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 22 days: Continue through [**2187-6-13**]. .
7. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day) as needed for anal pain.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days: Please continue through [**2187-5-30**].
10. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tube Feeds
Tubefeeding: Isosource 1.5 Cal Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 55
ml/hr
Hold feeding for residual >= : 200 ml
Flush w/ 30 ml water q6h
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
- Alcoholic Hepatitis
- Clostridium Dificile
- Severe Esophagitis
- Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 25067**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with
significant injury to your liver. This is likely related to
alcohol intake prior to coming to the hospital. Ultimately, your
liver began to recover with the help of steroids.
.
During your hospital stay, you also had bleeding from your
digestive tract. This bleeding resolved and your blood counts
remained stable. You were started on medications to help prevent
bleeding in the future.
.
Please START the following medications after discharge:
- Thiamine
- Folic Acid
- Pantoprazole
- Sucralfate
- Spironolactone
- Furosemide
- Flagyl (Metronidizole)** Continue through [**5-30**].
- Prednisone** Continue through [**6-13**].
.
Please STOP the following medication after discharge:
VICODIN
.
Should you experience any concerning symptoms after leaving the
hospital, please return to the emergency room or call your liver
doctor.
Followup Instructions:
Name: [**Last Name (LF) 497**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/LIVER CENTER
Address: [**Doctor First Name **] STE 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
*You will be contact[**Name (NI) **] with an appointment to see Dr. [**Last Name (STitle) 497**]
within 2 weeks. If you dont hear from his office by this
Thursday, please call the number above.
.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
ICD9 Codes: 0389, 2761, 5789, 2851
|
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|
Medical Text: Admission Date: [**2110-2-11**] Discharge Date: [**2110-2-14**]
Date of Birth: [**2045-3-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
nausea and abdominal discomfort
Major Surgical or Invasive Procedure:
cypher stents to left anterior descending artery
History of Present Illness:
64 y/o male w/ hx high cholesterol and borderline HtN, presents
to [**Hospital1 18**] ED by way of PCP w/ 1 day of indigestion and
palpitations which came on while having nacho's and beer. States
he was in his USOH until this episode. Denies shortness of
breath, chest pain, diaphoresis, dizziness, syncope.
Past Medical History:
high cholesterol
borderline hypertension
Social History:
Lives with wife. History of smoking. Alcohol use "occasional"
Physical Exam:
Gen: NAD but very mildly diaphoretic
Neck: no JVD
Card: RRR, nl s1s2, no mrg
Lungs: clear
Abd; soft , nt, nd, nabs
Ext: wwp, no cce
Pertinent Results:
EKG in ED: Sinus rhythm with borderline resting sinus
tachycardia. Borderline low limb and
lateral precordial voltage. Extensive anterior and lateral Q
wave myocardial
infarction pattern, probably recent, with ST segment elevations
in those leads
and probable slight reciprocal change in leads III and aVF.
Right axis
deviation attributable to loss of lateral QRS forces here. If
findings are more
chronic, then underlying ventriciular aneurysm is suspected.
Clinical
correlation is suggested. No previous tracing available for
comparison.
.
[**2110-2-11**] 12:10PM WBC-15.1*# RBC-4.81 HGB-14.2 HCT-41.8 MCV-87
MCH-29.6 MCHC-34.1 RDW-13.0
[**2110-2-11**] 12:10PM NEUTS-85.2* LYMPHS-8.9* MONOS-5.6 EOS-0.2
BASOS-0.2
[**2110-2-11**] 12:10PM CK-MB-449* MB INDX-12.4*
[**2110-2-11**] 12:10PM cTropnT-5.35*
[**2110-2-11**] 12:10PM ALT(SGPT)-88* AST(SGOT)-461* CK(CPK)-3608*
ALK PHOS-104 TOT BILI-0.8
.
Cardiac Catheterization Report:
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through a 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French XBLAD guide and a 6 French JR4 catheter, with manual
contrast
injections.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.01 m2
HEMOGLOBIN: 14.2 gms %
POST ANGIO
**PRESSURES
RIGHT ATRIUM {a/v/m} 15/16/12
RIGHT VENTRICLE {s/ed} 43/15
PULMONARY ARTERY {s/d/m} 43/25/32
PULMONARY WEDGE {a/v/m} 25/24/22
AORTA {s/d/m} 119/78/96
**CARDIAC OUTPUT
HEART RATE {beats/min} 91
RHYTHM SR
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 50
CARD. OP/IND FICK {l/mn/m2} 5.0/2.5
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1344
PULMONARY VASC. RESISTANCE 160
**% SATURATION DATA (NL)
SVC LOW 58
PA MAIN 65
AO 91
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 0.21
pO2 71
pCO2 36
pH 7.46
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE 100
9) DIAGONAL-1 DIFFUSELY DISEASED
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
**PTCA RESULTS
LAD
**BASELINE
STENOSIS PRE-PTCA 100
**TECHNIQUE
PTCA SEQUENCE 1
GUIDING CATH XBLAD 3.
GUIDEWIRES WHISPER
INITIAL BALLOON (mm) 2.0 X 20
FINAL BALLOON (mm) 3.0 X 13
# INFLATIONS 11
MAX PRESSURE (PSI) 300
**RESULT
STENOSIS POST-PTCA 0
SUCCESS? (Y/N) Y
PTCA COMMENTS:
We elected to treat the totally occluded LAD with
PTCA/Stenting.
Heparin and Integrilin were administered prophylactically.
A 6 French XBLAD 3.5 guide provided adequate support after
selective
engagement in the LAD. A Choice PTXS wire and Whisper wire were
used to
cross into the distal LAD with moderate difficulty due to
angulation of
the mid-LAD. A 2.0 x 20 mm Voyager was used to dotter through
the
occlusion (restoring flow) and to predilate at 6 atm. We were
unable to
cross with a 2.5 x 28 mm Cypher DES, so the LAD was further
predilated
with a 2.5 x 12 mm Quantum Maverick at 6, 10 and 12 atm, and
then with a
2.75 x 15 mm Quantum Maverick at 12 atm in 3 inflations. The
wire was
exchanged for a Stablizer XS wire, and the stent was delivered
with the
use of the Choice PTXS wire as a buddywire. The stent was
deployed at
18 atm, and a 3.0 x 13 mm Cypher DES was then deployed in
overlapping
fashion more proximally at 20 atm. The SDS was used to
post-dilate the
overlap area at 14 atm. We then crossed through the stent into
the
jailed diagonal and used the 2.0 x 20 mm Voyager to balloon the
ostium
at 6 atm. Intracoronary Nitroprusside was administered in the
mid-LAD
through the lumen of the 2.0 x 20 mm Voyager.
Final angiography demonstrated no dissection, no residual
stenosis
within the LAD and a 20% residual at the ostium of the diagonal,
with
TIMI-3 flow.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 26 minutes.
Arterial time = 1 hour 23 minutes.
Fluoro time = 39.3 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 255
ml, Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 1500 units IV
Other medication:
Eptifibatide 7.30 cc IV
Eptifibatide 13.0 cc/hr IV
TNG 10 mcg/min/IV
Nitroprusside 250 mcg IC
Fentanyl 25 mcg IV
Clopidogrel 300 mg PO
Midazolam 0.5 mg IV
Cardiac Cath Supplies Used:
.014 [**Company **], CHOICE PT XS, 300CM
.014 GUIDANT, WHISPER
.014 CORDIS, STABILIZER XS SUPERSOFT 300
2.0 GUIDANT, VOYAGER 20
2.5 [**Company **], QUANTUM MAVERICK, 12
2.75 [**Company **], MAVERICK, 15
6F CORDIS, XBLAD 3.5
300 CM MALLINCRODT, OPTIRAY 100CC
2.5 CORDIS, CYPHER OTW, 28
3.0 CORDIS, CYPHER RX, 13
COMMENTS:
1. Selective coronary arteriography of this right-dominant
system
revealed single vessel disease. The LMCA was free of
angiographically-evident flow-limiting stenoses. The LAD was
totally
occluded at the level of the first diagonal branch. The LCX had
mild
luminal irregularities. The RCA had mild luminal
irregularities.
2. Hemodynamic evaluation after PCI revealed mildly elevated
right-sided pressures (mean RA was 12 and RVEDP was 15 mmHg),
moderately
elevated left-sided pressures (mean PCW was 22 mmHg), and
moderately
elevated pulmonary pressures (PA was 43/25 mmHg). The cardiac
index was
normal at 2.5 L/min/m2 (using an assumed oxygen consumption).
3. Successful PCI of the LAD with two overlapping Cypher DES
(3.0 x
13 mm and 2.5 x 28 mm) (see PTCA comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Elevated right and left sided pressures.
3. Successful primary PCI of the LAD for acute ST-elevation
myocardial
infarction (anterior location).
.
ECHO:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 35% (nl >=55%)
Aorta - Valve Level: *4.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.33
Mitral Valve - E Wave Deceleration Time: 150 msec
TR Gradient (+ RA = PASP): *31 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderate
regional LV systolic dysfunction. No LV mass/thrombus.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic root. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal.
The left ventricular cavity size is normal. There is moderate
regional left
ventricular systolic dysfunction with severe hypokinesis of the
mid to distal
septum and anterior walls an akinetic apex (LAD). No masses or
thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall
motion are normal. The aortic root is moderately dilated. The
aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal LV cavity size with moderate regional LV
systolic
dysfunction c/w CAD (LVEF 35%). Normal RV cavity size and
systolic function.
Moderately dilated aortic root. Mild biatrial enlargement. Mild
pulmonary
hypertension.
.
Brief Hospital Course:
In the [**Name (NI) **] pt was noted to have EKG c/w recent anterior MI. He
was taken to the catheterization lab where he was found to have
one vessel coronary artery disease, elevated right and left
sided pressures. There the patient underwent a successful
primary PCI of the LAD with a cypher stent for acute
ST-elevation myocardial infarction. Pt had no arrythmias in the
post catheterization period. An echo fond EF of 35% without
regional hypokinesis and akinesis at the apex (see Results
Section). Pt was started on beta blocker, aspirin, increased
statin dose, an ace inhibitor, plavix, and coumadin. He was
instructed to take plavix for only three months. He was
discharged to home with follow-up scheduled for the [**Hospital1 18**]
cardiology clinic.
Medications on Admission:
GLUCOSAMINE-CHONDR-MSM 500-400MG--As needed for pain in joints
IBUPROFEN 600MG--One tablet by mouth three times a day for 3-5
days then as needed.LIPITOR 10MG--Take one daily
MECLIZINE HCL 25MG--One three times a day for dizziness
SILDENAFIL CITRATE 100MG
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 30 days.
Disp:*90 Tablet(s)* Refills:*0*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*180 Tablet(s)* Refills:*0*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute myocardial infarction
Discharge Condition:
stable
Discharge Instructions:
Return to emergency department if you have chest pain, shortness
of breath, or dizziness.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 94291**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2110-2-18**]
10:00
.
Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2110-3-3**] 3:45
Completed by:[**2110-3-14**]
ICD9 Codes: 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5363
}
|
Medical Text: Admission Date: [**2135-6-22**] Discharge Date: [**2135-7-1**]
Date of Birth: [**2055-11-16**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor / Fosamax
Attending:[**Doctor First Name 7926**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Ms. [**Known lastname **] is a 79 year old lady with pulmonary HTN (on adcirca,
tyvaso, letairis), CAD s/p stents, HTN, and recent T5 + T8
compression fractures, diastolic CHF, and multiple other medical
problems who presents because she is feeling unwell and has been
short of breath lately.
.
She has been feeling unwell since her discharge from our
hospital on [**2135-6-7**]. At the previous admission she was found to
have two new spinal compression fractures at T5 and T8. She was
treated for pain with tramadol, lido patch, and tylenol, but
hasn't been taking her tramadol recently because she was worried
about its long-term effects. She states that she has been
splinting and not breathing well because her back pain worsens
with movement, breathing, and lying flat. Back pain is [**2133-4-16**].
She states that she is still ambulatory and has always been SOB
when walking, but it's worse now. She denies chest pain, cough,
or recent episode of choking. She has required 5L of oxygen
today but is usually on 4L at home.
.
As for her UTI, she denies dysuria, hematuria, urinary urgency
and frequency, as well as nausea, vomiting, fever, or chills.
She does endorse cloudy urine. She was discharged on her last
admission with cipro 500 [**Hospital1 **] x 8 days (ended [**6-8**]) to treat a
UTI.
.
Due to feeling poorly, she saw her PCP today, who referred her
to our ER. At home today her BP was low - 80/50. Of note, she
recently started hydrochlorothiazide 25 mg QHS three days ago.
She also complains of leg edema to her hips, but states it's
much improved today.
.
* has had pneumovax in last few years
.
On the floor, Vitals: 98.3 116/61 pulse 95 rr 18 O2 sat 92 on 5L
.
Review of sytems:
(+) leg edema
negative unless mentioned above.
Past Medical History:
- Coronary artery disease status post inferior MI with
subsequent Cypher stenting to the mid RCA in [**2130-4-11**].
- Non-ST elevation MI in [**2133-12-12**] with cardiac
catheterization that showed 80% OM1 lesion with subsequent
stenting of the OM with a 2.5x18mm Endeavor DES. The LAD was
stented with a 2.25 x 20 mm Taxus stents as well as an
overlapping proximal 2.25 x 8 mm Taxus stent. This procedure
was
complicated by a small distal wire perforation without any
extravasation. Due to a balloon-induced dissection in the LAD, a
3.0 x 23 Promus stent was deployed as well as a 2.5 x 12 mm
Promus stent deployed in the LAD.
- Chronic dyspnea on exertion with diastolic dysfunction and
known pulmonary hypertension with right heart catheterization in
[**2134-11-11**] showing a PA pressure of 71/28 with a mean PA
33mmHg with a wedge of 8mmHg. She was not responsive to
vasodilator challenge in cath lab and thus is on advanced
therapy with adcirca and tyvaso reporting mild symptomatic
improvement.
- Hypertension.
- Hyperlipidemia.
- TIA, bilaterall less than 40 % carotid stenosis ([**2130**])
- bladder diverticulosis
- Obstructive Sleep apnea-Does use BiPAP
- s/p right total knee replacement
- osteopenia
- GERD
- s/p total Hysterectomy
- Lung surgery to correct large diaphgram hernia
- Kidney stone
- childhood asthma
Social History:
Lives in [**Location (un) 96048**] with her dughter. Formerly employed as
a nurse. [**First Name (Titles) **] [**Last Name (Titles) 96049**] socially in the past, but quit a long
time ago. Never drank alcohol, denies illicit drugs.
Family History:
Mother died from colon ca, father with cardiac history and early
MI.
Physical Exam:
Admission physical exam:
Vitals- 98.3 116/61 pulse 95 rr 18 O2 sat 92 on 5L
General- Alert, oriented, no acute distress but on NC 5L
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP prominent, no LAD
Lungs- no wheezes, rales, ronchi, but mild crackles at bilateral
bases
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU- foley in
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis, no
edema
Neuro- CNs2-12 intact, motor function grossly normal,
appropriate
Discharge physical exam:
PHYSICAL EXAMINATION:
VS- T=98.2 BP=116/58 HR=64 RR=18 O2 sat=94% on 4L
I/O X past 8 hours: 0/200. I/O over [**2135-6-28**]: [**Telephone/Fax (1) 96050**]
GENERAL- Obese elderly woman in NAD. On MRSA precautions.
Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. Eyes w/ erythromycin ointment.
EOMI. Conjunctiva were pink.
CARDIAC- RR, S2 > S1. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities. Significant kyphosis. Resp are
unlabored, no accessory muscle use. CTAB.
ABDOMEN- Soft, NTND.
EXTREMITIES- No c/c/e. 1+ pitting edema in LEs, not increased
from prior exam.
Pertinent Results:
Admission labs:
[**2135-6-22**] 09:47AM BLOOD WBC-8.4 RBC-3.73* Hgb-11.5* Hct-35.7*
MCV-96 MCH-30.8 MCHC-32.2 RDW-15.5 Plt Ct-213
[**2135-6-22**] 09:47AM BLOOD Neuts-76.7* Lymphs-8.0* Monos-4.8
Eos-10.1* Baso-0.4
[**2135-6-23**] 06:00AM BLOOD PT-12.2 PTT-25.6 INR(PT)-1.1
[**2135-6-22**] 09:47AM BLOOD Glucose-117* UreaN-30* Creat-1.2* Na-138
K-3.8 Cl-95* HCO3-32 AnGap-15
[**2135-6-23**] 06:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
[**2135-6-24**] 06:00AM BLOOD ANCA-NEGATIVE B
[**2135-6-24**] 06:00AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2135-6-24**] 06:00AM BLOOD RheuFac-8
[**2135-6-25**] 11:53AM BLOOD Lactate-0.8
Radiology:
[**2135-6-25**] Portable CXR:
FINDINGS: As compared to the previous radiograph, there is an
increase in interstitial markings and an increase in diameter of
the pulmonary vasculature. In conjunction with the increased
cardiac silhouette, these findings are suggestive of mild to
moderate pulmonary edema. The presence of a minimal left
pleural effusion cannot be excluded, given blunting of the left
costophrenic sinus. At the time of observation and dictation,
10:38 a.m., the referring physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 96051**] was paged
for notification, on [**2135-6-25**].
Given that no lateral radiograph was performed, the compression
fractures
cannot be evaluated.
CXR [**2135-6-24**]: FINDINGS: "Massive degenerative changes in the
cervical spine, but no evidence of compression. Mild
compression of T5, massive compression of T8. As compared to
previous chest radiographs that are available from [**2135-6-22**], these changes are constant. However, if compared to the
chest radiograph of [**2134-11-2**], these changes have
massively progressed. No evidence of new vertebral compression.
The lumbar spine shows anterolisthesis of L5 with respect to S1
and moderate degenerative changes, but no evidence of vertebral
compression. Extensive vascular calcifications. "
EKG [**2135-6-25**]:Sinus rhythm. Prior inferior wall myocardial
infarction. No major change from the previous tracing.
Microbiology:
URINE CULTURE (Final [**2135-6-26**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2135-6-22**] 10:56 pm BLOOD CULTURE FROM LEFT ARM.
**FINAL REPORT [**2135-6-28**]**
Blood Culture, Routine (Final [**2135-6-28**]): NO GROWTH.
Echo [**2135-6-27**]:
IMPRESSION: Suboptimal image quality. Right ventricular cavity
dilation and free wall hypokinesis. Normal left ventricular
cavity size with preserved global systolic function. Pulmonary
artery hypertension.
Compared with the prior study (images reviewed) of [**2135-5-30**],
right ventricular cavity size is similar, but with more
pronounced free wall dysfunction. The estimated PA systolic
pressure is also lower. This suggests more prominent right
ventricular systolic dysfunction.
DISCHARGE LABS
[**2135-7-1**] 07:06AM BLOOD WBC-6.9 RBC-3.31* Hgb-9.8* Hct-31.4*
MCV-95 MCH-29.8 MCHC-31.3 RDW-15.2 Plt Ct-236
[**2135-7-1**] 07:06AM BLOOD Glucose-116* UreaN-34* Creat-1.2* Na-138
K-3.8 Cl-91* HCO3-39* AnGap-12
[**2135-7-1**] 07:06AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0
Brief Hospital Course:
Patient is a 79yo F w/ PMHx pulmonary HTN (dCHF and primary pulm
HTN related) (on adcirca, tyvaso, letairis), CAD s/p stents,
HTN, and recent T5 + T8 compression fractures, diastolic CHF,
and multiple other medical problems who presented on [**6-23**]
feeling unwell and short of breath.
Pt was admitted w/ suspicion for pneumonia. Chest X-ray showed
likely atalectasis, no definite pneumonia, but revealed
worsening of her known vertebral compression fractures since
[**2134-10-12**]. Her EKG showed evidence of a known inferior
infarct, but no ST elevations or depressions or T-wave changes
to indicate an acute process. Troponins were negative. She was
found to have UTI, and urine and blood cultures were sent. Pt
was given vancomycin and levofloxacin. Pulmonary was consulted,
who felt pt's dyspnea was likely secondary to atalectasis and
splinting from her compression fractures, not pneumonia or acute
worsening of PH, which is typically a more gradual process.
Orthopedic surgery was consulted, who felt she was not a
candidate for kyphoplasty. Her pain was treated with
acetominophen, tramadol and lidocaine patches PRN. On [**6-25**] she
received one does of morphine sulfate, which she did not
tolerate well, becoming confused and somnolent. That same day,
while receiving IVFs patient acutely desaturated, not responsive
to supplemental oxygen. Flash pulmonary edema diagnosed. She was
also found to be hypotensive, thought likely secondary to the
narcotic dose she had received. She was transferred to the ICU.
The patient presented to the MICU after triggering of the floor
for hypoxia and altered mental status. When the patient arrived,
she was somnolent but oriented to person, place, and time. The
patient appeared volume overloaded with elevated JVD, 3+ pitting
edema, and diffuse wheezing bilaterally. The patient's protable
CXR at the time that she triggered on the floor showed interval
progression of her pulmonary edema (of note, her diuretics had
been discontinued). The patient also had increased serum
creatinine from her baseline. Her constellation of symptoms were
thought to be due to poor forward flow in the setting of acute
on chronic right heart failure. Because of her low BPs, the
patient was bolused with IV lasix and started on lasix gtt. The
patient diuresed well to the lasix gtt. Her volume status,
oxygen requirement, and serum creatinine improved with diuresis.
Of note, the patient's lasix gtt had to be intermittently
stopped for SBPs in the 70s-80s. On the AM, prior to transfer to
the unit, the patient was noted to have MRSA in her urine. She
was continued on Vancomycin for treatment of MRSA bacteruria and
blood cultures were also drawn. TTE was done that did not show
evidence of vegetations. The patient was called out to the
Cardiology floor for further diuresis with lasix gtt.
Pt was stable on arrival to the cardiology floor, with
near-baseline oxygen demand and good urine output. She was taken
off the lasix drip, and given 60 IV lasix [**Hospital1 **], to match the
daily amount she had been receiving continuously. She tolerated
this well, and continued to put out good urine with stable
lytes. She was weaned to PO lasix 60 mg po bid. Letairis was
also discontinued per recommendation from pulmonary, who felt it
might be contributing to her dyspnea. She was discharged on a
higher dose of PO lasix (60 vs. 40 mg po BID), and was advised
to stop taking letairis. At discharge, pt's weight was 81.6
(measured late in the day; other weights taken in the early
a.m.), about 2 kg below her admission weight.
On the day before discharge, her [**Last Name (un) **], which had been held for
her [**Last Name (un) **], was reinstated at 25 mg [**Hospital1 **], half of her home dose; on
day of discharge her creatinine bumped to 1.2, and she had
systolic blood pressures in the 80s to 90s. These episodes were
asymptomatic, with good mentation and urine output, no chest
pain or increased shortness of breath. For this reason we
decreased her [**Last Name (un) **] further to 12.5 mg [**Hospital1 **], and also decreased her
carvedilol, which had been increased to 25 mg [**Hospital1 **] during her
inpatient stay, back to her home dose of 12.5 mg [**Hospital1 **] on
discharge. At discharge she felt at her baseline in terms of
breathing and activity, satting in the mid-90s on 4 liters of
O2.
TRANSITIONAL ISSUES:
Patient is highly sensitive to fluid balance; She seems to do
best at a weight of about 175 lbs, or 80 kg. Going forward, her
I's and Os should be strictly monitored, with daily weights
taken.
Patient is being sent out on bactrim DS for her MRSA UTI, which
was culture-proven sensitive to bactrim. She should take one tab
PO BID, last day [**2135-7-4**]. Of note, patient experiences
some nausea with this antibiotic, and should take this pill with
food, separate from her other medications to avoid loss of daily
meds through emesis. She has also responded well to taking
compazine shortly before taking.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain
max daily dose
2. Atorvastatin 40 mg PO HS
3. Carvedilol 12.5 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
6. Furosemide 40 mg PO BID
7. Losartan Potassium 50 mg PO BID
8. Oxybutynin 2.5 mg PO BID
9. Ranitidine 300 mg PO DAILY
10. Tyvaso *NF* (treprostinil) 1.74 mg/2.9 mL (0.6 mg/mL)
Inhalation 9 puffs q6h
9 puffs four times daily
11. Adcirca *NF* (tadalafil) 40 mg Oral QD
12. Aspirin 162 mg PO DAILY
13. Vitamin D [**2122**] UNIT PO DAILY
14. TraMADOL (Ultram) 100 mg PO Q 8H
15. Lidocaine 5% Patch 2 PTCH TD DAILY
please apply on 12 hours and off 12 hours. One for shoulder and
one for back. Per patient request. Thanks!
16. Hydrochlorothiazide 25 mg PO QHS
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain
max daily dose
2. Adcirca *NF* (tadalafil) 40 mg Oral QD
3. Aspirin 162 mg PO DAILY
4. Atorvastatin 40 mg PO HS
5. Citalopram 20 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
7. Oxybutynin 2.5 mg PO BID
8. Ranitidine 300 mg PO DAILY
9. TraMADOL (Ultram) 100 mg PO Q 8H
10. Tyvaso *NF* (treprostinil) 1.74 mg/2.9 mL (0.6 mg/mL)
Inhalation 9 puffs q6h 9 puffs four times daily
11. Vitamin D [**2122**] UNIT PO DAILY
12. Sulfameth/Trimethoprim DS 1 TAB PO BID
13. Carvedilol 12.5 mg PO BID
HOLD for SBP < 100, HR < 60
14. Furosemide 60 mg PO BID
15. Lidocaine 5% Patch 2 PTCH TD DAILY: please apply on 12 hours
and off 12 hours. One for shoulder and one for back. Per patient
request.
16. Losartan Potassium 12.5 mg PO BID hold for sbp < 100
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Pulmonary Hypertension
Atelectasis with splinting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during your stay here at
[**Hospital1 69**]. You were admitted for
shortness of breath and fatigue. You were found to have a
urinary tract infection which we treated with antibiotics. You
were also found to be breathing less deeply because of back
pain, causing parts of your lungs to inflate less than normal.
With increased control of your pain, and use of your incentive
spirometer, this shortness of breath should improve. Some aspect
of this shortness of breath may have to do with a medication you
started recently, letairis, which we have discontinued.
You are being discharged to [**Hospital3 **] center. You
have appointments to follow up with your cardiologist's nurse
practitioner, and with your pulmonologist (see appointments
below).
We have made some changes to your medications. We increased your
furosemide (40 mg to 60 mg twice daily) and decreased your dose
of losartan (50 mg to 12.5 mg twice daily). You are also being
sent to rehab with 5 more days of Bactrim, the antibiotic for
your MRSA UTI, which you should take through [**7-4**]. Be sure to
review the medication reconciliation sheet to see what meds you
are currently taking.
Followup Instructions:
You have the following appointments with your specialists:
We are working on a follow up appointment in Pulmonary for your
hospitalization with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. It is recommended you be
seen within 1 week of discharge. The office will contact you at
the facility. If you have not heard within 2 business days
please call the office at [**Telephone/Fax (1) 612**].
Department: CARDIOLOGY (HEART FAILURE)
When: [**7-5**], 1:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], 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: CARDIOLOGY
When: WEDNESDAY, [**8-3**], 1 PM
With: DR. [**First Name (STitle) **] [**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
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2135-7-6**] at 9:40 AM
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: WEDNESDAY [**2135-7-6**] at 10:00 AM
Department: PULMONOLOGY
When: WEDNESDAY [**2135-7-6**] at 10:00 AM
With: DR. [**First Name (STitle) **]/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:[**2135-7-4**]
ICD9 Codes: 4168, 5180, 5990, 5849, 4280, 412, 5859, 2859, 2724, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5364
}
|
Medical Text: Admission Date: [**2136-6-3**] Discharge Date: [**2136-6-12**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Lactose / Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
CC: bradycardia
ECG:Bradycardic at 30, 2:1 block, 2nd degree Mobitz vs
Weinkebach, LAD, RBBB, LAFB
Major Surgical or Invasive Procedure:
pacemaker placed [**6-5**]
History of Present Illness:
Ms. [**Known lastname **] [**Last Name (Titles) **] a [**Age over 90 **] yo female who presented to the ED from her
[**Hospital3 **] with lethargy and a question of low BP. Pt had
an unwitnessed fall 2 days prior to presentation, but the
details of this fall/syncope are not known. In the ED she was
found to have a HR in the 30s with 2:1 block on her EKG. Her
blood pressures remained stable with this rate. She was seen by
cardiology who recommended correcting electrolytes (hyponatemia)
and suggested no need for emergent temporary pacer if she
remains HD stable. She was also hypoxic to 70s on RA. She has a
documented DNR/DNI, so was placed on a NRB. She was given 10 IV
lasix, 600cc IVFs, Levo/Flagyl and transferred to ICU. Upon
arrival her BP remained stable and she was A/A and oriented. Per
ED discussion with HCP - patient would want a pacemaker placed
and would want heart rate treated w/ medicines but remains
DNR/DNI.
Past Medical History:
HTN
Spinal Stenosis
Hypercholesterolemia
acoustic neuroma
MVP
s/p R wirst fx
s/p L IT fracture
ANEMIA [**2133-10-1**]
Dysphagia
OSTEOPOROSIS
URINAR INCONTINENCE
DEPRESSIVE DISORDER
MITRAL REGURGITATION
GLAUCOMA
CORONARY ARTERY DISEASE
OSTEOARTHRITIS
CHRONIC URINARY TRACT INFECTION
Social History:
Lives in retirement community with 24 hr care
Family History:
N/C
Physical Exam:
VS: T 98.6 BP 161/44 HR 30-40 RR 16 O2 sat 91-93% NRB
Gen-A&O x3, somnolent but arousable, NAD
HEENT- Left pupil surgical, Right pupil reactive, dry MM, OP
clear
NECK: supple, no LAD, JDP about 10
Cardio: bradycardic, regular rhythm, nl S1 S2
Lungs: + crackles at bases
Abd-Soft NT, ND, + BS
Ext- no edema, 2+ Dp pulses
Neuro: A/A Ox3, no focal deficits
Pertinent Results:
[**2136-6-3**] 11:40AM BLOOD WBC-7.9 RBC-3.33* Hgb-11.0* Hct-30.8*
MCV-93 MCH-33.1* MCHC-35.8* RDW-14.7 Plt Ct-231
[**2136-6-3**] 11:40AM BLOOD Neuts-69.8 Lymphs-22.0 Monos-7.2 Eos-0.6
Baso-0.4
[**2136-6-3**] 11:40AM BLOOD PT-12.1 PTT-26.7 INR(PT)-1.0
[**2136-6-3**] 11:40AM BLOOD Glucose-109* UreaN-28* Creat-1.2* Na-119*
K-6.7* Cl-85* HCO3-20* AnGap-21*
[**2136-6-3**] 11:40AM BLOOD CK(CPK)-179*
[**2136-6-3**] 12:45PM BLOOD proBNP-[**Numeric Identifier **]*
[**2136-6-3**] 11:40AM BLOOD cTropnT-<0.01
[**2136-6-3**] 11:40AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.3
[**2136-6-5**] 12:59PM BLOOD Type-ART pO2-66* pCO2-35 pH-7.46*
calHCO3-26 Base XS-1 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2136-6-3**] 02:47PM BLOOD Type-ART FiO2-100 pO2-25* pCO2-39 pH-7.39
calHCO3-24 Base XS--1 AADO2-666 REQ O2-100 Intubat-NOT INTUBA
[**2136-6-3**] 11:39AM BLOOD Glucose-119* Lactate-2.5* K-4.7
[**2136-6-3**] 02:47PM BLOOD freeCa-1.09*
.
bcx [**6-3**]: ngtd
ucx [**6-3**]: ngtd
.
heac CT [**6-3**]:
1. No intracranial hemorrhage.
2. Stable encephalomalacia and post-surgical changes in the left
cerebellopontine angle.
.
CXR [**6-3**]:Small bilateral pleural effusions with bilateral lower
lung zone airspace opacity probably representing a combination
of pulmonary edema and atelectasis. Underlying pneumonia cannot
be completely excluded.
.
Echo [**6-4**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
systolic function is normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-19**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
ECG:
Bradycardic at 30, 2:1 block, 2nd degree Mobitz vs Weinkebach,
LAD, RBBB, LAFB
Brief Hospital Course:
IMP/Plan: [**Age over 90 **] F w/ HTN, CAD p/w bradycardia and hypoxia presented
to hospital following possible syncopal episode 2d prior to
admission.
1) Bradycardia: Patient was admitted with HR in 30s and 2:1
block seen on EKG. She was DNR/DNI but PCP was amenable to
pacemaker placement and medical treatment. Etiology of heart
block was not clear but suspected worsening of baseline
conduction disease (RBB + LAFB at baseline). CEs were cycled
and were negative and electrolytes were repleted. She was
monitored in the MICU and transiently went in and out of
complete heart block. She had pacer pads in place and atropine
at the bedside. B/c her BPs were stable, cardiology did not
think she needed a temporary pacemaker placed urgently. She had
a permanent pacemaker placed on [**6-5**] with backup rate of 60.
She remained hemodynamically stable after pacemaker placement
and transfer to floor.
2) Hypoxia: Patient was tachypneic and hypoxic at admission.
Her cxr and exam were c/w with pulmonary edema likely secondary
to bradycardia. She did have a cough so could not exclude
pneumonia but she did not have a fever, WBC, or elevated
lactate. Her initial ABG showed a respiratory alkalosis likely
secondary to hyperventilation from hypoxia. She was placed on a
NRB and O2 SATS remain just above 90% on NRB. She was started
empirically on levaquin and flagyl for possible PNA and was
given lasix for diuresis. She was diuresed over the course of
her stay and her respiratory status improved. her abx were
changed from levo to ceftriaxone b/c of concern for prolongning
the QT interval on levaquin. Patient completed a 72 hr course of
Ceftriaxone. She was transferred to the floor on [**6-8**] where she
was weaned off oxygen.
3) Anemia: After patient was transferred to the floor, her hct
dropped significantly. She received 2U PRBC with appropriate
response of hct back to pt baseline.
4) Hyponatremia: Patient had sodium of 119 at admission. The
diff dx was hypovolemia (dehydration vs infection) vs CHF. Her
sodium improved significantly with diuresis. Sodium remains
stable.
5) Renal insufficiency: Cr remained at basline at 1.2.
6) HTN: Anti-hypertensive meds were initially held. After PM was
placed she was started on nifedepine 10 qd but her BPs dropped
significantly. She was slowly uptitrated on a low dose BB. Pt's
home dose nifedipine was held secondary to
7) Hyperlipidemia: Patient was restarted on home dose of
Lipitor.
8) Depression: Patient was restarted on home dose of Celexa,
brought in by patient.
9) FEN: Patient is on a dysphagia diet at home. During her stay
she was initially too tachypneic to tolerate POs. She was then
evaluated by S&S who were concerned for aspiration risk, so she
was started on PPN with plans to repeat the swallow eval in
several days. Upon repeat evaluation it was determined patient
may take pureed solids and honey thickened liquids.
10) Access: LIJ placed [**6-4**], but removed on [**6-6**] by EP under
fluoro after PM placed.
Midline placed by IR on [**6-6**].
11) Code status: DNR/DNI
12) Comm: son, [**Name2 (NI) 7337**] at bedside. daughter is HCP.
Daughter CELL: [**Telephone/Fax (1) 107198**]
Medications on Admission:
Cardizem
Xalanta
Celexa 5 mg Daily
Namenda
Lipitor
Xalanta
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for hyperlipidemia.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2)
Drop Ophthalmic QID (4 times a day).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1)
Dropperette Ophthalmic qhs ().
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
9. Celexa 10 mg/5 mL Solution Sig: One (1) ML PO daily ().
10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Bradycardia
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
Please take all medications as directed.
Followup Instructions:
Please follow up with Device clinic next week. Call
[**Telephone/Fax (1) 21817**] to make an appointment.
ICD9 Codes: 4280, 486, 2761, 2720, 2859, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5365
}
|
Medical Text: Admission Date: [**2159-2-23**] Discharge Date: [**2159-3-2**]
Date of Birth: [**2086-7-12**] Sex: F
Service: MEDICINE
Allergies:
Colchicine / Atorvastatin
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
AV fistula thrombus, GNR bacteremia
Major Surgical or Invasive Procedure:
Right AV thrombectomy
removal of hemodialysis line
History of Present Illness:
Ms. [**Known lastname **] is a 72 y.o. female with h/o HTN, CHF (diastolic, EF
of 55% and LVH on echo [**11-17**]), hyperlipidemia, gout, sarcoid,
ESRD on HD who was admitted for thrombectomy of left AV graft.
Had low-grade temp at admission to 100.0F. Tunneled HD line
placed one month ago for temporary HD. Thrombectomy successful,
graft patent. One day s/p thrombectomy, spiked a temp
post-procedure. She has had persistent fevers and Tmax of 103.4.
Pt was empirically started on vancomycin and flagyl overnight on
[**2-24**], and had bcx drawn. Dialyzed [**2-24**] through tunneled R IJ
line without complication. On [**2-25**], bcx grew 3/4 bottles of
GNRs. Zosyn added, and one dose gentamicin 80mg IV given. Pt
appeared more somnolent and tachycardic, so was transferred to
the MICU.
Pt denies CP, SOB, diarrhea, abd pain, chills or confusion.
Past Medical History:
- ESRD on HD, right upper extremity AV fistula, hemodialysis on
Tuesday, Thursday and Saturday, revision AV limb [**1-20**],
thrombectomy [**1-21**], placement of tunneled right IJ
- Hypertension, h/o left RAS
- IDDM
- Sarcoidosis with ocular involvement
- gout
- CHF Echo [**11-17**] LVEF >55%, LVH, mild AS, pulm art systolic
hypertension, [**2-13**]+ MR
- h/o knee surgery
- CVA ~20 yrs ago w/out residual deficits
Social History:
The patient lives with daughter, has [**Name (NI) 269**]. She has 4 children, 3
local.
No etoh, tobacco or drugs
Family History:
Hypertension and diabetes
Physical Exam:
Vitals: T - 101.1 HR 87 BP 134/57 RR 18 O2 sat 98% on 2L NC
General : Awake, conversing but sleepy, oriented x 2
HEENT: sl dry MM, anicteric sclera
Neck: Supple
CV: S1, S2 nl, III/VI systolic murmur heard throughout
(documented in previous exams)
Lungs: CTA b/l
Abd: Soft, NT, ND, hypoactive BS
Ext: no peripheral edema, warm extremities, palpable thrill RUE
AV graft. Graft site appears clean, no exudate on recently
changed dressing, no erythema.
Neuro exam: A & Ox 2
Pertinent Results:
Admission Labs:
[**2159-2-24**] 08:00AM BLOOD WBC-4.9 RBC-4.20# Hgb-12.2# Hct-38.5#
MCV-92 MCH-29.0 MCHC-31.6 RDW-17.0* Plt Ct-254
[**2159-2-24**] 08:00AM BLOOD Plt Ct-254
[**2159-2-24**] 08:00AM BLOOD Glucose-180* UreaN-38* Creat-7.9*# Na-138
K-4.9 Cl-97 HCO3-26 AnGap-20
[**2159-2-24**] 08:00AM BLOOD Calcium-10.9* Phos-4.6* Mg-2.3
.
[**2159-2-24**] CXR: No pulmonary edema or pneumonia or pneumothorax.
.
[**2159-2-27**] TTE:
The left atrium is moderately dilated. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (area 1.2-1.9cm2) No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2158-12-4**],
findings are similar.
Brief Hospital Course:
72 yo female with ESRD on hemodialysis, gout, hypertension, CHF,
s/p thrombectomy of AVF whom postoperatively was found to have
fever, tachycardia, somnolence, GNR bacteremia (proteus
mirabilis), treated with Cipro with resolution of signs and
symptoms.
.
#Fever: Fever was in the setting of Proteus mirabilis
bacteremia. The patient's right tunnelled IJ catheter tip was
also culture positive for Proteus, and this was thought to be
the source. The bacteria was pan-sensitive, and she was treated
with Cipro beginning [**2159-2-25**]. She had been on Zosyn for one day
until the culture came back pan-sensitive. Urinalysis was
negative. Surveillance cultures were negative after [**2159-2-25**].
Plan to continue on Cipro for a total course of 14 days
([**2159-3-12**]). TTE was negative for vegetations, although could not
be definitively ruled out. It was decided to defer TEE as the
patient was clinically much improved and suspicion for
endocarditis was low. Some surveillance cultures were not yet
finalized on the day of discharge, and the results will be
followed up as an outpatient.
.
# Mental status change: the patient was somnolent on initial
presentation. This was felt to be due to the acute infection,
and mental status improved with treatment of her bacteremia.
She was at baseline mental status, appropriately answering
questions, and oriented to person, place, and year prior to
transfer to the floor. During the remainder of her stay, there
were no other mental status changes.
.
# ESRD : She was followed by Nephrology and underwent dialysis
under usually weekly schedule (T/Th/Sat). Transplant surgery
evaluated and cleared the right AV fistula for use through which
she was dialyzed on [**2159-2-27**]. She also continues on sevelamer.
.
# Gout: Not active. Continued allopurinol.
.
# HTN/CAD: no acute issues. Intially when the patient
presented to the MICU, febrile, her home medications were held.
Prior to transfer to floor her home po antihypertensives were
resumed. She continues on amlodipine and labetalol, titrate
labetalol as needed (outpatient).
.
# CHF: ECHO performed during this admission (to rule out
vegetations) showed no changes from previous, EF > 55% but with
LVH. no acute decompensation. Continued Irbesartan and
Amlodipine for afterload reduction.
.
# Dispo: Full code. Daughter [**Name (NI) 19267**] is her health care proxy
should one be needed. Physical therapy evaluated the patient
and determined that she would need rehad inpatient PT/OT.
Medications on Admission:
Home Medications: (from [**2159-2-4**] d/c summary):
1. Aspirin 81mg PO qD
2. Irbesartan 75mg PO BID (HD DAYS ONLY)
3. Irbesartan 150mg PO BID (NON-HD DAYS ONLY)
4. Labetalol 800mg PO TID
5. Allopurinol 100mg PO qD
6. Zantac 75mg PO qD
7. Metoclopramide 10mg PO QIDACHS
8. Docusate Sodium 100mg PO BID
9. Pravastatin 20mg PO qD
10. Norvasc 10mg PO bid on non-HD days; 5mg PO bid on HD days
11. Hexavitamin 1 Cap PO qD
12. Insulin NPH 12U SC qAM.
13. Humalog Insulin Sliding Scale
.
Medications on transfer:
Labetalol HCl 200 mg PO TID
Metoclopramide 10 mg PO QIDACHS
Acetaminophen 325-650 mg PO Q4-6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Allopurinol 100 mg PO DAILY
Oxycodone-Acetaminophen 1 TAB PO Q4-6H:PRN
Amlodipine 5 mg PO BID
Piperacillin-Tazobactam Na 2.25 gm IV Q12H
Dolasetron Mesylate 12.5 mg IV Q8H:PRN
Ranitidine 150 mg PO DAILY
Docusate Sodium 100 mg PO BID
Sevelamer 800 mg PO TID
Heparin 5000 UNIT SC TID
Vancomycin HCl 1000 mg IV ONCE
Insulin SC
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Irbesartan 75 mg Tablet Sig: One (1) Tablet PO BID q [**Month/Day/Year **],
Thurs, Saturday only: on dialysis days only.
4. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID q Mon,
Wed, Fri, Sun only: non dialysis days only.
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous ASDIR (AS DIRECTED): please continue your
home sliding scale.
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous qam.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
Right Arterio-venous thrombosis now s/p thrombectomy
Proteus Bacteremia/Septicemia
Infected hemodialysis line
Secondary Diagnoses:
Congestive heart failure
hypertension
Sarcoidosis
diabetes mellitus type 2
end-stage renal disease on hemodialysis
Discharge Condition:
Good
Discharge Instructions:
You have been admitted with an infection related to your
dialysis line. You are being treated with antibiotics for this
infection, and your line was removed. If you have fever,
chills, shortness of breath, or any other new or concerning
symptoms, please call your doctor or return to the emergency
room for evaluation.
Please continue taking all of your medications as prescribed.
-you dose of labetalol has been decreased to 400mg three times a
day, but this can be increased if your doctor instructs
-your dose of amlodipine has also been decreased to 5mg daily.
-you will continue taking ciprofloxacin, an antibiotic, until
[**2159-3-12**] to complete the course of treatment.
Please follow up with your primary care physician as instructed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 608**]. You will be seen
by a physician at the rehab and they will arrange a followup
appointment for you.
You also have the following appointments already scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Known lastname 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2159-3-19**] 1:40
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2159-6-13**] 10:45
Completed by:[**2159-3-2**]
ICD9 Codes: 5856, 2875, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5366
}
|
Medical Text: Admission Date: [**2192-4-9**] Discharge Date: [**2192-4-26**]
Date of Birth: [**2130-9-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
# s/p ureterolysis (retroperitoneal fibrotic tissue) and
excision of ureteral stricture with primary reanastomosis of
ureter
# s/p placement of cook tulip inferior vena cava filter
History of Present Illness:
The patient is a 61 year old male with nephrolithiasis and
recent DVT who was admitted to the ICU after triggering for a
syncopal episode with falling Hct and concern for post-surgical
RP or intraabdominal bleeding. He has a history of
nephrolithiasis s/p lithotripsy and multiple prior urology
procedures. He subsequently developed a right upper ureteral
stricture with dense retroperitoneal fibrosis. He underwent
right ureteroscopy on [**2192-3-19**] and was found to have a tight UPJ
stricture which could not be stented. He was briefly admitted
on [**2192-3-22**] for right flank pain, which resolved. On [**2192-3-28**], he
was found to have a right posterior tibial DVT after presenting
to his PCP with calf pain, and was started on [**Date Range 99555**]. On
[**2192-4-9**], he underwent right upper ureterolysis with resection of
the stricture and ureteropyelostomy. His [**Date Range 99555**] was held for
the procedure and restarted the next day.
.
On [**2192-4-12**], he had an apparent syncopal episode during whch he
was diaphoretic, tachycardic to the 130s, and desaturated to 86%
on RA. EKG showed no significant change, CTA showed no evidence
of PE, and LE dopplers showed stable DVT in right posterior
tibial vein without extension. His Hct at that time was fairly
stable at 32.1, but his WBC count had increased from 7.4 on
[**2192-4-10**] to 14.0 that morning. His coags were normal. He ruled
out for MI with three sets of negative CEs.
.
This morning, he had another syncopal episode after morning
rounds. He sat up to void and while voiding he fell back on his
bed and was unresponsive for approximately 30 seconds per a
nurse [**First Name (Titles) 1023**] [**Last Name (Titles) **] the event. His EKG showed no new ischemic
changes. He was found to have BP 76/40 with sinus tachycardia
to 116 and satting 98% on RA. Abdominal US showed no evidence
of hydronephrosis and a small amount of fluid in the right lower
quadrant, along the patient's surgical incision site. He had
received his dose of [**Last Name (Titles) 99555**] this morning. His Hct was found to
be 26.2 from 32.1 the previous day. His WBC count had increased
to 19.2 with 88.7% neutrophils on diff. He was ordered for 2
units PRBCs and started on Ceftriaxone. Repeat labs a few hours
later at 12:44 showed Hct 23.9. His Cr had also increased to
1.7 from 1.2 in the morning. He received his blood from around
13:30 to 16:30 and was given D5-1/2NS at 75 ml/hr afterwards.
He was also given a 500 ml NS bolus in in the evening.
.
Repeat labs were drawn and he was scheduled for CT abdomen. He
was then transfered to the ICU. On ICU transfer, he was
tachycardic in the 120s-130s with BP in the 110s/70s. His IV
access was limited to a single PIV and attempts to gain
additional access were unsuccessful prior to his CT. He was
given NS boluses for a total of several liters. His
post-transfusion labs were notable for Hct 30.1, WBC 23.3, and
Cr 2.1. His CT showed a fairly large RP bleed and retained
contrast in the right kidney, but no hydronephrosis.
.
The patient reported abdominal tenderness on the right. He was
tired and wanted to sleep. He denied any palpitations or
lightheadedness. He had no other specific complaints. He
reports that he had BM yesterday and was passing flatus. He has
not had a BM today.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever or chills. Denies current headache,
rhinorrhea, or congestion. Denied cough, shortness of breath.
Denied chest pain, tightness, or palpitations. Denied nausea,
vomiting, or diarrhea. No dysuria. Denied arthralgias or
myalgias. Review of systems was otherwise negative.
Past Medical History:
# Nephrolithiasis
# DVT -- right posterior tibial diagnosed [**2192-3-28**] and started on
[**Month/Day/Year 99555**]
# Anxiety
# Migraines
Social History:
He is married and lives with his wife.
# Tobacco: None
# Alcohol: None
# Drugs: None
Family History:
No family history of DVT, PE, abnormal bleeding, or
coagulopathy.
Physical Exam:
VS: T 96.6, BP 123/83, HR 122, SpO2 93-96% on RA
Gen: Male in NAD. Resting comfortably. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. MMM, OP benign. NGT in place.
Neck: JVP not elevated. No cervical lymphadenopathy.
CV: Regular tachycardia with normal S1, S2. No M/R/G.
Chest: Respiration unlabored but somewhat tachypneic. CTAB
without crackles, wheezes or rhonchi.
Abd: Bowel sounds present. Moderately distended. Tender to
palpation near surgical site on right flank and RLQ. Surgical
incision with staples in place. No erythema and appears to be
healing well. Former drain site with small dressing C/D/I.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Moving all four limbs.
.
Discharge PE:
AFVSS.
Gen: NAD
Neck: neck supple, suture removed; JVP not elevated
HEENT: NCAT, MMMs
Pulm: CTAB
CV: RRR, nml s1/2 no [**3-23**]/m/g/r
Ab: right flank incision healing well, dressing c/d/i
GU: no foley; dark brown urine
Back: trace sacral edema
Right Ext: 1+ edema non-tense; thigh slightly larger in girth
than left
Neuro: Grossly non-focal
Pertinent Results:
Admission Labs:
[**2192-4-9**] 06:55PM BLOOD WBC-13.7*# RBC-3.78* Hgb-12.4* Hct-36.6*
MCV-97 MCH-32.9* MCHC-34.0 RDW-12.0 Plt Ct-188
[**2192-4-9**] 06:55PM BLOOD Plt Ct-188
[**2192-4-9**] 06:55PM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-142
K-3.6 Cl-106 HCO3-28 AnGap-12
[**2192-4-12**] 10:27AM BLOOD CK(CPK)-312
[**2192-4-9**] 06:55PM BLOOD Calcium-8.4 Phos-4.5 Mg-1.8
.
Discharge Labs:
.
[**2192-4-26**] 06:40AM BLOOD WBC-11.0 RBC-3.09* Hgb-10.2* Hct-30.2*
MCV-98 MCH-32.9* MCHC-33.7 RDW-14.5 Plt Ct-340
[**2192-4-26**] 06:40AM BLOOD Neuts-82.3* Lymphs-10.1* Monos-4.6
Eos-2.7 Baso-0.4
[**2192-4-26**] 06:40AM BLOOD Plt Ct-340
.
Imaging:
[**2192-4-11**] CXR PA-L: No evidence of pneumonia. Bibasilar
atelectasis.
.
[**2192-4-12**] CT-PA: No evidence of pulmonary embolism.
.
[**2192-4-12**] LENIs: Positive DVT study with occlusion of the
posterior tibial veins on the right side. There is no extension
of the clot as compared to the prior scan on [**2192-3-28**].
.
[**2192-4-13**] Ab-US: Limited study due to patient discomfort over the
surgical incision site. No evidence of hydronephrosis in the
right kidney. Fluid is noted in the right lower quadrant, likely
related to recent surgery.
.
[**2192-4-13**] Ab/P-CT: 1. Status post right ureteral resection for
stricture, with two very large retroperitoneal hematomas with
internal hematocrit levels, one in the right abdomen flank and a
second associated with the right psoas muscle and inseperable
from/compressing the IVC and right iliac vein. Assessment for
vascular injury could be obtained with a contrast enhanced
study. 2. Retained contrast in a dilated right collecting system
and renal lower pole cortex, despite ureteral stent. 3.
Cholelithiasis. 4. Bilateral pleural effusions. 5. Stable right
inguinal subcutaneous low-density lesion. This could be further
assessed on non-emergent basis once acute issues resolve. 6.
Fluid layering in the lower esophagus, raises concern for
potential of aspiration.
.
[**2192-4-14**] CXR: Portable chest compared to multiple prior
examinations. Nasogastric tube has been placed, tip terminates
in the stomach. Eventration right hemidiaphragm. Mild
atelectasis right lung base. Left lung relatively clear. Heart
and mediastinum unremarkable
.
[**2192-4-14**] LENIs: 1. Marked subcutaneous edema, limiting exam.
2. Nonvisualization of right posterior tibial veins, were
previously
determined to be thrombosed.
3. No evidence of new DVT.
.
[**2192-4-15**] CXR: Frontal view of the chest compared to multiple
prior examinations. Nasogastric tube appropriate. Low lung
volumes. Mild atelectasis at both lung bases. Upper lung zones
are clear. Heart top normal in size.
.
[**2192-4-16**] CT Ab-P: 1. Status post right ureteral resection for
stricture.
2. Two large retroperitoneal hematomas expanding in size with
interval
increase in dense material within, can be hemorrhage; however,
cannot exclude urine leak. Right psoas muscle retroperitoneal
hematoma is inseparable and compressing the IVC, completely
encasing the lumen; no flow is seen below. Assessment for
vascular injury is suboptimal; cannot exclude vascular injury.
3. Persistent dilatation of the right collecting system. Right
ureteral stent in place. Few renal stones are seen, one in the
upper pole of the right kidney, few adjacent to the right stent.
4. Cholelithiasis. 5. Stable right subcutaneous inguinal lesion;
incompletely characterized. Findings were discussed with Dr.
[**Last Name (STitle) 141**] at 11 a.m. [**2192-4-16**] by phone (patient's primary
care physician) and with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA (urology), at 11:10
am on [**2192-4-16**].
Findings discussed with Dr. [**Last Name (STitle) 365**] at 12 pm on [**2192-4-16**] by
phone.
.
[**2192-4-16**] MRI Ab-P: 1. Extensive intraluminal thrombus identified
within the IVC which extends superiorly up to 3.6 cm below the
level of the origin of the right renal vein. 2. Extensive
intraluminal clot also noted to occlude the entire right
external iliac and common veins. Clot is also seen within the
left common iliac vein and isolated in the internal iliac vein.
The left external iliac vein is patent. 3. Two large
retroperitoneal hematomas identified in the right pararenal
space and anterior to the right psoas muscle which is intimately
associated with the IVC.
.
[**2192-4-21**] CXR PA-L: There is persistent elevation of the right
hemidiaphragm and small bilateral pleural effusions. The
cardiomediastinal silhouette is stable. The pulmonary
vasculature is normal. Calcified granuloma is again seen lying
between the second and third left anterior ribs, stable dating
back to [**2180-6-26**]. There is a small amount of left
retrocardiac opacity which likely represents atelectasis.
.
[**2192-4-22**] Duplex Ab-P: 1. Right nephroureteral stent in place,
without evidence of hydronephrosis or infection.
2. Moderate free fluid, consistent with evolving blood products.
3. Patent intrahepatic IVC. Mid and distal IVC not assessed by
ultrasound.
.
[**2192-4-22**] Renal US: 1. Right nephroureteral stent in place, without
evidence of hydronephrosis or infection.
2. Moderate free fluid, consistent with evolving blood products.
3. Patent intrahepatic IVC. Mid and distal IVC not assessed by
ultrasound.
.
[**2192-4-22**] CT-Ab-P: 1. Slight interval reduction in size of the
retroperitoneal hemorrhage.
2. Persistent thrombosis of the IVC and right common iliac vein.
3. IVC filter at the level of the renal veins
4. Right-sided JJ stent in situ.
.
[**2192-4-23**] CXR PA-L:
Focal new right retrocardiac opacity may reflect focal
atelectasis or pneumonia. Small bilateral pleural effusions are
stable.
.
[**2192-4-24**] CT Ab-P, LE: 1. No right lower extremity hematoma.
Extensive right lower extremity edema.
Expanded and hyperdense appearance of the deep veins of the
right lower
extremity consistent with thrombosis.
2. Retained contrast in the right renal lower pole is consistent
with
segmental changes of ATN or could possibly relate to thrombosis
of a renal
vein branch.
3. Stable right retroperitoneal hematoma.
4. Known IVC and pelvic venous thromboses poorly assessed on
this noncontrast examination.
Brief Hospital Course:
61M with a history of RLE DVT [**2192-3-28**], who was admited [**2192-4-9**]
for right upper ureterolysis, resection of stricture, and
ureteropyelostomy post-operative course c/b RP bleed
compromising IVC flow requiring ICU transfer and transfusions,
IVC clot s/p filter, transferred to medicine for low grade fever
of unknown origin - likely secondary to IVC clot burden.
.
ICU Course:
.
# Retroperitoneal Bleed: His Hct was 36.6 on admission and was
stable in the low 30s for several days after his surgery. His
Hct had dropped to 26.2 and then further to 23.9. He was sent
for CT abdomen, which showed a right RP bleed. Of note, he was
was on [**Month/Day/Year 99555**] 100 mg SC BID prior to his surgery for treatment
of a recent DVT, and restarted on [**Month/Day/Year 99555**] [**2192-4-10**], the day after
his surgery. He was transfused a total of 6 units PRBCs this
admission, with stabilization of his hematocrit in the high 20s.
His abdomen was distended with initial bladder pressure
elevated to 21 and subsequent resolution to 9. On CT scan, there
was concern for compression of the IVC by the attending
radiolgist. On transfer from the ICU, there was a plan for
reimaging of his abdomen to further assess for compression.
.
# SIRS: He met SIRS criteria with an elevated WBC count,
tachycardia, and tachypnea. His WBC count increased from 7.4 on
the day after his surgery to 19.1 this morning and subsequently
23.3. His diff showed 88.7% neutrophils and no bands. He was
afebrile and did not have any obvious localizing symptoms of
infection. His leukocytosis may be a stress response related to
his RP bleeding, but infectious causes were considered. Blood
and urine cultures were sent on [**2192-4-11**] after he had a temp of
100.3, with no growth on urine culture and no growth to date on
blood cultures. He was given a dose of Ceftriaxone prior to ICU
transfer and started on vancomycin and zosyn, which were
subsequently discontinued.
.
# Hypotension / Tachycardia: He was tachycardic on ICU transfer
with HR in the 120s-130s. His BP was in the 110s systolic, but
had reportedly dropped to the 70s during his syncopal episode.
He appeared volume depleted on exam and had only received a
small amount of IV fluids prior to ICU transfer. He was ruled
out for PE with a negative CTA and unchanged LE dopplers after
his first syncopal episode on [**2192-4-12**]. He has an abnormal EKG
at baseline with partial RBBB and diffuse ST-T changes in
multiple leads, with changes during his recent events. His
tachycardia improved, however he did have ST depressions and a
troponin leak, making this a positive stress test equivalent,
suggesting demand ischemia.
.
# Acute Renal Failure: His baseline creatinine is around 1.0 and
was 0.9 on admission [**2192-4-9**]. His creatinine increased to 2.1.
He appeared volume depleted on exam and was producing dark,
concentrated appearing urine with some blood. His CT abdomen
showed retained contrast in his right kidney, presumably from
his CTA on [**2192-4-12**], but no hydronephrosis. Per Urology, he
likely has a partial obstruction at his ureteral stent, possibly
from a small clot.
.
# DVT: He was found to have a right posterior tibial DVT on
[**2192-3-28**] after presenting to his PCP with right calf pain prior to
this admission. There was no clear precipitating event. He did
have a urology procedure several weeks before and a one day
hospital admission for flank pain the week before his DVT
diagnosis. The patient refused to wear a pneumoboot on his left
leg despite its importance being explained.
.
# Abdominal Distention: He reported having a bowel movement the
day before ICU transfer. His stomach appeared distended on CT
abdomen, and an NGT was placed with drainage of 600 ml nonbloody
fluid. His bladder pressure was elevated at 21 and subsequently
resolved to 9 with suction.
.
Medicine Course:
.
The patient was stabilized and transferred to the vascular
service, then transferred again to Medicine for work-up of
fever.
.
# Fever of unknown origin: On transfer physical exam and history
did not point to any clear source of infection; the patient's
abdomen was re-imaged, with no evidence of intrabdominal
infection. Blood cultures and urine cultures were noted to be
negative, with one UA positive for nitrites [**4-21**] while on Cipro
(started [**4-19**]). Antibiotics were broadened to
Ceftriaxone/Ampicillin empirically; the patient spiked a feverdd
on these antibiotics, at which point the corresponding [**4-21**] UCx
subsequently showed no growth and antibiotics were stopped. The
patient's fevers were attributed to IVC and DVT clot burden as
well as RP hematoma. The patient spiked again to 101F the night
before discharge, in keepin with his trend of low grade fevers
on and off antibiotics clustering in the evenings. WBC
downtrended off antbiotics, and on discharge was 11 with no
bandemia. Abdominal exam remained benign.
.
# RLE DVT, IVC Clot: After transfer to medicine, the patient's
anticoagulation with coumadin was restarted after conferring
with the urology team, vascular team, and PCP. [**Name10 (NameIs) 99555**] was given
for 24 hours as a bridge then stopped by request of the urology
service and PCP. [**Name10 (NameIs) **] is being discharged on coumadin for a
presumed course of 6 months at which point anticoagulation will
be reevaluted. INR goal is [**2-23**].
.
# Worsening Right LE edema: On transfer to the medicine service,
the patient had 2+ pitting edema of the right lower extremity in
the setting of a known R LE DVT. 24h after starting [**Month/Day (3) **] and
coumadin, the patient had worsening R thigh edema. CT-Leg showed
no evidence of bleed. The working diagnosis was edema due to R
external iliac and IVC clot impeding venous drainage. Edema
improved on coumadin ([**Month/Day (3) **] was stopped as detailed above) and
with leg elevation. A degree of the edema was also attributed to
a declining albumin; a high protein diet was recommended.
.
# RP bleed: Was not an active issue on the medicine service. s/p
8 units pRBCs. Hct stable. Radiographically improved on CT-Ab-P.
.
# RU Ureteral Stricture: Was not an active issue on the medicine
service. Discharged with follow-up with urology.
.
# Anxiety: Continued home dose klonopin.
.
# Migraines: Continued home dose Fiorcet prn.
.
Transitional Issues:
.
# INR: Coumadin to be dosed after discharge by rehab facility
for INR [**2-23**].
.
# Pending blood cultures: Blood and urine cultures [**Date range (1) 99556**] will
need follow-up after discharge.
.
# Urology follow-up: Discharged with follow-up with urology for
follow-up of ureterolysis, resection of stricture.
.
# Vascular follow-up: Discharged with follow-up with vascular
for further management of IVC filter and IVC clot.
.
# Icidental radiographic findings for outpatient follow-up:
-bilateral renal para-caliceal cysts
-few right renal stones
-cholelithiasis
-right inguinal subcutaneous low-density lesion
-Retained contrast in the right renal lower pole is consistent
with segmental changes of ATN or could possibly relate to
thrombosis of a renal vein branch. Renal function was stable at
the time of imaging.
.
# Code: Full Code
Medications on Admission:
Simvastatin
Clonopin
Citalopram
Fioricet
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
3. citalopram 10 mg Tablet Sig: 1.5 Tablets PO once a day.
4. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-22**]
Tablets PO BID (2 times a day) as needed for Migraine Headache.
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. INR Check
Warfarin, target INR [**2-23**]
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day) for 3 days.
8. Electrolyte check
Check electrolytes [**2192-4-28**] and [**2192-4-30**] and fax results to Rehab
MD; replete K to > 4.0, Mg to > 2.0, Phos to > 3.0
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12h on
12h off to lateral right leg.
10. morphine 15 mg Tablet Sig: 0.5-1 Tablet PO every 6-8 hours
as needed for pain for 7 days.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. High Protein Diet
High protein diet
13. simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for gas pain, indigestion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
-Right ureteral stricture with dense retroperitoneal fibrosis
s/p ureterolysis of upper ureter and ureteropyelostomy.
-Retroperitoneal bleed
-IVC, right external iliac thrombosis and secondary fever
.
Secondary:
-Right lower extremity deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
.
You were hospitalized for a right ureteral stricture for which
you underwent ureterolysis of the right upper ureter and
ureteropyelostomy. You tolerated the procedure well.
.
Your post-operative course was complicated by a retroperitoneal
bleed, which required that you be transferred to the ICU for
close monitoring, and that you receive blood transfusions.
Subsequent imaging showed that the bleed had stopped and that
the blood collection was becoming smaller.
.
Your post-operative course was also complicated by the
development of a large clot in your inferior vena cava and one
of your pelvic veins called the right external ilac vein. These
clots are what likely caused the edema in your right leg. To
prevent these clots from travelling into your heart and into
your lungs, an inferior vena cava filter was placed by
interventional radiology.
.
The clots are also what probably caused the fever that developed
several days after the surgery. Repeating imaging of your
abdomen showed no evidence of a post-operative infection. All of
the cultures drawn from your urine and blood have been negative
for infection. You were treated with antibiotics initially due
to concern for an infection in your urine, however the urine
cultures were negative as well. Moreover, although your fever
continued after stopping the antibiotics, your white blood cell
count showed a trend toward normalizing and you continued to
appear well; all of these factors reassure us that you do not
have an infection and that your fevers are being caused by the
clots in your IVC, external ilac, and even your pre-existing
clot in your right leg deep veins.
.
You were treated for your clots with coumadin - urology and your
primary care physician agree with this management. Your right
leg swelling initially worsened after starting the
anticoagulation, but repeat imaging showed no evidence of a
bleed. The swelling then improved. We suspect that the swelling
will persist for a number of weeks before getting better because
it will take time for the clot to dissolve. Lasix helped the
clot and you will continue this medication for a week after
discharge. Your swelling is also being made worse by your low
protein levels; it is important that you eat a high protein diet
after discharge.
.
The following changes were made to your medications. Continue
your other medications as previously prescribed.
# START: Coumading 5mg; the rehab facility will titrate the
medication according to your INR, with a target INR of [**2-23**]. You
will remain on this medication for at least 6 months; your PCP
will [**Name9 (PRE) 10748**] at that time whether to stop it.
# START: Lasix every other day for 5 days (3 total doses), then
stop.
# START: A high protein diet.
# START: Morphine oral for leg pain as needed
# START: Colace to prevent constipation while taking Morphine
# START: Lidocaine patch for leg pain as needed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2192-5-28**] 9:00
Department: INTERNAL MEDICINE
When: TUESDAY [**2192-5-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 365**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: UROLOGY PRACTICE ASSOCIATES
Address: [**Street Address(2) 18723**], [**Location (un) **],[**Numeric Identifier 18724**]
Phone: [**Telephone/Fax (1) 18725**]
Appointment: Wednesday [**2192-5-9**] 2:00pm
Department: VASCULAR SURGERY
When: THURSDAY [**2192-5-3**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5845, 2851, 2720
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5367
}
|
Medical Text: Admission Date: [**2111-6-11**] Discharge Date: [**2111-7-1**]
Service: MEDICINE
Allergies:
Caffeine / Heparin Agents
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
PICC line placed and removed
?EGD
History of Present Illness:
Patient is a 83yo woman who was transferred from [**Hospital1 **] with 3
days of BRBPR found in her diaper. She has a medical history of
breast cancer s/p mastectomy, radiation, tamoxifen who had LN
recurrance 2 years ago treated initially with chemo and then
with radiation. More recently (6 weeks ago) she had a cerebellar
ICH/CVA, coag negative bacteremia and presumed endocarditis (on
vanco via PICC line) and c. diff colitis (with WBC max of 42,000
on [**5-26**] requiring flagyl + po vanco and associated with LGIB)
and a left superficial thrombosis associate with her PICC.
.
She was first noted to have blood clots mixed with her stool on
[**6-9**] and which worsened over the next 3 days. She was transfused
2U pRBC on [**6-6**] and [**6-10**].
.
In the ED her vs were stable; 99.2, HR in 80-90's, systolics in
120's, O2sat 90's on RA. Her physical exam showed her to be
alert and would open eyes to command (unclear baseline), benign
abdomin, bright red blood in diaper, rectal not done. NG tube
was already in place from [**Hospital1 **] (but above the diaphragm).
Reportedly an aspiration showed gastric contents without blood.
Hct was 27.2 and plts 54. She was transfused plts. CXR showed NG
tube mal-placement.
.
Surgery was made aware. GI was consulted and plans to see
patient on floor.
.
Unable to obtain ROS. [**Name (NI) **] son/HCP reports that since her
strokes 6 weeks ago that she is slow to respond, difficult to
wake up, but will respond with opening her eyes/shaking her head
and speaking, although her speach is difficult to understand. He
reports that her memory of people's identity is good, but she is
not oriented to place or time
Past Medical History:
left proximal brachial thrombosis secondary to PICC line ([**5-30**])
-Coagulase Neg Staph Bacteremia/Port removal in [**2111-5-23**] with
presumed endocarditis and planned 6wk abx treatment
-c.diff colitis tested positive [**5-23**] and started on flagyl with
addition of vanco. CT abd showed colitis of descending/sigmoid
colon
-? LGIB in past
-Breast CA s/p mastectomy and chemo. Right mastectomy 6 yrs
ago, followed by chemo and tamoxifen. She had recurrence in LNs
and
was treated with 16 months chemo ~1 yr ago. She was off for
several months, then got new LNs, so started XRT and got 37
treatments which finished in [**2111-3-8**]. She also gets frequent
PRBCs. Onc is Dr [**Last Name (STitle) 6099**] at N-W (part of Farber)
-h/o possible seizure in [**2108**] (MRI at that time with age related
change only by report)
-GERD
-Anemia
-? gall stones (h/o elevated LFTs)
- HIT Ab positivity
Social History:
Recent rehab resident, prior to CVA lived at home with cat. Son
[**Name (NI) **] involved in care. No smoking. EtOH socially.
Family History:
No history of strokes. Sister and mother with HTN.
Physical Exam:
PE:
VS: 99.2F HR 89 BP 154/81 100% RA
General: Elderly woman in NAD, alert, minimally responsive
HEENT: PERRL 2 to 2.5, OP with dry mucous membranes, dried
mucous, poor dentition.
Neck: attempted EJ site,
Chest: CTAB, right mastectomy scar, left porta cath removal site
with bleeding and yellow not foul smelling discharge with no
erythema/swelling.
Cardiac: distant, rrr no m/r/g
Abd: +BS, soft, no guarding, no rebound, diffusely tender
Ext: 2+ pulses, cool extremities
Skin: stage I on coccyx, no petchiae
Neuro: Alert, arousable, not oriented to place, date, age is
"too old", moving all 4 and responds to commands in right arm,
feet bilaterally, toes mute bilaterally.
Pertinent Results:
[**2111-6-11**] 09:01PM GLUCOSE-84 UREA N-53* CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-26 ANION GAP-10
[**2111-6-11**] 09:01PM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.3
[**2111-6-11**] 09:01PM PT-14.2* PTT-32.2 INR(PT)-1.3*
[**2111-6-11**] 07:05PM WBC-14.9* RBC-2.63* HGB-8.9* HCT-25.0* MCV-95
MCH-34.0* MCHC-35.7* RDW-22.7*
[**2111-6-11**] 07:05PM PLT COUNT-122*#
[**2111-6-11**] 02:20PM URINE HOURS-RANDOM
[**2111-6-11**] 02:20PM URINE GR HOLD-HOLD
[**2111-6-11**] 02:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2111-6-11**] 02:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2111-6-11**] 02:20PM URINE RBC-[**2-9**]* WBC-[**5-17**]* BACTERIA-MOD
YEAST-MANY EPI-0
[**2111-6-11**] 02:20PM URINE GRANULAR-0-2
[**2111-6-11**] 01:50PM GLUCOSE-96 UREA N-59* CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-27 ANION GAP-11
[**2111-6-11**] 01:50PM estGFR-Using this
[**2111-6-11**] 01:50PM CK(CPK)-51
[**2111-6-11**] 01:50PM cTropnT-0.19*
[**2111-6-11**] 01:50PM CK-MB-NotDone
[**2111-6-11**] 01:50PM WBC-12.4*# RBC-2.77* HGB-9.2* HCT-27.2*
MCV-98 MCH-33.2* MCHC-33.8 RDW-22.5*
[**2111-6-11**] 01:50PM NEUTS-88* BANDS-0 LYMPHS-1* MONOS-7 EOS-0
BASOS-0 ATYPS-1* METAS-3* MYELOS-0
[**2111-6-11**] 01:50PM PLT COUNT-54*#
[**2111-6-11**] 01:50PM PT-13.4* PTT-33.6 INR(PT)-1.2*
Brief Hospital Course:
In the MICU, pt was found to be HIT positive and was taken off
all heparin products. She required numerous transfusions of
PRBCs but her VS never showed changes indicating HD compromise.
Rather, her transfusion requirements were similar to those she
experienced as an outpatient. Abd CT showed an enlarging splenic
infarct.
Her mental status slowly improved over the course of her MICU
course such that she was responsive and more alert upon call out
to the floor but still only A and O x1.1
_______________________________
#Lower GI Bleed - Patient was initially admitted for the
hospital for passing blood clots mixed with stool. She
initially required multiple units of PRBCs. EGD done while in
the unit was unrevealing for a source of bleeding. Initially
colonoscopy was deferred because it was thought to be of limited
utility and benefit. While on the floor, the patient's HCT was
initially stable. She was continued on IV flagyl for her CDiff
colitis, which was thought to be a possible source of her
bleeding. Her HCT started trending down and there was noted to
be a few clots and some blood mixed with the stool. She was
again transfused 2 units PRBCs. GI was again consulted and they
decided to perform a colonoscopy to attempt to identify a source
of continued bleeding. Colonoscopy only showed multiple
diverticuli and internal hemorrhoids, both of which were thought
to be possible sources of her GI bleeding.
.
#Recent CVA and Intracranial hemorrhage - Before this admission,
the patient had a history of multiple embolic strokes as well as
an acute intracranial hemorrhage. After initial discharge from
the MICU, there was a question of possible anticoagulation in
this patient because of concern for HIT. A repeat MRI was
performed which showed an interval increase in embolic
phenomenom as well as a subacute on chronic hemorrhage. Repeat
echo was performed to evaluate embolic strokes. Again, no
vegitations were seen on the cardiac valves and no PFO was seen.
.
#Thrombocytopenia - There was an initial concern for HIT in this
patient. Hematology was consulted to help with assessment for
the diagnosis and determination if anticoagulation is needed.
With regard to the diagnosis of HIT, it is unlikely that she has
this. Her thrombocytopenia has been going throughout her
inpatient stay at both the [**Hospital1 18**] and [**Hospital1 **] hospitals. In
addition, there are many confounding factors for this finding,
including consecutive infections and polypharmacy (vancomycin,
ciprofloxacin). Furthermore, her optical density value is 0.45
and the cut-off for a positive test result is 0.40.
Publications support an optical density of 1.0 better for the
diagnosis of HIT. For these
reasons, the heme service did not believe that she had HIT and
thus argatroban was not indicated.
.
#Coag Neg Staff Endocarditis - On past admission, the patient
had 4/4 bottles positive for coag neg staff. TTE at the time
was negative for vegitations. She is being treated with a 6
week course of Vancomycin. Repeat Echo done on current
admission still did not show any vegitations.
.
#Breast Cancer - She is followed by Dr. [**Last Name (STitle) 6099**] at [**Hospital3 328**] NW.
On this admission, a new area of destruction of cortex of the
medial portion of the left
ilium was seen on CT Abd. There was a concern for possible
metastatic lesions from her breast cancer verses metastatic
lesions from another unknown primary source. Options for
further work up were discussed with Dr. [**Last Name (STitle) 6099**]. These were
presented to the patient's son. [**Name (NI) **] son relayed that his mother
would not want any further treatment including both chemo or
radiation. Based on this desire, it was decided that no further
work up of this lesion was warrented as the patient would not
want treatment.
.
#FEN - The patient has been maintained on a NG feeding tube for
most of her hospital stay. A swallow study completed showed
that she would be able to safely tolerate ground food and thin
liquids. Tube feeds were stopped and the patient was encouraged
to eat. It was very difficult for the patient to sucessfully
take in PO, either because of neurological dysfunction or a lack
of desire. The option of PEG placement was discussed with the
family.
_____________
After discussion with the patients son who is her health care
proxy, it was decided to make the patient comfort care only.
All of her antibiotics and other medications not related to
comfort were discountinued. She will be discharged with oral
morphine for comfort. She is being discharged to a hospice
facility for further care.
Medications on Admission:
1. Fluconazole
2. Furosemide
3. Iron supplement
4. Methylphenidate
5. Vanco 1g QD
Discharge Medications:
1. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-5 mg PO Q2H
(every 2 hours) as needed for discomfort.
Disp:*QS 1MTH * Refills:*0*
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual Q4HR PRN () as needed for
secretions.
Disp:*QS 1MTH Tablet, Sublingual(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]
Discharge Diagnosis:
Lower GI Bleed
Intracranial hemorrhage
Endocarditis
CDiff Colitis
Pneumonia
Deep Vein Thrombosis
Discharge Condition:
Patient is comfort care only and will be discharged to hospice
for further care.
Discharge Instructions:
Patient was treated in house for multiple medical problems.
After discussion with son who is patients health care proxy, it
was decided to make her comfort care only. She will be
discharged to hospice.
Followup Instructions:
Patient will be discharged to hospice care facility.
Completed by:[**2111-7-1**]
ICD9 Codes: 5789, 486, 431, 5990, 7907, 2768, 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5368
}
|
Medical Text: Admission Date: [**2177-10-9**] Discharge Date: [**2177-10-17**]
Date of Birth: [**2108-2-5**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 69-year-old
man who has a known cardiomyopathy and has been followed by
Cardiology. He recently complained of increasing dyspnea on
exertion and also increasing fatigue, especially since one
month prior to admission. He also complained of occasional
discomfort in the abdomen and discomfort in the epigastric
area on exertion. He also complained of palpitations and
heart rate in the 150s per report. Mr. [**Known lastname **] had cardiac
catheterizations, most recently in [**2170**], until just prior to
admission, and was at that time found to have normal coronary
arteries, elevated right and left heart pressures, with a
wedge of 15 and a cardiac index of 1.9. Ejection fraction
was estimated at 39%. His most recent echocardiogram in
[**2177-3-31**] showed a left ventricular ejection fraction of
35 to 40%, with [**Hospital1 **]-atrial enlargement and mild left
ventricular hypertrophy, with moderate aortic stenosis,
aortic insufficiency, with a peak gradient of 25 and a valve
area of 1.7 sq.cm., as well as mitral regurgitation and
tricuspid regurgitation. The patient denied any symptoms of
claudication, edema or lightheadedness. The patient was
admitted for further workup of his symptoms.
PAST MEDICAL HISTORY:
1. Atrial fibrillation
2. Sleep apnea (uses CPAP)
3. Alcoholic cardiomyopathy (drinks very rarely now)
4. Congestive heart failure
5. Benign prostatic hypertrophy
PAST SURGICAL HISTORY: Surgery for left heel spur.
ALLERGIES: Nitroglycerin (gives severe hypotension).
MEDICATIONS ON ADMISSION:
1. Cardizem 240 mg by mouth every morning
2. Coumadin 7.5 mg on Sunday, Tuesday and Thursday, and 5 mg
on other days
3. Digoxin 0.25 mg Monday through Friday
4. Lisinopril 2.5 mg once daily
5. Aldactazide 25 mg tablet (one-half) once daily
6. Proscar 5 mg by mouth once daily
7. Coreg 3.125 mg (one-half tablet) once daily
8. Lorazepam 0.5 mg by mouth as needed
9. Ambien as needed
PHYSICAL EXAMINATION: Temperature 99, heart rate 110 (atrial
fibrillation), blood pressure 139/76, oxygen saturation 93%
on room air. Alert and oriented, in no apparent distress.
Head, eyes, ears, nose and throat examination within normal
limits. Chest: Clear to auscultation bilaterally. Heart:
Systolic ejection murmur, II/VI, irregular heart rhythm.
Abdomen: Soft, nontender, nondistended. Extremities: Trace
edema bilaterally.
LABORATORY DATA: Hematocrit 47.4, white blood cell count
6.2, platelets 172. INR 1.5. Urinalysis negative. Glucose
116, sodium 136, potassium 4.6, BUN 18, creatinine 1.0.
HOSPITAL COURSE: The patient first underwent cardiac
catheterization as an outpatient, given worsening symptoms.
There was no angiographic evidence of obstructive coronary
artery disease, but there was moderate aortic stenosis,
moderate mitral regurgitation, and moderate systolic and
diastolic ventricular dysfunction. Cardiac output was
severely reduced. Left ventriculogram demonstrated moderate
mitral regurgitation. Global left ventricular systolic
function was moderately reduced, with an ejection fraction of
approximately 37%, and mild global hypokinesis.
Given the findings of aortic stenosis, mitral regurgitation,
and tricuspid regurgitation, the patient underwent on
[**2177-10-9**] aortic valve replacement with a 23 mm pericardial
valve and mitral valve replacement with a 29 mm porcine
mosaic valve. The patient tolerated the procedure well, and
there were no apparent complications. Please see the full
operative report for details.
The patient was admitted to the Intensive Care Unit in good
condition. He remained in atrial fibrillation, but his heart
rate was well controlled. He maintained adequate blood
pressure and oxygen saturation. His hematocrit
postoperatively was 37.6. On postoperative day one, the
patient was extubated without difficulty.
His central line and Foley catheter were removed.
Postoperatively, the patient experienced a run of
nonsustained ventricular tachycardia (19 beats), as well as
an episode of hypoxia and low-grade fever. A CT scan
angiogram was performed at the time, which was negative for a
pulmonary embolism. A chest x-ray showed a left lower lobe
collapse and infiltrate. The patient was started on
vancomycin and levofloxacin. Blood cultures and sputum
cultures were negative. The patient was continued on
Coumadin for his chronic atrial fibrillation.
Two days prior to discharge, the patient again had a run of
what appeared to be a nonsustained ventricular tachycardia.
Electrophysiology service was consulted and followed the
patient throughout his hospitalization course. The
Electrophysiology service recommended increasing the
amiodarone dose to 400 mg three times a day and then placing
the patient on a low-maintenance dose. His Lopressor dose
was lowered, as the patient became mildly symptomatic.
Physical Therapy followed the patient during his
hospitalization. The patient still required supplemental
oxygen to receive appropriate oxygenation levels, especially
on ambulation. It was thought that a rehabilitation center
with intensive pulmonary therapy would be most appropriate.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**Doctor Last Name 73800**] Care Center
DISCHARGE DIAGNOSIS:
1. Congestive heart failure, severe mitral regurgitation,
moderate aortic insufficiency, moderate to severe aortic
stenosis, moderate to severe tricuspid regurgitation status
post aortic valve and mitral valve replacement
2. Decreased left ventricular ejection fraction
3. Chronic atrial fibrillation
4. Sleep apnea, on CPAP
5. Alcoholic cardiomyopathy
DISCHARGE MEDICATIONS:
1. Coumadin; the patient was instructed to receive 4 mg on
[**2177-10-17**], and his future Coumadin dose to be adjusted to the
INR level of 2.0 to 2.5
2. Lasix 20 mg by mouth twice a day for ten days
3. Amiodarone 400 mg three times a day for five days, then
400 mg by mouth twice a day for seven days, then 400 mg by
mouth once daily for seven days and then 200 mg by mouth once
daily
4. Lopressor 50 mg by mouth twice a day
5. Captopril 6.25 mg by mouth three times a day
6. Spironolactone 12.5 mg by mouth once daily
7. Finasteride 5 mg by mouth once daily
8. Albuterol one to two puffs inhalers every four to six
hours as needed
9. Milk of magnesia as needed
10. Percocet one to two tablets by mouth every four to six
hours as needed for pain
11. Ibuprofen 400 mg by mouth every six hours as needed
12. Ranitidine 150 mg by mouth twice a day
13. Colace 100 mg by mouth twice a day
14. Potassium chloride 20 mEq twice a day for ten days
DISCHARGE INSTRUCTIONS:
1. The patient needs pulmonary assessment and treatment.
2. INR needs to be checked daily to INR level of 2.0 to 2.5.
3. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in approximately four
weeks.
4. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**] (Cardiology) in two to
three weeks.
5. Follow up with Dr. [**Last Name (STitle) **] (primary care physician) in one
to two weeks.
6. The patient is to wear the [**Doctor Last Name **] of Hearts monitor as
instructed, with results sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**] at [**Hospital1 1444**], phone number [**Telephone/Fax (1) 105621**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D.
[**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 10097**]
MEDQUIST36
D: [**2177-10-17**] 19:23
T: [**2177-10-18**] 00:43
JOB#: [**Job Number **]
ICD9 Codes: 9971, 4271
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5369
}
|
Medical Text: Admission Date: [**2177-3-2**] Discharge Date: [**2177-3-13**]
Date of Birth: [**2108-5-16**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is a 68-year old
female who was in her usual state of health until
approximately 8:40 in the morning on the day of admission
when she felt the room spinning and then developed a severe
headache. It was worse in the frontotemporal area. She also
had neck pain. She described the headache as being more
painful than the neck pain. She denied any numbness,
tingling, weakness or visual changes.
MEDICATIONS ON ADMISSION: Aspirin (though she had stopped
this 1 week prior to admission secondary to nose bleeds),
Fosamax each week, and Norvasc.
PAST MEDICAL HISTORY: Remarkable for hypertension, status
post total abdominal hysterectomy for endometrial cancer, and
a facelift. She is not a smoker.
FAMILY HISTORY: Shows an aunt that had an abdominal aortic
aneurysm.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs revealed the
temperature was 98.7, the heart rate was 78, the blood
pressure was 81/52, the respiratory rate was 15, O2
saturation was 100%. She was awake, alert, and oriented x 3.
Speech and comprehension were intact. Cranial nerves II
through XII were grossly intact. The pupils were 3 to 2.5.
the extraocular movements were full. The face was symmetric.
The tongue was midline. She had full shoulder shrug. Motor
exam showed that she was [**4-10**] throughout the upper and lower
extremities. Sensation showed that she was intact to the
light touch throughout the upper and lower extremities. She
had no pronator drift. Deep tendon reflexes were 3+
bilaterally at brachioradialis and biceps, 2+ at the knees
and ankles. The left toe was equivocal. The right toe was
upgoing.
RADIOLOGIC STUDIES: A CAT scan of the head did show a
subarachnoid hemorrhage in he right sylvian fissure.
LABORATORY DATA ON ADMISSION: White count was 10.5,
hematocrit was 37.6, platelets were 335. Sodium was 133,
potassium was 3.6, chloride was 96, bicarbonate was 27, BUN
was 18, creatinine was 0.5, and glucose was 123. PTT was 29.7
and INR was 0.9.
HOSPITAL COURSE: She was admitted to neurosurgery and
underwent a CTA which did show an approximately 3-mm aneurysm
at the right middle cerebral artery trifurcation. She was
brought to the operating room where she underwent a
craniotomy with a right clipping of the ruptured right MCA
bifurcation aneurysm.
Postoperatively, she was transferred to the surgical ICU. She
was awake, alert, oriented x 3. She followed all commands.
Her eyes were open. Motor exam was full. She had no drift.
Her face was symmetric. She was monitored closely with q. 1-
hour neuro checks. She was started on nimodipine. She was
tapered off her Decadron and was started on Keppra. Her blood
pressure was kept less than 130. She continued to be
neurologically intact throughout her admission. On
postoperative day #2, her blood pressure was allowed to rise
up to the 150s. She did receive 1 unit of packed red blood
cells for a hematocrit of 25. She was on HHH therapy,
hemodilution, hypertension, and hypovolemia for prevention of
vasospasm. She had a repeat CTA of the head on [**2177-3-7**]
that did show a residual amount of subarachnoid hemorrhage in
the right sylvian fissure, but no vasospasm was appreciated.
Her incision continued to be clean, dry, and intact. She was
transferred to the neuro stepdown unit on [**2177-3-10**]. It
was noted that she had some blood in her urine and some
burning, and the urine was sent which did show a urinary
tract infection. She was put on Bactrim, but when the culture
came back it was not sensitive to Bactrim and she was changed
to levofloxacin. She was evaluated by physical therapy who
felt that she would be ready for discharge to home when
medically stable. Her Foley was removed on [**3-11**], and she
was able to void. Her staples were removed on [**3-13**], just
prior to discharge, and the incision was well-healed.
CONDITION ON DISCHARGE: Neurologically stable.
FINAL DIAGNOSIS: Subarachnoid hemorrhage secondary to right
middle cerebral artery aneurysm.
RECOMMENDED FOLLOWUP: In 2 weeks with Dr. [**Last Name (STitle) 1132**].
MEDICATIONS ON DISCHARGE: Keppra 500 1 p.o. twice a day,
iron 325 mg 1 p.o. daily, Tylenol with codeine 1 to 2 p.o.
every 4 hours as needed, and levofloxacin 500 mg 1 p.o. for 7
days.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2177-3-13**] 08:49:20
T: [**2177-3-13**] 09:45:30
Job#: [**Job Number 109647**]
ICD9 Codes: 5990, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5370
}
|
Medical Text: Admission Date: [**2108-12-11**] Discharge Date: [**2108-12-16**]
Service: MEDICINE
Allergies:
Niacin
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
generalized weakness, odynophagia
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
85-year-old man with a history of recently diagnosed Kaposi's
sarcoma with visceral involvement, duodenal ulcer, ESRD not on
HD, HTN, HL, sCHF w/EF 40%, recent admission for GIB, is
transferred here from OSH for generalized weakness, confusion,
odynophagia.
.
Patient received his cycle 2 of paclitaxel on [**2108-12-5**] and has
been experiencing odynophagia from mucositis. For the past few
days he has felt "not well" at home, complaining of intermittent
shortness of breath, odynophagia and dysphagia. He presented to
[**Hospital6 10353**] on [**2108-12-10**]. There, he was found to have
pancytopenia. Initially CHF exacerbation was suspected given
clinical status and BNP of 65,987. However, chest CT without
contrast showed moderate pleural effusion with right lower lobe
atelectasis, but no evidence of pulmonary edema. Pneumonia was
suspected and patient was started on ceftriaxone and vancomycin.
His home furosemide was held.
.
While at [**Hospital6 10353**], patient started to be delirious,
not knowing where he was, attempting to get out of bed
frequently, and at one point falling without head trauma, per
his family.
At OSH, hct 23 and plts 35. His CXR showed bilateral pleural
effusions. He was started on ceftriaxone and vancomycin
empirically.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies abnormal bleeding,
bruising, lymphadenopathy. Denies dysuria, stool or urine
incontinence. Denies arthralgias or myalgias. Denies rashes or
skin breakdown. No numbness/tingling in extremities. All other
systems negative.
Past Medical History:
Past Oncologic History:
Kaposi's sarcoma diagnosed by LLE biopsy [**2108-10-23**] by
dermatology; evidence of visceral involvement on GI capsule
study [**2108-10-30**]. Admitted by Dr. [**First Name8 (NamePattern2) 916**] [**Last Name (NamePattern1) **] on [**2108-11-14**] for
cycle 1 of Taxol.
.
Other Past Medical History:
Upper GI bleed though secondary to Dieulafoy's lesion
ESRD with right sided AV fistula, not on HD
CAD s/p CABGx3 in [**2095**], s/p SVG to RCA stent [**2099**], SVG to OM
stent [**2106**]. Recent p-mibi with moderate ischemia in anterior
wall in [**6-7**], cath deferred due to renal function.
CHF, chronic systolic and diastolic, EF 40% on recent P-mibi
Moderate Aortic stenosis
Anemia
Hearing impairment
Right AV fistula placed [**2108-5-21**]
Hyperparathyroidism due to ESRD
Obesity
HTN
HL
BPH
Intraocular lens
Social History:
Lives at home on [**Location (un) 448**] of home with wife who has early
[**Name (NI) 11964**]. Has a caretaker who is in every other day to help
with medications, appointments. Previously worked for local
school system, fought in the infantry in WWII in [**Country 480**] and in
[**Country 2559**]. Distant history of tobacco use 60 years ago, 1ppd for 2
years, denies EtOH and illicit drug use.
Family History:
Sister w/brain CA, brother w/[**Name2 (NI) 499**] CA, both deceased. Brother
died of sudden cardiac death at age 56. Father died at age 80 of
?CVA. Mother died of [**Name (NI) 5895**] in her 80's.
Physical Exam:
VS: T 99.1, BP 122/70, HR 78, RR 24, 98%RA
GEN: Elderly man in NAD, awake
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. Bibasilar
crackles R > L, scattered expiratory wheezes
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: 1+ bilateraly LE edema to mid-shin, 2+ DP/PT bilaterally
SKIN: No rash, warm skin
NEURO: oriented to name, "hospital," but not date; answered
"[**Doctor First Name 4375**]" for US president; normal attention but hard of hearing;
CN II-XII intact, 5/5 strength throughout but exam not accurate
due to patient's not fully cooperating, intact sensation to
light touch
PSYCH: slightly confused, asking family members about
non-relevant things
LYMPH: no cervical, axillary, inguinal LAD
Pertinent Results:
[**2108-12-12**] 12:08AM BLOOD WBC-0.3*# RBC-3.17* Hgb-9.2* Hct-26.0*
MCV-82 MCH-29.1 MCHC-35.4* RDW-16.7* Plt Ct-47*#
[**2108-12-12**] 12:08AM BLOOD Plt Ct-47*#
[**2108-12-12**] 12:08AM BLOOD PT-13.7* PTT-26.8 INR(PT)-1.2*
[**2108-12-12**] 12:08AM BLOOD Glucose-118* UreaN-133* Creat-4.1* Na-144
K-4.3 Cl-105 HCO3-24 AnGap-19
.
IMAGING:
# Chest CT (OSH) moderate R pleural effusion with RLL
atelectasis
# CXR [**12-14**]: FINDINGS: In comparison with the study of [**12-12**],
there is layering of substantial right pleural effusion.
Probably smaller left pleural effusion shows layering as well.
Continued enlargement of the cardiac silhouette with evidence of
pulmonary vascular congestion. Underlying lungs are difficult to
evaluate, though there are probably at least atelectatic changes
at both bases.
# CXR [**12-12**]: IMPRESSION: Findings suggestive of a pleural
effusion on the right with opacities that can likely be
attributed to atelectasis. Pneumonia cannot be completely
excluded, however. Follow-up radiographs may be helpful for
continued evaluation.
Brief Hospital Course:
85-year-old man with Kaposi's sarcoma with visceral involvement,
CHF, CKD presents with confusion, dyspnea, odynophagia,
generalized weakness.
.
#. Goals of Care: Patient was transferred to the ICU for hypoxia
to the high 80s from pulmonary edema and the plan to initiate
dialysis to remove fluid. The patient did receive one round of
dialysis before he and his family decided to change his goals of
care. While in the ICU, it was decided that the patient would be
made comfort measures only. The patient was started on a
Morphine drip, Benadryl for itching related uremia, and Haldol
for terminal delirium. The patient was subsequently transfered
to the oncology inpatient service. Pt expired the following
night.
.
#. Dyspnea: Patient presented with some wheezing on exam,
bilateral crackles R>L. CT showed right-sided pleural effusion.
Intermittently tachypneic but with good O2 saturation. There is
no clear evidence of pneumonia. Patient does not have
significant coughs and the chest CT showed no clear infiltrate.
Antibiotics were discontinued on the oncology service. The
patient received nebs prn. Patient further received Furosemide
given concern for CHF on exam. Pt had one round of dialysis but
did not resolve pt's tachypnea.
.
#. Confusion: Not at home but started being delirious at [**Hospital1 9487**]. Might be due to hospitalization-related delirium
in an elderly person, CHF exacerbation, pneumonia. Head bleed is
a possible cause given thrombocytopenia. Uremia (urea > 100)
from CKD was ultimately presumed to be the most likely cause.
.
#. HTN: Normotensive on admission. The patient was continued on
Hydralazine, Labetolol and Ranolazine initially, though these
meds were held for hypotension that may likely happen with
dialysis.
.
#. Odynophagia: Was presumed due to mucositis from recent
chemotherapy. Patient received pain control with narcotics and
was monitored closely for thrush. Pt was also started on Fluc
and Acyclovir.
.
#. CKD: Cr 4.0 at baseline but urea in the 130s from the usual
80s. The patient subsequently received one round of dialysis
before his goals of care were changed.
.
#. Kaposi's sarcoma with known visceral involvement: Patient was
pancytopenic from recent chemotherapy. Pt was started on
Neupogen and WBC responded appropriately.
.
# Pt was on pneumoboots for DVT ppx as pt had thrombocytopenia.
Pt was DNR/DNI on admission, then made CMO in ICU. Pt was NPO
given high risk of aspiration.
Medications on Admission:
MEDS ON TRANSFER:
hydralazine 25 mg tid
rosuvastatin 40 mg daily
ferrous sulfate 324 mg daily
fluconazole 150 mg IV daily
Nephrocaps 1 capsule daily
filgrastim 300 mcg SC daily
nitroglycerin SL prn
labetolol 200 mg [**Hospital1 **]
famotidine 20 mg [**Hospital1 **]
finasteride 5 mg daily
ranolazine 5 mg daily
calcitriol 0.25 mg daily
vitamin D [**2097**] units [**Hospital1 **]
.
MEDS AT HOME:
ondansetron prn
prochlorperazine prn
furosemide 80 mg PO bid
aspirin 81 mg daily
labetalol 200 mg daily
calcitriol 0.25 mcg daily
cholecalciferol (vitamin D3) 2,000 unit daily
atorvastatin 80 mg daily
finasteride 5 mg daily
ranolazine SR 500 mg daily
ranitidine 150 mg qhs
hydralazine 25 mg q8h
epoetin alfa 10,000 unit/mL 1 injection weekly
clopidogrel 75 mg daily
Renal Caps 1 mg Capsule daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Kaposi's sarcoma
CHF
ESRD
Discharge Condition:
expired
Completed by:[**2108-12-16**]
ICD9 Codes: 5856, 4280, 4241, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5371
}
|
Medical Text: Admission Date: [**2159-10-22**] Discharge Date: [**2159-10-26**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female with a history of hypertension but no known history of
coronary artery disease, who presented to the Emergency Room
complaining of crushing [**10-24**] substernal chest pain since [**68**]
P.M. on the evening prior to admission. This was accompanied
by shortness of breath. In the Emergency Room, the patient
was noted to be hypotensive to the 80s/50s, and hypoxic to
86%, with a chest x-ray consistent with pulmonary edema. The
patient was intubated and started on a dopamine drip.
Electrocardiogram revealed a new left bundle branch block.
She had a CK of 581, with an MB of 98 (index of 16.1), and a
troponin-I of greater than 50. The patient was transferred
to the cardiac catheterization laboratory, where the
intervention was cancelled after extensive discussions with
the family. The patient was then transferred to the Coronary
Care Unit for conservative management of congestive heart
failure in the setting of an acute myocardial infarction.
PAST MEDICAL HISTORY:
1. Hypertension
SOCIAL HISTORY: The patient lives with her daughter. The
power of attorney is [**First Name8 (NamePattern2) **] [**Known lastname 62631**], phone number [**Telephone/Fax (1) 108765**].
MEDICATIONS ON ADMISSION: Maxzide.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Blood pressure 100/53, with a heart
rate of 71, breathing at 13. The patient was intubated on
assist control with an FIO2 of 70, a respiratory rate of 12,
tidal volume of 500, and PEEP of [**5-19**]. Oxygen saturation was
99%. In general, she appeared to be a frail, elderly female.
Head, eyes, ears, nose and throat examination: The pupils
were small but reactive bilaterally. The patient was
intubated. Cardiovascular examination: Regular rate and
rhythm, tachycardic, II/VI systolic ejection murmur over the
apex. Respiratory: Coarse breath sounds and bibasilar
crackles. Abdomen: Mildly distended, with sparse bowel
sounds, no hepatosplenomegaly, no rebound, no guarding.
Extremities: The feet were cool and without palpable pulses.
LABORATORY DATA: The patient had a white blood cell count
of 12.9, a hematocrit of 36.6, platelets of 322, a PT of
14.4, INR of 1.4, PTT of 94.5. Sodium 136, potassium 5.3,
chloride 102, bicarbonate 19, BUN 42, creatinine 1.1, glucose
313. She had a CK of 581, with an MB of 98, troponin-I
greater than 50. Chest x-ray revealed diffuse perihilar
haziness, consistent with pulmonary edema. Electrocardiogram
revealed sinus tachycardia at 130, with a left bundle branch
block which is new compared with the prior electrocardiogram
of [**2153**].
HOSPITAL COURSE: After an extensive discussion amongst the
family and the team, the patient was admitted to the Coronary
Care Unit service for conservative management of acute
myocardial infarction and congestive heart failure. She was
initially maintained on a heparin drip and aspirin, and was
monitored with 24 hour telemetry. She arrived to the floor
intubated and on a dopamine drip to sustain her blood
pressure.
By the next morning, the patient was extubated successfully,
and was weaned off the dopamine. She diuresed briskly with
lasix, resulting in a marked improvement in her respiratory
status. She remained hemodynamically stable throughout her
stay. She had a transthoracic echocardiogram, which revealed
severe hypokinesis of the anterior septum and free wall, an
ejection fraction of 40%, and moderate to severe mitral
regurgitation.
In light of this, our goal became to maximize her medical
regimen. She was started on low-dose Lopressor, which was
carefully titrated. She was continued on aspirin, and was
started on Captopril for afterload reduction. She tolerated
her new medical regimen without any difficulties.
The patient was transferred to the floor on [**10-24**]. Here
she had one episode of [**3-24**] substernal chest pain that did
not result in any electrocardiogram changes, and which
resolved with two sublingual nitroglycerins. The patient
remained pain-free throughout the duration of her hospital
stay.
Of note, the patient developed a cough and had a good sputum
sample, which had 2+ gram-positive cocci in pairs and
clusters. For this, she was started on Levaquin for empiric
treatment of pneumonia. She remained afebrile throughout her
stay, and there was no obvious opacity visible on chest
x-ray.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease
2. Congestive heart failure
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg by mouth once daily
2. Lopressor 25 mg by mouth twice a day
3. Colace 100 mg by mouth twice a day
4. Lasix 20 mg by mouth once daily
5. Levaquin 250 mg by mouth once daily
6. Zestril 10 mg by mouth once daily
7. Sublingual nitroglycerin 0.4 mg sublingually every five
minutes x 3 as needed
The patient was advised to follow up with her primary
cardiologist, Dr. [**Last Name (STitle) **], within one to two weeks. The
patient will be discharged to [**Hospital 2436**] Rehabilitation
facility prior to returning home.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36
D: [**2159-10-25**] 23:59
T: [**2159-10-26**] 01:02
JOB#: [**Job Number **]
ICD9 Codes: 4280, 486, 4240, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5372
}
|
Medical Text: Admission Date: [**2119-4-4**] Discharge Date: [**2119-4-18**]
Date of Birth: [**2053-5-26**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
Craniectomy
History of Present Illness:
Per admitting resident:
[**Known firstname **]-Pak-[**Known lastname **] is a 65 year-old man Vietinamese speaking only
with long standing history for HTN who presented to the ED after
acute left sided weakness. Patient was last seen normal around
5:40pm. By 6:30pm, patient was coocking in his kitchen when his
son heard a strong sound like something had fallen to the floor.
Later he heard his father calling for help. His son found him in
the floor lying in his left sided and he could not stand up. 911
was called and patient was brought to the hospital. Upon arrival
he was evaluated in the ED as described below.
Past Medical History:
? hypothyroidism
HTN
Family denied CHD
Social History:
Lives with his wife and sons. [**Name (NI) **] used to smoke and quit 21 years
ago. No drink.
Family History:
No family history of stroke, heart attack or seizures.
Physical Exam:
Physical Examination on admission:
NIH: score 18. (1a=2 1b=1 2=2 3=2 4=2 5a=3 5b=0 6a=2 6b0 7=0 8=1
9=0 10=1 11=2)
VS: BP 147\104 later 169\99mmHg HR 63 Sat 97% Room air
Genl: lethargic, following commands.
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: +BS, soft, NTND abdomen
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: obtuned. Following simple commands with right
hand. fluent dysarthric speech. Clear signs of neglection to the
left side.
Cranial Nerves: Pupils equally round and reactive to light, 4 to
2 mm bilaterally. Visual fields with left hemianopsia. Eye
deviation to the right side. Sensation intact V1-V3. Left facial
weakness. Tongue midline, movements intact.
Motor: decreased tone in the left arm and leg. Left arm showed
feel spontaneous movements no antigravity. Left leg antigravity,
but not sustained.
Sensation: patient reacted to the pinprick, but less intense in
the left sided.
Reflexes: 2+ and symmetric throughout. Toes upgoing left side.
Coordination: no tremor.
Exam at time of discharge:
Pertinent Results:
[**2119-4-4**] 06:50PM BLOOD WBC-6.6 RBC-5.38 Hgb-15.0 Hct-46.7 MCV-87
MCH-27.8 MCHC-32.0 RDW-13.7 Plt Ct-212
[**2119-4-5**] 02:12AM BLOOD Neuts-83.6* Lymphs-10.8* Monos-4.4
Eos-1.0 Baso-0.2
[**2119-4-4**] 06:50PM BLOOD PT-11.7 PTT-31.4 INR(PT)-1.0
[**2119-4-4**] 06:50PM BLOOD Glucose-94 UreaN-17 Creat-1.0 Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
[**2119-4-5**] 02:12AM BLOOD ALT-14 AST-21 CK(CPK)-171 AlkPhos-75
TotBili-0.9
[**2119-4-5**] 02:12AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1 Cholest-196
[**2119-4-5**] 02:12AM BLOOD Triglyc-78 HDL-50 CHOL/HD-3.9
LDLcalc-130*
[**2119-4-5**] 02:12AM BLOOD %HbA1c-6.1* eAG-128*
Imaging:
CT head [**4-4**]
IMPRESSION: Right basal ganglia intraparenchymal hemorrhage. No
shift of
normally midline structures. Consider MRI with gadolinium to
exclude an
underlying lesion.
CT head [**4-5**]:
IMPRESSION: Significant interval increase in size of a right
putamen
hemorrhage with increased extent of surrounding vasogenic edema
leading to new
9 mm leftward subfalcine herniation and marked effacement of
sulci as well as
anterior [**Doctor Last Name 534**] of right lateral ventricle. No evidence of uncal
or tonsillar
herniation. No evidence of new additional hemorrhage.
CT head [**4-6**]
IMPRESSION: Allowing for differences in slice selection, little
change in the
right parenchymal hemorrhage and surrounding edema with
persistent subfalcine
herniation and leftward shift of the normally midline
structures. No new
hemorrhage.
CT head [**4-8**]: A large right putamen hemorrhage is similar in
size, measuring 4.7 x 5.2 cm, with surrounding vasogenic edema.
This causes
compression/effacement of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle,
making evaluation for intraventricular hemorrhage difficult.
However, no
hemorrhage is seen in the remainder of the ventricular system.
There is a
stable 11-mm left shift of the midline structures indicative of
subfalcine
herniation. The study is otherwise unchanged, and no new
hemorrhage is
identified. The soft tissues appear unremarkable.
CT head [**4-10**];
IMPRESSIONS:
1. Large right frontotemporal hemorrhage slightly larger than
that seen two
days prior. Together with surrounding vasogenic edema, this
causes leftward
subfalcine herniation and right uncal herniation.
2. Subtle relative hypodensity along the medial right occipital
lobe with
loss of [**Doctor Last Name 352**]-white matter differentiation is concerning for
infarction,
possibly due to the leftward subfalcine herniation.
3. Dilatation of the left lateral ventricle, likely due to
compression on the
F. of [**Last Name (un) 2044**] from the mass effect, with slowly progressing
periventricular
hypodensities likely due to transependymal CSF migration.
CT head [**4-11**]
IMPRESSION:
1. Status post right frontotemporal craniectomy with evacuation
of large
right frontotemporal intraparenchymal hematoma with residual
gas, blood and
edema in the resection cavity. Associated mass effect, including
leftward
midline shift has slightly decreased, now measuring 8 mm.
2. Evolving right PCA territory infarct.
3. Unchanged hypodensity along the left lateral ventricle, again
consistent
with transependymal CSF migration.
4. Unchanged right posterior mid brain high-density focus, again
concerning
for hemorrhage.
MRI brain +/- [**4-11**];
IMPRESSION:
1. Persistent moderate mass effect from the right frontal
parenchymal
hemorrhage, status post partial evacuation without interval
change from the
most recent CT scan.
2. Persistent hydrocephalus with transependymal flow of CSF.
3. Focal hemorrhage within the mid brain and pons.
4. Evolving infarcts in the brainstem, splenium and right PCA
distribution.
5. Blush of enhancement surrounding the post-surgical changes in
the right
frontal lobe without evidence for an underlying mass.
CT head [**4-12**];
Continued evolution of known infarctions within the right
occipital lobe,
splenium, midbrain/pons, and left internal capsule, with
unchanged small
hemorrhage in the right posterior mid brain/pons. Dedicated MRA
can be
considered for assessment of vessels, if there is no
contra-indication.
Little change in exam, with small amount of residual hematoma
within the right
frontotemporal lobe and large amount of surrounding edema
causing 9-mm
leftward shift of normally midline structures. Unchanged
dilatation of left
lateral ventricle, with transependymal CSF migration.
Brief Hospital Course:
65 year-old man Vietinamese speaking only with long standing
history for HTN who presented to the ED after acute left sided
weakness. Patient had complete
arm>face>leg hemiparesis with signs of neglect.
.
Head CT showed a deep putamenal hematoma suggestive of
hypertensive etiology.
.
NEURO: Admitted w/ HOB elevation to 30 degrees, I/O goal of
-500 and SBP control to < 150. Normothermia and normoglycemia
were maintained via Tylenol and ISS.
.
By morning of HD1 patient had deteriorated clinically and on CT,
with midline shift and subfacline herniation. He was started on
mannitol. With this treatment he temporarily maintained his
examination until Monday [**4-10**]. However, in the evening of [**4-10**],
the patient was found to have blown pupils, became hypertensive,
and in respiratory distress. He was intubated, hyperventilated,
and received additional mannitol. A repeat CT head showed
worsening edema with subfalcine and bilateral uncal herniation
and was emergently taken to the OR for a decompressive
craniectomy for increased vasogenic edema. His exam post
operatively was poor, as his pupils were asymetric and minimally
reactive, he demonstrated extensor posturing in his upper
extremities and triple flexion in his lower extremities.
Post-operatively on repeat imaging he was found to have a right
PCA infarction thought to be secondary to compression from the
uncal herniation, as well as a small right midbrain duret
hemorrhage.
.
CV: BP was maintained via PO meds and NGT (Lisinopril) and
labetalol IV prn. Post-operatively the patient was hypotensive,
requiring pressors intermittently for POD # 1 and 2. His SBP
goal is 120-140.
.
PULM: The patient was intubated emergently on [**4-10**] at the time
of his clinical decompensation.
.
ID: Post-operatively, the patient spiked fevers with a T max of
104.9. He was empirically started on vancomycin and cefepime.
Blood cultures from [**4-11**] and [**4-12**] grew coagulase negative staph.
A respiratory culture grew gram negative rods. Ciprofloxacin
was added on [**4-13**].
.
GI: The patient was on IV famotidine for GI prophylaxis and
maintained on tube feeds for nutritional support.
.
Endocrine: The patient was continued on his home synthroid and
fingersticks were covered with regular insulin sliding scale.
.
Code status: Multiple family discussions were held throughout
the hospital course regarding goals of care. On [**4-13**] a family
meeting was held to further clarify goals of care, to discuss
rather the family would like a tracheostomy and PEG placement or
make the patient CMO. On [**4-17**], the family reported they
intended to withdraw care on [**4-18**] once the family could be
present. On the morning of [**4-18**] the patient once again had
blown pupils, agonal respirations and was becoming hypotensive.
His family was contact[**Name (NI) **] and present later that morning. He was
extubated and died shortly after extubation.
Medications on Admission:
Atenolol
ASA
Lisinopril
Levothyroxin
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparencyhmal hemorrhage
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 2760, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5373
}
|
Medical Text: Admission Date: [**2180-12-30**] Discharge Date: [**2181-3-7**]
Date of Birth: [**2110-12-26**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 yo male with recent pancreatitis from pancreatic CA on TPN
sent in for fever and hypotension SBP70s concerning for sepsis.
Mr. [**Known lastname 35831**] was discharged from [**Hospital1 18**] to [**Hospital3 105**] in
[**Location (un) 38**] on [**2180-12-20**]. he has been admitted to the [**Hospital1 **] for
sork-up for a newly identified pancreatic mass found during a
recent episode of gallstone pancreatitis. ERCP was unable to
perform sphincerotomy or obtain brush sample secondary to
significant inflammation and edema. The patient was sent to
[**Location (un) **] NPO on TPN for bowel rest in the hope that there would
be a redcution in the edema so that a Whipple procedure might be
possible. He states that he was in his usual state of health at
[**Location (un) 38**] until his TPN was switched from a 12 hour cycle to a
16 hour cycle. He states that he then began to have severe,
non-bloody diarrhea - up to 20 bowel movements a day. Patient
states that he has been unable to sleep at all for the last
several days. Per report from the OSH, TPN was switched on [**12-28**]
and diarrhea began. On [**12-29**], mental status changed were noted
and the patient refused all medications. WBC count rose to 14.2
but the patient remained afebrile. Stools were sent for c.diff
and are pending. This am temp was 102, BP 85/50, HR 105, RR 20
and )2 97%. Fever work-up was initiaited with UA, CXR, KUB,
BCx2, and repeat CBC. NS was started and the patient was
transferred with a BP of 100/60, HR 105 and T 102.8.
In the ED, T 100.3, BP 97/57 HR 103 and RR 16. Patient given IV
Vanc, Levo, and Flagyl. he also received 2 liters of fluid, a
CXR was performed in addition to blood cultures. LIJ was placed.
Patient was transferred to the ICU for further management fo
sepsis
Past Medical History:
Pancreatitis s/p ERCP. Details above.
CAD , history of MI [**2174**], CABG
s/p AICD (followed by Dr [**Last Name (STitle) **] at [**Hospital1 18**])
Asthma
Hyperlipidemia
s/p TURP
Diverticulitis
Hypertension, benign
Hard of hearing, mild
Small unbilical hernia
Social History:
Smoking: 40 pack year (quit in [**2158**]). H/o social alcohol use.
Quit in [**2160**]. One time use thereafter 2 yrs back. None since
then. No illicit drug use. Retired mechanic. Lives in his home.
Grandson who is 26 lives with him. Has a fiance' who lives
across the street. Wants fiance, Ms [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5239**] to be his
health care proxy.
Family History:
MI (father), ovarian cancer (mother)
Wife - smoker, dementia. Deceased many years back.
Physical Exam:
Gen: VS: T98.1F P 89 RR 28 BP 98/56 O2 sats: 96% RA. No acute
distress. Obese man lying in bed.
Eyes: PERRL, no pallor or icterus
ENT: Moist oral mucosae. No ulcers or thrush. No exudates or
erythema. Wears dentures
CV: S1,2 regular. No murmurs, rubs or gallops. Peripheral
vascular access.
RS: No crackles or wheezes.
Abd: Soft, obese. Bowel sounds heard and normal. Mild tenderness
to palpation in RUQ. No rebound tenderness or guarding. No
masses palpable but limited exam given obesity. Umbilical hernia
seen.
MSK- Extremeties: No cyanosis, clubbing, No joint swelling. No
peripheral LE edema.
Neuro: Alert and oriented. Normal attention. Fluent speech.
Skin: no rashes or ulcers noted.
Psychiatric: Appropriate, pleasant.
Pertinent Results:
[**2180-12-30**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2180-12-30**] 01:30PM NEUTS-93.2* BANDS-0 LYMPHS-4.2* MONOS-1.9*
EOS-0.7 BASOS-0.1
[**2180-12-30**] 01:30PM WBC-14.8*# RBC-3.89* HGB-11.4* HCT-32.2*
MCV-83 MCH-29.2 MCHC-35.3* RDW-15.4
[**2180-12-30**] 01:30PM ACETONE-NEGATIVE
[**2180-12-30**] 01:30PM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-4.0
MAGNESIUM-1.9 URIC ACID-1.8*
[**2180-12-30**] 01:30PM cTropnT-0.02*
[**2180-12-30**] 01:30PM LIPASE-54
[**2180-12-30**] 01:30PM ALT(SGPT)-34 AST(SGOT)-29 LD(LDH)-199
CK(CPK)-21* ALK PHOS-68 AMYLASE-62 TOT BILI-0.4
[**2180-12-30**] 01:30PM GLUCOSE-152* UREA N-45* CREAT-1.4* SODIUM-134
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-20* ANION GAP-17
[**2181-3-7**] 03:44AM BLOOD WBC-9.6 RBC-3.26* Hgb-10.1* Hct-30.5*
MCV-94 MCH-31.1 MCHC-33.2 RDW-17.6* Plt Ct-196#
[**2181-3-7**] 03:44AM BLOOD Glucose-91 UreaN-15 Creat-0.7 Na-139
K-3.7 Cl-101 HCO3-33* AnGap-9
[**2181-2-27**] 07:04PM BLOOD ALT-36 AST-32 AlkPhos-720* Amylase-68
TotBili-1.9*
[**2181-2-27**] 07:04PM BLOOD Lipase-68*
[**2181-2-27**] 06:43PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2181-3-4**] 02:12PM BLOOD Albumin-2.3* Calcium-7.3* Phos-1.8*
Mg-2.0
[**2181-1-21**] 03:26AM BLOOD calTIBC-77* Ferritn-476* TRF-59*
[**2181-1-21**] 03:26AM BLOOD Triglyc-111
[**2181-2-20**] 03:08AM BLOOD TSH-2.5
[**2181-2-20**] 03:08AM BLOOD T4-4.8 T3-50*
[**2181-2-28**] 02:13AM BLOOD Digoxin-2.0
.
CHEST PORT. LINE PLACEMENT [**2181-3-5**] 3:14 PM
FINDINGS: In comparison with the study of [**2-28**], there is little
change in the appearance of the heart and lungs. Low lung
volumes persist with some opacification at the left base that
could represent some combination of pleural effusion and
atelectasis.
The right subclavian PICC line extends to the lower portion of
the SVC.
.
ECHO
Conclusions
No spontaneous echo contrast or clotis seen in the body of the
left atrium. . There are simple atheroma in the descending
thoracic aorta. There are three mildly thickened aortic valve
leaflet with trace aortic regurgitation. There is no vegetation
on the aortic valve. The mitral valve leaflets are mildly
thickened with mild (1+) mitral regurgitation but no vegetation.
No clear vegetation or regurgitation is seen on the tricuspid or
pulmonic valve. The atrial and ventricular ICD leads are
visualized and there are no massess or vegetations on the leads.
The atrial lead terminates in the right atrial appendage.
IMPRESSION: no evidence of endocarditis or myocardial abscess on
TEE.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2181-2-27**] 8:59 PM
IMPRESSIONS:
1. No evidence of pulmonary embolus.
2. Post-surgical changes of Whipple, with moderate fat stranding
in the surgical bed, but no evidence of discrete fluid
collection to suggest abscess.
3. Enlarged lymph nodes in the chest are nonspecific.
4. Improving hepatic retractor injury.
5. Stable right adrenal nodule.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2181-2-22**] 9:03 PM
IMPRESSION: Evolution of left hepatic lobe lesion which is now
more ill- defined with mixed echogenicity suggests that this was
related to acute injury as previously described. No other focal
hepatic lesions. No biliary ductal dilatation. Small amount of
fluid around the liver edge. Right pleural effusion incompletely
imaged.
.
CT ABDOMEN W/CONTRAST [**2181-2-15**] 9:22 AM
IMPRESSION:
1. Status post Whipple procedure and removal of surgical bed
drains. A couple of foci of gas are consistent with removal of
the drainage catheters, but no new fluid collections identified.
2. Decrease in size of a left lobe hepatic lesion likely
reflecting retractor injury.
3. Increased bilateral pleural effusions and atelectasis.
4. Right adrenal nodule, unchanged.
.
CT ABDOMEN W/O CONTRAST [**2181-2-10**] 12:29 PM
IMPRESSION:
1. Overall decrease in size of the previously noted several
small intraabdominal fluid collections. No new fluid collections
are identified.
2. No significant change in position of the surgical drains as
above.
3. Nonspecific filling defect seen in several loops of small
bowel that may be related to enteric feeds. Differential
diagnosis also includes blood clots.
.
CT ABDOMEN W/CONTRAST [**2181-1-15**] 2:02 PM
IMPRESSION:
1. Findings concerning for anastomotic leak at the
hepaticojejunostomy, within the lesser sac. There is no discrete
abscess formation at this time, however there is more gas than
expected at six days postoperatively. Close continued followup
is advised.
2. Likely retraction injury within the left lobe of the liver,
although a developing abscess would be difficult to exclude and
clinical assessment as well as close interval followup is
advised. Markedly distended stomach with relatively decompressed
small-bowel loops. Distended, fluid-filled esophagus.
.
SPECIMEN SUBMITTED: gallbladder, Whipple Specimen.
Procedure date Tissue received Report Date Diagnosed
by
[**2181-1-9**] [**2181-1-9**] [**2181-1-13**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf
Previous biopsies: [**-8/4347**] DUODENUM BIOPSY (1 JAR).
DIAGNOSIS:
1. Pancreatic duodenectomy:
1. Unlined, inflammatory and hemorrhagic cyst with giant cell
reaction.
2. Segment of unremarkable small bowel.
3. No carcinoma seen.
2. Gallbladder, cholecystectomy:
Chronic cholecystitis.
.
CTA ABD W&W/O C & RECONS [**2181-1-1**] 3:40 PM
IMPRESSION:
1. Compared to prior exam, the inflammatory change surrouding
the head of the pancreas is improved and there is slight
decrease in the size of the enlarged uncinate process containing
tubular cystic structures. Additionally, the relative
contribution of the cystic portion of the mass appears
subjectively decreased in size. Diagnostic consideration for
this lesion include intraductal papillary mucinous neoplasm
versus pseudocyst related to prior pancreatitis.
2. Stable right adrenal adenoma.
3. Cholelithiasis without evidence of cholecystitis.
4. Stable pneumopericardium.
5. Small bilateral pleural effusions and adjacent atelectasis.
.
Brief Hospital Course:
70 yo male with recent pancreatitis from pancreatic CA on TPN
sent in for fever and hypotension SBP 70s concerning for sepsis.
.
Sepsis - currently stable - normotensive, afebrile s/p 2L IVFs,
IV vanc, levo and flagyl. WBC 14.2, CXR negative for PNA, blood
cultures pending. Differential includes pancreatitis, pancreatic
pseudocyst, line infection from TPN picc, and infectious
diarrhea. Blood cultures grew out gram positive cocci both here
and OSH
- send stool studies, inc c.diff toxins A and B
- f/u cx from ED - gram pos cocci
- f/u cx from OSH - gram pos cocci
- continue to monitor for s/sx of sepsis including hypotension,
change in mental status and fever.
- CT scan ABD
- cont vanc, and flagyl - can now d/c levo as has not grown any
gram neg's in 48 hours
- surveillance cultures to make sure is clearing infection
- consider Echo to r/o endocarditis
- goal to keep fluids even, can give IVFs is patient dry or
febrile
- catheter tip - coag negative staph
.
Diarrhea - patient reports 15-50 bowel movements while on 16h
TPN cycle. Reports that BM's have slowed to about 5 BM's a day.
Dnies blood, states that stools are liquid and wake him from his
sleep.
- multiple cdiff negative, have good reason for diarrhea with
bacteremia, will d/c flagyl
.
#Pancreatic Mass/Pancreatitis: Patient had CTA which confirmed
mass. Possible diagnosis of IPMN. Pt underwent ERCP. Due to
significant inflammation around pancreas, ampulla could not be
visualized and brushings could not be obtained. Duodenal biopsy
negative. Pt had been transferred to [**Hospital1 **] in [**Hospital1 1474**] so that
he could remain on TPN in an effort to reduce this inflammation
and possibly move forward with a Whipple.
- General Surgery consult appreciated
- CT ABD
- Pain well controlled with dilaudid.
.
Adrenal Adenoma: Seen on imaging as above. Will need follow up
imaging with PCP. [**Name10 (NameIs) **] was sent to PCP.
.
# Hypertension: holding current regimen of amlodipine, lopressor
and losartan for now until blood pressures stable. will continue
amiodarone
# h/o VT s/p ICD - patient states that his defbrillator has gone
off several times recently and possibly once since admission
- cards consult to interrogate ICD - parameters reset as patient
shocked for afib with RVR
# chronic systolic heart failure - no evidence of pulmonary
edema on CXR, cardiomegaly stable in appearance
# Coronary artery disease s/p CABG/
.
#Hyperlipidemia: restarted Simvastatin.
.
# Acute renal failure: likely [**3-10**] recent diarrhea, baseline 1.0,
now back to baseline
- gentle rehydration
- change meds back to regular dosing
.
# Code status: full code as discussed with patient. HCP per
patient preference - [**Name (NI) **] [**Last Name (NamePattern1) 5239**] (fiance). No information to be
given out to patient daughter or other family members.
.
Precautions: MRSA
.
# PPx: Heparin SC, pneumoboots, PPI
# FEN: NPO, nutrition consult needed to restart TPN, replete
lytes as needed
=
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================================================================
He was then transferred to the surgical service.
He went to the OR on [**2181-1-9**] for a Whipple.
Pain: APS was following along and managing his epidural. He had
borderline hypotension and so his epidural dose was decreased.
Once tolerating a diet, he was started on PO pain meds and was
comfortable.
Post-op Hypotension: He received several fluid boluses on POD 1
and received albumin on the evening on POD 1.
POD #5, transferred to TICU for new onset afib with HR 150's and
initial SBP's in 80's. No CP or palpitations. Brought back to OR
for dehisced PJ anastomosis with intrab sepsis.
.
Events:
[**1-14**]: Transferred to TSICU team, new rapid afib attempted
electrical cardioversion, started on amiodarone drip
[**1-15**]: dilt gtt, PO amio, TPN continued, EP c/s - ICD working
appropriately, febrile, cultures sent
[**1-16**]: Pt was put on vanc/cipro/flagyl, NGT and Reglan. OR -
reexploration, repair dehisced pancreaticjejunostomy with
stenting, feeding jejunostomy, drains x2
[**1-22**] 4 abd staples removed, serous fluid apprec. amio gtt for
afib
[**1-29**] Pt extubated
[**1-30**] reintubated for respiratory distress;
[**1-31**] lines removed for VRE in blood, 2 episodes melena;
[**2-6**] amio restarted, extubated, 2 units blood; [**2-6**]: Incr dilt
to attempt wean levo
[**2-8**]: Continued failure to wean pressors. TSH/cosyntrop normal.
Apneic episodes with 25mcg fent.
[**2-11**] changed levophed to neo
[**2-12**] pancreatic drain d/c'ed, lateral JP d/c'ed
[**2-13**] more confused, transfused 2 units for Hct 23, fever 101.2
[**2-14**] intubated electively, EGD showed no active UGI bleed
[**2-15**] self-extubated, began precedex for agitation
[**2-17**] - replaced RIJ w/ Rsubcl CVL, 2U PRBCs
[**2-21**] Wound vac removed w/ some purulent material, wet-->dry
dressings placed, Go-lytely for C-scope in AM
[**2-22**] lateral portion of wound opened and moist to dry packing
done.
[**2-22**]- Colonoscopy - Diverticulosis of the sigmoid colon
Polyp in the hepatic flexure (polypectomy)
Polyp at 50cm in the mid-descending colon (polypectomy)
Polyp at 30cm in the mid-sigmoid colon (polypectomy)
Polyp at 20cm in the distal sigmoid colon (polypectomy)
Otherwise normal colonoscopy to cecum
[**2-27**] - Septic, bradycardic, hypertensive, transferred to ICU.
Restarted on broad spectrum ABX.
[**2-27**] - Positive Blood cultures {PSEUDOMONAS [**Last Name (LF) 35836**], [**First Name3 (LF) **]
ALBICANS}.
[**2-28**] - still having bloody stools, transfused 2uRBC, prep'd for
C-scope in AM (potential bleed from polypectomy sites)
[**3-1**] - repeat colonoscopy for GI bleed. Transfused 4 Units PRBC.
[**2181-3-6**] - Wound VAC'd
[**2181-3-6**] - Continue IV Lasix for aggressive diuresis to goal
weight of less that 225 lbs. Needs PT!
.
RADS:
[**2-1**]: CT Abd - Interval resolution of previous lesser sac
collection. Sm fluid collection lat to stomach on L: 2.2x3.7 cm.
Fluid collection abutting splenic hilum : 2.6 x 3.8 cm. 3rd
focal fluid collection R mid-abdomen: 3.6x2.6 cm; slightly decr
since prior + anterior intra-abdominal fat stranding
[**2-15**]: CT Abd - foci of gas are consistent with removal of the
drainage catheters, but no new fluid collections. Decrease in
size of L lobe hepatic lesion likely reflecting retractor
injury.
[**2-17**] TTE: EF 40-45%. Mild LVH. No AS,trace AR. 1+MR. [**First Name (Titles) **] [**Last Name (Titles) 35837**]s.
[**2-22**] Liver US: Evolution of left hepatic lobe lesion related to
acute injury.
[**2-28**] TEE: no evidence of endocarditis or myocardial abscess on
TEE
.
Micro:
[**2-27**]: Urine cx: Pseudomonas 10-100K
[**2-27**]: Blood cx: [**Female First Name (un) **] (prelim)and pseudamonas (cipro, ceftaz
resist)
[**2-21**]: Swab: Gram stain shows 1+ PMN, no orgs
[**2-21**]: Blood cx: P
[**2-19**]: VRE Swab: Enterococcus (mod growth)
[**2-18**]: Blood cx x2: P
[**2-15**]: Sputum cx: pseudomonas (R ceftaz, cipro, pip, zosyn), no
fungus
[**2-15**]: Urine cx: pseudomonas >100K
[**2-15**]: Blood cx: Enterococcus (R to amp, PCN, vanco, S to
linezolid)
[**2-13**]: Urine cx - Pseudomonas 10-100K
[**2-13**]: BCx - GPC, chains
[**2-12**]: C-diff - negative
[**2-11**]: BCx: Enterococcus (R to amp, levo, vanco)
[**2-6**]: Sputum - pseudomonas
[**2-6**]: UCx - pseudomonas (pan sensitive)
[**1-25**]: BCx: ENTEROCOCCUS FAECIUM (PCN, amp, vanc res, linezolid
[**Last Name (un) 36**])
[**1-25**]: Sputum - 2+ GNRs pseudomonas aerug, pan-sensitive, yeast
[**1-23**]: + VRE
[**1-17**]: Abdomen - 3+ GNRs, 2+ GPCs, 2+ yeast -->moderate Pseud
aerug
[**1-3**]: C-diff - Positive
[**12-31**]: Cath Tip - MRSA
.
VRE: Most recently persistent VRE bacteremia. Original source
may have been in the abdomen given presence of GPC in pairs
from swab, although current CT is not
suggestive for worsening or enhancing fluid collection. Patient
is at risk for endocarditis. He completed a course of Linezolid
that ended on [**2181-3-1**].
A TEE showed no evidence of endocarditis or myocardial abscess
on TEE
Additional blood cultures on [**2-27**] were positive and grew
PSEUDOMONAS [**Month/Year (2) 35836**] and [**Female First Name (un) **] ALBICANS. He was started on
Meropenem, Fluconazole and should continue thru [**2181-3-16**].
.
Post-op Hyperglycemia: He was followed by [**Last Name (un) **] for blood
glucose control and his insulin was adjusted accordingly.
.
GI: He was receiving cycled tubefeedings and tolerating a
regular diet. He was having occasional loose stool, and C.diff's
were checked on several occasions, and all were negative.
His incision was opened at the bedside and drained. He had
serial debridements and the wound bed was clean and pink. He
continued with moist to dry gauze dressing changes. The wound
was VAC'd and can be VAC'd at rehab.
.
Renal: He continued to receive IV Lasix for diuresis as needed.
His input and ouput was watched closely and he was kept negative
~[**Telephone/Fax (1) 1999**] mL each day. His goal weight is 225 lbs. and most
recent weight was 240lbs.
.
PT: [**Name (NI) **] was deconditioned and unsteady. PT recommended rehab.
Medications on Admission:
Amiodarone 200mg daily
Amlodipine 5mg daily
Metoprolol 50mg [**Hospital1 **]
Heparin 5000units sc tid
ASA 81mg daily
Pantoprazole 40mg daily
Simethicone 80mg tid
Losartan 50mg daily
Prochloperazine 5mg q6h
Hydromorphone 1mg q6h
Ondansetron 4mg q6h
Questran 1 gm daily
Metoclopramide 5mg q6h
TPN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed.
8. Oxycodone 5 mg/5 mL Solution Sig: [**2-7**] PO Q6H (every 6 hours)
as needed for pain.
9. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical DAILY (Daily): apply to affected area on back .
10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five
(5) Units Subcutaneous once a day.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) Subcutaneous at bedtime.
15. Insulin Lispro 100 unit/mL Solution Sig: SS Subcutaneous
every four (4) hours: See sliding scale.
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
[**3-12**] Capsule, Sustained Releases PO BID (2 times a day) for 1
weeks: HOLD for K>4.5. continue while aggressive diuresis.
17. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 9 days: thru [**2181-3-16**].
18. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 9 days: thru
[**2181-3-16**].
19. Acetazolamide Sodium 500 mg Recon Soln Sig: Two Hundred
Fifty (250) mg Injection Q6H (every 6 hours) for 2 doses.
20. Furosemide 10 mg/mL Solution Sig: Two (2) Injection twice a
day: Continue with diuresis until at dry weight of 225 lbs (most
recently 240 lbs). .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Pancreatic Mass
Pancreatico-jejunostomy anastomosis Dehisced with
intra-abdominal sepsis/leak
Hypotension,
Arrythmia
VRE bacteremia
Post-op blood loss anemia
GI Bleed
Diverticulosis
Multiple Colon Polyp with polypectomies.
Wound infection
Positive Blood cultures (PSEUDOMONAS [**Last Name (LF) 35836**], [**First Name3 (LF) **]
ALBICANS
Discharge Condition:
Good
Tolerating tubefeeding and regular diet
Wound bed clean with good granulation tissue. Continue to VAC
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. You will have a CT
at 9:00am on [**2181-3-19**] in the [**Hospital Ward Name 23**] building. Nothing to eat or
drink 4 hours prior to you appointment. Then follow-up with Dr.
[**Last Name (STitle) 468**] at 11:00am on [**2181-3-19**]. Call [**Telephone/Fax (1) 2835**] with questions
or concerns.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2181-3-30**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2181-3-30**] 12:00
Completed by:[**2181-3-7**]
ICD9 Codes: 5990, 5180, 5849, 2851, 7907
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5374
}
|
Medical Text: Admission Date: [**2144-7-4**] Discharge Date: [**2144-7-10**]
Service: MEDICINE
Allergies:
Lopressor / Toprol Xl / Penicillins / Sulfonamides / Bupropion
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
Fall; right leg pain.
Major Surgical or Invasive Procedure:
1. Temporary pacer wire placement.
2. Open reduction internal fixation.
History of Present Illness:
[**Age over 90 **] yo M with history of hypertension, depression who presents
after fall with R intratrochanteric femur fracture. Patient
states that he remembers falling trying to get from his table at
dinner to his walker. He was seen by Ortho in ED who recommended
gamma nail to right femur. On the medical floor, patient
complained about R hip pain and dysuria despite foley placement.
He denied any history of cardiac problems. [**Name (NI) **] denies chest pain,
palps, SOB. He had a holter here in [**2134**] showing a RBBB with
sinus rhythm.
Patient noted to have a baseline PR 300 ms, with old RBBB, new
LAFB. Also with A tachy with 3:1 block. Decision was made for
temp wire placement which was done by EP on [**7-6**]. Patient
subsequently transferred to CCU for monitoring and in
anticipation of surgery on [**7-7**] by ortho.
Past Medical History:
1. Hypertension
2. Severe depression requiring inpatient stays and ECT [**2142**]
3. COPD
4. Diabetes
5. Anxiety
6. Seborrhea
7. Bradycardia
8. Arthritis
9. Impaired hearing
10. ? PAF
Social History:
Lives at [**Hospital 100**] Rehab since [**2142**] after functional decline. Wife
lives there as well and suffers from dementia. Former smoker,
does not drink alcohol
Family History:
Mother died young, does not know cause of death of father.
Physical Exam:
gen - Lying in his left side, wimpering. Complaing of right leg
pain. Alert. Oriented to person and "[**Hospital3 **]". Does not know
the year. Knows his two daughters.
cv - Bradycardic. Regular. No clear murmurs.
pulm - Bibasilar crackles. Good air movement.
abd - Soft. Non-tender. Non-distended.
ext - Warm. Right hip dressings are c/d/i. Some pain around the
sites, but no erythema or warmth. Moves both distal extremities.
Pertinent Results:
Admit Labs: [**2144-7-4**]
WBC-13.7* RBC-4.15* Hgb-14.1 Hct-40.0 MCV-96 MCH-34.1*
MCHC-35.3* RDW-16.0* Plt Ct-193
PT-11.7 PTT-24.2 INR(PT)-1.0
Glucose-141* UreaN-29* Creat-1.4* Na-138 K-4.9 Cl-106 HCO3-22
AnGap-15
RIGHT HIP ([**2144-7-4**]): Displaced intertrochanteric fracture of the
right hip.
CXR ([**2144-7-4**]): No acute cardiopulmonary process.
EKG: Atrial tachycardia with 2;1 block at a rate of 57. Since
the previous tracing of [**2139-3-29**] the rhythm is new. Positional
changes are noted over the lateral precordium.
Brief Hospital Course:
1. Rhythm:
Initial EKG showed atrial tachycardia with RBBB, LAFB; severe
first degree AV block had been noted on prior tracings. Pre-op,
a temp wire was placed. EP followed the patient and did not
feel that a permanent pacer indicated. Nodal agents were
avoided during the hospitalization.
2. Hip Fracture:
After placement of temp wire, patient went to OR with ortho and
underwent ORIF. Did well post-op with pain management and PT.
Plan was for discharge to rehab with plan for continued physical
therapy.
3. Hypertension:
Continued lisinopril.
4. Depression/Anxiety:
Tearful, anxious on exam. Apparently long [**Last Name **] problem s/p
ECT ~ 2 yrs ago.
Continued wellbutrin, xanax. Is followed at [**Hospital 100**] Rehab by
psychiatry.
5. COPD:
Continued advair and combivent.
6. Coronary artery disease:
Patient has old IMI based on EKG, but coronary disease per
patient. Aspirin was restarted.
7. Diabetes:
Used an insulin sliding scale.
Medications on Admission:
1. Lasix 20 mg daily
2. Lisinopril 2.5 mg daily
3. Bupropion 150 mg [**Hospital1 **]
4. Trazadone 25 mg QHS
5. Xanax 0.25 mg TID
6. Pantoprazole 20 mg daily
7. Combivent IH QID
8. Advair 50/500 [**Hospital1 **]
9. Tylenol #3
10. Latanoprost 0.005% both eyes QHS
11. Sorbitol 70% solution, 15 ml daily
12. Art tears PRN
Discharge Medications:
1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-21**]
Puffs Inhalation Q6H (every 6 hours).
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-21**]
Drops Ophthalmic PRN (as needed).
13. Insulin Regular Human 100 unit/mL Solution Sig: Please see
attached SS Injection ASDIR (AS DIRECTED).
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
1. Right intratrochanteric fracture
2. Severe conduction disease (RBBB, LAFB, high grade AV block)
Secondary:
1. Hypertension
2. Severe depression
3. COPD
4. Diabetes
5. Anxiety
6. Arthritis
7. Impaired hearing
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
You were admitted with a femur fracture. It will be important
for you to continue taking all your medications, as prescribed.
You will continue to require physical therapy.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-21**] weeks.
You have an appointment with Dr. [**Last Name (STitle) 2637**] on [**2144-8-4**] at 10:20am
ICD9 Codes: 496, 5849, 4019, 2859, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5375
}
|
Medical Text: Admission Date: [**2189-2-16**] Discharge Date:
Date of Birth: [**2127-2-24**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man
with hypertension, Type 2 diabetes with no prior cardiac
history who presented to an outside hospital on [**2-15**]
with an acute onset of shortness of breath and overproductive
cough. He was transferred to the [**Hospital6 649**]. ST and T wave changes were observed. The
chest x-ray showed pulmonary edema/Lasix was given and the
patient felt a little better. The patient quoted a monitor
planned energy level.
PAST MEDICAL HISTORY: Significant for degenerative joint
disease of the neck and spine, hypertension, Type 2 diabetes.
His risk factors include hypertension and diabetes.
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin, Plavix 75 mg q.d., Aggrastat, Lovenox,
last dose was on [**2-16**], Glipizide 5 mg q.d., Lopressor
25 mg b.i.d., Lasix 40 mg intravenously once a day, these
were on arrival.
FAMILY HISTORY: Significant for coronary artery disease.
SOCIAL HISTORY: He was married, he denied any ethanol abuse.
He is a tobacco smoker for 48 years. He is a disabled
truckdriver due to degenerative joint disease.
REVIEW OF SYSTEMS: Significant for pain from back pain,
because of his degenerative joint disease.
LABORATORY DATA: His laboratory data on admission were
complete blood count of 9.8, hematocrit 38.7, platelets 276,
BUN 14 and creatinine 1.0. CK 177, MB 6.6.
HOSPITAL COURSE: This is a man who entered the
Catheterization Laboratory and severe three vessel disease
was diagnosed with an left ventricular end diastolic pressure
of 34. The patient was taken to the Operating Room on
[**2189-2-18**] where he had a coronary artery bypass graft
times three by Dr. [**Last Name (STitle) **]. Postoperatively the patient
was transferred to the Cardiothoracic Intensive Care Unit
where he was transfused for a low hematocrit and the patient
was transferred to the floor on [**2-19**] in the evening of
postoperative day #1. On postoperative day #2, the patient's
Foley catheter was discontinued in the morning as well as his
chest tubes. Chronic Pain Service was consulted for his
ongoing pain for which they stated we should continue the
OxyContin and Percocet for breakthrough pain. The patient's
wires were discontinued on [**2189-2-21**]. He tolerated
this procedure well. No bleeding was noted. The patient was
continued on his medications and he was discontinued home
pending Level 4 or 5 stairs.
DISCHARGE MEDICATIONS: (tentatively)
1. Lopressor 50 p.o. b.i.d.
2. Glucophage 300 mg p.o. b.i.d.
3. OxyContin 400 mg p.o. b.i.d.
4. Glyburide 5 mg p.o. q.d.
5. Percocet, he will get 80 tablets for pain along with
Colace
6. Aspirin 325 mg p.o. q.d.
7. Lasix 20 mg p.o. b.i.d.
8. Potassium chloride 20 mEq p.o. b.i.d. for a total of one
week
9. Prescription for Zantac 150 mg p.o. b.i.d.
FOLLOW UP: He is to follow up with Dr. [**Last Name (STitle) **] in four
weeks and he is to follow up with his primary care physician
as well.
Addendum will include date of discharge and any medication
changes.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2189-2-21**] 20:19
T: [**2189-2-21**] 21:44
JOB#: [**Job Number 30684**]
ICD9 Codes: 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5376
}
|
Medical Text: Admission Date: [**2112-1-6**] Discharge Date: [**2112-1-14**]
Date of Birth: [**2032-7-23**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1120**] is a 79-year-old woman
who presented to the [**Hospital6 1109**] on [**1-6**]
with complaint of chest pain which occurred following
vomiting coffee ground material. She underwent a cardiac
catheterization which showed 40-50 percent left main,
proximal LAD, diagonal, circumflex, OM and PDA stenosis.
Unable to evaluate ejection fraction due to ectopy with
likely posterolateral hypokinesis. She was transferred to [**Hospital1 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **], on the day of admission to
[**Hospital1 **], for coronary artery bypass grafting, but had large
volume of hemoptysis. She was transferred to the CCU and
underwent upper GI endoscopy which revealed duodenitis,
hiatal hernia, gastritis, with no active bleeding. She was
placed on IV Protonix, anticoagulation was stopped, and she
had no further evidence of bleeding over the next two days.
She was then cleared by the GI service to proceed with
coronary artery bypass grafting.
PAST MEDICAL HISTORY: Coronary artery disease.
Hypothyroidism.
Asthma.
Skin CA.
Meniere's disease.
GERD.
Left ear deafness.
Left shoulder arthritis.
MEDS AT HOME:
1. Advair 250/50, 2 puffs [**Hospital1 **].
2. Synthroid 100 mcg once daily.
3. Hydrochlorothiazide.
4. Singulair 10 once daily.
5. Vistaril.
MEDS AT [**Hospital Ward Name **] MEDICAL CENTER:
1. Aspirin 325 once daily.
2. Protonix 40 IV bid.
3. Synthroid 88 once daily.
4. Singulair 10 once daily.
5. Lipitor 40 once daily.
6. Advair 250/50, 2 puffs [**Hospital1 **].
7. Subcu heparin.
8. Carafate 1 gm [**Hospital1 **].
9. Lopressor 25 mg [**Hospital1 **].
ALLERGIES: Erythromycin.
REVIEW OF SYMPTOMS: No TIA, CVA, seizure, or headaches.
Positive Meniere's. Positive polio as a child. Pulmonary:
Positive asthma with no sputum production. Cardiac:
Positive dyspnea on exertion, occasional palpitations. No
PND. No orthopnea. GI: Positive GERD. No previous
hemoptysis. Positive hemorrhoids. GU: No frequency. No
dysuria. Heme, ID: No issues. Endocrine: Hypothyroidism.
No diabetes.
PHYSICAL EXAM: Neuro grossly intact. No carotid bruits.
Pulmonary: Clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm. No murmur. Abdomen is soft,
nontender and nondistended. Extremities are warm, trace
pedal edema bilaterally with no varicosities.
LAB DATA: White count 8.5, hematocrit 33.4, platelets 159,
sodium 140, potassium 3.9, chloride 109, CO2 27, BUN 10,
creatinine 0.7, glucose 121, PTT 32.1, INR 1.1.
The patient had carotid duplexes that showed no significant
hemodynamic lesions on either right or left. Additionally,
she had an echocardiogram that showed an EF of 60 percent
with no AS, trace AR, 1 plus MR, and normal PA pressures.
HOSPITAL COURSE: Ultimately, on [**1-11**] the patient was
brought to the operating room where she underwent coronary
artery bypass grafting. Please see the OR report for full
details. In summary, the patient had a CABG x 5 with a LIMA
to the diag, saphenous vein graft to the LAD, saphenous vein
graft to the ramus, saphenous vein graft to the OM, and
saphenous vein graft to the PDA. Her bypass time was 97
minutes with a crossclamp time of 78 minutes. She tolerated
the operation well and was transferred from the operating
room to the Cardiothoracic Intensive Care Unit. At the time
of transfer, the patient had Levophed at 0.03 mcg/kg/min,
Nitroglycerin at 0.5 mcg/kg/min, lidocaine at 2 mg/min and
propofol at 20 mcg/kg/min.
The patient did well in the immediate postoperative period.
Her anesthesia was reversed. She was weaned from the
ventilator and successfully extubated. On the course of the
operative day, she was also weaned from her Levophed drip as
well, and her Nitroglycerin was titrated to control periods
of hypertension postoperatively. The patient also remained
on a lidocaine drip overnight.
On postoperative day 1, the lidocaine drip was discontinued.
The patient was transitioned from IV Nitroglycerin to oral
beta blockers, following which the IV Nitroglycerin was
weaned off.
On postoperative day 2, the patient's central lines, Foley
catheter, and chest tubes were removed, and she was
transferred to the floor for continuing postoperative care
and cardiac rehabilitation. Over the next two days, the
patient had an uneventful postoperative course. Her activity
level was increased with the assistance of the nursing staff,
as well as physical therapy, and on postoperative day 3 the
patient was considered to be stable and ready to transfer to
rehabilitation at [**Hospital1 **] TCU.
At the time of this dictation, the patient's physical exam is
as follows: Temperature 98, heart rate 87--sinus rhythm,
blood pressure 129/57, respiratory rate 20, O2 sat 98 percent
on 2 liters, weight preoperatively 68 kg, and at discharge
68.5 kg.
LAB DATA: White count 12.3, hematocrit 32.5, platelets 201,
sodium 139, potassium 3.9, chloride 102, CO2 28, BUN 16,
creatinine 0.7, glucose 106.
Neuro: Alert and oriented x 3, moves all extremities,
follows commands, nonfocal exam. Pulmonary: Clear to
auscultation bilaterally. Cardiac: Regular rate and rhythm,
S1 and S2. Sternum was stable. Incision with dry sterile
dressing. No drainage or erythema. Abdomen was soft,
nontender, nondistended with hypoactive bowel sounds.
Extremities were warm and well-perfused with 1 plus edema
bilaterally. The patient had bilateral saphenous vein graft
site incisions with Steri-Strips, open to air.
CONDITION ON DISCHARGE: Good.
FOLLOW UP: Dr. [**Last Name (STitle) 1159**] in [**3-17**] weeks following discharge from
rehabilitation and with Dr. [**Last Name (STitle) **] in 4 weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg [**Hospital1 **].
2. Lasix 20 mg [**Hospital1 **].
3. Colace 100 mg [**Hospital1 **].
4. Potassium chloride 20 mEq [**Hospital1 **].
5. Aspirin 81 mg once daily.
6. Tylenol 325-650 q 4 h prn.
7. Advair 250/50, 1-2 puffs [**Hospital1 **].
8. Synthroid 88 mcg once daily.
9. Singulair 10 mg once daily.
10.Pantoprazole 40 mg once daily.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass graft x 5 with a left internal mammary
artery to the diagonal, saphenous vein graft to the left
anterior descending, saphenous vein graft to ramus, saphenous
vein graft to obtuse marginal, and saphenous vein graft to
posterior descending artery.
Hypothyroid.
Asthma.
Skin cancer.
Meniere's.
Gastroesophageal reflux disease.
Status post upper gastrointestinal bleed.
Arthritis.
Left ear deafness.
DISPOSITION: Again, the patient is to be discharged to
[**Hospital1 **] TCU.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2112-1-14**] 12:17:32
T: [**2112-1-14**] 12:58:27
Job#: [**Job Number 59703**]
ICD9 Codes: 4111, 4240, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5377
}
|
Medical Text: Admission Date: [**2119-7-13**] Discharge Date: [**2119-7-18**]
Date of Birth: [**2038-12-16**] Sex: F
Service: SURGERY
Allergies:
Macrodantin / Fentanyl / Dilaudid
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic right foot
Major Surgical or Invasive Procedure:
Right femoral above-knee popliteal bypass with 6 mm PTFE graft.
History of Present Illness:
This 80-year-old lady with extensive peripheral [**First Name3 (LF) 1106**] disease
status post a failed graft in her left leg and a below-the-knee
amputation. She has also had iliac artery angioplasties in the
past. She has developed ischemic rest pain in her right foot. An
arteriogram showed that she had a superficial femoral artery
occlusion with reconstitution of the diseased above-knee
popliteal artery
with 2-vessel runoff distally. She has no usable conduit left.
Past Medical History:
HTN
spinal stenosis
PVD, s/p L CFA-BK [**Doctor Last Name **] [**7-16**], R CEA, s/p angioplasty R CIA/L
fempop graft [**11-15**] c/b CIA disruption requiring covered stent,
repeat angioplasty/stent of distal bpg anastamosis, thrombectomy
of L PT [**2118-3-16**]
Social History:
Smoker
No alcohol
Family History:
Non contributary
Physical Exam:
a/o x 3
nad
grossly intact
cta
rrr
abd - benign
surgical inc c/d/i
dopplerable DP/PT
Pertinent Results:
[**2119-7-18**] 06:06AM BLOOD
WBC-9.9 RBC-3.57* Hgb-10.5* Hct-31.3* MCV-88 MCH-29.5 MCHC-33.6
RDW-15.4 Plt Ct-517*
[**2119-7-18**] 10:40AM BLOOD
PT-33.5* PTT-37.2* INR(PT)-3.6*
[**2119-7-18**] 06:06AM BLOOD
Glucose-89 UreaN-29* Creat-1.3* Na-142 K-4.2 Cl-108 HCO3-26
AnGap-12
[**2119-7-18**] 06:06AM BLOOD
Calcium-9.4 Phos-3.5 Mg-1.9
[**2119-7-18**] 06:06AM BLOOD
WBC-9.9 RBC-3.57* Hgb-10.5* Hct-31.3* MCV-88 MCH-29.5 MCHC-33.6
RDW-15.4 Plt Ct-517*
Brief Hospital Course:
Mrs. [**Known lastname **],[**Known firstname **] T was admitted on [**2119-7-13**] with an ischemic
right foot. Sheagreed to have an elective surgery.
Pre-operatively, she was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
It was decided that she would undergo a Right femoral above-knee
popliteal bypass with 6 mm PTFE graft
.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She as then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care.When stable she wa
delined. His diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status.
While in VICU coumadin was started. Her INR was followed in the
usual manner.
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. Shecontinues to make steady progress
without any incidents. She was discharged home with vna
To note she has been set up to have her inr checked by her PCP.
[**Name10 (NameIs) **] DC her inr is 3.6 / down from 4.1.
Medications on Admission:
gaba 400''',plavix 75',furosemide 20',lipitor 40' ecotrin 81',
lisinopril 5', lopressor ?
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Warfarin 1 mg Tablet Sig: half of tablet Tablet PO HS (at
bedtime): your goal INR is [**1-14**]. You must have your INR checked
by your PCP this has been arranged.
Disp:*30 Warfarin (Oral) 1 mg Tablet* Refills:*2*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed. Tablet(s)
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
Ischemic right foot.
Discharge Condition:
Good
Discharge Instructions:
Division of [**Month/Day (3) **] and Endovascular Surgery Lower Extremity
Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-14**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
COUMADIN (WARIFIN)
What is warfarin?
Warfarin is the generic name for Coumadin?????? (brand or trade
name).
Warfarin belongs to a class of medications called
anticoagulants, which help prevent clots from forming in your
blood and or keep grafts open.
Why am I taking warfarin?
You are taking warfarin because you have a medical condition
that puts you at risk for forming dangerous blood clots, or to
keep open vessels that have stents and or vessels that allow
blood to flow for ischemic leg symptoms.
How do I take warfarin?
Warfarin is taken once daily at the same time every day,
preferably in the evening, with or without food.
If you miss a dose of warfarin, take the missed dose as soon as
possible on the same day. If you forget, do not double up the
next day! Write the day of your missed dose on your calendar and
let your health care provider know at your next visit.
Why is warfarin use monitored so carefully?
Warfarin is a medication that requires careful and frequent
monitoring to make sure that you are being adequately treated,
but not over- or under-treated. If you have too much warfarin in
your body, you may be at risk for bleeding. If you have too
little warfarin in your body, you may be at risk for forming
dangerous blood clots. Medications, food and alcohol can also
interfere with warfarin, making close monitoring even more
important.
What is INR?
INR, which stands for International Normalized Ratio, is a blood
test that helps determine the right warfarin dose for you.
The INR tells us how much warfarin is in your bloodstream and is
a measure of how fast your blood clots.
A high INR means you are more likely to bleed (your blood does
not clot very fast).
A low INR means you are more likely to form a clot (your blood
clots very fast).
All patients will have an INR goal depending on their medical
condition(s), yours is [**1-14**].
What are the possible side effects of warfarin?
The major side effect of warfarin is bleeding (especially when
your INR is too high). Here are some symptoms of bleeding to
look for and to report to your health care provider:
[**Name10 (NameIs) 33276**] bruising or bruises that won't heal
Bleeding from your nose or gums
Unusual color of urine or stool (including dark brown urine, or
red or black/tarry stools)
What do I need to know about drug interactions with warfarin?
Many drugs can potentially interfere with warfarin and may cause
your INR to change, putting you at risk for bleeding or a clot.
These drugs include prescription medications, over-the-counter
medications (like aspirin, ibuprofen, naproxen), and dietary and
herbal supplements. They should be avoided unless otherwise
directed by health provider. [**Name10 (NameIs) **] should take your Aspirin as
directed.
What role does my diet play?
The amount of vitamin K in your diet may affect your response to
warfarin. Certain foods (like green, leafy vegetables) have high
amounts of vitamin K and can decrease your INR. You do not have
to avoid foods high in vitamin K, but it is very important to
try to maintain a consistent diet every week.
What about alcohol?
Alcohol use also may affect your response to warfarin. Excessive
use can lead to a sharp rise in your INR. It is best to avoid
alcohol while you are taking warfarin.
Safety Tips
Carry a wallet ID card and/or wear an emergency alert bracelet
Tell all health care providers (physicians, nurses, pharmacists,
dentists, etc.) that you are taking warfarin, especially if you
have any planned surgeries or procedures.
Alert your health care provider if you are pregnant or become
pregnant while taking warfarin.
Plan ahead when traveling by having enough warfarin and arrange
for follow-up blood tests. It is also important to keep your
diet consistent.
Avoid any sport or activity that may result in a serious fall or
injury.
Use a soft-bristled toothbrush to protect your gums.
Use an electric razor if you are prone to cut yourself when
shaving.
Call Dr[**Name (NI) 5695**] office if you have any questions regarding
your new medication.
Followup Instructions:
Call Dr [**Last Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 3121**] and schedule an
appointment for two weeks.
YOU HAVE BEEN SET UP TO HAVE YOUR INR CHECKED. THIS IS VERY
IMPORTANT FOR COUMADIN CAUSES BLEEDING. YOUR GOAL INR IS [**1-14**].
YOUR INR ON DISCHARGE IS 4.1. THIS IS HIGH. YOUR COUMADIN DOSE
HAS BEEN LOWERED. VNA WIIL COME TO YOUR HAOUSE AND DRAW YOUR
INR, THEY WILL DR [**First Name (STitle) **] OFFICE KNOW. HE WILL ADJUST YOUR
COUMADIN FROM THERE. PHONE NUMBER IS [**Last Name (LF) **],[**First Name3 (LF) 2671**] T.
[**Telephone/Fax (1) 33277**].
Completed by:[**2119-7-18**]
ICD9 Codes: 4280, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5378
}
|
Medical Text: Admission Date: [**2199-5-15**] Discharge Date: [**2199-5-24**]
Date of Birth: [**2153-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
[**5-16**] CEREBRAL ANGIOGRAM
History of Present Illness:
HPI:45 y/o male patient presents from OSH s/p excruciating
headache that awoke him from his sleep 4:30 in the morning. He
states that he has a history of migraines, but reports that this
pain is worse than his migraine pains. He also reports some neck
pain and nausea and vomiting. He denies any dizziness, loss of
vision, loss of consciousness, or trauma. In OSH, CT scan was
ordered and patient recieved nimodipine 7:30 am and was then
transfered to [**Hospital1 18**] with a SAH for further neurosurgical workup.
Past Medical History:
PMHx:Non-insulin dependent diabetes, Migraine headaches,
tonsillectomy, hyperlipidemia, borderline hypertension
Social History:
Denies tobacco, recretional drug use, or ETOH
Family History:
Mother CVA
Physical Exam:
PHYSICAL EXAM:
HR:88 R :12
Gen: lethargic, obese gentleman, comfortable, NAD.
HEENT: Pupils:PERRL 2 AND FLICKER EOMs: intact
Neck: Supple.
Extrem: Cold to touch, dorsalis pedis 2+.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-19**] 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 equally round and reactive to light,2 and flicker
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 [**4-23**] throughout. No pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
DISCHARGE EXAM:#############
Pertinent Results:
Admission Labs:
[**2199-5-15**] 08:30AM WBC-12.1* RBC-4.93 HGB-13.2* HCT-39.5*
MCV-80* MCH-26.8* MCHC-33.4 RDW-16.2*
[**2199-5-15**] 08:30AM NEUTS-84.1* LYMPHS-12.7* MONOS-2.6 EOS-0.3
BASOS-0.4
[**2199-5-15**] 08:30AM PLT COUNT-294
[**2199-5-15**] 08:30AM PT-12.4 PTT-21.6* INR(PT)-1.0
[**2199-5-15**] 08:30AM GLUCOSE-374* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
[**2199-5-15**] 08:30AM CK(CPK)-49
Labs on Discahrge:
[**2199-5-23**] 05:40AM BLOOD WBC-10.7 RBC-4.39* Hgb-11.8* Hct-35.1*
MCV-80* MCH-26.8* MCHC-33.5 RDW-15.9* Plt Ct-361
[**2199-5-23**] 05:40AM BLOOD PT-12.7 PTT-20.6* INR(PT)-1.1
[**2199-5-23**] 05:40AM BLOOD Glucose-257* UreaN-8 Creat-0.6 Na-137
K-4.1 Cl-100 HCO3-28 AnGap-13
[**2199-5-23**] 05:40AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.1
[**2199-5-24**] 05:10AM BLOOD Phenyto-14.5
[**2199-5-20**] 05:45PM BLOOD %HbA1c-8.0*
Imaging:
CTA Head [**5-15**]:
TECHNIQUE: MDCT axial images of the head were obtained prior to
and following administration of 80 cc of Optiray intravenously
per head CTA protocol. Coronal, axial, and sagittal maximum
intensity projection images, as well volume-rendered
3D-reconstructed images were processed on a separate workstation
and reviewed.
CT HEAD: There is large amount of subarachnoid blood, mostly at
the level of the foramen magnum, extending into interpeduncular,
ambient, quadrigeminal plate and suprasellar cisterns. Small
amount of subarachnoid hemorrhage is seen in the left sylvian
fissure. Trace intraventricular hemorrhage is seen in the
occipital [**Doctor Last Name 534**] of the left lateral ventricle; blood is also
present in the fourth ventricle. There is no shift of normally
midline structures or hydrocephalus. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. There is no evidence of major
vascular territorial infarction or mass. There is no parenchymal
hemorrhage or fracture. Imaged paranasal sinuses and mastoid air
cells are pneumatized and well aerated.
CTA: The carotid arteries and their major branches are patent
without
evidence of stenosis or aneurysm larger than 2mm in diameter.
There is a
small amount of noncalcified plaque and tiny punctate
calcification involving the left vertebral artery, seen at the
level of, but separate and distinct from the PICA origin, which
is unremarkable. On the rotational 3D volume-rendered images,
there is an apparent 3 mm outpouching, emanating from left
posterolateral aspect of that vertebral artery, separate from
the PICA origin, which may represent partial-volume averaging of
mural plaque with associated overlying contour anormality and
the adjacent quite tortuous PICA vessel.
IMPRESSION: Focal noncalcified and calcified plaque in the
distal left
vertebral artery at the level of, but separate from, the left
PICA origin;
this appears as a focal outpouching or contour abnormality on
the 3D volume-rendered images, which may be technical in nature.
While this process may simply represent so-called "benign
perimesencephalic
SAH," this is a diagnosis- of- exclusion, and, given the overall
large amount and the distribution of the subarachnoid
hemorrhage, the ventricular hemorrhage (highly atypical), as
well as the equivocal finding in the left vertebral artery, of
unknown significance, catheter cerebral angiography was
scheduled and performed, directly thereafter.
EKG [**5-15**]:
Sinus rhythm with first degree atrio-ventricular conduction
delay. Otherwise, within normal limits. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 226 94 370/417 34 25 51
Brief Hospital Course:
Pt. was taken to the Angio suite from the emergency room for a
four vessel cerebral Angio, given the questionable finding on
CTA of an aneurysm arising from the vertebral artery.
Diagnostic angiogram on first look was negative for an
underlying aneurysm, the patient was transferred to the ICU for
hemodynamic and neurologic monitoring as hydrocephalus was a
concern.
On [**5-17**] the patient remained neurologically stable and was
transferred to the SD unit.
[**5-22**], he had another angiogram with revealed distal parietal
branch of the MCA occulusion wiithout any ill effect. [**Last Name (un) **] was
also consulted for elevated blood surgars(history of DM 2), and
adjustements to his medical regimen were made. He was restarted
on Metformin, began glipizide and lantus on [**5-24**]. He was
further seen and evaluated by PT/OT; who determined that he
would be an appropriate candidate for rehabilitation. He was
discharged to an appropriate facility on [**5-24**], with directions
for follow up care.
Medications on Admission:
Metformin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*45 Capsule(s)* Refills:*0*
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-21**]
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*45 Tablet(s)* Refills:*0*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO TID (3 times a day).
Disp:*180 Capsule(s)* Refills:*0*
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
7. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
Disp:*15 Tablet(s)* Refills:*0*
8. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Known firstname **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
**You also need to call and schedule a follow up appointment at
the [**Last Name (un) **] Diabetes center for ongoing managment of your
diabetes. This appointment should be made within the next week.
Their phone number is: ([**Telephone/Fax (1) 17484**]. Be sure to tell them you
were seen during your inpatient hospitalization at [**Hospital1 18**].
Completed by:[**2199-5-24**]
ICD9 Codes: 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5379
}
|
Medical Text: Admission Date: [**2130-10-6**] Discharge Date: [**2130-10-11**]
Date of Birth: [**2130-10-6**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] is a 2175-gram
product of a 34-4/7 week gestation born to a 43-year-old G4
P3 now 4 mother whose other children are 16, 18, and 26 years
old. Prenatal screens included blood type A positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, and GBS unknown. Pregnancy was
complicated by asthma and chronic hypertension, treated with
albuterol and labetalol respectively. There was no maternal
fever. The rupture of membrane time was unclear, as mother
was leaking fluid prior to admission. Baby boy [**Known lastname **] was
delivered by spontaneous vaginal delivery, requiring only
blow by oxygen in the delivery room. Apgars were 8 at 1
minute and 9 at 5 minutes of life.
PHYSICAL EXAMINATION: Birth weight was 2175 grams, 50th
percentile, length 48 cm, 75th percentile, and head
circumference was 30.5 cm, and 25th percentile. In general,
he is a well appearing preterm male in no acute distress on a
open warmer. HEENT examination revealed molding of the head
with a flat, soft, anterior fontanel and red reflexes present
bilaterally. The palate was intact. The lungs were clear to
auscultation bilaterally without grunting or flaring. Heart
examination revealed a regular rate and rhythm without
murmur. Femoral pulses were 2 plus bilaterally. Abdomen was
soft, with active bowel sounds, and no masses. The back was
without clefts, [**Hospital1 **], or dimples. Anus was patent. GU
examination revealed a normal preterm male. External
genitalia with testes palpable bilaterally. His hips were
stable. His extremities were warm and well perfused. His
skin was without lesions and he has an appropriate neurologic
examination for his age.
HOSPITAL COURSE:
1. Respiratory. Baby boy [**Known lastname **] was in room air throughout
the hospitalization. He never had apnea, bradycardia, or
desaturations.
2. Cardiovascular. Baby boy [**Known lastname **] was hemodynamically
stable throughout the hospitalization, with normal blood
pressure and profusion.
3. Fluids, electrolytes, and nutrition. Oral feedings were
initiated of Special Care 20 at 2 to 3 hours of life. He
was allowed to take by mouth as desired throughout with a
minimum but advanced every day. He occasionally had
difficulty with spittiness, but he demonstrated overall
excellent oral feedings. Dextrose sticks were stable
throughout. Electrolytes were normal at 24 hours of life.
Baby boy [**Known lastname **] had a normal voiding and stooling
pattern.
4. Hematology. Initial hematocrit was 53.8 percent with
normal platelets of 156,000. He did not require
transfusions during the hospitalization. Initial
bilirubin was 5.3 at 24 hours of life and this remained
stable the following day. There was no clinical evidence
of jaundice.
5. Infectious Disease. Secondary to the risk factors of
preterm labor and unknown GBS status, CBC and blood
cultures were sent on admission and the baby was treated
with ampicillin and gentamicin. CBC was reassuring with a
white count of 8.3 with 35 percent polys and 0 bands.
Blood cultures remained negative and ampicillin and
gentamicin were discontinued at 48 hours.
6. Sensory. Hearing screening was performed with automated
auditory brainstem responses and passed in both ears.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: To home with parents in a car seat.
FAMILY PEDIATRICIAN: [**Hospital3 1810**] Primary Care
Clinic.
CARE/RECOMMENDATIONS:
1. At the time of discharge, Baby boy [**Known lastname **] is feeding
Special Care 20 calories per ounce as desired. His weight
at discharge is 2140 grams.
2. Baby boy [**Known lastname **] does not require any medications.
3. Car seat position screening was performed and passed.
4. State newborn screen was sent.
5. Hepatitis B vaccination was given on [**2130-10-6**]. Synagis
vaccine was given on [**2130-10-10**].
6. Synagis RSV prophylaxis should be considered from [**9-18**]
through [**3-20**] if one of the following three criteria are met:
1. Born at less than 32 weeks; 2. Born between 32 and 35
weeks, with two of the following: Daycare during RSV season,
smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings; 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 caregivers.
7. Followup will be with the primary pediatrician at [**Hospital **]
[**Hospital3 1810**] Primary Care Clinic in 1 to 2 days
after discharge. A visiting nurse will see the patient at
home in the first 1 to 2 days after discharge.
8. Baby boy [**Known lastname **] is to follow up with his mother's
obstetrician, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 7594**] for circumcision in 2
weeks.
DISCHARGE DIAGNOSES:
1. Prematurity at 34-4/7 weeks.
2. Suspected sepsis, ruled out.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 57619**]
MEDQUIST36
D: [**2130-10-10**] 16:20:26
T: [**2130-10-11**] 03:38:00
Job#: [**Job Number 57620**]
ICD9 Codes: V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5380
}
|
Medical Text: Admission Date: [**2121-6-14**] Discharge Date: [**2121-6-16**]
Date of Birth: [**2086-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Nsaids / Levaquin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
transfer from [**Hospital1 1474**] with rapid atrial rhythm, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a complicated 34 year old woman with hypertrophic
nonobstructive cardiomyopathy, atrial tachyarrhythmias, PVI for
AF complicated by R atrial perforation and clot in pericardium
with recent VF arrest with prolonged CPR and subsequent
admission to [**Hospital1 18**] [**Date range (1) 5932**]. The patient was discharged to home
on [**5-27**] and did well for about one week per her report. She then
developed increased lower extremity edema bilaterally as well as
left hand swelling per her report. She felt that she might be
volume overloaded so she presented to [**Hospital 1474**] Hospital on [**6-3**].
States she was minimally active (using wheelchair/bedside
commode) but she was trying to be as active as possible.
On admission to [**Hospital1 1474**], INR was supratherapeutic 5.8 which
increased to 7.2 on [**6-5**]. She was treated with various
medications (zaroxolyn, lasix IV & PO) for volume overload. CT
of the chest demonstrated large right-sided pleural effusion and
right-sided infiltrate. On [**6-9**], right-sided thoracentesis was
performed with removal of 1300 cc fluid. Initially treated with
ceftriaxone/azithromycin for pneumonia, changed to
azithromycin/cefuroxime on [**6-6**]. She was diuresed ~ 5 L in first
3 days. She tells me her breathing felt "improved" after the
[**Female First Name (un) 576**], but increased resp distress noted after thoracentesis
([**6-10**]); she was further diuresed. RUQ ultrasound performed due
to elevation of bilirubin (level unclear) which was benign.
Patient afebrile throughout admission, BPs ranging 90s-120s. HR
typically 40-50s, with brief episodes in the 90s. Weight noted
to be 88.9 kg on admission and 82.1 on transfer. Last BP in
nursing notes documented to be 65/60 with HR 54 prior to
transfer; CCU attending note states patient blood pressure
80s-90s and HR 90-110s prior to transfer. She received 250 cc NS
bolus at [**2023**] this evening.
On review of symptoms, she denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
black stools or red stools. States she hads had cough since
prior admission and small amounts of blood in sputum during
recent [**Hospital1 18**] hospitalization and at home but none since [**Hospital1 1474**]
admission. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
# Hypertrophic cardiomyopathy.
- Cardiac MR on [**2121-2-28**] with asymmetric LVH with maximal wall
thickness of 19 mm at mid septum with focal hyperenhancement
consistent with hypertrophic CM. EF 55%.
# SVT with A fib, left atrial tach and AVNRT s/p pulmonary vein
isolation on [**2121-3-18**] complicated by right atrial perforation,
pericardial clot
# Questionable history of WPW
# Tobacco use with bronchitis and associated multifocal a tach.
# Anxiety
# Obesity
# Asthma, ?COPD
# Ob/gyn history includes 4 TABs, 2 deliveries with one
surviving son, both premature (25 weeks and 23+ weeks); the
second infant was delivered in the context of chorioamnionitis
and did not survive.
Cardiac Risk Factors: (-) Diabetes, (+) Dyslipidemia,
(-)Hypertension
Cardiac History: CABG: n/a
Percutaneous coronary intervention: n/a
Pacemaker/ICD: n/a
Cardiac history, compiled from OMR:
Age:
12: Initial presentation with syncope
13: Seen at [**Hospital3 1810**] for history of syncope, chest
pain and progressive exercise intolerance; diagnosed with
hypertrophic cardiomyopathy, and underwent catheterization in
which LVEDP was found to be 20. Started on ongoing verapamil
therapy.
16: Cardiac arrest secondary to complex tachycardia,
successfully resuscitated. Repeat catheterization showed left
ventricular end diastolic pressure of 36-40 without outflow
tract obstruction. EP showed inducible atrial flutter with a
rapid ventricular blood pressure; dx'ed w/rapid antegrade
conduction and possible pre-excitation. Started on Norpace
(dysopyramide); kept on verapamil and Norpace for many years.
Had occasional palpitations, chest pain and light headedness.
25: Appendicitis during pregnancy, with post-op course
complicated by congestive heart failure, intubated and then
eventually extubated without difficulty; delivered son at 25
weeks.
RECENT HISTORY:
* [**2121-2-8**]: Atrial arrythmias (MAT diagnosed at [**Hospital1 18**],
Afib/flutter seen at OSH), started on amiodarone.
* [**2121-3-1**]: Admitted from [**Hospital 1474**] Hosp w palpitations,
diagnosed as AVNRT, discharged with increased dose of verapamil,
made long-acting.
* [**2121-3-18**]: Pulmonary vein isolation procedure. Post-procedure
atrial tachycardia w/multiple morphologies-->cardioversion.
Respiratory distress and post-procedure
re-intubation<--pulmonary edema and possible contribution of
pan-sensitive klebsiella PNA. Ongoing fevers, ?PE treated with
heparin. Discharged on amiodarone 200 mg TID.
* [**2121-4-5**]: Dyspnea, chest pain, possible pneumomediastinum;
diagnosed with large pericardial effusion; pericardial window
done; post-op atrial tachycardia. During post-op course, had
difficult-to-assess fluid status and was taken to the cath lab;
in holding area had PEA arrest, coded for 1 hour; intubated for
6 days and put on CVVH after cath confirmed volume overload;
extubated; and then reintubated 2 days later for aspiration and
hypoxia, then had pneumothorax as complication of intubation;
ultimately extubated again, treated for pneumonia. Admission
also notable for ARF and pancreatitis.
* [**2121-5-12**]: Admitted from rehab with dyspnea and chest pain,
anemia and mild CHF symptoms; having atrial tachycardia with
varying 2:1 and 3:1 conduction. Discharged [**5-15**].
* [**2121-5-18**]: Admit for shortness of breath, coded for 30 minutes
while being evaluated in ED: PEA w wide-complex near-sine-wave
tachycardia [**3-15**] hyperkalemia; regained pulse in 30 minutes,
after which she had NSR w RBBB; then had wide complex tachy and
BP drop; defibrillated x1 200J, briefly on dopamine gtt.
Admission notable for ongoing fluid overload and
weakness/apparent deconditioning. Source of hyperkalemia was
never clear and did not repeat itself. Pt discharged on [**5-25**] to
home after refusing placement to rehab. Pt had been at home
until her most recent admission to [**Hospital1 1474**].
Social History:
Lives with fiance', son, and uncle. Currently on disability. 40
pack-year smoker (2 ppd x 20 years) but denies recent smoking.
No alcohol. Regular marijuana use in past but denies recently.
No pets at home.
Family History:
No family history of sudden cardiac death or premature CAD. Mom
has DM, HTN. [**Name (NI) **] son has aortic stenosis and hypertrophic
cardiomyopathy, had cardiac surgery during infancy.
Physical Exam:
VS: T , BP 108/70, HR 59, RR 14, O2 100% on 2L NC
Gen: WDWN middle aged female in NAD, resp or otherwise. Oriented
x3. Flat affect, pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10 cm.
CV: PMI prominent at 5th intercostal space, slightly displaced
laterally. Regular rhythm with 2/6 systolic murmur at LUSB.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diminished breath
sounds noted at bilateral bases. No crackles, wheeze, rhonchi.
Prior thoracentesis site noted on right back, covered with clean
bandage without surrounding bruising.
Abd: Obese, soft, NTND, No HSM or tenderness.
Ext: 1+ pitting edema to bilateral knees, 1+ bilateral DP
pulses,
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Scattered ecchymoses on bilateral upper arms secondary to prior
lab sticks.
Pulses:
Right: Carotid 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; 1+ DP
Pertinent Results:
[**2121-6-15**] 02:40AM BLOOD WBC-9.6 RBC-3.22* Hgb-9.8* Hct-31.3*
MCV-97 MCH-30.3 MCHC-31.2 RDW-18.6* Plt Ct-480*
[**2121-6-15**] 02:40AM BLOOD Neuts-72.6* Lymphs-21.2 Monos-4.9 Eos-0.6
Baso-0.6
[**2121-6-15**] 02:40AM BLOOD PT-29.8* PTT-38.6* INR(PT)-3.0*
[**2121-6-16**] 06:20AM BLOOD PT-31.5* PTT-38.9* INR(PT)-3.3*
[**2121-6-15**] 02:40AM BLOOD Glucose-97 UreaN-11 Creat-0.6 Na-136
K-3.8 Cl-92* HCO3-36* AnGap-12
[**2121-6-16**] 06:20AM BLOOD Glucose-85 UreaN-12 Creat-0.6 Na-137
K-3.7 Cl-94* HCO3-34* AnGap-13
[**2121-6-15**] 02:40AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.2
MEDICAL DECISION MAKING .
EKG demonstrated sinus bradycardia with normal axis, which was
signicantly changed from prior EKG showing rapid (rate 100s)
atrial fibrillation ([**5-25**]). No ischemic ST-T wave deviations.
Prominent P waves in precordial leads, inverted in V1. Poor R
wave progression.
TELEMETRY demonstrated: pending, sinus bradycardia at OSH
2D-ECHOCARDIOGRAM performed on [**2121-5-19**] demonstrated: The left
and right atria are moderately dilated. There is moderate
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
valvular [**Male First Name (un) **] or resting LVOT gradient. 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 aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The estimated
pulmonary artery systolic pressure is high normal. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2121-5-1**], the
magnitude of tricuspid regurgitation and the estimated pulmonary
artery systolic pressure have decreased.
ETT: n/a
Right-CARDIAC CATH performed on [**2121-4-21**] demonstrated:
HEMODYNAMICS:
**PRESSURES
RIGHT ATRIUM {a/v/m} 48/48/37
RIGHT VENTRICLE {s/ed} 72/48
PULMONARY ARTERY {s/d/m} 72/38/42
PULMONARY WEDGE {a/v/m} 52/53/38
**CARDIAC OUTPUT
HEART RATE {beats/min} 91
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 48
CARD. OP/IND FICK {l/mn/m2} 5.4/2.6
**RESISTANCES
PULMONARY VASC. RESISTANCE 59
**% SATURATION DATA (NL)
PA MAIN 48
AO 90
Outside studies from [**Hospital1 1474**]:
CXR ([**6-13**]): small to moderate bilateral pleural effusions,
persistent left lower lobe airspace opacity. Improved airspace
opacity in the right lower lobe & RML.
CT chest ([**6-8**]): extensive consolidation of right lower lobe
minimally sparing the superior segment. Large right pleural
effusion & small left pleural effusion seen. Masslike alveolar
density seen at posterior pleural border of the left lower lobe
superior segment measuring 2.1 X 2.4 cm in size. A second
masslike pleural based lesion eventually collected with
peripheral atelectatic lung tissue in seen anterior lateral
border of right upper lobe anterior sgement, measuring 2.2 X 1.6
cm. Abnormally enlarged right lower paratracheal lymph nodes
measuring 1.7 X 1.3 cm in size. No pericardial effusion.
Abdominal ultrasound ([**6-11**]): cholesterolosis of the gallbladder
Outside Labs:
Pleural fluid cell count: 1405 WBC (1 poly, 7 lymph, 92 monos),
glucose 113, total protein 2.8, amylase 40, LDH 195, pH 8
Cell block (thoracentesis, [**6-10**]): neutrophils, reactive
mesothelial cells, lymphocytes, and RBCs
ABG ([**6-11**]): 7.58/42/147 on 3L NC
WBC 9.8 (82N, 13L, 5M), Hgb 8.6, Hct 27.8, Plt 449
MCV 97
Retics 2.3
PT 29.9, PTT 42, INR 3
Iron 27, TIBC 340, ferritin 55
[**6-14**]: Na 135, K 3.5, Cl 91, CO2 36, Ca 8.6, Mg 2.2, glucose 78,
BUN 12, Cr 0.5
Total protein 6.1, albumin 2.7
Tbili 0.9, direct bili 0.6
alk phos 129
ALT 21, ALT 11, LDH 321
CK 24, CKMB 2, troponin ultra 0.2
Cholesterol 125, HDL 34, LDL 67, TG 122
TSH 4.8
BNP ([**6-14**]) 2944 (range 2700-5000)
Mg ([**6-14**]) 2.2
Phos ([**6-14**]) 4.1
[**Doctor First Name **] negative
RF negative
Brief Hospital Course:
This is a 34 year old woman with hypertrophic cardiomyopathy and
a cardiac history dating back to episodes of syncope at age 12
and her first cardiac arrest at age 16; now admitted for episode
of atrial tachycardia with hypotension, which resolved after IV
fluids.
# Atrial Tachycardia: Ms. [**Known lastname **] had tachycardia at the OSH
which was transient. She is now back in sinus bradycardia,
which is consistent with past episodes of atrial
tachyarrythmias. Although she has had a past chart diagnosis of
WPW there has been no recent evidence of this. She will go home
on decreased dose of Metoprolol XL 25mg daily. We are holding
verapamil given bradycardia. She is to continue on home
amiodarone dose. She will follow up with Dr. [**Last Name (STitle) **] in [**Hospital **]
clinic who will discuss possible Pacemaker placement. The
patient is refusing pacemaker placement currently. She is to
continue on home Warfarin dosage. INR should be followed by PCP
with [**Name9 (PRE) 5933**] in Coumadin as needed.
# CAD/Ischemia: No evidence of ischemia/CAD currently.
# Pump: Ms. [**Known lastname **] suffers from severe diastolic heart failure
with preserved systolic function by echocardiogram. She is
pre-load dependent but also susceptible to fluid overload, fluid
balance is therefore delicate. She was started on
Spironolactone at the OSH and will go home on Spironolactone
12.5mg [**Hospital1 **]. She is to continue her home dose of Lasix. She
will continue with Metoprolol as above
# Valves: Last echo shows no clear valvular dysfunction. She
suffers from Hypertrophic Cardiomyopathy and is pre-load
dependent.
# Past dyspnea and respiratory distress. She is currently at
baseline O2 reqiurement and appears comfortable. Imaging at OSH
was reviewed with radiology here, there is a mass which likely
represents infection/fluid and is very low probability of
malignancy since it was absent from a recent CT chest. She will
need follow up imaging to assure that it has resolved.
# Depression: Continue bupropion and sertraline
Medications on Admission:
Medications on admission to outside hospital:
1. Montelukast 10 mg PO qhs
2. Calcium Acetate 667 mg Two (2) Capsule PO TID W/MEALS
3. Sertraline 150 mg PO daily
4. Bupropion 75 mg PO daily
5. Amiodarone 100 mg PO daily
6. Pantoprazole 40 mg PO daily
7. Verapamil 40 mg PO Q8H
8. Camphor-Menthol 0.5-0.5 % Lotion. One (1) Appl Topical
QID (4 times a day) as needed.
9. Metoprolol Succinate 100 mg (Toprol XL) PO daily
10. Clonazepam 1 mg PO TID as needed for anxiety.
11. Furosemide 80 mg PO BID
12. Warfarin 4 mg PO daily
13. Ipratropium Bromide 17 mcg/Actuation Aerosol 2 IH QID.
14. Percocet 5-325 mg; 1-2 tabs twice a day as needed for pain.
15. Ascorbic Acid 500 mg PO BID
16. Docusate Sodium 200 mg [**Hospital1 **]
17. FerrouSul 325 mg (65 mg Iron) PO once a day.
18. Senna 8.6 mg Capsule PO twice a day.
19. B Complex Plus Vitamin C Oral
20. Folic Acid 1 mg PO daily
21. trazodone (dose unclear)
.
Meds on transfer from [**Hospital1 1474**]:
* KCL 20 meQ 20 mg [**Hospital1 **]
* furosemide 40 mg [**Hospital1 **]
* mg hydroxide 30 mL q8h prn
* lidocaine patches (2) daily
* cyclobenzaprine 5 mg q8h prn
* spironolactone 25 mg [**Hospital1 **]
* coumadin 4 mg daily
* sertraline 150 mg daily
* metoprolol 12.5 mg PO BID
* mg oxide 400 mg [**Hospital1 **]
* amiodarone 100 mg daily
* guaifenesin 200 mg q4h prn
* zofran 4 mg q4h prn
* ferrous sulfate 300 mg daily
* trazodone 100 mg qhs
* atrovent in q6h prn
* albulterol inh q6h prn
* ascorbic acid 500 mg [**Hospital1 **]
* senna [**Hospital1 **]
* folate 1 mg daily
* colace 200 mg [**Hospital1 **]
* protonix 40 mg daily
* buproprion 75 mg daily
* singulair 10 mg QHS
* oxycodone/apap 1 tab q8h prn
* clonazepam 1 mg TID
* Cefuroxime 500 mg PO BID (start [**6-6**], course planned until
[**6-16**])
* azithromycin 500 mg daily ([**Date range (1) 5934**])
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16).
14. B Complex Oral
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
twice a day as needed for pain.
16. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO three
times a day: with meals
.
18. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
Disp:*15 Tablet(s)* Refills:*0*
19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
Acute diastolic heart failure
Atrial tachycardia
Hypotension
Hypertrophic Cardiomyopathy
.
Secondary:
H/o cardiac arrest
H/o multiple cardiac tachyarrythmias
Anxiety
Obesity
Asthma
Discharge Condition:
Good, afebrile, ambulating
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
tachycardia (rapid heart rate). Your symptoms improved with
fluid management and control of your heart rate. Your
Metoprolol dose has been decreased to 25mg daily. You have been
started on a new diuretic Spironolactone 12.5mg twice daily.
Your Verapamil has been stopped, please do not take this
medication.
.
Please follow-up as below. It is also recommended that you have
a repeat chest CT scan in 1 month to evaluate small pulmonary
nodules (left lower and right upper lobes) that were
incidentally found.
.
Please continue to take your remaining home medications as
prescribed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs.
Adhere to 2 gm sodium diet
.
You should call your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5861**], or your
cardiologist, Dr. [**Last Name (STitle) **], or return to the emergency
department if you experience palpitations, chest pain, shortness
of breath, loss of consciousness, fever greater than 101.5
degrees F, or any other symptoms that concern you.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5861**]. An appointment has
been set up for you on Tuesday, [**6-24**] at 2:30pm. Phone:
[**0-0-**]. Discuss having a repeat chest CT scan in 1 month
to evaluate small pulmonary nodules (left lower and right upper
lobes) that were incidentally found.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:
[**2121-8-8**] 4:00pm.
ICD9 Codes: 4254, 4280, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5381
}
|
Medical Text: Admission Date: [**2126-1-22**] Discharge Date: [**2126-2-6**]
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
woman who was found to be dizzy all of a sudden when changing
from a lying to sitting position. She apparently did not
have a headache, nor did she have one on arrival in the
Emergency Department. She was brought to [**Hospital3 3583**]
with slurred speech. Head CT showed a 2.0 to 3.0 centimeter
cerebellar hemorrhage and she was transferred to [**Hospital1 346**] for further management.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Anxiety disorder.
3. Leg stasis ulcers.
4. Osteoarthritis.
5. Irritable bowel syndrome.
6. Status post cataract surgery.
ALLERGIES: She has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Ativan.
2. Meclizine.
SOCIAL HISTORY: Her son is her health care proxy.
PHYSICAL EXAMINATION: On examination, her temperature is
97.5, heart rate 75, blood pressure 206/96, respiratory rate
20, oxygen saturation 93% in room air. She was an elderly
woman in no acute distress on admission. Head, eyes, ears,
nose and throat examination - The pupils are equal, round,
and reactive to light and accommodation. Extraocular
movements are full. Lungs showed coarse bilateral breath
sounds. Cardiovascular - irregularly irregular, grade III/VI
systolic murmur at the base. The abdomen was soft,
nontender. Extremities - venous stasis, left greater than
right. Neurologically, she is awake, alert, oriented to
[**Hospital 86**] Hospital, [**Hospital6 1129**]. Cranial
nerves - The pupils are equal, round, and reactive to light
and accommodation, 4.0 down to 3.0 millimeters bilaterally.
Extraocular movements are full. No nystagmus. The face was
symmetric. Tongue was midline. Speech was markedly
dysarthric. Motor strength - She had a positive grasp reflex
in the right upper extremity, both arms drifted downward,
4+/5 finger flexion, triceps, biceps and deltoids, cannot
sustain IPs to gravity and persistent with TIATs. Deep tendon
reflexes 3+ everywhere with couple beats of clonus in
bilateral lower extremities. Toes on the right were upgoing,
left were mute.
LABORATORY DATA: On admission, white blood cell count was
9.6, hematocrit 40.2, platelet count 196,000. Sodium 142,
potassium 4.1, chloride 102, bicarbonate 29, blood urea
nitrogen 18, creatinine 0.9, glucose 124.
Head CT again showed 2.0 by 3.3 centimeter right cerebellar
parenchymal hemorrhage with no intraventricular extension.
Chest x-ray showed pulmonary vascular congestion.
Electrocardiogram showed atrial fibrillation with borderline
right bundle branch block with no ST changes.
HOSPITAL COURSE: The patient was admitted to the Neurologic
Intensive Care Unit for close neurologic observation. On
[**2126-1-23**], the patient had a repeat head CT which was
unchanged from previous scan. Her neurologic status remained
stable. She continued to be awake and alert. Speech was
garbled, following commands, left greater than right. The
left pupil was 0.5 millimeter larger than the right.
Attempts to show two fingers on the left and wiggle her toes
bilaterally. Follows simple commands. Her blood pressure
was being controlled to keep it less than 140 using Nipride
as needed. The patient had several episodes of severe
agitation requiring Haldol and Ativan during the night which
caused her to be neurologically lethargic. She was not
following commands, withdrawal and localized in all
extremities and toes were downgoing bilaterally. She was
then switched from Ativan to just Haldol to control her
agitation and severe anxiety. On [**2126-1-27**], she was sleepy
but arousable to voice. She sticks out her tongue, squeezes
hands bilaterally, wiggles her toes bilaterally. The pupil
was still slightly larger on the left than the right with a
left exotropia and toes were still downgoing. Head CT on
[**2126-1-28**], was unchanged. On [**2126-1-28**], she was much brighter,
wiggling her toes, following commands. The patient had a
swallow evaluation done on [**2126-1-29**], which showed that she
failed her swallow evaluation and would require a feeding
tube. That was placed. The patient was transferred to the
regular floor on [**2126-1-29**]. That evening she had an episode
of acute respiratory distress and was transferred back to the
Intensive Care Unit. However, not intubated, she was given
Lasix with good effect. On [**2126-1-30**], she was awake and
oriented to hospital, wiggling her toes and showing her
thumbs bilaterally. Her face was symmetric. An
echocardiogram showed left ventricular ejection fraction
greater than 55% with moderate tricuspid regurgitation and
mitral regurgitation and severe pulmonary artery
hypertension. On [**2126-2-1**], the patient was continued to be
in the Intensive Care Unit and was seen by cardiology service
for episodes of sinus pauses up to 2.8 seconds. She was
asymptomatic from this but also having what looked like
possible ventricular tachycardia, fourteen beats. With
closer observation, cardiology felt that this might be atrial
fibrillation with aberrancy. Cardiology felt that her pauses
were likely due to beta blockers and so they were
discontinued and the patient was put on alternative non
negative chronotropic medication such as an ace inhibitor. No
other treatment was necessary at that time. On [**2126-2-2**], she
was transferred to the regular floor. She was awake and
following commands times four, speech was dysarthric. The
patient was seen by physical therapy and occupational therapy
and found to require acute rehabilitation. She was also
evaluated by the [**Hospital **] Clinic for increased glucose levels
up into the high 100s. They recommended starting the patient
on Glipizide 2.5 mg p.o. once daily and watching her insulin
sliding scale. She also had two episodes of guaiac positive
stool. She does have a history of irritable bowel syndrome
and has not had a screening colonoscopy in the last six or
seven years. That is recommended as an outpatient. The
patient's hematocrit has remained stable despite this guaiac
positive stool with no episodes of tachycardia or frank
blood. Her condition remains stable. She is neurologically
stable and ready for transfer to rehabilitation. However the
planned date of transfer she had a severe episode of melena and
was transfered to medicine service in MICU forfurther care.
MEDICATIONS ON TRANSFER:
1. Glipizide 2.5 mg p.o. q.a.m.
2. Neutra-Phos one packet p.o. twice a day for three days.
3. Insulin sliding scale.
4. Calcium Carbonate 10cc p.o. twice a day for two days
which was started on [**2126-2-4**]/
5. Metronidazole 500 mg nasogastric q8hours for five days,
started on [**2126-2-2**].
6. Famotidine 20 mg intravenously q12hours.
7. Enalapril 5 mg p.o. once daily.
8. Levofloxacin 250 mg intravenously q24hours for seven days
for aspiration pneumonia. Started on [**2126-2-2**].
9. Albuterol nebulizers.
10. Haldol p.r.n. for agitation.
11. Heparin 5000 units subcutaneous q12hours.
12. Tylenol 650 mg p.o. q4hours p.r.n.
CONDITION ON TRANSFER: unstable.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2126-2-5**] 16:52
T: [**2126-2-5**] 17:05
JOB#: [**Job Number 104748**]
ICD9 Codes: 431, 5070, 4280, 2765
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5382
}
|
Medical Text: Admission Date: [**2131-12-9**] Discharge Date: [**2131-12-14**]
Date of Birth: [**2049-5-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2131-12-10**]
1. Mitral valve replacement with a 27-mm St. [**Male First Name (un) 923**] Epic
bioprosthesis, reference number [**Serial Number 87003**], serial number
[**Serial Number 88164**].
2. Resection of left atrial appendage.
3. Repair transected/avulsed azygos vein.
History of Present Illness:
82 year old female with known mitral regurgitation followed by
serial echocardiograms. Her most recent echocardiogram revealed
now severe mitral regurgitation. She has noted peripheral edema
which has worsened over the past year. She underwent a cardiac
catheterization in preparation for surgery which showed no
significant coronary artery disease. She is referred today for
evaluation for mitral valve surgery.
Past Medical History:
Atrial fibrillation (Presented 5-7 years ago)
Mitral regurgitation
Hypertension
Past Surgical History:
Bilateral TKR
Resection of left arm Basal cell cancer
Hammer toe surgery
Social History:
Lives with: Husband. [**Name2 (NI) **], MA
Occupation: Retired
Tobacco: Never
ETOH: Social/rare use
Family History:
Mother and father died of heart disease in their
70's/80's. Sister with heart disease in her 70's.
Physical Exam:
Pulse: 82 AF Resp: 18 O2 sat: 95%
B/P Right: 144/60 Left:
Height: 64" Weight: 156
General: [**Last Name (un) 664**] 82 yo in NAD
Skin: Warm[X] Dry [X] intact [X]
HEENT: NCAT[X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: Irregular rhythm, Nls1-S2, III/VI holosystolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] 1+ LE Edema
Varicosities: Left below knee with varicosities. Mild RLE
varicosities.
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Transmitted vs Bruit
Pertinent Results:
Pre-op:
[**2131-12-9**] 08:57PM PT-17.6* PTT-24.5 INR(PT)-1.6*
[**2131-12-9**] 08:57PM PLT COUNT-337
[**2131-12-9**] 08:57PM WBC-12.5* RBC-4.33 HGB-12.8 HCT-38.2 MCV-88
MCH-29.5 MCHC-33.4 RDW-15.1
[**2131-12-9**] 08:57PM %HbA1c-6.4* eAG-137*
[**2131-12-9**] 08:57PM CALCIUM-9.7 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2131-12-9**] 08:57PM LIPASE-36
[**2131-12-9**] 08:57PM ALT(SGPT)-19 AST(SGOT)-22 ALK PHOS-90
AMYLASE-56 TOT BILI-0.5
[**2131-12-9**] 08:57PM GLUCOSE-104* UREA N-13 CREAT-0.7 SODIUM-144
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-29 ANION GAP-14
[**2131-12-9**] 09:00PM cTropnT-<0.01
[**2131-12-9**] 09:30PM URINE RBC-0-2 WBC-[**3-16**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2131-12-9**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
Discharge:
[**2131-12-14**] 04:35AM BLOOD Hgb-10.1* Plt Ct-309
[**2131-12-13**] 04:40AM BLOOD WBC-15.3* RBC-3.48* Hgb-10.3* Hct-31.3*
MCV-90 MCH-29.4 MCHC-32.8 RDW-15.2 Plt Ct-252
[**2131-12-14**] 04:35AM BLOOD Plt Ct-309
[**2131-12-14**] 04:35AM BLOOD PT-19.9* INR(PT)-1.8*
[**2131-12-14**] 04:35AM BLOOD UreaN-18 Creat-0.6 Na-138 K-4.1 Cl-102
[**2131-12-13**] 04:40AM BLOOD Glucose-78 UreaN-19 Creat-0.5 Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
[**2131-12-10**]-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. The right atrium is dilated. No atrial septal defect
is seen by 2D or color Doppler. Right ventricular chamber size
and free wall motion are normal. There are focal calcifications
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is partial anterior mitral leaflet flail. An
eccentric, posteriorly directed jet of Moderate to severe (3+)
mitral regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. TA in 4 chamber view is 3.1 cm in end
systole.The IVC is dilated to 25mm. There is no pericardial
effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on
[**Known firstname **] [**Known lastname **] prior to surgery. All the ECHO findings were also
done, interpreted and conveyed to surgeon by Dr.[**First Name8 (NamePattern2) 6506**] [**Name (STitle) 6507**]
as well. POST-BYPASS: There is a bioprosthesis sitting in the
mitral position. It is stable and functioning well. There is
valvular or perivalvular leak seen. The transmitral gradient was
7mm of Hg mean with cardiac output of 5.0 L/min.The thoracic
aorta is intact. Normal RV systolic function. LVEF 55%.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-12-12**]
12:57 PM
[**Hospital 93**] MEDICAL CONDITION: 82 year old woman s/p MVR tissue
Final Report: In comparison with study of [**10-10**], all of the
monitoring and
support devices have been removed. No evidence of pneumothorax.
Substantial enlargement of the cardiac silhouette with bibasilar
effusions and atelectasis.
Brief Hospital Course:
The patient was brought to the operating room on [**2131-12-10**] where
the patient underwent Mitral Valve Replacement (27mm tissue) and
Left Atrial Appendage Ligation. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. She was hemodynamically
stable, weaned from inotropic and vasopressor support. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. Coumadin was resumed for atrial
fibrillation. The patient was transferred to the telemetry floor
for further recovery. Chest tubes and pacing wires were
discontinued per cardiac surgery protocol without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on post-op day four the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged to Pleasant [**Hospital **] Nursing and Rehab in
[**Location (un) 23638**], MA. in good condition with appropriate follow up
instructions.
Medications on Admission:
Digoxin 250mcg daily
**Coumadin 5mg daily**-last dose 4 days ago
Evista 60mg daily
Calcium and Vitamin D 400-600mg tab twice daily
Lisinopril 30mg daily
Vitamin B 12 1000mcg Inj monthly
Fluocinonide Topical 0.05% PRN
Cardizem CD 120mg daily
Lasix 40mg daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 2 weeks.
10. Evista 60 mg Tablet Sig: One (1) Tablet PO daily ().
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
13. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): Target INR 2-2.5 for Afib
5 mg on [**12-14**].
Discharge Disposition:
Extended Care
Facility:
Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**]
Discharge Diagnosis:
Mitral Regurgitation
Atrial Fibrillation
s/p Mitral Valve Replacement and Left Atrial Appendage Ligation
PMH:
Hypertension
Past Surgical History:
Bilateral TKR
Resection of left arm Basal cell cancer
Hammer toe surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet
Sternal Incision - healing well, no erythema or drainage
Edema: [**1-13**]+ pedal edema bilat LE
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:
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Tuesday [**12-25**] @ 2:00 pm
Cardiologist Dr. [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **] [**1-2**] @ 1:15 pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 88165**] in [**4-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for Atrial fibrillation
Goal INR 2-2.5
First draw day after discharge [**2131-12-15**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as required
Upon discharge from rehab, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] should be contact[**Name (NI) **]
to follow Coumadin and INR
Completed by:[**2131-12-14**]
ICD9 Codes: 4240, 4280, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5383
}
|
Medical Text: Admission Date: [**2118-5-31**] Discharge Date: [**2118-6-3**]
Date of Birth: [**2038-11-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
weakness, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 79 yo M with h/o stage IIIa NSCLC on chemo
(Alimta), CAD s/p BMS to LAD on ASA/Plavix, and AFib on Coumadin
who presented to the ED today for weakness. Pt reports that he
received a 1/2 dose of chemotherapy (Alimta + neulasta) 3 weeks
ago and has in general been feeling weak since then. It had been
decided to stop this secondary to toxicity (likely
pancytopenia).
His son, who is accompanying him today, reports that for the
past 3 days, he has been feeling more weak and was unable to
transfer him from the bed to the bathroom. Patient also reports
feeling significantly more dizzy upon standing then usual. He
notes having lost about 9 lbs in the past 3 weeks secondary to
chemotherapy and decreased appetitite. Pt reports he was coming
in for a pre-scheduled appointment today, but when his son
[**Name (NI) 20227**]'t get him into the car secondary to weakness/dizziness,
he called his oncologist who instructed him to come in through
the ED.
.
Of note, pt fell this past Friday on the way into his apartment.
He did not hit his head and reported he "plopped" down on his
bottom. Given the structure of the stairwell, he was unable to
move his foot and twisted his L knee that is painful upon
movement.
.
In the ED, initial VS were: 98.0 110/65 85 18 96% 4L NC. Exam
notable for guaiac + yellow stool. EKG unremarkable ( 88 bpm,
normal axis, normal intervals, TWI in V2 (old)). Labs notable
for Hgb/HCT 6.9/22.5 (baseline 27-30), INR 11.8, Cr 1.6
(baseline). Bedside echo showed no pericardial effusion. CXR
without acute process and knee x-ray showed moderate
suprapatellar joint effusion. GI recommended that OMED consult
them on floor. Patient was ordered for 2 units RBC and 2 units
FFP. He received vitamin K 10mg IV in ED and FFP but has not yet
received pRBC. Vitals prior to transfer: 138/88 80 100% RA.
.
On arrival to the MICU, pt is mentating well, HD stable.
.
ROS: denies hematemasis, melena or hematochezia. Denies
abdominal pain or lower extremity weakness.
Past Medical History:
1. CAD s/p NSTEMI ([**11-19**]) s/p LAD BMS
2. RUL NSCL Ca
- FDG-avid right paratracheal, tracheobronchial and precarinal
nodes (dx'd [**2113**])
- completed 2 cycles of cisplatin & etoposide. Second cycle dose
reduced due to pancytopenia with the first cycle.
- completed radiation [**2115-1-3**].
- started cycle 1 of alimta on [**2115-7-30**]
3. GERD
4. Hypertension
5. Hyperlipidemia
6. Gout
7. Skin Cancer
8. s/p Tonsillectomy
Social History:
Home: Married, with 5 adult children
Occupation: Retired civil engineer
EtOH: former heavy alcohol use, quit 13 years ago
Drugs: Denies
Tobacco: former smoker, quit 30 years ago
Family History:
Two brothers died of MIs, one who was in his 50s and one who was
in his 60s when they died.
Sister - died of [**Name (NI) 4278**] Lymphoma in her 40s
Physical Exam:
Admission PE:
Vitals: T:afebrile BP:127/76 P:91 R: 18 O2: 92%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, ecchymosis around L eye oropharynx
clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffusely rhonchorus, RUL very decreased breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, pulsatile descending aorta ~ 5cm
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L knee with pre-patellar effusion, ttp, diffuse
echymoses throughout le
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge PE:
VS: Tm 98.6 126-152/70-86 80-108 18-20 92-94RA
8h: -352 / 60PO
24h: -880 / 700PO
General: Alert, oriented, no acute distress, + ecchymosis
underneath L eye
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple
CV: irregular rhythm, S1 S2
Lungs: course breath sounds throughout, otherwise good air
movement
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L knee effusion improving, non tender to palpation, no
increased warmth or erythema, no pain with knee flexion or
extension, + large ecchymosis on the posterior L thigh with
extension to the L upper thigh, entire area nontender to
palpation --> bruise continuing to fade
Neuro: moving all extremities spontaneously, normal muscle
strength and sensation throughout
Pertinent Results:
Admission labs:
[**2118-5-31**] 05:26PM LD(LDH)-386* TOT BILI-0.8
[**2118-5-31**] 05:26PM IRON-49
[**2118-5-31**] 05:26PM calTIBC-216* HAPTOGLOB-119 FERRITIN-1365*
TRF-166*
[**2118-5-31**] 05:26PM HCT-18.0*
[**2118-5-31**] 05:26PM PT-25.9* PTT-35.3 INR(PT)-2.5*
[**2118-5-31**] 05:26PM RET AUT-0.8*
[**2118-5-31**] 12:12PM GLUCOSE-108* UREA N-32* CREAT-1.6* SODIUM-139
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2118-5-31**] 12:12PM estGFR-Using this
[**2118-5-31**] 12:12PM WBC-9.2 RBC-2.34*# HGB-6.9*# HCT-22.5*#
MCV-96 MCH-29.6 MCHC-30.8* RDW-15.6*
[**2118-5-31**] 12:12PM NEUTS-86.8* LYMPHS-7.9* MONOS-4.9 EOS-0.2
BASOS-0.2
[**2118-5-31**] 12:12PM PLT COUNT-317#
[**2118-5-31**] 12:12PM PT-113.9* PTT-65.6* INR(PT)-11.8*
[**2118-5-31**]
blood cx X2: Pending
[**2118-5-31**]
Non contrast abdomen CT (wet read)
1. No evidence of bleed in the abdomen/pelvis to explain the hct
drop.
2. Small pericardial effusion. Extensive coronary
calcifications. Post
radiation fibrotic changes in the right lower lobe, small
gallstone.
3. Extensive atherosclerotic calcification of the abdominal
aorta and visceral branches, with aneurysmal dilation of long
segment of the infrarenal aorta measuring 3.8 cm, previously 3.3
cm. Ectasia of the right common iliac artery, 1.8cm. Left renal
artery origin stenosis with mild post stenotic dilation.
CXR [**2118-5-31**]
Post-treatment changes seen in the right upper lung. No
evidence
of acute cardiopulmonary process.
EKG: 88 bpm, normal axis, normal intervals, TWI in V2 (old)
Leg ultrasound
CONCLUSION:
Suprapatellar hematoma predominantly laterally in the left knee.
Contralateral right knee hypoechoic oval-shaped lesion with a
discrete tail. Peripheral nerve sheath tumor is considered.
MRI suggested.
Discharge labs:
[**2118-6-3**] 07:05AM BLOOD WBC-7.5 RBC-3.03* Hgb-9.4* Hct-28.2*
MCV-93 MCH-31.0 MCHC-33.3 RDW-16.7* Plt Ct-251
[**2118-6-3**] 07:05AM BLOOD Neuts-85.2* Lymphs-7.1* Monos-7.0 Eos-0.6
Baso-0.1
[**2118-6-3**] 07:05AM BLOOD PT-15.2* PTT-31.3 INR(PT)-1.4*
[**2118-6-3**] 07:05AM BLOOD Glucose-78 UreaN-25* Creat-1.2 Na-140
K-4.1 Cl-101 HCO3-34* AnGap-9
[**2118-6-2**] 06:50AM BLOOD LD(LDH)-434*
[**2118-6-3**] 07:05AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.5
Brief Hospital Course:
Mr. [**Known lastname **] is 79M with h/o stage IIIa NSCLC on chemo (Alimta),
CAD s/p BMS to LAD in [**2113**] on ASA/Plavix, and AFib on Coumadin
who initially presented to ED for weakness, found to have crit
of 18 and supratherapeutic INR, admitted to the MICU, with work
up for acute bleeding negative thus far and s/p 3U PRBCs with
appropriate bump in crit.
# anemia: The patient initially presented with new crit drop in
the setting of chemotherapy about three weeks ago. It is
possible that this new anemia is related to chemo, however,
given the acute nature of drop, a more acute process is likely.
Hemolysis labs were also normal. The patient also had CT scan
that was negative for retroperitoneal bleed. Of note, he was
noted to have guaic positive stools. Specifically, in the
setting of a recent fall and having a supratherapeutic INR, more
likely that there was some bleeding into his L thigh, especially
given the overlying area of ecchymosis. An ultrasound was done
that showed evidence of small hematoma. The patient received
three units PRBC in total during this admission, and upon
discharge, the patient's crits were stable.
# dizziness/lethargy: The patient reported that he was feeling
dizziness with standing in the days preceding presentation.
Likely that he was symptomatic from his anemia. While on the
floor, the patient reported feeling well and denied having any
dizziness. He was discharge home with PT.
# L knee effusion: The patient was found to have L knee effusion
on plain film, likely in the setting of recent fall. His knee
was monitored clinically, and on repeat ultrasound, the effusion
had resolved.
# CAD s/p BMS: The patient has history of CAD s/p BMS in [**2113**],
being maintained on ASA/Plavix. His ASA and Plavix were
initially held. After talking with his outpatient cardiologist,
it was decided to hold his Plavix indefinitely. His metoprolol
and ASA were both restarted. The patient was also continued on
his atorvastatin 80 mg daily.
# atrial fibrillation: The patient has a CHADS of 2. His
coumadin was held initially given his supratherapeutic INR.
After getting FFP and Vitamin K, the patient's INR normalized.
Prior to discharge he was restarted on coumadin 2.5 mg daily. He
should have his INR checked on [**Last Name (LF) 766**], [**6-6**]. The patient's
rate was controlled with metoprolol 50 mg [**Hospital1 **].
# supratherapeutic INR: The patient was to found to have an INR
of 11.8 on admission. This was likely in the setting of
decreased PO intake in recent days due to his chemotherapy. He
was given Vitamin K and FFP and his INR normalized. The patient
was restarted on coumadin 2.5 mg upon discharge.
# NSCLC: The patient is s/p most recent treatment with neulasta
and alimta. He was continued on compazine PRN.
Transitional Issues:
- ? peripheral nerve sheath tumor: The patient was incidentally
found to have a hypoechoic lesion on his R knee. As per
radiology, they suggested an MRI to further characterize the
lesion.
- The patient should have his INR checked on [**Hospital1 766**], [**2118-6-6**]
with results sent to Dr. [**Last Name (STitle) **] Address: [**Street Address(2) 80228**],
[**Location (un) **],[**Numeric Identifier 80229**] Phone: [**Telephone/Fax (1) 80227**] Fax: [**Telephone/Fax (1) 80230**]
Medications on Admission:
allopurinol 100 mg daily
atorvastatin 80 mg daily
clopidogrel 75 mg daily
folic acid 1 mg daily
metoprolol 50 mg [**Hospital1 **] (recently halved since starting chemo)
pantoprazole 40 mg daily
compazine 5 mg 1-2 tabs q6h PRN nausea
warfarin 2.5 mg 1-2 tabs daily
ASA 325 mg daily
calcium-Vitamin D
docusate sodium 100 mg [**Hospital1 **]
melatonin 5 mg qhs
psyllium husk
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO Q6H
(every 6 hours) as needed for nausea.
7. warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium-Vitamin D Oral
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. melatonin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. psyllium husk Oral
13. Outpatient Lab Work
Please check INR on [**2118-6-6**] and please send results to Dr.
[**Last Name (STitle) **]
Address: [**Street Address(2) 80228**], [**Location (un) **],[**Numeric Identifier 80229**]
Phone: [**Telephone/Fax (1) 80227**]
Fax: [**Telephone/Fax (1) 80230**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary diagnosis:
anemia
lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
weak and you were found to have a very low blood count and a
very high INR. You were initially in the intensive care unit
and needed to get blood transfusions. We did not find any
source of your bleeding, but we think it could have happened
when you fell.
We made the following changes to his medications:
INCREASE pantoprazole to 40 mg by mouth twice daily
STOP Plavix
Followup Instructions:
PCP [**Name Initial (PRE) **]:Thursday, [**6-9**] at 2pm
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 80231**],MD
Address: [**Street Address(2) 80228**], [**Location (un) **],[**Numeric Identifier 80229**]
Phone: [**Telephone/Fax (1) 80227**]
Hematology/Oncololgy:PENDING
With: Drs. [**Name5 (PTitle) **]/[**Doctor Last Name 10351**]
Phone:[**Telephone/Fax (1) 6568**]
**We are working on a follow up appointment with Drs.
[**Name5 (PTitle) **]/[**Doctor Last Name 10351**] in the next week. You will be called at home
with the appointment. If you have not heard within 2 business
days or have questions, please call [**Telephone/Fax (1) 6568**].
Department: NEUROLOGY
When: THURSDAY [**2118-9-1**] at 11:30 AM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 11625**] [**Telephone/Fax (1) 558**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
Completed by:[**2118-6-4**]
ICD9 Codes: 2851, 4019, 2724, 412, 2749
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5384
}
|
Medical Text: Admission Date: [**2153-7-29**] Discharge Date: [**2153-8-1**]
Date of Birth: [**2074-11-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is 78 y/o F with h/o atrial fibrillation on coumadin and h/o
of GIST s/p excision and partial gastrectomy in [**2143**] who later
developed local recurrence and omental metastasis s/p resection
of omental mass in [**3-/2153**] and now presents today with 3 day
history of dull epigastric abdominal pain. Pt had CT scan at
OSH showing intraperitoneal bleeding and pt was subsequently
transferred to [**Hospital1 18**] for further management. At OSH, pt had BP
in 90s, hct 23.5 and inr 4.0. Pt denies fevers, chills,
nausea/vomiting, or diarrhea
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- . Paroxysmal Atrial Fibrillation on coumadin
- . Heart Failure with preserved EF
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
.
1. CVA in [**2136**]
2. TIA in [**2138**]
3. Hypertension
4. Hypothyroidism
5. Abdominal mass - GIST (diagnosed [**2143**]) s/p surgery, on
Gleevec therapy, follows Dr. [**Last Name (STitle) 13754**] in Heme/Onc.
.
PAST ONCOLOGIC HISTORY:
- Mrs. [**Known lastname 13755**] initially presented [**2143-9-2**] with abdominal
pain. At that time, she was found to have a large mass in her
abdomen.
- On [**2143-9-6**], she underwent an incomplete resection of this
tumor. It was found to be increasing in size and she was treated
on Gleevec from [**1-/2145**] to 12/[**2146**]. At that time, she stopped it
as she was having some side effects from this therapy, most
notably severe cramping. On the Gleevec, her tumor had decreased
in size. However, the mass grew while she was off the Gleevec
and she was restarted on it again in 07/[**2149**]. She was restarted
at 200mg daily to avoid issues with cramping.
- On [**2151-6-29**] she had a CT scan which showed new liver lesions
which were concerning. An ultrasound was obtained [**2151-7-13**] which
showed these lesions and raised concern for metastatic disease.
- She was increased from Gleevec 200mg daily to 400mg daily on
[**2151-9-8**].
- She had stable CT scans and the liver lesions were determined
to be cysts, she was decreased from 400mg daily to 200mg daily
due to nausea on [**2152-4-5**].
-CT scan [**10/2152**] there was increase in size of a right upper
mesenteric nodule with no other enlarging disease. Her case was
discussed previously and surgery is an option. At this time she
is interested in trying 400mg Gleevec to see if this
controls/shrinks this mass. If the mass continues to enlarge she
would consider surgery.
Social History:
Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has
grandchildren who visit her.
-Tobacco history: negative
-ETOH: negative
-Illicit drugs: negative
Family History:
No family history of cancer, lung disease or heart disease. +
for DM.
Physical Exam:
T 98 P 70 BP 112/64 R 20 SaO2 98% RA
Gen: no acute distress
heent: no scleral icterus
neck: supple
Lungs: clear
heart: regular rate and rhythm
abd: soft,no tender, nondistended, no guarding, nonrigid
Extrem: no edema
Pertinent Results:
[**2153-7-29**] 03:20PM BLOOD WBC-5.9 RBC-2.63*# Hgb-7.8*# Hct-23.5*#
MCV-90 MCH-29.9 MCHC-33.4 RDW-16.6* Plt Ct-215
[**2153-7-29**] 03:20PM BLOOD Plt Ct-215
[**2153-7-29**] 03:33PM BLOOD Hgb-8.1* calcHCT-24
[**2153-7-30**] 02:30AM BLOOD Glucose-109* UreaN-24* Creat-1.1 Na-143
K-3.6 Cl-106 HCO3-27 AnGap-14
[**2153-7-30**] 02:30AM BLOOD WBC-5.6 RBC-3.03* Hgb-9.1* Hct-26.8*
MCV-89 MCH-30.0 MCHC-33.8 RDW-17.1* Plt Ct-214
[**2153-7-30**] 06:02AM BLOOD Hct-27.4*
[**2153-7-31**] 03:57AM BLOOD WBC-5.4 RBC-3.42* Hgb-9.9* Hct-29.8*
MCV-87 MCH-29.0 MCHC-33.3 RDW-16.9* Plt Ct-206
[**2153-7-31**] 11:52AM BLOOD Hct-25.1*
[**2153-7-31**] 04:10PM BLOOD Hct-28.8*
[**2153-8-1**] 06:35AM BLOOD WBC-4.6 RBC-3.35* Hgb-10.0* Hct-30.2*
MCV-90 MCH-30.0 MCHC-33.3 RDW-16.8* Plt Ct-252
Brief Hospital Course:
78 years old female with dx of GIST tumor, anticoagulated for
Afib admitted wth intraabdominal bleeding on [**7-29**] Patient was
admitted to SICU. Transfused 2u PRBC and 1u FFP.
Neurologic:
- Intact, mentating well. Continue to follow
- Adequate pain control with dilaudid IV PRN Then switched to Po
pain medication.
Cardiovascular:
- Clinically stable
- Maintain SBP>90, Continous monitoring showed heart rate
control.
- continue to follow Hct and coags
Pulmonary:
- Clinically stable, breathing room air
- No respiratory distress.
Gastrointestinal / Abdomen:
- GIST tumor s/p multiple resections with blood collection in
abdomen
- No surgical intervention at this time unless change in
clinical picture
Nutrition:
- NPO during HD 1 and 2. The restarted on Clears on HD3 advanced
to regular cardiac healthy diet on HD4. Patient tolerate the
diet, no abdominal pain or distention.
Renal:
- Stable. Urine out up was monitored with foley. On HD 4 foley
was d/c and patient voided.
Hematology:
- Anemia secondary to likely bleeding in abdomen
- INR 4.0, 2uFFP and 10mg vit K was given on [**7-29**]
- Transfused 2uPRBC, and follow Hct which remined stable for the
rest of her hospitalization.
Endocrine:
Insuline SS, f/u blood sugars
DVT profilaxis with pneumatic boots
Medications on Admission:
Coumadin 4 mg Mon
Coumadin 3 mg TueWedFriSatSun
Coumadin 5 mg [**Last Name (un) **]
Metoprolol 25 mg daily
amiodarone 200 mg daily
levothyroxine 200 mcg daily
istalol 0.5% 1 drop each eye [**Hospital1 **]
lumigan 0.03% 1 drop each eye daily
furosemide 80 mg daily
gleevec 200 mg daily
CaCO3 650 mg [**Hospital1 **]
cholecalciferol 1000 units daily
januvia 100 mg daily
Discharge Medications:
1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lumigan 0.03 % Drops Sig: One (1) Ophthalmic once a day: 1
drop.
5. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
7. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
History of Atrial Fibrilation on coumadin presents with
intraperitoneal bleeding from GIST tumors in setting of
anticoagulation
Heart Failure with preserved EF
Diabetes Mellitus
Hypercholesterolemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please schedule an appointment with your PCP within [**Name Initial (PRE) **] week to
restart medications (Coumadin and Gleevec) and f/u INR. 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
10lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
PLease schedule a follow up appointment with Dr. [**Last Name (STitle) **].
Phone number: ([**Telephone/Fax (1) 1483**]
Please schedule an appointment with PCP within [**Name Initial (PRE) **] week.
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2153-8-3**] 1:00
Provider: [**Name10 (NameIs) 3150**],[**Name11 (NameIs) **] MD Phone:[**Telephone/Fax (1) 11133**]
Date/Time:[**2153-8-24**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2153-10-31**]
11:20
Completed by:[**2153-8-1**]
ICD9 Codes: 4280, 2449, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5385
}
|
Medical Text: Admission Date: [**2166-2-15**] Discharge Date: [**2166-2-24**]
Date of Birth: [**2100-10-22**] Sex: M
Service: MEDICINE
Allergies:
Darvocet-N 50
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Epistaxis, nausea, hypotension
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 65 yo M with Hx of multiple CVAs, CAD with
stents (DES to RCA [**2164**], off plavix), HTN, pacemaker, Mechanical
Aortic valve who has had several recent admissions to [**Hospital1 18**] for
anemia (thought secondary to epistaxis and hematuria). Most
recently admission was([**Date range (1) 80819**]), where he initially presented
with SOB, dizziness and Hct of 22, and guaiac pos stools. He
was transfused, and did not bump appropriately to transfusions;
labs were suggestive of hemolysis although coombs and antibody
testing were normal. His Hct stabilized and was 23.6 on
discharge; he was sent home with a plan to f/u with hematology
and undergo outpatient egd/[**Last Name (un) **]. Overnight, he experienced an
episode of copious epistaxis and returned to the ED today
complaining of HA, nausea and mild SOB.
In the ED, initial vs were: 98.8 86 93/48 18 100% on RA. BP
declined to 70s/40s and Hct was down approx 3 pts to 20.8 with
INR 3.1. Rectal exam showed black, guaiac pos stool and nasal
examination showed slight oozing of the septum. The patient was
given approximately 800 cc NS, protonix 80 mg IV, zofran IV, and
given 3 units prbcs. During his transfusion, reportedly passed
a large amount of melena, and was cross-matched for another 4
units prbcs. Vitals on transfer were: BP 86/50, HR 74, RR 25,
100% on RA. He was admitted to the ICU for ongoing hypotension
in the setting of anemia.
On the floor, patient reports dizziness, nausea and abdominal
tenderness. Has some SOB, which he describes as chronic. No
epistaxis today.
Review of systems:
(+) Per HPI, also reports recent constipation the past week
(relieved with today's melena, as well as intermittent black
stools for the past several months.
(-) 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 dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- CVA x 4 (most recent [**7-9**] while on warfarin, ASA and plavix)
- HTN
- CAD - single vessel distal LAD
- MI - in [**2164**], 3 stents unknown type unknown date
- s/p ICD implantation [**2163-12-8**] Parciology PC [**Telephone/Fax (1) 107924**]
- CHF - preserved EF, diastolic
- AVR - Mechanical valve [**2159-3-31**]
- DM-II
- COPD
- Low Back Pain
- Nephrolithiasis
- Duodenal ulcer on EGD [**2161-9-28**]
Social History:
-Smoking/Tobacco: 60 pack years, quit 2 years ago
-EtOH: seldom
-Illicits: IV drugs once in his life when young, never again
-Lives at/with: daughter and her family. She assists with his
medications. Independent with ADLs and ambulates with cane. From
[**2162**]-[**2164**] he lived in [**State 9512**] and so we have no records of his
care at that time. He states that he has never been in the
military, never been incarcerated although he has been around
individuals who have. He is not currently sexually active and
has had female partners in the past.
Family History:
(from OMR) There is diabetes mellitus, hypertension and
dyslipidemia in several immediate family members. His sister had
CHF/?MI begining in her late 40s. His mother had breast cancer
and CHF.
Physical Exam:
Vitals: T: 96.6 BP: 83/46 P: 70 R: 18 O2: 99% on RA
General: elderly AA man, appearing in mild discomfort
HEENT: NCAT, Sclera anicteric, MMM, oropharynx clear, nasal
mucosae with dried blood visible on nasal septum b/l
Lungs: mild bibasilar rales, otherwise CTAB
CV: Regular rate and rhythm, normal S1 + S2, II-III/VI systolic
murmur loudest RUSB
Abdomen: soft, non-distended, bowel sounds present, TTP in upper
quadrants b/l, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema b/l (per
family, slightly improved from baseline)
Discharge:
Pertinent Results:
Admission Labs [**2166-2-14**]
WBC-6.8 RBC-2.49* Hgb-8.1* Hct-23.6* MCV-95 MCH-32.6* MCHC-34.4
RDW-18.2* Plt Ct-184
PT-38.0* PTT-47.9* INR(PT)-3.9*
Glucose-105* UreaN-22* Creat-0.7 Na-133 K-4.1 Cl-105 HCO3-21*
AnGap-11
HCT nadir 20.8
CXR ([**2166-2-20**]): Small bilateral pleural effusions, larger on the
left side associated with adjacent atelectasis worse in the left
side are new. Cardiomegaly is stable. Left transvenous pacemaker
leads terminate in standard position in the right atrium and
right ventricle. Mild vascular congestion is new. Sternal wires
are aligned. Degenerative changes are in the thoracic spine.
Patient is status post AVR.
EGD: Erythema and contact bleeding in the antrum compatible with
diffuse gastritis
[**2166-2-23**] 07:00AM BLOOD PT-28.8* PTT-106.5* INR(PT)-2.8*
[**2166-2-22**] 06:35AM BLOOD PT-23.8* PTT-83.0* INR(PT)-2.3*
[**2166-2-21**] 07:25AM BLOOD PT-22.4* PTT-65.5* INR(PT)-2.1*
[**2166-2-20**] 09:54AM BLOOD PT-20.9* PTT-47.5* INR(PT)-1.9*
[**2166-2-19**] 06:18PM BLOOD PT-20.8* PTT-39.7* INR(PT)-1.9*
Brief Hospital Course:
1. Acute blood loss anemia: Multifactorial with (a) epistaxis;
(b) gastritis; (c) anticoagulation. A total of 8 units of pRBC
were transfused and aspirin/warfarin were held. No reversal of
anticoagulation was done given mechanical valve and prior
stroke. After EGD showed gastritis, pantoprazole dose was
increased. ENT follow-up was arranged to help manage epistaxis
which stopped spontaneously.
2. Hypotension: Per family and the patient, he has had
chronically low BPs for at least the past month. Likely
secondary to hypovolemia in the setting of acute bleed. SBP
remained in 90s after stabilization of bleeding. Given CHF/CAD,
Low dose beta blocker and daily morning lasix was resumed on
discharge since BP was at its baseline.
3. Epistaxis: Patient with multiple episodes of epistaxis in the
past several months. Last ENT evaluation showed evidence of
anterior bleeding. Afrin was given for 3 days was given as well
as nasal saline, humidified air and vaseline to nasal mucosa.
ENT follow-up was arranged.
4. Gastritis: Given guaiac positive stool, EGD was done and
showed gastritis. Pantoprazole dose was increased.
5. Mechanical AVR: Anticoagulated with goal INR 2.5-3.5. Managed
with a heparin gtt with warfarin resumed after stabilization of
HCT. He was instructed to take 2mg Warfarin on discharge
([**2166-2-23**]), repeat level will be drawn by VNA on [**2166-2-24**] and [**Company 191**]
will be in touch with patient. Pt's PCP [**Name Initial (PRE) 21150**] (Dr. [**Last Name (STitle) **] was
paged and this issue discussed.
Date - INR value:Warfarin Dose
[**2166-2-19**] - 1.9:3mg
[**2166-2-20**] - 1.9:3mg
[**2166-2-21**] - 2.1:3mg
[**2166-2-22**] - 2.3:3mg
[**2166-2-23**] - 2.8:2mg
6. Congestive heart failure, diastolic, acute on chronic:
Initially dry to euvolemic but after administration of pRBC,
experienced orthopnea with CXR showing mild vascular congestion.
Improved with one day of IV furosemide diuresis. As above,
resumption of beta-blocker and lisinopril was initially limited
by SBP, though BP normalized to his baseline of low 90s. Once
daily lasix and low dose betablockade was resumed.
Medications on Admission:
(list confirmed with patient on arrival to the floor)
- Flovent HFA 110 1 puff twice daily
- folic acid 1 mg daily
- furosemide 20 mg daily
- glyburide 10 mg daily
- Combivent 18-103 mcg 1 puff twice daily as needed for
shortness of breath
- lisinopril 2.5 mg daily
- metoprolol succinate (Toprol) 12.5 mg daily
- nitroglycerrin SL 0.4 mg as needed chest pain
- oxycodone 10 mg daily as needed for back pain
- polyethylene glycol 3350 17 gram daily as needed for
constipation
- aspirin 81 mg daily
- colace 100 mg twice daily
- warfarin with goal INR 2.5-3.5
- recently prescribed but not yet taken: ferrous sulfate 300 mg
daily and omeprazole 20 mg daily
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day as needed for shortness of breath or
wheezing.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed as needed for chest pain.
7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for back pain.
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day as needed for constipation.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. ferrous sulfate 324 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: take night of [**2166-2-23**] (Sunday). Discuss Monday night's dose
with [**Hospital 191**] [**Hospital3 **] nurse.
[**Last Name (Titles) **]:*10 Tablet(s)* Refills:*0*
14. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
1. Acute blood loss anemia
2. Gastritis, diffuse with active bleeding
3. Epistaxis
4. Mechanical heart valve
5. Prior stroke
6. Coronary artery disease, native [**Last Name (un) 108044**]
7. CHF, diastolic, chronic
8. Diabetes, type II, controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a low blood count (anemia). This is most
likely from both a nose bleed (epistaxis) but may also be from
some bleeding in your stomach (gastritis). You received a total
of 8 units of blood transfused. To help promote healing of the
stomach, we have increased your dose of pantoprazole to twice
daily. You had some fluid overload (heart failure) from the
transfusions and required a higher lasix dose, but this has been
readjusted back to your baseline.
You were treated with IV heparin bridge until your INR was at
normal levels again. You will need to have your INR and BLood
count checked tomorrow and faxed to your doctor's office.
Followup Instructions:
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
When: WEDNESDAY [**2166-2-26**] at 10:50 AM
With: Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular
primary care doctor in follow up.
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2166-2-26**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: CARDIAC SERVICES
When: MONDAY [**2166-3-3**] at 3:30 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
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2166-3-5**] at 4:30 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2851, 4280, 496, 4589, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5386
}
|
Medical Text: Admission Date: [**2129-3-14**] Discharge Date: [**2129-3-23**]
Date of Birth: [**2067-3-29**] Sex: M
Service: SURGERY
Allergies:
E-Mycin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Disabling left leg claudication,
status post prior ligation of popliteal artery aneurysm
Major Surgical or Invasive Procedure:
[**2129-3-14**]
Left superficial femoral artery to posterior
tibial artery bypass graft using 6 mm ringed Propaten
[**2129-3-15**]
Cardiac Catheterization with PTCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 96769**] stents(x3) to the
mid to ostial RCA
History of Present Illness:
The patient is a male who had an arm vein
bypass femoral-popliteal done approximately 17 years ago for
a large popliteal aneurysm. It lasted for that number of
years and then occluded approximately 5 minutes before
presentation. This was even with a previously normal graft
study before that. Angiogram showed occlusion of the graft.
There was no way to open up the graft since it was months
after symptoms. In addition, there would be no percutaneous
measure because the aneurysm was ligated. The patient has no
veins whatsoever and did not have this similar anomaly in his
left arm with essentially 2 brachial arteries. After a long
discussion with the patient and the family he is not capable
of staying at his current level. In other words he was so
debilitated by this that he felt he needed surgery. He
understands that his only option other than PTFE would be
either an arterial construct which would be very difficult to
harvest or thigh femoral vein which would also be very
challenging. He understands the risk of graft failure either
acutely or shorter long-term as well as graft infection and
consents to go forward with the procedure.
Past Medical History:
PMH: PVD, Hyperlipidemia, H/O thyroid CA, colon polyps
Social History:
Smoking: none
Alcohol: infrequent
Family History:
n/c
Physical Exam:
vss
A&O x 3 in NAD
Lungs:cta bilat
Card: rrr, no m/r/g
Abd: soft +bs, no m/t/o
Extrem: warm bilat, LLE incision c/d/i, slight errythema at
distal incision
DP PT
L P P
R D P
Pertinent Results:
[**2129-3-23**] 06:37AM BLOOD Hct-29.5*
[**2129-3-23**] 06:37AM BLOOD PT-24.9* INR(PT)-2.4*
[**2129-3-21**] 06:15AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-138
K-3.8 Cl-101 HCO3-31 AnGap-10
[**2129-3-18**] 03:36AM BLOOD CK(CPK)-408*
[**2129-3-17**] 08:24AM BLOOD CK(CPK)-628*
[**2129-3-16**] 05:16PM BLOOD CK(CPK)-1116*
[**2129-3-16**] 04:39AM BLOOD CK(CPK)-1071*
[**2129-3-15**] 07:41PM BLOOD CK(CPK)-590*
[**2129-3-15**] 01:45PM BLOOD CK(CPK)-645*
[**2129-3-15**] 06:00AM BLOOD CK(CPK)-483*
[**2129-3-14**] 09:50PM BLOOD CK(CPK)-213
[**2129-3-18**] 03:36AM BLOOD CK-MB-7 cTropnT-2.31*
[**2129-3-17**] 08:24AM BLOOD CK-MB-16* MB Indx-2.5 cTropnT-2.01*
[**2129-3-16**] 04:39AM BLOOD CK-MB-102* MB Indx-9.5* cTropnT-1.75*
[**2129-3-15**] 07:41PM BLOOD CK-MB-40* MB Indx-6.8* cTropnT-0.76*
[**2129-3-15**] 01:45PM BLOOD CK-MB-55* MB Indx-8.5* cTropnT-0.97*
[**2129-3-15**] 06:00AM BLOOD CK-MB-38* MB Indx-7.9* cTropnT-0.30*
[**2129-3-14**] 09:50PM BLOOD CK-MB-9 cTropnT-<0.01
[**2129-3-16**] 04:39AM BLOOD %HbA1c-7.2* eAG-160*
Cardiology Report ECG Study Date of [**2129-3-14**] 4:23:54 PM
Probable sinus rhythm. Low amplitude P waves. Cannot rule out
ST-T wave
abnormalities. Baseline artifact. Since the previous tracing of
[**2129-3-9**] the rate is faster. Further comparison cannot be made.
Portable TTE (Focused views) Done [**2129-3-15**] at 7:23:31 PM
FINAL
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.4 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. There is mild regional left ventricular
systolic dysfunction with distal inferoseptal and apical
hypokinesis. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The number of aortic valve leaflets cannot be
determined. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Limited emergency echo. Mild regional left
ventricular systolic dysfunction with overall normal systolic
function.
Portable TTE (Complete) Done [**2129-3-16**] at 11:50:08 AM FINAL
The left atrium is normal in size. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with distal inferoseptum,
inferior wall hypokinesis. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2129-3-15**],
the region of hypokinesis in the distal inferoseptum has
decreased.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2129-3-14**] and underwent Left
superficial femoral artery to posterior tibial artery bypass
graft using 6 mm ringed Propaten. He tolerated the procedure
well and was taken to the PACU for recovery. He was found to
have a low h/h and was hypertensive post operatively. He
received 1u prbcs, and was placed on a nitro gtt. A heparin gtt
was also initiated post op given his arterial disease. Once
hemodynamically stable he was transferred to the VICU where he
continued to be monitored closely. On POD 1 he was weaned off
the nitro. His hct was still low and he was transfused another
unit of prbcs. On [**3-15**], pod 1 the pt experienced some chest pain
and a cardiac work up was started. His ekg st elevation in S
II,III and his cardiac enzymes were positive, and trending
upwards. Dr. [**Last Name (STitle) **] (cardiology) was consulted to see the pt and
felt the pt was having an acute MI. Mr. [**Known lastname **] was taken
urgently for a cardiac cath with the following findings: LMCA
was calcified
with minimal disease. The LAD had an ostial 60-70% lesion. The
LCx had
minimal disease. The RCA had an ostial 90% lesion, and a mid
60%
calcified tubular lesion. 3 drug eluding stents were placed in
the RCA and the pt tolerated the procedure well. He remained
hemodynamically stable and was transferred back to the CCU. He
remained in the CCU for 1 day, where he remained hemodynamically
stable. He was started on plavix for the DES, and continued on
iv heparin, and started on coumadin for PAD. He was transferred
back to the vascular team and the VICU on the afternoon of [**3-16**].
His A1C was found to be >7 and the [**Last Name (un) **] diabetes team was
asked to consult on his case. They monitored him closely and had
him on a humalog sliding scale while in the hospital. Throughout
the remainder of his hospital stay, his cardiac status was
monitored closely. He was started on the appropriate medications
s/p MI. He worked with physical therapy throughout his post
operative course and was found to be stable to go home without
services. His hct remained slightly decreased and on [**3-21**] it was
recommended to transfuse 1 unit of prbcs. However, the pt had no
IV access and refused to allow the team to place an EJ line. On
[**3-22**] his hct had trended down to approximately 24 and we
strongly encouraged him to be transfused. Given difficulty with
piv and ej placement, an IJ was placed by a surgical resident at
the bedside. Mr. [**Known lastname **] was transfused 2u prbcs with an
appropriate rise in his hct. He remained hemodynamically stable
and his hct was stable on [**3-22**]. He was tolerating a po diet,
ambulating without assistance and voiding without difficulty. He
was deemed stable for discharge home on [**2129-3-22**]. He will need
cardiology follow up and will inevitably need CABG for his LAD
disease at some point in the future. After his follow up with
cardiology, he may start a cardiac rehabilitation program. His
PT/INR will be followed by his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] and he will see the
[**Last Name (un) **] diabetes team for further evaluation of his diabetes in
the next few weeks.
Medications on Admission:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): otc - use if taking narcotics.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain .
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GERD: otc
- .
9. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for anxiety: home medication.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: call pcp for refills.
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
16. glucometer
check blood sugars multiple times per day as recommened by the
diabetes team
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Homecare
Discharge Diagnosis:
Primary:
Disabling left leg claudication (long standing PVD)
Secondary:
Post op MI
Diabetes
Hyperlipidemia
H/O thyroid CA
H/O colon polyps
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-5**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
You also experienced a post operative myocardial infarction
(heart attack) and underwent a cardiac catheterization with
stenting of your Right Coronary Artery. It is important that
you follow up with your cardiologist in the next few weeks and
get set up with a cardiac rehab center as soon as you are
cleared by Dr. [**Last Name (STitle) **] (he will give you a persciprtion for cardiac
rehab)
You have been started on several new medications including
coumadin (warfarin). It is very important that you have your
PT/INR values monitored by your PCP , [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**]. He will let you
know if you need to adjust your coumadin dose.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2129-4-1**] 9:15
Dr. [**Last Name (STitle) 131**] will follow your PT/INR (coumadin lab values). The VNA
will draw your INR friday, and at least twice a week after that
and send the results to : DR. [**Last Name (STitle) **],[**First Name3 (LF) 132**] C.
[**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
Fax: [**Telephone/Fax (1) 445**]
Dr. [**Last Name (STitle) 9671**] 2 weeks (diabetes)([**Telephone/Fax (1) 17484**] Call for appt.
Dr. [**Last Name (STitle) **] (cardiology) [**Telephone/Fax (1) 7960**]. His office will call you with
f/u appt (2-3 weeks)
Cardiac Rehab - to start when cleared by Dr. [**Last Name (STitle) **]
Completed by:[**2129-3-23**]
ICD9 Codes: 2724, 4439
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5387
}
|
Medical Text: Admission Date: [**2126-10-15**] Discharge Date: [**2126-11-12**]
Date of Birth: [**2052-5-23**] Sex: F
Service:Blue General Surgery
The patient expired on [**2126-11-12**].
Briefly, the patient is a 74-year-old female with a history
of autoimmune hepatitis and cirrhosis, who had a previous
umbilical hernia repair, which was noticed to have persistent
operating room on [**2126-10-18**] for repair of the fascial
adhesions. However, the wound continued to drain ascites in
copious amounts.
The patient was reoperated on [**2126-10-21**] and a Marlex mesh
was placed in order to close the fascial defect. As the
patient has a baseline history of cirrhosis, the patient's
threatening upper GI bleed from esophageal varices and
gastric varices which were unable to be controlled by
esophagogastroscopy and banding.
The patient emergently underwent a TIPS procedure via
Radiology on [**2126-10-27**]. The bleeding was assumed to be
controlled, and the patient was relatively stable. She was
maintained on octreotide and azathioprine for her autoimmune
hepatitis. She is also on Solu-Medrol. After the TIPS
procedure, however, the patient's bilirubin was noted to be
rising from 2.9 into the 6 range. The bilirubin continued to
rise into the range of 23 to 25. Postoperative there was too
much shunt from the TIPS procedure, and the patient was taken
to partially occlude the TIPS catheter.
She underwent downsizing of the TIPS on [**2126-11-8**]. Patient
tolerated the procedure fairly well, however, her bilirubin
continued to rise. The patient was becoming hypotensive in
the Intensive Care Unit and required constant monitoring.
Multiple discussions were held with the family regarding
patient's general health status. It was carefully noted to
the family that the patient's baseline liver failure would
not allow her to fully recover, and she when slowly, she
would continue to deteriorate. However, at this time the
patient's family wanted everything done. Pulmonary artery
line was placed in order to help manage the patient's
hypertension and fluid status. Also her perineum was tapped
for 1 liter of ascites fluid.
During this time, also, the patient's urine output began to
dwindle, and the patient became enuretic on [**2126-11-10**]. The
patient's respiratory status became very marginal and she was
also becoming more encephalopathic. At this time, an
ultrasound was also done which confirmed a very little flow
through the TIPS.
At this time, discussion again was held with the family
explaining the patient was going to be requiring intubation
and due to baseline health status, would most likely not be
able to be extubated. She would also require dialysis as her
kidneys have become nonfunctional.
Patient's daughter, who is also the healthy proxy, understood
the gravity of the situation, and pursued to make the patient
comfort measures only. Patient's daughter was explained that
this would include no chest compressions, no chemicals,
interventions, no mechanical ventilation, and no medications.
If we did this, patient would most likely pass away over the
next 24 hours.
Health-care proxy daughter was aware and in compliance with
the following plan. This patient was made CMO. She was not
intubated and no dialysis was pursued. The patient was also
placed on a Morphine drip at 5 mg an hour to make her
comfortable as she was complaining of pain.
The following morning, [**2126-11-12**] at 4:35 am, patient was
found to be asystolic. Upon examination, she had no pulse,
no blood pressure. The patient was pronounced dead at 4:35
am on [**2126-11-12**].
The family was made aware, and the daughter consented to
autopsy which will be happening this morning.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 3181**]
MEDQUIST36
D: [**2126-11-12**] 07:28
T: [**2126-11-12**] 07:37
JOB#: [**Job Number 94954**]
ICD9 Codes: 5715, 5185
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5388
}
|
Medical Text: Admission Date: [**2198-11-6**] Discharge Date: [**2198-11-20**]
Date of Birth: [**2175-5-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Tracheobronchomalacia with airway occlusion from granulation
tissue.
Major Surgical or Invasive Procedure:
[**2198-11-7**]
1. Flexible and rigid bronchoscopy.
2. Foreign body (silicone stent) removal.
3. Excision of granulation tissue with electrocautery.
4. Stent placement in the left mainstem and trachea.
[**2198-11-11**] Rigid and flexible bronchoscopy,
foreign body (stent) removal, and tracheostomy revision with
replacement of tracheal tube.
History of Present Illness:
23 year-old male with history of static encephalitis at 2 mo
old, chronic seizure disease, and trachomalacia s/p
y-stent/trach at [**Hospital1 1774**] [**9-28**], discharged on [**2198-10-10**] after
prolonged hospitalization for pseudomonas pneumonia and
tracheomalacia requiring trach/G-tube placement. Approximately
one month following hospitalization, the patient had increased
suctioning requirements and intermittent fevers and was admitted
to [**Hospital3 1810**] [**Location (un) 86**], where he was found to have
recurrent left lower lobe pseudomonal and MRSA pneumonia and
started on meropenem and gentamicin. He was also found to have
granulation tissue and mucuous in his trach tube and was
transferred to the [**Hospital1 18**] for stent placement and trach change.
Past Medical History:
PMH:
1.diphtheria static encephalitis at 2mo old
2.infantile spasms progressing to refractory seizure d/o
seizure history, as documented by [**Hospital1 18**] Neurology:
h/o chronic seizure d/o which started as infantile spasms and
progressed to refractory seizures. Per father, at baseline,
patient has spastic movements of his arms and legs. He has
about 3 seizures per day, which consist of his "arms and mouth
stiffening," and twitching movements of his mouth. During his
[**Hospital3 1810**] [**Location (un) 86**] hospitalization [**9-28**], he was found
to have a dilantin level of 37.3 and phenobarbital level of
23.5; his dilantin was held until levels became non-toxic and
the dose was then decreased to 100 mg PO qam and 125 mg PO
qpm. His dilantin level prior to [**Hospital1 18**] transfer was 14.6.
3.s/p VNS in [**2193**]
Social History:
Mother - healthy
Father - seizure disorder - 0-3 seizure/day. His seizures are
manifest as generalized tonic events with arm and leg stffening
and facial grimacing movements. These episodes typically last
1-2 minutes and self resolve. The
family uses Diastat prn seizure> 5 minutes. Father is not sure
if patient has ever had an episode of status epilepticus or
required ICU stay for his seizures.
Family History:
non-contributory
Physical Exam:
General: Lying in bed, non-communicative
HEENT: large ears and no other dysmorphic features
CV: RRR on tele
Resp: Copius UA secretions transmitted
Ab: Gtube, S, ND
Ext: contractures in LE, flaccid UE and MAE spont
Neuro: MSE: Awake, non-verbal, does not respond to commands.
CN's: PERRL. Does not track movement but blinks to threat and
light. He averts eyes to light. His tongue appear ML. Gags with
suctioning. Bifacial weakness.
Pertinent Results:
[**2198-11-7**] WBC-6.1 RBC-3.73* Hgb-11.2* Hct-32.9 Plt Ct-342
[**2198-11-10**] WBC-11.6*# RBC-3.87* Hgb-11.8* Hct-33.0 Plt Ct-353
[**2198-11-13**] WBC-4.2 RBC-3.28* Hgb-10.0* Hct-28.8*
[**2198-11-16**] WBC-6.1 RBC-3.90* Hgb-11.8* Hct-34.8 Plt Ct-291
[**2198-11-7**] Glucose-95 UreaN-7 Creat-0.5 Na-136 K-4.0 Cl-101
HCO3-29
[**2198-11-16**] Glucose-97 UreaN-13 Creat-0.5 Na-138 K-3.9 Cl-104
HCO3-25
[**2198-11-16**] 02:41AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.1
[**2198-11-7**] 02:29AM BLOOD Phenyto-15.0
[**2198-11-13**] Phenoba-18.5 Phenyto-7.6*
[**2198-11-14**] Phenoba-19.7 Phenyto-6.0*
[**2198-11-14**] Phenyto-8.4*
[**2198-11-14**] Phenyto-8.4* Phenyfr-0.9* %Phenyf-11
[**2198-11-15**] Phenyto-11.8
[**2198-11-6**]
Chest X-Ray
A roughly 6 cm long tracheostomy cannula ends at the level of
the thoracic inlet at the upper margin of a tracheal stent which
is seen to continue into the left main bronchus. A right
bronchial component is not clearly identified, nor is the
connection between the trachea and left bronchial components.
Lung volumes are generally low and pulmonary vasculature is
congested. Opacification at the base of the left lung could be
atelectasis or pneumonia. Heart size is top normal. Tip of the
left PIC catheter projects over the mid SVC. A left axillary
power pack may be the source of a filamentous lead heading
inferiorly, but the connection is not clear. Pleural effusion,
if any, is small, on the left. There is no pneumothorax.
CHEST (PORTABLE AP) [**2198-11-14**] 1:11 PM
FINDINGS: Comparison with study of [**11-12**], allowing for
differences in obliquity of the patient, there is little change.
The tracheal tube tip lies about 2.5 cm above the carina. No
evidence of focal pneumonia.
Brief Hospital Course:
Admitted on [**2198-11-6**] and underwent flexible and rigid
bronchoscopy, foreign body (silicone stent) removal, excision of
granulation tissue with electrocautery, 12x4 ultraflex stent
placement in left mainstem, 16x4 ultraflex stent in trachea, and
Portex #6 uncuffed tracheostomy tube placed. The patient
tolerated the procedure well with no complications. He returned
to TICU on humified trach mask. Antibiotics (gentamicin,
meropenem) were continued for pseudomonal pneumonal coverage. A
bronchoscopy was obtained by interventional pulmonology on
[**2198-11-8**], which revealed patient tracheal and left mainstem
stents. Neurology was consulted to evaluate and provide
management recommendations for the patient's seizure disorder.
He continued on phenytoin, topamax, clonazepam, and
phenobarbital, with drug levels monitored daily. For nutrition,
he was maintained on Probalance 65cc/hr x24 hr(1872 kcals, 84g
protein). Repeat bronchoscopy was done on [**2198-11-9**], found stent
in appropriate position and patent airways. In the evening of
[**2198-11-9**], the patient was found to have increased secretions and
became tachypneic, hypertensive, and tachycardic. Oxygen sats
dropped to 80%. Respiratory therapy attempted to bag ventilate,
yet had difficulty. The patient was transferred to the SICU
where he was bronched at the bedside. The uncuffed Portex #6
trach was changed to a Portex #6 cuffed tube. The patient was
placed on a propofol drip and ventilator, with improvement in
oxygen saturation. Fentanyl and lorazepam were administered for
breakthrough agitation, with good response. Repeat bronchoscopy
obtained on [**2198-11-10**] which revealed distal stent migration. It
was pulled back to the proximal trachea and redilated to 15-16mm
with a balloon. On [**2198-11-11**] the patient underwent a rigid and
flexible bronchoscopy with removal of the tracheal stent and
tracheostomy revision. A 7 cuffed [**Last Name (un) 295**] tracheal tube was
placed, with LMS stent in place. The patient tolerated the
procedure well. Multiple attempts were made to wean the patient
off the ventilator. On [**2198-11-14**] the patient was successfully
weaned to trach collar, which he has since tolerated. He
continued to do well over the weekend. His abdomen became
distended, the tube feeds were held, KUB obtained which showed
mild gastric diltation which resolved. His tube-feeds were
restarted [**11-18**] which he tolerated well. On discharge, the
patient will return to [**Hospital1 13820**] House on previously prescribed
seizure medications. There is no indication for antibiotics at
this time.
Medications on Admission:
Meds on transfer:
Phenobarbital 60 mg PO bid
Phenytoin 100 mg PO qam 125 mg PO qpm
Topiramate 225 mg PO QAM 250 MG PO qpm
Clonazepam 2 mg PO qam 3 mg PO qpm
Lorazepam 1 mg IV q 4hr prn agitation
2 mg IV q4hr prn seizure activity
Meropenem [**2191**] mg IV q8hr
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
2. Mupirocin Calcium 2 % Cream [**Year (4 digits) **]: One (1) Appl Topical TID (3
times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Year (4 digits) **]: [**1-23**]
Puffs Inhalation Q6H (every 6 hours).
4. Clonazepam 1 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO QAM (once a day
(in the morning)).
5. Clonazepam 1 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO QPM (once a
day (in the evening)).
6. Phenobarbital 30 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2
times a day).
7. Phenytoin 50 mg Tablet, Chewable [**Month/Day (2) **]: Two (2) Tablet,
Chewable PO QAM (once a day (in the morning)).
8. Phenytoin 50 mg Tablet, Chewable [**Month/Day (2) **]: 2.5 Tablet, Chewables
PO QPM (once a day (in the evening)).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Fentanyl Citrate 25-100 mcg IV Q4H:PRN
11. Lorazepam 1-2 mg IV Q2H:PRN
12. Dornase Alfa 1 mg/mL Solution [**Last Name (STitle) **]: 2.5 ML Inhalation daily
().
13. Topiramate 50 mg Tablet [**Last Name (STitle) **]: Five (5) Tablet PO at bedtime.
14. Topiramate 50 mg Tablet [**Last Name (STitle) **]: 4.5 Tablets PO QAM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 75260**] [**Hospital3 28900**] and Rehab
Discharge Diagnosis:
Tracheobronchomalacia with airway occlusion from granulation
tissue.
Diptheria Encephalitis, infantile spasms progressing to
refractory Seizure d/o
s/p Vagal Nerve Stimulator in [**2193**]
Tracheostomy/y-stent/g-tube in [**9-28**] @ [**Hospital1 1774**] c/b pseudomonal/MRSA
PNA
Discharge Condition:
Stable
Discharge Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10084**]
Precautions: Contact: (MRSA; ); Seizure
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10084**] as needed
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51052**] [**Telephone/Fax (1) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2198-11-19**]
ICD9 Codes: 5185
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5389
}
|
Medical Text: Admission Date: [**2184-9-12**] Discharge Date: [**2184-9-16**]
Date of Birth: [**2118-12-6**] Sex: F
Service: MEDICINE
Allergies:
Trazodone / Risperdal / Indocin / Flexeril / Gantrisin /
Coumadin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo F with h/o AF, diastolic HF, pulm HTN, chronic pain on
narcotics and other medical issues admitted through the ED
because of altered mental status and respiratory distress.
.
Per patient, she awoke this AM with urgency to have bowel
movement. Tried to stand and fell because she was weak. She
lying on her knees for some time (unclear total time). Pt hit
head on ground however did no LOC. Remembered whole event.
Called EMS who brought pt to [**Hospital1 **]-N. Was given 2mg of narcan for
unresponsiveness. Head/Neck CT was apparently completed and was
reported negative. She was then transferred to [**Hospital1 18**] for further
evaluation. Utox was negative
.
Of note, patient was reported had a similar event a few weeks
ago which was thought to be been caused by an accidental
overdose of oxycodone.
.
In [**Hospital1 18**] [**Name (NI) **], pt was evaluated however given AMS, pt was admitted
to ICU for further work-up. Prior to transfer, pt was given
ceftriaxone. In ICU, patient appeared lethargic but answered
questions appropriately.
Past Medical History:
Hypertension
Atrial fibrillation
Diastolic CHF
Interstitial lung disease secondary to asbestosis
COPD on chronic O2 on 2L NC
Seizure disorder
Obstructive sleep apnea
Rheumatoid arthritis
Osteoarthritis on heavy narcotic use chronically
Chronic low back and shoulder pain s/p laminectomy
Recurrent urinary tract infection
s/p left TKR in [**12-2**]
s/p laminectomy and periumbilical herniorrhaphy [**12-3**]
Social History:
The patient lives alone. She had just been discharged from
rehab. Has a distant smoking history of 40 to 50 pack years. No
alcohol use. Is retired. Limited function due to chronic pain
and disability.
Family History:
Non-Contributory
Physical Exam:
Admission physical exam:
General: Lethargic, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles with end expiratory wheezes
CV: Bradycardic, irregular rate
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema.
.
Discharge physical exam:
Vitals: Tm 99.0 BP 98-110/54-80 HR 65-83 RR 20 92-98% 3L
General: Alert, oriented x 3, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: Supple, no LAD
Lungs: Mild, diffuse wheeze but moving air
CV: Irregularly irregular rhythm
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
Ext: Warm, well perfused, 2+ radial/pedal pulses.
Neuro: Coarse tremor of left hand. Patient reports it is
longstanding.
Pertinent Results:
Admission labs:
[**2184-9-12**] 08:49AM BLOOD WBC-9.3 RBC-3.23* Hgb-9.7* Hct-27.6*
MCV-85 MCH-29.9 MCHC-35.1* RDW-14.4 Plt Ct-236
[**2184-9-12**] 08:49AM BLOOD PT-21.1* PTT-57.6* INR(PT)-1.9*
[**2184-9-12**] 08:49AM BLOOD Glucose-135* UreaN-28* Creat-0.7 Na-125*
K-3.1* Cl-84* HCO3-33* AnGap-11
[**2184-9-12**] 08:49AM BLOOD ALT-7 AST-19 LD(LDH)-196 CK(CPK)-55
AlkPhos-87 TotBili-0.4
[**2184-9-12**] 08:49AM BLOOD Albumin-3.7 Calcium-8.6 Phos-2.8 Mg-2.4
[**2184-9-12**] 06:01AM BLOOD Lactate-1.1
[**2184-9-12**] 05:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2184-9-12**] 05:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
CT head
FINDINGS: No hemorrhage, large territorial infarction, edema,
mass, or shift of normally midline structures is present. There
is evidence of mild sequelae of chronic small vessel ischemic
disease in bihemispheric subcortical and periventricular white
matter. The ventricles and sulci are appropriate size and
configuration for age. The basal cisterns are widely patent. The
visualized paranasal sinuses are well aerated. No fractures or
soft tissue hematomas.
IMPRESSION: No acute intracranial process.
.
EKG: [**2184-9-12**] Atrial fibrillation with controlled ventricular
response. Q-T interval prolongtion. ST-T wave abnormalities.
Since the previous tracing of [**2184-8-23**] the rate is slower and
aberrantly conducted beats are no longer seen.
.
[**2184-9-14**] CXR:
Pulmonary vascular congestion and dilated mediastinal veins are
unchanged since [**9-12**], but severe cardiomegaly has improved
and mild pulmonary edema persists. The heterogeneity of
opacification in the lungs could obscure discrete pulmonary
nodules. It is strongly recommended that conventional
radiographs be obtained to make sure that what appear to be
discrete opacities are instead asymmetric edema rather than
nodules.
.
[**2184-9-16**] CXR:
Vascular congestion has almost completely resolved. Cardiomegaly
is stable. There are no large lung nodules. Opacity in the left
mid lung is consistent with fluid in the fissure. There are
moderate degenerative changes in the thoracic spine.
Of note, the interpretation of this radiograph is limited due to
technique and apical lordotic view in the frontal radiograph.
.
Discharge labs:
[**2184-9-16**] 05:57AM BLOOD WBC-8.6 RBC-3.05* Hgb-9.2* Hct-26.9*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.5 Plt Ct-178
[**2184-9-16**] 05:57AM BLOOD Glucose-147* UreaN-20 Creat-0.8 Na-132*
K-4.4 Cl-91* HCO3-34* AnGap-11
Brief Hospital Course:
The patient is a 65-year-old woman with a history of atrial
fibrillation, diastolic dysfunction, found down at home and
transferred to [**Hospital1 18**] with hyponatremia and altered, both of
which quickly resolved in the MICU. The patient has been
transferred to Medicine for likely placement in rehabilitation
given her failure after just a few hours at home.
.
# Altered mental status: The patient's mental status appears to
have cleared by the time of her transfer to Medicine from the
MICU. The original differential diagnosis included
medication-related v. head trauma v. hyponatremia (and
dehydration with diarrhea) v. infection. Head trauma ruled out
by CT. No sign of infection on imaging and labs. Hyponatremia
cleared fairly quickly with normal saline. The patient may also
have used too much of her dual nodal agents, which led to
bradycardia and poor perfusion. The patient's clonazepam was
also stopped. Medication and low sodium, possibly together, the
lead suspects for her altered mental status. The patient's
mental status has been appropriate during her entire Medicine
stay.
.
# Atrial fibrillation: The patient originally had bradycardia,
which may have been related to incorrect medication use of her
dual nodal agents. The bradycardia resolved in the MICU. On the
medicine floor, she instead became tachycardic. The patient had
an episodes of poor rate control, for which she received IV
metoprolol and diltiazem. The patient also had two episodes of
symptomatic atrial fibrillation (shortness of breath), during
which she had adequate blood pressure to uptitrate her nodal
blockers. Control of her rate finally occurred with metoprolol
50mg TID and diltiazem 90mg QID. The patient was kept on
dabigatran for stroke prevention.
.
# Leukocytosis: The patient's white blood cell count jumped to
11.6. She was not febrile, but she did sound more rhonchorous on
physical exam on [**2184-9-14**]. The patient's white count resolved on
Wednesday, [**9-15**]. No more rhonchi by [**2184-9-16**]. Urine
culture not suggestive of infection. X-ray not suggestive of
consolidation. By discharge, leukocytosis had resolved.
.
# Possible lung nodules: The radiologist [**Location (un) 1131**] the patient's
chest X-ray, Dr. [**Last Name (STitle) **], was concerned for possible lung nodules.
Given her vascular congestion, however, possible nodules cannot
be seen. Diuresis with furosemide was continued. The patient
should have follow up X-ray to examine for nodules, although a
final X-ray did not show any nodules.
.
# Respiratory status/COPD: The patient has a home O2
requirement. The patient reports chronic cough, likely secondary
to COPD. No fevers but a leukocytosis developed. Her
respiratory status may also be a result of symptomatic atrial
fibrillation or pulmonary edema, given chext X-ray with vascular
congestion.
The patient was saturating well on nasal cannula at 2L by the
end of the hospitalization.
.
# Hyponatremia: Likely related to hypovolemia, especially as
hyponatremia resolved after patient received total of 4L NS.
Patient has returned to slightly below normal baseline.
.
# Coronary artery disease: Continue aspirin. Simvastatin does
reduced to 10mg, based on FDA guidelines for patients who are
simultaneously on diltiazem.
.
# Acute-on-chronic diastolic CHF: Continued aspirin, furosemide,
lisinopril. The patient received one dose of IV furosemide
because of vascular congestion seen on exam. By discharge, final
X-ray showed clearance of vascular congestion.
.
# Depression: Continued aripripazole and venlafaxine. Clonazepam
was held, given recent AMS, and patient showed no evidence of
withdrawal from benzodiazepine.
.
.
TRANSITIONS OF CARE:
- The patient will need a follow-up X-ray to determine if she
does have lung nodules.
- The patient's physician should determine if she needs
clonazepam. This medication was stopped in the hospital and not
restarted.
Medications on Admission:
1. aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
3. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
5. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
8. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO once a day.
9. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.
10. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a
day.
11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inh* Refills:*2*
12. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
13. furosemide 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three
times a day.
15. methocarbamol 750 mg Tablet Sig: One (1) Tablet PO three
times a day.
16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day.
17. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 1 weeks.
Disp:*1 60 gram tube* Refills:*1*
18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash for 2 weeks.
Disp:*1 tube* Refills:*0*
19. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
20. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
21. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO twice a day.
22. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO twice a day
Discharge Medications:
1. aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhalation Inhalation once a day.
5. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO once a day.
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a
day.
11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day.
13. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
14. lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. dabigatran etexilate 75 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day).
16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: [**11-30**] Tablet, Chewables PO QID (4 times a day) as needed for
indigestion.
17. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Village - [**Location 4288**]
Discharge Diagnosis:
Altered mental status
Hyponatremia
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 6330**],
It was a pleasure participating in your care at [**Hospital1 771**].
.
You were admitted to the hospital because you had fallen and
were not responsive. You briefly spent time in the Intensive
Care Unit, where you were found to have low sodium, which was
quickly fixed. Your confusion also cleared. On the medicine
floor, your heart rhythm, which is called atrial fibrillation,
was not controlled. We changed your medications to control that
rate and to prevent you from having symptoms, such as feeling
tired or short of breath. You will go to a rehabilitation
facility to strengthen you before you return back home. They can
also montior your medication, to make sure you do not take too
many medications that can make you sleepy or confused.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
We changed the doasges of these medications to help control your
heart rate:
START metoprolol 50mg three times per day.
START diltiazem ER 360mg daily.
.
We changed the dosage of your cholesterol medication because it
can interact badly with the diltiazem:
START simvastatin 10mg daily.
.
We stopped your clonazepam because you arrived to the hospital
confused, and this medication can add to confusion.
STOP clonazepam.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2184-10-5**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], 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: 2761, 311, 4280, 496, 4168
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5390
}
|
Medical Text: Admission Date: [**2146-3-3**] Discharge Date: [**2146-3-14**]
Date of Birth: [**2104-5-9**] Sex: M
Service: UROLOGY
CHIEF COMPLAINT: Electrolyte abnormalities and change in
mental status.
HISTORY OF PRESENT ILLNESS: A 41-year-old male, with a
history of renal cell cancer diagnosed in [**2145-11-1**], who
presented with seizure and found to have METS to the brain.
The patient had resection of the brain METS with residual
left hemiparesis. He is status post stereotactic
radiosurgery on [**2145-12-15**] which was complicated by PTH
RP causing hypercalcemia, SIADH, and anxiety with recent
admission to [**Hospital1 18**] on [**2146-2-3**] with mental status
changes and hypercalcemia. The patient now presented to the
clinic with electrolyte abnormalities. On recent admission,
the patient's hypercalcemia was treated with hydration,
calcitonin and 90 mg of pamidronate on [**2146-2-18**] with
good effect. The patient has a history of hypocalcemia after
receiving Zometa in the past, and his electrolytes were
carefully monitored. The patient was started on Tums when
the patient's calcium fell below 9.
Since discharge, on [**2146-2-25**], the patient's labs had
been checked daily, and the patient has been on lasix prn and
Neutra-Phos, salt tablets, and Tums as needed. Starting
[**2-28**], calcium was elevated, and the patient was told to
restart calcitonin. Subcu injections were [**Last Name (LF) 16535**], [**First Name3 (LF) **]
the patient was taking nasal spray. Despite taking the
calcitonin, the patient's calcium continued to increase, and
was elevated to 11.7 with albumin of 2.2, with corrected
calcium of approximately 13.2.
The patient's girlfriend reported that for the past one to
two days, the patient had had increasing lack of response to
questions, and decreased strength on the left side,
decreasing appetite, and increasing lethargy. The patient
has no history of falls, and has normal bowel movements. The
patient has been complaining of some left-sided abdominal
pain with positive low-grade fevers since discharge to
approximately 99??????. The patient's girlfriend was concerned
and called Dr. [**Last Name (STitle) 1860**] who arranged for inpatient admission.
PAST MEDICAL HISTORY:
1. Renal cell carcinoma diagnosed in [**2145-11-1**] with brain
METS, status post right frontal craniotomy in [**2145-11-1**],
SRS in [**2145-12-2**], which initially presented with seizures
and brain METS were found.
2. Hyponatremia.
3. SIADH.
4. Hypercalcemia.
5. PTH RP from RCC.
6. History of multiple UTIs and anxiety.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Sodium chloride 2 gm po tid.
2. Levetiracetam 1 gm po bid.
3. Protonix 40 mg po qd.
4. Nortriptyline 100 mg po hs.
5. Epogen 40,000 U subcu q Tuesday.
6. Dexamethasone 0.5 mg po qod for 7 days--last dose on [**2146-3-3**].
7. Calcitonin 200 U nasal spray qd.
8. Clonazepam 0.5 mg po q hs.
9. Colace 100 mg po bid prn.
10.Senna 1 tab po bid prn.
11.Bisacodyl 10 mg po qd prn.
12.Tylenol prn.
13.Insulin subcu--the patient has not needed it for the past
5 days.
SOCIAL HISTORY: The patient lives with his girlfriend and
works as a paralegal. The patient denies alcohol, tobacco,
or IV drug use.
FAMILY HISTORY: No family history of renal cell cancer.
PHYSICAL EXAM: Temperature 98.2, blood pressure 105/64,
heart rate 108, respiration rate 16, satting 97% on room air.
The patient was generally a pleasant gentleman appearing his
stated age, in no apparent distress, and slow to respond to
questions. The patient's sclerae were anicteric, and mucous
membranes were dry. Examination of the heart showed that the
patient was tachycardic with regular rhythm. S1 and S2 were
heard with no murmurs. The patient had decreasing breath
sounds and crackles in bilateral bases. Examination of the
back showed no CVA tenderness. No lumbar spinal tenderness.
The patient's abdomen was soft with positive bowel sounds.
No HSM. Mild left-sided tenderness. Mild left-sided rib
tenderness. Examination of the extremities revealed that the
patient had no edema and good pulses.
Neuro exam revealed that the patient was oriented x 3.
Increasing lack of response to questions. The patient
followed commands. Pupils equal, round and reactive to
light. Extraocular movements were intact. Smile was
decreased on the left side. Tongue was midline. Strength:
In upper extremities finger grip was [**4-6**] on the right, [**3-7**] on
the left, [**3-7**] shoulder shrug on the left. Left lower
extremity - hip flexor [**3-7**], right was [**3-7**], and [**4-6**] right
dorsi plantar flexion and toe extension, and [**3-7**] left dorsi
plantar flexion and toe extension.
LABS: Sodium 121, calcium 11.7, albumin 2.2.
HOSPITAL COURSE: The patient was admitted to the medicine
service with change in mental status most likely due to
hypercalcemia and possible hyponatremia. The patient's
mental status was watched by correcting the electrolyte
abnormalities. The patient also was scheduled for
nephrectomy. The patient's anemia was secondary most likely
to chronic disease and renal cell cancer. The patient was
continued on Epogen. Neuro exam showed residual left
hemiparesis from resection. The patient has steroid induced
diabetes and was continued on fingersticks. The patient was
put on a diabetic diet with IV fluids, and was continued to
be monitored.
On hospital day #2, the patient was put on 3% saline for
hyponatremia which the patient tolerated without any
difficulty. The patient continued to complain of some dry
throat. He was afebrile with stable blood pressure. Heart
rates ran from 99-108, and taking in 260 cc PO and made 500
cc in urine. The patient was continued to be monitored. He
was on fluid restriction of 1,500 cc/D. On hospital day #2,
both endocrine and renal services followed the patient,
managing electrolyte abnormalities.
On hospital #3, the patient had a right IJ placed without any
complications. The patient remained afebrile, but continued
to be tachy at 109, otherwise doing well. The patient's
sodium improved to 128 on treatment, and the patient was
otherwise stable. The steroid was stopped, and the patient
was put on a house diet. Also, the insulin was stopped.
On hospital day #4, the patient received 1 unit of blood for
a hematocrit of 25.4, and the patient's post-transfusion
hematocrit was 28.1. The patient did not sleep well the
prior night and was more lethargic. He remained afebrile
with stable vitals except for a heart rate at 113. The
patient's abdomen was somewhat distended but nontender. The
patient was preopped for the OR and was taken to the OR and
underwent a left nephrectomy for left renal mass. The
patient was then admitted to Neuro SICU for management. The
patient was intubated overnight and was continued on Ancef
for antibiotic. Labs were checked to monitor the
electrolytes.
On postop day #1, the patient was continued on seizure meds
and propofol was weaned to extubate the patient. The
patient's hemodynamics were stable, but still looked dry.
The patient's was weaned and extubated. Chest tube was
removed. The patient continued to be NPO with NG tube which
was removed. The patient had decreased urine output
overnight. The patient's IV fluid was changed to D5 1/2NS.
The patient remained afebrile, and Ancef was stopped.
On postop day #2, the patient had no complaints of pain. He
had a soft, nontender abdomen with no erythema around the
incision. The patient was continued on dilaudid for pain
management. Hemodynamically, the patient was stable. He was
started on sips. The patient was continued on Epogen. The
patient's A-line was removed, and the Foley was continued.
On postop day #3, the patient remained afebrile with stable
vital signs. The patient was advanced to clear liquids and
continued on TPN. The patient's labs were checked, and
sodium remained stable at 125 and calcium at 7.7.
On postop day #3, the patient was seen by neuro oncology who
recommended obtaining an MRI in [**2146-6-2**], and continue
current management. On postop day #4, the patient remained
afebrile with stable vital signs. The patient removed his
central line overnight which was replaced. The patient was
continued on sodium tablets for treatment of hyponatremia.
On postop day #5, the patient was changed to PO pain meds.
The patient was put on fluid restriction and continued sodium
tablets for SIADH.
On postop day #6, the patient had emesis overnight, but the
nausea had improved with Zofran. The patient had no
appetite. The patient remained afebrile with tachys to 119,
otherwise with stable vital signs. The patient was put on IV
fluids and continued on sodium tablets. Magnesium was
repleted. On postop day #7, the patient had no complaints of
nausea, vomiting, fever, chills. The patient stated that he
had had flatus. He remained afebrile with heart rate still
at 104 with the rest of the vitals remaining stable. The
patient was alert and interactive. Abdomen was soft,
nontender, nondistended. The wound had no erythema. The
patient's sodium was stable at 129. Free calcium was stable
at 119. Otherwise, the patient was doing well.
The patient was seen by physical therapy and walked with
assistance. The patient was tolerating diet without any
difficulty, had had flatus, and was not nauseous or vomiting
after taking the regular diet. The patient was thus
discharged.
DISCHARGE STATUS: Good.
DISCHARGE DIAGNOSES:
1. Status post left nephrectomy.
2. Papillary renal cell cancer,
3. Metastatic renal cell cancer to brain, status post
craniotomy.
4. Diabetes induced by steroid therapy.
5. Syndrome of inappropriate antidiuretic hormone.
6. Hyponatremia.
DISCHARGE MEDICATIONS:
1. Epogen 10,000 U subcu 3 x week, Monday, Wednesday,
Friday.
2. Nortriptyline 100 mg po q hs.
3. Clonazepam 0.5 mg po q hs.
4. Bisacodyl 10 mg po qd prn.
5. Levetiracetam 750 mg po bid.
6. Percocet 1-2 tabs q 4-6 h prn pain.
7. Protonix 40 mg po qd.
8. Sodium chloride 1 gm po tid.
9. Tylenol 325 mg po 1-2 tabs prn pain.
10.
FOLLOW-UP:
1. Please follow-up with Dr. [**Last Name (STitle) 4229**] in [**1-4**] weeks; please call
for follow-up appointment.
2. Please follow-up with Dr. [**Last Name (STitle) 1860**], nephrologist, in [**1-4**] weeks
at [**Hospital 2793**] Clinic; please call for follow-up appointment.
3. Please follow-up with Dr. [**First Name (STitle) **], endocrinologist, as needed
per recommendation by renal service.
DISCHARGE INSTRUCTIONS: Please have labs checked three times
a week. Please have chem-10 and ionized calcium checked.
Please have these results faxed to Dr. [**Last Name (STitle) 1860**] at ([**Telephone/Fax (1) 16536**].
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2146-3-14**] 12:46
T: [**2146-3-14**] 14:25
JOB#: [**Job Number 16537**]
ICD9 Codes: 2765
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5391
}
|
Medical Text: Admission Date: [**2190-3-9**] Discharge Date: [**2190-3-15**]
Date of Birth: [**2148-2-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
found down unresponsive
Major Surgical or Invasive Procedure:
intubated for airway protection
History of Present Illness:
HPI: 40 y/o man found unresponsive in his bed by unknown party.
EMS was called and on arrival, pt was opening eyes to pain, had
a RR of 8 and sating 99% on RA. An oral airway was placed. Per
EMS report, many empty alcohol bottles were found in his room.
On exam, pupils were miotic, pt opened eyes to pain, but was not
moving his extremities. There were no signs of trauma.
.
Pt presented to the ED with VS: 97.4 110 110/80 9 100% RA
.
In the [**Name (NI) **], pt received Narcan for pinpoint pupils without
significant relief. He was intubated for airway protection.
Tox screen was positive for an alcohol level of 374, otherwise
negative and CK of 222. Lactate was initially 3.7 trending down
to 2.3 with 1L NS. Anion gap of 19. ABG s/p intubation was
7.33/47/308/26. Amylase was 17 and INR 1.0. UA showed trace
ketones. Head CT and CXR were unremarkable.
.
Past Medical History:
unknown
Social History:
unknown
Family History:
unknown
Physical Exam:
AFSS
GEN: overweight, nad
HEENT: PERRLA, eomi, anicteric
CV: regular, nl s1, s2, no m/r/g.
PULM: CTAB anteriorly, no w/r
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL
NEURO: grossly intact
PSYCH: flat
Pertinent Results:
WBC 4.1, Hgb 15.0, Hct 43.6, Plts 208
PT: 12.2 PTT: 24.5 INR: 1.0
Fibrinogen: 260
.
ETOH level 374, serum tox otherwise negative
Urine tox negative opiates, benzos, [**Last Name (LF) **], [**First Name3 (LF) **], benzos,
cocaine & methadone
.
Na:145 K:3.9 Cl:102 TCO2:24 BUN:13 Creat:1.0 Glu:139
Lactate:3.7, repeat Lactate 2.3
Amylase 17, CKs 222
.
UA + trace ketones
.
STUDIES:
[**2190-3-9**] AP SUPINE CHEST X-RAY: An endotracheal tube with its tip
at the orifice of the right main stem bronchus is noted. A
nasogastric tube is positioned with its sidehole in the mid
esophagus and its tip in the mid esophagus. Low lung volumes are
noted. The cardiomediastinal silhouette is unremarkable. There
is no pneumothorax.
IMPRESSION:
1. Endotracheal tube too low, with the tip at the orifice of
the right main stem bronchus.
2. Nasogastric tube with its side port in the upper esophagus
and its tip in the lower esophagus.
.
[**2190-3-9**] Non Contrast Head CT:
FINDINGS: There is no acute intracranial hemorrhage, shift of
normally midline structures, hydrocephalus, major or minor
vascular territorial infarction. The density values of the
brain parenchyma appear maintained. There is moderate mucosal
thickening within the left maxillary sinuses with small air
bubbles noted. Mild mucosal thickening is also noted within the
anterior ethmoid sinuses. The remainder of the visualized of
the paranasal sinuses and mastoid air cells appear well aerated.
The soft tissues and osseous structures are unremarkable.
IMPRESSION: No acute intracranial hemorrhage. Left maxillary
sinus disease, likely chronic.
.
EKG: Sinus tachy at 118 with no acute ST changes.
CXR Pa/lat [**2190-3-11**]:
Ill-defined right upper lobe opacity is persistent projecting
between the second and third anterior right ribs. Given the
provided clinical history, is suggestive of aspiration; followup
is recommended. The cardiomediastinal silhouette is normal.
There is no pleural effusion.
IMPRESSION: Persistent right upper lobe opacity. Given clinical
history is suggestive of aspiration. Followup is recommended
[**2190-3-15**] 07:00AM BLOOD WBC-6.8 RBC-4.28* Hgb-13.7* Hct-39.9*
MCV-93 MCH-31.9 MCHC-34.3 RDW-13.6 Plt Ct-280
[**2190-3-14**] 06:30AM BLOOD PT-12.0 PTT-26.3 INR(PT)-1.0
[**2190-3-15**] 07:00AM BLOOD Glucose-134* UreaN-10 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-26 AnGap-12
[**2190-3-14**] 06:30AM BLOOD ALT-74* AST-124*
[**2190-3-15**] 07:00AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.1
[**2190-3-15**] 07:00AM BLOOD CRP-6.0*
[**2190-3-12**] 03:27PM BLOOD Lactate-1.9
[**2190-3-15**] 07:00AM BLOOD ESR-60*
Brief Hospital Course:
42 y/o M found down unresponsive with elevated ETOH level,
elevated serum lactate and an anion gap of 19 with ketonuria.
.
# MS change: Secondary to Seroquel overdose (purposeful) and
alcohol intoxication. Briefly intubated and ventilated for
airway protection. Transferred to medical service for clearance
prior to psychiatric discharge. No signs/symptoms of seratonin
syndrome. At apparent baseline mental status at discharge.
# aspiration pneumonia -- seen on chest x-ray and consistent
clinical history with overdose and being found comatose,
subsequent fever and cough. Treatment with 14 days oral
augmentin. He should have repeat CXR in 3 months to assure
radiologic resolution.
# bilateral antecubital fossae cellulitis, in sites of
peripheral IV placement -- improved on Augmentin. Has two days
of vancomycin, but has no history of MRSA, so it was
discontinued. He continued to improve without vanco. Blood
cultures were no growth to date on discharge.
# alcoholic hepatitis: stable throughout stay, should be
followed up as outpatient. Advised to abstain from alcohol and
enter alcohol rehab.
# depression/anxiety/suicidal ideation/overdose: discharge to
inpatient psychiatry. The psychiatric service followed
throughout his inpatient stay.
Medications on Admission:
unknown
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 5 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. suicidal ideation/Seroquel overdose
2. alcohol intoxication/withdrawal
3. bilateral arm cellulitis
4. aspiration pneumonia
5. depression
Discharge Condition:
stable
Discharge Instructions:
You were hospitalized after an overdose of seroquel. You are
being discharged to an inpatient psychiatric facility. You were
diagnosed with aspiration pneumonia and bilateral arm cellulitis
during your stay. Please return to the emergency department if
you have shortness of breath, increased cough or sputum
production, fever greater than 101, or increased arm
redness/drainage.
Followup Instructions:
Please arrange appointments with your primary care provider and
psychiatrist on discharge from the psychiatric facility.
ICD9 Codes: 5070, 2720, 311
|
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}
|
Medical Text: Admission Date: [**2162-7-7**] Discharge Date: [**2162-7-13**]
Date of Birth: [**2162-7-7**] Sex: M
Service: Neonatology
HISTORY: [**Doctor Last Name **] is a 36-1/7 week gestational infant born to
a 22-year-old G3P1 mother. Serologies: A+, antibody negative,
GBS positive, Hepatitis B surface antigen negative, RPR
nonreactive. She was admitted in labor at 36 weeks gestation
and had rupture of membranes for five hours prior to
delivery. She received anti-partum antibiotics for 9 hours
prior to delivery and had a rapid second stage of labor and
delivered the infant after 30 seconds of pushing. Apgar
scores were good with an 8 and 9.
The infant quickly developed grunting, flaring and retraction
in the delivery room and the Newborn Intensive care unit was
called to evaluate the infant at 10 minutes of age. The
infant was then transferred to the newborn intensive care
unit for further evaluation. Birthweight was 2595 grams, and
gestational age appeared to be 36-1/2 weeks gestation.
PHYSICAL EXAMINATION: The infant was noted to be in moderate
respiratory distress requiring oxygen to maintain saturations
greater than 90%, normal facies, soft anterior fontanel,
intact palate, moderate retraction and grunting and flaring,
decreased air entry throughout without a murmur, normal
femoral pulses, normal flat, soft abdomen without
hepatosplenomegaly. Normal male genitalia. Stable hips,
normal perfusion and normal tone and activity. At that time
the patient was admitted to the Newborn intensive care unit.
HOSPITAL COURSE:
Respiratory: The patient developed immediate respiratory
distress and required oxygen up to 40% He was placed on a
CPAP of 6 cm of water for which he continued with respiratory
distress. Because the infant did not improve with nasal CPAP
he was intubated with a 3.5 ET tube at 8 cm and Surfactant was
administered. The infant then quickly weaned on his oxygen
an was extubated after 2 hours after surfactin delivery. The
infant then weaned to room air by day of life two,
intermittently requiring oxygen and completely off by the day
of life three. The infant continued to have intermittent
tachypnea throughout his hospitalization which has improved
over the past several days. However, there has been no
distress noted and his oxygen saturation has been excellent
in room air. We feel this is resolution of his hyaline
membrane disease and the intermittent tachypnea will resolve
with time. At discharge his RR for the past 12 hours was 35 to
78.
He did not demonstrate any apnea or bradycardia of
prematurity.
Cardiovascular: There have been no cardiovascular issues, he
has had normal blood pressures and no murmurs noted
throughout his hospitalization.
Fluids, Electrolytes and Nutrition: The infant was initially
made NPO on D10-W at 60 cc's per kilo per day. He has had a
good diuresis over the past several days an was started on
p.o. feeds on day of life two. He both bottle and breast fed
very well. Mother's milk production is excellent and he has
been doing well. His current weight is 2475 gms (his
birthweight was 2595 gms) and he is eating very well.
Electrolytes done on day of life two were completely normal.
Gastrointestinal: The infant had hyperbilirubinemia. On day
of life 5 it was noted to be 16.6. A Bili blanket was placed
overnight and in the morning a follow-up bilirubin was 16.5.
At that time we elected to place him on full phototherapy
throughout the day on day of life six. On day of life 7, day
of discharge, his bilirubin was 11.8/0.3. Mom's blood type
is A+ and the baby's blood type is AB+, coombs negative.
Close follow-up is recommended to monitor [**Doctor Last Name 9231**] resolution
of his hyperbilirubinemia.
Hematology. The infant's hematocrit on admission was 42.4.
He has not had to give any transfusions or a follow-up of
hematocrit.
Infectious Disease: The infant underwent a sepsis evaluation
upon admission. The wbc count was 9.2 (33 neutrophils, 0
bands). A blood culture was negative. [**Doctor Last Name **] received 48
hours of ampicillin and gentamicin. There were no other
infectious concerns throughout his stay.
Neurology. The patient has had a normal neurologic
examination and has been acting appropriately. There have
been no head imaging studies and he has not required sedation.
Sensory. Hearing test was performed with automated auditory
brainstem responses and the infant passed bilaterally.
Ophthalmologic examination was not indicated.
Psychosocial: Social work was involved with the family. The
contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To home. The name of the primary care provider
is [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 43361**], RN, CPNP at [**Hospital3 1810**] Primary
Care Center. (P) [**Telephone/Fax (1) 38541**]. (F) [**Telephone/Fax (1) 58065**].
Mother has made an appointment for the day of discharge.
CARE AND RECOMMENDATIONS:
1. The infant is discharged to home with ad lib breast
feeding or bottle feeding pumped to breast milk.
2. There are no medications.
3. The infant failed the car seat screening test and was
discharge hone in a car bed.
4. The infant had a newborn State Screening done and status
is pending.
5. The first dose of Hepatitis B vaccination series was given.
DISCHARGE DIAGNOSIS:
1. Prematurity at 36 weeks gestation.
2. Hyaline membrane disease, status post surfactant delivery.
3. Rule out sepsis.
4. Hyperbilirubinemia.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], MD [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 57691**]
MEDQUIST36
D: [**2162-7-13**] 12:52:38
T: [**2162-7-13**] 14:16:49
Job#: [**Job Number **]
ICD9 Codes: 769, 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5393
}
|
Medical Text: Admission Date: [**2113-9-5**] Discharge Date: [**2113-9-19**]
Date of Birth: [**2055-7-18**] Sex: F
Service: MEDICINE
Allergies:
Cefepime / Aztreonam
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
R thigh muscle biopsy
R forearm skin biopsy
Tracheostomy tube placement
History of Present Illness:
58-year-old female with CAD s/p CABG, accelerated phase CML s/p
allo SCT [**2112-4-6**] complicated by upper and lower GI GVHD [**2112-4-25**]
and liver GVHD [**8-/2112**] presenting from OSH electively intubated
for hypoxic and hypercarbic failure in the setting of worsening
respiratory status. She was recently on prednisone 8mg daily and
developed sore throat and cough 09/[**2112**]. Steroid dose was
increased to 20mg with quick taper and she was started on
levofloxacin. Despite the levofloxacin and continuation of
atovaquone for PCP prophylaxis, she had increasing dyspnea and
presented to [**Hospital 1727**] Medical Center on [**2113-8-29**].
.
Initially, concern was for cardiac cause for her dyspnea (she
has a history of CABG in [**2105**]). TTE showed normal EF. She
underwent cardiac catheterization that showed clean coronaries.
She desatted to 80s and was transferred to OSH ICU for bipap,
which was not helpful. CXR showed RLL consolidation and she was
started on vancomycin/zosyn/azithromycin ([**2113-9-5**] is day 5).
She has not had fevers or leukocytosis.
.
Additionally, she was found to have b/l LE DVTs (found when
accessing during cardiac cath). CT was negative for PE. She was
initially on heparin gtt but developed thrombocytopenia with
plts dropping from >100k on admission to 58k. IVC filter was
placed; she was started on bivalrudin and transitioned to
fondaparinux prior to transfer. HIT antibody returned negative.
.
Throughout her hospital course, she was becoming progressively
weaker. She had been ambulating independently on admission and
progressed to not being able to lift her legs with elevated CK
(790's on [**9-4**]), ESR, CRP. She then dessated to 70s on high
flow NC yesterday and was slow to recover her sats. Given her
hypoxia and overall progressive weakness, she was electively
intubated for concern for respiratory fatigue after discussion
with oncology here ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Dr [**Last Name (STitle) 6944**]. Bronchoscopy was
performed after pt was intubated and revealed thick mucoid
secretions. Cultures sent. On transfer, vent settings were peep
5, fiO2 40%, TV 400.
.
CXR was not revealing for cause of acute respiratory failure,
though she does have retrocardiac consolidation on CXR from
[**9-4**], potentially related to atelectasis. She had low IgG and
received IVIG on [**9-2**]. Prednisone had initially been continued
at 20mg, but then uptitrated to prednisone 60mg (and converted
to solumedrol 40mg IV BID) after d/w heme-onc here for concern
of GVHD. In addition her cyclosporine was held as well. She has
been hemodynamically stable, though UOP noted to be dropping to
20cc/hr on ambulance ride over.
.
On the floor, she has no specific complaints. Denies CP.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, Denies shortness of breath. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting. + diarrhea. Denies abdominal pain. Denies
arthralgias or myalgias.
Past Medical History:
ONCOLOGIC HISTORY:
- [**2102**]: Asymptomatic abnormal CBC noted by PCP during routine
visit
- [**2103-9-10**]: Bone marrow biopsy showed myeloproliferative
disorder, likely chronic myelogenous leukemia. Per patient
report, began taking interferon three times weekly shortly
after diagnosis.
- [**9-/2105**]: Started Gleevec 400 mg daily. At some point
thereafter, her dose was increased to 600 mg daily
- [**12/2107**]: Gleevec increased to 400 mg twice daily with
hydroxyurea and allopurinol
- [**2108-1-24**]: Seen at [**Hospital6 8865**], found to be
in late chronic phase CML. Stem cell transplant was
recommended, but she did not wish to pursue this course.
- [**9-/2111**]: Gleevec held due to worsening anemia and
thrombocytosis. Started on Nilotinib
- [**10/2111**]: Nilotinib held due to QTC prolongation, started on
Dasatinib
- [**2112-2-5**]: First seen at [**Hospital1 18**]. Bone marrow biopsy showed
accelerated phase CML. began induction chemo with 7+3.
- [**2112-3-29**]: Admission for MRD SCT
- [**2112-5-8**]: Discharged on day +32. Transplant complicated by
mucositis with biopsy of the esophagus suggesting upper GI GVHD
which was treated with steroids.
- [**2112-6-9**] colonoscopy showing lower GI GVHD
- [**2112-9-4**] readmitted with recurrent aGVHD of the liver upper
and
lower GI tract in the setting of reducing immunosuppression
.
PMHx:
- atherosclerotic coronary vascular disease
- status post CABG in [**2104**]
- hypertension
- hyperlipidemia
- Right ankle surgery in [**2099**]
- Total abdominal hysterectomy in [**2098**]
- Appendectomy at age 13
Social History:
- Married, lives in [**Location **], [**State 1727**], with her husband; originally
from Germancy and moved here in [**2077**]
- Used to work as an administrator
- Tobacco: quit [**2098**], previously smoked for 8 years 10 cigs/day
- ETOH: denies
Family History:
- father - died of MI, nil other health problems
- mother - had heart problems, DM
Four siblings
- 2 bothers had CABG
- 1 brother prostate cancer
- Her sister [**Name (NI) **] [**Name (NI) **] is her donor and is well
Physical Exam:
Admission Physical Exam:
General: Alert and answering questions yes/no with head nods,
intubated, no acute distress
HEENT: ET tube present, unable to assess OP
Neck: supple, JVP not elevated, no LAD
Lungs: CTA b/l in anterior fields
CV: Regular rate and rhythm, normal S1 + S2
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
Skin: R PICC in place, L dorsal forearm with scabbed areas over
elbow that are purplish hue
Neuro: [**1-21**] muscle strength in LE b/l, 4+/5 muscle strength in UE
b/l
.
DISCHARGE EXAM:
HR 92 BP 165/85 O2 100% temp 98.3
vent settings: CPAP/PSV PEEP 5
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: cta b/l
CV:regular rate and rhythm, frequent early beats, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place, good UOP
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, able to lift arms to 90 degree angle, unable to lift legs
off chair but hip extensors [**2-21**] and deltoids [**2-21**] (improved)
SKIN: bilateral hands bandaged per derm, right thigh biopsy site
with surrounding ecchymosis but no hematoma, no errythema or
warmth
Pertinent Results:
Admission Labs:
[**2113-9-5**] 01:17PM BLOOD WBC-6.8 RBC-2.54*# Hgb-8.2*# Hct-23.6*#
MCV-93 MCH-32.4* MCHC-34.9 RDW-14.9 Plt Ct-66*#
[**2113-9-5**] 01:17PM BLOOD Neuts-90* Bands-2 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-1* Promyel-1*
[**2113-9-5**] 01:17PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Stipple-OCCASIONAL
[**2113-9-5**] 01:17PM BLOOD PT-12.1 PTT-29.1 INR(PT)-1.0
[**2113-9-5**] 01:17PM BLOOD Gran Ct-6499
[**2113-9-6**] 03:54AM BLOOD Ret Aut-1.5
[**2113-9-5**] 01:17PM BLOOD ALT-102* AST-126* LD(LDH)-474*
CK(CPK)-276* AlkPhos-225* TotBili-0.8
[**2113-9-5**] 01:17PM BLOOD Albumin-2.6* Calcium-8.9 Phos-2.9# Mg-1.9
[**2113-9-6**] 03:54AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.0 Iron-160
[**2113-9-6**] 03:54AM BLOOD calTIBC-170* VitB12-818 Folate-6.5
Hapto-121 Ferritn-PND TRF-131*
[**2113-9-5**] 01:17PM BLOOD TSH-0.88
[**2113-9-5**] 04:52PM BLOOD Type-ART pO2-165* pCO2-37 pH-7.48*
calTCO2-28 Base XS-4
[**2113-9-5**] 04:52PM BLOOD Lactate-1.3
.
DISCHARGE LABS:
[**2113-9-19**] 03:56AM BLOOD WBC-5.6 RBC-2.75* Hgb-9.4* Hct-27.2*
MCV-99* MCH-34.1* MCHC-34.6 RDW-21.7* Plt Ct-101*
[**2113-9-19**] 03:56AM BLOOD PT-11.7 PTT-99.1* INR(PT)-1.0
[**2113-9-19**] 03:56AM BLOOD ACA IgG-PND ACA IgM-PND
[**2113-9-19**] 03:56AM BLOOD Glucose-121* UreaN-22* Creat-0.3* Na-137
K-4.5 Cl-105 HCO3-26 AnGap-11
[**2113-9-17**] 04:45AM BLOOD CK(CPK)-103
[**2113-9-16**] 03:50AM BLOOD ALT-53* AST-42* LD(LDH)-439* AlkPhos-142*
TotBili-0.7
[**2113-9-19**] 03:56AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2
[**2113-9-19**] 03:56AM BLOOD [**Doctor First Name **]-PND
[**2113-9-16**] 09:20AM BLOOD Cyclspr-43*
.
Micro:
Blood Culture, Routine (Final [**2113-9-11**]): NO GROWTH.
MRSA SCREEN (Final [**2113-9-7**]): No MRSA isolated.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2113-9-6**]):
Feces negative for C.difficile toxin A & B by EIA.
Respiratory Viral Antigen Screen (Final [**2113-9-6**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
[**2113-9-5**] 8:24 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2113-9-5**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2113-9-7**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2113-9-6**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Final [**2113-9-12**]): NO MYCOBACTERIA
ISOLATED.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2113-9-7**]):
Feces negative for C.difficile toxin A & B by EIA.
[**2113-9-11**] 6:46 pm BRONCHIAL WASHINGS
GRAM STAIN (Final [**2113-9-11**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2113-9-13**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2113-9-18**]):
NO LEGIONELLA ISOLATED.
PAECILOMYCES SPECIES. RARE GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2113-9-12**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
SKIN biopsy pending at tmie of discharge
.
Imaging:
IMPRESSION:
CT ABD & PELVIS W/O CONTRAST Study Date of [**2113-9-5**] 5:43 PM
1. No evidence of retroperitoneal hematoma.
2. Left lower lobe consolidation with adjacent small left
nonhemorrhagic
pleural effusion. This finding is concerning for infection in
the appropriate clinical setting.
3. Increased attenuation of the liver, compatible with
hemosiderosis,
unchanged.
4. Cholelithiasis without evidence of cholecystitis.
5. Extensive calcified atherosclerotic disease of the aorta and
its branches without associated aneurysmal changes.
6. Right thigh lipoma is partially imaged.
.
EMG:
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for a
myopathy with
denervating ("inflammatory") features, most severely affecting
the lower
extremities. The findings are not suggestive of an acquired
demyelinating
polyneuropathy, such as Guillain- [**Location (un) **] syndrome.
.
ECHO [**2113-9-15**]: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). A mid-cavitary gradient is identified. There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic 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.
Compared with the prior study (images reviewed) of [**2112-3-15**], no
change.
.
CHEST CT: report pending at time of discharge
.
PATHOLOGY:
Muscle biopsy, r4 rectus femoris muscle:
Inflammatory myopathy, see note.
Note: Section showed myofibers with prominent inflammatory
infiltrate composed of foamy macrophages, lymphocytes, and
plasma cells. Degenerative and regenerative fibers are seen.
In some areas, myofibers are replaced by adipose and connective
tissue, consistent with a subacute clinical picture. CD3 labeled
prominent T cell infiltrate with numerous CB8 positive cytotoxic
and scattered CD4 positive helper cells, while CD20 labeled B
lymphocytes are rare in perivascular zones. CD68 highlighted
abundant macrophages, some involved in myophagocytosis. The
findings would be consistent with GVH myositis in the clinical
context of CML status post alloSCT and history of GI and liver
GVH disease. GVH myositis is indistinguishable histologically
from sporatic polymyositis. Further studies including
biochemical panel will be reported as an addendum.
.
R forearm: pending at time of discharge
Brief Hospital Course:
58-year-old female with CAD s/p CABG, accelerated phase CML s/p
allo SCT [**2112-4-6**] complicated by upper and lower GI GVHD [**2112-4-25**]
and liver GVHD [**8-/2112**] presenting from OSH electively intubated
for hypoxic and hypercarbic failure in the setting of myopathy.
.
# Hypercarbic hypoxic respiratory failure: Pt was initially
electively intubated given diffuse myopathy affecting
respiratory muscles. Pt was managed on endotracheal intubation
for 11 days before being trached on [**9-15**]. Her daily NIF has
remained (-14)-(-18). During trials on trach collar, she has
maintained her oxygen saturation and respiratory rate, however
her blood pressure elevates and she reports subjective feelings
of dyspnea and fatigue. Goal now for weaning her from the vent
is treatment of her diffuse myositis to improve respiratory
failure in the long term with gentle weaning to trach collar.
.
# Motor weakness: Based on muscle biopsy, inflammation is
consistent with GVHD. Muscle biopsy shows impressive
inflammation despite having been on steriods prior to biopsy.
Muscle strength appeared to initially improve on steroids,
though now has been stable x 1 week. Following muscle biopsy,
she was started on cyclosporine 25mg IV BID and received 1 dose
of IVIG. She has had minimal improvement in her strength and is
aware that this will be a prolonged recovery process.
.
# Mold on BAL: Sparse growth seen on bronchial aspirate from
[**9-11**]. Given clinical improvement and radiological improvement
on CT scan [**9-19**], we do not feel that this is likely a pathogenic
organism. We do recommend repeat CT chest in [**2-22**] weeks for
continued monitoring.
.
# depression: Ms [**Known lastname **] has started to appear overwhelmed and
frustrated by her current condition and long term recovery that
is necessary. We have deferred starting an SSRI but this should
be reconsidered outside of an acute hospitalization.
.
# Pancytopenia: Developed in setting of starting cyclosporine.
Her CBC has been stable and she has not required any recent
transfusions. Threshold for transfusion would be platelets <10,
hct <25
.
# bilateral hand bullae: First noticed on [**9-6**]. Dermatology was
consulted and felt that her purpura was due to trauma and her
coagulopathy. The bullae were probably the result of hemorrhage
into thin skin. They were drained and per derm, continued with
light pressure dressings to prevent re-accumulation.
.
# Hypertension: Pt has history of hypertension and had been
managed at home on amlodipine 5mg, and metoprolol succinate
300mg daily. These were initially held on presentation, but
resumed as she improved clinically. She has been stable on
amlodipine 5mg daily, metoprolol tartrate 100mg q6hr, and
captopril 12.5mg TID. She has been noted to get hypertensive to
170s when on trach collar. We would expect this to resolve as
she becomes more comfortable on the trach collar and her
strength improves. It would be possible to up titrate her
captopril if she requires.
.
# DVT: Pt has bilateral DVT, however in setting of diffuse
ecchymoses and hematomas, heparin drip was held. Pt had CTA at
outside hospital to r/o PE and had an IVC filter placed. She
was placed on compression stockings to avoid further
complications of thrombophlebitis.
.
# Elevated LFTs: LFT have been stably elevated during this
hospitalization, likely secondary to her known GVHD.
.
# elevated PTT: Unclear etiology since patient has been off
heparin drip for 1 week now. She is still getting heparin SQ TID
and suspect that given decreased muscle mass, she may be
supratheraputic from SQ heparin alone. Further work up is
pending, including [**Doctor First Name **], anti-cardiolipin antibody, and
anti-lupus antibody.
.
CHRONIC ISSUES:
.
# CML s/p allogeneic stem cell tx: Pt was continued on acyclovir
and atovaquone for prophylaxis. She had been on budesonide,
however this has been held recent as it cannot be given through
her dobhoff. She has been started on cyclosporin and IVIG for
diffuse myositis.
.
# CAD: s/p CABG in [**2104**]. Continued home medications. Repeat ECHO
here showed no wall motion abnormalities. She also had cardiac
catheterization at outside hospital for workup of initial
presenting dyspnea which revealed clean coronary arteries.
.
TRANSITIONAL ISSUES:
Pt is full code.
.
She will require repeat IVIG either [**9-29**] or [**10-16**] per
rheumatology recs.
.
She should have repeat CT chest in [**2-22**] weeks for follow up on
interval change in L infiltrate.
.
We have decreased her heparin SQ to [**Hospital1 **] given persistently
elevated PTT. This should be re-evaluated if remains elevated
and further work-up would be warranted.
.
We have resumed home blood pressure medications. If necessary,
her captopril could be up titrated.
.
Patient and her husband are aware that she will have a prolonged
recovery period. She has expressed some thoughts of depression
and would likely benefit from an SSRI.
.
Tube feds currently Beneprotein, 21 gm/day, Goal rate: 40 ml/hr,
Residual Check: q4h Hold feeding for residual >= : 200 ml
.
Pt has not been getting her budesonide as it clogs her dobhoff.
This should be discussed with hem/onc at her follow up visit.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth twice a day
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 ml daily
BUDESONIDE [ENTOCORT EC] - 3 mg [**Hospital1 **]
CYCLOSPORINE MODIFIED [NEORAL] - 25mg [**Hospital1 **]
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth 1X/WEEK (TH)
LORAZEPAM - 0.5 mg-1mg daily PRN
METOPROLOL SUCCINATE - 300 mg daily
OMEPRAZOLE - 20 mg daily
PREDNISONE TAPER 8mg daily
DOCUSATE SODIUM [COLACE] 100mg daily
MAGNESIUM OXIDE-MG AA CHELATE [MG-PLUS-PROTEIN] 133 mg daily
SENNOSIDES [SENNA] - 8.6 mg [**Hospital1 **]
Discharge Medications:
1. acyclovir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours).
2. atovaquone 750 mg/5 mL Suspension [**Hospital1 **]: 1500 (1500) mg PO
DAILY (Daily).
3. metoprolol tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours).
4. captopril 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
5. lidocaine HCl 2 % Solution [**Hospital1 **]: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for mouth discomfort.
6. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed for heart burn.
7. amlodipine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
9. trazodone 50 mg Tablet [**Age over 90 **]: 0.5 Tablet PO HS (at bedtime).
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Last Name (STitle) **]: One (1) Tablet, Chewable PO TID (3 times a day).
13. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO BID (2 times a day).
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
15. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Last Name (STitle) **]: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
PRN: wheeze.
16. fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
17. diazepam 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime as
needed for insomnia for 1 doses.
18. heparin (porcine) 5,000 unit/mL Cartridge [**Hospital1 **]: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
19. Lorazepam 0.5-1 mg IV Q6H:PRN anxiety
20. methylprednisolone sodium succ 40 mg Recon Soln [**Hospital1 **]: Thirty
(30) mg Injection Q12H (every 12 hours).
21. cyclosporine 250 mg/5 mL Solution [**Hospital1 **]: Twenty Five (25) mg
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Graft versus host disease myositis affecting respiratory muscles
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for difficulty breathing and
had a breathing tube placed to help. This was transitioned to a
tracheostomy. You had a muscle biopsy done to determine what
caused your weakness. It looks like your graft versus host
disease caused damage to your muscle and affected your
respiratory muscles. You were started on a new medicine called
cyclosporin and got 1 dose of IVIG to treat the muscle weakness.
You were also continued on steroids. There was some concern for
a pneumonia, though this looks like it has resolved on your most
recent CT scan. Your feeding tube was left in place for you to
get adequate nutrition until your muscle strength improves.
We will send a complete list of your medications to the LTAC.
Followup Instructions:
Department: RHEUMATOLOGY
When: WEDNESDAY [**2113-9-27**] at 1:30 PM
With: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DERMATOLOGY
When: WEDNESDAY [**2113-9-27**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16424**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2113-10-2**] at 12:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2113-10-2**] at 12:30 PM
With: [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 3240**], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Specialty: Neurology
Address: [**Hospital1 85781**],[**Location (un) 5259**] 127, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 8139**]
We are working on a follow up appointment for you to be seen by
Dr. [**First Name (STitle) **] within 15 days of your discharge from the hospital.
Your rehab facility should be called with this appointment. If
you have questions or have not heard within 2 business days,
please have the facility call the number above to schedule.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2762, 486, 2875, 4019, 2724, 2859, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5394
}
|
Medical Text: Admission Date: [**2108-5-8**] Discharge Date: [**2108-5-17**]
Date of Birth: [**2108-5-8**] Sex: F
Service: NB
IDENTIFICATION: Baby Girl [**Known lastname **] is a 9 day old former 34 [**2-11**] wk
infant being discharged from the [**Hospital1 18**] NICU.
HISTORY OF PRESENT ILLNESS: [**Known firstname 2197**] [**Known lastname **] is the former 2.49
kg product of a 34 and [**2-11**] week gestation pregnancy born to a
27 year-old, Gravida IV, Para 0 woman. Prenatal screens:
Blood type B positive, antibody negative, Rubella immune, RPR
nonreactive, hepatitis B surface antigen negative. Group beta
strep status unknown. The mother's medical history is notable
for systemic lupus with a positive antinuclear antibody
test, ADHD and history of therapeutic abortion x3. The
pregnancy was also complicated by pregnancy induced
hypertension, prompting admission on [**2108-5-7**]. Mother was
treated with magnesium. Due to persistent elevated blood
pressures, induction of labor was begun with Pitocin.
Rupture of membranes occurred at 4 hours prior to delivery
and the mother was treated with Penicillin for unknown group
B strep status for 6 hours prior to delivery. There was no
maternal fever.
Infant was born by vaginal delivery with forceps assistance,
due to concern of variable fetal heart rate decelerations and
an overall non reassuring fetal heart rate tracing. There was
significant vaginal bleeding, suggestive of placental
abruption noted at delivery. The infant emerged with
diminished tone and absent cry. She required suctioning,
stimulation and positive pressure ventilation with gradual
improvement in color, tone and respiratory effort. Apgars
were 4 at 1 minute, 7 at 5 minutes and 8 at 10 minutes. She
was admitted to the NICU for treatment of prematurity.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight was 2.49 kg. Head circumference
was 32.5 cm. Length was 47 cm. All were 75th percentile for
gestational age. General: Well-developed preterm infant.
Initial moderate respiratory distress with rapid improvement.
Skin: Warm and pink, initially with sluggish capillary
refill, gradually improving, no rashes. HEENT: Fontanel
soft and flat, palate intact. Neck supple, no lesions.
Chest: Coarse breath sounds, well aerated. Cardiovascular:
Regular rate and rhythm. No murmur. Abdomen: Soft, no
hepatosplenomegaly, quiet bowel sounds. Three vessel cord.
Genitourinary: Normal female. Anus patent. Femoral pulses
+2. Extremities: Hips and back normal. Neuro: Appropriate
tone and activity. Moro and grasp intact.
HOSPITAL COURSE:
1. Respiratory: [**Known firstname 2197**] required blow-by oxygen briefly upon
admission to the Neonatal Intensive Care Unit. The
transitional respiratory distress resolved within a few
hours of life. [**Known firstname 2197**] has been in room air for the
remainder of her Neonatal Intensive Care Unit admission.
She has not had any spontaneous episodes of apnea or
bradycardia. At the time of discharge, she is breathing
comfortably in room air with a respiratory rate of 40 to
60 breaths per minute.
2. Cardiovascular: There is a known maternal history of
lupus. An EKG was done on [**2108-5-9**] with results within
normal limits. A soft murmur has been noted
intermittently during admission. A chest x-ray, four
limb blood pressures and a repeat EKG were obtained on
[**2108-5-17**], all within normal limits. Patient remained
hemodynamically stable throughout admission. Murmur
is consistent with physiologic flow murmur or PPS.
3. Fluids, electrolytes and nutrition: [**Known firstname 2197**] was initially
n.p.o. and started on IV fluids. Enteral feeds were
started on day of life 1 and gradually advanced to full
volume. She required some gavage feedings. She has been
all p.o. feedings for 72 hours prior to discharge. She
is taking breast milk or Enfamil 20 calories per ounce.
Weight on the day of discharge is 2.365 kg with a
corresponding length of 48 cm and a head circumference of
32 cm.
4. Infectious disease: [**Known firstname 2197**] was evaluated for sepsis upon
admission to the Neonatal Intensive Care Unit. A
complete blood count was within normal limits. A blood
culture was obtained prior to starting intravenous
Ampicillin and Gentamycin. Blood culture was no growth at
48 hours and the antibiotics were discontinued.
5. Hematology: Hematocrit at birth was 40.5%. Platelets
were normal at 322,000. [**Known firstname 2197**] did not receive any
transfusions of blood products.
6. Gastrointestinal: [**Known firstname 2197**] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Her
peak serum bilirubin was 12.3 total over 0.3 mg per ml
direct. She received several days of phototherapy,
discontinued on [**5-13**]. Since discontinuing her
phototherapy, her rebound bilirubins rose slightly, but have
remained stable in the 11-12 range for 24 hrs prior to
discharge. Last value was 11.6 on morning of [**5-17**].
7. Neurologic: [**Known firstname 2197**] has maintained a normal neurologic
exam during admission and there are no neurologic
concerns at the time of discharge.
8. Sensory: Audiology hearing screening was performed with
automated auditory brain stem responses. [**Known firstname 2197**] passed in
both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, [**Street Address(2) 67241**],
[**Location (un) **], [**Numeric Identifier 48775**]. Phone number [**Telephone/Fax (1) 63424**].
CARE AND RECOMMENDATIONS:
1. Breast feeding or taking Enfamil 20 ad lib.
2. No medications.
3. Car seat position screening was performed. [**Known firstname 2197**] was
observed in her car seat for 90 minutes without any
episodes of bradycardia or oxygen desaturation.
4. State newborn screens were sent on [**5-11**] and [**2108-5-17**]. No
notification of abnormal results to date.
5. Immunizations: Hepatitis B vaccine was administered on
[**2108-5-9**].
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP:
1. Dr. [**Last Name (STitle) **], primary pediatrician, within 3 days of
discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and [**2-11**] week gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis, ruled out.
4. Unconjugated hyperbilirubinemia.
5. Cardiac murmur.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (Titles) 67242**]
MEDQUIST36
D: [**2108-5-17**] 03:09:02
T: [**2108-5-17**] 04:26:48
Job#: [**Job Number 67243**]
ICD9 Codes: 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5395
}
|
Medical Text: Admission Date: [**2191-5-19**] Discharge Date: [**2191-5-26**]
Date of Birth: [**2191-5-19**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 71802**] is the 2.2-kilogram product of a
35-4/7-weeks gestation born to a 29-year-old G1, P0 mother.
Prenatal screens: O-positive, antibody negative, hepatitis
surface antigen negative, rubella immune, RPR nonreactive,
GBS unknown. This pregnancy was complicated by
oligohydramnios and suspected intrauterine growth
restriction. Mother was beta complete at time of delivery.
Infant was delivery by C-section secondary to infant breech
position. Infant had Apgars of 8 and 8. Required brief blow-
by O2 and bulb suctioning. Infant was admitted to the newborn
intensive care unit for management of prematurity.
PHYSICAL EXAM ON ADMISSION: Weight was 2.2 kilograms (25-
50th percentile), head circumference 32 cm (25th-50th
percentile), length 45 cm (25th-50th percentile).
PHYSICAL EXAM TODAY AT TIME OF DISCHARGE: Small infant,
swaddled in open crib. She was pink, mildly jaundiced, well
perfused in room air. Chest: Clear with equal breath sounds.
Cardiovascular: Regular rate and rhythm, soft systolic murmur
heard best in axilla. Abdomen is soft with active bowel
sounds. GU: Immature female genitalia. Extremities: Legs
flexed at birth. Infant moving all extremities appropriately.
Neuro: Active with good tone.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Known lastname **] was
admitted to the newborn intensive care unit with mild
respiratory distress requiring nasal cannula O2 400 cc flow
up to 50%. She required nasal cannula for a total of
approximately 72 hours at which time she transitioned to room
air. Has been stable on room air since that time.
Cardiovascular: She has been cardiovascularly stable with a
new onset murmur consistent with PPS in quality. She was assessed
by the Cardiology consult service who agreed murmur was most
likely benign. Blood pressure was normal, 61/30 with a mean of
40 and heart rate ranges have been 130s-180s.
Fluid and electrolyte: Birth weight was 2.21 kilograms.
Discharge weight is 2005gm. She was initially started on
60 cc per kilogram per day of D10W. Enteral feedings were
initiated on day of life #2. She is currently ad-lib feeding
taking in adequate amounts of breast milk or Similac 24
calorie. She is voiding and stooling.
GI: Her peak bilirubin was on [**5-24**], of 9.9/0.2. She has
not required any phototherapy at this time.
Hematology: Hematocrit on admission was 44.1. She has not
required any blood transfusions.
Infectious disease: CBC and blood culture obtained on
admission. CBC was benign. Blood cultures remained negative
at 48 hours at which time antibiotics were discontinued.
Neuro: Infant has been appropriate for gestational age.
Sensory: Hearing screen was performed with automated auditory
brainstem responses, and the infant passed in both ears on
[**2191-5-26**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34570**],
telephone number is ([**Telephone/Fax (1) 67099**].
CARE AND RECOMMENDATIONS: Continue ad-lib feeding breast
milk 20 calorie or supplementation with Similac 24 calorie.
Follow up appointment with Dr. [**Last Name (STitle) **] of Cardiology at CH has been
scheduled for [**2196-6-10**]:30PM.
MEDICATIONS: Ferrous sulfate supplementation 0.2 mL p.o.
daily (25 mg per mL), Tri-Vi-[**Male First Name (un) **] 1 mL p.o. daily.
IRON AND VITAMIN SUPPLEMENTS: Iron supplementation is
recommended for preterm and low birth weight infants until 12
months of corrected age.
All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units (maybe
provided as multivitamin preparation) daily until 12 months
corrected age.
CAR SEAT POSITION SCREENING: Was performed and the infant
passed.
STATE NEWBORN SCREEN: Was sent most recently on [**5-21**] and
results have been within normal limits.
IMMUNIZATIONS RECEIVED: Infant received hepatitis B vaccine
on [**5-25**].
DISCHARGE DIAGNOSES: Premature infant born at 35-4/7-weeks
gestation, transient respiratory distress, rule out sepsis
with antibiotics, cardiac murmur - possible peripheral pulmonic
stenosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2191-5-25**] 21:26:38
T: [**2191-5-26**] 06:56:25
Job#: [**Job Number 71803**]
ICD9 Codes: V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5396
}
|
Medical Text: Admission Date: [**2114-4-17**] Discharge Date: [**2114-4-26**]
Date of Birth: [**2059-12-24**] Sex: F
Service: CCU
CHIEF COMPLAINT: The patient was admitted with the chief
complaint of shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
female with a history of breast cancer treated with surgery,
high dose chemotherapy (including Adriamycin), auto bone
marrow transplant and radiation, who has had other admissions
since her treatment. The patient had been doing well up until
approximately three weeks ago. The patient developed a
nonproductive cough, denied any fevers, chills, pleuritic
chest pain and began to have episodes of shortness of breath.
The patient now reports being short of breath at
approximately angle of 20 degrees and could not lie flat at
night. No chest pain, no diaphoresis, occasional hot
flashes, no nausea or vomiting. The patient states that she
has had weight loss over the past few weeks secondary to poor
appetite, but denies any night sweats, and no hemoptysis.
The patient states she has had occasional palpitations. The
patient also reports polyuria and polydipsia which she states
has been long-standing. The patient denies any history of
tuberculosis or contacts with tuberculosis.
PAST MEDICAL HISTORY:
1. Inflammatory breast cancer diagnosed in [**2105**], with
positive lymph nodes. At that time, she underwent
surgery, high dose chemotherapy and auto bone marrow
transplant and radiation.
2. Depression.
3. Obesity.
4. She has no known history of hypercholesterolemia or
hypertension.
ALLERGIES: She is allergic to Penicillin which causes hives.
MEDICATIONS ON ADMISSION:
1. Femara 2.5 mg p.o. once daily.
2. Effexor 75 mg p.o. once daily.
3. Zoloft 100 mg p.o. once daily.
SOCIAL HISTORY: She lives with her roommate. She quit
tobacco twenty years ago. She denies any ethanol or illicit
drug use. She is the owner of a restaurant.
FAMILY HISTORY: She had an uncle with a myocardial
infarction at age 52. She had a grandmother with breast
cancer who developed that in her 80s. She has an aunt with
ovarian cancer. Her mother is alive and well at age 88.
PHYSICAL EXAMINATION: On admission, physical examination was
remarkable for temperature of 96.9, blood pressure 92/76,
pulse 89, respiratory rate 25, oxygen saturation 99 percent.
She was a pleasant middle age woman in no acute distress but
anxious, short of breath lying down. Pertinent examination
findings revealed normal S1 and S2. She had decreased breath
sounds at the right base. Her abdominal examination was
soft, nontender, nondistended. Extremity examination showed
no edema, 2 plus dorsalis pedis bilaterally.
LABORATORY DATA: Her laboratory data was remarkable for a
white blood cell count of 8.7 with a normal differential,
hematocrit 43.7, platelet count 187,000. Chem7 was
remarkable for a blood glucose of 747 with an anion gap of
14. Her INR was 1.3. She had a D-dimer of 3258.
CT angiogram was obtained as there was concern for pulmonary
embolus. It showed no pulmonary embolus and moderate right
sided pleural effusion, a small left effusion and no
pathologically enlarged lymph nodes, no infiltrate, no
atelectasis or collapse.
An electrocardiogram showed sinus tachycardia at 114 beats
per minute with late R wave progression, questionable lead
placement. There is also a Q wave in V1 through V3 and T
wave inversions in those leads.
HOSPITAL COURSE: Initially, the main concern of the
admitting team was for her new onset likely type 2 diabetes
mellitus. She had a urinalysis sent which did not reveal
evidence of ketonuria. It was therefore felt that this was a
likely new onset type diabetes mellitus. The other main
concern of the team was the new right sided pleural effusion
which would obviously be concern for recurrence of her
cancer. The patient was initially admitted to the Medical
Intensive Care Unit for treatment of her hyperosmolar state
and her hypoglycemia. In the Intensive Care Unit, her
glucose normalized with an insulin drip and then with sliding
scale insulin and NPH. The right sided pleural effusion was
also tapped and yielded 300cc of fluid, however, this fluid
specimen was subsequently lost and therefore no laboratory
evaluation was done on the specimen. Most remarkable during
this course, an echocardiogram was obtained and this showed
an ejection fraction of 15-20 percent along with 4 plus
tricuspid regurgitation and mitral regurgitation, a small to
moderate loculated pericardial effusion. One dose of Lasix
was given in the Intensive Care Unit with 500cc of urine
output and the patient reported slight improvement in
dyspnea. This result was surprising as the patient has no
known history of any cardiac disease and has never reported
any significant chest pain. The congestive heart failure
service was consulted and recommended a subsequent cardiac
catheterization. The reasoning behind this was that, while
she does have new onset type 2 diabetes mellitus, there was
concern given the Q waves on her electrocardiogram of a
possible silent anterior myocardial infarction that had
caused her decompensation. Therefore, she was transferred
back to the [**Hospital Ward Name 517**] for cardiac catheterization and this
led to her subsequent admission in the Medical Intensive Care
Unit.
The cardiac catheterization revealed clean coronary arteries
but increased left and right sided pressures. Her wedge was
noted to be 25. She had a pulmonary artery pressure of 45/25
and right ventricular pressure of 45/18 and an extremely
elevated right atrial pressure of 22/19. The patient also
had a decreased cardiac output and cardiac index. Her
cardiac output was 3.4 and her cardiac index was 1.8. She
was therefore transferred to the Coronary Care Unit for
tailored inotropic and diuretic therapy. Also of note, once
she was transferred to the Medical Intensive Care Unit, she
had an ALT of 193 and AST of 95 and alkaline phosphatase of
158. Also of note, she had sets of cardiac enzymes which
were negative and an AlC which was drawn and was 13.8.
The [**Hospital 228**] hospital course in the Coronary Care Unit:
Ischemia - The patient ruled out for myocardial infarction
and had clean coronary arteries and she was
continued on Aspirin 81 mg p.o. once daily.
Pump - The patient was initially started on Milrinone with
reasoning to increase her forward flow and cardiac index
to help with diuresis. She was also given Lasix p.r.n.
with goal to make her negative 1.5 to two liters a day.
With regards to the etiology of her congestive heart
failure, several laboratory studies were checked which
included a TSH which was normal, and also iron studies
were obtained to rule out hemochromatosis and this was
normal as well. An HIV test was also checked, and this
was normal. It was therefore felt by the Coronary Care
Unit team that the most likely etiology of her
cardiomyopathy was due to Adriamycin toxicity. It was
thought that it was possible that the patient had been in
long-standing congestive heart failure and had been
compensated and the recent new onset of type 2 diabetes
mellitus may have produced the exacerbation. She was
eventually weaned off the Milrinone drip and her
congestive heart failure medications were titrated. She
was eventually discharged on a course of Digoxin 0.125 mg
p.o. once daily, Aldactone 25 mg p.o. once daily, low dose
Lisinopril (2.5 mg p.o. once daily), and Coreg 3.125 mg
p.o. twice a day. She will be followed as an outpatient
in the Congestive heart Failure Clinic.
With regard to rhythm, the patient remained in normal
sinus rhythm.
Prevention - The patient was continued on an Aspirin.
Diabetes mellitus - The patient had been followed by the
[**Last Name (un) **] team during her hospital stay. She had her insulin
and Humalog sliding scale regimens titrated and she will
follow-up with [**Last Name (un) **] approximately one week after
discharge.
Increased liver function tests - Hepatitis panel was
checked and was negative. Right upper quadrant ultrasound
was checked and this was also negative but did show some
evidence of fatty liver. During the rest of her hospital
course, her liver function tests continued to decrease
substantially. It was thought that the most likely
etiology of her increased liver function tests was a
congestive hepatitis due to poor forward flow.
DISCHARGE DIAGNOSES:
1. Congestive heart failure, likely Adriamycin toxicity.
2. Congestive hepatitis.
3. New onset type 2 diabetes mellitus.
4. History of breast cancer, status post surgery,
chemotherapy, radiation, auto bone marrow transplant.
5. Depression.
FOLLOW UP: The patient has several follow-up appointments
including three sessions with [**Last Name (un) **]. She also has an
appointment in the Congestive Heart Failure Clinic with Dr.
[**First Name (STitle) 2031**]. She also has an appointment with Dr. [**Last Name (STitle) 1299**] as a
new primary care physician.
INVASIVE SURGICAL PROCEDURES: Cardiac catheterization with
ejection fraction of 15-20 percent.
DISCHARGE MEDICATIONS:
1. Zoloft 100 mg p.o. once daily.
2. Effexor 75 mg p.o. twice a day.
3. Femara 2.5 mg p.o. once daily.
4. Aspirin 81 mg p.o. once daily.
5. Digoxin 0.125 mg p.o. once daily.
6. Coreg 3.125 mg p.o. twice a day.
7. Lisinopril 2.5 mg p.o. once daily.
8. Aldactone 25 mg p.o. once daily.
9. Humalog sliding scale.
10.
Insulin NPH 30 units subcutaneously at breakfast and 14 units
at bedtime.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 11827**]
Dictated By:[**Name8 (MD) 11828**]
MEDQUIST36
D: [**2114-4-26**] 22:20:46
T: [**2114-4-28**] 09:17:22
Job#: [**Job Number 11829**]
ICD9 Codes: 4280, 4254, 5119, 4240, 4168, 4589
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5397
}
|
Medical Text: Admission Date: [**2104-8-25**] Discharge Date: [**2104-9-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
R hip hemiarthroplasty
History of Present Illness:
Patient is an 88 yo F with Alzheimer's dz, depression, GERD who
presents from [**Hospital 100**] Rehab following an unwitnessed fall. Per
report, the patient was found in a hallway after the staff heard
a "thump." The patient was lying on the ground complaining of R
hip pain. She was therefore brought into [**Hospital1 18**] for further
evaluation. Patient refuses to give additional history,
requesting to "please let me sleep."
.
In the ED, AVSS. The patient was complaining of pain everywhere
so CT head, neck, CXR, R knee, and hips were performed. Given
morphine 2mg IV. Imaging was significant for a R femoral head
fx. Given her significant dementia, she was admitted to medicine
with orho following
.
On arrival to the floor, patient insists on being allowed to
sleep. She does complain of pain to her right leg
.
ROS: Unable to assess given patient's mentation
Past Medical History:
1. Alzheimer's Disease.
2. Depression.
3. Gastroesophageal reflux disease.
4. Macular degeneration.
5. Hearing loss.
6. h/o pre-syncope and falls
7. Hemorrhoids
Social History:
Lives at [**Hospital 100**] Rehab facility currently. Per daughter, has been
suffering from dementia for several years, has not been able to
regularly recognize daughter in past 2 years. Reports patient
more unstable on feet in last few months with several falls.
Also has 2 sons but daughter [**Name (NI) **] is HCP.
Family History:
NC
Physical Exam:
VS: T 96.6, BP 128/76, HR 75, RR 16, 93%RA
Gen: lying in bed, awake and lucent, asking to go to sleep
HEENT: anicteric sclera, MMM, poor dentition
Neck: supple, no lad
Lung: CTAB anteriorly, patient would not allow posterior exam
Heart: RRR, 3/6 SEM heard best at base
Abd: soft, mild tenderness non-focal + BS, no rebound
Ext: warm, 1+ DP pulses, R hip internally rotated
Skin: friable, soft, no rash
Neuro: awake and alert/lucent, would not cooperate with rest of
exam
Pertinent Results:
MICRO:
C.diff [**8-28**]: positive
Urine [**8-31**] +E.coli >10^5
.
IMAGING:
EKG [**2104-8-25**]: NSR at 72 bpm, nl axis, early R wave progression, Q
in III, compared to EKG dated [**2099-12-28**], precordial TWI
resolved.
.
EKG [**2104-9-1**] 11:35 am: NSR at 78, NANI, I and aVL with new 1mm ST
depressions; II with new TWF, III and aVF with 0.[**Street Address(2) 1755**]
elevations and new TWF/TWI and deeper Q waves, V2 with [**Street Address(2) 4793**]
depressions, diffuse precordial T wave flattening.
.
EKG [**2104-9-1**] 3:49 pm: NSR with mult PACs, limb lead ST changes
resolved, still with inferior TWF/TWI, V2 with 2mm ST
depressions, diffuse precordial T wave flattening unchanged.
.
CT Head [**8-25**]: No ICH or fracture.
.
CT C Spine [**8-25**]: Study is limited by patient motion. No definite
fracture. Grade 1 anterolisthesis at the C3-4 level is likely
degenerative but clinical correlation is recommended.
.
CXR [**8-25**]: Mild prominence of pulm vasculature. Small Pericardial
Effusion.
.
CXR [**2104-9-1**]: In comparison with the study of [**8-31**], there are
even lower lung volumes with bilateral atelectatic changes,
especially at the left base. The area behind the heart is
difficult to evaluate and the possibility of pneumonia in this
region cannot be excluded in the absence of a lateral view.
.
XRay Hip [**8-25**]: displaced R femoral neck fracure.
.
cbc:
[**2104-8-25**] 04:20AM BLOOD WBC-11.9*# RBC-3.99* Hgb-12.2 Hct-36.3
MCV-91# MCH-30.7 MCHC-33.7 RDW-13.3 Plt Ct-250
[**2104-8-29**] 09:00AM BLOOD WBC-16.5* RBC-3.72* Hgb-11.4* Hct-34.3*
MCV-92 MCH-30.7 MCHC-33.3 RDW-13.5 Plt Ct-350
[**2104-9-2**] 05:57AM BLOOD WBC-17.0* RBC-3.40* Hgb-10.4* Hct-31.6*
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.2 Plt Ct-429
.
coags:
[**2104-8-25**] 04:20AM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1
[**2104-9-2**] 05:57AM BLOOD PT-16.1* PTT-29.3 INR(PT)-1.4*
.
chem-10:
[**2104-8-25**] 04:20AM BLOOD Glucose-151* UreaN-23* Creat-0.8 Na-137
K-4.1 Cl-102 HCO3-24 AnGap-15
[**2104-8-28**] 04:50AM BLOOD Glucose-93 UreaN-28* Creat-0.7 Na-143
K-3.8 Cl-117* HCO3-20* AnGap-10
[**2104-9-2**] 05:57AM BLOOD Glucose-131* UreaN-27* Creat-1.0 Na-149*
K-4.0 Cl-119* HCO3-19* AnGap-15
.
LFTs
[**2104-8-25**] 04:20AM BLOOD CK(CPK)-39
[**2104-8-29**] 09:00AM BLOOD ALT-15 AST-42* AlkPhos-117 Amylase-184*
TotBili-0.5
[**2104-9-2**] 05:57AM BLOOD ALT-28 AST-57* LD(LDH)-371* CK(CPK)-142*
AlkPhos-152* TotBili-0.3
.
cardiac enzymes:
[**2104-9-1**] 04:45AM BLOOD proBNP-[**Numeric Identifier 96039**]*
[**2104-9-1**] 12:27PM BLOOD CK-MB-24* MB Indx-9.8* cTropnT-0.91*
proBNP-[**Numeric Identifier **]*
[**2104-9-1**] 05:31PM BLOOD CK-MB-21* MB Indx-10.0* cTropnT-1.01*
[**2104-9-2**] 05:57AM BLOOD CK-MB-16* MB Indx-11.3* cTropnT-0.92*
.
abg:
[**2104-9-1**] 12:45PM BLOOD Type-ART pO2-124* pCO2-37 pH-7.36
calTCO2-22 Base XS--3
Brief Hospital Course:
A/P: 88 yo F with Alzheimer's dementia p/w a fall resulting in a
hip fx, s/p hemiathroplasty, complicated by C. diff infection.
She was transferred to MICU w/ hypoxic respiratory failure 2' to
evolving MI, CHF, and pulmonary edema. Poor prognosis and level
of consciousness. She was made CMO per family meeting on [**2104-9-2**],
and passed away on while on the medicine floor on [**2104-9-5**].
.
# R hip fracture: associated w/ fall at rehab. s/p R hip
arthroplasty. Unable to assess pain due to decreased mental
status. Morphine PO was given for pain and continued with code
status was made CMO.
.
# Acute myocardial infarction. Pt suffered an MI that was likely
the cause of her tachypnea. She ruled in with positive troponin
and MBI; she had ECG changes (ST elevation in III and aVF). She
had a peak Troponin of 1.01 She was managed medically w/
Lovenox, plavix, B-[**Last Name (LF) 7005**], [**First Name3 (LF) **]. All of her medications were
d/c-ed with her code status change to CMO.
.
# Tachypnea/Volume Overload/Pulmonary Edema. Likely related to
acute MI, leading to CHF and pulmonary edema. Pt was oxygenating
and ventilating well in the MICU, but had very poor mental
status. She did have a significant non-gap metabolic acidosis,
could be contributing as source of increased ventilation. She
was managed for her MI as above. Her acidosis was corrected by
lactated ringers and free water boluses 400cc q4h to reduce
hypercholemic acidosis. She was also treated w/ gentle diuresis.
With her changed to CMO status, her diuresis was stopped. The
patient was placed on morphine PO.
.
# C.diff colitis: Likely related to peri-operative antibiotics.
She was started PO vancomycin due to her worsening mental
status. With the change in her CMO status, the antibiotic was
stopped.
.
# Depressed mental status/decreased responsiveness: Pt had
dementia with subacute delerium. Over her hospital stay, she
became less responsive. She waxed and waned in her mental
status, which was likely delerium related to her MI and
infection. With her multiple medical problems and her
progressing non-responsive mental status, her prognosis was
deemed extremely poor. A family meeting was held, code status
was changed to CMO. She was given Morphine and Zydis PRN for
agitation.
.
# Leukocytosis. Likely related to significant C.diff, plus UTI,
plus possible MI. Worsened despite C.diff treatment. D/C-ed
antibiotics with change in code status.
.
# UTI. E.coli related. No antibiotics w/ change in code status
to CMO.
.
# Hypernatremia. Likely due to intravascular volume depletion
and diuresis. She received free water via NGT 400ml q4h, with a
calculated free water deficit to 1.5 L. With her CMO status,
her labs were d/c-ed and she stopped receiving water through her
NGT.
.
# Dementia. Advanced. Held antipsychotics given depressed mental
status and change in CMO status.
.
# Atrial fibrillation. Irregularly irregular on floor during
exam, reverted to sinus w/ PACs. Nursing reports brief episodes
of tachycardia to 160s. With her CMO status, her tele and vital
signs were d/c-ed.
.
# Depression: CMO as above, no meds.
.
# FEN: NPO given poor mental status and CMO.
# PPx: All d/c-ed as patient is CMO.
# Access: PIV d/c-ed w/ CMO status.
# Dispo: Expired while in hospital. Death Certificate filled
out.
.
# Code: CMO on [**2104-9-2**] after discussion with son [**Doctor Last Name **] and
daughter ([**Name (NI) **]) (power of attn) [**8-27**].
Medications on Admission:
[**Month/Year (2) **] 81mg daily
Pepto-Bismol q4-6hrs prn
Celexa 20mg daily
Colace 100mg [**Hospital1 **]
Namenda 5mg daily
Vitamin E 400units daily
Oxazepam 15mg prn
Milk of Mag
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
None
Discharge Condition:
None
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2104-9-5**]
ICD9 Codes: 9971, 2930, 5070, 5990, 2760, 4280, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5398
}
|
Medical Text: Admission Date: [**2176-10-23**] Discharge Date: [**2176-11-1**]
Date of Birth: [**2107-8-31**] Sex: F
Service: SURGERY
Allergies:
Nifedipine / amlodipine
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
ischemic bowel
Major Surgical or Invasive Procedure:
[**2176-10-23**] Exploratory laparotomy, low anterior resection of
this resection of the colorectal anastomosis, end colostomy,
extensive lysis of adhesions.
[**2176-10-25**] Exploratory laparotomy, completion right colectomy,
takedown of the stoma and ileostomy.
History of Present Illness:
[**Hospital Unit Name 153**] admission note:
69 yo F with HTN, T2DM, COPD on 2 L NC (baseline), h/o
infrarenal AAA s/p repair complicated by bowel ischemia with
multiple bowel surgeries most recently LOA/LAR/end colostomy
[**2176-10-23**] and re-exploration with right colectomy and end
ileostomy on [**2176-10-25**] transferred from the colorectal service
for hypertension up to SBP 200s and tachycardia to the
130s-150s.
Per surgery, patient tolerated the surgery without issue. She
received a total of 2 pRBC and about 2L of cyrstalloids.
Patient has been getting metoprolol intermittently prior to her
surgery. Per report, patient was found to be tachycardic up to
the 130s with SBP up to the low 200s. Upon reviewing the [**Month (only) 16**],
patient was found to have recieved metoprolol 5 mg IV x [**4-11**],
hydralazing 10 mg IV x 2. Patient has been on a dilaudid PCA
pump and denied pain. EKG showed sinus tachycardia. UOP has
been about 748 cc since midnight. Patient has been on
vancomycin and zosyn empirically [**2176-10-23**]. Patient was
thought to be more confused, ? delirium, so neurology was
consulted.
Upon arriving to the MICU, patient reports feeling some
palpitation, SOB which is slightly worse than baseline. She
feels foggy but not confused.
UA and cardiac biomarkers were pending at the time of transfer.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough or wheezing.
Denies chest pain, chest pressure. Denies constipation,
abdominal pain, diarrhea, dark or bloody stools. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- CAD (TTE [**6-16**] w EF 60%)
- DM2
- HTN
- COPD on home O2
- Recurrent PNA
- h/o interstitial lung disease of hypersensitivity pneumonitis
s/p prednisone ~ [**2174**] s/p wedge resection of RML [**6-/2174**]
- GERD
- Hx thyroid dz
- previous smoker
- L thalamic ICH w residual mild RLE weakness ([**10/2174**])
- Concern for cryptogenic cirrhosis
- lactose intolerance
- s/p TAH/BSO unknown
- s/p Appy unknown
- Tonsillectomy unknown
- L lumpectomy [**2171**]
- s/p Lung biopsy [**2174**]
- s/p open infrarenal AAA repair w/ dacron (Kechejian-[**2175-3-31**])
- s/p Sigmoid colectomy end colostomy ([**Doctor Last Name **]-[**2175-4-2**])
- s/p Hartmann's reversal, SBR, bladder repair, liver bx
([**Doctor Last Name **]-[**2175-11-16**])
- s/p take down of the ileostomy in [**2-/2176**]
Social History:
- lives at home with boyfriend, [**Name (NI) **] [**Telephone/Fax (1) 88094**]
- Does not report a substance use history
- Says that she is a social drinker and does not drink very
often
- Had long smoking history but stopped smoking 5 years ago
Family History:
Father died age [**Age over 90 **] w/complications of Alzheimer's. Mother is
aged 97 w/mild memory issues and is retired RN.
Physical Exam:
Arrival to [**Hospital Unit Name 153**]:
General: drowsy but arousable to voice and answers questions
appropriately, oriented x 3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRLA
Neck: supple, EJ elevated to 2-3 cm above the clavical, IJ did
not appear overtly compressable on ultrasound, no LAD
CV: regular, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diminished breath sounds bilaterally, scatterred wheeze
on the right base, no rhonchi or rales
Abdomen: firm, non-tender, non-distended, bowel sounds present,
no organomegaly, + 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, gait deferred.
DC Physical Exam:
General: A&OX3, does not appear short of breath, pain contolled,
tol reg diet, adequate ileostomy output.
VS: 98.3, 98.1, 92, 156/80, 16, 96% 2 L, 93% RA
Cardiac: RRR, blood pressure much improved
Lungs: deminished in bases, baseline
abd: flat, soft, stay sutures in place, midline incision with
3-4 cm open area with facial suture exposed scant serous
drainage, aquacel rope applied with dsd covering, llq jp drain
site closed with steristrips draining scant yellow drianage, no
errythema, left sided ileostomy with liquid green output.
Lower extrmeities: +1 edema in lower extremitites improved.
GYN/GU: voiding without issue, labia with small amount of edema
b/l improved
Pertinent Results:
Admission labs:
[**2176-10-24**] 07:25AM BLOOD WBC-11.7*# RBC-3.62* Hgb-9.4* Hct-30.0*
MCV-83 MCH-26.1* MCHC-31.5 RDW-18.0* Plt Ct-148*
[**2176-10-24**] 07:25AM BLOOD Glucose-116* UreaN-29* Creat-1.3* Na-139
K-4.7 Cl-109* HCO3-22 AnGap-13
[**2176-10-24**] 07:25AM BLOOD Calcium-7.3* Phos-4.8*# Mg-2.1
[**2176-10-23**] 12:29PM BLOOD Lactate-1.0 K-3.9
[**2176-10-23**] 01:49PM BLOOD freeCa-1.03*
Notable labs:
[**2176-10-26**] 12:30PM BLOOD ALT-5 AST-24 AlkPhos-53 TotBili-0.6
[**2176-10-25**] 04:00AM BLOOD LD(LDH)-207 CK(CPK)-77
[**2176-10-24**] 07:25AM BLOOD CK-MB-3 cTropnT-<0.01
[**2176-10-25**] 04:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2176-10-26**] 12:30PM BLOOD CK-MB-3 cTropnT-<0.01
[**2176-10-26**] 05:00PM BLOOD cTropnT-<0.01
[**2176-10-27**] 04:51AM BLOOD cTropnT-<0.01
[**2176-10-26**] 12:30PM BLOOD TSH-6.1*
[**2176-10-26**] 12:30PM BLOOD Free T4-1.1
Discharge labs:
Micro:
[**2176-10-24**] 4:50 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
[**2176-10-25**] 6:30 am BLOOD CULTURE Source: Venipuncture 1 OF 2.
Blood Culture, Routine (Pending):
[**2176-10-26**] 5:00 pm BLOOD CULTURE Site: ARM
Blood Culture, Routine (Pending):
Studies:
[**2176-10-26**] CTA CHEST W&W/O C&RECON
1. Pulmonary edema on a background of centrilobular emphysema.
Given normal heart size on the recent chest radiograph, this may
be noncardiogenic pulmonary edema. Small-moderate bilateral
pleural effusions with adjacent compressive atelectasis.
2. No pulmonary embolism.
3. Moderate atherosclerotic calcifications of unknown
hemodynamic significance.
4. Cirrhosis and splenomegaly no completely imaged.
[**2176-10-26**] CT HEAD W/O CONTRAST
There is no acute intracranial hemorrhage, edema, mass effect or
major vascular territorial infarct. Ventricles and sulci are
minimally prominent, compatible with global age-related volume
loss. Basal cisterns are patent. There is no shift of normally
midline structures. A hypodense focus in the left thalamus is
from prior hemorrhage. Hypodense foci in the left subinsular
region and left frontal lobe are unchanged from [**2175-6-16**]. A
hypodense focus in the left centrum semiovale (2A:15) may
represent a tiny lacune, new from [**2175-6-16**]. Otherwise,
[**Doctor Last Name 352**]-white matter differentiation is preserved. No acute
osseous abnormality is identified. The visualized paranasal
sinuses and mastoid air cells are clear.
[**2176-10-26**] CHEST (PORTABLE AP)
Patchy opacity at the right lung base could reflect atelectasis,
although aspiration or pneumonia could also have this
appearance. Followup imaging would be advised. The left lung
is grossly clear. No pleural effusions. No pneumothorax.
Overall, cardiac and mediastinal contours are stable. A
tortuous calcified aorta consistent with atherosclerosis. No
evidence of pulmonary edema. Nasogastric tube is seen coursing
below the diaphragm with the tip within the stomach and the
side port near the gastroesophageal junction. Advancement
should be considered to minimize the risk of aspiration.
Pathology: pending
[**2176-10-25**] Pathology Tissue: STOMA AND TRANSVERSE COLON,
[**2176-10-23**] Pathology Tissue: Decending colon, Rectum.
CHEST (PORTABLE AP) Study Date of [**2176-10-29**] 6:44 PM
In comparison with the study of [**10-29**], there is little overall
change. Bibasilar opacification is consistent with bilateral
pleural
effusions and compressive atelectasis. In the appropriate
clinical setting, supervening pneumonia would have to be
considered.
Brief Hospital Course:
The patient was admitted to the inpatient colorectal surgery
service after a complicated intraoperative course which can be
further described in the operative note. The patient was stable
on the inpatient floor, she was monitored closely for
hypotension as her pressure was low in during the procedure. On
the morning of post=operative day one, the patient's abdominal
pain was minimal however, the stoma was noted to be
dusky/blue/black, in the afternoon of post-operative day one the
stoma was nectrotic. This was monitored overnight into
Post-operative day two and the patient remained stable. On the
morning of post-operative day two, the patient was stable
however, after examinateion with a test tube, the stoma was
necrotic past the facia and it was decided by Dr. [**Last Name (STitle) **] that
she would be taken to the operating room for an exploratory
laparotomy, colectomy, and ileostomy. The patient was then
tachycardic and hypertensive post-operatively and transfered to
the [**Hospital Unit Name 153**] for closer monitoring.
[**Hospital Unit Name 153**] Course
Reasons for transfer: Tachycardia and Hypertension
69 yo F with HTN, T2DM, COPD on 2 L NC (baseline), h/o
infrarenal AAA s/p repair complicated by bowel ischemia with
multiple bowel surgeries most recently LOA/LAR/end colostomy
[**2176-10-23**] and re-exploration with right colectomy and end
ileostomy on [**2176-10-25**] transferred from the colorectal service
for hypertension up to SBP 200s and tachycardia to the 130s-150s
# Sinus Tachycardia. EKG excluded atrial fibrillation,
multifocal atrial tachycardia, and atrial flutter. Her UA was
negative. Blood cultures was NGTD. There was initial concern
for possible PNA, but CT chest did not show evidence of
consolidation. She was also ruled out of PE based on the CTA
chest. Beta blocker withdrawal seems unlikely as she received
multiple doses of metoprolol prior to transfer. She did not
have any evidence of bleeding and her exam did not show evidence
of hypovolemia by bedside ultrasound. There was initial thought
of possible heart failure, but patient auto-diuresed for the
most part and did not require signifant amount of diuretics.
She had extensive surgery prior to her transfer to the [**Hospital Unit Name 153**],
making it a result of the stress response certainly possible.
Patient was continued on broad spectrum antibiotics given that
she was found to have ischemic colon in her second surgery
during this admission. She was on esmolol gtt per surgery while
in the [**Hospital Unit Name 153**] that was ultimately transitioned to labetolol upon
transferring to the surgical floor
# Hypertension. Unclear etiology, although may have required
additional agents in the past for blood pressure. Patient is
unable to take CCB given previous allergy/hypersensitivity
reaction. Reports only taking metoprolol 50 mg daily which was
confirmed by PCP's record. There was initial concern of beta
blocker withdrawal although patient received multiple doses of
metoprolol prior to transfer. Esmolol gtt was used for rate
control and BP control initially, and was ultimately switched to
labetolol for BP control given more alpha action.
# Toxic metabolic encephalopathy/Delirium: Patient was noted to
be mildly somnolent and inattentive post-operative so neurology
was consulted. Per neurology note: "Her motor exam is remarkable
for asterixis, which was also superimposed on her finger to nose
testing. All of these signs make the toxic-metabolic
encephalopathy more likely, which can be common in acutely ill
patients. However, given her history of thalamic
intraparenchymal hemorrhage, it would be important to control
her hypertension as well to prevent further intracranial
hemorrhage. In setting of hypertension, PRES can be considered,
but also less likely as patient is not complaining of headaches
and there is no clinical seizures. She does complain of visual
hallucinations, but this can also be consistent with toxic
metabolic encephalopathy." Head CT witout contrast showed no
acute process. Patient was managed with supportive care for
delirium. PCA pump was discontinued as she was having
difficulty using it appropriately.
# s/p Colectomy [**2-8**] ischemia. Complicated surgical history with
total colectomy during this hospital course. She was started on
vancomycin and zosyn empirically given the extensive bowel
ischemia found on surgery. Her abdominal exam post-operatively
improved over time, and she was ultimately transitioned to
clears upon transferring back to the surgical floor from the
[**Hospital Unit Name 153**].
# COPD on O2 2L. Appears to be at baseline with O2 requirement
at the time of her [**Hospital Unit Name 153**] stay. She was continued on home
tiotropium and swtiched to advair as symbicort is non-formulary.
She was given albuterol and ipratropium nebs as needed.
# T2DM, not on any medications at baseline. Patient was kept on
sliding scale while in the [**Hospital Unit Name 153**].
# Mood d/o. Celexa was held temporarily when she was NPO in the
[**Hospital Unit Name 153**]. Benzodiazepine was also held while she was in the [**Hospital Unit Name 153**]
because of underlying delirium.
The patient was transferred to back to the inpatient colorectal
surgery service. Cardiology followed for hemodynamic monitoring.
The patient remained stable. on the inpatient unit. Her diet was
advanced as she had appropriate return of bowel function. She
had transient shortness of breath. A chest Xray was obtained on
[**2176-10-29**] which did not show fluid overload, her shortness of
breath was attributed to her baseline COPD. She was given
albuterol and atrovent nebulizing treatments which improved her
status. She intermittently used nasal canula oxygen as she had
done prior to her admission. Physical therapy consulted on the
patient, she refused to be discharged to a rehabilitation
facility. Her daughter agreed to take her to her house to stay
with VNA and home PT. The midline incision was noted to drain
and [**2-10**] staples were removed, exposing fascia which drained
small amounts of sero-sang drainage. The patient was followed by
pastoral care and case managment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation TID
2 puffs
2. Citalopram 10 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Temazepam 15 mg PO HS
7. Aspirin 81 mg PO DAILY
8. Ferrous Sulfate 160 mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Albuterol-Ipratropium 2 PUFF IH Q6H
12. Ipratropium Bromide Neb 1 NEB IH PRN Shortness of breath or
wheeze
13. Albuterol 0.083% Neb Soln 1 NEB IH PRN shortness of breath
or wheeze
14. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit
Oral daily
15. Potassium Chloride 10 mEq PO BID Duration: 24 Hours
Hold for K > 5.0
16. Estrace *NF* (estradiol) 0.1 mg/g Vaginal 2-3 times a week
1 gram
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Acetaminophen (Liquid) 650 mg PO Q6H
RX *acetaminophen 325 mg [**1-8**] tablet by mouth every six (6) hours
Disp #*45 Tablet Refills:*0
6. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
7. Labetalol 250 mg PO TID
RX *labetalol 100 mg 2.5 tablet(s) by mouth three times a day
Disp #*150 Tablet Refills:*1
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1-2-1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
RX *oxycodone 5 mg 1/2-1 tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
10. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION TID
2 puffs
11. Vitamin D3 *NF* (cholecalciferol (vitamin D3)) 1,000 unit
Oral daily
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Ferrous Sulfate 160 mg PO DAILY
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
if this medication is needed please call your pcp and if
symptoms are severe please go to the emergency room for medical
attention
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml every six (6)
hours Disp #*20 Each Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Anastomotic Stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a resection of your
previous anastomosis and end colostomy formation. Unfortunately,
after this first procedure you developed some impaired blood
flow to the stoma of the colostomy and you were brought back to
the operating room with Dr. [**Last Name (STitle) **] and part of the right colon
was removed and an ileostomy was formed. After this procedure,
you were taken care of in the intensive care unit to monitor
your cardiac issues. You have recovered from this procedure well
and you are now ready to return home. Samples from your colon
were taken and this tissue has been sent to the pathology
department for analysis. You will receive these pathology
results at your follow-up appointment. If there is an urgent
need for the surgeon to contact you regarding these results they
will contact you before this time. You have tolerated a regular
diet, passing gas and your pain is controlled with pain
medications by mouth. You may return home to finish your
recovery. It is very important that you have close follow-up
with the Colorectal Surgery Team and the wound ostomy nurses as
you are going home to your daughters house and not to rehab.
Please make an appointment with your primary care provider to
discuss your admission and changes in your cardiac medications.
Please pay close attention to your medication list and monitor
your blood pressure and heart rate at home. Please call our
office or your primary care provider if the top number of you
blood pressure is greater than 150 or lower than 90. Please
monitor your heart rate occationally at home and call if it is
greater than 95 beats in one minute or lower than 60 beats in
one minute.
If you have any of the following abdominal symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
difficulty with your ileostomy output.
You have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. You must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
you find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if you notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If you notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. You may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to you by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. The stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as you have been instructed by
the wound/ostomy nurses. You will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. You
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until you are comfortable caring
for it on your own.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. You have a small opening in he incision
where he incision line was opened. This should be packed with
gazue and changed 2-3 times daily s instructed by the floor
nursing staff. The other staples will stay in place until your
first post-operative visit at which time they can be removed in
the clinic, most likely by the office nurse. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub. You also have a small
incision where the JP drain was once in place and this was
removed prior to discharge. Please monitor this for the signs
and symptoms listed above of infection. If the drain site bleeds
or drains large amounts of sero-sang fluid requiring you to
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. [**Last Name (STitle) **].
You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please make a follow-up appointment with [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP or
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP and the wound/ostomy nurses for 7-10 days
after discharge. Please call the Colorectal Surgery Clinic to
make this appointment, [**Telephone/Fax (1) 160**]. Please call the is number
with any questions or concerns.
Please make an appointment with your primary care provider to
discuss this admission and the changes in your medication
regimen.
Completed by:[**2176-11-1**]
ICD9 Codes: 9971, 4019, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5399
}
|
Medical Text: Admission Date: [**2136-6-28**] Discharge Date: [**2136-7-9**]
Date of Birth: [**2066-3-12**] Sex: M
Service: SURGERY
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
pancreatic cancer
Major Surgical or Invasive Procedure:
[**2136-6-28**] - Retroperitoneal lymph node biopsies, exploratory
laparotomy, open cholecystectomy
History of Present Illness:
This 71-year-old man with severe chronic obstructive pulmonary
disease presents with pancreatic cancer that is borderline
resectable. He was prepared by a Pulmonology consult deemed to
be an acceptable but high risk for pancreatic resection and he
opted to proceed. He was electively brought to the operating
room for a planned Whipple procedure, but intra-operatively it
was noted that serosal implants existed beyond the nodal disease
which rendered this stage IV pancreatic cancer and the operation
was aborted. Retroperitoneal lymph node biopsies, exploratory
laparotomy and open cholecystectomy was performed.
Past Medical History:
PMH: COPD, on home oxygen 2L continuously; Anxiety; Depression;
OSA; Hx of ARF; DMII, HTN, CAD s/p PTCA [**35**] yrs BU, ?seizures vs.
syncope
PSH: open appendectomy, tonsillectomy, bilateral carotid stents
Social History:
Patient retired (used to work for oxygen device company) and
lives with his mother in [**Name (NI) 7740**]. Has 5 children. Previously
smoked 3-4 packs/day x 45 years gradually decreasing for past 8
years, now 0.75 pack per day. Patient states he quit alcohol 30
years ago. Prior crack/cocaine x 2 yrs. Quit a few yrs ago.
Family History:
Mother CABG [**14**], alive 95. Father died at of pancreatic cancer at
age 72.
Physical Exam:
VITALS: Afebrile, vitals signs stable.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
INCISION: incision is clean, dry and intact, without evidence of
erythema or drainage, staples have been removed.
Pertinent Results:
[**2136-6-28**] 05:21PM BLOOD WBC-11.1* RBC-3.43* Hgb-10.8* Hct-32.7*
MCV-95 MCH-31.5 MCHC-33.1 RDW-15.3 Plt Ct-169
[**2136-6-28**] 05:21PM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-140
K-3.6 Cl-111* HCO3-25 AnGap-8
[**2136-7-2**] 12:39PM BLOOD CK-MB-3 cTropnT-<0.01
[**2136-6-28**] 05:21PM BLOOD Calcium-8.7 Phos-2.6*# Mg-1.4*
[**2136-7-2**] CHEST (PA & LAT): Right basal opacity most consistent
with atelectasis. No evidence of pneumothorax is present.
Increased bilateral lung lucency most likely reflects emphysema
[**2136-7-2**] CT ABD & PELVIS WITH CONTRAST: status-post CCY, with a
moderate amount of free intermediate density fluid in the
perihepatic region and gallbladder fossa, extending to the
inferior margin of the liver. No rim enhancement. Small amount
of pneumoperitoneum, relates to the recent surgery. Biliary
stent in place, with minimal pneumobilia, without biliary
dilation. Stable pancreatic ductal dilation, secondary to known
pancreatic mass. Mild narrowing of the SMV, just proximal to the
confluence. Bilateral trace pleural effusions with basal
atelectasis. Small amount of simple pelvic free fluid. No
retroperitoneal air to suggest duodenal perforation.
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative period and transitioned to PO
narcotic medication with adequate pain control on POD#3. The
patient had some mental status changes in the post-operative
period, which was attributed to his medications versus acute
post-op delirium changes. He had serial neurologic exams. His
medication list was optimized to avoid anticholingeric or
delirium-inducing medications. It appeared that his home Xanax
was discontinued on admission and when resumed his mental status
improved. The patient remained alert and oriented to person and
place, but not always date/time.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. He did
experience some episodic hypotension post-op requiring
re-intubation and fluid resuscitation. Their vitals signs were
closely monitored with telemetry. The patient's home
anti-hypertensive medications were resumed on POD#[**4-13**] once his
pressures responded to fluids. His home dose of Plavix was
restarted on POD#5, and his aspirin was continued immediately
post-op. A right-sided central venous catheter was placed pre-op
and removed on POD#5 when he was deemed hemodynamically stable.
RESPIRATORY: The patient was extubated in the immediate post-op
period successfully.
His ABG revealed evidence of hypercarbia and carbon dioxide
retention post-op and he required re-intubation on POD#0. The
patient had no episodes of desaturation or pulmonary concerns
following being extubated after this pulmonary episode. The
patient denied cough or respiratory symptoms following this, and
was maintained on nebulizers and pulmonary treatments.
Pulmonology was consulted pre-op for clearance, and they
continued following post-op, and they recommended continuing his
MDIs. Pulse oximetry was monitored closely and the patient
maintained adequate oxygenation. He had a CXR on POD#5 which
showed some right lower lobe atelectasis, but otherwise was
reassuring.
GASTROINTESTINAL: The patient was NPO following their procedure
and maintained on IV fluids for hydration while NPO. Serial
abdominal exams were performed, and once flatus resumed, the
patient was transitioned to a clear liquid diet and their IV
fluids were hep-locked on POD#[**4-13**]. The patient experienced no
nausea or vomiting. A regular diet was initiated on POD#[**6-15**] and
the patient tolerated this well. There was some concern on POD#4
that the patient was clinical worsening. His WBC was elevated to
21, he spiked low grade temperatures and had new-onset
tachycardiac (with stable EKG findings) which raised the concern
for anastomotic leak or intra-abdominal bleeding. On POD#4, an
upright abdominal X-ray revealed no free air and a CT of the
abdomen and pelvis showed only a simple peri-hepatic fluid
collection with post-operative changes and no extravasation of
contrast or perforation. He was empirically placed on IV
Vancomycin and Zosyn with improvement. He was closely monitored
with serial abdominal exams, which were reassuring.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#2, at which time the
patient was able to successfully void without issue. On POD#4 a
Foley catheter was replaced for some low urine output and the
need for monitoring given the previous concerns for anastomotic
leak or bleeding. The patient's intake and output was closely
monitored for urine output > 30 mL per hour output. The Foley
was successfully removed again on POD#8. The patient's
creatinine was stable.
HEME: The patient's post-op hematocrit was stable and trended
closely. The patient remained hemodynamically stable and did not
require transfusion. The patient's coagulation profile remained
normal. The patient had no evidence of bleeding from their
incision.
ID: Their white count was 21 post-operatively (POD#4) and their
incision was closely monitored for any evidence of infection or
erythema. The patient initially only received standard
peri-operative antibiotics, but was started on empiric IV
Vancomycin and Zosyn on the evening of POD#4 given concerns for
anastomotic leak or infection. Blood and urine cultures were
obtained for low grade temperatures. He clinically improved with
IV antibiotics and his fevers resolved. Blood cultures revealed
[**3-16**] bottle positive for gram negative rods which speciated
E.coli that was pan-sensitive. He was continued on IV Zosyn and
transitioned to PO-Cipro for a 2-week course, which he will
complete on discharge.
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale. His home anti-hyperglycemic medications were
resumed when diet was restored.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
[**Hospital1 **] for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op once cleared by physical therapy. The
patient also had sequential compression boot devices in place
during immobilization to promote circulation. GI prophylaxis was
sustained with Protonix/Famotidine when necessary. The patient
was encouraged to utilize incentive spirometry, ambulate early
and was discharged in stable condition. He was discharged home
with his family, as rehabilitation was recommended, but the
family declined.
Medications on Admission:
albuterol 5 mg/mL, alprazolam 1 mg'''', plavix 75 mg', effexor
75 mg' QOD, finasteride 5 mg', fluticasone-salmeterol 250/50
mcg', glipizide 2.5 mg'', ipatroprium-albuterol 18/103 mcg'',
lisinopril 10 mg', metoprolol 100 mg', percocet 5/325 mg QID,
promethazine 6.25 mg/5 mL', aspirin 325 mg', docusate 100 mg',
flaxseed oil, magnesium oxide 400 mg'', omega-3 FAs 1000 mg''
Discharge Medications:
1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
[**2-12**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/wheeze.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold if diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. 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*
13. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
17. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day).
18. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for anxiety.
19. alprazolam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
20. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
21. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
22. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Unresectable metastatic pancreatic cancer
2. Gram negative bacteremia
3. Delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to Dr.[**Name (NI) 9886**] surgical service for
evaluation and management of your pancreatic malignancy. You are
now being discharged home. Please follow these instructions to
aid in your recovery:
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
General Discharge Instructions:
* Please resume all regular home medications, unless
specifically advised not to take a particular medication.
* Please take any new medications as prescribed.
* Please take the prescribed analgesic medications as needed.
You may not drive or operate heavy machinery while taking
narcotic analgesic medications. You may also take acetaminophen
(Tylenol) as directed, but do not exceed 4000 mg in one day.
* Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
* Avoid strenuous physical activity and refrain from heavy
lifting greater than 10 lbs., until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
* Please also follow-up with your primary care physician.
Incision Care:
* Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
* Avoid swimming and baths until cleared by your surgeon.
* You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
* If you have staples, they will be removed at your follow-up
appointment.
* If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2136-7-23**]
8:45 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-8-17**] 11:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2136-8-17**] 12:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 611**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2136-8-17**] 12:00
.
Please follow up with your PCP [**Last Name (NamePattern4) **] [**3-15**] weeks after discharge
ICD9 Codes: 5180, 2762, 7907, 496, 4019, 3051
|
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