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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5400
}
|
Medical Text: Admission Date: [**2153-12-12**] Discharge Date: [**2153-12-21**]
Service: A-Cove
IDENTIFICATION: The patient is a [**Age over 90 **]-year-old woman who was
admitted to the A-Cove Internal Medicine Service after being
transferred from the Medical Intensive Care Unit Service.
The patient was admitted to the hospital on [**2152-12-12**];
admitted to the A-Cove Service on [**2152-12-17**]. The
patient has a healthcare proxy named [**Name (NI) 1743**] [**Name (NI) 31**]
(telephone number is [**Telephone/Fax (1) 37695**]). The attending physician
on the [**Name9 (PRE) 37696**] Service was Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **].
HISTORY OF PRESENT ILLNESS: She came to us in the Internal
Medicine Service with atrial fibrillation and a lung mass.
This [**Age over 90 **]-year-old woman with a history of cholelithiasis was
transferred to the [**Hospital1 69**] on
[**2153-12-12**], for endoscopic retrograde
cholangiopancreatography to remove a common bile duct stone.
The case was complicated by atrial fibrillation to the 160s.
The patient was transferred to the Medical Intensive Care
Unit where she was rate controlled with intravenous Lopressor
and loaded with intravenous amiodarone.
On [**2153-12-14**], she was successfully cardioverted with
300 joules but subsequently went back into paroxysmal atrial
fibrillation. On [**2153-12-15**], a chest x-ray was done to
rule out congestive heart failure as a cause, and a right
hilar mass was found. Chest CT showed a large bihilar mass
invading into the right lung parenchyma and bilateral pleural
effusions which were very concerning small-cell lung cancer.
A long discussion was had with the patient and her family and
revealed that the patient was not interested in a treatment
of the lung cancer; and, therefore, she was not interested in
any further workup and converted to do not resuscitate/do not
intubate.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Coronary artery disease with angina.
2. Cholelithiasis.
3. Gastroesophageal reflux disease.
4. She has had an ovarian cyst excision.
MEDICATIONS ON TRANSFER: Medications when transferred to our
unit were amiodarone 400 mg p.o. b.i.d., Lopressor 25 mg p.o.
b.i.d., levothyroxine 500 mcg p.o. q.d., and
lansoprazole 30 mg p.o. q.d.
CODE STATUS: The patient is do not resuscitate/do not
intubate.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She lives alone on [**Hospital3 **]. She has a
niece and a son-in-law who are involved in her care.
PHYSICAL EXAMINATION ON PRESENTATION: Her physical
examination on admission revealed vital signs with
temperature of 98, heart rate 80 to 100 and irregular, blood
pressure 150 to 180/80 to 90, respiratory rate of 18, 94% on
4 liters. The woman was overall a well-developed/poorly
nourished white female in no apparent distress, and she was
not responding to questions at the time of examination, being
very drowsy having just been given Ativan for agitation. She
was anicteric. Extraocular muscles were intact. The
oropharynx was clear and moist. She had no jugular venous
distention. No lymphadenopathy. Heart had a regular rate
and rhythm, first heart sound and second heart sound. No
murmurs, rubs or gallops. Distant heart sounds. The chest
showed diffuse wet crackles bilaterally. The abdomen was
nondistended, bowel sounds were positive, soft, and
nontender. Extremities showed no cyanosis, clubbing or
edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Her laboratory
values showed a white blood cell count of 8.4,
hematocrit 28.5, platelets 190, mean cell volume 89. Her
SMA-7 revealed a sodium of 139, potassium 3.7, chloride 104,
bicarbonate 25, blood urea nitrogen 11, creatinine 0.5,
glucose of 94. Calcium 8.2, phosphorous 2.2, magnesium 1.7.
PT/INR was 1.1 with a PTT of 65. The patient was transferred
to us on heparin which was discontinued.
RADIOLOGY/IMAGING: Electrocardiogram on [**2153-12-17**],
revealed sinus tachycardia at 100, normal axis, normal
intervals, T wave flattening in I and F. No V3 tracing.
Unchanged from [**2153-12-12**].
Chest x-ray on [**2153-12-15**], showed interstitial edema,
small bilateral effusions.
Chest CT on [**2153-12-15**], showed no filling defects;
however, right greater than left pleural effusion with
atelectasis, soft tissue mass bilateral hilar with subcarinal
extending into the right lung parenchyma obliterating the
bronchus intermedius, mild narrowing of right and left main
stem bronchi concerning for small-cell lung cancer.
HOSPITAL COURSE: As mentioned, it was determined by the
patient and her family that the large lung mass would not be
worked up, and so the patient was no longer a followed for
this; a bronchoscopy which had originally been planned to be
done was done.
1. CARDIOVASCULAR: The patient had new onset atrial
fibrillation. She was loaded with amiodarone, and she was
eventually converted to sinus rhythm. She was maintained on
amiodarone 400 mg p.o. b.i.d., and she was on
metoprolol 25 mg p.o. b.i.d. for rate control.
It was determined that anticoagulation would not be
beneficial because the lung cancer represented a bleeding
risk, so no further anticoagulation was done.
2. CONGESTIVE HEART FAILURE: From a congestive heart
failure perspective, the patient was volume overloaded in
congestive heart failure, which may have resulted in her
being in atrial fibrillation because atrial fibrillation
stopped on the medications and with the diuresis that was
achieved. In fact, she was diuresed to the extent that her
blood pressure began to go down. She was gradually given
hydration without recurrence of her atrial fibrillation.
After two days her telemetry was discontinued because the
patient was do not resuscitate/do not intubate, and no
intervention would necessarily have been done in any case
based on her current medication regimen.
3. GASTROINTESTINAL: The patient was status post endoscopic
retrograde cholangiopancreatography for a 2-cm common bile
duct stone. She was doing well. Liver function tests were
beginning to normalize. She was maintained on levofloxacin
for a 14-day course.
4. HEMATOLOGY: From a hematologic perspective, she was
heparin and then this was discontinued, and her hematocrit
did not go below 25 so she was not transfused.
5. PROPHYLAXIS: For prophylaxis because of her
gastroesophageal reflux disease, she was given lansoprazole.
6. DISCHARGE DISPOSITION: Again, she was do not
resuscitate/do not intubate and it was determined that the
patient would be suitable for being transferred to the Bay
Point [**Hospital 3058**] rehabilitation facility at [**Hospital1 1474**] (which
will be done on Friday, planned for 1 p.m.), and she would
then hopefully be able to go back to her home and with some
degree of services depending on what was needed after her
rehabilitation stay.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 250 mg p.o. q.d. (through [**2153-12-26**]).
2. Isordil 10 mg p.o. t.i.d.
3. Dulcolax 10 mg p.r. q.8h. p.r.n.
4. Milk of Magnesia 30 cc p.o. q.6h. p.r.n.
5. Colace 100 mg p.o. b.i.d.
6. Senna 2 tablets p.o. q.h.s.
7. Protonix 40 mg p.o. q.d.
8. Amiodarone 400 mg p.o. b.i.d. (and a taper will
eventually be needed, but not at this point, so she will be
maintained on 400 mg p.o. b.i.d. She will have to follow up
with Dr. [**Last Name (STitle) 410**] who is her outpatient provider. [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1312**]
[**Last Name (NamePattern1) 410**] is at telephone number [**Telephone/Fax (1) 37697**] She was also
discontinued on metoprolol 25 mg p.o. t.i.d.).
DISCHARGE DIAGNOSES:
1. Cholelithiasis.
2. Paroxysmal atrial fibrillation.
3. Gastroesophageal reflux disease.
4. Coronary artery disease with stable angina.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2153-12-20**] 16:58
T: [**2153-12-20**] 16:12
JOB#: [**Job Number 37698**]
ICD9 Codes: 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5401
}
|
Medical Text: Admission Date: [**2173-3-12**] Discharge Date: [**2173-3-21**]
Date of Birth: [**2097-5-3**] Sex: F
Service: CT SURGERY
ADMISSION DIAGNOSIS: Coronary artery disease.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft times five.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
woman with a history of coronary artery disease, status post
percutaneous transluminal coronary angioplasty and stent
placement in [**2167**], for angina. She has been well for the
past five and one half years until one week prior to
admission where she developed crescendo angina with episodes
occurring at rest. Workup at [**Hospital3 **] ruled out a
myocardial infarction. However, Persantine Thallium showed a
reversible defect in the posterolateral wall with an ejection
fraction of 60%. She was referred for catheterization at
[**Hospital1 69**].
Her catheterization showed 70 to 80% left main and left
anterior descending stent D1 disease. No significant
circumflex disease. Left to right collaterals to the right
posterior descending artery. Right coronary artery with a
tight midlesion and proximal ostial posterior descending
artery lesion. The ejection fraction was preserved at 60%.
PAST MEDICAL HISTORY: Significant for:
1. Coronary artery disease, status post stent in [**2167**], as
above.
2. Hyperlipidemia.
3. Noninsulin dependent diabetes mellitus.
4. History of deep vein thrombosis times two in the right
lower extremity, status post venous ligation with veins
left in situ by report.
5. Status post cholecystectomy.
6. Arthritis in both knees, status post steroid injections.
MEDICATIONS ON ADMISSION:
1. Glucophage 1000 milligrams p.o. q.d.
2. Glucotrol 10 milligrams q.d.
3. Actos 45 milligrams q.d.
4. Lipitor 20 milligrams q.d.
5. Lopressor 25 milligrams q.d.
6. Vasotec 10 milligrams q.d.
7. Aspirin 81 milligrams q.d.
8. Coumadin which was held for catheterization.
ALLERGIES: Morphine, Codeine which cause nausea and
vomiting.
PHYSICAL EXAMINATION: On admission, significant for regular
rate and rhythm. The lungs are clear. Palpable distal
pulses.
LABORATORY DATA: On admission, significant for a white count
of 10.0, hematocrit 30.0. Normal chemistries. Normal
coagulation studies. Electrocardiogram shows sinus rhythm at
78 with left axis deviation and left ventricular hypertrophy.
Chest x-ray showed no acute cardiopulmonary process. Venous
duplex of the lower extremity veins was done which revealed
patent greater and lesser saphenous veins.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service where she remained pain free until she was taken for
coronary artery bypass graft on [**2173-3-15**]. She had coronary
artery bypass graft times five with left internal mammary
artery to the left anterior descending, saphenous vein graft
to the posterior descending artery and sequential to the PL,
saphenous vein graft to the OM and to the diagonal. The
patient tolerated the procedure well and was taken to the
Cardiothoracic Intensive Care Unit postoperatively where on
postoperative day number one she was extubated and
transferred to the floor. She was evaluated by physical
therapy.
On the morning of postoperative day number three, she was
found to be in atrial fibrillation. She was rate controlled
with Lopressor and converted with Procainamide. She
continued to work with physical therapy. She remained in
sinus rhythm throughout the remainder of her hospital stay
and on postoperative day number six was found to be suitable
for discharge to home. She is to follow-up with [**First Name8 (NamePattern2) **] [**Doctor Last Name 1537**]
in three weeks time and with [**First Name8 (NamePattern2) **] [**Last Name (un) 18323**] tomorrow who will
also follow her INR. Given her history of deep vein
thrombosis, the patient's Coumadin was resumed on
postoperative day number two.
DISCHARGE MEDICATIONS:
1. Coumadin dose per [**First Name8 (NamePattern2) **] [**Last Name (Titles) 18323**].
2. Lopressor 100 milligrams p.o. b.i.d.
3. Lipitor 20 milligrams p.o. q.h.s.
4. Procainamide SR 500 milligrams p.o. q6hours.
5. Glucophage 1000 milligrams p.o. q.a.m..
6. Glucotrol 10 milligrams p.o. q.d.
7. Actos 45 milligrams p.o. q.a.m.
8. Lasix 20 milligrams p.o. q.d. times five days.
9. KayCiel 20 meq p.o. q.d. times five days.
10. Colace 100 milligrams p.o. b.i.d.
11. Vasotec 20 milligrams p.o. b.i.d.
12. Percocet one to two tablets p.o. q4hours p.r.n.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 22884**]
MEDQUIST36
D: [**2173-3-21**] 13:33
T: [**2173-3-21**] 15:50
JOB#: [**Job Number 33605**]
ICD9 Codes: 4111, 9971
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5402
}
|
Medical Text: Admission Date: [**2167-3-28**] Discharge Date: [**2167-4-9**]
Date of Birth: [**2167-3-28**] Sex: F
Service: Neonatology
HISTORY: Infant is a 36-1/7 week admitted to the Neonatal
Intensive Care Unit on day of life four, 3225 grams female who
was admitted to the NICU after observing significant apnea
and bradycardia during a routine car seat screening.
Infant was born to a 33-year-old gravida 2, para 1 now 2
mother. Serologies: A positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, GBS negative.
Past maternal medical history notable for history of
tonsillectomy, laparoscopy.
Past obstetric history notable for full-term male newborn who
was born by cesarean section due to CPD.
This pregnancy was uncomplicated. Mother was well
throughout. No intercurrent or chronic illnesses including
HSV. Plan was to deliver by repeat C section later in the
month, but did enter preterm labor prompting an earlier C
section. No maternal fever. Rupture of membranes occurred
at the time of delivery. Clear fluid. Apgars were five at
one minute and eight at five minutes.
Infant was sent to the Newborn Nursery. Newborn Nursery
course uneventful. Infant's temperatures ranged from
97.7-98.6, heart rate was 130/140, respiratory rate 40-50,
voiding and stooling. Breast feeding plus supplementation.
Birth weight 7 pounds 2 ounces. Peak weight loss to 6
pounds, 4 ounces on day of life #3. On day of admission to
the Neonatal Intensive Care Unit, the weight was 6 pounds, 6
ounces.
Noticed to be jaundiced on day of life two. Bilirubin was
12.5 on day of life three. Bilirubin was 14.8, phototherapy
begun, then 12.8 and on day of life four, bilirubin was 13.2.
Infant was receiving phototherapy on day of admission.
Presented to the NICU for car seat screening, due to
gestational age less than 37 weeks. Apnea and bradycardia
noted prompting NICU admission and further evaluation.
PHYSICAL EXAM ON ADMISSION: Birth weight was 3225 grams
(90th percentile). Weight on admission was 2880 grams,
length 49 cm (75th percentile), head circumference 34.5 cm
(90th percentile). Anterior fontanel is soft and flat,
palate intact, neck supple. Lungs clear and equal with good
aeration. Regular, rate, and rhythm, no murmur, normal
pulses. Abdomen is soft, positive bowel sounds, no
hepatosplenomegaly or other masses. Normal female, patent
anus, no sacral anomalies. Hips stable. Extremities: Pink
and well perfused. Reflexes are normal and symmetric.
Positive morrow, positive suck, positive grasp.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Infant remained in room air throughout this
hospitalization with oxygen saturations greater than 98%,
respiratory rate 30-50. Last apnea and bradycardia was on
[**2167-4-4**]. Apnea and bradycardia events thought to be
due to immaturity as no other etiologies were evident at the
time of admission and during the observation/hospitalization
period. Infant was not treated with methylxanthines.
2. Cardiovascular: Infant has remained hemodynamically
stable this hospitalization. On the discharge exam a 2/6 SEM
murmur was heard at the left mid-to-lower sternal border which
radiated across axilla and back. Pulses are strong throughout,
perfusion is good and she remains well-saturated in room air.
This pattern in premature infants is consistent with
peripheral pulmonic stenosis (PPS), a benign murmur. Another
etiology to consider is a small VSD. An EKG was obatined and
will be read by the cardiology service at [**Hospital3 1810**]
and we will notify you of the results. Would recommend a
formal cardiology consult if any clincal change, change in
murmur, or if murmur persists. I have discussed this with the
mother.
3. Fluids, electrolytes, and nutrition: Infant has been
breast feeding and po feeding adlib with expressed breast milk
or [**Hospital3 37112**] 20. The mother has been supplementing with [**Name (NI) 37112**]
20 after breast feeding. Infant has been tolerating feedings
without difficulty. Most recent weight is 3100 gms. Head
circumference 33.5 cm, length 51 cm.
4. Gastrointestinal: The infant was admitted to the Neonatal
Intensive Care Unit receiving single phototherapy for a
maximum bilirubin level of 14.8. Phototherapy was
discontinued on day of life five. Bilirubin level was drawn
on [**4-9**], on the day of discharge, and was 10.2/0.3.
Infant did not receive any transfusions this hospitalization.
Most recent hematocrit on day of life four was 47.8%.
5. Infectious Disease: A complete blood count, differential,
and blood culture were drawn on admission for rule out
sepsis. The complete blood count showed a white blood cell
count of 6.6, hematocrit 47.8%, platelets 111,000, 51 polys,
and 0 bands. Antibiotics were not started due to no maternal
sepsis risk factors. The blood culture remains negative to
date. A repeat platelet count was sent on day of life five
which was 530,000.
6. Neurology: No issues. Sensory: Audiology hearing
screening was performed with automated auditory brain stem
responses. Infant passed both ears.
7. Psychosocial: Parents involved with [**Doctor First Name **]. [**Hospital1 346**] Social Work involved with family.
The contact social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Former 36-1/7 week gestation infant,
stable in room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 714**] [**Last Name (NamePattern1) **], [**Hospital3 47775**], phone #[**Telephone/Fax (1) 43701**].
FEEDINGS AT DISCHARGE: Breast feeding adlib with
supplementation of [**Telephone/Fax (1) 37112**] 20 calories/ounce on demand q3-4h.
MEDICATIONS: None.
CAR SEAT POSITION SCREENING: Was performed prior to
discharge, and the infant passed.
STATE NEWBORN SCREEN: State Newborn Screens were sent, last
one [**4-9**], results are pending.
IMMUNIZATIONS: The infant received hepatitis B vaccine on
[**2167-4-7**].
FOLLOW-UP APPOINTMENTS: Scheduled with primary pediatrician
on [**2167-4-10**] at 12:30 pm.
DISCHARGE DIAGNOSES:
1. Preterm female.
2. Status post apnea of prematurity.
3. Status post rule out sepsis.
4. Status post hyperbilirubinemia.
5. Cardiac murmur - most likely peripheral pulmonic stenosis.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 47014**]
MEDQUIST36
D: [**2167-4-9**] 00:53
T: [**2167-4-9**] 04:04
JOB#: [**Job Number 49369**]
ICD9 Codes: 7742, V053, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5403
}
|
Medical Text: Admission Date: [**2138-11-6**] Discharge Date: [**2138-11-15**]
Date of Birth: [**2077-8-15**] Sex: M
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:
Vesiculectomy with ileal neobladder construction
History of Present Illness:
This is a 61-year-old man who presented with
gross hematuria and had a diagnosis of moderate grade TCC in
[**2135**]. He underwent 3 courses of BCG and in [**2137**], developed T2
muscle invasive TCC. He was aware of all options for
treatment, and wished for radical cystectomy with creation of
neobladder.
Past Medical History:
Arthritis, GERD, bladder cancer s/p BCG x2 and cystoscopy.
Social History:
No alcohol abuse, no nicotine abuse.
Was in Printing business, used dyes.
Family History:
3 uncles, 2 [**Name2 (NI) 12232**] with bladder CA
Physical Exam:
HEENT: no significant abnormalities noted
CV: RRR no MRG appreciated
RESP: CTA B/L, no RRW
ABD: soft, tender appropriately to palpation, BS +, mildly
distended, wounds CDI
EXT: no CCE, peripheral pulses palpable b/l
Pertinent Results:
[**2138-11-13**] 06:30AM BLOOD WBC-7.1 RBC-3.55* Hgb-11.2* Hct-32.1*
MCV-90 MCH-31.5 MCHC-34.8 RDW-15.0 Plt Ct-264
[**2138-11-6**] 06:22PM BLOOD WBC-8.6 RBC-4.00*# Hgb-12.5*# Hct-36.5*#
MCV-91 MCH-31.2 MCHC-34.1 RDW-14.6 Plt Ct-167
[**2138-11-13**] 06:30AM BLOOD Plt Ct-264
[**2138-11-6**] 06:22PM BLOOD PT-15.1* PTT-31.7 INR(PT)-1.4*
[**2138-11-13**] 06:30AM BLOOD Glucose-123* UreaN-30* Creat-1.3* Na-137
K-4.1 Cl-105 HCO3-25 AnGap-11
[**2138-11-6**] 02:45PM BLOOD UreaN-15 Creat-1.4*
[**2138-11-7**] 04:28AM BLOOD CK-MB-15* MB Indx-1.1 cTropnT-<0.01
[**2138-11-6**] 08:12PM BLOOD Type-ART Temp-37.6 pO2-108* pCO2-45
pH-7.36 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
Brief Hospital Course:
Pt was admitted for Vesiculectomy and ileal neobladder
construction. Pt did well post operatively, but had episodes of
PVC's for which he was taken to MICU for observation.
Cardiology evaluated pt in MICU and began lopressor 25 mg [**Hospital1 **]
for ventricular Bigeminy. On POD 2 pt was transferred to floor
where he passed flatus and was advanced slowly on his diet,
which he tolerated in continuity. Pt conitued to have flatus
for entire post operative course, and normal bowel function
returned on POD 8. Pt's pain was intiially controlled with a
PCA, whcih was changed over to oral pain medication on POD 3.
[**Hospital 1094**] hospital course was significant for leakage of serous fluid
for the first 5 post operative days. JP creatinine was elevated
and CTU was c/w with extravasation of urine form neo bladder.
There was no ureteral leak on CTU. Pt was taught on how to
flush foley catheter, and was confortable with home care. JP
output dropped to less tha 10cc for 24hrs, and was d/c'd prior
to discharge. On POD 9 pt was cleared for discharge and sent
home with scheduled for follow up in 7 - 10 days for removal of
catheter. Pt was given Bactrim for 7 days and instructed to
begin CIprofloxacin on day prior to appointment with Dr. [**First Name (STitle) **]
for catheter removal.
Medications on Admission:
Advair 250/50, Flonase 1 [**Hospital1 **], Singulair 10 qd, Zyrtec 15 qd,
Zocor 40 hs, albuterol NEB PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 10 days.
Disp:*50 Tablet(s)* Refills:*0*
5. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: DO NOT START THIS MEDICATION UNTIL THE DAY BEFORE YOU
RETURN TO OFFICE FOR FOLEY CATHETER REMOVAL.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bladder cancer
Discharge Condition:
stable
Discharge Instructions:
Return to ER if:
- persistent temp > 101.4
- severe abdominal or pelvic pain
- persistent nausea, vomiting or diarrrhea
- pus or bloody discharge from wound or urine
Followup Instructions:
f/u with Dr. [**First Name (STitle) **] in 1 -2 weeks, call office for appointment
ICD9 Codes: 9971, 2851, 5859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5404
}
|
Medical Text: Admission Date: [**2150-1-28**] Discharge Date: [**2150-1-29**]
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left thalamic hemorrhage.
Major Surgical or Invasive Procedure:
Endotracheal intubation and mechanical ventilation.
History of Present Illness:
Patient is a 86 year old right handed woman with history of
diabetes and hypertension who presents with intracerebral
hemorrhage. She was visiting a friend with her husband around
11 Am when she had headache and was given an aspirin but could
not put it in her mouth because her right arm was weak. Her
friend then helped her swallow the aspirin but then she vomited
dark brown emesis. She was taken to [**Hospital1 **] where vitals were
108/81 94 24 and non contrast head CT showed left thalamic
hemorrhage. Since patient was not responsive and had fixed 5 mm
pupils, she was electively intubated at 11:15 am and given
Nipride. Her blood pressure then increased to 162/91 on nipride
at 2 PM. Patient was then transferred to [**Hospital1 18**] for further
management.
Past Medical History:
1. Diabetes
2. Hypertension
Social History:
She is former office worker. Drinks alcohol socially. No tobacco
or drug use. She lives with husband and has walked with walker
since fall in [**7-26**]. Requires assistance with some activities of
daily living.
Family History:
No strokes, intracerebral hemorrhage or seizures.
Physical Exam:
Vitals: Blood pressure 75/33, pulse 86, intubated with AC
500x12/5, not overbreathing the ventilator.
Gen: Intubated, not currently sedated. No acute distress.
Neck: Supple, no carotid bruits.
Chest: Clear to auscultation anterolaterally.
Abd: Soft, non tender, non distended.
Ext: No clubbing, cyanosis, or edema.
Neuro: Intubated, not on sedation. Does not responds to voice or
sternal rub.
Eyes midline with pupils fixed at 5 mm bilaterally. No
oculocephalic reflex or
blink to threat. No gag or right corneal reflex. +left corneal
reflex. Papilledema bilaterally. Unable to assess facial
symmetry secondary to endotracheal tube. Normal tone. No
spontaneous movements. Extensor posturing of arms to stimuli
and withdraws to stimuli in legs bilaterally. Reflexes 1+/4 at
biceps but otherwise absent. Toes equivocal bilaterally.
Pertinent Results:
[**2150-1-28**] 04:35PM WBC-10.0 RBC-2.89* HGB-9.2* HCT-29.5*
MCV-102* MCH-31.8 MCHC-31.2 RDW-14.5
[**2150-1-28**] 04:35PM NEUTS-64 BANDS-20* LYMPHS-9* MONOS-5 EOS-0
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2150-1-28**] 04:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2150-1-28**] 04:35PM PLT COUNT-285
[**2150-1-28**] 04:35PM PT-13.5 PTT-24.9 INR(PT)-1.2
[**2150-1-28**] 04:35PM GLUCOSE-191* UREA N-21* CREAT-1.1 SODIUM-140
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-22 ANION GAP-19
[**2150-1-28**] 04:35PM CK(CPK)-37
[**2150-1-28**] 04:35PM CK-MB-NotDone cTropnT-0.12*
[**2150-1-28**] 11:34PM CK-MB-NotDone cTropnT-0.12*
-----
Non-contrast head CT [**2150-1-29**]: FINDINGS: There is a large area of
intraparenchymal hemorrhage in the left thalamus measuring 2.8 x
2.3 cm. It is causing shift of the normally midline structures
to the right. There is also a large amount of blood in the left
lateral ventricle and a small amount of blood in the occipital
[**Doctor Last Name 534**] of the right lateral ventricle. The ventricles are
prominent, which could represent hydrocephalus. Recommend
comparison with the prior study. There is also blood extending
to left side of the pons and ambient cistern, and the pons
appears displaced to the right. There is also blood in the right
cerebellar hemisphere. Suprasellar cistern is patent. There is
an air fluid level in the right maxillary sinus.
IMPRESSION:
1) Large intracranial hemorrhage as described above, causing
shift of the midline structures to the right.
2) Air fluid level in the right maxillary sinus.
-----
Brief Hospital Course:
Patient is an 86 year old woman with history of hypertension and
diabetes who
presented to [**Hospital1 18**] as a transfer from [**Hospital1 **] after onset of
headache, emesis, and depressed mental status. Noncontrast head
CT at [**Hospital1 **] demonstrated a left thalamic hemorrhage. Repeat
head CT after arrival to [**Hospital1 18**] showed extension with large area
of intraparenchymal hemorrhage in the left thalamus measuring
2.8 x 2.3 cm, causing shift of the normally midline structures
to the right. There was also a large amount of blood in the left
lateral ventricle and a small amount of blood in the occipital
[**Doctor Last Name 534**] of the right lateral ventricle. The ventricles were
prominent, which could represent hydrocephalus. There was also
blood extending to left side of the pons and ambient cistern,
and the pons appeared displaced to the right. There was also
blood in the right cerebellar hemisphere.
Exam showed left corneal reflex, papilledema, arm extensor
posturing, and leg withdrawal. Given the absence of some
brainstem reflexes suggestive of brainstem compression and
herniation, family was notified of the gravity of her prognosis.
She was admitted to the NeuroICU for monitoring and blood
pressure control. Neurosurgery was consulted regarding drain for
hydrocephalus; they did not feel surgical intervention was
warranted. Over the next several hours, her exam worsened, with
loss of corneal reflexes, no blink to threat, decorticate
posturing and triple flexion of the lower extremities. She
required intravenous pressors for blood pressure support. Family
meeting was held with ICU staff, Neurology team, and patient's
family and gravity of situation reinforced. Family at that point
decided to focus care on comfort measures only. Pressor support
discontinued around 14:28 [**2150-1-29**]. Mechanical ventilation
discontinued. Morphine and Ativan given for patient comfort.
Patient expired [**2150-1-29**] at 18:00. Family notified.
Medications on Admission:
1. Metformin 850 mg po bid
2. Lisinopril 12.5 mg po qd
3. Niacor
4. Seed oil
Discharge Medications:
Not applicable.
Discharge Disposition:
Expired
Discharge Diagnosis:
Left thalamic hemorrhage with intraventricular extension,
herniation.
Discharge Condition:
Expired.
Discharge Instructions:
Not applicable.
Followup Instructions:
Not applicable.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 431, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5405
}
|
Medical Text: Admission Date: [**2171-1-10**] Discharge Date: [**2171-1-16**]
Date of Birth: [**2106-7-11**] Sex: F
Service: CSU
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 6330**] is
a 64-year-old woman with no history of heart disease who was
admitted to [**Hospital 1474**] Hospital with right upper quadrant pain.
The patient has had this discomfort for number of months.
Mostly she notices it if she walks after a meal. She has
also had some episodes during the middle of the night. It
does not radiate; there has been some mild shortness of
breath. The pain has worsened over the past 2 weeks. She
has had nausea and vomiting for the past 2 days and was
admitted to the emergency room at [**Hospital 1474**] Hospital and
ultimately admitted. An EKG shown after admission showed ST
elevations in V5 and V6. The patient had positive troponins
and was transferred [**Hospital1 69**] for
further management and cardiac catheterization.
PAST MEDICAL HISTORY: Past medical history is significant
for hypertension, diabetes, coronary artery disease,
hysterectomy and back surgery.
MEDICATIONS: Prior to admission include Glucophage,
glyburide, atenolol; Lisinopril and hydrochlorothiazide.
ALLERGIES: The patient states no known drug allergies.
FAMILY HISTORY: Family history is negative for coronary
disease.
SOCIAL HISTORY: Denies tobacco, denies alcohol use. She is
widowed with one daughter who lives nearby.
PHYSICAL EXAMINATION: Physical exam reveals heart rate in
the 60s, blood pressure 157/75, respiratory rate 20.
GENERAL: No acute distress. HEENT: Anicteric, noninjected.
Pupils equally, round, and reactive to light. Neck is supple
with no thyromegaly or lymphadenopathy and no JVD and no
bruits. Mucous membranes are moist. CHEST: Clear to
auscultation. CARDIOVASCULAR: Regular rate and rhythm, S1-
S2 without S3 or murmurs. Abdomen is soft, nontender with no
masses, liver or spleen enlargement. EXTREMITIES: Warm,
well-perfused with no edema. Neurological exam: Cranial
nerves are intact. Motor is intact.
LABORATORY DATA: White count 12.8, hematocrit 38, platelets
359, INR 1.6, PTT 130, sodium 133, potassium 4.3, chloride
96, CO2 17, BUN 25, creatinine 1.1 lactate 2.8. CK is 121,
troponin 1.5, alk phos 81, AST 35, ALT 23. EKG sinus rhythm
with left ventricular hypertrophy, left anterior fascicular
block, [**Street Address(2) 4793**] elevations in V5 and 6.
HOSPITAL COURSE: The patient was brought directly to the
catheterization lab where she was found to have severe left
main and three-vessel disease with 80 percent left main
diffuse, 80 percent left anterior descending, 90 percent of
ostial left circumflex, OMB that was freshly occluded, right
coronary artery with an ostial 90 percent lesion and PDA with
an ostial 90 percent lesion. An intra-aortic balloon pump
was placed and Cardiac Surgery was consulted after which the
patient was brought emergently to the operating room. Please
see the OR report for full details.
In summary, the patient had a CABG times 3 with LIMA to the
left anterior descending, saphenous vein graft to obtuse
marginal and saphenous vein graft to PDA. Her bypass time
was 75 minutes with a crossclamp time of 46 minutes. She
tolerated the operation well was transferred from the
operating room to the cardiothoracic intensive care unit. At
the time of transfer the patient was AV paced at 87 beats per
minute with a mean arterial pressure of 73 and a CVP of 16.
She had milrinone at 0.25 mics kilogram per minute, Neo-
Synephrine at 0.3 mics per kilogram per minute and propofol
at 20 mics per kilogram per minute. Additionally, the
patient had an intra-aortic balloon pump at one to one. Once
in the cardiothoracic intensive care unit. the patient
remained hemodynamically stable. She was kept sedated
throughout the period of the operative day. Sedation was
initially discontinued to assess neurological status, during
which the patient was noted to move all extremities and
follow commands. She was then resedated until morning of
postoperative day 1, at which point her sedation was weaned.
She was successfully weaned from the ventilator and
extubated. Additionally on postoperative day 1 the patient's
milrinone infusion was weaned and ultimately discontinued.
On postoperative day 2 the patient remained hemodynamically
stable. She was noted to have a period of atrial
fibrillation and for this was started on amiodarone and her
intra-aortic balloon pump was weaned and removed on
postoperative day 2. On postoperative day 3 the patient
converted back to normal sinus rhythm. Her amiodarone
infusion was changed to oral dosing was transferred to [**Hospital Ward Name 121**] 2
for continuing postoperative care and cardiac rehabilitation,
close hemodynamic monitoring as well as pulmonary toilet.
Over the next several days, the patient had an uneventful
postoperative course. Her activity level was increased with
the assistance of the nursing staff and Physical Therapy
staff and on postoperative day 5 it was decided that the
patient was stable ready to be discharged to home. At the
time of this dictation patient's physical exam is as follows.
Temperature 98.7, heart rate 77 sinus rhythm, blood pressure
144/63 respiratory rate 18, O2 sat 94 percent on room air.
Weight preoperatively 75 kg; at discharge 77 kg. Physical
exam: NEURO: Alert and oriented x3. Moves all extremities.
Follows commands. Nonfocal exam. PULMONARY: Clear to
auscultation bilaterally. CARDIAC: Regular rate rhythm, S1-
S2 with no murmur. Sternum is stable. Incision with Steri-
Strips. No erythema or drainage. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
EXTREMITIES: Warm with trace edema; left lower extremity
endoscopic harvest site with Steri-Strips open to air, clean
and dry. The patients condition at the time of discharge is
good.
She is to be discharged home with visiting nurses.
DISCHARGE DIAGNOSES:
1. CAD status post coronary artery bypass grafting times
three with LIMA to the LAD, saphenous vein graft to OM and
saphenous vein graft to the PDA.
2. Hypertension.
3. Diabetes mellitus.
4. Hysterectomy.
5. Status post back surgery.
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq q.d. times 2 weeks.
2. Colace 100 mg b.i.d.
3. Aspirin 81 mg q.d.
4. Percocet 5/325 1-2 tablets q. for 6 hours p.r.n.
5. Metformin 500 mg b.i.d.
6. Glyburide 5 mg b.i.d.
7. Amiodarone 200 mg b.i.d.
8. Metoprolol 50 mg b.i.d.
9. Lasix 20 mg q.d. times 2 weeks
10. Lisinopril 40 mg q.d.
11. Lipitor 10 mg q.d.
It should be noted that the patient was started on Lipitor
while in the hospital and she should have follow-up liver
function tests as well as fasting cholesterol.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2171-1-16**] 12:05:40
T: [**2171-1-16**] 15:42:37
Job#: [**Job Number 9866**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5406
}
|
Medical Text: Admission Date: [**2107-11-8**] Discharge Date: [**2107-11-12**]
Date of Birth: [**2107-11-8**] Sex: M
Service: NB
ID: [**First Name5 (NamePattern1) **] [**Known lastname 65639**] is a 4 day old term infant with
[**Doctor Last Name 37202**]-Wiedemann Syndrome being transferred from [**Hospital1 18**] NICU to
[**Hospital6 33**] NICU.
HISTORY OF PRESENT ILLNESS: [**First Name5 (NamePattern1) **] [**Known lastname 65639**] is a former 4.355
kg product of a 38 and [**1-7**] week gestation pregnancy born to a
34-year-old G1, P0 woman. Prenatal screens: Blood type O
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis C surface antigen negative, group beta strep status
negative. The pregnancy was notable for an abnormal quadruple
screen showing increased risk for Down's syndrome. A level 2
ultrasound was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32866**] at [**Hospital 1474**]
Hospital. The ultrasound raised the question of [**Doctor Last Name 37202**]-
Wiedemann syndrome with the findings of a large protruding
tongue, enlarged kidneys with pyelectasis and increased
abdominal circumference; magnetic resonance imaging test
was performed at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] which
confirmed these findings. An amniocentesis was performed
showing karyotype 46 XY. Prenatal genetic testing for
[**Doctor Last Name 37202**]-Wiedemann syndrome showed paternal and maternal
methylation patterns in the critical region of chromosome
11p15.5 to be normal.
The mother presented in labor. Rupture of membranes occurred less
than 24 hours prior to delivery.
The infant was born by spontaneous vaginal delivery. He had
an episode of obstructive apnea with cyanosis in the delivery
room requiring positioning and brief blow by oxygen. Apgars were
8 at 1 minute, and 9 at 5 minutes. He was admitted to the
neonatal intensive care unit for further evaluation and
treatment.
PHYSICAL EXAMINATION: Physical examination upon admission to
the neonatal intensive care unit: Weight 4.355 kg, length 53
cm, head circumference 33 cm, length and weight greater than
the 90th percentile, head circumference at the 50th
percentile. HEENT: anterior fontanel, normal size, soft and
flat. Face bruised. Palate intact. Significant macroglossia which
at times obstructed the airway. Normal red reflex both eyes.
No ear creases. CHEST: Breath sounds clear. CARDIOVASCULAR:
No murmurs. Regular rate and rhythm. ABDOMEN: Soft. 3-vessel
cord. No omphalocele, no hepatosplenomegaly. Both kidneys
enlarged and smooth. No other masses appreciated.
GENITOURINARY: Normal phallus. Left testicle high in canal.
Right testicle not palpable. Patent anus. MUSCULOSKELETAL:
Hip unable to be abducted full 90 degrees. Normal sacral
dimple with small hair tuft. Hemihypertrophy with the right
leg longer than the left leg. Very large hands and feet.
NEURO: Active, moving all extremities. Normal tone. SKIN:
Well perfused. No lesions.
HOSPITAL COURSE BY SYSTEMS WITH PERTINENT LABORATORY DATA:
RESPIRATORY: [**Doctor First Name **] has been in room air for his entire
neonatal intensive care unit admission. Baseline respiratory
rate is 30 to 50 breaths per minute. Oxygen saturation
greater than or equal to 95%.
CARDIOVASCULAR: A murmur was noted on day of life 2. A
cardiac echo was performed on [**2107-11-10**], which showed
3 small muscular ventricular septal defects, the largest
approximately 2 to 3 mm in size and posterior apical in
location. Two small additional anterior muscular ventricular
septal defects were seen as well, all restrictive with left to
right flow. Also seen was a patent foramen ovale and trivial
peripheral pulmonary artery stenosis. Biventricular function was
normal. [**Doctor First Name **] has maintained normal heart rates and blood
pressures throughout admission. Recent blood pressure was 68/42
with a mean of 49, baseline heart rate is 130 to 160 beats per
minute. [**Doctor First Name **] was evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10123**], cardiologist from
[**Hospital3 1810**], [**Location (un) 86**]. Repeat cardiology evaluation is
recommended prior to discharge, with additional follow-up with
cardiology after discharge.
FLUIDS, ELECTROLYTES AND NUTRITION: Infant experienced mild
hypoglycemia over first 24 hours of life, responding to IVF
supplementation as well as initiation of enteral feedings. IVF
were discontinued by DOL #2, and since that time, d-stiks have
been stable on full enteral feedings. By the time of discharge,
infant was receiving 60 cc/kg/day E20, just advanced to 80
cc/kg/day. He was taking up to [**1-2**] volume of his feedings PO
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 38296**] nipple, and rest PG. Serum electrolytes on day
of life 1 showed sodium of 137, potassium of 4.6, chloride of
104, total CO2 of 21. Due to risk for parathyroid abnormalities,
calcium level was checked and was normal at 8.6. Due to risks of
hyperlipidemia, a lipid profile was performed on [**11-12**], showing
baseline values of cholesterol 113, triglycerides 131, HDL
cholesterol 25, and calculated LDL cholesterol 62. The weight on
the date of discharge is 4170 gm.
ENDOCRINE: Thyroid function tests were measured on [**11-12**], and
were within normal limits, with TSH 16.2, T4 11.9, and T3 85.
Calcium level was normal, suggesting appropriate parathyroid
function.
INFECTIOUS DISEASE: There were no sepsis risk factors and no
infection issues during admission.
GASTROINTESTINAL/RENAL: An abdominal ultrasound was performed on
[**2107-11-9**] to evaluate the abdominal cavity and kidneys. The liver
was normal. No masses were identified. Gallbladder also normal.
The left portal vein was noted to be enlarged and the
umbilical vein was widely patent. Kidneys were enlarged (see
below) but no other anomalies were noted. [**Doctor First Name **] required
treatment for unconjugated hyperbilirubinemia with phototherapy.
Peak serum bilirubin occurred on day of life 3 with a total of
16.1/0.7 mg per dL, decreasing to 14.5/0.5 on the day of transfer
at which point phototherapy was discontinued.
HEMATOLOGICAL: Hematocrit was 43.9% at birth. Platelets were
207,000.
GU: By ultrasound on [**11-9**], kidneys were noted to be enlarged: the
left kidney measured 7 cm and the right kidney measured 6.5 cm,
with loss of corticomedullary differentiation in both kidneys. On
the left there was mild dilatation of the renal collecting
system. The nephrology service at [**Hospital1 **] was consulted by
phone, and they recommended consideration of
voiding cystourethrogram to rule out posterior urethral valve and
1 month outpatient follow up for the enlarged kidneys. VCUG was
thought to be of low yield by the neonatology service, and has
not been performed at the time of transfer. BUN/Cr were measured
on [**11-11**] and were normal at 5/0.7, and infant has had normal
urine output throughout. Note pelvic ultrasound to evaluate for
cryptoorchidism was not performed.
GENETICS: Dr. [**First Name4 (NamePattern1) 622**] [**Last Name (NamePattern1) 36467**] met the family prenatally and
also consulted on [**Doctor First Name **] after he was born. Infant's appearance
was consistent with diagnosis of [**Doctor Last Name 37202**]-Wiedemann Syndrome.
Evaluation of endocrine and lipid status was recommended and
performed as outlined above. Baseline serum AFP level was sent
on [**11-12**] (results pending), and infant will require serum AFP
levels and abdominal ultrasounds every 3 months through age 8
given high risk of tumor development. The genetics service is
pursuing further genetic testing on the parental and
amniocentesis samples sent prenatally, and may send addition
tests on the infant as an outpatient. Infant will need follow-up
with Dr. [**Last Name (STitle) 36467**] approximately 3 months after discharge, phone
#[**Telephone/Fax (1) 37200**] or [**Telephone/Fax (1) **].
NEUROLOGY: [**Doctor First Name **] has maintained a normal neurological
examination during admission. There are no neurological
concerns at the time of discharge.
Audiology: Hearing screening has not yet been performed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transferred to [**Hospital6 33**]
for continuing care. The parents have not as yet chosen a
primary pediatrician.
CARE RECOMMENDATIONS:
1. Feedings: Enfamil 20, minimum of 80 cc per kg per day PO
or PG. Periodic monitoring of d-stiks.
2. Medications: No medications.
3. Car seat position screening has not been performed.
4. State newborn screen was sent on day of life 3 with no
notification of abnormal results to date.
5. Immunizations received - hepatitis B vaccine was
administered on [**2107-11-11**].
6. 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.
ONGOING CARE ISSUES AND FOLLOW-UP:
Infant will require repeat abdominal and pelvic ultrasound in [**1-2**]
weeks to monitor renal size, insure appropriate closure of the
umbilical vein, and to evaluate for cryptoorchidism given
non-palpable right testicle. Consideration can be given to a
VCUG if additional hydronephrosis is noted. Cardiology (Dr.
[**Last Name (STitle) 10123**] should be contact[**Name (NI) **] prior to discharge, and outpatient
follow-up with Cardiology arranged. Infant will also need
follow-up with Genetics (Dr. [**Last Name (STitle) 36467**] after discharge. The
Genetics service is available by phone through [**Hospital3 18242**] page operator should further questions arise.
DISCHARGE DIAGNOSIS:
1. [**Doctor Last Name 37202**]-Wiedemann syndrome.
2. Unconjugated hyperbilirubinemia.
3. Multiple ventricular septal defects.
4. Renal hypertrophy with mild left hydronephrosis.
5. Immature feeding pattern requiring PG supplementation.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2107-11-12**] 01:08:48
T: [**2107-11-12**] 02:30:24
Job#: [**Job Number 65640**]
ICD9 Codes: V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5407
}
|
Medical Text: Admission Date: [**2184-12-16**] Discharge Date: [**2184-12-21**]
Date of Birth: [**2104-11-3**] Sex: M
Service: MEDICINE
Allergies:
Biaxin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
hypotension, altered mental status
Major Surgical or Invasive Procedure:
Left internal jugular central line
History of Present Illness:
80 yo M tobacco smoker with severe COPD on continuous home
oxygen 2L NC (FEV1/FVC: 60%, FEV1: 17% and FVC: 28% in '[**82**]) and
lung CA on day 16 of cycle 2 of Navelbine, who was recently
admitted to [**Hospital1 18**] for CCOPD exacerbation and cellulitis/DVT
([**Date range (1) 32120**]). After his last admission, he was started on a
prednisone taper and continues to be on prednisone 15mg once
daily. He lives in an [**Hospital3 **] facility in [**Location (un) **] and
has been receiving chemotherapy as an out patient. This AM, the
pt was found covered in stool at the [**Hospital3 **] facility.
He was found by the staff to be weak and disoriented in addition
to incontinent of stool. As per the report sheet, he was
reported feeling "pretty good" with baseline sob/doe. However he
was found to be speaking in [**1-30**] word sentences and EMT found the
pt to be hypotensive with BP of 84/54. The pt reports he
normally is able to walk [**4-2**] steps prior to developing SOB even
with oxygen however in recent days he does not believe he can do
even that. He reports a possible fever several days previously
(measured by VNA but he was not how high), but without chills or
rigors. He denies any dysuria, urinary frequency, diarrhea, or
abdominal pain or n/v, head ache, neck stiffness or change in
vision including peripheral vision. The pt also denies any
significant back pain. He received tylenol for the fever and it
has since resolved. He denies any chest pain, palpitations, LE
edema. He denies any change in his appetite but reports he has
been eating a lot of sugar, he also denies any change in his
body weight or abdominal distension. He received a flu shot this
year and a pneumovax several years previously. The pt believes
he is here for his weekly chemotherapy tx and is unclear why he
was in the [**Name (NI) **] or the [**Hospital Unit Name 153**].
In the ED, the pt was found to be hypotensive to the 84/54 with
HR of 76 with oxygen saturation of 90% on RA. The pt was placed
on 4L NC with saturation in the mid 90s, however he was
desaturating to the 80s with movement. He was therefore started
on NRB in the ED. ABG at the time was the follow: 7.38/38/74. In
addition, he was found to have a WBC of 0.7, an ANC of < 500,
and lactate 2.1. The pt also had a proBNP of 1712. UA was
negative. CXR demonstrated a right para mediastinal mass which
measured 4.7 x 3.9 cm in size (unchanged from previous) and
vague nodular densities at lung bases with some pulmonary edema
but no focal infiltrates. A right IJ was placed. CVP was
initially measured between [**9-8**], and after fluid resuscitation
was found to be 20. He was given cefepime and vancomycin for
presumed febrile neutropenia as well as dexamethasone 10mg IV x1
as he is chronically on prednisone. In addition, the pt received
2unit of PRBC for Hct of 23.7 and 3L of NS and was transferred
to the [**Hospital Unit Name 153**].
Past Medical History:
Oncology History: Mr. [**Known lastname 21781**] was initially found to have
multiple polyps on routine colonoscopy in [**2182-11-28**]. A repeat
colonoscopy on [**2183-9-2**] with bx showed high grade dysplasia and
CIS. Follow up PET scan demonstrated abnormal FDG activity in a
lung nodule and in the transverse colon. On [**2184-7-2**] a
biopsy of the right upper lobe nodule yielded an
undifferentiated carcinoma which was positive for CK 7, negative
for CK 20 and TTF-1 and LCA. Although this pattern is not
specific it is compatible with primary pulmonary carcinoma.
After much discussion, a medical regimen consisting of Nevelbine
wsa initiated as his significant COPD and other co-morbidities
precluded a surgical approach. He is now on cycle two of
Nevelbine which he has tolerated well as an outpt.
PAST MEDICAL HISTORY:
1. Presumed primary lung CA metastatic to colon on Navelbine
2. COPD on 2L home oxygen. PFT on [**2183-9-18**] with FEV1/FVC: 60%,
FEV1: 17% and FVC: 28%.
3. CAD: ETT-MIBI [**1-27**] w/ moderate partially reversible inferior
defect, no c/o angina, med management -echo ([**9-30**]): EF 60%, no
WMA, could not assess PASP
4. Hyperlipidemia
5. Type II Diabetes
6. Chronic Renal Insufficiency baseline between 1 to 1.3.
7. Hypoxemia
8. History of DVT. Treated with heparin and coumadin.
9. Pelvic fracture and liver laceration from a MVA.
10. Anemia
11. Depression
12. Alcoholism
Social History:
He is now living in an [**Hospital3 **] facility. He requires
continuous oxygen. He is a former construction worker who never
married and has no children. He is estranged from his two
sisters.
[**Name (NI) **]: 1 PPD x 60 years, quit smoking 1 mo ago.
EtOH: Used to drink alcohol heavily, but quit 1 year ago
Illicit drugs: He denies IVDU.
Family History:
Father: deceased at 85. He had a history of DM.
Mother: deceased at 85 from "natural causes."
Brother: deceased from an accident at the age of 19.
Sister: His sisters are alive, but he doesn't communicate with
them.
Physical Exam:
VS in ED: T: 97.3, HR: 52 (as high as 72), BP: 91/38 (as low as
76/42), RR: 16, SaO2: 90% on RA
VS in [**Hospital Unit Name 153**]: T: 97.6, HR: 74, BP: 106/47, RR: 16, SaO2: 98% on
NRB
GEN: elderly male who appears his stated age, wearing FM.
conversing in short [**3-2**] word sentences.
HEENT: surgical pupils, EOMI, anicteric, op clear, mmm
CHEST: [**Month (only) **]. air movement with prolonged expiratory phase. no
crackles or obvious wheezing.
Neck: Right IJ
CV: rrr, s1, s2, no m/r/g
ABD: well healed vertical surgical wound in midline, markedly
distended, soft, NT, BS+ bilaterally, tympanic to percussion, no
obvious fluid wave
EXT: wwp, +1 non-pitting edema, mild chronic venous stasis
changes
NEURO: A+O x3 ([**Hospital1 18**], [**Location (un) **], [**Last Name (un) 2450**], [**Last Name (un) 24934**], himself, his
[**Last Name (un) **])
no rectal tone examined given ANC <500.
Pertinent Results:
[**2184-12-16**] 11:21PM O2 SAT-77
[**2184-12-16**] 10:40PM LD(LDH)-233 CK(CPK)-600*
[**2184-12-16**] 10:40PM CK-MB-3 cTropnT-<0.01
[**2184-12-16**] 10:40PM CORTISOL-13.5
[**2184-12-16**] 07:43PM LACTATE-1.7
[**2184-12-16**] 07:43PM HGB-10.5* calcHCT-32 O2 SAT-59
[**2184-12-16**] 06:15PM TYPE-ART PO2-74* PCO2-48* PH-7.38 TOTAL
CO2-29 BASE XS-1
[**2184-12-16**] 04:49PM URINE HOURS-RANDOM
[**2184-12-16**] 04:49PM URINE UHOLD-HOLD
[**2184-12-16**] 04:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2184-12-16**] 04:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2184-12-16**] 12:47PM GLUCOSE-275* LACTATE-2.1*
[**2184-12-16**] 12:30PM GLUCOSE-260* UREA N-24* CREAT-1.4* SODIUM-136
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
[**2184-12-16**] 12:30PM ALT(SGPT)-15 AST(SGOT)-32 CK(CPK)-935* ALK
PHOS-76 AMYLASE-34 TOT BILI-0.4
[**2184-12-16**] 12:30PM cTropnT-<0.01
[**2184-12-16**] 12:30PM CK-MB-3 proBNP-1712*
[**2184-12-16**] 12:30PM TOT PROT-6.1* CALCIUM-8.3* PHOSPHATE-4.0#
MAGNESIUM-1.7
[**2184-12-16**] 12:30PM WBC-0.7*# RBC-3.21* HGB-8.1* HCT-23.7*
MCV-74* MCH-25.3* MCHC-34.3 RDW-20.2*
[**2184-12-16**] 12:30PM NEUTS-32* BANDS-12* LYMPHS-28 MONOS-20* EOS-0
BASOS-0 ATYPS-0 METAS-8* MYELOS-0
[**2184-12-16**] 12:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2184-12-16**] 12:30PM PLT SMR-UNABLE TO PLT COUNT-390
[**2184-12-16**] 12:30PM PT-17.9* PTT-35.4* INR(PT)-2.2
Micro:
[**2184-12-16**] 1:00 pm BLOOD CULTURE VENIPUNCTURE.
AEROBIC BOTTLE (Preliminary):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) 26976**] [**Last Name (NamePattern1) 32121**], RN @ 4I [**Numeric Identifier 6026**] @ 0353AM
ON
[**2184-12-17**].
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC BOTTLE (Pending):
CXR [**2184-12-16**]:
The right paramediastinal mass is not significantly changed in
size, and on this radiograph measures 4.7 x 3.9 cm in size.
Vague nodular densities are again seen at the right lung base
superimposed over the pericardial fat pad, and also at the left
lung base along the diaphragmatic border. There are slightly
increased interstitial markings asymmetrically involving the
right hemithorax relative to the left. The cardiac and
mediastinal silhouettes appear unchanged. Aortic contour appears
within normal limits. No definite pleural effusions, although
extreme right costophrenic angle has been coned off of this
image. No evidence of pneumothorax. Focal pleural thickening/rib
fractures again seen at the lateral mid thoracic ribs on the
right.
IMPRESSION: Slight and asymmetric interstitial prominence of the
right hemithorax likely edema."
ECG [**2184-12-16**]: poor baseline ? for aflutter, LAD, RSR' in V1-V4,
no ST changes, poor R wave progression
Brief Hospital Course:
A/P: This is an 80 year old gentleman with lung cancer
metastatic to colon undergoing Navelbine chemotherapy, severe
COPD on home oxygen undergoing taper who was admitted with
sepsis to [**Hospital Unit Name 153**] and found to be neutropenic with Klebsiella
bacteremia. In [**Name (NI) 153**], pt had transient pressor requirement along
with IVF support for hypotension which resolved by HD 2. Stress
dose steroids were started. He was generally afebrile through
course in [**Hospital Unit Name 153**] and did not require intubation By the end of the
[**Hospital Unit Name 153**] stay once he was breathing with adequate saturation on 2L.
He was continued on empiric vancomycin, cefepime, and received
one dose of gentamicin. Blood cultures from admission grew 2 out
4 bottles with final culture being Klebsiella sensitive to
cefepime, resistant to levofloxacin and gentamcin. Vancomycin
was discontinued, cefepime was maintained Per Dr. [**Name (NI) 3274**], pt
received GM-CSF for his neutropenia. [**Hospital Unit Name 153**] course also remarkable
for intermittent atrial flutter seen on telemetry and
supratherapeutic INR for which coumadin was held. LE dopplers
revealed no presence of DVT.
.
On transfer to the general medical [**Hospital1 **] ([**2183-12-19**]), the patient
was afebrile, hemodynamically stable with no pressor or IVF
requirement. His neutropenia was noted to resolve s/p GM-CSF
treatment. Surveillance blood cultures taken on the His
respiratory status was still not at baseline and therefore the
pt was steroid regimen was made more potent by changing the
steroid to solumedrol. This was noted to improve the patients
respiratory status. The pt also was noted to become
significantly dysthymic, becoming tearful at times and with
evidence of hallucinatory behavior and therefore a psychiatry
consult was called. It was noted that the patients
antidepressants had not been given during his [**Hospital Unit Name 153**] stay and
these were therefore restarted with subsequent improvement in
his mental status. He was able to sleep, appeared euthymic and
no longer exhibited hallucinatory behavior.
By discharge the patient had returned to his baseline
respiratory status and had no signs of infection including
fever, chills, malaise or gastrointestinal symptoms. Given his
ongoing need to complete his IV antibiotic course, severe COPD,
metastatic lung cancer, ongoing chemotherapy and his home
situation (he lives alone), it was believed, with agreement from
the physical therapy service, that he would benefit from
transfer to an extended care facility.
In summary, this is an 80 year old gentleman with metastatic
lung cancer on chemotherapy, severe COPD, type II diabetes, DVT,
and depression who was admitted to [**Hospital Unit Name 153**] for sepsis, COPD
exacerbation, and found to have Klebsiella bacteremia. He was
treated with IV cefepime for his infection and high dose
steroids for his COPD. Sepsis was likely related to
immunosuppression secondary to chemotherapy. He is to continue
5 more days of antibiotics for his infection and a prednisone
taper for his COPD exacerbation. He will follow up with Dr.
[**Last Name (STitle) **] for further coordination of his chemotherapy for his
metastatic lung cancer.
Issues and plan from this hospitalization.
.
1. Sepsis/hypotension: Secondary to Klebsiella
infection/bacteremia. Source not yet clear although pt had R
PICC which is possible nidus; however culture from tip negative.
Certainly he was more susceptible to infection given his
chemotherapy-related neutropenia (he was 2 weeks out from last
treatment, hence he was at the nadir) His hemodynamic status
appears to have returned to nl.
-- continue IV cefepime for 5 days
--surveillance blood from [**12-17**] and [**12-18**] are negative thus far.
2. COPD: appears back at baseline, exacerbation likely secondary
to infection.
-Cont. oxygen supplementation, he is back at baseline O2
requirement
-albuterol nebs and tiatropium (replaces ipratropium) atrovent
nebs only as needed, --continue prednisone taper (see discharge
plan).
3. Neutropenia, resolved s/p GM-CSF treatment
-appears to be improving, continue to monitor CBC and ANC.
4. Metastatic lung cancer, on Navelbine treatment, will have to
defer further cycles for now, will coordinate with Dr. [**Last Name (STitle) **]
to determine timing of further treatment.
5. History of DVT: on coumadin was held for supratherapeutic
INR.
-LENI this admission negative for DVT. DVT from [**10-2**] now gone.
-Transitioning to Lovenox, needs INR to be back in [**12-31**] range
before restarting this.
-Would check INR every 2 days the first few days after
discharge.
-when INR in therapeutic range start 150 mg SC lovenox once a
day
6. Atrial flutter/atypical rhythm:
-Asymptomatic
7. Type II Diabetes: continue insulin with [**Hospital1 **] NPH with SS.
Although this may be difficult to control with addition of
higher dose of steroids, will attempt control with sub Q
insulin.
8. Abdominal distention: this appears to be normal for this pt.
Had this on admission too. Appears that he had this as far back
as [**2184-5-28**] and plain films at that time were negative for
any abnormality including SBO, free air or ascites.
-if worsens would consider repeat imaging.
9. Chronic Renal Insufficiency: Cr appears back at baseline
10. Depression: Have changed psychatric regimen, had some signs
of depression and and hallucinations this admission, resolved
when we restarted pt on trazodone and venlafaxine.
-Continue trazodone 150 mg qHS, and Effexor 75 mg qAM
11. Anemia: Known chronic anemia, had acute [**Month (only) **]. in Hct as well.
Guaiac is currently unknown (given his ANC <500, no rectal exam
performed). S/p 2 units this admission.
-cont. epogen and iron supplements.
12. FEN: diabetic, heart friendly, diet.
.
13. Access: Mid-line venous catheter.
.
14. Communication: Sister: [**Name (NI) 17**] [**Name (NI) **] (HCP): [**Telephone/Fax (1) 32122**]
.
15. Disp: Extended care facility.
.
Code status remains full.
Medications on Admission:
1. Navelbine as outpt (inhibits microtubule formation).
2. Advair 250/50 1 puff [**Hospital1 **]
3. Combivent and albuterol nebs
4. Prednisone 15mg once daily
5. Glyburide 10mg [**Hospital1 **]
6. Insulin regular SS
7. Coumadin 5mg QHS
8. Effexor XR 75mg once daily
9. Trazodone 100mg QHS
10. Lipitor 20 mg QHS
11. Protonix 40mg once daily
12. Colace 100mg [**Hospital1 **]
13. Senna 1 tab once daily
14. Fe 325mg [**Hospital1 **]
Discharge Medications:
1. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days: From [**2184-12-22**] to [**2184-12-24**].
Disp:*3 Tablet(s)* Refills:*0*
4. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H
(every 8 hours) for 5 days.
Disp:*15 piggyback (2 g per piggyback)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day: in morning.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed: Use only if neededed.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation
Inhalation Q3-4H (Every 3 to 4 Hours) as needed.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain or fever.
12. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation.
Inhalation Q4H (every 4 hours).
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
injection Subcutaneous as directed: Use standard sliding scale,
fingersticks four times a day, 2 units for 151-200, 4 units for
201-250, 6 units 251-300, 8 units for 301-350, 10 units for
351-400. 12 for greater than 400 and [**Name8 (MD) 138**] M.D.
If less than 50 give juice, [**Name8 (MD) 138**] M.D.
18. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO at bedtime as needed for agitation.
19. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: from [**2184-12-25**] to [**2184-12-27**].
20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: From [**2184-12-28**] to [**2184-12-30**].
21. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO once a day:
starting [**2184-12-31**].
22. Outpatient Lab Work
Please check chemistries, CBC, and coagulation studies on
[**2184-12-22**].
23. Lovenox 150 mg/mL Syringe Sig: One (1) injection
Subcutaneous once a day: Please do not start this medication
until INR has returned to therapeutic range.
24. Insulin NPH-Regular Human Rec 50-50 unit/mL Suspension Sig:
One (1) injection Subcutaneous twice a day: 10 units at
breakfast.
8 units at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Sepsis secondary to Klebsiella bacteremia
COPD exacerbation
Metastatic lung cancer
Atrial flutter
Depression
Discharge Condition:
Good. Breathing now returned to baseline. Afebrile, able to
work with physical therapy. Tolerating regular diet.
Discharge Instructions:
Please return to hospital if respiratory status starts to
deteriorate. (i.e)Gets more tachypneic or oxygen requirement
begins to increase).
Please return to hospital if lower extremity edema starts to
worsen.
Please continue prednisone taper and continue cefepime therapy
for 5 more days.
Please have pt follow up with Dr. [**Last Name (STitle) **] to coordinate
further treatment of metastatic lung cancer.
Followup Instructions:
Please have pt follow up with his oncologist Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at [**Hospital1 18**] ON [**2184-12-28**] at 10:30.
Please have patient follow up with his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 9556**].
Please have patient follow up with mental health therapist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26687**] of Mass Mental [**Telephone/Fax (1) 32123**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
ICD9 Codes: 0389, 5859, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5408
}
|
Medical Text: Admission Date: [**2200-7-7**] Discharge Date: [**2200-7-11**]
Date of Birth: [**2128-2-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increasing chest pain
Major Surgical or Invasive Procedure:
[**2200-7-7**] CABG x 3 (LIMA->LAD, SVG->OM, PDA)
History of Present Illness:
72 yo M with exertional angina x 3 years, now increasing. Cath
with LM and 3VD. Mr. [**Name14 (STitle) 69830**] now presents for elective surgical
revascularization.
Past Medical History:
HTN
GERD
HOH
LLE varicose veins
s/p hernia repair
tonsilectomy
hemorrhoidectomy
Social History:
retired facilities director
lives with wife
1 glass wine/day
quit tob 25 years ago
Family History:
Daughter with CABG at age 50
Physical Exam:
NAD HR 72 BP 130/70 RR 20
Skin unremarkable
HEENT benign
Neck supple
Lungs CTAB
Heart RRR no M/R/G
Abdomen soft/NT/ND
Extrem warm trace BLE edema
some varicosities left leg
Pertinent Results:
[**2200-7-10**] 06:25AM BLOOD Hct-25.7*
[**2200-7-9**] 06:30AM BLOOD WBC-8.9 RBC-3.38* Hgb-9.9* Hct-28.0*
MCV-83 MCH-29.2 MCHC-35.3* RDW-14.4 Plt Ct-158
[**2200-7-10**] 09:10AM BLOOD PT-13.3* PTT-27.1 INR(PT)-1.2*
[**2200-7-9**] 06:30AM BLOOD Glucose-130* UreaN-31* Creat-1.3* Na-135
K-4.7 Cl-102 HCO3-25 AnGap-13
[**2200-7-10**] 06:25AM BLOOD Creat-1.1 K-4.4
[**2200-7-10**] CXR
Stable postop chest with persistent bibasilar atelectasis which
has improved on the left.
[**2200-7-7**] ECHO
Pre bypass:
The left atrium is mildly dilated and elongated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. The aortic arch and
descending aorta are mildly dilated. There are simple atheroma
in the aortic arch and the descending thoracic aorta. is mildly
dilated. No thoracic aortic dissection is seen. 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 to mild mitral regurgitation. Vena contracta
measures less than 3 mm. Pulmonary venous inflow pattern is
normal. Mitral annulus averages 3.4 cm in diameter. Cardiac
output is calculated at 5.2 L/min.
Post bypass:
Preserved biventricular function. LVEF > 55% without wall motion
abnormalities. Mitral Regurgitation remains trace to mild. There
is now trace pulmonic insufficiency. Aortic contours are intact.
The remaining exam is unchanged. All findings were discussed
with the surgeons at the time of the exam.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 69831**] was admitted to the [**Hospital1 18**] on [**2200-7-7**] for elective
surgical management of his coronary artery disease. He was taken
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively he was transferred to
the CSRU in stable condition on neosynephrine and propofol. He
was extubated the same day. He was weaned from his neosynephrine
and transferred to the step down unit on POD #1. Beta blockade,
aspirin and a statin were resumed. He was gently diuresed
towards his preoperative weight. His drains and wires were
removed per protocol. Mr. [**Known lastname 69831**] continued to make steady
progress and was discharged home on postoperative day four. He
will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
lisinopril
omeprazole
asa
norvasc
lipitor
lecithin
vitamin c
toprol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: Take once daily with potassium for 5 days then stop. .
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days:
Take with lasix and stop in 5 days. .
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
CAD
HTN
GERD
HOH
LLE varicosities
s/p Left hernia repair [**2191**]
s/p tonsillectomy as child
s/p hemorrhoidectomy [**2153**]'s
Discharge Condition:
Good.
Discharge Instructions:
1) Call with fever, redness or drainage from incisions or weight
gain more than 2 pounds in one day or five pounds in one week.
2) No lifting more than 10 pounds for 10 weeks or driving for 1
month.
3) You may shower, no baths, no lotions, creams or powders to
incisions until they have healed.
4) Take lasix and potassium for five days as instructed and then
stop.
5) Call with any questions or concerns.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks ([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) 67158**] 2 weeks [**Telephone/Fax (1) 41537**]
Dr. [**Last Name (STitle) 20222**] and/or [**Last Name (un) **] 2 weeks [**Telephone/Fax (1) 6256**]
Please call all providers for appointments.
Completed by:[**2200-7-11**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5409
}
|
Medical Text: Admission Date: [**2155-9-4**] Discharge Date:
Date of Birth: [**2107-11-15**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 47-year-old morbidly obese
Caucasian male with multiple medical problems who was recently
discharged from [**Hospital6 256**] on [**2155-9-1**] after a 50 day hospital stay in the Medical Intensive
Care Unit for endocarditis with enterococcus, pan resistant
Klebsiella and coagulation negative Staph bacteremia. He was on
multiple antibiotic regimens and is transferred back to [**Hospital6 1760**] from his rehabilitation facility.
The patient was in the Medical Intensive Care Unit for 50 days
and treated with multiple antibiotic regimens for endocarditis
with multiple resistant bacteria and was also noted to have a
somewhat altered mental status, as well as right upper extremity
paresis while in the Medical Intensive Care Unit. He was
discharged to [**Hospital3 **] Facility and was brought
back to the Emergency Department today for a question of altered
mental status and right upper extremity paresis.
The patient, his mother, and his wife state that nothing has
changed since his discharge from the Medical Intensive Care Unit
and in fact the patient has been doing significantly better since
he was discharged from [**Hospital6 256**]. His
right upper extremity paresis has been ongoing for the last two
weeks as is his lower extremity weakness. Per the patient's
wife, there is no noted change in the patient's mental status.
The intern from the Medical Intensive Care Unit was contact[**Name (NI) **] and
came down to the Emergency Department who confirmed that the
patient's mental status appeared much improved compared with the
time of his discharge.
The patient denies fevers, chills, night sweats, nausea,
vomiting, diarrhea, melena, bright red blood per rectum,
abdominal pain, headaches, visual changes. He reports chronic
back pain since being stationary in his bed.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Diabetes mellitus type 2.
3. Prostate cancer, status post radical prostatectomy with
perineal approach in [**2154-11-24**] complicated by multiple
wound infections. Prostate cancer was [**Doctor Last Name **] 6 adenocarcinoma.
4. Hypercholesterolemia.
5. Hypertension.
6. Depression/anxiety.
7. Endocarditis - aortic valve vegetation, enterococcus, pan
resistant Klebsiella bacteremia and coagulation negative Staph
bacteremia.
8. Baseline confusion.
9. Right hand/upper extremity paresis.
10. Echocardiogram done on [**2155-8-4**] significant for left
ventricular ejection fraction over 55% with 3+ aortic
regurgitation and 2+ mitral regurgitation.
11. Catheterization on [**2155-7-23**] negative for CAD.
MEDICATIONS:
1. Metoprolol 50 mg b.i.d.
2. Imipenem 500 intravenous q. 8.
3. Epogen 15,000 subcutaneously three times a week.
4. Ciprofloxacin intravenously 400 mg q. 12 hours.
5. Aspirin 81 mg q.d.
6. Klonopin 1 mg nasogastric tube t.i.d.
7. Zoloft 50 mg q.d.
8. Heparin 5,000 subcutaneously.
9. Atrovent/albuterol inhalers.
10. Capoten 50 mg t.i.d.
11. Zantac 150 b.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.9. Blood
pressure 111/54. Heart rate 100. Respiratory rate 20.
Oxygen saturation 100% on room air. General: Morbidly obese
male, uncomfortable, appears in distress, noncompliant with
interview. Head, eyes, ears, nose and throat: Pupils equal,
round and reactive to light. Extraocular movements intact.
Moist mucous membranes. Oropharynx clear. Neck: Supple,
full range of motion, no evidence of jugular venous
distention, trachea was in place and appears clean, dry and
intact. Lungs: Distant breath sounds but clear to
auscultation bilaterally. Cardiovascular: Distant heart
sounds, but regular rate and rhythm, normal S1, S2, systolic
murmur appreciated. Abdomen: Obese, G tube site clean, dry
and intact, normal active bowel sounds, soft, nontender,
nondistended. Extremities: Nonpitting edema at the
bilateral lower extremities and edema of the right upper
extremity, no clubbing or cyanosis. Neurological: Alert and
oriented times three, cranial nerves II through XII are
grossly intact, bilateral lower extremities 4/5 strength,
right upper extremity moves fingers, sensation is intact.
LABORATORIES: White blood cell count 14.3, hematocrit 27.0,
platelet count 410,000. Sodium 138, potassium 3.7, chloride
101, bicarbonate 25, BUN 18, creatinine 0.6, glucose 104.
Urinalysis positive nitrates, trace leukocytes. Head CT: No
bleed, no mass effect.
HOSPITAL COURSE:
1. Infectious Disease: The patient was admitted with a history
of endocarditis with bacteremia secondary to multiple strains of
various bacteria with varying resistant patterns. Blood cultures
drawn on the day of the patient's admission were positive for [**3-28**]
blood culture bottles with coagulation negative Staph, all
sensitive to vancomycin, rifampin and tetracycline. The patient
was immediately placed on vancomycin 1 gram intravenously q. 12
hours. Vancomycin levels were drawn and noted to be within the
normal range. The patient had a PICC line from his stay in the
Medical Intensive Care Unit that was discontinued. The tip was
sent for culture and came back with coagulation negative Staph
also resistant to methicillin, sensitive to tetracycline and
vancomycin. The patient was continued on vancomycin for line
infection and recurrent bacteremia. He was continued on
ampicillin for suppressive therapy given his endocarditis and
recurrent bacteremia. The patient remained febrile throughout
his hospitalization and denied any symptoms localizing any
further infection. The infectious disease team assisted in
comanagement of his infection during the hospitalization.
2. Endocarditis: The Cardiothoracic Surgery Team was re-
consulted once the patient was re-admitted to the hospital. Dr.
[**Last Name (STitle) 1537**] and his team saw the patient and agreed to take him to the
Operating Room on [**Last Name (LF) 766**], [**9-15**] for a valve replacement
therapy. A Surgery Consult, chest x-ray, and a urinalysis were
done for preop. The patient was continued on vancomycin and
ampicillin for endocarditis.
3. Neurology: The patient was admitted with a questionable
history of altered mental status but was noted to be alert and
oriented times three throughout his hospitalization. The
Neurology Consult Team was involved in the patient's care for his
right upper extremity paresis and lower extremity weakness.
Mononeuritis multiplex was the prevailing theory in terms of the
etiology for the patient's multifocal deficits. Given that the
treatment for this syndrome is high dose steroids, and the
patient was not a candidate for steroids given his bacteremia,
sacral ulcers and his preoperative status, it was decided not to
place him on steroids upon admission. The Neurology Team also
expressed a concern of abscesses in the patient's spinal cord or
brain and recommended an MRI. Given that the patient's weight
exceeded the limit for the MRI, this was not an option. The
neuroradiologist was contact[**Name (NI) **] and felt that a CT scan was
significantly inferior for detecting abscesses in the spine and
brain and therefore further work-up of the patient's mononeuritis
multiplex was postponed and he was continued on treatment for his
bacteremia.
4. Endocrine: The patient was admitted with a history of
diabetes mellitus type 2 and was maintained on glargine 60 units
q.h.s. with an insulin sliding scale. He had well-controlled
blood sugars throughout his hospitalization.
5. Cardiovascular: The patient was admitted with a history of
hypertension, hypercholesterolemia and diabetes mellitus type 2.
He was maintained on his aspirin, beta-blocker and ACE inhibitors
throughout his hospitalization and was known to be
hemodynamically stable. He denied any chest pain, shortness of
breath, or palpitations throughout his hospitalization. See
above for details of his endocarditis.
6. Pulmonary: The patient demonstrated adequate oxygen
saturations throughout his hospitalization (on trach mask) and
was maintained on his albuterol and ipratropium MDI.
7. Fluid, electrolytes and nutrition: The patient was admitted
with a G tube and on tube feeds. A Nutrition Consult was
obtained and the patient was maintained on hypocaloric high
protein tube feeds throughout his hospitalization, in order to
promote weight loss while maintaining nutritional status. A
weight taken demonstrated that the patient lost approximately 90
pounds since his stay in the Medical Intensive Care Unit. A
speech and swallow study was obtained to evaluate the patient's
swallow for evidence of aspiration. The patient's diet was
advanced and he was able to take solids, but also continued tube
feeds in order to maintain adequate nutrition. He was maintained
on his hypocaloric tube feeds throughout his hospitalization.
8. Decubitus ulcer: The patient was noted to have two Stage 1
and one Stage 2 sacral decubitus ulcers. A wound care nurse
followed the patient throughout his hospitalization. The
patient's ulcers were managed with b.i.d. Tegaderm dressing
changes.
An addendum will be added to address the patient's
continued medical care after [**2155-9-13**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**First Name3 (LF) 13272**]
MEDQUIST36
D: [**2155-9-13**] 02:25
T: [**2155-9-13**] 17:37
JOB#: [**Job Number 51883**]
ICD9 Codes: 7907, 5185
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5410
}
|
Medical Text: Admission Date: [**2145-12-19**] Discharge Date: [**2145-12-23**]
Date of Birth: [**2095-12-13**] Sex: M
Service: NEUROLOGY
Allergies:
Iodine / Morphine Sulfate
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
Merci clot retrieval
History of Present Illness:
Mr. [**Known lastname 15360**] is a 50 yo RHM with h/o HTN, HL, RCC who presents
with acute onset L facial droop, L sided weakness and
dysarthria.
His wife was with him when she noticed a sudden L facial droop,
weak L arm/leg and slurred speech at 13:30. She gave him an
aspirin and called EMS. He arrived at [**Hospital1 18**] with fingerstick
70-80, and received D5. He had right gaze preference but could
cross midline, and L hemiparesis but leg was antigravity on
noxious stimulation. NIHSS 10.
He was 3.5 hours from event, and had no contraindications, so
was
given IV tPA. He has no significant improvement after 30
minutes,
so neuro IR was called. In IR suite, R MCA was occluded and
MERCI
clot retrieval attempted. Multiple attempts at clot retrieval
were completed, however clot was large and well organized so
limited flow could be restored.
Past Medical History:
- HTN
- HL
- arrhythmia- on stress testing [**3-/2145**], increased ectopy
including frequent APB's, couplets, triplets and several runs of
nonsustained wide complex tachycardia. Atrial
fibrillation/flutter was noted in recovery. Holter showed atrial
ectopy and a few runs of NSVT in the absence of symptoms.
- RCC s/p L nephrectomy, no chemo/XRT, in remission on annual
exams
- normal cardiac cath [**2144**]
Social History:
lives with wife, has 2 children. Supervisor for [**Company 2318**]. No
tobacco, EtOH.
Family History:
father had MI in 50s
Physical Exam:
VS afeb HR 60 BP 123/78 RR 18 02 95/RA
GEN: African American man, NAD
HEENT: sclera anicteric
CV: RRR, no m/r/g
NEURO:
Mental status: eyes open, awake, alert, responsive to questions
and oriented x 3. Naming, repetition, comprehension intact.
Moderate dysarthria. Able to read.
CN: PERRL 4 to 2mm. R gaze preference, overcomes on command. No
nystagmus. L facial droop. Tongue midline.
MOTOR: normal bulk and tone. Strength 5/5 R delt, [**Hospital1 **], tri,
finger
flex, IP, ham, tib ant, gastroc. L side some proximal movement
at
shoulder not antigravity, lateral movement of leg to command,
antigravity flexion and withdrawal to pain.
[**Last Name (un) **]: intact to light touch and pain in all extremities.
Decreased sensation to light touch on L face V1-V3. Extinction
to
DSS on left.
DTR: 2+ and symmetric, toes withdraw bilaterally
Pertinent Results:
[**2145-12-21**] 06:35AM BLOOD WBC-11.0 RBC-3.93* Hgb-11.7* Hct-34.2*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.2 Plt Ct-136*
[**2145-12-22**] 06:05AM BLOOD PT-13.4 PTT-25.0 INR(PT)-1.1
[**2145-12-21**] 06:35AM BLOOD Glucose-100 UreaN-12 Creat-1.4* Na-137
K-4.6 Cl-106 HCO3-24 AnGap-12
[**2145-12-22**] 11:25AM BLOOD ALT-19 AST-23 AlkPhos-43 TotBili-0.5
[**2145-12-20**] 06:04AM BLOOD CK(CPK)-250
[**2145-12-20**] 06:04AM BLOOD CK-MB-4 cTropnT-<0.01
[**2145-12-20**] 02:38AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 Cholest-190
[**2145-12-20**] 02:38AM BLOOD %HbA1c-6.0* eAG-126*
[**2145-12-20**] 02:38AM BLOOD Triglyc-161* HDL-36 CHOL/HD-5.3
LDLcalc-122
CT Head/CTA head and neck/CT perfusion head [**2145-12-19**]
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage.
There is
hyperdensity in the distal M1 segment of the right middle
cerebral artery
(image 2:15), concerning for thrombus. There is a small focus of
cortical
hypodensity in the right frontal lobe (image 2:21), concerning
for developing
infarction. The ventricles are normal in size and configuration.
The imaged
bones appear unremarkable. There is a small focus of polypoid
mucosal
thickening in the inferior left maxillary sinus. There is fluid
in a single
left mastoid air cell.
CT PERFUSION: There is elevated mean transit time in the right
middle
cerebral artery territory. There is no evidence of blood volume
asymmetry in
the middle cerebral artery territory.
NECK CTA: There is a bovine configuration of the great vessel
origins. The
great vessel origins are tortuous. The cervical common carotid,
internal
carotid, and vertebral arteries are patent without evidence of
stenoses. The
right vertebral artery is dominant. The distal cervical right
internal
carotid artery measures 4.8 mm in diameter, and the distal
cervical left
internal carotid artery measures 5.5 mm in diameter.
Foci of gas in the veins of the neck and in the cavernous sinus
are likely
related to the intravenous contrast administration via a power
injector.
Evaluation of the imaged lung apices is limited by respiratory
motion, but no
obvious abnormalities are detected. Degenerative changes are
noted in the
cervical spine.
HEAD CTA: There is complete occlusion of the distal M1 segment
of the right
middle cerebral artery. There appears to be some reconstitution
of the more
distal right middle cerebral arterial branches, possibly via the
external
carotid branches. No atherosclerotic plaque is visualized in the
intracranial
circulation. There is fetal configuration of the left posterior
cerebral
artery. The intracranial portion of the nondominant left
vertebral artery is
hypoplastic distal to the low origin of the posterior inferior
cerebellar
artery. The left aspect of the anterior communicating artery is
wider than
the right, with an apparent small infundibulum at the junction
of the left
anterior cerebral artery with the anterior communicating artery.
No definite
aneurysm is seen.
IMPRESSION:
1. Occlusion of the M1 segment of the right middle cerebral
artery. In the
absence of atherosclerosis in other intracranial or cervical
vessel, a cardiac
or another embolic source should be considered.
2. CT perfusion demonstrates ischemia in the right middle
cerebral artery
territory, without evidence of a matching completed infarction
at the time of
the exam. A small focus of cortical edema in the right frontal
lobe on the
noncontrast CT suggests a developing acute infarction.
3. Apparent infundibulum of the left aspect of the anterior
communicating
artery.
MRI and MRA head and neck [**2145-12-20**]
MRI BRAIN WITHOUT IV CONTRAST: Edema and restricted diffusion in
the right
lenticulostriate arterial distribution, involving the putamen
and extending
into the body of the caudate, are consistent with acute
infarction as
suggested on non-contrast CT. There is susceptibility artifact
within the
putamen, corresponding to hyperdense area seen on overnight
non-contrast head
CT, which is consistent with hemorrhage. There are also tiny
distal cortical
foci of restricted diffusion in the right temporal and parietal
lobes.
Overall, findings are suggestive of initial M1 occlusion with
tiny distal
emboli. There is no shift of normally midline structures,
hydrocephalus nor
effacement of the basal cisterns. Normal vascular flow voids are
seen within
the major vessels of the circle of [**Location (un) 431**]. The soft tissues,
visualized
osseous structures, and orbits appear normal. Minimal fluid
signal is seen
within the mastoid air cells, as well as minimal mucosal
thickening in the
ethmoid and maxillary sinuses.
MRA HEAD: The major branches of the circle of [**Location (un) 431**] are patent,
with no
evidence of high-grade stenosis, occlusion, or aneurysm
formation. Fetal-type
circulation is noted on the left, with large patent left
posterior
communicating artery and hypoplastic P1 segment of the left PCA.
The
intracranial left vertebral artery is also noted to be
hypoplastic.
MRA NECK: The cervical common and internal carotid arteries as
well as the
vertebral arteries are patent. No high-grade stenosis or
occlusion is
demonstrated.
IMPRESSIONS:
1. Hemorrhagic infarction in the right lenticulostriate
distribution involves
the putamen and body of caudate, consistent with initial M1
occlusion as seen
on admission CTA. Additional tiny distal cortical foci of
infarction in the
right temporal and parietal lobes are consistent with tiny
distal emboli.
2. MRA shows patent circle of [**Location (un) 431**] and cervical carotid and
vertebral
arteries.
Surface Echo [**2145-12-20**]:
The left atrium is moderately dilated. No thrombus/mass is seen
in the body of the left atrium. The right atrium is moderately
dilated. No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
Pt received IV tPA and subsequently IA tPA and Merci clot
retrieval. After this, he spent 1 day in the Neuro ICU for
monitoring. His repeat NCHCT showed some area of hyperdensity
that was interpreted as hemorrhagic transformation vs contrast,
given that the CT was performed within hours of an arteriogram.
His strength continued to improve.
Cardiology was consulted. Given his history of heart
arrhyhtmias, he was started on Coumadin with an aspirin bridge.
HgbA1C was 6.0 and fasting lipid panel showed mildly elevated
TG's. He was started on simvastatin. His WBC count elevated
modestly and he was found to have a UTI, which was treated with
Ceftriaxone IV. He will complete course of cefpodoxime upon
discharge.
On discharge, his neurological exam was notable for full
strength when testing individual muscle groups, however, there
was still some slowness to movements on the left as compared to
the right, and his gait was still slightly unsteady with a
slightly externally rotated left leg.
He will receive home services for PT/OT and VNA for anticoag
follow up.
He will follow up with Drs. [**Last Name (STitle) 7741**] and [**Name5 (PTitle) **] in stroke clinic.
Medications on Admission:
Toprol XL 25 mg Qday
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 7 days: Last
dose [**2145-12-27**]. .
4. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
6. cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Outpatient Physical Therapy
evaluate and treat
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right middle cerebral artery embolism with infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with a stroke that was the cause of your left
sided weakness. You received an intervention and medicine to
dissolve the offending clot, and your weakness improved. You
were started on a cholesterol-lowering medicine which you should
continue taking. You were also started on the blood thinner
coumadin. You will need to have your blood INR checked
regularly, with a goal INR between 2 and 3.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2146-1-14**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-6-8**] 5:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2146-6-8**]
5:00
Please follow up in Neurology with Drs. [**Last Name (STitle) 7741**] and [**Name5 (PTitle) **] on
[**2146-2-2**] at 1:30 pm in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) 86**], MA.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 431, 5990, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5411
}
|
Medical Text: Unit No: [**Numeric Identifier 65940**]
Admission Date: [**2161-1-25**]
Discharge Date: [**2161-3-13**]
Date of Birth: [**2161-1-25**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] [**Name2 (NI) 1105**] is the 1460
gram product of an IVF triplet at 30 weeks gestation, born to
a 32 year- old, Gravida II, Para 0 to [**Name (NI) 1105**] mother. Prenatal
screens: Maternal blood type A positive, antibody negative.
Hepatitis B surface antigen negative. RPR nonreactive.
Rubella immune. GBS unknown. Pregnancy notable for IUGR and
oligo for triplet B, requiring delivery on [**1-25**].
MATERNAL MEDICATIONS: Zantac, iron, terbutaline. Mother
received betamethasone.
The triplets were delivered by Cesarean section. Triplet C
emerged vigorous with good cry, brought to warmer, dried,
suctioned, stimulated, required PPV x 30 seconds. Apgars 8 at
1 minute and 8 at 5 minutes. Admitted to the NICU for
further management.
PHYSICAL EXAMINATION: Birth weight on admission was 1460
grams, 75th percentile. Length 41 cm, 50 to 75th percentile.
Head circumference 29.5 cm, 75th percentile.
HOSPITAL COURSE: Respiratory: Intubated day of life 1. The
patient received Surfactant x2. Extubated to C-Pap day of
life 4. Transitioned to room air day of life 7 and has
remained well saturated in room air. Started caffeine on day
of life 3 for apnea. Caffeine D'C d on [**2161-3-4**] and he has
been free of any significant episodes for at least 5 days
prior to discharge.
Cardiovascular: Patient has been hemodynamically stable
since birth, no murmur.
Fluids, electrolytes and nutrition: Triplet C, initially
n.p.o. with 80 ml/kg per day of parenteral nutrition; enteral
feeds started day of life 4; n.p.o. day of life 15, secondary
to bloody stools and pneumatosis on KUB; n.p.o. for 14 days;
feedings resumed on day of life 31. On full feeds of
Nutramigen 24 cals per ounce he again developed guiac
+ stools, which over a several day period became gross guiac
positive, but no visible blood , with a benign abdomen and
guaiac negative stools. He was switched to Neocate on [**3-10**].
His guiac tests have become less positive, since the formula
change. His weight at discharge was 2500 grams.
Gastrointestinal: Treated for hyperbilirubinemia on day 2 to
7 with phototherapy, peak bilirubin 7.6 over 0.3.
Hematology: No history of blood transfusions; last
hematocrit of 35 on day of life 27. Hct/retic on [**3-9**] was
32.8/3.6.
Infectious disease: Initial CBC and blood culture at birth
was unremarkable. Ampicillin and Gentamycin was discontinued
at 48 hours. Vancomycin and Gentamycin started on day of
life 15 with left lower quadrant pneumatosis on KUB.
Vancomycin and Gentamycin discontinued on day of life 16,
Zosyn started on day of life 16. Received 14 day course for
medical management of Zosyn. Last dose day of life 29. Last
CBC unremarkable and blood culture negative.
On [**3-4**] he developed eye drainage for which he received a 5
day course of Erythromycin eye ointment.
Neurology: Head ultrasound on [**2-3**] was within normal limits.
Sensory: Ophthalmology, immature eyes. Eyes examined most
recently on [**2-23**] revealing immaturity of the retinal vessels .
A follow-up exam on [**3-9**] was mature z 3 ou.
Psychosocial: [**Hospital1 69**] social
worker is involved with the family. The contact social worker
is [**Name (NI) 36130**], can be reached at [**Telephone/Fax (1) **].
Circumcision: Done on [**3-9**].
DISCHARGE POSITION: Home.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Location (un) 8985**], [**Telephone/Fax (1) 65936**].
Newborn state screening has been done on [**1-29**] ,[**2161-2-9**] and [**3-9**].
Hearing screen passed on [**3-11**].
Immunizations: Hepatitis [**2161-2-27**].
Follow-up appointments:[**Location (un) 2274**]/BUR Dr. [**Last Name (STitle) **] [**3-16**], VNA day post
discharge, EI referral made..
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress syndrome.
3. Rule out sepsis.
4. [**Hospital **] Medical management.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 65941**]
MEDQUIST36
D: [**2161-2-10**] 17:15:31
T: [**2161-2-10**] 18:31:00
Job#: [**Job Number 65942**]
ICD9 Codes: 769, 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5412
}
|
Medical Text: Admission Date: [**2170-12-13**] Discharge Date: [**2170-12-29**]
Date of Birth: [**2106-4-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Pancytopenia (sent from [**First Name3 (LF) 3390**] [**Name Initial (PRE) 3726**])
Major Surgical or Invasive Procedure:
Right IJ line
History of Present Illness:
64 y/o M with history of MS presenting from [**Name Initial (PRE) 3390**] with progressive
lower extremity edema and new systolic murmur. Patient reports
subacute deterioration from his baseline. In the 2-3 weeks, he
has been feeling more fatigued, weak, with one episode of severe
weakness when he had trouble getting out of bed. He also has
experienced increasing shortness of breath at rest. In
addition, he started having bilateral lower extremity swelling
2-3 days ago (has had a remote history of this, but not as
severe). ROS notable for constipation, remote history of bloody
stools and urine, constipation and LE pinpoint rash. Denies
F/C, orthopnea, PND, cough. This AM, his VNA visited and
thought he was pale, concerned about anemia, so sent him to [**Name Initial (PRE) 3390**].
[**Name10 (NameIs) 3390**] office exam notable for new murmur and palpable liver edge
with some jaundice, concern for valvular insufficency and
hepatic congestion, and labs showing pancytopenia.
In the ED inital vitals were, 98.1 92 114/53 20 98% 4L Nasal
Cannula. Exam was notable for bilateral lower extremity edema,
elevated jugular venous pressure, and a systolic murmur, in
addition to scleral icterus and jaundice. Labs were notable for
WBC 1.9, hemoglobin 3.0 and hematocrit 9.6, with platelets of
12. He had a transaminitis with elevated LDH and normal total
bili. Automated smear was negative for schistocytes. Troponin
was negative x 2 and EKG was sinus tachycardia at [**Street Address(2) 7592**]
elevations or depressions. BNP was elevated to 3543. He was
transfused 2U PRBC. Urinalysis was concerning for urinary tract
infection, so patient was started levaquin. CXR concerning for
RLL infiltrate, and patient given levaquin and azithromycin.
Bedside ECHO in ED concerning for ?RV mass, vegetation?
On arrival to the ICU, patient comfortable, hemodynamically
stable.
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, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.
Past Medical History:
Multiple Sclerosis - Diagnosed in [**2154**]. Multiple resolving
flares. Multiple lesions detected on [**Year (4 digits) 4338**]. Has been treated with
alternative medications and acupuncture after having a bad
experience with amantadine.
Osteoporosis
Vitamin D deficiency
Social History:
On disability. Was VP of publishing company and travelled
extensively many years ago. Lives alone, rarely goes outside,
has groceries delivered to him and has a housekeeper.
- Tobacco: Currently uses tobacco and marijuana
- Alcohol: Denies
- Illicits: medical marijuana
Family History:
Mother: Ovarian [**Name (NI) 3730**] - Died at age 60
Father: Died in accident at age 50.
Siblings: No siblings.
Denies diabetes or hypertension.
Physical Exam:
Admission exam:
Vitals: 97.2, 70, 123/61, 23, 90% on high [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP elevated to angle of the jaw at 70 deg angle,
no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**2-18**] holosystolic
murmur at LLSB, no rubs or gallops
Abdomen: +BS, soft, RUQ tenderness, no hepatosplenomegaly, no
rebound tenderness or guarding
GU: foley draining red-tinged blood
Ext: 2+ edema in the b/l LE, R>L up to mid leg. petechiae on
b/l LE. warm, well perfused, 2+ pulses, no clubbing, cyanosis
Neuro: CNII-VII intact, motor strength 5/5 in LUE, [**4-17**] in RUE,
[**4-17**] in LLE, [**3-17**] in RLE
Pertinent Results:
Admission labs:
WBC-2.4*# RBC-1.23*# Hgb-3.3*# Hct-9.9*# MCV-80*# MCH-26.5*#
MCHC-31.2 RDW-30.5* Plt Ct-14*#
Neuts-43* Bands-0 Lymphs-39 Monos-6 Eos-0 Baso-0 Atyps-11*
Metas-0 Myelos-0 NRBC-10* Plasma-1*
PT-16.9* PTT-33.4 INR(PT)-1.6*
Fibrino-495*
ESR-50*
Ret Aut-7.5*
Glucose-100 UreaN-40* Creat-1.8*# Na-135 K-4.3 Cl-94* HCO3-29
AnGap-16
ALT-146* AST-185* LD(LDH)-584* AlkPhos-106 TotBili-1.0
Lipase-20
proBNP-3543*
cTropnT-<0.01
Albumin-3.4* Calcium-8.2* Mg-2.5
D-Dimer-1223*
Hapto-102 Ferritn-663*
calTIBC-244* VitB12-602 Folate-15.2 Ferritn-584* TRF-188*
Triglyc-78
Cortsol-17.1
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE
IgM HAV-NEGATIVE HIV Ab-NEGATIVE HCV Ab-NEGATIVE
HSV, parvo B19, EBV, CMV negative
.
DISCHARGE LABS
[**2170-12-29**] 12:00AM BLOOD WBC-3.8* RBC-2.38* Hgb-7.0* Hct-20.8*
MCV-87 MCH-29.4 MCHC-33.8 RDW-16.5* Plt Ct-39*
[**2170-12-29**] 12:00AM BLOOD Neuts-73* Bands-0 Lymphs-19 Monos-1*
Eos-2 Baso-2 Atyps-0 Metas-0 Myelos-1* NRBC-1* Other-2*
[**2170-12-29**] 12:00AM BLOOD PT-16.7* PTT-36.2 INR(PT)-1.6*
[**2170-12-29**] 12:00AM BLOOD Glucose-78 UreaN-15 Creat-0.6 Na-138
K-3.8 Cl-105 HCO3-27 AnGap-10
[**2170-12-29**] 12:00AM BLOOD ALT-21 AST-16 LD(LDH)-160 AlkPhos-81
TotBili-0.5
[**2170-12-29**] 12:00AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.7 UricAcd-2.6*
.
MICROBIOLOGY:
[**2170-12-13**] 5:55 pm URINE Site: CATHETER
URINE CULTURE (Final [**2170-12-16**]):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| CITROBACTER FREUNDII
COMPLEX
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 32 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Pleural fluid ([**2170-12-21**])-
GRAM STAIN (Final [**2170-12-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
Sputum endotracheal ([**2170-12-21**])- contaminated, culture not
performed
GRAM STAIN (Final [**2170-12-21**]): [**11-6**] PMNs and >10 epithelial
cells/100X field.
Sputum ([**2170-12-19**])- contaminated, culture not performed, no
legionella
Blood culture ([**2170-12-18**])- NGTD, pending final
Blood culture ([**2170-12-17**])- NGTD, pending final
Blood culture ([**2170-12-13**])- NGTD, pending
Sputum ([**2170-12-17**])-
GRAM STAIN (Final [**2170-12-17**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2170-12-19**]):
RARE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
CMV IgG POSITIVE, IgM NEGATIVE, no CMV DNA detected
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2170-12-17**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2170-12-17**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2170-12-17**]): NEGATIVE
<1:10 BY IFA.
Hepatitis serologies ([**2170-12-13**])- HBsAg negative, HBs Ab negative,
HBc Ab negative, HAV Ab negative, IgM HAV negative
IMAGING:
CXR [**2170-12-13**]:
IMPRESSION: Subtle minimal ill-defined opacity within the right
lung base may reflect an area of developing infection. No
evidence for pulmonary edema.
ECHO [**2170-12-14**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
RUQ U/S [**2170-12-14**]:
IMPRESSION:
1. Small liver hemangioma. Otherwise, normal-appearing liver.
2. Fullness of the bilateral renal pelvises without
hydronephrosis.
3. Gallbladder wall edema without significant distention of the
gallbladder
likely relates to third spacing. Sludge within the dependent
portion of the
gallbladder.
4. Splenomegaly.
5. Bilateral pleural effusions.
6. Trace ascites.
7. Left renal cyst.
BLE U/S [**2170-12-14**]:
IMPRESSION:
1. Partially occlusive thrombus within a left posterior tibial
vein with
possible occlusive thrombus in a second left posterior tibial
vein versus
superficial vein.
2. No additional deep venous thrombosis within the bilateral
lower
extremities.
CXR [**2170-12-15**]:
IMPRESSION:
1. Interval placement of an endotracheal tube which has its tip
approximately 10 cm above the carina. The tube should be
advanced approximately 4 cm. The patient's nurse, [**Doctor First Name 7279**], was
notified by phone on [**2170-12-16**] at 8:42 a.m. the need for
repositioning.
2. Both costophrenic angles are not included on this study.
There is a
bilateral diffuse airspace process which again appears slightly
improved
favoring that this represents some moderate-to-severe pulmonary
edema rather than diffuse pneumonia. However, clinical
correlation is advised. Overall cardiac and mediastinal contours
are stable. No large pneumothorax
appreciated.
[**Year (4 digits) 4338**] Brain, C-spine [**2170-12-21**]:
Scattered areas of high signal intensity in the subcortical and
periventricular white matter, extending to the callosal septal
region,
consistent with demyelination and related with a history of
multiple
sclerosis. The plaques are more numerous since [**2163**], there is no
evidence of abnormal enhancement. No mass effect or shifting of
the normally midline structures is present.
The alignment of the cervical vertebral bodies appears
maintained,
disc degenerative changes are identified, consistent with disc
desiccation, mild posterior disc bulge is noted at C4-C5,
causing anterior thecal sac deformity and impinging the thecal
sac (image 13, series 19). There is no evidence of neural
foraminal narrowing or significant spinal canal stenosis.
Disc degenerative changes are also present at C6-C7 level with
narrowing of the intervertebral disc space, Schmorl's node and
endplate changes are
visualized at this level, consistent with bone marrow
replacement for fat
(image 8, series 16). The spinal cord demonstrates areas of high
signal
intensity on the fat suppression sequence, more evident at C2,
C3 and C5
levels, likely consistent with demyelinating plaques. There is
no evidence of abnormal enhancement in this area.
.
Head CT [**2170-12-25**]
Final Report
INDICATION: 64-year-old male with MS presents with coagulopathy,
respiratory
distress and mental status change. Rule out ICH.
COMPARISON: [**Month/Day/Year 4338**] of [**2170-12-21**].
TECHNIQUE: Contiguous axial images were obtained through the
brain without IV contrast.
CT HEAD WITHOUT IV CONTRAST: A tiny amount of hyperdense
material is seen in a right frontal sulcus (2:20) and a right
temporal sulcus (2:14) concerning for subarachnoid hemorrhage.
In addition, there is a small amount of hyperdense material
layering in the posterior [**Doctor Last Name 534**] of the left lateral ventricle
concerning for intraventricular hemorrhage (2:17). There is no
intraparenchymal hemorrhage or extra-axial collection.
There is no major vascular territory infarction, mass effect, or
edema.
[**Doctor Last Name **]-white matter differentiation is preserved. There is
age-appropriate
prominence of ventricles and sulci compatible with diffuse
parenchymal volume loss. Globes and lenses are intact. Mucosal
thickening in the left maxillary and sphenoid sinuses is noted,
but the remainder of visualized paranasal sinuses and mastoid
air cells are well aerated. There is no suspicious lytic or
sclerotic bone lesion.
IMPRESSION:
1. Findings concerning for subarachnoid hemorrhage in the right
frontal and
temporal lobes and a tiny amount of intraventricular hemorrhage
in the left
lateral ventricle. Close interval follow up recommended to
exclude
progression.
2. Left maxillary and sphenoid sinus inflammatory disease.
COMMENT: Findings discussed by phone with Dr. [**First Name8 (NamePattern2) 1255**] [**Name (STitle) 1256**] at 10
PM on
[**2170-12-25**].
NOTE ADDED IN ATTENDING REVIEW: In retrospect, the diffusely
abnormal
hyperintensity on the FLAIR sequences from the MR examination of
[**2170-12-21**] was in the subarachnoid space, rather than
cortically-based (as reported). This likely represented diffuse
subarachnoid hemorrhage in cortical sulci, and there was a
"sedimentation layer" in the trigone and occipital [**Doctor Last Name 534**] of the
left lateral ventricle at that time (8,12:[**10-23**]). No pathologic
leptomeningeal or dural enhancement was demonstrated on that
exam.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: WED [**2170-12-26**] 10:51 AM
.
HEAD CT [**2170-12-26**]
CLINICAL INFORMATION: 64-year-old male with MDS and MS, found to
have
intracranial hemorrhage and altered mental status, for followup.
COMPARISON: [**2170-12-25**] CT, [**2170-12-21**] MR.
TECHNIQUE: Axial MDCT images were acquired of the head without
contrast and
reformatted into coronal and sagittal planes.
FINDINGS:
Hyperdense material is again seen layering within the occipital
[**Doctor Last Name 534**] of the
left lateral ventricle. There has been interval development of
hyperdense
material layering within the occipital [**Doctor Last Name 534**] of the right lateral
ventricle,
increasing the probability that this does in fact represent
hemorrhage. While the ventricles are mildly prominent, there is
no dilatation of the temporal horns to suggest hydrocephalus.
The sulci also are prominent. The [**Doctor Last Name 352**] matter/white matter
differentiation remains preserved. Hypodensity in the frontal
white matter, extending superiorly from the corpus callosum is
consistent with the known demyelinating lesions seen better on
[**Doctor Last Name 4338**].
Hyperdense foci are also seen within frontal sulci (image 26),
which is
nonspecific and could represent subarachnoid hemorrhage or
calcification.
There is minimal mucosal change of the left maxillary sinus, and
there is
partial opacification of left mastoid air cells. Additionally,
there is an
air-fluid level seen within the left sphenoid sinus with mucosal
thickening.
IMPRESSION:
1. Redistribution of intraventricular hemorrhage, now seen
within the
occipital horns of the lateral ventricles, bilaterally.
2. Subtle hyperdensity within multiple sulci, likely reflecting
resorption and redistribution of the diffuse subarachnoid blood
seen on the MR study of [**2170-12-21**] is unchanged from the NECT
obtained only 10 hours earlier.
3. There has been further ventricular dilatation since the
remote MR study of [**2163-2-12**], but this more likely reflects
progressive global, including central atrophy, rather than
developing hydrocephalus.
.
BONE MARROW BIOPSY
Cell culture was established to provide metaphase
cells for chromosome analysis.
No metaphases were available from this specimen,
therefore the cytogenetic analysis could not be
performed.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
nuc ish(D7Z1,D7S522)x1[43/100],
(EGR1x1,D5S23/D5S721x2)[30/100],(D8Z1x2),(D20S108x2)[100]
FISH evaluation for a 7q deletion was performed with the
Vysis LSI D7S522/CEP7 Dual Color Probe ([**Doctor Last Name 7594**] Molecular)
for D7S522 at 7q31 and CEP7 (D7Z1) (chromosome 7 alpha
satellite DNA) at 7p11.1-q11.1 and is interpreted as
ABNORMAL. A single D7S522/D7Z1 hybridization signal was
observed in 43/100 nuclei, which exceeds the normal range
(up to 3% MONOSOMY 7) established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**].
FISH evaluation for a 5q deletion was performed with the
Vysis LSI EGR1/D5S23, D5S721 Dual Color Probe ([**Doctor Last Name 7594**]
Molecular) for EGR1 at 5q31 and D5S721/D5S23 at 5p15.2
and is interpreted as ABNORMAL. A single hybridization
signal was observed in 30/100 nuclei examined, which
exceeds the normal range (up to 3% EGR1 deletion)
established for this probe in the Cytogenetics Laboratory
at [**Hospital1 18**].
FISH evaluation for a chromosome 8 aneuploidy was
performed with the D8Z2 DNA Probe (chromosome 8 alpha
satellite DNA) ([**Doctor Last Name 7594**] Molecular) at 8p11.1- q11.1 and is
interpreted as NORMAL. Two hybridization signals were
detected in 94/100 nuclei examined, which is within the
normal range established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**]. Up to 6% of cells in
normal samples can show apparent trisomy 8 using this
probe set. A normal chromosome 8 FISH finding can result
from absence of trisomy for chromosome 8 or from an
insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 20q deletion was performed with the
Vysis LSI D20S108 Probe ([**Doctor Last Name 7594**] Molecular) at 20q12 and is
interpreted as NORMAL. Two hybridization signals were
observed in 97/100 nuclei examined, which is within the
normal range established for this probe in the Cytogenetics
Laboratory at [**Hospital1 18**]. Up to 8% of cells in normal samples
can show apparent 20q deletion using this probe set. A
normal 20q FISH finding can result from absence of a 20q
deletion, from a 20q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
.
SPECIMEN SUBMITTED: BON E MARROW CORE BX ILIAC CREST (1 JAR)
Procedure date Tissue received Report Date Diagnosed
by
[**2170-12-14**] [**2170-12-14**] [**2170-12-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/mn????????????
============== DIAGNOSIS ============
SPECIMEN: BONE MARROW CORE BIOPSY.
DIAGNOSIS:
HYPERCELLULAR MARROW WITH EXTENSIVE FIBROSIS, TRILINEAGE
DYSPLASIA, AND INCREASED MYELOBLASTS. SEE NOTE.
Note: The findings are highly suspicious for a myelodysplastic
disorder best classified as refractory anemia with excess blasts
(RAEB-2) based on the number of myeloblasts in the peripheral
blood (a marrow aspirate could not be obtained) and the core
biopsy immunostained with CD34. However, given the clinical
presentation of the patient with severe anemia and acute high
output cardiac failure the findings in this marrow need to be
interpreted with caution and a follow up biopsy is highly
recommended, unless cytogenetic studies confirm myelodysplastic
syndrome or other related myeloproloferative disorder. Please
correlate with cytogenetic findings and clinical evolution.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The peripheral blood smear is adequate for evaluation.
Erythrocytes exhibit anisopoikilocytosis, targets, bite cells,
elliptocytes, dacrocytes, and show polychromasia and basophilic
stippling. The white cell count is decreased. Neutrophils are
decreased and exhibit dysplastic features including
hyposegmentation. Pseudo Pelger-[**Doctor Last Name **]??????t forms are present as well
as hypogranular forms. Monocytes are normal in number and
exhibit mild dysplasia. Lymphocytes are decreased in number and
include some large granular lymphocytes. Platelets are
decreased in number and many are hypogranular and large.
Multiple nucleated red blood cells are seen (50% of nucleated
cells) and exhibit significant dyspoiesis including asymmetric
nuclear budding, nuclear fragments and cytoplasmic nuclear dy
synchrony. Differential shows 54% neutrophils, 2% bands, 18%
lymphocytes, 7% monocytes, 2% eosinophils, 4% basophils; 12%
blasts and 1% myelocytes.
Aspirate Smear:
An aspirate smear was not submitted.
Biopsy and clot sections:
Two cores are received both measuring 9mm in length. One core
consists almost entirely of fibrotic marrow with variable
cellularity, which ranges from 5% to 20%. The second core is
cellular with an overall cellularity of 70-80%. The M:E ratio
appears decreased. Erythroid precursors are increased and
exhibit dyspoietic maturation. Myeloid precursors are decreased
in number and exhibit dysplastic maturation. Megakaryocytes are
increased and exhibit dysplastic maturation.
Special Stains: A CD34 stain highlights blasts comprising
10-20% of the marrow cellularity. CD33 is immunoreactive in
approximately one third of the marrow cells. E-Cadherin and
glycophorin-A highlight erythroblasts. There is a greater
percentage of cells staining for glycophorin-A than E-cadherin
which is immunoreactive in about one third of the cells,
indicating that the majority of the erythroblasts are undergoing
maturation. CD42 reveals numerous megakaryocytes. MPO
staining is dim and stains approximately 20% or less in the
cells. CD68 stains most myeloid precursors as well as increased
marrow histiocytes. CD117 (CKit) has strong staining in the
mast cells and reveals an increased number. Dimly stained cell
with CD117 correspond to increased megakaryocytes.
Cytogenetic Studies:
See separate report.
Flow Cytometry Studies:
See separate report.
Clinical: Anemia, leukopenia and thrombocytopenia. 64 year old
male with progressive MS [**First Name (Titles) **] [**Last Name (Titles) 7595**] associated with
pancytopenia concerning for aplastic process.
.
SPECIMEN SUBMITTED: Immunophenotyping - PB
Procedure date Tissue received Report Date Diagnosed
by
[**2170-12-17**] [**2170-12-17**] [**2170-12-22**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3157**]/dsj??????
Previous biopsies: [**-1/5104**] BON E MARROW CORE BX ILIAC
CREST (1 JAR)
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR,
Glycophorin A, Kappa, Lambda, and CD antigens 2, 3, 4, 5, 7, 8,
10, 11c, 13, 14, 15, 19, 20, 33, 34, 41, 56, 64, 71, 117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield. There are two dominant populations in the
blast gate. One population is slightly dimmer than lymphocytes
for CD45 and exhibits a phenotype consistent with myeloblasts
(positive for CD45, CD34, CD33, CD11c, CD117 (dim), CD15, CD13
and are negative for CD14, CD41, CD56, CD64, and glycophorin. A
second population which express only low levels of CD45 lacks
all lymphoid and myeloid markers but is positive for CD71 and
glycophorin-a and represent erythroblasts.
INTERPRETATION
Immunophentopyic findings consistent with an increased
population of myelodysplastic and erythroblasts, and suggest a
myelodysplastic syndrome with increased blasts or acute
leukemia. Please correlate with the morphologic findings in the
marrow biopsy and a blast count. Please see concurrent bone
marrow report S11-[**Numeric Identifier 7596**].
Note: This test was performed using analyte specific reagents
(ASRs). These ASRs have not been cleared or approved by the US
Food and Drug Administration (FDA). However, the FDA has
determined that such clearance or approval is not necessary .
This test was developed and its performance characteristics
determined by the Flow Cytometry Laboratory at [**Hospital1 771**], which is licensed by CLIA to perform
high complexity tests. This test was used for clinical
purposes; it should not be regarded as for research.
Clinical: Multiple sclerosis and new pancytopenia.
Gross: Bone marrow for immunophenotyping.
Brief Hospital Course:
64 yo M with advanced progressive multiple sclerosis presenting
with increasing fatigue/weakness, b/l LE swelling, and
pancytopenia, bone marrow consistent with MDS, course
complicated by hypoxic respiratory failure, DVT/PE, Pneumonia,
ICH.
.
# Hypoxic Respiratory Failure: Patient initially presented with
increasing fatigue. Developed hypoxic respiratory failure
requiring intubation. Differential included PE (patient with
DVT found on LE ultrasound), transfusion associated circulatory
overload [**2-14**] to rapid multiple transfusions, and less likely
pneumonia. CXR revealed a diffuse bilateral pattern. Initially
covered with Vanc/Cefepime, but then discontinued Vanc/Cefepime
after 2 days when likelihood of pneumonia low. Patient treated
for DVT (potential PE) with heparin drip. Extubation was
performed on HD 5, however patient was extremely tachypnic and
required re-intubation. Antibiotics were restarted with
vancomycin, cefepime, and levofloxacin and patient completed a
ten day course. He was diuresed over the next several days with
IV lasix (bolus and drip) for treatment of transfusion
associated circulatory overload. In addition, patient had a
large left sided effusion, largely related to volume
overload/pulmonary edema, which was drained by thoracentesis.
Fluid was consistent with transudate and culture was negative.
Difficulty extubating was also thought to be related to
underlying multiple sclerosis causing neuromuscular weakness.
Negative inspiratory force was low, but gradually improved and
on HD 10, patient was successfully extubated. His respiratory
status continued to improve and he had saturations in the mid to
high 90s on room air at the time of discharge.
# Deep vein thrombosis: Patient had bilateral swelling of lower
extremities on presentation. Doppler ultrasound showed a
partially occlusive clot in the left lower extremity. Patient
was placed on heparin drip with goal PTT 60-80 given patient's
high risk of bleeding given his pancytopenia. He was kept on
heparin drip while intubated, and upon extubation and clearance
by speech and swallow he was transitioned to lovenox and given
one dose of warfarin. Lovenox was however discontinued due to
thrombocytopenia. The patient therefore underwent successful
placement of an IVC filter by IR. A CTA was deferred given
patient's initial acute kidney injury.
# Hypotension: Concern of sepsis from urinary and pulmonary
sources. Sedation may also have contributed to hypotension.
Adrenal insufficiency ruled out by normal cortisol AM level and
cortisol stim test. Right IJ placed, but patient did not
require pressor support. Blood pressures remained low normal
throughout his hospitalization. His systolic blood pressures
were in the 100-110s at the time of discharge.
.
# Myelodysplastic syndrome: Patient presented with pancytopenia.
Bone marrow biopsy showed MDS with erythroblasts without
evidence of leukemia. Viral studies negative for CMV, HSV, HIV,
EBV, and parvovirus. Patient treated with supportive blood
products, transfusion threshold Hct<21 and Plt<30. Patient
required a total of 12 units of pRBC and 14 units of platelets
throughout hospitalization. He was started on neupogen 480mcg
daily per BMT recommendations, this was discontinued on
discharge as he was no longer acutely infected. Once patient's
respiratory status was stabilized, he was transferred to BMT
floor for further management. Given the patients current
deconditioned status he is not a good candidate for therapy at
this time. He will follow-up with Hematology/Oncology as an
outpatient to determine further management of his MDS. For now
he will be managed with transfusion support.
.
# Multiple sclerosis: Patient has progressive MS, with recent
deteriorations. Per conversation with outpatient neurologist,
[**Month/Day (2) 7595**] was not a necessary medication and was discontinued.
Oxacarbazepam was initially held as concern for cause of
pancytopenia, however it was restarted once bone marrow showed
MDS. An [**Month/Day (2) 4338**] was performed which showed increased numbers of
plaques compared to [**Month/Day (2) 4338**] from [**2163**]. Patient complained of
worsening right greater than left upper and lower extremity
weakness, which improved following extubation, but was still
quite debilitating. In addition, difficulty extubating was
attributed to MS [**First Name (Titles) 3**] [**Last Name (Titles) 4338**] showed plaques in C3-C5 concerning for
involvement of the phrenic nerve. However, as above, following
extubation, patient had no signs of neuromuscular weakness
effecting his ability to breath independently. The patient was
evaluated by PT who felt the patient would benefit from
intensive rehab.
.
# Supraventricular tachycardia: Patient was noted to have 2
episodes of tachycardia to the 150s after transfer to the BMT
service. EKG showed an SVT (most likely AVNRT). During theses
episodes his blood pressure decreased to SBP of high 80s. He
also became mildly confused during the first episode. Each time
he was given adenosine 6 mg once with return of sinus rhythm and
improvement in his blood pressure. Following the second episode
he was started on metoprolol tartrate which was titrated upward
to 25 mg [**Hospital1 **]. He remained in sinus rhythm for the remainder of
his hospitalization. He will need to follow-up with his [**Hospital1 3390**] [**Last Name (NamePattern4) **].
[**First Name (STitle) **] regarding need for outpatient cardiology referral.
.
# Intracranial hemorrhage: On [**12-25**] patient was noted to be
confused. Given his low platelet count there was concern for an
intracranial hemorrhage. A head CT did show a small focus of
intraventricular hemorrhage in the left lateral ventricle and
small foci of possible SAH. The patient was given vitamin K to
reverse the coumadin he had received that day, FFP and
platelets. Repeat head CT 7 8 hours later was unchanged and the
patients neuro exam was stable. Neurosurgery was consulted and
recommended keeping platelets > 80 for 7 days and follow up in 1
month.
.
# Acute mental status changes: Patient was noted to be confused
on transfer from the ICU. This was felt to be multi-factorial in
nature. ICU delirium was likely a factor as mental status
improved with better sleep hygiene. Additionally, as above the
patient was noted to have a small intracranial hemorrhage.
Infectious work-up including blood cultures and urine cultures
were negative though the patient was undergoing treatment of
pneumonia. Chemistry panel was unremarkable. The patients
mental status continued to improve and was at baseline at the
time of discharge.
.
# Urinary retention- Patient noted to be retaining urine after
removal of a foly catheter. Catheter was replaced. He will need
repeat voiding trial in [**3-16**] days ([**1-1**], [**1-2**])
.
# Elevated INR - Patient noted to have INR elevated to 1.3-1.6.
He was given vitamin K 5 mg x 2. He was started on PO vitamin K
5 mg weekly. This medication should be continued on discharge.
His INR should be monitored at rehab with discontinuation of
medication when INR is within normal limits.
.
# Urinary tract infection: Urine culture was positive for
pansensitive citrobacter from the urine. Patient completed a
7-day course of ciprofloxacin. Subsequent urine cultures were
negative as were several blood cultures.
.
# Hypernatremia: Patient's sodium was high during admission.
This was treated with free water flushes via OG tube while
patient was intubated. Hypernatremia resolved and did not
return.
.
# Transaminitis: Initially elevated, then trended down. RUQ
showed no signs of hepatic congestion or infiltrative disease.
No venous thrombosis. Hepatitis serologies negative, CMV
negative, EBV, HIV negative. [**Month (only) 116**] still be medication induced.
This resolved prior to discharge.
.
# Acute kidney injury: Cr initially elevated, likely [**2-14**] severe
hypovolemia in the setting of severe anemia. Trended back to
baseline with transfusions and remained stable throughout
hospitalization.
.
# Hyperuricemia: Uric acid was 11.0. Potassium and phosphate
were not consistent wtih tumor lysis syndrome. Patient was
started on allopurinol to decrease uric acid level as there was
concern that high level may be contributing to acute kidney
injury. His allopurinol dose was decreased to 100 mg daily prior
to discharge.
.
# Overall goals of care: Established friend, [**Name (NI) 6739**], to be
health care proxy. Following extubation, patient expressed his
wishes to be DNR/DNI. Paperwork for code status and health care
proxy were completed with the assistance of social work.
# Transitional issues:
- Patient is DNR/DNI
- Patient will follow-up with Dr. [**Last Name (STitle) 3759**] (Heme/Onc), Dr.
[**Last Name (STitle) 739**] (Neuro [**Doctor First Name **]), Dr. [**Last Name (STitle) **] (Neurology), he should
also call to make an appointment with Dr. [**First Name (STitle) **] ([**First Name (STitle) 3390**]) after
being discharged from rehab
- Blood cultures were pending at the time of discharge
- Patient was discharged to [**Hospital3 **] facility in
[**Hospital1 8**]
- Patient will need monitoring of his INR, CBC and Chem-10
Medications on Admission:
Alendronate 70mg po qweek
[**Hospital1 **] 20mg subcutaneous daily
Provigil 200mg po qAM, 100mg po qPM
Naltrexone 1.5mg po TID
Oxcarbazepine 150mg po BID/TID
Lorazepam 0.5mg po qHS prn
Calcium carbonate-Vit D3 800mg-400U tab po BID
Vitamin C 1000mg po daily
MVI
Discharge Medications:
1. modafinil 100 mg Tablet Sig: 1-2 Tablets PO qAM ().
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
3. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. allopurinol 100 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): hold for SBP < 90 HR < 60 . Tablet(s)
6. calcium carbonate-vit D3-min 600 mg calcium- 400 unit Tablet
Sig: One (1) Tablet PO twice a day.
7. ascorbic acid 500 mg/5 mL Syrup Sig: One (1) PO DAILY
(Daily).
8. therapeutic multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. docusate sodium 50 mg/5 mL Liquid Sig: [**5-22**] mL PO BID (2
times a day) as needed for constipation.
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
12. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for anxiety/insomnia.
13. phytonadione 5 mg Tablet Sig: One (1) Tablet PO once a week.
14. ketoconazole 1 % Shampoo Sig: One (1) application Topical
every other day.
15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
[**1-16**] Tablet, ER Particles/Crystalss PO once a day as needed for
hypokalemia : Please administer
Potassium 3.8 - 3.6: 40 mEq PRN
Potassium 3.5 - 3.3: 60 mEq PRN
Potassium 3.2 - 3.0: 80 mEq PRN
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY
Multiple sclerosis
Myelodysplastic Syndrome
Intraventricular hemorrhage
Deep venous thrombosis
Supraventricular Tachycardia
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:
Mr [**Known lastname 7597**]
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you had swelling in you legs. You
were found to have a clot in your left leg. You were also found
to have very low blood counts due to your bone marrow not
working properly. You were given blood and platelets. Since
your blood counts are low we cannot give you blood thinners to
treat the clot so a filter was placed in one of your blood
vessels to prevent it from traveling to your lungs.
You also had trouble breathing while in the hospital and
required placement of a breathing tube. This was successfully
taken out and you are now breathing on your own.
Your heart was noted to have an irregular rhythm that was very
fast. We started you on medication to help control your rate.
You were also noted to have a small bleed in your brain. This
has been stable. There is nothing that needs to be done for
this currently however you will need to follow-up with the
neurosurgeons in 1 month.
We made the following changes to your medications
1. STOP [**Hospital1 **]
2. STOP Naltrexone
3. DECREASE Provigil to 200 mg in the morning and stop taking it
at night
4. DECREASE Ativan to [**1-14**] pill as needed at night
5. START Metoprolol tartrate 25 mg twice a day
6. START allopurinol 100 mg daily
7. START senna, colace as needed for constipation
8. START tylenol as needed for pain
9. START vitamin K 5 mg every week
10. START ketoconazole shampoo every other day
.
Please feel free to call if you have any questions or concerns
Followup Instructions:
Department: NEUROLOGY
When: FRIDAY [**2171-1-18**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2171-1-29**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2171-1-29**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
* The office of Dr. [**Last Name (STitle) 739**] in neurosurgey will contact
you regarding a follow-up appointment in 1 month if the rehab
does not hear from them they should call ([**Telephone/Fax (1) 88**]
.
* After discharge from rehab you will need to follow-up with Dr.
[**First Name (STitle) **] his number is [**Telephone/Fax (1) 7477**]
ICD9 Codes: 5070, 0389, 5849, 5119, 5990, 5789, 2760, 4280, 3051, 4589, 4240, 2768
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5413
}
|
Medical Text: Admission Date: [**2142-7-23**] Discharge Date: [**2142-8-3**]
Date of Birth: [**2079-5-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Left sided chest pain/back pain
Major Surgical or Invasive Procedure:
[**2142-7-23**]
1. Replacement of ascending aorta and hemiarch with a 32-mm
Dacron Vascutek Gelweave graft using deep hypothermic
circulatory arrest.
2. Coronary artery bypass grafting x1 with left internal
mammary artery to left anterior descending coronary
artery.
History of Present Illness:
62 year old gentleman with a history of a type B aortic
dissection in [**2141-6-9**] and ascending aortic aneurysm discovered
at that time which has been managed medically with blood
pressure control. Given the significance of his aneurysm along
with possiblity of a connective tissue disorder, it was planned
to proceed with surgery. He underwent a cardiac catheterization
which revealed left anterior descending artery disease
Past Medical History:
Hypertension
Type B Aortic Dissection
Abdominal aortic aneurysm
Ascending aortic aneurysm
Chronic obstructive pulmonary disease
Depression
Gastroesophageal reflux disease
Osteoarthritis
Anemia
Chronic Kidney Disease Stage 4 - Due to dissection of the renal
artery
Past Surgical History:
Teeth Extraction
Tonsillectomy
Social History:
Occupation: retired
Last Dental Exam: many yrs ago, edentulous
Lives with: roommate
Race: Caucasian
Tobacco: quit 1 yr ago after 2ppd x 40 yrs
ETOH: rare
Family History:
Family History: non-contributory, father died of cirrhosis
Occupation: retired
Lives with: roommate
Race: Caucasian
Tobacco: quit 1 yr ago after 2ppd x 40 yrs
ETOH: rare
Physical Exam:
Pulse: 57 Resp: 20 O2 sat: 98%
B/P Left: 137/88
Height: 6'2" Weight: 215 lb
General: well-developed male in no acute distress
Skin: Dry [x] intact [x] lipoma on upper back
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []expiratory wheezes throughout
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: alert and oriented to person and place, non focal
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: no bruit Left: no bruit
Pertinent Results:
[**2142-7-31**] 10:05AM BLOOD WBC-10.9 RBC-3.26* Hgb-9.6* Hct-28.5*
MCV-88 MCH-29.4 MCHC-33.6 RDW-15.3 Plt Ct-291
[**2142-7-30**] 02:01AM BLOOD WBC-10.9 RBC-3.31* Hgb-9.7* Hct-28.8*
MCV-87 MCH-29.3 MCHC-33.7 RDW-15.5 Plt Ct-254
[**2142-7-31**] 10:05AM BLOOD Glucose-112* UreaN-58* Creat-3.0* Na-134
K-5.1 Cl-100 HCO3-24 AnGap-15
[**2142-7-30**] 02:01AM BLOOD Glucose-103* UreaN-53* Creat-3.0* Na-134
K-4.8 Cl-99 HCO3-25 AnGap-15
TTE [**2142-7-23**]:
Pre-bypass: The left atrium and right atrium are normal in
cavity size. No spontaneous echo contrast or thrombus 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 thickness, cavity size, and global systolic function are
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated at the
sinus level. The ascending aorta is moderately dilated. The
aortic arch is mildly dilated. There are simple atheroma in the
aortic arch. The descending thoracic aorta is markedly dilated.
There are complex (>4mm) atheroma in the descending thoracic
aorta. The abdominal aorta is moderately dilated. A mobile
density is seen in the descending aorta consistent with an
intimal flap/aortic dissection. The aortic wall is thickened
consistent with an intramural hematoma. There is flow in the
false lumen. 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 no pericardial effusion.
Post-bypass: There is a well-seated aortic graft above the level
of the aortic annulus that measures 32 mm in diameter.
Biventricular systolic function is unchanged. The aortic contour
is unchanged post decannulation.
[**2142-8-1**] 05:58AM BLOOD WBC-11.8* RBC-3.16* Hgb-9.0* Hct-27.5*
MCV-87 MCH-28.6 MCHC-32.8 RDW-15.5 Plt Ct-293
[**2142-8-1**] 05:58AM BLOOD PT-21.9* PTT-31.8 INR(PT)-2.0*
[**2142-8-1**] 05:58AM BLOOD Glucose-87 UreaN-61* Creat-3.1* Na-131*
K-5.0 Cl-97 HCO3-25 AnGap-14
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2142-7-23**] where he underwent replacement of
ascending aorta and hemiarch with a 32-mm Dacron Vascutek
Gelweave graft using deep hypothermic circulatory arrest and
coronary artery bypass grafting x1 with left internal mammary
artery to left anterior descending coronary artery. See
operative note for full details. 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 some
breathing difficulty requiring BIPAP. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. He was started on Vancomycin and
Cefepime for a presumed left sided pneumonia for a 10 day
course. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. He was in and out of
rate controlled atrial fibrillation throughout his hospital
course and started on Amiodarone and Coumadin with an INR goal
2-2.5. He will be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and the [**Hospital 756**]
[**Hospital3 **] for his Coumadin dosing. The patient was
transferred to the telemetry floor for further recovery on post
operative day 5. On post operative day 6 the patient was
swallowing a medication, started choking and had a vagal episode
losing consciousness for a few seconds. The patient was
hemodynamically stable after the episode with no events on the
monitor throughout the episode. He was transferred to the CVICU
for further monitoring. He remained hemodynamically stable and
was transferred back to the telemetry floor in stable condition.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. The patient
was ambulating with oxygenation desaturation. Reassessment of
his pulmonary status proved further pulmonary rehabilitation was
required prior to discharge home. The wound was healing and pain
was controlled with oral analgesics. He was transfused 2units
of PRBC for a hematocrit of 25.6% on [**2142-8-2**]. Hematocrit rose
appropriately. The patient was discharged to rehab in good
condition with appropriate follow up instructions.
Medications on Admission:
Albuterol INH PRN
Norvasc 10 mg daily
Famotidine 20 mg daily
Lisinopril 5 mg daily
Metoprolol 12.5 mg [**Hospital1 **]
Omeprazole 20 mg daily
Zoloft 100 mg daily
Simvastatin 40 mg daily
Aspirin 325mg daily
Allergies: SULFA DRUGS
Discharge Medications:
1. Outpatient Lab Work
Labs Chem 7 on [**8-9**] with results to Dr [**Last Name (STitle) **] fax ([**Telephone/Fax (1) 11957**]
2. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication Atrial fibrilation
Goal INR 2.0-2.5
First draw [**8-6**] for further dosing
3. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours) for 3 days: for treatment of
pneumonia .
4. Cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q24H
(every 24 hours) for 3 days: for treatment of pneumonia .
5. Chest PT
Chest PT q6h to LLL
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. PICC line
Per PICC line protocol
10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
2 days: please give sat and sun - lab draw monday for further
dosing .
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for prior to
walking .
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
18. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as
needed for dyspnea.
22. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
23. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center for Rehab & Sub-Acute Care - [**Location (un) 2312**]
Discharge Diagnosis:
1. Ascending aortic aneurysm.
2. Chronic type B aortic dissection involving the
descending thoracic aorta and abdominal aorta.
3. Single-vessel coronary disease.s/p Replacement of ascending
aorta and hemiarch with a 32-mm Dacron Vascutek Gelweave graft
using deep hypothermic circulatory arrest/Coronary artery bypass
grafting x1 with left internal mammary artery to left anterior
descending coronary artery
4. Chronic obstructive pulmonary disease.
5. Chronic renal failure.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - 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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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 [**2142-8-28**] at 2:15 PM [**Telephone/Fax (1) 170**]
Nephrology: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2142-8-14**] 2:00
[**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2142-8-9**] 9:00
Labs Chem 7 on [**8-9**] with results to Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 11957**]
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks ([**Telephone/Fax (1) 101276**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrilation
Goal INR 2.0-2.5
First draw [**8-6**] for further dosing
Completed by:[**2142-8-3**]
ICD9 Codes: 486, 2761, 496, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5414
}
|
Medical Text: Admission Date: [**2175-10-2**] Discharge Date: [**2175-10-6**]
Date of Birth: [**2104-2-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Protamine Sulfate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2175-10-2**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending
artery with vein grafts to diagonal and obtuse marginal.
History of Present Illness:
Mrs. [**Known lastname **] is a 71 yo female with history of CAD s/p angioplasty
of LAD in [**2175-6-14**], diabetes, and carotid disease with chest
discomfort over the past month with mild exertion who was
referred for catheterization. A complex restensosis of her
intramyocardial LAD was found in addition to diagonal artery
disease. Based on her significant LAD disease she is referred to
Dr. [**Last Name (STitle) **] for surgical evaluation.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes type II
Carotid artery disease
Asthma
Sinusitis
Pancreatisis [**2172**]
Colon polyp removed [**2174**]
Mild arthritis in the winter
Kidney stones 35 years ago
s/p tonsillectomy
Bilateral cataract surgery
s/p PPM for presyncope
Social History:
Lives alone. Occasional wine. 10 pack year history of tobacco,
quit over 35 years ago. Denies recreational drug use. Does not
use any assistive devices to ambulate. Daughter helps pt make
medical decisions and is her HCP.
Family History:
Mother died of breath cancer age 54; brother had brain cancer
Physical Exam:
Pulse: 80 SR Resp: 18 O2 sat: 98% RA
B/P Right: 169/78 Left: 173/74
Height:4'[**76**]" Weight:61.2 kg (135 lbs)
General: WDWN female in NAD
Skin: Warm, dry and intact. NO C/C/E
HEENT: NCAT, PERRLA, EOMI< Sclera anicteric, OP benign
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Spider veins present (B). Mild anterior
varicosities below knee but GSV appears suitable.
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: 1
Carotid Bruit Right: Mild bruit Left: None
Pertinent Results:
[**2175-10-2**] Intraop TEE --
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage. 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 no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Post-CPB:
Patient is AV-Paced, on NTG infusion. Preserved biventricular
systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. Other parameters as
pre-bypass.
[**2175-10-5**] 05:50AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.0* Hct-27.1*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.3 Plt Ct-182
[**2175-10-5**] 05:50AM BLOOD Plt Ct-182
[**2175-10-5**] 05:50AM BLOOD Glucose-84 UreaN-27* Creat-0.6 Na-140
K-3.8 Cl-104 HCO3-31 AnGap-9
Brief Hospital Course:
On [**10-2**] Ms. [**Known lastname **] was admitted and taken to the operating room
where she underwent coronary artery bypass grafting x 3 (left
internal mammary artery to left anterior descending artery with
vein grafts to diagonal and obtuse marginal) with Dr.[**Last Name (STitle) **].
Cross clamp time was 46 minutes. Cardiopulmonary Bypass time was
62 minutes. Please refer to Dr.[**Name (NI) 5572**] operative note for
further surgical details. She was intubated and sedated,
transferred to the CVICU in critical but stable condition.
Within 24 hours, she awoke neurologically intact and was
extubated without incident. All lines and drains were
discontinued in a timely fashion. Beta-blocker/Statin/ASA/Plavix
and diuresis was initiated. She continued to progress and was
transferred to the step down unit for further monitoring.
Physical therapy was consulted for evaluation. The remainder of
her postoperative course was essentially uneventful. She was
cleared by Dr.[**Last Name (STitle) **] for discharge to rehab on POD# four. All
follow up appointments were advised.
Medications on Admission:
Lipitor 40mg daily
Advair Disk 250 mcg/50mcg 1 inhalation each day
Metformin 500mg one tablet once daily
Toprol XL 25mg two tablets in am and two tablets in pm
Singular 10mg once a day
Ambien 10mg daily at hs
Aspirin 325mg daily
Calcium with vitamin D 600mg/400IU daily
Plavix 75mg daily - last dose [**2175-9-26**]
Claritin 10mg daily
Quinapril Hcl 40mg daily
Fish oil 1000mg daily
Vitamin A, C, E twice daily
Albuterol inhalation PRN
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. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*2*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
6. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
Disp:*qs * Refills:*0*
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for itching/redness.
Disp:*qs * Refills:*0*
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*30 ML(s)* Refills:*0*
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Hypertension
Hyperlipidemia
Diabetes mellitus type II
Carotid Disease
Prior PPM(for presyncope)
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-19**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-17**] weeks, call for appt
Dr. [**Last Name (STitle) 6924**] in [**1-17**] weeks, call for appt ([**Telephone/Fax (2) 79498**]
Wound check on [**Hospital Ward Name 121**] 6 as directed
Completed by:[**2175-10-6**]
ICD9 Codes: 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5415
}
|
Medical Text: Admission Date: [**2162-9-12**] Discharge Date: [**2162-9-14**]
Date of Birth: [**2106-5-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 yo woman with h/o bilateral infiltrating ductal carcinoma
being transfered from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] after presenting with a fever
to 101.3F and rigors at home. She is day 10 s/p chemotherapy
(Cyclophosphamide and Taxotere). While at home, she has been
experencing nausea and diarrhea. Starting on Friday, she started
to feel generally worse and began to experience some chills.
Then Saturday evening, she began to experience rigors and had a
temperative of 101.5.
She spoke to the oncology fellow on call who recommended she be
evaluated at the nearest hospital. She then went to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and was found to have a fever (100.2) and was profoundly
neutropenic (WBC 0.4 with 3% PMNs). She was initially started on
vancomycin and zosyn, which was later transitioned to cefepmine
and vancomycin. She was also found to have low blood pressures
(80-90s) and was admitted to their ICU. She denies passing out
during this episode and was awake the whole time. She received
fluid resuscitation and her blood pressures responded
approrpiately. She did not require pressors. She also received
filgastrim 480 x2.
.
Upon arrival to the floor, patient appears well and in no acute
distress. She says that she continues to experience some nausea
and abdominal pain. She denies CP and SOB.
.
Review of systems:
(+) Per HPI
(-) 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:
Osteopenia
Postmenopausal bleeding
.
PAST ONCOLOGIC HISTORY: [As per note from Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**],
Onc Fellow on [**2162-9-3**]]
- [**2152**]: right-sided IDC, grade I, 7 mm in size, ER +, HER-2
negative. Underwent mastectomy and took Tamoxifen for 3.5 years.
- noted breast lump in left breast 4/[**2161**]. Ultrasound and
mammogram done [**2162-5-11**] characterized it as a 1.2 cm irregular
dense mass with associated microcalcifications in the upper
outer
quadrant. Core biopsy done [**2162-5-14**] showed IDC, grade 3, ER
positive and Her2 negative.
- left mastectomy [**2162-6-29**], pathology showed 1.1 cm IDC, grade 3,
DCIS present, LCIS absent, negative margins, LVI absent, 0/2
sentinel lymph nodes positive, ER +, PR -, Her 2 -
- Oncotype with recurrence score of 62
- BRCA [**11-29**] negative
Social History:
Social History: Married, no children. Works as a
psychotherapist.
- Tobacco: Remote (15-20 pack year; quit 20 yrs prior)
- Alcohol: Occasional on weekends; [**1-29**]
- Illicits: Denies
Family History:
Sister: pancreatic Ca
Mother: Cerebral aneursym rupture
Paternal Grandmother: Breast Cancer in her 80s
Cousin: Ovarian Ca
Basal cell Ca in brother and father.
Physical Exam:
Admission Physical Exam:
Vitals: T: 100.5 BP: 106/76 P: 79 R: 12 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no evidence of
thrush
Neck: supple, JVP not elevated, no LAD appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild tenderness (diffusely), non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis.
Mild edema of UE b/l, no edema appreciated LE.
DISCHARGE EXAM:
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Labs: From OSH
At presentation - [**2162-9-11**]
CBC: 0.4 > 11.6/32.9 < 138 N3.3 [ANC ~13, calculated from diff%]
Coags: PT 13.0/PTT 31/INR 1.2
Chem: 132/3.9/97/28//0.8<127 Ca 8.8 Mg 1.8
Tpro 6.0 Alb 3.5 AST 11 ALT 10 Tbili 0.1 AlkP 52 Lipase 12
Lactate 0.6
.
Prior to transfer - [**2162-9-12**]
CBC: 0.7 > 9.5/27.8 < 122 N3.7% [ANC ~26, calculated off diff%]
Chem: 138/3.1/108/21/6/0.6<110
.
UA: small blood, [**12-1**] RBCs, 1-4 WBCs, trace protein, 1+ bacteria,
15 Ketones, [**12-1**] epis
.
Admission Labs:
[**2162-9-13**] 05:30AM BLOOD WBC-1.9*# RBC-3.28* Hgb-11.1* Hct-31.9*
MCV-97 MCH-33.7* MCHC-34.7 RDW-12.5 Plt Ct-218
[**2162-9-13**] 05:30AM BLOOD Neuts-16* Bands-1 Lymphs-48* Monos-25*
Eos-2 Baso-3* Atyps-0 Metas-2* Myelos-3* NRBC-2*
[**2162-9-13**] 05:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL
[**2162-9-13**] 05:30AM BLOOD PT-12.5 PTT-26.4 INR(PT)-1.1
[**2162-9-13**] 05:30AM BLOOD Gran Ct-407*
[**2162-9-13**] 05:30AM BLOOD Glucose-92 UreaN-7 Creat-1.0 Na-141 K-3.3
Cl-109* HCO3-20* AnGap-15
[**2162-9-13**] 05:30AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.8
.
Brief Hospital Course:
56 yo woman with h/o bilateral invasival ductal carcinoma day 10
s/p adjuvent chemotherapy (Cycle 1) presenting to OSH with fever
to 101.7 and rigors, found to be neutropenic, and transferred to
[**Hospital1 18**] [**Hospital Unit Name 153**] for futher management.
[**Hospital Unit Name 153**] Course:
Patient was transfered from OSH in the setting on neutropenic
fever which had been complicated by hypotension. While there
she was aggressively fluid resuscitated and did not require
pressors. She was observed in their ICU and was hemodynamically
stable prior to transfer. Upon arrival, she had a temperature
of 100.5 and was normotensive. She was continued on cefepime
for her neutropenic fever and monitored overnight in the ICU.
She remained hemodynamically stable during her ICU course and
was transferred to the oncology medical floor.
OMED course:
# Neutropenic fever: Patient was day 11 s/p her first cycle of
chemotherapy. ANC was 407 upon transfer. Was continued on
cefepime, which she was placed on in [**Hospital Unit Name 153**] for neutropenic fever.
Source of fever unclear, though influenza was considered given
her h/o muscle aches. Micro data was unrevealing. Her ANC
recovered quickly to 4482 within 24 hours. She reported feeling
"fabulous" at that time compared to the prior day on admission.
Since no source was identified and pt was doing well, she was
discharged without antibiotics and plans for follow up in
oncology clinic shortly after discharge.
# Breast cancer: Patient was day 11 s/p her first cycle of
chemotherapy as noted above. She reported significant nausea
which appeared partially controlled by zofran. Denied loss of
appetite or vomiting. Admitted to chronic diarrhea. Pt's
potassium was noted to be low during admission, which was
thought to be secondary to this report of chronic diarrhea. She
was aggressively repleted and sent home on a 3 day course of
potassium supplementation with plans to re-check electrolytes
within 2-3 days and follow up with oncologist.
TRANSITIONAL ISSUES:
1. Follow up potassium
2. chemotherapy per oncology recs
3. monitor for recurrence of fevers
Medications on Admission:
DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a day
take for 3 days, starting on the day prior to chemotherapy fax
to [**Telephone/Fax (1) 34802**]
LORAZEPAM - 0.5 mg Tablet - [**11-29**] Tablet(s) by mouth every four
(4) hours as needed for sleep, nausea
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for nausea take for 2 days after chemotherapy,
then as needed
OXYCODONE - 5 mg Tablet - [**11-29**] Tablet(s) by mouth q 4-6 hours as
needed for pain do not drive or operate machinery while on this
medication.
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every six (6) hours as needed for nausea
IBUPROFEN [ADVIL] - (Prescribed by Other Provider)
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/insomnia.
2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
3. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
6. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day for 3 days.
Disp:*3 packets* Refills:*0*
7. Outpatient Lab Work
Please check CHEM-7 in [**12-31**] days and have results faxed to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**] at fax#: [**Telephone/Fax (1) 34802**].
Dx: Breast cancer, hypokalemia.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
neutropenic fever
Secondary Diagnoses:
breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for letting us take part in your care at [**Hospital1 771**]. You were transferred to the hospital
because you had fevers and your white blood cell count was low.
You were given antibiotics until your white blood cell count
improved. You should follow up with your oncologist to discuss
resuming chemotherapy. Your potassium was low while you were in
the hospital, which can happen with chronic diarrhea. Please
continue the potassium supplements as prescribed and have your
electrolytes checked in [**12-31**] days (prescription attached).
Please call Dr. [**First Name (STitle) 4587**] by Friday if you have not heard back from
her about your lab results.
The following additions have been made to your medications:
--potassium chloride 20 mEq by mouth once a day for 3 days
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2162-10-8**] at 11:30 AM
With: [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) **], 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: FRIDAY [**2162-10-8**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital 2039**] CARE CENTER
When: MONDAY [**2163-1-3**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 34803**], MD [**Telephone/Fax (1) 34804**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2768
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5416
}
|
Medical Text: Admission Date: [**2133-8-17**] Discharge Date: [**2133-8-21**]
Date of Birth: [**2059-5-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old man
with metastatic adenocarcinoma of unclear primary, presumably
lung. This was diagnosed in [**2124**], after biopsy of
supraclavicular lymph node. He was treated with XRT and
surgery and did quite well subsequently. Recently, he was
diagnosed with microscopic hematuria.
Urologic evaluation revealed a duplicated right ureter with
filling defect and wall thickening in the duplicated ureter
at the level of the iliac crest with right hydronephrosis.
A right ureteronephrectomy was planned with suspicion for a
transitional cell carcinoma. On laparoscopy, studding of the
liver with presumed metastases was noted. The procedure was
aborted after multiple liver biopsies. The patient was
extubated post surgery but subsequently developed respiratory
distress and wheezing. Chest x-ray was done and was
suggestive of pulmonary edema. The patient was hypoxic on
100% oxygen and was reintubated. He was then sent to the
Medical Intensive Care Unit for 24 hours and then diuresed.
He was able to come off ventilator and was sent to ALCOVE.
PAST MEDICAL HISTORY: The patient has a past medical history
of adenocarcinoma, metastatic to the right supraclavicular
node, unclear primary, diagnosed in [**2124**]; status post XRT.
Chronic obstructive pulmonary disease, secondary to
emphysema. Congestive heart failure with an ejection
fraction of 40% in [**2130**]. Hypertension.
MEDICATIONS ON ADMISSION: Zantac; Lipitor; Valsartan;
Hydrochlorothiazide.
PHYSICAL EXAMINATION: On admission to ALCOVE, temperature
was 99.8; blood pressure 170/72; pulse 88, irregular;
respiratory rate 20; 99% on five liters. In no apparent
distress. Alert, oriented, somewhat forgetful of recent
medical events. Cardiovascular: Regular rhythm, no murmurs,
no rubs. Respiratory: Poor expansion; few lung crackles;
few wheezes. Abdomen: Tender from incision, which is non
weeping, non erythematous and central. Bowel sounds
positive. No distention, no masses. Neurologic: A bit
forgetful, otherwise intact; possible element of denial.
ENT: Extraocular movements intact. NC/AT. Skin: No skin
rashes, no edema.
LABORATORY DATA: White blood cell count of 12.2; hematocrit
of 31.5; PLT 309; NA 137; K 4.0; CL 99; C02 26; BUN 21; CR
1.3; glucose 130. CK triple was 83, 70 and 60, ruled out for
myocardial infarction. Magnesium 2.0.
Chest x-ray on [**8-17**] revealed significant pulmonary edema;
left retrocardiac opacity. [**8-18**] revealed substantial
clearing of pulmonary edema.
HOSPITAL COURSE: 1.) Cardiovascular: On telemetry, the
patient was noted to have multiple premature ventricular
contractions. These were asymptomatic and not treated. Due
to the sudden episodes of pulmonary edema, we decided to send
him for repeat echo which showed him to have an ejection
fraction of 20%, half of what it was two years ago. This is
felt to be due to just progressive left ventricular
dysfunction, in the setting of hypertension and most likely
the primary cause for the pulmonary edema.
He was placed on Digoxin 0.125 mg and started on Coumadin as
well as put on Lasix 40 mg twice a day, in order to prevent
further episodes of pulmonary edema.
2.) Respiratory: The patient was brought to the floor on
five liters of oxygen saturating at about 90%. He was stable
on that until the night when he decompensated and we needed
to put him on non rebreathing mask, when he desaturated to
the mid 80's on nasal prongs. They also gave him 20 mg of
Lasix intravenous. By morning, he was back on oxygen. Over
the course of the admission, he did not have any further
episodes of pulmonary edema. He was able to be weaned off of
treatment by the last 24 hours of hospitalization and was
saturating between 89 and 92% on room air, ambulating freely.
There was no evidence of any pneumonia or infectious
pulmonary process throughout the course of dissection.
Additionally, the patient had three unwitnessed episodes of
hemoptysis, in which he coughed up small amount of clear
mucus laced with red blood. This was thought to be secondary
to trauma on intubation which bled slightly on the starting
of heparin for anticoagulation. There is no evidence that
this is a more malignant pathology behind this at this time.
3.) Neurologic: Prior to starting anticoagulation, it was
thought prudent to assess for risk of intracranial metastases
which would be an absolute contraindication for any sort of
anticoagulation. The patient underwent head CT. He
tolerated the procedure well. No abnormalities were found on
the study.
4.) Renal: The patient remained stable throughout the course
of admission. His creatinine was 1.3 at the upper level of
normal. He was given Mucomyst and hydration prior to CT of
the head with contrast to lessen the chances of any
nephrotoxicity. He tolerated the procedure without
complications.
5.) Gastrointestinal: The system was inactive during the
time of admission. Diet as tolerated.
DISPOSITION: The patient was discharged home in stable
condition to the care of his family. He will be followed up
by his primary care physician and by his oncologist, Dr.
[**Last Name (STitle) **] in the near future for possible treatment and
evaluation of his cancer and other health problems.
MEDICATIONS: Coumadin 5 mg p.o. q. day. Toprol XL 100 mg
p.o. q. day. Lasix 40 mg p.o. twice a day. Digoxin 0.125 mg
p.o. q. day. Diovan 160 mg p.o. q. day. Zantac 150 mg p.o.
twice a day.
DISCHARGE DIAGNOSES:
Pulmonary edema.
Congestive heart failure.
Metastatic carcinoma.
Hypertension.
Chronic obstructive pulmonary disease.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern4) 6627**]
MEDQUIST36
D: [**2133-8-21**] 17:28
T: [**2133-8-27**] 20:01
JOB#: [**Job Number 6628**]
ICD9 Codes: 496, 4280, 2859, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5417
}
|
Medical Text: Admission Date: [**2146-6-8**] Discharge Date: [**2146-6-17**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
c diff colitis, s/p fall, dysarthria
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
[**Age over 90 **] yo m s/p fall 2 weeks ago. Patient was admitted to [**Hospital1 **]
with PNA (briefly in ICU) then discharged to rehab 6 days ago
where he was doing well until fall (?slipped on diarrhea)
yesterday. Per family now noticed slurred speech and vague motor
difficulties.
.
Of note, pt was diagnosed with C diff at rehab today started
Flagyl.
.
On ROS patient reports new onset of hand tremor bilaterally. Has
h/o gait disturbance [**3-11**] peripheral neuropathy at baseline.
Reportedly head CT at [**Hospital3 **] 2 wks ago was "normal"
.
In ED, repeat head ct showed no bleed but incidental mass likely
meningioma. Neurosurg saw patient in ED and suggested MRI to
evaluate further.
Past Medical History:
Idiopathic peripheral neuropathy (per family),
HTN,
Petite mal sz 8yrs and 2.5yrs ago on phenobarb
s/p hernia repair
PNA at [**Hospital3 **] 2 weeks ago
Social History:
nonsmoker, ex-etoh drinker (non x 2yrs). lived with
wife at home before last admitting to [**Hospital3 **] hosp.
Family History:
noncontributory.
Physical Exam:
Tmax 101 Tc 99.2 115/57 89 18 98 on 2L
Gen: WD/WN, comfortable, NAD
HEENT: Pupils: PERRLA, EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm no edema
Neuro: Oriented to person, place, and date.
Language: no speech abnormalities noted, easily understandable,
with good comprehension and repetition.
Neuro: nl strength b/l, intentional tremor, mild dysmetria on
finger to nose bilaterally. CN2-12 intact.
Pertinent Results:
.
IMAGING:
CT HEAD W/O CONTRAST [**2146-6-8**] 5:12 PM
1. No acute intracranial pathology including no intracranial
hemorrhage.
2. Well-defined relatively hyperdense extra-axial mass seen
within the frontal interhemispheric fissure measuring up to 18
mm in greatest dimension. The appearance of this mass is most
consistent with a meningioma. MRI is recommended for further
evaluation.
3. White matter changes consistent with small vessel
disease and multiple old lacunar infarcts.
.
ECG Study Date of [**2146-6-8**] 2:41:08 PM
Probable multifocal atrial tachycardia
Consider left ventricular hypertrophy
Modest nonspecific ST-T wave changes
No previous tracing available for comparison
.
MR HEAD W & W/O CONTRAST [**2146-6-9**] 1:21 AM
Probable meningioma along the anterior falx.
There is a second small meningioma in the left posterior fossa
abutting the
sigmoid sinus.
Small vessel ischemic sequela. No acute infarction.
.
ECG Study Date of [**2146-6-9**] 8:26:22 AM
[**Month (only) 116**] be sinus tachycardia but consider also atrial tachycardia
Borderline left axis deviation - is nonspecific
Modest nonspecific ST-T wave changes
Since previous tracing of the same date, ventricular response
more regular
.
[**6-11**] renal us:
IMPRESSION: No evidence of hydronephrosis. Mild scarring of the
kidneys bilaterally, otherwise normal-appearing parenchyma
.
[**6-13**] abd film:
IMPRESSION: Unremarkable bowel gas pattern. No evidence of
ileus.
.
ct abd [**6-14**]:
IMPRESSION:
1. No bowel obstruction.
2. No fluid collections or abscesses. A small amount of free
fluid is seen in the abdomen and pelvis.
3. Thickened loops of bowel as described above consistent with
the given history of colitis. Progression of wall thickening of
bowel loops is seen to involve the distal ileum as well.
4. Anasarca.
5. Bilateral pleural effusions and atelectasis as described
above.
Brief Hospital Course:
Mr. [**Known lastname 20400**] was a [**Age over 90 **] year old male with htn, seizure d/o, who
presented with speech difficulty/new bilateral hand tremors and
C. diff colitis. In brief, he had a MICU stay for hematemesis
and ARF with rising WBC. He abdomen continued to be distended
and he continued to have copious diarrhea. It was determined
that his C.diff infection was so severe he would require
colectomy but his family did not want to put the patient through
surgery. After much discussion with the MICU attending Dr.
[**Last Name (STitle) **], the family decided to make the patient DNR/DNI and keep
only minimal support with antibiotics. Upon transfer to the
floor, the family, including his son the HCP, the patient's wife
and daughter in law, decided to pursue comfort measures only
around 10pm. The antibiotics and IVF were discontinued. The
patient was maintained on morphine for pain control. He expired
around 1AM.
.
His hospital course is described below by problem list.
.
# C diff:
Found positive at OSH, likely secondary to recent antibiotics
used for treating pneumonia. WBC count began to rise day after
admission, with low grade fevers, and increase abdominal
distension. Pt had a CT abd scan which showed thickened loops of
bowel consistent with the given history of colitis. Vancomycin
PO was added to flagyl as pt was not clinically improving after
couple of days on flagyl alone. Pt had decrease PO intake and
was encouraged to drink more fluids and was aggressively
hydrated. He was transferred to the ICU for hematemesis and ARF
and in the unit his white count continued to rise and he
continued to have signs of colitis. He was treated with flagyl,
PO/PR vancomycin, cholestyramine and zosyn. His studies lacked
signs of ileus, though he was noted to have distention and
trouble with tube feeds so he was kept NPO and followed by GI.
He had daily KUB to monitor for toxic megacolon.
.
# Hematemesis: New onset coffee-ground emesis with likely
aspiration of contents. NGT placed and suctioned ~1L dark brown
material. Pt hemodynamically stable, Hct 42. Transferred to ICU
for monitoring. He had his hematocrit checked frequently, was
given IVF and remained stable and never required blood products.
GI followed the patient and an endoscopy was not done. He
remained NPO for aspiration risks.
.
# Aspiration pneumonia: New LL lobe infiltrate with likley
aspiration noted. Already on broad coverage with zosyn, but
concern that patient may be becoming septic with hypothermia and
increased wbc count, given this the patient was kept on zosyn
and vancomycin was added. He was kept NPO as well.
.
# Dysarthria:
Unclear duration of speech difficulty per history. Possibly due
to underlying delirium secondary to new Cdiff infection.
Unlikely to be TIA or stroke given negative head imaging post
fall and no other focal neurological deficits, absence of signs
concerning neighboring brainstem dysfunction. Extra-axial mass
not in location to be contributing to speech difficulty as not
in Broca's area and no evidence of mass effect on brain
parenchyma region involved in facial, tongue motor function.
Cannot exclude toxic-metabolic etiologies given underlying
infection and renal failure.
.
# Intention tremor:
Also of unknown duration. Not on medications that would cause
tremors. No electrolye abnormalities. Calcium low but within
normal when corrected for albumin. He has family hx of essential
tremors and is currently on beta blocker for heart disease.
Thyroid panel was normal.
.
# Intracranial mass:
Found incidentally on head imaging upon admission. Most likely
meningioma based on CT and MRI. Neurosurgery eval pt on
admission and no intervention was recommended, with suggested
followup in 3 month with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] and a repeat MRI
head at that time.
.
# HTN: The patient was normotensive, though in the ICU his
beta-blocker was held given his hematemesis.
.
# Seizure d/o:
Does not seem to be cause of fall as it appears to be mechanical
with lack of post-ictal state and no loss of consciousness.
Continued on phenobarb and gapabentin, without epileptic
activity during hospital course. Prior to transfer out of the
ICU his gabapentin was held given his renal failure.
.
# ARF:
Baseline Cr 1.2 and increased to 1.8 on day 2 of hospital
course. Most likely in the setting of infection and diarrhea. UA
negative for UTI. He was aggressively hydrated, but given his
diarrhea, his renal failure continued to worsen. The family did
not want dialysis, so hydration was continued and nephrotoxins
were held.
Medications on Admission:
Toprol xl 50mg qd
Milk of Mag
Neurontin
Tylenol
Prilosec,
Phenobarbitol
Triamterene/HCTZ 50/25 qd
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Clostridium difficile colitis
Meningioma
Acute renal failure
Intention tremor
Seizure disorder
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2146-6-28**]
ICD9 Codes: 5070, 2762, 486, 5845, 2930, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5418
}
|
Medical Text: Admission Date: [**2141-5-10**] Discharge Date: [**2141-5-13**]
Date of Birth: [**2121-5-14**] Sex: F
Service: [**Hospital1 **]
CHIEF COMPLAINT: Status post suicide attempt
HISTORY OF PRESENT ILLNESS: A 19 year old single white
female who was brought to the [**Hospital6 2018**] Emergency Department after a suicide attempt. Per the
patient, the patient's boyfriend, and [**Name (NI) 9168**] records, the
patient reportedly was drinking alcohol and swallowed
approximately 20 pills of 50 mg of Diphenhydramine
(over-the-counter Benadryl). After ingesting the medication,
she reportedly called her boyfriend, and her boyfriend
notified [**Name (NI) 9168**]. Suicide note was found at the scene. The
patient was brought to the [**Hospital6 2018**], and admitted to Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. History of mood disorder/bipolar disease
2. History of several suicide attempts
3. History of "cutting"
4. History of sexual abuse/sexual assault
5. History of substance abuse
SOCIAL HISTORY: She has a tenth grade education with a GED.
She is estranged from her parents, who live in [**State 531**]. She
has a boyfriend, who currently lives in [**Name (NI) 531**] as well.
She also has a history of injurious behavior via cutting her
arms and legs.
PSYCHIATRIC HISTORY: She has been prescribed psychiatric
medications but has been noncompliant.
PHYSICAL EXAMINATION: Heartrate 130, blood pressure 130/80,
respiratory rate 16, oxygen saturation 100% on nonrebreather.
In general she is obtunded, with a very poor response to
noxious stimuli, limited response to sternal rub. Head,
eyes, ears, nose and throat: Normocephalic, atraumatic.
Pupils equally round, reactive minimally at 4 mm, unable to
check if her extraocular motions are intact, dry mucous
membranes and poor gag reflex. Neck: Supple. Chest:
Coarse upper airway breathsounds. Heart: Tachycardiac, no
murmurs. Abdomen: Soft, nontender, nondistended, decreased
bowel sounds. Extremities: Warm and dry, no edema.
Multiple linear abrasions on her left and right medial
forearms, resembling areas where she cut herself with
razorblades. Bilateral thighs with old linear scars of
previous cutting episodes. Neurologic: Moans to noxious
stimuli, minimally responsive, moves extremities to very
painful stimuli.
LABORATORY DATA: On admission white blood cell count 9.3,
hematocrit 41.1, platelets 343. Sodium 143, potassium 4.7,
chloride 106, bicarbonate 25, BUN 7, creatinine 0.6 and a
glucose 104. Calcium 9.5, magnesium 2.0, phosphorus 3.6, ALT
26, AST 40, alkaline phosphatase 58, amylase 31, albumin 5.1,
urine toxicology screen negative. Urinalysis negative.
Serum toxicology screen positive for ethanol level 227.
Electrocardiogram sinus tachycardia at 145, no ST segment
changes. QTC is 453.
IMPRESSION: A 19 year old female with a history of mood
disorders, and by history three previous suicide attempts,
who apparently ingested 20 some Benadryl tablets accompanied
by ethanol abuse in a suicide attempt. The patient is
obtunded and can not protect her airway.
HOSPITAL COURSE: The patient was intubated for
respiratory/airway protection, until the Benadryl was
mobilized and metabolized. She was put on Propofol for
sedation and extubated without event. She had one episode of
vomiting while she was intubated, and developed a ?
aspiration pneumonitis, but did not develop aspiration
pneumonia. She was extubated on hospital day #2 without
event. After she was extubated, she was given incentive
spirometry which she used well and on the day of discharge
her oxygen saturation was 96 to 98% on room air, ambulating
and resting. Her pulmonary status is good, and appears to
have no more respiratory problems whatsoever.
Cardiac - The patient had a prolonged QTC at 453, in the
setting of overdose of Benadryl. Her electrocardiograms were
checked, and the QTC prolongation resolved. Haldol was not
given to the patient secondary to the possible side effects
of QTC prolongation.
Psychiatry - Psychiatry consult was obtained in this patient,
they recommended a 1:1 observation sitter, as well as they
were actively involved with helping obtain psychiatric care
for the patient. On psychiatric evaluation the patient was
unreliable as a historian. Given her prior suicide attempts,
she had told others that this overdose was meant as a suicide
attempt. But given her ethanol use, and unreliability, she
met the criteria for a Section 12 for psychiatric inpatient
evaluation.
Toxicology - The Toxicology Team followed the patient from
her presentation at [**Hospital6 256**]
throughout her hospital stay. They recommended airway
protection (intubation), as she was not able to protect her
airway. Furthermore, she was given an activated charcoal as
a single dose via her nasogastric tube after airway
production. Electrocardiograms were checked q. 6 hours as
the diphenhydramine could cause conduction abnormalities.
Physostigmine was considered, however, was not given,
secondary to the fact that the patient was not agitated,
there was no agitated delirium and specifically was not
indicated at that time.
Skin - The patient developed a very mild cellulitis on her
right medial forearm, overlying the area of her cutting
episode. The patient was started on Oxacillin 2 gm
intravenously q. 4 hours while an inpatient. She was given
intravenous antibiotics for 24 hours and then was changed to
Dicloxacillin 500 mg p.o. q.i.d. times 13 days to finish out
a 14 day course of antibiotics.
DISPOSITION: A 19 year old female status post ethanol and
Benadryl overdose in an apparent suicide attempt, also status
post intubation/extubation which is for airway protection
secondary to obtunded state from her overdose. She was
extubated without event and transferred to the floor without
problems. She has been afebrile. Her white blood count is 11
and she is hemodynamically stable. She will continue a
course of antibiotics for 13 days to treat her cellulitis.
She is medically stable to be discharged to an inpatient
psychiatric facility, under Section 12 order, for inpatient
psychiatric care.
DISCHARGE DIAGNOSIS:
1. Status post extubation
2. Overdose of Benadryl and ethanol, suicide attempt
3. Cellulitis (over area of cutting)
4. History of bipolar disease
5. History of cutting
6. History of multiple suicide attempts
7. History of substance abuse
DISCHARGE MEDICATIONS: Dicloxacillin 500 mg p.o. q.i.d.
times 13 days (total of 14 day course treatment)
DISCHARGE INSTRUCTIONS:
1. The patient is to be discharged directly to an inpatient
psychiatric facility.
2. She is under Section 12.
3. One-to-one sitter.
4. Suicide precautions
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 48865**]
MEDQUIST36
D: [**2141-5-13**] 09:39
T: [**2141-5-13**] 09:57
JOB#: [**Job Number 49035**]
ICD9 Codes: 5070
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5419
}
|
Medical Text: Admission Date: [**2124-2-3**] Discharge Date: [**2124-2-8**]
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
BiPAP on [**2124-2-3**]
History of Present Illness:
89 y/o female with PMH of COPD, CAD, CHF (EF>55%), HTN, DM, pAF,
silent aspirator, recent admission for SOB and new presumed
diagnosis of BOOB (on steroid taper) who is called out from MICU
where she was admitted for hypoxic respiratory distress
requiring BIPAP.
.
Initially presented from [**Hospital 100**] Rehab where she developed acute
SOB. VS at the time were: 168/100, p160s, rr30s, 89% RA. Treated
w/ Lasix 60mg PO + 60mg IV. Transferred to [**Hospital1 18**] ED where VS on
presentation were t 100.6, p130s, 138/76, rr35, 98%NRB. She was
noted to have significant work of breathing. She was placed on
Bipap, which she tolerated well. ABG was 7.36/37/248 on BIPAP
5/5/1.0 after 2 hours. She was given asa, solumedrol 125mg IV
x1, ceftaz 2gm IV and flagyl 500mg IV. Of note, also had an
episode of AFib with AVR with HR in 130s, hemodynamically
stable, HR decreased to 100s after 10mg IV diltiazem.
Transferred to MICU where pt was attempted on trial off bipap.
Maintained off BIPAP and weaned down to 2L NC overnight.
Therefore called out to the floor the following day.
Past Medical History:
1. COPD - [**11-5**] FEV1 1.01 (not on home O2)
2. CAD s/p MI
3. CHF EF> 55%
4. PVD
5. CVA and carotid disease
6. HTN
7. neuropathy
8. hyperlipidemia
9. osteopenia
10. DM
11. vit B12 deficiency
12. gait disorder
13. spinal stenosis -s/p surgery [**2115**]
14. PAFIB
15. ?BOOB (on steroid taper)
16. Recurrent aspiration pneumonia
Social History:
SH: Resides at [**Hospital 100**] Rehab [**Location (un) 550**]. Has 10 children. *Smokes half
ppd*, in
past smoked more (total 40 yrs). Occ EtOH. No other drugs.
Family History:
Noncontributory
Physical Exam:
Exam on Admission:
=================
VS: t98.5, p125, 138/88, rr31, 93% 2L
Gen: NAD, off bipap
HEENT: PERRL, dry MM
CVS: irreg irreg, tachy, [**1-10**] holosystolic murmur at the apex
Lungs: bilateral crackles half way up lung fields
Abd: soft, NT, ND, +BS
Ext: 1+ edema bilaterally
Pertinent Results:
Admission Labs:
==============
WBC-24.9 Hgb-11.5 Hct-35.5 MCV-90 Plt Ct-259
Neuts-90.2* Bands-0 Lymphs-6.3* Monos-2.4 Eos-1.0 Baso-0.1
Glucose-212* UreaN-38* Creat-1.5* Na-135 K-4.9 Cl-102 HCO3-18*
AnGap-20
ALT-237* AST-61* AlkPhos-381* TotBili-1.4
cTropnT-0.03*
CK-MB-NotDone proBNP-4255*
Calcium-9.3 Phos-4.1 Mg-2.1
TSH-2.0
.
Blood gas:
[**2124-2-3**] 05:33AM: Type-ART Temp-38.1 Tidal V-500 FiO2-100
pO2-248* pCO2-37 pH-7.36 calHCO3-22 Base XS--3 AADO2-439 REQ
O2-74 Lactate-2.2*
.
Radiology:
=========
[**2124-2-3**] CXR-
1. Continued right upper lobe consolidation. Worsening left
retrocardiac opacity.
2. Cardiac failure
.
[**2124-2-4**] CXR: There is cardiomegaly unchanged with small bilateral
pleural effusions, unchanged from [**2124-2-3**] with associated
bibasilar atelectasis. The right upper lobe opacity is unchanged
from [**2124-2-3**] allowing for differences in technique.
However, compared to [**2124-1-8**], there has been
improvement in the peripheral right upper lobe opacity.
Brief Hospital Course:
This is an 89 yo female with PMH COPD, CHF, ?BOOP, recurrent
admissions for SOB who presented with acute SOB and hypoxia
requiring BIPAP transiently in the MICU, now weaned off to 2L NC
with stable sats.
.
1. Hypoxic respiratory failure: Improved respiratory status, now
stable on 2L O2 via NC. Most likely etilogy of event was
multifactorial from recurrent pneumonia, CHF (diastolic dysfn),
BOOP exacerbation.
-continue with cefpodoxime to finish total course of 7 days for
possible new PNA
-continue albuterol/atrovent nebs
-continue prednisone 10mg/day until pulmonary appt on [**2124-2-8**] for
further evaluation
-continue with strict I/O's (goal even), daily weights and lasix
prn to meet goal or depending on symptoms (shortness of breath,
etc)
.
2. UTI: on cefpodoxime. Final urine cx from [**2124-2-3**] shows MRSA,
but less than 100,000 colonies, so we are not covering for this
as patient is not bacteremic or febrile. Please recheck urine
analysis and culture in one week and f/u on results. Will see
[**Month/Day/Year **] for follow-up in 2 weeks. Given h/o urinary retention in
past, should keep in foley. If foley removed and patient not
voiding at rehab, bladder scan should be done and foley/straight
cath should be placed if residual>200 cc.
.
3. CHF: BNP elevated. Clinically slightly volume overloaded but
intravascularly depleted. Given renal insufficiency and
respiratory stability will hold off on further diuresis. Already
-1.6 L out for LOS in the hospital.
-maintain even i's/o's
-strict I/O's, daily wts
-lasix prn symptoms and/or to meet goal as above
.
4. Afib: diltiazem and lopressor for rate control. [**Country **] score of
4. Not on coumadin. ASA 325mg for anti-coagulation.
.
5. CAD: cont statin, asa, bb
-holding ACEi in setting of elevated cr
.
6. Elevated Tn: likely tn leak in setting of CHF, renal
insufficiency
.
6. CRI: 1.7. baseline of 1.1-1.5. Hold nephrotoxic agents.
Renally dose meds. Monitor daily lytes.
.
7. DMII: cont glyburide. FS QID. SSI
.
8. Leukocytosis: Likely in setting of steroids. Trend WBC/T
curve. cont abx as above.
.
9. PPX: PPI, tylenol, bowel regimen, Hep SC
.
10. FEN: cardiac/low sodium (passed speech-swallow- no
aspiration) - see dietary instructions as detailed in d/c
paperwork
.
11. Full code
Medications on Admission:
Protonix 40mg qd
Prednisone 10mg qd
Simvastatin 20mg qd
Trazodone 25mg qd
Vit D/cholecalciferol 800mg qd
combivent nebs
asa 325mg qd
calcicum 650mg [**Hospital1 **]
b12 100mcg qd
diltizem CD 240mg qd
Docusate
Folic acid 1mg qd
glyburide 5mg qd
glargine 9U bedtime
humalog SS
lopressor XL 75mg qd
MVI 1 tab qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold for HR<60 and SBP<100.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100 and HR<60. Tablet(s)
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Insulin Sliding Scale
12 units of Glargine at bedtime with sliding scale
please see attached sheet
20. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary - hypoxic respiratory failure requiring BiPAP, COPD/CHF
exacerbation, A fib with RVR
Secondary - COPD, CHF, ?BOOP, CAD s/p MI, HTN, neuropathy,
hyperlipidemia, NIDDM, PAFIB, recurrent aspiration PNA
Discharge Condition:
Stable, on 2LNC (baseline)
Discharge Instructions:
-continue with medications as prescribed
-physical therapy as tolerated
-if patient having difficulty voiding, please check bladder scan
and if >200, recommend placing foley or straight cath for
drainage
-follow-up with scheduled appts
-please check finger stick glucoses per sliding scale attached
-if patient has shortness of breath, can try nebs and lasix
given h/o COPD, CHF
- please continue with antibiotics for a total of 10 days
- continue oxygen as needed to keep sats > 93%
- continue with RISS while on prednisone, if sugars stable once
off prednisone, then can d/c RISS and continue with just
glyburide
- continue with aspiration precautions as detailed - patient
needs 1:1 assistance with feeding at every meal, needs to be
sitting upright and keep her chin tucked in while swallowing,
alternate small sips with small bites, and diet of
nectar-thickened liquids and ground solids
- encourage chest PT daily, incentive spirometry
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2124-2-8**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2124-2-8**] 11:30
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2124-2-23**]
9:00
Completed by:[**2124-2-8**]
ICD9 Codes: 5070, 4280, 5859, 5990, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5420
}
|
Medical Text: Admission Date: [**2159-4-4**] Discharge Date: [**2159-4-6**]
Date of Birth: [**2081-9-8**] Sex: F
Service: NEUROSURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Reoccuring Colloid Cyst
Major Surgical or Invasive Procedure:
Right sided craniotomy
History of Present Illness:
77-year old female who was
recently diagnosed with a recurrent colloidal cyst. The patient
apparently had this lesion drained in [**2133**] at [**Hospital 1263**] Hospital
through a frontal craniotomy and transcallosal approach. The
patient was doing well and has had no specific complaints since.
She recently had a fall for which she was worked up which
revealed this newly diagnosed progressive lesion. The patient
overall feels well.
Past Medical History:
HTN, Rheumatoid arthritis, Bronchitis
Social History:
Lives with son, nonsmoker, no alcohol
Family History:
Noncontributory
Physical Exam:
Heart rrr 1/6 sem, no bruits
Lungs Clear to Auscultation
Extremities no cce
Other anticteric, no thyromeg, no [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] obvious neurologicaly abnormalities
Pertinent Results:
[**2159-4-6**] 05:48AM BLOOD WBC-18.3* RBC-3.63* Hgb-11.5* Hct-34.9*
MCV-96 MCH-31.7 MCHC-33.0 RDW-14.4 Plt Ct-356
[**2159-4-6**] 05:48AM BLOOD Plt Ct-356
[**2159-4-6**] 05:48AM BLOOD Glucose-143* UreaN-14 Creat-0.6 Na-133
K-4.6 Cl-99 HCO3-26 AnGap-13
[**2159-4-5**] 12:38PM BLOOD CK(CPK)-58
[**2159-4-5**] 12:38PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2159-4-6**] 05:48AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.4
[**2159-4-6**] 05:48AM BLOOD Phenyto-15.9
[**2159-4-4**] 11:03AM BLOOD Glucose-104 Lactate-0.8 Na-126* K-3.2*
Cl-92*
[**2159-4-4**] 11:03AM BLOOD Hgb-11.8* calcHCT-35 O2 Sat-98 COHgb-2
MetHgb-0
Brief Hospital Course:
Ms [**Known lastname 82060**] was admitted electively for a right sided craniotomy
without any complications. She was monitored in the PACU
overnight, her BP was kept less 160, she was treated with
Dilantin prophylactically. On her first post operative day she
was transferred to the floor, she was without any neurological
deficits except for orientation to date. She tolerated a regular
diet and was urinating without difficulty. PT/OT saw the patient
and felt she could benefit from short stay in rehab for
cognitive issues. We feel her confusion is related to the
Decadron, change in enviornment and lack of sleep.
Medications on Admission:
Hydrochlorothiazide (Esidrix)
(12.5')
Lipitor (Atorvastatin)
Omeprazole [Prilosec]
Other 1 (meloxicam d/c)
Other 2 (ocuvite, vit C, calcium D,
oxybutinin)
Plaquenil
([**Hospital1 **])
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3
times a day) for 8 days.
12. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 1 days.
13. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) for 1 days.
14. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) for 1 days.
15. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO ONCE (Once) for
1 doses.
Discharge Disposition:
Extended Care
Facility:
Sachem Skilled Nursing & Rehabilitation - [**Location 21318**]
Discharge Diagnosis:
Brain Mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you 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**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? 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 [**8-10**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast
Completed by:[**2159-4-6**]
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5421
}
|
Medical Text: Admission Date: [**2189-7-22**] Discharge Date: [**2189-8-10**]
Date of Birth: [**2111-4-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vitamin E / Hydrocortisone / Penicillins / Bacitracin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Mental status changes and fever
Major Surgical or Invasive Procedure:
[**2189-7-29**] 1. Left thoracotomy, placement of epicardial left atrial
and left ventricular bipolar pacing leads and insertion
of abdominal pocket dual-chamber pacemaker.
2. Multilevel left-sided intercostal nerve block.
[**2189-7-29**] Removal of previously implanted
transvenous DDD pacing system.
[**2189-8-5**] Delayed primary closure of old pacemaker pocket.
History of Present Illness:
78 year old male with history of MSSA endocarditis mitral valve
and suspected pacer lead infection discharged from [**Hospital3 635**]
hospital for 3 days to nursing home. Presented back to [**Hospital3 635**]
hospital mental status changes,
confusion and agitation - diagnosed with metabolic
encephalopathy. Additionally he has been complaining of right
knee pain but worsening just prior to admission at [**Hospital3 635**]
hospital. He is now being transferred for surgical evaluation.
Prior admission to [**Hospital3 635**] hospital with dc to rehab for
Staphyloccus bacteremia treated with oxacillin completed 6 week
course on [**2189-7-1**] - Antibiotics were resumed this admission at
[**Hospital3 635**] hospital with oxacillin and vancomycin and ceftriaxone
until sensitives were available due to + [**Hospital3 **] culture and
sepsis.
Also noted for tick bite and was tested at [**Hospital3 635**] hospital
which the lyme, anaplasma and babesia were negative He was
discharged to rehab on oxacillin and rifampin for 6 week course.
Past Medical History:
Mitral valve endocarditis
Septic emboli
AV block
Atrial Fibrillation
Degenerative joint disease
Peripheral vascular disease
Anemia
s/p Aortic valve replacement(23 Mosaic porcine)
s/p permanent pacemaker
Abdominal surgery after stabbing incident
Social History:
retired [**Last Name (un) 33982**]
lives alone
Tobacco:10 pack year history off and on - quit in [**4-18**]
ETOH occasional 1 shot brandy in coffee 2-3 days/week
beer with dinner
Family History:
non-contributory
Physical Exam:
Pulse: 72 Resp: 20 O2 sat: 100 on RA temp 98.0
B/P 151/68
General: No acute distress, cachetic
Skin: Dry [x] intact [] stage 1 decub on coccyx, non healing
stage 2 ulcer front of left calf, multiple areas of eccyhmosis
in
particular right flank, bilateral forearms
Midline sternal incision healing no erythema/drainage
Midline abdominal surgical scar
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur systolic [**2-13**]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Cool, Edema no edema, bilateral knees with
tenderness with ROM - PICC line left arm no erythema at site
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 and Left: murmur vs bruit
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 96424**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 96425**]Portable TTE
(Complete) Done [**2189-7-22**] at 4:29:11 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2111-4-12**]
Age (years): 78 M Hgt (in): 71
BP (mm Hg): 151/68 Wgt (lb): 155
HR (bpm): 72 BSA (m2): 1.89 m2
Indication: H/O cardiac surgery. Endocarditis.
ICD-9 Codes: 424.90, V43.3, 424.0, 424.2
Test Information
Date/Time: [**2189-7-22**] at 16:29 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2009W053-: Machine: Vivid [**6-15**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.6 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Right Ventricle - Diastolic Diameter: *2.7 cm <= 2.1 cm
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 20 mm Hg
Mitral Valve - Pressure Half Time: 95 ms
Mitral Valve - MVA (P [**12-12**] T): 2.3 cm2
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.7 m/sec
Mitral Valve - E/A ratio: 0.76
Mitral Valve - E Wave deceleration time: *315 ms 140-250 ms
TR Gradient (+ RA = PASP): *42 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.9 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
Normal IVC diameter (<2.1cm) with >55% decrease during
respiration (estimated RA pressure (0-5mmHg).
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with conduction
abnormality/ventricular pacing.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients. No masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. Minimally increased gradient consistent with
trivial MS. Mild to moderate ([**12-12**]+) MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Significant PR.
pericardial effusion.
Conclusions
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-5 mmHg. There is moderate symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. A bioprosthetic aortic valve prosthesis
is present. The aortic valve prosthesis appears well seated,
with normal disc motion and transvalvular gradients. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are severely
thickened/deformed but without rheumatic deformity. An
underlying vegetation cannot be excluded, but is not seen. There
is a minimally increased gradient consistent with trivial mitral
stenosis. Mild to moderate ([**12-12**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Normal functioning aortic bioprosthesis. Markedly
thickened/deformed mitral leaflets and annulus with minimal
mitral stenosis and at least mild-moderate mitral regurgitation.
Pulmonary artery systolic hypertension.
If clinically indicated, a TEE would be better able to define
the mitral valve morphology and severity of mitral
regurgitation.
CLINICAL IMPLICATIONS:
Based on [**2186**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2189-7-22**] 17:36
Brief Hospital Course:
Mr. [**Known lastname **] is a 78 year-old male who completed his course of
antibiotics for MSSA mitral valve endocarditis and possible
pacer lead infection . He was admitted for lead removal. Once
cleared by infectious disease, he was taken to the operating
room for pacer insertion and removal of old pacer system. See
operative report for further details. This was complicated by a
hematoma at old pacer site pocket which was opened and packed.
On [**2189-8-5**] he underwent delayed closure of the old pacer pocket
which he tolerated.
ID: He was seen by infectious disease who recommended continuing
nafcillin and rifampin until culture date final. He developed a
reaction to nafcillin and was changed to gentamycin for 5 days
and cefazolin. PICC line was removed and the tip was cultured
with no growth. His cultures remained negative since admission.
He was placed on cefazolin for treatement with completion plan
for [**2189-9-8**].
Cardiology: he was followed by EP throughout his hospital
course. The [**Company 1543**] DDR was interrogated with normal
function.
Respiratory: with aggressive pulmonary toilet and nebs he weaned
to room air with oxygen saturations in the high 90's.
Renal; he was gently diuresed. His renal function remained
normal. His lytes were repleted appropriately.
GI: His bowel function remained normal.
Wound: Upon admission he was found to have coccygeal stage I
pressure ulcer, and LLE old traumatic ulcer. See wound care
notes.
Nutrition: He was followed by nutrition throughout his hospital
course. His diet improved with PO supplementals.
PICC: Placed [**2189-7-31**] in interventional radiology. Successful
placement of a
5-French double-lumen, 41 cm, a left PICC with tip in the distal
SVC.
Disposition: He was followed by physical therapy throughout his
stay. He continued to make steady progress and was discharged
to rehab.
Medications on Admission:
Apirin 81'
Coumadin
Dulcolax 1'
Flomax 0.4'
KCL 20'
lopressor 25"
Magnesium Oxide 400'
Oxycontin IR 5/prn
Oxycontin CR 30"
Prednisone 5'
Prilosec 20'
Oxacillin 2 q4hr
Rifampin 300'''
Senekot 2 tabs'
MVI
Miralax-prn
Discharge Medications:
1. Cefazolin 1 gram Recon Soln Sig: Two (2) gm Injection every
eight (8) hours: through [**2189-9-8**].
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
6. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet
PO once a day as needed for constipation.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast: groin .
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Oxycodone 15 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO twice a day.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**]
Discharge Diagnosis:
Lead infection s/p removal of implanted pacemaker
S/p Pacemaker placement
Mitral valve endocarditis
Discharge Condition:
Good
Discharge Instructions:
Keep wounds clean and dry.
Please shower daily, no bathing or swimming.
Take all medications as prescribed.
Call for any fever 100.5, redness or drainage from wounds.
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Suture removal from pacer site at follow up with Dr [**Last Name (STitle) 914**]
[**2189-8-18**]- [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] (ID) clinic appt on [**9-7**], at 9:30am. [**Telephone/Fax (1) **]
Dr [**Last Name (STitle) 914**] [**2189-8-18**] plase call for appointment [**Telephone/Fax (1) **]
Dr [**Last Name (STitle) 96426**] [**Hospital **] clinic in 2 weeks
Dr [**Last Name (STitle) **]. Eten in [**1-13**] weeks
Completed by:[**2189-8-10**]
ICD9 Codes: 2859, 4439
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5422
}
|
Medical Text: Admission Date: [**2130-1-3**] Discharge Date: [**2130-1-6**]
Date of Birth: [**2077-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 52 yo m with recent hypercarbic hypoxic failure s/p
tracheostomy on mechanical ventilation, insulin dependent
diabetes, hypertension, obstructive sleep apnea, and chf who
presents with fever x 2-3 days with no obvious source.
Patient was recently admitted with hypercarbic hypoxic
respiratory failure requiring intubuation and subsequent
tracheostomy. Found to have MRSA pna refractory to 24 d of
treatment-- then switched to linezolid. During his last
hospital course, he was found to be in renal failure thought to
be from ATN as it improved with improved bp. He was discharged
on linezolid, and continued at rehab ([**12-28**])scheduled to end
[**1-4**]. Of note, picc line was changed to midline [**12-31**] with
picc line tip cx negative. He was started on cefepime, iv
flagyl, po vanco, in addition to the linezolid all during the 5
day rehab stay.
Past Medical History:
Past Medical History:
1. Morbid obesity.
2. Hypertension.
3. Obstructive sleep apnea on CPAP 12 with 2 liters of
supplemental O2 (not currently using). On 5L nC at home.
4. Insulin-dependent diabetes (Followed at [**Last Name (un) **]. Seen by an
ophthalmologist once a year. He has not seen a podiatrist in
over two years. [**4-21**]: Hemoglobin A1c 8.6, urine albumin to
creatinine 31.6).
5. CHF (EF indeterminate on most recent Echo).
6. Polycythemia.
7. ? h/o COPD (he has never had pulmonary function testing).
8. Degenerative disc disease.
9. Diabetic neuropathy.
10. Venous stasis/leg ulcers.
11. Right knee with torn cartilage (?meniscal injury).
12. History of left hip pain status post fall one year ago using
Lidoderm patches.
13. Hyperlipidemia (Last cholesterol [**4-21**]: TC 157, TG 238, HDL
45, LDL 76)
.
Past Surgical History:
1. Status post splenectomy secondary to motor vehicle accident
(he is unclear of his vaccination status, he is not sure when he
last received the Pneumovax).
2. Status post vascular repair of his right groin (details
unclear).
3. Tracheostomy
Social History:
He is married, but is estranged from his wife. [**Name (NI) **] works
part-time for a property management company. He walks with a
cane at baseline He denies current tobacco use. He smoked
briefly for 2 years, however quit over 10 years ago. He drinks
EtOH occasionally. He has never been a heavy drinker. He denies
illicit drug use.
Family History:
Family History: His mother has hypertension. His father died
from complications of diabetes and hypertension. He did not have
coronary artery disease. He has four brothers, all which are
healthy. He has 2 boys aged 21 and 27, both healthy. His uncle
is status post heart transplant (details unknown).
Physical Exam:
v/s T 101 BP 140/80 P 85, 300 cc of yellow clear urine in foley
catheter
vent setting: AC 12, TV 550, Peep 5, FIO2 of 45% sat 93%
GEN: trached, rigoring
HEENT: OP clear, stage 2, dime sized ulcer, no drainage,
tracheostomy site clean
LUNGS: difficult lung exam, CTA x 2
HEART: s1 s2 no m/r/g
ABDOMEN: soft, obese, vertical scar and scar on RLQ, +bs, foley
in place
EXTREMITIES: venous stasis changes b/l, good pt/dp pulses
NEURO: able to follow simple commands, squeezes hand for
responses
Pertinent Results:
Prior culture data:
urine cx- enterococcus [**Last Name (un) 36**] to vanc
respiratory cx [**2129-12-22**]- mrsa
catheter tip culture neg from [**12-31**]
blood cx [**12-29**]- NGTD
OSH: wbc 15.2, hct 48, na 153, co2 33, ldh 343
Brief Hospital Course:
Patient is a 52 yo m with recent hypercarbic hypoxic failure s/p
tracheostomy on mechanical ventilation, insulin dependent
diabetes, hypertension, obstructive sleep apnea, and chf who
presents with fever x 2 days.
Respiratory failure - did well on SBT and able to last 2 hours
on trach mask. Did well on passy muir valve and able to eat
regular diet while on valve. Should continue to wean off vent
while at [**Hospital **] rehab.
Fever - Resolved while patient was hospitalized. Not on
antibiotics. Stool was negative for c diff x 2. Blood cultures
NGTD. CXR without signs of pneumonia.
Hypernatremia - got free water boluses through NG tube. Na was
146 at the time of discharge. Should be checked again over the
weekend and twice a week after that.
Elevated CPK- neg mb fraction and mildly elevated troponin,
denied chest pain. Troponins trended down during admission.
Diabetes- insulin dependent diabetes, baseline lantus 75 [**Hospital1 **] and
humalog sliding scale.
CODE Status- full
Medications on Admission:
atorvastatin 40'
asa 81'
ipratrop/albut
fluticasone
docusate
heparin sc
lactulose
tylenol prn
miconazole powder
biscodyl
senna
linezolid
insulin sliding scale
fentanyl patch 100 mcg/hr q72 (weaned by 25 mcg)
lasix 40'
naloxone for constipation
metoprolol 25'''
captopril 25'''
haldol prn [**3-20**] iv prn
famoditine
oxymetazoline nasal spray
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Respiratory Failure
Fevers
Discharge Condition:
Fair; tolerating trach mask for 2 hours periods
Discharge Instructions:
--Continue to wean ventilation at rehab.
--When you are on trach mask and have the passy muir valve on
you can eat regular food.
--please check sodium twice a week and give free water boluses
as needed for hypernatremia
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2130-2-23**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2130-2-23**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] / DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2130-2-23**] 2:30
ICD9 Codes: 4280, 2760, 496, 3572, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5423
}
|
Medical Text: Admission Date: [**2176-9-12**] Discharge Date: [**2176-9-18**]
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
male with no prior history of coronary artery disease who
presented to an outside hospital with chest pains on [**2176-9-9**].
He had diagnostic catheterization on [**9-11**], which showed
severe three vessel disease after a suboptimal Thallium scan.
The patient at that time also was ruled out for a myocardial
infarction by serial enzymes. The patient's initial health
state was also complicated by anemia with initial hematocrit
at 20. Endoscopy on [**9-12**] showed no gastrointestinal bleeds.
The patient was transfused two units of packed red blood
cells, and was stable.
At this point, the patient was transferred to [**Hospital1 346**] for a possible coronary artery
bypass graft.
PAST MEDICAL HISTORY:
1. Renal cancer status post left nephrectomy in [**2173**]
2. History of AV block with pacemaker
3. History of colon polyps and diverticulosis
4. Chronic obstructive pulmonary disease
MEDICATIONS: Vioxx 25 mg every other day for back pain,
Combivent, and nitro paste one inch every four hours as
needed.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Pulse 94, blood pressure 118/60,
oxygen saturation 95% on room air. General: A pleasant man,
in no acute distress. Head, eyes, ears, nose and throat:
Pupils equal, round and reactive to light and accommodation,
extraocular movements intact. Neck: Negative jugular venous
distention. Cardiac: Regular rate and rhythm. Pulmonary:
Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended. Extremities: No peripheral edema.
Vascular: +2 dorsalis pedis.
LABORATORY DATA: Hematocrit 31, white blood cell count
12.9, platelets 412. Sodium 138, potassium 4.7, BUN 20,
creatinine 1.7. CK 24, 24, 14. Troponin negative.
Electrocardiogram on [**9-9**] showed ventricular pacing.
Catheter on [**9-11**] showed severe three vessel disease.
Echocardiogram showed normal left ventricular ejection
fraction. Esophagogastroduodenoscopy showed mild esophagitis
and duodenitis, negative ulcers.
HOSPITAL COURSE: The patient was admitted to Cardiothoracic
Surgery, and was transported to the operating room on [**9-13**].
The patient's operative diagnosis included coronary artery
disease, unstable angina, hypertension, chronic obstructive
pulmonary disease, and anemia. The procedure was a coronary
artery bypass graft x 3 with left internal mammary artery to
the left anterior descending, saphenous vein graft to the
posterior descending artery, and saphenous vein graft to the
obtuse marginal. The patient tolerated the procedure well,
and was transported to the Post-Anesthesia Care Unit in
stable condition.
On [**9-14**], the patient progressed well in the Cardiothoracic
Intensive Care Unit. The patient was extubated and then
transferred to Far 6.
On [**9-15**], the patient continued to do well, with increased
ambulation.
On [**9-16**], the patient was ambulating at a Level III, and a
decision was made to discharge the patient home after the
patient was cleared by Physical Therapy.
Biopsy of the sternal bone marrow showed hypocellularity but
no malignancy.
On postoperative day four, the patient continued to do well.
The bone marrow biopsy which was taken in the operating room
from the sternum showed normal bone marrow as a preliminary
result.
As long as the patient continues to progress well, and is
cleared by Physical Therapy, the patient will be discharged
home with VNA on [**2176-9-18**].
DISCHARGE PHYSICAL EXAMINATION: Temperature 98.9, pulse 92,
blood pressure 118/64, respirations 20, oxygen saturation 95%
on room air, +5 kg. Cardiovascular regular rate and rhythm,
respiratory clear to auscultation bilaterally, with slight
diffuse crackles. Abdomen soft, nontender, nondistended.
Extremities: No peripheral edema. Incision intact and dry
and clean.
COMPLICATIONS: None.
DISCHARGE MEDICATIONS: Percocet 5 one to two by mouth every
three to four hours as needed, milk of magnesia 30 mg by
mouth daily at bedtime as needed, Tylenol 650 mg by mouth
every four hours as needed, Combivent inhaler two puffs twice
a day, Lopressor 75 mg by mouth twice a day, lasix 20 mg by
mouth twice a day for seven days, potassium chloride 20 mEq
by mouth once daily for seven days with the lasix, Docusate
100 mg by mouth twice a day, aspirin 81 mg by mouth once
daily, Vioxx 25 mg by mouth once daily as needed for back
pain.
CONDITION ON DISCHARGE: Stable and good to home with VNA.
FOLLOW UP: With Dr. [**Last Name (STitle) **] in three to four weeks, and with
his primary care physician in three to four weeks.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft x 3
2. History of renal cancer status post left nephrectomy
3. AV block with pacemaker
4. History of diverticulosis with colon polyps
5. History of chronic obstructive pulmonary disease
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2176-9-18**] 03:41
T: [**2176-9-18**] 03:52
JOB#: [**Job Number 25110**]
ICD9 Codes: 4111, 496, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5424
}
|
Medical Text: Admission Date: [**2177-10-23**] Discharge Date: [**2177-10-29**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old
male with a history of hypertension, coronary artery disease,
status post antral septal myocardial infarction in [**2173**],
moderate AI, preserved EF, thoracic aneurysm, left CEA,
tobacco use transferred from outside hospital for
thoracoabdominal 7.5 cm aneurysm. Patient symptomatic
yesterday when awoke at 2:00 a.m. with sharp cutting pain in
mid to lower back that persisted prompting admission to
outside hospital. At outside hospital received Lopresor and
nitro drip for blood pressures in the 170s. Of note the
patient stopped taking his medications approximately four to
five years ago. On arrival at [**Hospital1 188**] Emergency Department the blood pressure was 167/82,
heart rate 87. The patient titrated on a nitro drip and
started on Esmolol drip. The patient was pain free. The
patient was evaluated by both Vascular Surgery and
Cardiovascular Surgery and transferred to the Coronary Care
Unit.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
[**2173**].
2. Chronic renal insufficiency baseline creatinine of 1.3.
3. Cerebrovascular accident in [**2166**] with right hemiparesis
and dysarthria status post left CEA.
4. Chronic obstructive pulmonary disease.
5. Hypertension.
6. Degenerative hip disease.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is not taking any regular
medications.
SOCIAL HISTORY: He lives alone, approximately 130 pack year
smoking history. The patient reports approximately one beer
per day, but per discharge summary the patient with chronic
alcohol use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vital signs 97.1, blood pressure 94/41
on right and 97/43 on left on Esmolol drip, heart rate 59,
respiratory rate 12. General, the patient appears older then
stated age, appears fatigue, but speaking with a clear voice.
HEENT unrevealing. Cardiovascular regular rate and rhythm.
Normal S1 and S2. No murmurs. No S3 or S4 appreciated.
Lungs clear to auscultation. No rales, wheezes or rhonchi.
Abdomen positive bowel sounds, soft, nontender, no palpable
pulsatile mass. Extremities no edema. Extremities warm
throughout. 2+ radial and femoral pulses bilaterally. 1+
dorsalis pedis pulses and posterior tibial pulses
bilaterally.
DATA: Hematocrit 43.3, BUN 19, creatinine 1.2.
Electrocardiogram normal sinus rhythm, left axis deviation,
PR .2 seconds, left ventricular hypertrophy, with left strain
pattern, T wave inversion V4 through V6, evidence of old
anteroseptal myocardial infarction. Echocardiogram report
from outside hospital preserved left ventricular function,
moderate AI, minimal left ventricular hypokinesis.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 8478**]
MEDQUIST36
D: [**2178-2-2**] 11:26
T: [**2178-2-4**] 11:48
JOB#: [**Job Number 53783**]
ICD9 Codes: 496, 4280, 4019, 412, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5425
}
|
Medical Text: Admission Date: [**2113-4-26**] Discharge Date: [**2113-5-4**]
Date of Birth: [**2030-2-4**] Sex: F
Service: MEDICINE
Allergies:
Biaxin / Ibuprofen / Amoxicillin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Left-sided hemiplegia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a lovely 83-year-old woman with a pmhx. significant for
adenocarcinoma of lung (dx in [**2107**], treated with surgery, chemo
and radiation), atypical meningioma (s/p R sided resection
5-years-ago), CLL (stage 0), and DVT/PE (on warfarin therapy)
who is transferred to [**Hospital1 18**] from [**Hospital 14076**] Hospital after acute
onset of left sided weakness while on a trip to Moheegan Sun.
Patient states that ever since she returned from [**State 108**] about 3
weeks ago, she has noticed increased weakness, apraxia (cannot
but button her shirt or put on socks), and confusion. On day
prior to admission, patient went to CT with her husband and some
friends on a "senior trip." While sitting at a lunch table
eating a bagel, patient started shaking and developed L-sided
weakness. Patient reports that she never lost consciousness,
though dose endorse some confusion surrounding the episode.
Ms. [**Name13 (STitle) 14077**] was taken to [**Hospital 14076**] Hospital in [**Location (un) 14078**], CT where MRI
showed hemorrhagic brain metastases. She was admitted to their
ICU her anticoagulation was reversed; INR had trended down to
1.9 prior to transfer. According to reports from [**Last Name (un) 14076**],
patient's mentation had improved overnight as well. Hct and
Chem 10 normal at OSH, as per report. Patient transferred to
[**Hospital1 18**] as all of her care has been here thus far; also discussion
of possible palliative XRT to [**Doctor Last Name **].
.
ROS: Patient endorses some confusion, left sided weakness.
Denies pain, though did have headache in ambulance during
transfer. No chest pain, shortness of breath, abdominal pain,
dysuria, fevers, chills, or any other concerning signs or
symptoms.
Past Medical History:
-NSCLA (stage IIIb) per above
-CLL.
-Left frontal meningioma.
-Peptic ulcer disease.
-Colonic adenoma.
-Goiter with hypothyroidism.
-Osteoporosis.
-Osteoarthritis.
-Hypercalcemia.
-Emphysema.
-Status post cholecystectomy.
-Atrial fibrillation with bilateral DVTs and IVC filter.
-Cataract.
-History of URI.
-Pulmonary emboli ([**2110**])
-DVT in [**2107**]
PAST ONCOLOGIC HISTORY:
- 83-year-old female with a history of stage zero CLL, underwent
resection of an atypical left frontal meningioma in 04/[**2107**]. At
that time, she had a CT chest, which showed a 1.5 cm speculated
mass in her right upper lobe.
- She underwent a right upper lobectomy and esophageal cavernous
hemangioma resection with tracheal laceration repair on
[**2108-8-24**]. At that time, it was a T4 adenocarcinoma and all
lymph nodes were negative.
- In [**2109-10-3**], she had a right lower lobe nodule which was
increasing in size. It was watched closely, and in [**11/2109**] it
once again was found to be increasing in size.
- On [**2109-12-27**], she underwent a wedge resection, which showed a
moderately differentiated adenocarcinoma, potentially
different from her first primary in the right lower lobe. She
has continued to be followed since that time.
- She was started on Navelbine therapy at a dose of 30 mg/m2 on
[**2110-8-21**]. This was decreased to 25mg/m2 on her 5th cycle due to
Neutropenia.
- She had evidence of disease progression on a CT scan performed
[**2111-4-2**] so the Navelbine was stopped.
- She received radiation to a bony lesion from [**Date range (1) 14079**]. She
had improvement of the pain after this.
- She started on Alimta on [**2112-3-31**]. She had a CT scan on
[**2112-8-18**]
which showed progression.
- She was started on Gemcitabine alone on [**2112-9-1**] which was
stopped due to pulmonary toxicity.
- She was started on Taxotere alone on [**2112-11-10**] which she
continued while in [**State 108**].
Social History:
: Lives with husband in condominium; daughter lives upstairs.
Was a homemaker, and also worked as a secretary for her husband.
Three children, 9 grandchildren, 9 great-grandchildren. Smoked
2 PPD for 27 years. Denies alcohol use. Was able to do most
ADLs up until about 3 weeks ago.
Family History:
mother died from bile duct CA age 89.
sister [**Name (NI) **] died from gastric CA age'[**48**].
sister [**Name (NI) **] died from esophageal CA age 74.
sister [**Name (NI) 4489**] died from lower extr DVT age 82.
father died from ?MI age [**Age over 90 **].
niece with pancreatic cancer
Physical Exam:
VS: T: 96.9, HR: 74, BP: 151/61, RR 23, SPO2: 93% on 2L
GENERAL: Elderly woman, lying in bed, no acute distress
HEENT: Mucous membranes dry, eyes slightly erythematous and
tearing, cavernous area on left upper skull, well-healed
CHEST: Diminished sounds at right base, otherwise CTA
CARDIAC: Regular rate and rhythm; no murmurs, rubs, or gallops
ABDOMEN: +BS, soft, non-tender, non-distended
EXT: Trace edema b/l
NEURO: Alert to person and time; knows president. Initially
confused as to oreientation -- this rapidly cleared by day 2
hospitalization. PEARLA, hearing intact to voice, tongue
midline, left facial droop. Complete left hemiplegia.
Sensation intact throughout.
Pertinent Results:
Admission labs:
[**2113-4-26**] 03:52PM BLOOD WBC-9.4 RBC-4.17* Hgb-11.5* Hct-36.2
MCV-87 MCH-27.7 MCHC-31.9 RDW-15.7* Plt Ct-221
[**2113-4-26**] 03:52PM BLOOD PT-17.8* PTT-26.7 INR(PT)-1.6*
[**2113-4-26**] 03:52PM BLOOD Glucose-122* UreaN-10 Creat-0.7 Na-140
K-4.7 Cl-108 HCO3-25 AnGap-12
[**2113-4-26**] 03:52PM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
STUDIES:
[**4-26**] CT Head:
1. New intraparenchymal hemorrhage within the right frontal
lobe, presumably representing a hemorrhagic metastatic lesion.
2. Additional smaller hemorrhagic metastatic lesions throughout
the
supratentorial brain.
3. Extensive vasogenic edema throughout the cerebral
hemispheres, without
evidence for midline shift or herniation.
4. Large soft tissue mass within the subcutaneous tissues of the
left frontal vertex and soft tissue nodule adjecent to the left
parotid gland, similar to prior MRI.
[**2113-4-28**] 03:20AM BLOOD WBC-12.6* RBC-3.99* Hgb-11.4* Hct-34.3*
MCV-86 MCH-28.7 MCHC-33.3 RDW-15.7* Plt Ct-207
[**2113-4-29**] 06:05AM BLOOD WBC-19.1*# RBC-4.07* Hgb-11.8* Hct-35.4*
MCV-87 MCH-28.9 MCHC-33.2 RDW-16.1* Plt Ct-190
[**2113-4-30**] 12:00AM BLOOD WBC-19.0* RBC-4.14* Hgb-11.7* Hct-35.9*
MCV-87 MCH-28.3 MCHC-32.7 RDW-15.9* Plt Ct-185
[**2113-5-2**] 12:30AM BLOOD WBC-28.3* RBC-4.62 Hgb-13.1 Hct-40.3
MCV-87 MCH-28.3 MCHC-32.4 RDW-16.1* Plt Ct-158
[**2113-5-3**] 04:10PM BLOOD WBC-38.7* RBC-4.83 Hgb-14.0 Hct-42.8
MCV-89 MCH-28.9 MCHC-32.6 RDW-16.1* Plt Ct-140*
[**2113-4-26**] 3:52 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2113-4-29**]**
MRSA SCREEN (Final [**2113-4-29**]): No MRSA isolated.
[**2113-4-29**] 2:15 pm URINE Site: CATHETER Source: Catheter.
**FINAL REPORT [**2113-5-1**]**
URINE CULTURE (Final [**2113-5-1**]):
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
This is an 83-year-old woman with a pmhx. of adenocarcinoma of
lung (s/p surgery and chemo), CLL, atypical meningioma who
presents from OSH with complete left-sided hemiplegia in setting
of hemorrhagic mets to [**Doctor Last Name **].
# METS TO BRAIN/LEFT HEMIPLEGIA: Patient now with new
hemiplegia and report of hemorrhagic mets to brain (upwards of
6) on MRI at OSH. Initially with confusion as well, but since
resolving. Likely mets are from previous adenocarcinoma of
lung, which is currently being treated by heme/onc (now on
regimen of Taxotere). Patient also had INR ~3 at OSH (on
coumadin for history of PE, afib), contributing to bleeding
around site of mets. As per report, MRI also showing cerebral
edema. At OSH, patient was started on decadron and Keppra;
neuro exam has been stable since arrival. CT head showed new
hemorrhage, as above. Neurosurgery was consulted, felt no
intervention was needed. Radiation oncology saw the patient and
began brain XRT, of which 6 of 10 treatements were completed.
She will undergo the rest from rehab. The patient was seen by
physical therapy and speech and swallow therapy. SHe was
continued on levetiracetam and dexamethasone.
# LUNG ADENOCARCINOMA: Patient is currently treated by
heme/onc (Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **] for lung cancer.
Currently on regimen of Taxotere since [**11-16**]. Last treatment
scheduled for [**4-13**] was held as patient wasn't feeling well
(complaining of diarrhea, deconditioning). The patient's primary
oncologist was notified of her admission.
# UTI: Pt had postive urine culture after leukocytosis noted. A
Proteus infection was treated with Cefpodoxime x 5 day.
# LEUKOCYTOSIS: Noted during hospitalization without fever. No
clear source, no hypoxia or increased cough. A UTI was treated.
Given history of prior CLL and current decadron, it was felt
that this was benign.
# Pre-renal Azotemia: Asymptomatic, rising BUN with stable HCT.
Noted on day of discharge. Was ordered for 1 liter of IV [**12-10**]
NS, but patient only able to recieve abut 125cc. Can be given
at [**Hospital3 **] 125cc/hr, and Chem 7 should be followed by
covering MD there.
# HYPOTHYROIDISM: Continue home synthroid
# Atrial Fibrillation/history of bilat DVTs: Was on Coumadin,
however given the brain hemorrhage this was discontinued. She
has an IVC filter in place, and is now maintained on
pneumoboots, which should be continued
# GERD: Continue home ranitidine
# CODE STATUS: Patient made clear her desire for DNR/DNI
status.
# Further ONC care need to be arrange with her Oncologist Dr.
[**Last Name (STitle) **] ([**Hospital1 18**]) and Radiation Oncologist (Dr. [**Last Name (STitle) **]. Her
consulting neurosurgeon is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Medications on Admission:
Albuterol inhaler prn
Alendronate 35 Qweek
Restasis eye drops
Fluticasone 50mcg [**12-10**] sprays in each nostril per day
Furosemide 20mg QD
Synthroid 100mcg QD
Lorazepam 0.5mg every 4 hours as needed for nausea (during
chemo)
Compazine
Ranitadine 150mg QD
Warfarin 2mg as directed by coumadin clinic (since [**2110**])
Docusate sodium
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO ONCE
(Once) for 1 doses.
7. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
8. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
L hemiplegia
Brain metastasis w/ hemorrhage
UTI - Proteus mirabilis
Leukocytosis w/ lymphocytosis - likely secondary to CLL +
steroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with dense L sided paralysis from hemorrhagic
stroke due to brain metastasis from cancer. You began Radiation
treatment and will receive a total of 10 treatments. You are
placed on thick liquids because of aspiration risk when you
drink think liquids, and you will be observed when eating.
You were taken off coumadin. You have an IVC filter in place for
protection from pulmonary embolus. You should be maintained of
pneumatic boots for DVT prophylaxis.
You were treated for a UTI.
You have a high white blood cell count without evidence of
infection. It is felt this is due to a combination of steroids
and CLL
Followup Instructions:
RADIATION ONCOLOGY APPTMENTS AT [**Hospital1 18**]
[**2113-5-5**] - XRT at 9:15 AM
[**Date range (3) 14080**] - no XRT
[**2113-5-9**], [**2113-5-10**] and [**2113-5-11**] - XRT at 8 AM each day
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: MONDAY [**2113-5-29**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6740**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 431, 5990, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5426
}
|
Medical Text: Admission Date: [**2150-5-13**] Discharge Date: [**2150-5-27**]
Date of Birth: [**2072-4-21**] Sex: F
Service:
REASON FOR TRANSFER: Second orthopedic opinion status post
hip fracture.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old female
with multiple medical problems including coronary artery
disease, congestive heart failure and chronic obstructive
pulmonary disease who initially presented to the [**Hospital3 417**]
Hospital on [**2150-4-25**], after suffering a
left hip fracture (displaced subcapital fracture). This
occurred as a result of a mechanical fall, apparently related
to left leg weakness the patient attributed to her diabetic
neuropathy. On admission to [**Hospital3 417**] she was placed in
Bucks traction while various medical workup occurred in
preparation for planned unipolar hemiarthroplasty. She was
given a course of amoxicillin for "bronchitis." Urine grew
Klebsiella and E. coli although the patient reported "chronic
UTIs" and it is unclear whether she had thrombocytopenia
(platelets 60's) so the Hematology Service was consulted.
They felt she should be transfused with platelets before and
after the surgery. The Cardiology Service was consulted and
felt she could safely undergo hip arthroplasty without
further preoperative coronary evaluation. Unfortunately,
although medically cleared for surgery, the patient by that
time had developed a significant coccygeal decubitus ulcer.
She was transferred to [**Hospital1 **] Rehab on [**4-29**] for
aggressive wound care in the hopes that hip surgery could be
performed around the end of [**Month (only) **].
At [**Hospital1 **] Rehab careful wound care of the
coccygeal decubitus ulcer was provided. She completed her
seven day course of amoxicillin. Chest x-ray on [**4-30**]
showed a left infiltrate with effusion, and borderline
congestive heart failure. Follow-up x-rays showed worsening
of the infiltrate and effusion and aspiration pneumonia was
suspected, so Flagyl was begun on [**5-7**]. Her TSH was
elevated (felt to be secondary to amiodarone) and her
Synthroid was increased from 12.5 mcg to 25 mcg q. day. On
[**5-8**] the Orthopedic Service saw her and discontinued the
Bucks traction.
She was transferred here today for second opinion regarding
the hip surgery. The patient is very eager to have the hip
repaired and complains mostly of hip pain and related leg
muscle spasm. She denies dyspnea or chest pain. She has had
a cough that she says is old and chronic; minimal sputum
production was reported. Her appetite is poor and she has
been receiving TPN. She says that she "ate a little bit"
yesterday for the first time in days. The coccygeal ulcer
does not bother her currently.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft times three in [**2135**]. The exact coronary anatomy
at that time is unknown.
2. Congestive heart failure, ejection fraction 20%.
Confirmed by echocardiogram.
3. Chronic obstructive pulmonary disease (not currently on
any inhalers).
4. Mitral regurgitation confirmed by echocardiogram.
5. Amiodarone induced hypothyroidism.
6. Atrial fibrillation, currently in sinus rhythm status
post cardioversion not on Coumadin at the time of admission.
7. Left subcapital displaced hip fracture [**2150-4-19**].
8. Diabetes mellitus type 2 of unknown duration.
9. Chronic renal insufficiency likely secondary to diabetic
nephropathy. Baseline creatinine [**12-22**].
10. Hypertension.
11. Gout.
12. Rheumatoid arthritis.
13. Coccygeal decubitus ulcer.
14. Gastroesophageal reflux disease.
15. Lactose intolerance.
16. Intermittent claudication.
17. Colon cancer status post partial colectomy.
18. Right carotid bruit (no history of transient ischemic
attack or stroke).
19. Thrombocytopenia.
ALLERGIES: Atorvastatin, Cipro, clarithromycin,
procainamide, macrolides, quinolones, NSAIDS, Latex
(reactions undocumented).
MEDICATIONS ON TRANSFER:
1. Allopurinol 300 mg p.o. q. day.
2. Amiodarone 200 mg p.o. q. day.
3. Artificial tears two drops O.U. t.i.d.
4. Vitamin C 500 mg p.o. b.i.d.
5. Lovenox 30 mg subcu q. day.
6. Epo 40,000 units subcu q. Wednesday.
7. Iron sulfate 300 mg p.o. b.i.d.
8. RISS 5 ml/200 mg p.o. b.i.d.
9. Synthroid 25 mcg p.o. q. day.
10. Nexium 40 mg q. day.
11. Chondroitin 500 mg p.o. b.i.d.
12. Metamucil one packet p.o. b.i.d.
13. Flomax 0.4 mg p.o. q. hs.
14. Milk of magnesia p.r.n.
15. Senna two tabs p.o. b.i.d.
16. Multivitamin one p.o. q. day.
17. Flagyl 500 mg IV q. 8h. day No. five of seven.
18. Zinc sulfate 200 mg p.o. q. day.
19. Tylenol p.r.n.
20. Alprazolam 0.25 mg p.o. q. 3h. p.r.n.
21. Guaifenesin b.i.d.
22. Percocet one tab p.o. q. 4h. p.r.n.
23. Peripheral parenteral nutrition.
FAMILY HISTORY: Significant for lung cancer relative unknown
at time of dictation at present.
SOCIAL HISTORY: Married times 58 years. Has five children,
one in [**State 4260**], one in [**Location (un) 3844**] and three locally. She has
a 40 pack year history of tobacco use. Occasional alcohol
use. Able to climb 13 stairs to enter her apartment on
[**Location (un) 1773**]. No elevator. DNR/DNI per report.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.7 degrees,
blood pressure 140/60, pulse 54, respiratory rate 22,
oxygenation 98% on two liters. General: Alert, pleasant,
elderly female lying very still in bed. HEENT: Pupils
equal, round and reactive to light and accommodation.
Extraocular movements intact. Anicteric sclerae. Moist
mucus membranes. Chest: Bilateral basilar crackles, left
greater than right. No wheeze. Scattered rhonchi that clear
with cough. Cardiovascular: Faint S1, S2. Regular, no
murmurs heard. Abdomen soft, non-tender, non-distended.
Positive bowel sounds. Extremities: Two plus pitting edema
to buttocks bilaterally. Dorsalis pedis pulses not palpable.
Several scattered dark non-tender distal bullae approximately
3-4 mm diameter on toes bilaterally. Not present on upper
extremity. No cyanosis or clubbing. Back not examined.
Plan to examine when more staff available to turn patient to
examine decubitus ulcer. Photographs in chart from [**Hospital1 33995**] documented. Neuro examination:
Cranial nerves II through XII grossly intact. Alert and
oriented times three. Motor examination limited by hip
fracture. Sensation grossly intact to light touch.
LABORATORY [**5-12**] FROM OUTSIDE HOSPITAL: PT 14.2, INR 1.3,
sodium 138, potassium 4.2, chloride 107, bicarb 18, BUN 56,
creatinine 2.7, glucose 137, calcium 7.7, magnesium 2.3,
phosphorus 2.6, triglycerides 117. Albumin 14.
[**5-11**]: White blood cell count 6.2, hematocrit 32.6,
platelet count 153,000. Alk phos 185,000. Total bilirubin
0.42. ALT 36, CK 96, LDH 222, total protein 5.1, albumin
2.4.
Micro: Clostridium difficile negative on [**5-6**] and [**5-8**]. Urine culture negative on [**5-11**].
ELECTROCARDIOGRAM: [**4-29**]: Normal sinus rhythm of 64 beats
per minute, right axis deviation, intraventricular conduction
delay, poor R-wave progression, T-wave inversion in leads V5
through V6 and 1 and aVL. No ST segment deviation.
RADIOLOGY: Chest x-ray on [**5-7**]: Left lower lobe
infiltrate with effusion. Right lung clear. Cardiomegaly.
HOSPITAL COURSE: [**2150-5-13**]: The patient was admitted to
the Medicine Service and was hemodynamically stable. Was
complaining of feeling tired and not able to sleep with some
pain in her back over the location of the decubitus ulcer.
Labs on the first day at [**Hospital1 188**]: White count 7.3, hematocrit 34.5, platelet count
149,000. The Chem-7 was 137, 4.4, 107, 17, 59, 2.4 and 109.
A chest x-ray at [**Hospital1 69**] showed
cardiomegaly with congestive heart failure and pulmonary
edema. Moderate left effusion, small right effusion. No
pneumothorax. An orthopedic consult was obtained on the date
of admission with Dr. [**First Name (STitle) 1022**] being the attending surgeon. At
that time it was Dr.[**Name (NI) 2989**] opinion that the patient would not
be a candidate for surgery until her decubitus ulcer
infection was controlled. The patient would be started on
deep venous thrombosis prophylaxis and Nutrition would be
consulted along with Psychiatry secondary to the patient's
dysthymia regarding her medical condition.
[**2150-5-14**]: A Psychiatry consultation was obtained. At
that time it was recommended that the patient be started on
Remeron at 7.5 mg to help with her anxiety and depressed
mood. The patient's lung examination was concerning for
crackles half the way up on the left and one-third up on the
right. Given this finding along with the chest x-ray
findings, it was recommended that the CHF Service would
consult. Dr. [**First Name (STitle) **] was asked to consult. On this date it was
felt that the patient would be able to have the surgery and
was actually typed, screened and cross-matched for two units
of packed red blood cells in preparation for surgery.
[**2150-5-15**]: Dr. [**First Name (STitle) **] spoke with the patient's outpatient
cardiologist who reported the patient is not usually in
congestive heart failure and this was probably an acute
exacerbation secondary to increased fluids due to the
patient's poor p.o. intake. The patient was started on 60 mg
of intravenous Lasix on the morning of [**5-15**] and 80 mg of
intravenous Lasix in the p.m. with only 300 cc of diuresis.
At this time it was felt that the patient was a poor
operative candidate and the surgery would have to be
postponed. Of note, there was also some concern about the
patient's dysrhythmias. The patient had had left bundle
branch block according to her outpatient cardiologist and
also had a history of atrial fibrillation status post
cardioversion and on the [**5-15**] the patient was found
to be in right bundle branch block. Due to the acute
exacerbation of congestive heart failure it was felt that the
patient was at high risk for re-entering rapid atrial
fibrillation and a Cardiology consult was obtained. The
Cardiology consult felt that the patient would benefit from
nesiritide as well as Lasix and transferred to ______ Two or
Three (Cardiology floors) when available. The goal for
diuresis would be one to two liters per day and to follow the
oxygenation lung examination and chest x-ray. Of note, wound
care per protocol was applied to the decubitus ulcer.
[**2150-5-16**]: The patient's code status was changed to
DNR/DNI by Dr. [**First Name (STitle) **] after speaking with the patient and her
husband. The patient had minimal diuresis of 250 cc
overnight with Lasix. The patient was continued on
amiodarone for atrial fibrillation. The coccygeal ulcer
continued to be dressed appropriately. The patient developed
a new issue of hyperglycemia. The insulin sliding scale was
adjusted accordingly.
[**2150-5-17**]: The patient was transferred to the Cardiology
floor (Far three) and nesiritide drip was started at 0.01
mcg/kg/min. The patient's diuresis was slightly improved at
400 cc in two hours on nesiritide and Lasix 80 mg IV times
one. The patient's lung examination had not improved.
Repeat chest x-ray showed persistent congestive heart failure
with effusions as described above. The patient's nesiritide
drip was increased to 0.15 mcg/kg. At this point the patient
was becoming increasingly frustrated with the progress of her
medical conditions. Psychiatry continued to follow and felt
that Remeron might be contributing to her sedation and that
her depression might be secondary to her multiple medical
conditions. Substantial discussion was conducted regarding
the need for intracardiac monitoring while the patient was
being diuresed. The patient, however, was extremely
reluctant to undergo additional interventions such as
Swan-Ganz catheter placement and was actually scheduled for
the Operating Room on [**2150-5-18**], despite her poor
oxygenation at 99% on five liters nasal cannula and poor
diuresis (CHF). Upon further discussion, the patient agreed
to go to the Coronary Care Unit for intracardiac monitoring
during her diuresis and on [**2150-5-18**], she was transferred
to the Coronary Care Unit. Chest x-ray findings suggested a
potential aspiration pneumonia.
A transthoracic echocardiogram was obtained that showed an
ejection fraction of less than 20%, moderate dilation of the
right atrium. Left ventricle: Mild symmetric left
ventricular hypertrophy, severe left ventricular systolic
dysfunction. Left wall motion: The following resting
regional left ventricular wall motion abnormalities were
seen: Basal inferior - akinetic; mid inferior - akinetic;
basal inferolateral - akinetic; mid inferolateral - akinetic;
inferior apex - akinetic; lateral apex - akinetic. Right
ventricle dilated. Moderate global. Right ventricular free
wall hypokinesis. Aorta: Aortic root is normal diameter.
Aortic valve leaflets are mildly thickened. Mitral valve:
Valve leaflets mildly thickened, 3+ mitral regurgitation.
In the Coronary Care Unit a pulmonary artery catheter was
placed in the left subclavian with CVP 25, PA pressure 57/28,
pulmonary capillary wedge pressure 30, cardiac output 6.6,
cardiac index 3.9, SVR 21. The patient was on strict I's and
O's, daily weights, daily chest x-ray. Due to the patient's
decreased SVR, the patient was pan cultured for a question of
sepsis. Orthopedics continued to follow the patient in the
Coronary Care Unit. A Nutrition consult was obtained due to
the patient's poor p.o. intake. The decubitus ulcer
continued to be dressed per standard protocol.
[**2150-5-19**]: The patient continued to be hemodynamically
stable, was breathing at 97% on three liters with an
increased pulmonary artery pressure at 64/30.
[**2150-5-20**]: The patient's levofloxacin and Flagyl was
discontinued after cultures showed no growth and the chest
x-ray was most consistent with congestive heart failure. The
patient was started on hydralazine 25 q.i.d. p.o. for
afterload reduction. At this point the patient's only
antibiotic was vancomycin 750 mg IV q.o.d. renally dosed.
[**2150-5-21**]: A Podiatry consult was obtained to evaluate
the patient's risk of infection secondary to open bullae on
her distal extremities with decreased sensation in the
setting of diabetes preoperatively. At this time the patient
was on hydralazine 25 q.i.d., Lasix 10 mg drip per hour,
metolazone 5 mg b.i.d. and nesiritide 0.02 mcg/kg/min, _____
25 q.i.d. The patient responded well and was negative one
liter over 24 hours. Due to the fact that the Swan-Ganz
catheter was no longer needed but central access was still
desired, the patient had her subclavian line changed using
the Seldinger technique to a triple lumen catheter in the
usual sterile fashion. Of note, at this time the patient's
platelet count was 81,000, creatinine 3.2. Possibly as a
result of the decreased platelets and/or uremic platelets, it
was difficult to attain adequate hemostasis post procedure,
therefore, lidocaine with epinephrine was injected at the
site. After applying direct pressure for 30 minutes, finally
after lidocaine with epinephrine adequate hemostasis was
achieved.
[**2150-5-22**]: Due to the fact the patient's pulmonary artery
pressures had declined and central intracardiac monitoring
was no longer required, the patient was transferred to the
floor on Natrecor drip at 0.02 mcg/kg/min, hydralazine 20
q.i.d., Lasix 20 mg drip per hour.
[**2150-5-23**]: The patient's Natrecor and Lasix drip were
discontinued as it was felt by the primary team as well as
the CHF Service that the patient was back to her baseline dry
weight of 65.5 kilograms and her lung examination had
improved. This was confirmed by chest x-ray as well. Of
note, the patient's hematocrit had dropped to 29.5 and she
was transfused one unit of packed red blood cells. The
patient was made NPO after midnight in anticipation of the
repair of her left minimally displaced subcapital femur
fracture on [**2150-5-24**].
[**2150-5-24**]: A left hip hemiarthroplasty was performed.
Surgeon [**Doctor Last Name 12528**] under general anesthesia with an estimated
blood loss of 250 cc. Intraoperatively the patient received
one unit of packed red blood cells and [**Pager number **] cc of lactated
Ringer's. The patient completed the surgery without
complications and was hemodynamically stable and transferred
to the Post Anesthesia Care Unit.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2150-5-27**] 19:49
T: [**2150-5-27**] 21:39
JOB#: [**Job Number 52243**]
ICD9 Codes: 4280, 496, 5849
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5427
}
|
Medical Text: Admission Date: [**2141-9-6**] Discharge Date: [**2141-9-11**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Aphasia and hemiplegia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 107440**] is an 87 y/o RH man with history of HTN
who presents with speech difficulties and right hemiplegia.
History taken from Wife:
He was in normal state of health. Yesterday at bedtime wife
checked in with husband at around 8-9pm and was at that moment
seemingly normal. She asked how he was and after a few attempts
at having him talk he finally got a "yes" out of him when asked
if he was alright. This a.m around 7 he fell out of bed hitting
hit right temporal area. He was not able to talk or move his
right side and EMS was called. Here in the ED he was noted to be
aphasic but was able to nod head yes and no to some questions.
His only verbal output was garbled and so no further history was
attainable from the patient himself.
Past Medical History:
HTN
Dyslipidemia
BPH
Social History:
Lives with Wife [**Name (NI) **]. Of Irish descent. No alcohol, tobacco,
drugs.
Family History:
Unknown.
Physical Exam:
When I saw him in the ED, he was initially weak on the right,
but
then recovered an was antigravity. He had a decreased blink to
visual threat on the right and also a right facial droop. here
was some neglect (crossed the midline) but had trouble
localizing
pain in his right arm.
His aphasia improved over the course of the hospitalization, but
minimally - he could say hello and sing 'Happy Birthday' but
otherwise mostly babbled.
Vitals: T:97.5 P: R: 16 BP: 118/75 SaO2:100%
General: Awake
HEENT: NC/AT, no scleral icterus noted, MMM,
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: Holosystolic murmur best heard over RUSB
Abdomen: soft, NT/ND, normoactive bowel sounds,
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, aphasic, garbled speech when attempted.
was able to follow some simple one step commands. able to close
eyes, show two fingers, locate his right arm.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils L 3mm, R 2mm. reactive. Fundoscopic exam technically
difficult
III, IV, VI: Left gaze, able to pass midline.
V: Facial sensation intact to light touch?.
VII: Left facial droop. hard to appreciate in hard cervical
collar.
VIII: Hearing not tested.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: not tested in hard cervical collar.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone increased in lower left extremity.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 0 throughout with following exceptions
R bic [**12-23**] finger flex [**12-23**]
-Sensory: questionable but nods yes to being able to feel right
side.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor on the left and extensor on right.
-Coordination: not tested.
-Gait: not tested.
Pertinent Results:
[**2141-9-11**] 06:45AM BLOOD WBC-7.3 RBC-4.25* Hgb-13.0* Hct-38.0*
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.5 Plt Ct-144*
[**2141-9-6**] 08:24AM BLOOD Neuts-67.8 Lymphs-22.1 Monos-6.7 Eos-2.9
Baso-0.5
[**2141-9-11**] 06:45AM BLOOD PT-21.5* INR(PT)-2.0*
[**2141-9-11**] 06:45AM BLOOD Glucose-89 UreaN-9 Creat-0.9 Na-143 K-3.5
Cl-107 HCO3-29 AnGap-11
[**2141-9-9**] 05:35AM BLOOD ALT-18 AST-23 AlkPhos-69 TotBili-0.5
[**2141-9-11**] 06:45AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8
[**2141-9-7**] 02:30AM BLOOD VitB12-366
[**2141-9-7**] 02:30AM BLOOD %HbA1c-5.7 eAG-117
[**2141-9-7**] 02:30AM BLOOD Triglyc-65 HDL-55 CHOL/HD-2.7 LDLcalc-78
[**2141-9-7**] 02:30AM BLOOD TSH-0.41
Cardiac Echo [**2141-9-7**]
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular systolic function
is hyperdynamic (EF>75%). Right ventricular chamber size and
free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension.
IMPRESSION: Hyperdynamic left ventricular systolic function.
Calcified aortic valve with moderate stenosis and mild
regurgitation. Moderate pulmonary artery systolic hypertension.
EKG [**2141-9-8**]
Atrial fibrillation with rapid ventricular response. Wandering
baseline
and baseline artifact. Left ventricular hypertrophy. Compared to
the previous tracing of [**2141-9-6**] atrial fibrillation with rapid
ventricular response has appeared.
Rate PR QRS QT/QTc P QRS T
123 0 84 332/442 0 42 -58
CTA head and neck
1. Large left MCA territorial infarction, predominantly
involving the
territory supplied by the superior division of the middle
cerebral artery.
2. Small calcific focus within the left superior M2 division,
immediately distal to the MCA bifurcation, likely reflecting a
calcified plaque that has embolized from a more proximal source,
such as the aorta or the common or internal carotid artery.
3. Large region of prolonged transit reflecting the "ischemic
penumbra," with only a small infarct core.
4. No intracranial hemorrhage.
MRI head
TECHNIQUE: Multiplanar T1, T2, spin echo, diffusion-weighted,
FLAIR imaging
was performed of the brain. In addition, 3D time-of-flight
imaging was also
performed.
FINDINGS: There is an acute infarction involving the left
frontotemporal lobe
(left MCA distribution). Abnormal T2 and FLAIR hyperintensity
within this
region as well as restricted diffusion is identified. There is
no evidence of
hemorrhagic blood products to suggest hemorrhagic
transformation. No other
infarctions are identified. Non-specific foci of T2/FLAIR
hyperintensity in
the right frontal lobe (3, 20 and 3, 17), as well as
periventricular
hyperintense foci likely represent chronic small vessel ischemic
changes. The
ventricles and sulci are normal in appearance. There is no
evidence of
hydrocephalus. There is no shift of normally midline structures.
MRA OF THE BRAIN: There is lack of filling of the superior
branch of the left
M2 concerning for occlusion. This corresponds to the region of
acute
infarction. In addition, there is no filling of the left distal
vertebral
artery which may be hypoplastic or stenotic. The remainder of
the circle of
[**Location (un) 431**] is unremarkable.
IMPRESSION: Acute left MCA infarct without evidence of
hemorrhage.
Non-opacification of the superior left M2 branch consistent with
occlusion.
Poor opacification of the left distal vertebral artery may
represent a
hypoplastic vertebral artery versus occlusion. This could be
further
evaluated by MRA of the neck.
Brief Hospital Course:
Hemiparesis
And aphasia - attributed to ischemic stroke clinically with
appropriate imaging correlates as above. Voluntary control of
the right leg improved quickly and arm was antigravity, but
without use of the right hand.
Aphasia
His aphasia improved over the course of the hospitalization, but
minimally - he could say hello and sing 'Happy Birthday' but
otherwise mostly babbled.
Stroke
Considered cardioembolic given newly recognized atrial
fibrillation and occlusion of large vessel, proximal MCA on
left. Therefore started coumadin. This was given on Saturday
10mg, Sunday 5mg and INR was therapeutic on Monday. Therefore
decreased dose to 2.5mg - this will need further adjustment.
Continued ASA (coumadin inferior for risk reduction for
cardiovascular disease). Pravastatin continued at 20 mg (see
below).
Atrial Fibrillation and Bigeminy
Newly recognized this admission. Likely etiologic for stroke.
Atenolol 25 mg has been sufficient for rate control. This was
recognized when the beta-blocker was held given acute stroke.
Nonetheless, we are suspicious of this at other times. Patient
typically in sinus rhythm or bigeminy.
Dyslipidemia
Quite well-controlled. Target under LDL 70, but at 78 and this
was not perfect non-fasting level. We decided not to increase
pravastatin above 20 mg.
Hypertension
Some brief mild hypertension while here, but continued atenolol
and amlodipine to good effect.
BPH
Continued doxazosyn
This patient is not diabetic, but sliding scale was used
in-house in this setting. A1c normal.
Medications on Admission:
Amlodipine
Aspirin (baby)
atenolol
doxazosin
pravastatin
torsemide
Discharge Medications:
1. Tylenol 8 Hour 650 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO every eight (8) hours.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. insulin regular human 100 unit/mL Solution Sig: As per
insulin sliding scale. Injection ASDIR (AS DIRECTED).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) as needed for stroke.
7. Famotidine 20 mg IV Q12H
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Patient received 10mg on [**9-9**] mg on [**9-10**], decreased to 2.5
mg on discharge.
10. doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary
Ischemic infarction of middle cerebral artery, left.
Secondary
HTN
Dyslipidemia
BPH
Discharge Condition:
Mental Status: Not confused, but unable to speak - can sing
Happy Birthday and follows many commands comprehension better
than speech).
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital after having a stroke. This has
happened in the context of you having atrial fibrillation, but
not being anticoagulated. We started coumadin and charted your
early progress. You will need intensive physical, occupational,
cognitive and speech therapy and you are therefore going to
inpatient rehabiliation.
Followup Instructions:
Please follow-up with your primary care doctor when you leave
rehabilitation.
Please see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in clinic in a few weeks for
follow-up after stroke:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2141-10-24**] 2:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 4019, 2724, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5428
}
|
Medical Text: Admission Date: [**2103-1-24**] Discharge Date: [**2103-1-29**]
Date of Birth: [**2059-7-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mild shortness of breath
Major Surgical or Invasive Procedure:
[**2103-1-24**] Minimally Invasive Mitral Valve Repair utilizing a 38mm
Annuloplasty Band
History of Present Illness:
This is a 43 year old female with known heart murmur since age
25. She has been followed by serial echocardiograms which have
shown worsening mitral regurgitation with increasing left
ventricular dimensions. She therefore has been referred for
cardiac surgical intervention. Most recent ECHO from [**Month (only) **]
[**2102**] revealed severe MR, dilated LV, EF of 55% and only trace
TR. Subsequent cardiac catheterization confirmed 4+ MR. Coronary
angiography showed clean coronary arteries.
Past Medical History:
Mitral Regurgitation
Social History:
Denies tobacco history. Admits to only social ETOH. She lives
with her daughter. She is a high school teacher. Denies IVDA.
Family History:
Denies premature CAD. Father currently alive in his 70's,
suffers from heart failure and diabetes.
Physical Exam:
Vitals: BP 130-140/86-88, HR 84, RR 12
General: well developed female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 4/6 systolic murmur left lower
sternal border
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2103-1-29**] Chest x-ray: A small right apical pneumothorax is
unchanged in size, with visceral pleural line overlying the
right third posterior rib level. Subcutaneous emphysema is again
demonstrated in the right axilla. Multifocal areas of discoid
atelectasis in the left mid and both lower lung regions have
slightly improved, and a small left pleural effusion has not
changed.
[**2103-1-28**] 05:33AM BLOOD WBC-9.7 RBC-3.00*# Hgb-9.8*# Hct-26.8*#
MCV-90 MCH-32.8* MCHC-36.6* RDW-14.0 Plt Ct-198
[**2103-1-27**] 06:10AM BLOOD Glucose-135* UreaN-9 Creat-0.6 Na-135
K-4.3 Cl-103 HCO3-27 AnGap-9
[**2103-1-26**] 07:45AM BLOOD Mg-1.9
COMPARISON: [**2103-1-28**].
INDICATION: Pneumothorax.
A small right apical pneumothorax is unchanged in size, with
visceral pleural line overlying the right third posterior rib
level. Subcutaneous emphysema is again demonstrated in the right
axilla. Multifocal areas of discoid atelectasis in the left mid
and both lower lung regions have slightly improved, and a small
left pleural effusion has not changed.
IMPRESSION: No change in small right apical pneumothorax.
echo [**1-24**]
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.0 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 5.0 cm
Left Ventricle - Fractional Shortening: *0.18 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
INTERPRETATION:
Findings:
Pre-CPB study performed to rule out LSVC/ASD and severe aortic
atheroslcerosis.
Retrograde coronary sinus and Pulmonary artery vent cannulae
placed under TEE
guidance and postions conformed.
LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast
in the body
of the LA. Depressed LAA emptying velocity (<0.2m/s) All four
pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Moderately dilated LV cavity. Low normal LVEF.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque. Normal ascending aorta diameter. Normal
descending
aorta diameter. No thoracic aortic dissection.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe
MVP. Partial
mitral leaflet flail. Severe (4+) MR. Eccentric MR jet.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
PRE-BYPASS: The left atrium is markedly dilated. No spontaneous
echo contrast
is seen in the body of the left atrium. The left atrial
appendage emptying
velocity is depressed (<0.2m/s). No atrial septal defect is seen
by 2D or
color Doppler. The left ventricular cavity is moderately
dilated. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular
chamber size and free wall motion are normal. The ascending,
transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic
plaque. No thoracic aortic dissection is seen. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic
regurgitation. The mitral valve leaflets are myxomatous. There
is
moderate/severe mitral valve prolapse. There is partial mitral
leaflet flail.
Severe (4+) mitral regurgitation is seen. The mitral
regurgitation jet is
eccentric. There is no pericardial effusion.
POST CPB:
First Attempt: Severely hypokinetic LV inferiro and spetal walls
with
mioderately hyokinetic RV free wall and severe hypotension
requiring
re-institutuion of full CPB.
2nd Attempt:
Improved biventricular systolic function. EF = 55%
Annuloplasty ring in mitralposition, trace MR, and no
significant
transmitralor LVOT gradient.
After thorough de-airing of the LV and LA and with background
inotropic
support, the focal and global LV aand RV function gradually
improved allowing
separation from CPB.
Posterior annuloplasty ring in mitral positon, well seated and
mecahnically
stable. Trace MR and no sigfnificant gradient across the mitral
valve.
LV and RV function returned to baseline.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Patient was admitted and underwent a minimally invasive mitral
valve repair by Dr. [**Last Name (STitle) 1290**]. There were no complications and
following the operation, patient was brought to the CSRU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. Her CSRU course was
uneventful and she transferred to the SDU on postoperative day
one. Chest tube was left in for several days secondary to
persistent serosanginous drainage. Chest tube was eventually
removed with resultant small right apical pneumothorax which
remained stable by serial chest x-rays. Postoperatively, she
also required several units of packed red blood cells for
anemia. Following blood transfusions, her hematocrit improved
from 18 to 26%. Postoperatively, she remained in a normal sinus
rhythm. Some premature atrial beats were noted on telemetry for
which beta blockade was initiated and slowly advanced as
tolerated. No episodes of atrial fibrillation were noted. The
remainder of her hospital stay was uneventful and she was
medically cleared for discharge on postoperative day five.
Medications on Admission:
[**Female First Name (un) **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Mitral regurgitation - s/p mitral valve repair, Postop right
apical pneumothorax, Postop anemia
Discharge Condition:
Good
Discharge Instructions:
Activity as tolerated.
Monitor wounds for signs of infection.
Please call with any questions or concerns.
Leave Dressing on chest tube site until [**1-30**] pm then remove, can
cover with dry guaze if needed changing daily
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**4-26**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 23651**] in [**2-24**] weeks, call for appt
Dr. [**First Name (STitle) 1726**] in [**2-24**] weeks, call for appt [**Telephone/Fax (1) 36012**]
Completed by:[**2103-1-30**]
ICD9 Codes: 4240, 486, 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5429
}
|
Medical Text: Admission Date: [**2122-6-20**] Discharge Date: [**2122-6-23**]
Date of Birth: [**2046-7-14**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Lactose
Attending:[**Doctor First Name 2080**]
Chief Complaint:
cough, SOB, fevers
Major Surgical or Invasive Procedure:
placement of right IJ central line
History of Present Illness:
75 year old woman with mixed connective tissue disease with
features of scleroderma (on chronic prednisone), ILD, trigeminal
neuralgia, esophageal dysmotility, HTN, and diastolic CHF, who
presents with 2 days of fatigue, non-productive cough, and
subjective fevers. Has also been feeling more SOB. Denies
headache, neck pain, chest pain, palpitations, abdominal pain,
diarrhea, or dysuria.
.
In the ED initial VS were 102.8, 138, 141/60, 30, 93% on RA.
Exam notable for bibasilar rales, benign abdominal exam. Labs
notable for WBC 18.9 (90% PMNs), lactate 6.1, trop 0.12 -> 0.14,
UA neg. EKG with STD laterally, though resolved with decreasing
HR. CXR showed small right pleural effusion, mild pulmonary
edema, possible pneumonia. Patient was given vanc/zosyn for
suspected pneumonia, ASA 325mg, hydrocortisone 100mg, and 1L NS
and repeat lactate was 2.6. She remained borderline hypotensive
with MAPs 55-60 so a right IJ was placed and patient was started
on levophed. She received a total of 2.5L NS. CT abd/pelvis was
performed and patient was transferred to the MICU for further
evaluation.
.
On arrival to the MICU, the patient is comfortable and states
that her breathing is improved and she is feeling more
comfortable.
Past Medical History:
- Mixed connective tissue disease with features of scleroderma
(high-titer positive [**Doctor First Name **], 1:1280 in a speckled pattern, positive
RNP antibodies,normal RF, neg anti-CCP antibody testing, neg
Ro/La, neg anti-Scl-70 Ab, neg [**Doctor Last Name 1968**] Ab, neg anticentromere Ab)
- Interstitial lung disease
- Patulous esophagus
- GERD
- Trigeminal neuralgia
- Raynaud's complicated by right index finger ischemic
ulceration s/p surgical intervention one year ago
- Diastolic CHF
- HTN
- Hyperlipidemia
- Rectal prolapse
- Bilateral knee osteoarthritis
- Chronic low back pain/lumbar stenosis
- Venous stasis, RLE>LLE
- RLE complicated fractures more than 20 years ago following MVA
- H/o right retinal vein occlusion greater than five years ago
Social History:
The patient is originally from [**Country 11150**], lives with her son and
daughter-in-law, both of whom are physicians, and with several
grandchildren. She is widowed. Denies alcohol, tobacco use, or
other illicits. Independent with ADLs, though less mobile
recently due to rectal prolapse.
Family History:
The patient's brother with diabetes and MI in his 50s. No other
family history of any rheumatologic diseases or lung diseases.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD, RIJ in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds and rales at both bases, no
wheezing
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: + foley
Rectal: No prolapse
Ext: Left leg > right leg (chronic), no pitting edema, warm and
well perfused, 2+ DP/PT pulses, no evidence of raynaud's
Neuro: Slightly dysarthric speech (unchanged and secondary to
the trigeminal neuralgia), decreased sensation over right side
of face, CNs otherwise intact, strenth [**5-9**] throughout, sensation
in extremities grossly intact, gait not assessed.
.
DISCHARGE EXAM:
Vitals: 118/69 75 100%RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds and mild course rhonchi at both
bases, no wheezing
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Left leg > right leg (chronic), no pitting edema, warm and
well perfused, 2+ DP/PT pulses, no evidence of raynaud's
Neuro: Slightly dysarthric speech (unchanged and secondary to
the trigeminal neuralgia), decreased sensation over right side
of face, CNs otherwise intact, strenth [**5-9**] throughout, sensation
in extremities grossly intact, gait intact
Pertinent Results:
ADMISSION LABS:
[**2122-6-20**] 11:30AM BLOOD WBC-18.9* RBC-5.18 Hgb-13.4 Hct-41.9
MCV-81* MCH-25.8* MCHC-31.9 RDW-16.8* Plt Ct-293
[**2122-6-20**] 11:30AM BLOOD Neuts-90.8* Lymphs-7.3* Monos-1.2*
Eos-0.4 Baso-0.3
[**2122-6-20**] 02:20PM BLOOD Glucose-104* UreaN-18 Creat-0.8 Na-136
K-3.6 Cl-98 HCO3-22 AnGap-20
[**2122-6-20**] 02:20PM BLOOD ALT-24 AST-28 AlkPhos-55 TotBili-0.5
[**2122-6-20**] 11:30AM BLOOD cTropnT-0.12*
[**2122-6-20**] 02:20PM BLOOD cTropnT-0.14*
[**2122-6-20**] 08:00PM BLOOD cTropnT-0.05*
[**2122-6-20**] 02:20PM BLOOD Albumin-3.3*
[**2122-6-20**] 11:45AM BLOOD Lactate-6.1*
[**2122-6-20**] 02:52PM BLOOD Lactate-2.6*
.
DISCHARGE LABS:
[**2122-6-23**] 06:10AM BLOOD WBC-9.4 RBC-4.51 Hgb-11.1* Hct-36.4
MCV-81* MCH-24.6* MCHC-30.4* RDW-16.6* Plt Ct-291
[**2122-6-23**] 06:10AM BLOOD Neuts-77.5* Lymphs-19.6 Monos-2.3 Eos-0.2
Baso-0.4
[**2122-6-23**] 06:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9
[**2122-6-20**] 01:58PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2122-6-20**] 01:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
MICROBIOLOGY:
[**2122-6-20**] BLOOD CULTURE X 2: Pending
[**2122-6-20**] URINE CULTURE: Negative
.
IMAGING:
CXR PORTABLE AP [**2122-6-20**] 11:00: Mild pulmonary vascular
congestion and small right pleural effusion, possibly
exaggerated by low lung volumes or slightly worse compared to
[**2122-1-2**]. Right base consolidation/ infection cannot be
excluded.
.
CXR PORTABLE AP [**2122-6-20**] 14:43: There are low lung volumes due
to poor inspiratory effort. There is prominence of the
pulmonary vascular markings suggestive of pulmonary edema.
There is also a right-sided pleural effusion and a developing
left retrocardiac opacity. Heart size is upper limits of normal
but stable. No pneumothoraces are seen.
.
CXR PORTABLE AP [**2122-6-20**] 16:25:
There is a right IJ central line with distal lead tip at the
cavoatrial junction. Heart size is again seen enlarged. There
is prominence of the pulmonary vascular marking suggestive of
moderate pulmonary edema. There is a right-sided pleural
effusion. There is a wide vascular pedicle. No pneumothoraces
are seen.
.
CT CHEST [**2122-6-20**]:
1. Superimposed consolidation within the lower lobes
bilaterally on a background of pulmonary fibrotic changes. This
may represent superimposed pneumonia or aspiration.
2. Bilateral atelectasis within the dependent portions of the
upper lobes which along with the lower lobe consolidation limits
identification of previously noted bilateral pulmonary nodules.
3. Stable enlarged left supraclavicular lymph nodes.
4. Coronary artery calcifications.
5. Patulous esophagus with fluid within the upper esophagus
which places the patient at risk for aspiration.
6. Bilateral hypodense thyroid nodules which could be further
evaluated with thyroid ultrasound on a nonurgent basis if not
previously performed.
.
VIDEO SWALLOW [**2122-6-22**]: Essentially normal pharyngeal swallow
with one episode of penetration with thin liquids.
Brief Hospital Course:
75 year old woman with mixed connective tissue disease with
features of scleroderma (on chronic prednisone), ILD, HTN, and
diastolic CHF, admitted with bilateral pneumonia complicated by
hypotension, now improving.
.
# Pneumonia/Sepsis: Patient with bilateral infiltrates on CT,
dyspnea and hypoxia on admission. She was found to be in sepsis
on admission, and was briefly placed on levophed. With
initiation of vancomycin and zosyn, respiratory symptoms
improved and hypotension resolved. She was narrowed to
ceftriaxone/azithro, and continued to have stable vital signs
and breath comfortably. She was transferred to the medical
floor. On the floor, she was transitioned to levofloxacin for a
PO outpatient regimen. She continued to saturate well on room
air, and had no fevers. She underwent speech and swallow
evaluation for possible aspiration as the source of her
bilateral pneumonia, but was not found to aspirate. The patient
was discharged on 5 remaining days of levofloxacin. She should
follow up with her primary care physician at discharge.
# Mixed connective tissue disease: Currently on prednisone 20 mg
daily, which is being tapered in preparation for colorectal
surgery. Patient with patulous esophagus and evidence of food
retention, likely due to scleroderma. The patient underwent
speech and swallow bedside evaluation and video swallow. She
was noted to have some oropharyngeal discoordination, without
evidence of aspiration. The patient was also noted to have some
mild food retention in the esophagus. Swallowing difficulties
discussed with outpatient rheumatologist ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4894**]), who would
like to start the patient on a promotility [**Doctor Last Name 360**] following her
colorectal surgery. The patient was also started on Bactrim
prophylaxis, as she has been on prolonged high dose steroids.
The patient will follow up with rheumatology as previously
scheduled.
.
# Rectal prolapse: New over past few weeks and associated with
significant pain and decreased quality of life. Has been
evaluated by surgery who would like to wait to repair until
after patient is off steroids. Patient currently undergoing
outpatient steroid taper in preparation for surgery. The
patient was kept on current steroid dose of 20 mg Prednisone
daily throughout admission. She will decrease to 15 mg
prednisone daily per rheumatology recommendations on [**Doctor Last Name 766**]
[**2122-6-29**]. Patient will follow up with surgery as an outpatient
as previously scheduled.
.
# Chronic, compensated, diastolic CHF: Patient was found to have
a small pleural effusion and pulmonary edema on CXR, but overall
appeared euvolemic on exam. She did not require diuresis during
admission. She was continued on aspirin 81 mg daily throughout
admission. Losartan was held for hypotension, but was restarted
with blood pressure stability and transition to the medical
floor.
.
# HTN: Chronic. Losartan held for hypotension on admission.
Once the patient's blood pressure stabilized and she was
transferred to the medical floor, she was resumed on home
losartan.
.
# Hyperlipidemia: Chronic. Continued simvastatin.
.
# GERD: Chronic. Patient was continued on home omeprazole.
.
# ILD: Spirometry from [**2122-5-18**] with restrictive defect, though
seems to be improving. Followed by Dr. [**Last Name (STitle) **].
.
# Communication: Son [**Name (NI) 33690**] ([**Telephone/Fax (1) 33691**]
.
# Code: Full (confirmed)
========================================
TRANSITIONAL ISSUES:
# Patient to f/u with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4894**] regarding prednisone taper and
possible promotility [**Doctor Last Name 360**] for esophageal dysmotility
# Patient to f/u with colorectal surgery as previously scheduled
Medications on Admission:
1. Hydromorphine 2mg daily prn pain
2. Losartan 25mg daily (for raynaud's)
3. Omeprazole 20mg [**Hospital1 **]
4. Prednisone 20mg daily (currently being tapered by rheum)
5. Simvastatin 10mg daily
6. Aspirin 81mg daily
7. Calcium carbonate-Vitamin D3 500mg(1,250 mg)-400 unit; 2 tabs
daily
8. Oxazepam 10mg QHS for insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin 750 mg daily Disp #*5 Tablet Refills:*0
4. Omeprazole 20 mg PO BID
5. PredniSONE 20 mg PO DAILY
Please continue this through [**6-28**], then decrease to 15 mg daily
from [**Date range (1) 33692**], then decrease to 10 mg daily starting [**7-6**].
Tapered dose - DOWN
6. Oxazepam 10 mg PO HS:PRN insomnia
hold for sedation or rr<10
7. Simvastatin 10 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg daily Disp #*30
Tablet Refills:*0
9. HYDROmorphone (Dilaudid) 1-2 mg PO DAILY:PRN back pain
Hold for sedation or RR<12.
10. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis: Pneumonia
Secondary diagnosis: Mixed connective tissue disorder,
dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 33693**],
.
You were admitted to the hospital with a severe pneumonia
requring a short stay in the intensive care unit. You were
started on antibiotics and your infection improved. You were
transitioned to the medical floor. On the medical floor, you
continued to feel better and were breathing comfortably on room
air. You were transitioned to an oral antibiotic called
levofloxacin. You should continue this for 5 days following
discharge.
.
During your admission, you also complained of difficulty with
swallowing. You underwent a swallow evaluation that showed you
have some difficulty coordinating swallowing, but that you are
still able to do so without causing danger to yourself. Part of
your difficulty swallowing may be caused by your mixed
connective tissue disorder. You should follow up with Dr.
[**Last Name (STitle) 4894**] regarding this issue. In the mean time, eat multiple
small meals daily and chew food finely before swallowing.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
MEDICATIONS CHANGED THIS ADMISSION:
START levofloxacin 750 mg by mouth daily for 5 days
START bactrim single strength daily
You should continue prednisone 20 mg daily through this week.
Next [**Last Name (LF) 766**], [**6-29**] you should decrease to 15 mg
daily, then the following week starting [**7-6**] you should
decrease to 10 mg daily.
.
If your symptoms worsen with this slow taper, you should call
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4894**] for further management.
Followup Instructions:
Name:PEARL [**Last Name (NamePattern4) 33694**],MD
SPECIALTY: PRIMARY CARE
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER
Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3858**]
WHEN:TUESDAY,[**6-30**] AT 11:45am
.
Department: RHEUMATOLOGY
When: WEDNESDAY [**2122-7-22**] at 4:00 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
ICD9 Codes: 0389, 486, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5430
}
|
Medical Text: Admission Date: [**2150-9-9**] Discharge Date: [**2150-9-10**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
evaluation of tracheostomy
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
75y/o M with a PMH of ESRD on HD, CAD, ischemic cardiomyopathy,
PAF, morbid obesity, COPD, OSA, and chronic tracheostomy
transferred to [**Hospital1 18**] for evaluation of tracheostomy. Per [**Hospital1 **]
reports there is concern for malfunctional tracheostomy as the
patient's peak pressures have been rising on ventilator. Per
respiratory therapy notes from [**Hospital1 **], prior to [**2150-9-9**] was on
AC 14/650/+5/50%, peak pressures rising over past week to mid
30s and 40s. RT has been unable to pass the inline catheter due
to resistance. Pt taken off vent to swith to 14 fr however
unable to pass airway. He was switched to SIMV 650/12/50%/ PEEP
5 with increased comfort.
The patient underwent a recent R BKA on [**2150-8-27**]. He had episodes
of hypoxia related to mucous plugging and sputum grew MRSA and
was started on a short course of vancomycin. He has chronic
decubitous ulcers. He received a short course of linezolid,
aztreonam and flagyl during his post-op BKA course, all
discontinued on [**9-1**]. He is on dialysis for ESRD.
Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)
and acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Known coccyx ulcers
Allergies: Penicillin and sulfonamides
Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].
Family History:
noncontributory
Physical Exam:
99.7 97.9 96/44 77 15 99% on vent
Alert and oriented with appropriate affect.
Trach in place.
Heart regular with no murmur.
Lungs with good air entry b/l and scattered crackles.
s/p right BKA, +1 edema in LE.
Obese with soft abdomen and bowel sounds present.
No rash, no asterixis.
Pertinent Results:
[**2150-9-9**] 08:49PM BLOOD WBC-7.5 RBC-2.90* Hgb-7.4* Hct-26.0*
MCV-90 MCH-25.6* MCHC-28.4* RDW-17.8* Plt Ct-202
[**2150-9-10**] 05:38AM BLOOD WBC-6.5 RBC-3.00* Hgb-7.6* Hct-25.8*
MCV-86 MCH-25.4* MCHC-29.5* RDW-19.3* Plt Ct-216
[**2150-9-9**] 08:49PM BLOOD PT-37.6* PTT-53.2* [**Month/Day/Year 263**](PT)-4.0*
[**2150-9-9**] 08:49PM BLOOD Glucose-149* UreaN-32* Creat-3.8* Na-140
K-3.8 Cl-104 HCO3-29 AnGap-11
[**2150-9-10**] 05:38AM BLOOD Glucose-109* UreaN-34* Creat-4.2* Na-139
K-3.7 Cl-103 HCO3-29 AnGap-11
[**2150-9-10**] 05:38AM BLOOD Albumin-2.4* Calcium-7.8* Phos-1.9*
Mg-2.7*
Micro:
[**2150-9-9**] 11:34 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-9-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Preliminary):
BAL [**9-10**]:
BRONCHIAL LAVAGE RIGHT MIDDLE LOBE.
GRAM STAIN (Pending):
RESPIRATORY CULTURE (Pending):
FUNGAL CULTURE (Pending):
CXR [**2150-9-9**]:
In comparison with study of [**6-27**], there is little change in the
appearance of the tracheostomy tube. Dobbhoff tube is in place,
though the image ends above the diaphragm so the tip cannot be
seen. Central catheter tip similarly is difficult to evaluate
and appears to be in the right atrium.
Prominence of interstitial markings persists and there are
probable bilateral pleural effusions.
Brief Hospital Course:
75 y/o with chronic tracheostomy, HD-dependent ESRD, sacral/LE
ulcers, R [**Hospital 6024**] transferred to the MICU for evaluation of his
tracheostomy.
# Respiratory failure:
Mr. [**Known lastname 77792**] has a history of hypercarbic/hypoxic respiratory
failure and is s/p trachostomy earlier in [**2149**]. He was noted to
have increasing peak pressures with difficulty in passing a
catheter due to resistance and was transferred for further
evaluation of his trach. IP was consulted and performed
bronchoscopy on [**9-10**]. He was found to have diffuse airway edema
consistent with volume overload. There were no significant
secretions and a full survey of the airways reveals all airways
were patent without any endobronchial lesions. His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.
He should be continued on vancomycin for treatment of MRSA
pneumonia.
Please note that the findings of the sputum culture and BAL were
pending at the time of discharge.
# ESRD:
Related to diabetic nephropathy. Patient did not receive HD at
[**Hospital1 18**] as he will be receiving it upon return to [**Hospital1 **].
Continued renagel.
# Atrial Fibrillation:
Continued metoprolol. Coumadin was held for supratherapeutic
[**Hospital1 263**] of 4. Please dose coumadin as needed to maintain [**Hospital1 263**] of
[**1-18**].
Please note that coumadin is not on the current medication list
as it should be held given that his [**Month/Day (3) 263**] is elevated. This is
most likely due to the interaction of coumadin with his current
antibiotics (levofloxacin and fluconazole). Please restart
coumadin cautiously once his [**Month/Day (3) 263**] is < 2.5 to maintain an [**Month/Day (3) 263**]
between 2 and 3.
Also note that subcutaneous heparin was stopped during your
hospital stay.
# Type II DM: continued sliding scale insulin and Lantus.
# R BKA with Sacral and leg ulcers:
Continued current wound care, no signs of active infection
# Plasma cell dyscrasia:
Found to have IgA kappa on serum electrophoresis with an
imbalance in the free kappa:lambda light chain ratio. BM biopsy
showed 5-10% plasma cells. During his work up the hematology
team felt he likely had MGUS and ordered a retroperitoneal
biopsy of a mass that was noted on his abd CT scan. His FNA was
non-diagnostic and a needle core biopsy showed fragments of
lymphoid tissue with quiescent appearing germinal centers.
Continued outpatient follow up
# Nutrition: NPO; tube feeds continued.
# Access - mid-line
# Code- full
Medications on Admission:
Fluconazole 100mg/50ml daily to end [**9-14**]
Levofloxacin 500mg IV Q24 (stop date [**9-14**])
Vancomycin 1gm IV
Epogen 20,000units QHD
Lispro SS
Heparin 5000U TID
Simvastatin 10mg daily
Docusate 100mg [**Hospital1 **]
Senna 2 tab [**Hospital1 **]
Famotidine 20mg daily
Warfarin 2mg daily
Renagel 800mg TID w/ meals
Tylenol 650mg Q6
Percocet 2 tab po Q4
Zofran 4mg IV Q6
Dulcolax 10mg po PRN constipation
Coumadin 2.5mg po daily
Metoprolol 12.5mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: hold if sedated.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Fluconazole 10 mg/mL Suspension for Reconstitution Sig: One
Hundred (100) mg PO once a day for 4 days: Last dose 9/29.
9. Levofloxacin 25 mg/mL Solution Sig: Five Hundred (500) mg
Intravenous once a day for 4 days: last day = [**9-14**].
10. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
with dialysis for as directed days: per treatment course as
directed by physicians at [**Hospital1 **].
11. Epogen 20,000 unit/mL Solution Sig: 20,000 units Injection
with dialysis.
12. Insulin
Please continue insulin according to the regimen you were on
prior to transfer to [**Hospital1 18**].
13. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
six (6) hours as needed for nausea.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: hold for sbp < 90 or hr < 55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnosis: Respiratory failure
Secondary Diagnoses: Pneumonia, End stage renal disease, Sacral
and leg ulcers, diabetes, Chronic diastolic heart failure,
Atrial fibrillation on coumadin
Discharge Condition:
On mechanical ventilation via trach. Afebrile with HR in
70s-80s and BP 98/40.
Discharge Instructions:
You were admitted for evaluation of your tracheostomy. A
bronchoscopy was performed and showed that your trach tube was
in the correct position without any obstruction.
1. Please attend all follow-up appointments as recommended by
your normal providers.
2. Please continue all medications as instructed. We stopped
your subcutaneous heparin during your stay. We also would like
you to dose coumadin carefully as the [**Hospital1 263**] is currently elevated
at 4. This is most likely from the interaction of coumadin with
fluconazole and levofloxacin.
3. Please return to the hospital if you develop fevers,
worsening respiratory status, or any other concerning symptom.
4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please continue to see your normal providers through [**Hospital **]
Health Care.
Completed by:[**2150-9-10**]
ICD9 Codes: 5856, 4280, 496, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5431
}
|
Medical Text: Admission Date: [**2155-12-3**] Discharge Date: [**2155-12-4**]
Date of Birth: [**2080-12-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
left carotid artery stenosis
Major Surgical or Invasive Procedure:
Carotid artery angioplasty and stenting
History of Present Illness:
The pt is a 74-yo man with hyperlipidemia, possible
hypertension, ischemic cardiomyopathy with EF 25-45%, CAD s/p MI
and emergent 4vCABG + LV Aneurysmectomy [**2151**], and left carotid
artery stenosis, who presents for angiography and
revascularization of carotid artery stenosis. Recent
surveillance testing has shown the left carotid artery to have
80-99% stenosis with a peak systolic velocity of 514 cm/sec and
diastolic velocities of 151 cm/sec. There was retrograde flow
involving the left vertebral artery consistent with a probable
subclavian artery stenosis. The patient has no history of prior
stroke or TIA, and has not had any neurological symptoms
including difficulty with speech, headaches, changes in vision,
weakness, numbness or tingling. He also denies any cardiac
symptoms including chest pain, SOB, DOE, orthopnea, PND, leg
swelling, palpitations, syncope or presyncope, or claudication.
.
The pt underwent carotid angiography and stent placement in the
cardiac cath lab, and is admitted to the CCU for further care
and monitoring.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (?)Hypertension
2. CARDIAC HISTORY:
- Ischemic cardiomyopathy with EF 25-45%
- CAD s/p MI and emergent 4vCABG + LV Aneurysmectomy [**2151**] at [**Hospital1 112**]
- Severe left carotid artery stenosis
3. OTHER PAST MEDICAL HISTORY:
- Rectal cancer diagnosed over 40 years ago, s/p colostomy
- Bladder cancer, diagnosed in [**2147**] and [**2152**], s/p BCG treatment
x 2
- Prior remote knee surgery
Social History:
Married w/ 4 children, lives with wife. Semi-retired dentist.
Remote tobacco history, no EtOH.
Family History:
Brother w/ CHF in 60s, otherwise non-contributory.
Physical Exam:
VS: T=98.2F, BP=119/48, HR=62, RR=17, O2 sat=97% 2L NC
GENERAL: WDWN elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVD. +Left carotid bruit -? radiation of RUSB
murmur.
CARDIAC: RRR, normal S1-S2, +II/VI SM @ RUSB. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: +BS, soft/NT/ND. +Colostomy on left abdomen. No
palpable masses or HSM.
EXTREMITIES: WWP, no c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+ Radial 2+
Left: DP 2+ PT 2+ Radial 2+
Pertinent Results:
[**2155-12-3**] 07:50AM BLOOD WBC-7.6 RBC-3.80* Hgb-12.0* Hct-34.5*
MCV-91 MCH-31.7 MCHC-34.9 RDW-13.7 Plt Ct-246
[**2155-12-3**] 07:50AM BLOOD Neuts-87.5* Lymphs-7.4* Monos-4.2 Eos-0.7
Baso-0.3
[**2155-12-3**] 04:27PM BLOOD CK(CPK)-147
[**2155-12-3**] 04:27PM BLOOD CK-MB-3
[**2155-12-4**] 06:31AM BLOOD WBC-8.6 RBC-3.39* Hgb-10.8* Hct-30.9*
MCV-91 MCH-31.9 MCHC-35.0 RDW-13.7 Plt Ct-207
[**2155-12-4**] 06:31AM BLOOD PT-13.0 PTT-25.4 INR(PT)-1.1
[**2155-12-4**] 06:31AM BLOOD Glucose-105 UreaN-15 Creat-1.0 Na-142
K-4.1 Cl-108 HCO3-27 AnGap-11
[**2155-12-4**] 06:31AM BLOOD CK(CPK)-233*
[**2155-12-4**] 06:31AM BLOOD CK-MB-4
[**2155-12-4**] 06:31AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3
.
[**2155-12-3**] Cardiac Catheterization (Preliminary Report):
1. Severe left internal carotid artery stenosis
2. Successful PTCA and stenting of the left ICA with a bare
metal stent.
3. Left subclavian artery stenosis (50 mm Hg gradient between
non-invasive blood pressure monitoring)
4. Abdominal aneurysm
5. Successful closure of the right femoral arteriotomy site
with a 6F
closure device.
.
[**2155-12-3**] ECG: NSR @ 80, RAD/RBBB, non-specific ST-Twave changes
.
Results Pending at the Time of Discharge:
Final Cardiac Catheterization Report
Brief Hospital Course:
Mr. [**Known lastname **] presented with severe left carotid artery stenosis.
He underwent angiography and stent placement of the left carotid
artery. He was then admitted to the CCU for intense blood
pressure monitoring and frequent neuro checks. He was given
neosynephrine to maintain blood pressures over 100 systolic. He
did not require nitroglycerin for hypertension. He was
monitored with serial neuro exams and did not experience any
neurologic symptoms. He was continued on his aspirin and
plavix. No changes were made to his medications. He was weaned
off the neosynephine on the morning of discharge and remained
symptomatically well. He was ambulating without difficulty. He
was put on pneumoboots for DVT prophylaxis. He was discharged
with follow-up appointments for a repeat carotid ultrasound and
appointment with Dr. [**First Name (STitle) **] on [**2155-1-15**].
Medications on Admission:
- Zocor 20mg every evening
- Plavix 75mg daily every evening
- Toprol XL 150mg every morning
- ASA 81mg every morning (took 324mg today)
- Doxazosin 4mg every evening at bedtime
- MVI
Discharge Medications:
1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
6. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary -
Carotid artery stenosis s/p stent placement
Secdonary -
Conronary artery disease
Ischemic cardiomyopathy
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital to have a stent placed in your
carotid artery to open a blockage which was found by your
cardiolgoist. The stent was placed during your hospitalization.
You will need to take plavix 75 mg daily and ASA 325 mg daily.
You had been started on the plavix and ASA prior to your
admission. No changes were made to your medications.
Go to the emergency room or call your primary docotor if you
experience fevers, chills, chest pain, shortness of breath,
vision change, weakness in your extremities, numbness or
tingling, dizziness, blood in your stool, or black stool.
Followup Instructions:
You will need to follow up with with Dr. [**First Name (STitle) **] on [**1-15**] at
11:40am. The office is located on [**Hospital Ward Name 23**] 7 ([**Hospital1 18**] [**Hospital Ward Name 516**])
in the Cardiology Suite.
A carotid ultrasound has been scheduled for [**1-5**] at 1:30pm. The
radiology suite is ocated on [**Hospital1 18**] [**Hospital Ward Name 517**], Clinical Center
[**Location (un) 470**].
Please call Dr.[**Name (NI) 66745**] office to schedule a follow-up
appointment. The number is [**Telephone/Fax (1) 1690**].
ICD9 Codes: 4280, 2724, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5432
}
|
Medical Text: Admission Date: [**2133-5-16**] Discharge Date: [**2133-5-21**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC: fever,hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 48 yo M w/ h/o ESRD s/p failed transplant, h/o hep B/C/?D,
h/o paf on coumadin, h/o sarcoid, h/o pulmonary aspergillosis,
and h/o MRSA line sepsis [**5-6**] and presumed recurrence [**10-6**], who
presented to the ED [**5-16**] from dialysis with hypotension noted
after HD. Pt was recently admitted to vascular surgery service
for L TMA and d/c'd on Vanc (at HD) [**4-23**]. Pt was at [**Hospital **]
Rehab until the day of admission when he went to HD and became
hypotensive and was transferred to the ED.
.
In the [**Name (NI) **], pt had R femoral triple lumen placed and received 1L
NS, vanc, levo, and flagyl and due to persistent SBP in the 70s
he was admitted to the MICU. In the MICU his antibiotics were
continued and he was given an additional 1L NS. He has been
hemodynamically stable and is now being transferred to the
floor.
Past Medical History:
PMH:
Past Medical History:
1. ESRD s/p failed transplant [**7-4**] now collapsing
glomerulonephritis, HD qMWF at [**Location (un) 4265**]
2. Amyloidosis
3. Sarcoidosis
4. Hx of pulmonary aspergillosis - on itraconazole, followed by
pulm
5. Hx of hyperkalemia
6. Hep B, C, ? D
7. HTN
8. Hx of IV drug use
9. h/o sinusitis requiring drainage
10. recent epistaxis requiring intubation
11. SPEP/UPEP positive
12. paroxysmal atrial fibrillation - off BB, on coumadin
13. h/o C diff [**3-8**]
14. MRSA line sepsis ([**5-6**]), new tunneled fem line [**5-6**], TTE neg
for veg, line sepsis ([**11-5**]), new tunneled fem line [**12-6**]
15. h/o purulent ascites [**3-8**] while on PD
16. gynecomastia
17. iron deficiency anemia
18. renal osteodystrophy
19. adrenal insufficiency - on prednisone 5 mg po qd
20. h/o b/l UE DVT [**3-8**]: pt should not have IJ or SCL lines
21. h/o pancreatitis [**3-8**]
** ECHO [**5-6**]: EF > 55%, 1+ MR
Social History:
Soc Hx:
Lives with girlfriend, on disability; 1 packper day x30 years of
tobacco use, still currently smoking. No alcohol, but previous
history of abuse.
Family History:
Diabetes
Physical Exam:
PE: VS 98.4 HR 100 BP 120/64 R 12 O2 100% on 2L NC
Gen: lethargic but arousable to voice.
HEENT: EOMI, PERRL, OP clear, anicteric
Neck: supple, no appreciable LAD.
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 TMA (dark skin around sutures, otherwise clean,
dry), right femoral triple lumen, left tunneled HD catheter.
Neuro: moves all 4, oriented to person, year, not to place,
answers questions, follows commands.
Pertinent Results:
Studies:
[**5-16**] CXR: IMPRESSION: No interval change from [**2133-4-19**], with
persisting calcified mediastinal and hilar lymphadenopathy,
biapical pleural scarring, and scarring/bronchiectasis in the
upper lobes and right lower lobe. No new consolidation to
suggest acute pneumonia.
.
[**5-16**] Head CT:
1. No evidence of intracranial hemorrhage.
2. Bilateral internal capsule hypodensities as well as
hypodensity adjacent to the frontal [**Doctor Last Name 534**] of the left lateral
ventricle which are new compared to the prior study of [**9-14**], [**2130**]. These may represent chronic microvascular infarction
or Virchow-[**Doctor First Name **] spaces. Given the patient's age, however, a
demyelinating process cannot be excluded. MRI with DWI is more
sensitive in the detection of acute infarction.
[**2133-5-16**] 03:55PM PLT SMR-VERY HIGH PLT COUNT-629*#
[**2133-5-16**] 03:55PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
TARGET-OCCASIONAL
[**2133-5-16**] 03:55PM NEUTS-73.7* BANDS-0 LYMPHS-11.4* MONOS-10.7
EOS-3.5 BASOS-0.7
[**2133-5-16**] 03:55PM WBC-13.5* RBC-4.12* HGB-10.6* HCT-34.0*
MCV-83# MCH-25.7* MCHC-31.2 RDW-19.1*
[**2133-5-16**] 03:55PM CALCIUM-9.6 PHOSPHATE-2.7# MAGNESIUM-2.0
[**2133-5-16**] 03:55PM GGT-206*
[**2133-5-16**] 03:55PM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-238*
AMYLASE-48 TOT BILI-0.1
[**2133-5-16**] 03:55PM GLUCOSE-239* UREA N-20 CREAT-5.0*# SODIUM-137
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2133-5-16**] 04:11PM LACTATE-2.4*
[**2133-5-16**] 04:35PM URINE RBC-0-2 WBC-[**7-11**]* BACTERIA-FEW
YEAST-NONE EPI-0 TRANS EPI-0-2 RENAL EPI-0-2
[**2133-5-16**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2133-5-16**] 04:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2133-5-16**] 05:09PM PT-26.2* PTT-36.6* INR(PT)-2.7*
[**2133-5-16**] 07:20PM O2 SAT-73
[**2133-5-16**] 07:27PM TYPE-[**Last Name (un) **] PO2-26* PCO2-59* PH-7.30* TOTAL
CO2-30 BASE XS-0
[**2133-5-16**] 08:41PM FK506-2.0*
Brief Hospital Course:
This is a 48 y/o male with ESRD on HD with hx mult line
infections with recent L TMA (trans-metatarsal amp), who
presented to ED initially with hypotension, fever, requiring
monitoring in the MICU overnight, who remained hemodynamically
stable and was transferred to the medical floor for further
management.
1. Hypotension/sepsis - Pt was hemodynamically stable after
fluid resuscitation. Given his history of line infection, his
most likely source of possible sepsis was another line infection
from his HD line. His CXR, urine were all clear. He was
evaluated by vascular, who did not feel his L TMA was the source
of the infection, but that the patient would need an eventual
left BKA. His blood cultures from [**5-16**] and onwards have been no
growth to date. He was started on vancomycin/levofloxacin/flagyl
and then changed to just vancomycin once patient was stable and
it was felt that his infection was from his HD line. He needs to
continue vancomycin empirically for 2 weeks, to be dosed at HD.
As the patient has a history of extremely poor and difficult
access, his HD line CANNOT be removed. The patient remains on
daily low-dose prednisone given his history of adrenal
insuffieciency in the past.
The patient's MS was also lethargic initially, which has
improved to his baseline after starting appropriate treatment
with antibiotics.
.
2. ESRD - On HD Tues/Thurs/Sat. On sevelemer, cinecalcet, and
tacrolimus. Needs to be dosed vanco at HD until [**2133-5-27**].
.
3. Hx adrenal insufficiency - was on stress dose steroids
briefly, changed over to low-dose po prednisone as pt is
hemodynamically stable
.
4. DM - continue insulin SS as directed
.
5. Pain - continue lidocaine patches and oxycodone prn
.
6. Afib - Hold metoprolol as patient was initially hypotensive
and now normotensive. On coumadin 1 mg qod, which was increased
to 2 mg qod upon discharge as his INR was 1.5. His goal INR is
[**3-6**]. He should have repeat PT/PTT/INR in [**4-4**] days as dose
adjustment may be necessary.
.
7. Psych - On welbutrin and remeron. D/c'd zyprexa due to the
lethargy.
.
# FEN - Reg diet, monitor lytes. IVF prn hypotension.
# Code: Full. Confirmed with HCP
# PPx - heparin SQ, protonix for GI. bowel regimen.
# Access: L femoral tunneled HD cath, right femoral line was
d/c'd on [**5-21**] with good hemostasis
# Comm: HCP [**Name (NI) 102395**] [**Name (NI) 10664**] (girlfriend) [**Telephone/Fax (1) 102392**]
Medications on Admission:
Meds on admission:
Docusate Sodium 100 mg PO BID
Famotidine 20 mg PO Q24H
Itraconazole 100 mg PO BID
Oxycodone-Acetaminophen 5-325 mg [**2-2**] PO Q4-6H prn
Tacrolimus 0.5 mg PO DAILY
Lidocaine 5 % Adhesive Patch, 12 h on 12 h off
Senna 8.6 mg PO BID prn
Folic Acid 1 mg PO DAILY
Metoprolol Tartrate 12.5 mg PO BID
Sevelamer 800 mg PO TID
Prednisone 5 mg PO DAILY
Cinacalcet 30 mg PO DAILY
coumadin 1mg PO QOD
epo 20K T, th, sat
HD T, TH, Sat
Tylenol prn
Xenaderm
zyprexa 5 po QD
mirtazapine 15 mg PO qHS
wellbutrin 100 SR QD
Atarax 10 mg PO TID prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Itraconazole 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
9. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Bupropion 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
12. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO QOD ().
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: for right femoral
line.
14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD ().
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous QHD (each hemodialysis) for 10 days: to be
dosed on dialysis days during hemodialysis, last dose on [**5-27**] to
finish a 14 day course.
17. Epoetin Alfa 10,000 unit/mL Solution Sig: 15,000 Injection
ASDIR (AS DIRECTED): to be given during hemodialysis on HD days.
18. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Insulin
Insulin sliding scale as directed on attached sheet
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary - line infection
Secondary - ESRD, amyloidosis, sarcoidosis, HTN, PAF, MRSA line
sepsis
Discharge Condition:
Stable, afebrile with VSS
Discharge Instructions:
-continue with all medications as prescribed
-continue vancomycin to finish a 2-week course (last dose on
[**2133-5-27**]) - this should be dosed at hemodialysis
-continue coumadin every other day for goal INR [**3-6**] - recheck
PT/PTT/INR in [**4-4**] days for dose adjustment
-continue with hemodialysis as scheduled on Tues, Thurs, and Sat
-if symptoms of dizziness/lightheadedness, fevers, shortness of
breath, confusion, or any other concerning symptoms occur please
come to the ED or seek medical attention immediately
-vancomycin needs to be continued for 2 weeks and dosed at each
hemodialysis
Followup Instructions:
1) Dr. [**Last Name (STitle) **], [**2133-5-28**] at 9:25 am
2) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2133-7-13**] 9:50
Completed by:[**2133-5-21**]
ICD9 Codes: 0389, 4240
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5433
}
|
Medical Text: Admission Date: [**2196-12-3**] Discharge Date: [**2196-12-4**]
Date of Birth: [**2143-2-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20128**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 53 yo M with hx of bipolar d/o,
baseline mild dementia, was found down at [**Hospital3 **] in her
bathroom. She states that she did hit her head however she
states that she did not lose conciousness. The patient states
that she remembers everything. She said that she fell while she
was getting up from the toilet and using the handicap handles,
she slipped and did not grab the handles and fell backwards and
hit her lower back and her posterior.
.
In ED, expressed LBP, mild headache, no neck pain.
.
In the ED, initial vs were: 96.2, 80, 146/80, 16, 100%/8L. She
had left sided posterior head contusion. Labs significant for
Hct 31.9, MCV 105 (baseline), creatinine 2.8 (baseline) with BUN
50, Na 132, K 5.3. Tox screen was negative. UA showed [**3-4**] WBC,
neg nit, few bact, 25 protein. CXR showed low lung volumes and
crowding of bronchovascular space. T-spine and C-spine showed no
acute fx and CT head showed no acute ICH. L-spine limited but no
fracture. VS on transfer were: 97.3, 74, 138/74, 16, 97%. Noted
that cannot clear spine [**2-2**] pain with neck flexion so changed to
[**Location (un) 2848**] J collar.
.
After the patient was transferred to the floor she continued to
complain of lower back pain however no other symptoms. She did
not have any neck pain, weakness, paralysis, loss of sensation,
chest pain, shortness of breath, or abdominal pain.
Past Medical History:
- CKD Stage IV with renal osteodystrophy and anemia of chronic
disease: Etiology of her renal dysfunction is thought to be
caused by nephrogenic diabetes insipidus / lithium
nephrotoxicity. She was treated with Lithium [**2180**] through [**2184**]
for her bipolar disorder.
- Secondary hyperparathyroidism
- Noninsulin dependent diabetes mellitus
- Hypertension
- Hypothyroidism
- Right hemiparesis caused by a brachial plexus injury. Please
note that the patient did NOT have a stroke as is indicated in
other past medical records.
- SIB "a long time ago" including OD on pills and cutting
herself.
Social History:
Born in [**Location (un) 86**], lived here all her life. Worked in limited care
and family services until [**2187**]. Moved into [**Doctor Last Name **] House shortly
after her right hemiparesis secondary to a brachial plexus
injury. Parents are deceased, has a good relationship with her
brother. [**Name (NI) **] military or legal history, never been married.
Family History:
Patient denies family history of psychiatric illness. Denies any
family suicide attempts or completed suicides.
Physical Exam:
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: II-XII intact, 5/5 strength in 4 ext, normal gait,
negative romberg
Pertinent Results:
[**2196-12-3**] 11:36PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2196-12-3**] 11:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 11:36PM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2196-12-3**] 11:36PM URINE MUCOUS-RARE
[**2196-12-3**] 04:00AM URINE HOURS-RANDOM
[**2196-12-3**] 04:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2196-12-3**] 02:00AM GLUCOSE-120* UREA N-50* CREAT-2.8*
SODIUM-132* POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-21* ANION
GAP-17
[**2196-12-3**] 02:00AM estGFR-Using this
[**2196-12-3**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-3**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-3**] 02:00AM URINE HOURS-RANDOM
[**2196-12-3**] 02:00AM URINE HOURS-RANDOM
[**2196-12-3**] 02:00AM URINE UHOLD-HOLD
[**2196-12-3**] 02:00AM URINE GR HOLD-HOLD
[**2196-12-3**] 02:00AM WBC-6.8 RBC-3.04* HGB-10.7* HCT-31.9*
MCV-105* MCH-35.2* MCHC-33.5 RDW-12.7
[**2196-12-3**] 02:00AM NEUTS-71.1* BANDS-0 LYMPHS-17.7* MONOS-6.7
EOS-3.9 BASOS-0.6
[**2196-12-3**] 02:00AM PLT COUNT-156
[**2196-12-3**] 02:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2196-12-3**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 02:00AM URINE RBC-0-2 WBC-[**3-4**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
Brief Hospital Course:
# Fall: The patient had a head CT which was negative. Otherwise
the patient also had a c-spine CT which did not reveal any
fractures or dislocations. The patient was assessed for her
mental status which was determined to be able to produce a
reliable history. She stated that at the time the only other
place of injury was [**4-9**] back pain. She was evaluated to not
have any distracting injuries. Her c-spine was palpated which
did not have any tenderness. She had her collar taken off and
her neck ranged without any pain or neurologic deficits. The
patient had plain films done of her T-L-S spine which were all
negative for fractures or malalignments. Otherwise the patient
gives very clear history that this was not a syncopal episode
and that she never lost conciousness. She states that she
grabbed the handlebars on her toilet incorrectly which is what
caused her to fall. Given this the patient did not have a
syncope work up but was rather cleared from a fall perspective.
The patient was evaluated by physical therapy which determined
that the patient was safe to be discharged home and would
require a visit from outpatient physical therapy to evaluate for
how well she ambulates with her walker. The patient was
monitored on tele without any evidence of any arrhythmias.
Otherwise the patient was discharged with follow up to her
primary care doctor
.
# Acute Renal Failure: The patient had a minor elevation of her
kidney function from 2.8 to 3.1. Given this she had a CK checked
which was in the normal range and therefore made rhabdomyolysis
less likely. She was given IV fluid hydration and discharged
again with follow up to her primary care doctor.
.
#. Fever: The patient had one isolated episode of a temperature.
She spiked a temp to 101.8 which subsequently was evaluated for
with blood cultures which were negative, urine analysis which
was negative and a chest x-ray which was negative. The patient
did not have any other temperatures above 100.
Medications on Admission:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO THREE
TIMES WEEKLY (). Capsule(s)
5. Sodium Bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day). Tablet(s)
6. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
12. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once
a day (at bedtime)).
13. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
14. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
17. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed
Discharge Medications:
1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO QMOWEFR
(Monday -Wednesday-Friday). Capsule(s)
5. sodium bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
10. quetiapine 200 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. lorazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
16. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO HS (at bedtime).
17. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
How to Prevent Falling: Recommendations for Patients and Their
Caregivers
1. Make your environment safe:
?????? Make sure that you have good lighting in your home. A well
lit home will help you avoid tripping over objects that are not
easy to see. Put night lights in your bedroom, hallways, stairs
and bathrooms.
?????? Rugs should be firmly fastened to the floor or have nonskid
backing. Loose ends should be tacked down.
?????? Electrical cords should not be lying on the floor in walking
areas.
?????? Put hand rails in your bathroom for bath, shower and toilet
use.
?????? Have rails on both sides of your stairs for support.
?????? In the kitchen, make sure items are within easy reach. Don't
store things too high or too low. Then you won't have to use a
stepladder or a stool to reach them. It's also a good idea to
avoid storing things too low, so you won't have to bend down to
get them.
?????? Wear shoes with firm nonskid soles. Avoid wearing
loose-fitting slippers that could cause you to trip.
2. Avoid dangerous medications and alcohol:
?????? Sedatives and sleeping pills, including Alprazolam (Xanax),
Chlordiazepoxide (Librium), Diazepam (Valium), Oxazepam (Serax),
Triazolam (Halcion), Flurazepam (Dalmane), and Meprobamate
(Miltown, Equanil).
?????? Over-the-counter medications for sleep or colds that contain
Diphenhydramine (Benadryl), like Tylenol PM, Benylin, or Nytol.
?????? Tricyclic Antidepressants, including Amitriptyline (Elavil)
and Imipramine (Tofranil)
?????? Bring all of your medications to your Doctor and carefully
review them to be sure they are safe.
?????? Avoid drinking alcohol.
3. Take 1200-1500 mg Calcium and 800 Units of Vitamin D every
day.
?????? Look for a generic brand that contains 600 mg calcium
(carbonate or citrate) and 400 Units of Vitamin D3, and take one
twice a day.
?????? Examples: Caltrate 600 + Vitamin D3 (contains calcium
citrate, better absorbed, less constipating), or Calcarb 600 +
400 D (contains calcium carbonate, less expensive, take with
meals).
?????? There are chewable options for calcium, but take an 800 or
1000 Unit Vitamin D3 pill in addition every day. These options
include: Tums 600 (take [**2-3**] daily) and Viactiv or Adora
(chocolate-flavored, take 3 daily).
4. Exercise: Three types of exercise are important:
?????? Aerobic: Daily walking, swimming, or biking. Work up to
20-30 minutes daily, to the point that you break a sweat. Use
every opportunity to walk or climb stairs.
?????? Strengthening: Do leg-lifts at least 3 days a week. Start
with no weight or a small velcro weight wrapped around your
ankles. While sitting in a straight-backed chair, lift each leg
until it is straight at the knee. Keep it extended for a count
of 3. Do this at least 10 times for each leg. Repeat each set
of 10 leg- lifts two to three times at each session.
?????? Balance: Practice balance daily by standing with feet
together, one in front and to the side of the other, and one
directly in front of the other until you can hold each position
for 1 minute. Then, practice standing on one foot until you can
remain that way for at least 1 minute without holding on to
something. Be sure to do this next to something you can grab on
to if you lose your balance.
5. Assistive Devices and other interventions:
?????? Canes and walkers can prevent falls if they are used
properly. They should be prescribed, measured, and adjusted by
a physical therapist or physician. [**Name10 (NameIs) **] [**Name Initial (NameIs) **] cane on the good
(stronger) side. [**Male First Name (un) **]??????t be embarrassed about using these. It is
more embarrassing to fall, break a hip, and lose your
independence.
?????? Hearing aides, glasses, and cataract operations can also help
prevent falls by improving your sensory function. Ask your
Doctor if you should have your hearing or vision checked.
?????? Get a Life-Line Device or other emergency system, so you can
call for help by simply pressing a button if you fall and can
not reach a phone.
?????? Drink plenty of fluids (at least [**1-2**] quarts a day) to prevent
dehydration.
?????? Take care of your feet. Wash them daily and inspect them for
lesions. If you have sores or foot pain, see your Doctor.
?????? Have your Doctor check your blood pressure while you are
standing up to be sure it doesn??????t fall too low. Get out of bed
slowly and pump your feet before standing up in the morning to
avoid sudden drops in blood pressure.
6. Resources for more information:
?????? National Safety Council:
[**URL 37657**]
Click on the Falls Prevention Resources and Safe Steps Video.
This provides a useful guide to preventing injuries in your
home.
?????? National Center for Injury Prevention and Control:
[**URL 37658**] There is a good home safety
checklist at this site.
?????? National Institute on Aging:
[**Female First Name (un) 37659**]
This provides information in Spanish.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-1-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-4-24**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 20129**]
ICD9 Codes: 0389, 5845, 486, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5434
}
|
Medical Text: Admission Date: [**2114-11-24**] Discharge Date: [**2114-12-1**]
Service: [**Location (un) **] Medicine
CHIEF COMPLAINT: Fatigue.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] was transferred to
the Medicine Service from the Medical Intensive Care Unit.
An 84-year-old female admitted to [**Hospital1 190**] MICU [**2114-11-24**] after being found by
VNA on [**2114-11-21**] being somnolent, fatigued, and
lightheaded when standing. The patient denied any melena,
bright red blood per rectum, hematemesis, hemoptysis,
hematuria, abdominal pain. She was found to have an elevated
BUN-creatinine ratio and hematocrit of 19 with her baseline
of 30, and the patient was taken to [**Hospital6 27253**], where she had guaiac positive brown stool, and
nasogastric lavage was negative.
The patient was subsequently transferred to [**Hospital1 346**] for further management. Upon
arrival to [**Hospital1 69**], she was
hemodynamically stable, in-fact somewhat hypertensive. She
was guaiac negative at [**Hospital1 69**].
In the MICU, she was transfused 2 units of packed red blood
cells with an appropriate hematocrit increase to 24. She
required 40 mg of intravenous Lasix between the units of
blood for some mild congestive heart failure. Her resting
heart rate was in the 40s, so her beta blocker was held, and
hydralazine was titrated up for blood pressure control.
Her Coumadin was held as well, and INR allowed to drift down.
She remained hemodynamically stable for 24 hours, and was
transferred to the Medical floor for further management.
PAST MEDICAL HISTORY:
1. Stroke in [**2114-9-28**] with residual left sided
weakness.
2. History of two transient ischemic attacks.
3. Coronary artery disease with nonST segment elevation
myocardial infarction at [**Hospital 4415**] three
years ago, no intervention.
4. History of congestive heart failure.
5. Non-insulin dependent-diabetes mellitus.
6. Anemia on Procrit, baseline hematocrit on 30. Has had
esophagogastroduodenoscopy and colonoscopy showing Barrett's
esophagus.
7. Chronic renal insufficiency, baseline creatinine of 2.0.
8. Hypothyroidism.
9. Hypertension.
10. PMR.
11. Atrial fibrillation.
12. History of ARDS.
ALLERGIES: Penicillin and sulfa.
OUTPATIENT MEDICATIONS:
1. Glipizide 5 mg q am, 2.5 q pm.
2. Cozaar 100 mg po q day.
3. Aspirin 81 mg po q day.
4. Isordil 10 sublingual qid.
5. Sublingual nitroglycerin prn.
6. Hydralazine 50 mg qid.
7. Protonix 40 mg po q day.
8. Levoxyl 100 mcg po q day.
9. Lipitor 10 mg po q day.
10. Nitropatch 0.6 mg transdermal on for 12 hours q day.
11. Cardura 4 mg po q day.
12. Atenolol 25 mg po q day.
13. Lasix 80 mg po q day.
14. Coumadin q day.
MEDICATIONS UPON TRANSFER FROM THE MICU:
1. Cozaar 100 mg po q day.
2. Levoxyl 100 mg po q day.
3. Lipitor 10 mg po q day.
4. Doxazosin 4 mg po q day.
5. Protonix 40 mg po q day.
6. Lasix 80 mg po q day.
7. Hydralazine 75 mg po qid.
8. Regular insulin-sliding scale.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No tobacco, no alcohol, recently widowed.
Home with VNA. Health-care proxy is daughter, [**Name (NI) **], whose
phone number is [**Telephone/Fax (1) 47514**].
EXAM ON TRANSFER: Vital signs: Temperature is 98.6, heart
rate 51, blood pressure 160/21, and 99% on 2 liters oxygen.
General: Elderly female in no acute distress. HEENT:
Pupils are equal, round, and reactive to light and
accommodation, normocephalic, atraumatic. Mucous membranes
dry. Clear oropharynx. Neck is supple, no jugular venous
distention, no lymphadenopathy, normal carotid upstrokes.
Chest: Faint crackles on left, no wheezes. Heart regular
rate, S1, S2 normal, no murmurs, rubs, or gallops. Abdomen
is soft, nontender, nondistended, positive bowel sounds, no
hepatosplenomegaly. Extremities: Multiple ecchymoses, no
clubbing, cyanosis, or edema. Neurologic: Alert and
oriented times three, 5/5 strength bilateral upper
extremities and lower extremities. Cranial nerves II through
XII intact. Nonfocal examination.
LABORATORIES ON TRANSFER: White blood cell count 9.3,
hematocrit 24.6 up from 19 after 2 units of blood, platelets
302. Sodium 132, potassium 4.0, chloride 103, bicarb 21, BUN
130, creatinine 1.7, platelets 175. ALT 13, AST 13, LDH 168,
alkaline phosphatase 60, amylase 55, total bilirubin 0.4,
lipase 42, albumin 2.5, calcium 8.3, magnesium 1.9,
phosphorus 5.4, reticulocyte count 0.8.
HOSPITAL COURSE: This is an 84-year-old female with multiple
medical problems admitted with increased fatigue and found to
have a hematocrit of 19 down from her baseline 30 with
guaiac-positive stool and negative nasogastric lavage at an
outside hospital. She was initially admitted to the MICU,
and subsequently transferred to the floor.
1. Gastrointestinal bleed: Initially, there was a question
of whether or not this patient had a GI bleed with a guaiac
positive stool at an outside hospital, but no history of
frank melena or hematemesis, and her most recent stool guaiac
negative. The patient was transfused again when she got to
the floor, two more units to have her hematocrit above 30
with her history of coronary artery disease, the next day it
was noted that her hematocrit had dropped from 32 to 25, and
that she did pass a large melanotic stool.
At this time, she again was transfused above 30 and did
maintain at this level throughout the rest of her
hospitalization. She had an esophagogastroduodenoscopy done
at that time which did not show any active bleeding from her
stomach or proximal duodenum. It did show duodenal
diverticulosis.
The patient did have a past history of a Dieulafoy's lesion
in the past as seen by her outside hospital medical records,
this was not seen during her esophagogastroduodenoscopy
during this visit. It was thought that most likely her bleed
was from a diverticulum in the setting of patient having a
high INR.
Her INR on transfer to the floor from the MICU was 3.2 after
having her Coumadin held. Coumadin was held for the next few
days with no drop in her INR. In-fact, it increased to 3.9
over the next three days. This was thought secondary to poor
nutritional status. In the setting of her hematocrit dropped
and melanotic stools seen on the floor, her anticoagulation
was reversed with vitamin K and 2 units of fresh-frozen
plasma. Her hematocrit remained stable for the remainder of
the hospitalization after reversal of her anticoagulation.
2. Cardiovascular: 1. Coronary artery disease: The patient
does have a history of coronary artery disease with a nonST
segment elevation myocardial infarction three years ago. She
did not have any symptoms of angina during this
hospitalization. She was maintained on her antihypertensives
which were increased with her refractory hypertension.
2. Pump: An echocardiogram was obtained on Ms. [**Known lastname **] in
order to evaluate her wide pulse pressures for the question
of aortic insufficiency, although she did not have a murmur.
This study showed a normal systolic function and normal
valves with only 1+ aortic regurgitation and 1+ mitral
regurgitation. There was a dilated left atrium and severe
pulmonary hypertension. It was thought that this pulmonary
hypertension might be secondary to the patient being in some
congestive heart failure after receiving blood transfusions.
3. Rhythm: The patient has a history of atrial fibrillation
and in the setting of her Lopressor being held for prolonged
P-R and bradycardia to the 40s, she did develop one episode
of rapid ventricular response, atrial fibrillation to the
120s. She was restarted on her Lopressor at this time, and
had a controlled rate. She had no other episodes of rapid
atrial fibrillation after this.
4. Hypertension: Ms. [**Known lastname **] continued to have severe
hypertension with systolic blood pressures in the 190s-low
200s during her stay here. This was despite increase of her
Hydralazine to 100 qid, restarting of the Lopressor.
Continuation of her Cozaar 100 q day and starting the patient
on amlodipine. Her nitropatch, which had been held on
admission in the setting of bleed was also restarted and her
blood pressure still remained in the high 180s to 190s. Ms.
[**Known lastname **] did have abdominal bruits, and there is a question
whether she may have renal artery stenosis by her examination
in the hospital. I am unsure if she has had already a workup
for secondary causes of hypertension.
3. Heme: Ms. [**Known lastname **] had been admitted while on
anticoagulation for her atrial fibrillation and history of a
recent stroke. In the setting of anticoagulation, she did
have a gastrointestinal bleed, likely from diverticulosis.
Her anticoagulation was reversed in this setting, and she was
not discharged on Coumadin. I will defer to her primary care
physician for question of restarting anticoagulation.
She does have a baseline anemia of chronic disease. Iron
studies showed an iron of 75 which is normal, a total iron
binding capacity of 221 which is low. Vitamin B12 of 253, a
folate of 8.6, ferritin of 124. Haptoglobin and other
hemolysis laboratories are also normal. Question whether her
anemia may be related to her chronic renal insufficiency.
4. ID: Ms. [**Known lastname **] did have an elevated white blood cell
count during this hospitalization of 15,000. Urinalysis
showed 20 white blood cells with no squamous, epi's, and no
red blood cells, and she was thought to have a urinary tract
infection in the setting of recent catheterization. She was
given a course of Levaquin for this.
5. Endocrine: The patient has a history of diabetes mellitus
and was maintained on Glipizide and insulin-sliding scale
during this hospitalization. She was continued on Levoxyl
for her hypothyroidism.
6. Renal: Her BUN which was very highly elevated in the
setting of gastrointestinal bleed began to trend down after
her hematocrit became stable. At the time of discharge, her
BUN was 69 down from 131 on admission.
Code: The patient was DNR/DNI status.
DISPOSITION: Home with [**Hospital6 **].
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed likely diverticular.
2. Pulmonary hypertension.
3. Urinary tract infection.
4. Congestive heart failure.
5. Atrial fibrillation.
6. Diabetes mellitus.
7. Hypothyroidism.
8. Anemia.
DISCHARGE MEDICATIONS:
1. Glipizide 5 mg q am, 2.5 mg po q pm.
2. Nitroglycerin patch 0.6 mg/hour q am on for six hours, off
for six hours.
3. Amlodipine 10 mg po q hs.
4. Levofloxacin 250 mg po qod for seven days.
5. Magnesium oxide 400 mg po bid.
6. Metoprolol 25 mg po bid.
7. Hydralazine 100 mg po qid.
8. Pantoprazole 40 mg po q day.
9. Colace and Senokot.
10. Erythropoietin 3,000 units q week.
11. Influenza virus vaccine x1.
12. Multivitamin one po q day.
13. Losartan 100 mg po q day.
14. Aspirin 81 q day.
15. Levoxyl 100 mcg po q day.
16. Lipitor 10 mg po q day.
Discharged to home with services.
DISCHARGE CONDITION: Good.
FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 47515**] at
[**Hospital **] Medical.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8859**], M.D. [**MD Number(1) 4728**]
Dictated By:[**Last Name (NamePattern1) 9352**]
MEDQUIST36
D: [**2114-12-10**] 15:07
T: [**2114-12-13**] 10:14
JOB#: [**Job Number 47516**]
cc:[**Numeric Identifier 47517**]
ICD9 Codes: 4280, 4168, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5435
}
|
Medical Text: Admission Date: [**2122-11-1**] Discharge Date: [**2122-11-12**]
Date of Birth: [**2052-2-14**] Sex: F
Service: MED
Allergies:
Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a 70 y.o female with a history of severe
diastolic CHF (EF 55%), COPD, DMII, chronic renal insufficiency,
and a recent ICU admit x 2 for MRSA aortic valve endocarditis
and pseudomonal sepsis (secondary to wound infection), status
post intubation x 2 on her prior admits, who presented on
[**2122-10-31**] with lethargy, weakness, and low grade temps over one
day. Initially, she was found to be hypotensive to systolic
80's/60's in ED with temp 100.3 (baseline SBP 70-90s), wbc 11,
and there was concern in the ED given her history for early
sepsis. Patient initially admitted to [**Hospital Unit Name 153**]. She was placed on a
dopamine drip for hypotension, vancomycin 1gm IV Q24 x 1 day
(last dose 9-27), ceftazidime 2 gm IV Q12 x 1 day (last dose
[**11-2**]), azithromycin 250 mg, 500 mg x 1 day (Dc'd [**11-4**]) and
Flagyl 500 mg PO. She was found to have clostridium difficile in
her stool with diarrhea and was maintained on oral flaygl. She
remained stable on flagyl, afebrile. She was transferred out to
the floor on [**11-5**] where she was managed conservatively.
Past Medical History:
CHF
DM on insulin
AFib
Anemia
CAD
Pulmonary HTN
Hypercholesterolemia
COPD/BOOP on home O2
Thyroid CA s/p resection/now hypothryoid
Myoclonic tremors
H/O PE
OSA on CPAP
Depression/Anxiety
MRSA/VRE
Social History:
Divorced, with 3 children
Retired Accountant
VNA assistant at home
Family History:
NC
Physical Exam:
Tc=98 Tm=98.4 P=83 BP=118/58 RR=20 98% on 2 L O2 via NC
Gen - NAD, AOx 3
HEENT - PERLA, glasses, MMM, no LAD, anicteric
Heart - irregular Rate, - M/R/G, S1, S2
Lungs - CTAB, transmitted bronchial breath sounds
Abd - soft, NT, ND + BS
Ext - tender bilateral LE, cyanosis, difficult to palpate d.
pedis, p. tibial
Neuro - CN II-XII intact, +2 DTR x 4, 5/5 strength x 4
Pertinent Results:
[**2122-11-1**] 10:30PM TYPE-MIX TEMP-37.2
[**2122-11-1**] 10:30PM O2 SAT-62
[**2122-11-1**] 09:12PM TYPE-ART PO2-86 PCO2-47* PH-7.38 TOTAL CO2-29
BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2122-11-1**] 09:12PM LACTATE-0.7
[**2122-11-1**] 09:12PM O2 SAT-96
[**2122-11-1**] 07:45PM CK(CPK)-100
[**2122-11-1**] 07:45PM CK-MB-4 cTropnT-0.03*
[**2122-11-1**] 07:45PM TSH-8.2*
[**2122-11-1**] 07:45PM HCT-32.1*
[**2122-11-1**] 07:43PM URINE HOURS-RANDOM UREA N-494 CREAT-54
SODIUM-87
[**2122-11-1**] 07:43PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2122-11-1**] 07:43PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2122-11-1**] 07:43PM URINE RBC-64* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2122-11-1**] 01:00PM URINE HOURS-RANDOM
[**2122-11-1**] 01:00PM URINE GR HOLD-HOLD
[**2122-11-1**] 01:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2122-11-1**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2122-11-1**] 11:38AM TYPE-ART TEMP-38.2 RATES-/14 O2 FLOW-5 PO2-88
PCO2-50* PH-7.38 TOTAL CO2-31* BASE XS-2 INTUBATED-NOT INTUBA
[**2122-11-1**] 11:30AM GLUCOSE-147* UREA N-23* CREAT-1.4* SODIUM-137
POTASSIUM-5.3* CHLORIDE-100 TOTAL CO2-31* ANION GAP-11
[**2122-11-1**] 11:30AM LACTATE-1.2
[**2122-11-1**] 11:30AM WBC-11.7*# RBC-3.46* HGB-10.2* HCT-31.5*
MCV-91 MCH-29.4 MCHC-32.3 RDW-16.9*
[**2122-11-1**] 11:30AM NEUTS-91.1* LYMPHS-3.8* MONOS-3.8 EOS-1.1
BASOS-0.2
[**2122-11-1**] 11:30AM HYPOCHROM-1+ ANISOCYT-1+
[**2122-11-1**] 11:30AM PLT COUNT-273
[**2122-11-1**] 11:30AM PT-20.1* PTT-38.3* INR(PT)-2.5
Brief Hospital Course:
The patient was initially admitted to the [**Hospital Unit Name 153**]. She was placed
on a dopamine drip for hypotension, vancomycin 1gm IV Q24 x 1
day (last dose 9-27), ceftazidime 2 gm IV Q12 x 1 day (last dose
[**11-2**]), azithromycin 250 mg, 500 mg x 1 day (Dc'd [**11-4**]) and
Flagyl 500 mg PO. She was transferred out to the floor on [**11-5**].
1. C. Diff: patient intially started with broad antibiotic
coverage with ceftaz, vanco, flagyl and azithromycin given
history. There was initial concern for recurrent pseudomonal
sepsis vs MRSA vs c diff. The patient's only complaints were
weakness and diarrhea and intermittent RLE pain. Lactate level
was 1.2. Blood and urine cultures were negative. Cortisol level
was normal. C diff was positive and antibiotics were tailored to
Flagyl for 1 month. She was discharged on day 7 of flagyl and
had persistent diarrhea while on flagyl in the hospital. It was
deemed that if her diarrhea persists at [**Location (un) 550**], the issue may be
readdressed in 1 week as to whether vancomycin should be
started.
2. Hypotension: Patient presented with mild hypotension with a
tenuous BP history. Dopamine low dose was instituted in the [**Hospital Unit Name 153**]
originally while all of her blood pressure meds were held. Her
BP was stabilized, her initial low BP was exacerbated by
diarrhea and CHF. Of note, she has a history of low SBP 70-90s
at baseline.
3. Diastolic dysfunction: The patient presented with pedal
edema, after BP stabilized, the patient was subsequently
diuresed. Lasix, beta-blocker, ace initially were held but
restarted once her BP stabilized. A delicate balance is needed
as she has a history of tenuous volume status.
4. Acute on chronic renal failure: Her creatinine was mildly
above her baseline on presentation. The differential included
hypovolemia/hypotension vs baseline deterioration. Received
fluid boluses in ED but the plan was to hold off on further
boluses unless necessary. Her medications were renally dosed.
Her creatinine improved to 1.3 off of IVF and on her standing
dose of lasix.
5. DM: On home dose glargine w/ Sliding scale. Blood sugars
labile but well-controlled on day of discharge. She should
continue with the glargine at night.
6. CAD: Patient ruled out by enzymes. Pateint's beta blocker,
ace and nitrates were held until her blood pressure stabilized.
She was maintained on her statin and aspirin.
7. Atrial fibrillation: Patient's coumadin was initially held in
case of possible procedure. Her INR was checked daily and her
coumadin dosed appropriately. However, she was given coumadin
2.5 mg QHS on [**2122-11-4**]. However, throughout her stay, her INR
rose to over 4 and thus, her coumadin was held. Her goal INR
being [**3-10**]. [**Last Name (un) 7965**] is her cardiologist and per report, she
has been refractory to cardioversion in the past.
8. Hypothyroid: She was maintained on synthroid 225 mcg PO QD
with a TSH in normal range.
9. Pain control: Patient with a history of chronic pain that is
unchanged (especially bilateral lower extremities). On renally
dosed neurontin and oxycodone, slightly lower than home doses.
Her pain was well-controlled on this regimen.
10. Hypercarbia/COPD: She had a pco2 of 50 on admission which
improved to 47. She is normally on home oxygen of 2L. She
remained stable throughout the remainder of her hospital stay.
11. Anemia: She has a history of chronic anemia. She remained on
procrit, iron. GUAIAC was positive in ED but patient is on iron.
On ppi. Had coloscopy, EGD in [**2119**] which were negative.
12. Cough: The patient developed a purulent cough with
yellow-greenish phlegm. A chest xray was performed on the day of
discharge to assess for pneumonia. Her O2 sats remained stable.
CXR did not show any infiltrate or worsening pulmonary edema but
rather interval improvement.
13. code: FULL
14. communication: patient. Has daughter/son who are
intermittently involved in her care.
15. After a team meeting, the patient agreed to be discharged to
[**Hospital3 **] facility after PT evaluation and concern
by all participating health care providers that she is unable to
take care of herself at home.
Medications on Admission:
Outpatient
Amiodarone 200 mg PO QD
ASA 325 mg PO QD
Spironolactone 25 mg PO QD
Zocor 20 mg PO QHS
Prevacid 30 mg PO QD
albuterol/atrovent MDI prn
oxycodone 5 mg prn
metoprolol 75 PO BID
neurontin 900 mg qam, 800 qpm
lasix 40 mg PO BID
colace 100 mg [**Hospital1 **]
senna prn
lisinopril 10 mg PO QD
coumadin 2.5 mg Qhs
levothyroxine 1.225 mg
oxycontin 10 mg PO BID
celexa
isosorbide dinitrate 10 mg PO TID
Inpatient
Amiodarone 200 mg PO QD
ASA 325 mg PO QD
Simvastatin 20 mg PO QD
Pantoprazole 40 mg PO Q12
Metronidazole 500 mg PO TID
SSI
Ferrous sulfate 325 mg PO BID
Epogen 4000 unit SC QMWF
Levothyroxine 225 mcg PO QD
Gabapentin 600mg PO TID
Oxycodone 10 mg PO Q12
Spironolactone 25 mg PO QD
Metoprolol 50 mg PO TID
Ipratropium Bromide MDI 2 puff QID
Albuterol [**2-6**] puff IH QID
Mirapex 0.25 mg PO TID
Ritalin 10 mg PO qam
Coumadin 2.5 mg PO QHS
Lasix 40 mg PO BID
Trazadone 25 mg PO QHS prn
Ondansetron 4 mg IV Q6 prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Clostridium difficile diarrhea
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-11-24**]
11:50
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2123-4-27**] 11:00
ICD9 Codes: 5849, 496, 2449, 4589, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5436
}
|
Medical Text: Admission Date: [**2159-2-22**] Discharge Date: [**2159-3-5**]
Date of Birth: [**2159-2-22**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 3501**] is a 2.5 kg
product of a 34 week gestation born to a 30 year old gravida
8, para 2, now 3 black female. Prenatal screen is 0
positive, antibody negative, RPR nonreactive, Rubella immune,
hepatitis surface antigen negative, Group B Streptococcus
unknown. Pregnancy complicated by a shortened cervix and
preterm labor at 26 weeks gestation, treated with
Betamethasone, Terbutaline and bedrest, presented in labor.
Intrapartum antibiotics given 11 hours prior to delivery.
Nubain 8 1/2 hours prior to delivery. Artificial rupture of
membranes three hours prior to delivery, vaginal delivery of
vigorous female, received Blow-by oxygen and suctioning.
Apgar scores were 8 and 9. The infant was transferred to the
Newborn Intensive Care Unit for further management of
prematurity.
PHYSICAL EXAMINATION: Physical examination on admission
revealed weight 2.5 kg, 75th to 90th percentile, length 46
cm, 50th to 75th percentile, head circumference was 31.5 cm,
50th percentile. Anterior fontanelle soft and flat,
nondysmorphic intact palate, clear breath sounds, good
aerations, no murmurs. Soft abdomen, three vessel cord. No
hepatosplenomegaly. Normal fetal genitalia, patent anus, no
hip clicks, no sacral dimple, positive mongolian buttocks,
normal tone, activity and good perfusion.
HOSPITAL COURSE:
Respiratory - The infant has remained stable in room air
throughout hospital course. Had mild apnea and bradycardia
of prematurity with last episode being on [**2159-2-27**].
Cardiovascular - No issues.
Fluids, electrolytes and nutrition - Birthweight was 2.5 kg,
discharge weight 2480 gms. The infant was initially started
on 50 cc/kg of PE 20 and has been adlib feeding throughout
hospital course and currently at adlib feeding breastmilk or
Enfamil 20 calorie.
Gastrointestinal - Peak bilirubin was on day of life #4 of
13.6/0.4. She was treated with phototherapy for a total of
four days and the issue has resolved.
Hematology - Hematocrit on admission was 50.5, has not
required any blood transfusions during this hospital course.
Infectious disease - Complete blood count and blood culture
obtained. On admission complete blood count was benign and
blood culture remained negative at 48 hours. The infant has
not received antibiotics.
Sensory - Hearing screen was performed and automated brain
stem responses, passed with both ears.
Psychosocial - Social worker has been involved with the
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home to parents.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) **], phone
#[**Telephone/Fax (1) 38541**].
CARE RECOMMENDATIONS:
1. Feeds at discharge - Enfamil 20 calorie or breastmilk
2. Medications - None.
3. Carseat - Carseat position screening test was performed
and the infant passed.
4. State newborn screens - Two state newborn screens have
been sent for protocol [**2-25**] and one on the day of discharge.
No abnormal values have been reported to date.
5. Immunizations received - Received hepatitis B vaccine on
[**2159-2-26**].
6. Immunizations recommended -
I. Synagis respiratory syncytial virus prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1. Born at less than 32
weeks; 2. Born between 32 and 35 weeks with plans for
daycare during respiratory syncytial virus season, with a
smoker in the household or with preschool siblings; or 3.
With chronic lung disease.
II. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSIS:
1. Preterm female born at 34 weeks, corrected 35 5/7 weeks
2. Mild apnea and bradycardia of prematurity, resolved
3. Rule out sepsis, resolved
4. Hyperbilirubinemia, resolved
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 38294**]
MEDQUIST36
D: [**2159-3-4**] 16:24
T: [**2159-3-4**] 16:35
JOB#: [**Job Number 45952**]
ICD9 Codes: 7742, V290, V053
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5437
}
|
Medical Text: Admission Date: [**2102-1-4**] Discharge Date: [**2102-1-10**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 79 year old with
multiple medical problems including AFib on Coumadin status
post AICD, CRI, type 2 diabetes mellitus, CHF, who presents
from outside hospital following discovery of subarachnoid
hemorrhage after a fall. Yesterday the patient had a
mechanical fall at home, specifics unclear. EMS was called,
but the patient refused to go to the hospital. There was
loss of consciousness for unclear duration and head trauma.
In the morning the patient did not feel well and went to
[**Hospital **] [**Hospital 1459**] Hospital. A head CT showed three separate
areas of hemorrhage in the midline above ventricle, two above
the falx, and surrounding edema left greater than right mass
effect, no shift or fluid collections. Chest x-ray at
outside hospital also showed a patchy right upper lobe
infiltrate and elevated right diaphragm with mild vascular
congestion.
Patient denied cough, shortness of breath, fevers, chills,
sweats, chest pain, abdominal pain.
PAST MEDICAL HISTORY:
1. AFib on Coumadin status post ICD.
2. CRI.
3. Type 2 diabetes.
4. CHF.
5. Hypertension.
ALLERGIES: Penicillin.
MEDICATIONS:
1. Lisinopril.
2. Digoxin.
3. Allopurinol.
4. Lasix.
5. Sotalol.
6. Detrol.
7. Paxil.
8. Coumadin.
9. Kayexalate.
10. Colchicine.
11. Glyburide.
PHYSICAL EXAM: Temperature 96.7, pulse 79, blood pressure
113/96, respirations 16, and O2 saturation 93% on room air,
and 97% on 3 liters. In general, in neck brace. Oriented to
person, not place or year. Neurologic: Pupils 4 mm to 2 mm
reactive to light and accommodation. EOMI. Face with right
droop at rest, symmetric with smile. Tongue symmetric.
Sensation intact. Normal palatal elevation. No pronator
drift, but difficult to assess. Hand grips [**3-22**] and
symmetric. Able to wiggle toes. Bilateral Babinski. Neck:
Unable to assess JVP in collar. Lungs clear anteriorly and
laterally. Cardiovascular: Irregularly, irregular, 3/6
systolic ejection murmur at the left sternal border and left
upper sternal border. Abdomen: Bowel sounds present, mild
right upper quadrant tenderness. Liver edge palpable 3 cm
below costal margin with no guarding or rebound.
LABORATORIES: Were significant for a white count of 7.3 with
76 polys, hematocrit of 44.5, and platelets of 116,
creatinine is 2.1, INR of 2.4.
HOSPITAL COURSE: After admission, patient underwent q1h
neuro checks. Initially was started on Levaquin for right
upper lobe pneumonia that was seen at the outside hospital,
but this was stopped after there was no infiltrates seen.
Patient was given FFP and vitamin K. A right upper quadrant
ultrasound which was evaluated secondary to
hyperbilirubinemia and thrombocytopenia was normal. However,
there was a 7 cm AAA. Neurosurgery was consulted, and took
patient to angiogram to rule out a sinus thrombosis. This
was not seen, but patient developed acute renal failure post
angiogram. Patient also spiked a temperature while in the
ICU with gram-positive cocci in clusters in the sputum.
The patient also continued with the C spine as Neurosurgery
did not clear it secondary to ossified fracture of
longitudinal ligament at C2, C3 with grade I anterolisthesis.
Patient continued to do poorly, and there was no plan to take
the patient to the operating room. He was planning to be
called out to the floor, but instead of transferred from the
West MICU to the East MICU.
When he arrived to the East MICU, patient was noted to have
paradoxical breathing with bloody sputum production, and was
mostly unresponsive. An ABG was done, which demonstrated
7.43, 44, 117. Family was notified that the patient was
doing poorly.
At 2 a.m. on [**2102-1-10**], the patient acutely became tachypneic
and tachycardic, and then hypotensive. He was suctioned for
a very large amount of secretions. It was thought he may
have aspirated. IV fluid bolus was given without effect, and
the patient quickly became pulseless, and then apneic with
only occasional agonal breathing. This quickly decreased to
a respiratory rate of 0. Patient had an AICD and pacer, and
this continued to discharge even after patient became
pulseless. A magnet was obtained so that the AICD would not
fire.
Patient on exam was without pulse. On auscultation, no heart
or lung sounds were heard for two minutes. Pupils were fixed
and dilated. Time of death was 2:20 a.m. on [**2102-1-10**]. Family and attending were notified.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ACV
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2102-3-21**] 14:53
T: [**2102-3-23**] 08:09
JOB#: [**Job Number 53333**]
ICD9 Codes: 4280, 5070, 2875, 5849
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5438
}
|
Medical Text: Admission Date: [**2177-11-17**] Discharge Date: [**2177-11-25**]
Date of Birth: [**2112-12-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Hydrocodone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
CAD
Major Surgical or Invasive Procedure:
[**2177-11-20**] CABG x4 (lima-lad, v-pda, v-om1, v-D1) /closure LAD to
PA and RCA to PA fistulas
History of Present Illness:
64 year old female with episodes of
palpitations that underwent stress test with ischemic changes
and
was stopped due to leg fatigue. She was referred for cardiac
catheterization that revealed CAD and anamolous artery, she is
transferred for surgical evaluation
Past Medical History:
PMHx: Severe anxiety and depression, Diabetes mellitus type 2,
Hypertension, Hyperlipidemia, Tobacco abuse, Sleep apnea,
Hypothyroidism, Impaired renal function, Chronic Bronchitis,
Carpal tunnel, Tubal ligation, Pinning of right hand, Left knee
arthroscopic , TIA vs CVA with aphasia that lasted one month
Social History:
Race: Caucasian
Last Dental Exam: 6 years
Lives with: spouse
Contact: [**Name (NI) **] (husband)
Phone # [**Telephone/Fax (1) 90501**] cell [**Telephone/Fax (1) 90502**]
Cigarettes: Smokes about [**4-22**] cigarettes per day - 40 pack year
history
ETOH: denies
Illicit drug use: denies
Family History:
Family History:
Father leaky valve
Mother racing heart
Physical Exam:
Physical Exam
Pulse: 62 Resp: 20 O2 sat: 99% RA
B/P Right: 121/57 Left: 124/69
Height: 5 Weight: 144 Lbs
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] abdominal folds, palpable hernia luq
Extremities: Cool multiple varicosities pulses with doppler
Edema - none
Neuro: Alert and oriented x3 non focal
Pulses:
Femoral Right: cath site Left: +1
DP Right: doppler Left: doppler
PT [**Name (NI) 167**]: doppler Left: doppler
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets are moderately thickened. The left
cusp is hypomobile. No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. An
eccentric, posteriorly directed jet of Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
A tiny fistula may be seen entering the proximal PA. By history
this comes from the Circumflex artery.
An epi-aortic scan showed no calcifications at the planned
cannulation site.
Post-CPB:
The patient is in SR on no inotropes.
Preserved biventricular systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta
intact.
Fistula in [**MD Number(3) 62535**] not be visualized.
CAROTIDS:
FINDINGS: Mild heterogeneous plaques are seen bilaterally along
the proximal internal carotid arteries. The peak systolic
velocity in the right internal carotid artery ranges from 76 to
83 cm/sec and the left internal carotid artery from 72 to 77
cm/sec. The peak systolic velocity in the right common carotid
artery is 93 cm/sec and in the left common carotid artery is 80
cm/sec. Bilateral external carotid arteries are patent. There is
antegrade flow in the bilateral vertebral arteries. The ICA/CCA
ratio on the right is 0.85 and on the left is 0.90.
[**2177-11-24**] 05:50AM BLOOD WBC-6.8 RBC-2.81* Hgb-8.1* Hct-25.1*
MCV-89 MCH-28.7 MCHC-32.2 RDW-13.9 Plt Ct-170
[**2177-11-24**] 05:50AM BLOOD UreaN-39* Creat-1.0 Na-137 K-3.9 Cl-102
[**2177-11-17**] 06:00PM BLOOD ALT-12 AST-19 LD(LDH)-175 CK(CPK)-94
AlkPhos-56 Amylase-65 TotBili-0.3
[**2177-11-17**] 06:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2177-11-17**] 06:00PM BLOOD Lipase-35
[**2177-11-24**] 05:50AM BLOOD Mg-2.1
[**2177-11-25**] 05:35AM BLOOD WBC-6.7 RBC-2.95* Hgb-8.8* Hct-26.3*
MCV-89 MCH-29.8 MCHC-33.3 RDW-13.9 Plt Ct-244
[**2177-11-25**] 05:35AM BLOOD UreaN-43* Creat-1.0 Na-140 K-4.3 Cl-103
Brief Hospital Course:
The patient was brought to the operating room on [**11-20**] where the
patient underwent:
PROCEDURES:
1. Coronary bypass grafting x4 with left internal mammary
artery to left anterior descending coronary; reverse
saphenous vein single graft from aorta to second
diagonal coronary artery; reverse saphenous vein single
graft from aorta to the first obtuse marginal coronary
artery; reverse saphenous vein single graft in the aorta
to the posterior descending coronary artery.
2. Ligation and division of coronary to pulmonary artery
fistula x3.
3. Epiaortic duplex scanning.
4. Endoscopic left greater saphenous vein harvesting.
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. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. She went into
A Fib postop and converted to SR with amiodarone.
By the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions.
Medications on Admission:
[**Last Name (un) 1724**]:Xanax 0.25 mg TID prn, aspirin 81 mg daily, Prozac 40 mg
daily, Synthroid 100 mcg daily, Lovastatin 40 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*1*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): prn for pain.
Disp:*240 Tablet(s)* Refills:*2*
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
400mg [**Hospital1 **] x 7 days, then 400mg daily x 7 days, then 200mg daily.
Disp:*90 Tablet(s)* Refills:*0*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 1 weeks.
Disp:*7 Packet(s)* Refills:*0*
10. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
13. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary Artery Disease s/p cabg x4/ closure LAD/PA and RCA/PA
fistulas
postop A Fib
Severe anxiety and depression
Morbid Obesity - but has lost 200 Lbs
Diabetes mellitus type 2
Hypertension
Hyperlipidemia
Tobacco abuse
Sleep apnea prior to weight loss - no episodes recently
Hypothyroidism
TIA vs CVA - with aphasia that lasted 1 month
Impaired renal function
Chronic Bronchitis
rt foot s/p fx after fall
Past Surgical History
Carpal tunnel
Tubal ligation
Pinning of her right hand
Left knee arthroscopic
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
leg- c/d/i, trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) 914**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 170**] [**2177-12-22**] 1:00pm
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Doctor First Name **]) ([**Telephone/Fax (1) 84379**]
[**12-24**] @ 10:40 AM
Please call to schedule the following:
Primary Care in [**4-22**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 90503**]
**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:[**2177-11-25**]
ICD9 Codes: 4111, 9971, 4019, 2724, 2449, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5439
}
|
Medical Text: Admission Date: [**2155-7-3**] Discharge Date: [**2155-7-8**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
Received IV tPA
History of Present Illness:
88 year old right handed man hx of atrial fibrillation (on
coumadin) and hypercholesterolemia, who had acute onset of
expressive aphasia and right sided hemiparesis at 7pm on [**7-3**]. Patient was gardening at home and was last seen normal at
6:30pm. His family found him at 7pm on the ground with right
sided weakness. He was unable to get. Patient was unable to
produce any speech. He was taken to [**Hospital1 18**] and arrived at ED at
7:55pm. Stroke code was called at 7:55pm. Stroke fellow was at
bedside at 8:08pm. His
vitals were BP 136/81, pulse 120, RR 20, and O2 94%. His NIHSS
was 22 (-2 questions, -2 expressive aphasia, -2 dysarthria, -2
right homonymous hemianopsia, -2 gaze deviation to the left, -2
visual and sensory neglect, -2 right lower facial droop, -4
right
arm weakness, -2 right leg weakness, -2 right hemisensory loss,
unable to test coordination on the right side due to weakness.
Patient was agitated during the CT non-contrast. He required
Ativan 1mg for completion of the imaging. CT brain showed no
signs of acute infarct. No bleed or mass. Initial read of CTA
brain showed no
evidence of stenosis or occlusion of intracranial vessels. No
aneurysm seen. CTA neck showed no significant atherosclerosis of
carotids or vertebrals.
Patient was given iv TPA bolus of 6.1mg at 8:58pm. He got an
infusion of 55.3mg iv TPA over one hour. He was transferred to
the Trauma ICU.
Past Medical History:
Angina
NSTEMI
hypercholesterolemia
Atrial fibrillation
PSH:
Cardiac cath and PCI
left knee surgery
Social History:
Lives with his son. Does not smoke or use illegal
drugs
Family History:
non-contributory. No hx of strokes or MI for either parent
Physical Exam:
VS: BP 136/81 P 120 R 20 02 94% RA
Gen: thin
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, positive bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert, follows commands to lift left arm and leg,
sticks out tongue to command, unable to produce speech, patient
is able to moan,
CN: right homonymous hemianopsia, no papilledema in the right
fundus, unable to see the left fundus, pupils equal, round, and
reactive, eyes are deviated to the left and do not cross midline
to the right, right lower facial droop
Motor: flaccid right arm, decreased bulk of all 4 ext., no
tremor
right arm is 0/5 strength, right leg is anti-gravity for
four seconds and then drifts down to the bed
left arm and leg are anti-gravity
Sensory: does not withdraw right arm or leg to noxious
does withdraw left arm and leg to noxious
Reflex: T BR B K A toes
Left 2 2 2 1 1 down
Right 1 1 1 1 1 up
Coord: unable to assess
Gait: unable to assess
Pertinent Results:
[**2155-7-3**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->=1.035
[**2155-7-3**] 09:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2155-7-3**] 09:30PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2155-7-3**] 08:10PM GLUCOSE-119* UREA N-36* CREAT-1.3* SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14
[**2155-7-3**] 08:10PM WBC-5.5 RBC-5.11 HGB-15.0 HCT-46.0 MCV-90
MCH-29.4 MCHC-32.6 RDW-14.0
[**2155-7-3**] 08:10PM NEUTS-59.2 LYMPHS-31.3 MONOS-6.1 EOS-2.7
BASOS-0.7
[**2155-7-3**] 08:10PM PLT COUNT-235
[**2155-7-3**] 08:10PM PT-17.3* PTT-27.8 INR(PT)-1.6*
[**2155-7-4**] 03:06AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-7-6**] 05:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-7-6**] 11:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2155-7-8**] 05:40AM BLOOD PT-17.2* PTT-28.3 INR(PT)-1.6*
[**2155-7-8**] 05:40AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-141
K-4.1 Cl-108 HCO3-26 AnGap-11
[**2155-7-4**] 03:06AM BLOOD %HbA1c-5.5
[**2155-7-4**] 03:06AM BLOOD Triglyc-70 HDL-35 CHOL/HD-4.6 LDLcalc-113
Blood and urine cultures from [**2155-7-6**]- nothing to date, pending
CT head/CTA head and neck/CT-perfusion [**2155-7-3**]:
IMPRESSION:
1. CT perfusion shows an acute infarction in the distribution of
the distal inferior division of the left MCA vascular territory.
No evidence of acute intracranial hemorrhage on non-contrast CT.
No definite stenosis or occlusion seen in the left MCA on CTA.
2. Atherosclerotic plaques which are partially calcified at the
bifurcation of the ICA causes minimal narrowing without evidence
of stenosis or occlusion.
3. Hypodensity along right lateral temporal lobe may represent
old infarct or old insult.
Repeat CT head [**2155-7-4**]:
IMPRESSION: Increased conspicuity to infarct involving the left
frontal lobe in the distribution of the left MCA. No evidence of
hemorrhagic
transformation and no new significant mass effect.
Transthoracic ECHO [**2155-7-4**]:
The left atrium is markedly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-22**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No PFO, ASD, or cardiac source of embolism seen.
Normal global and regional biventricular systolic function. Mild
aortic regurgitation. Mild-moderate mitral regurgitation.
Moderate tricuspid regurgitation. Marked biatrial enlargement.
CXR [**2155-7-3**]:
Mild cardiomegaly, peripheral and central pulmonary vascular
engorgement and mild edema all point toward cardiac
decompensation. Pleural effusion, if any, is minimal. There are
no focal findings to suggest pneumonia.
EKG [**2155-7-3**]:
Atrial fibrillation with rapid ventricular response.
Non-specific ST-T wave changes. RSR' pattern in lead V2.
Brief Hospital Course:
After receiving IV tPA, the patient was admitted to the ICU for
further monitoring per protocol post tPA. CT perfusion
eventually showed an acute infarction in the distribution of the
distal inferior division of the left MCA vascular territory.
The patient was monitored on telemetry his his atrial
fibrillation with rapid ventricular response carefully
controlled so as not to drop blood pressure in the acute period.
His evaluation included fasting lipids that revealed an LDL
113; his lipitor was increased to 40 mg daily. A1C was within
normal limits. Transthoracic ECHO showed atrial septal defect,
patent foramen ovale, or source of cardioembolism.
Nevertheless, given the presentation in atrial fibrillation with
rapid ventricular response, it was thought that the most likely
mechanism for the infarct was cardioembolic. Given the tPA
load, the decision was made to resume the patient on warfarin
with aspirin bridging to a therapeutic INR (range 2-3).
Therefore, the aspirin should be stopped once the INR is greater
than 2. The patient passed speech and swallow and was started on
a diet. He was stable for transfer to the floor on [**2155-7-6**].
Physical and occupational therapy saw the patient and
rehabilitation was recommended. On [**7-6**], the patient developed
a transient fever on the floor, but urinalysis and urine/blood
cultures were negative and a chest x-ray was unchanged. He
defervesced and remained clinically stable. His heart rate was
generally well-controlled on a low dose beta-blocker, but was
transiently tachycardic with periods of exertion; the resolved
spontaneously. Over the course of the hospitalization, the
patient remained aphasic with a dense right upper extremity
flaccid paralysis. There was trace weakness in the leg with hip
flexion that seemed to improve. The patient was DNR/DNI during
the hospitalization.
Medications on Admission:
Atenolol 25mg daily
Aspirin 81mg daily
Coumadin 2.5mg daily
Lipitor 10mg qod
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for fever or pain.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): Please
discontinue aspirin when the patient's INR on warfarin is
greater than 2. Tablet, Delayed Release (E.C.)(s)
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cerebral embolism with infarct
Atrial fibrillation
Discharge Condition:
Stable, has aphasia and flaccid right arm paralysis/plegia and a
perhaps trace weakness on right hip flexion.
Discharge Instructions:
The patient should take medications as prescribed and follow up
with appointments as scheduled. Should the patient experience
any new, worsening or concerning symptoms, including vision
change, confusion, or new weakness, please contact the patient's
neurologist (Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at [**Telephone/Fax (1) 40554**]) or immediately
take him to the nearest emergency department. The patient is
currently on both warfarin and aspirin. His INR was 1.6 this
morning, and should be checked daily. The aspirin should be
stopped when the INR is greater than 2. His warfarin should be
re-dosed to a target INR of [**2-23**].
Followup Instructions:
Neurologic follow-up:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2155-9-8**] 2:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2156-5-28**] 11:15
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 5849, 4019, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5440
}
|
Medical Text: Admission Date: [**2160-7-10**] Discharge Date: [**2160-7-15**]
Date of Birth: [**2079-4-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2160-7-10**]: Aortic valve replacement with 19 mm tissue and
Coronary Artery bypass graft x 1 (RSVG->RCA)
History of Present Illness:
80 year old female with known aortic valve disease which has
been followed by serial echocardiograms. Her most recent
echocardiogram showed severe aortic stenosis, moderate aortic
insufficiency and mild mitral regurgitation. She
is quite symptomatic with severe dyspnea on exertion. She has
also had an two admissions for heart failure in the past few
months and for the past two months she has been at rehab. Given
the severity of her disease, she has been referred for tissue
AVR/CABG.
Past Medical History:
Coronary artery disease
Aortic stenosis
Diastolic heart failure
Myocardial infarction
Mitral regurgitation
CVA [**60**] yrs ago
Anxiety/Depression
Hyperlipidemia
Hypertension
Gout
History of blood clot in left leg/? iliac
chronic neck/back pain
osteoarthritis chronic
sacral ulcer colitis
tobacco abuse recently stopped
anemia recent fall left thigh hematoma
decubitus of coccyx
Social History:
Race:Caucasian
Last Dental Exam: 1-2 weeks ago
Lives with: Currently at rehab but was living with son in his
home. Has
in-law-apartment in son's home, [**Location (un) **] VNA nurse 3 x per wk
dressing changes
Contact:[**Name (NI) **] (son) Phone #[**Telephone/Fax (1) 92341**]
Occupation:retired
Cigarettes: Smoked no [] yes [x] quit few weeks ago
Hx:30-50 PY Hx
Other Tobacco use:denies
ETOH: [x] [**2-26**] drinks/week
Illicit drug use:denies
Family History:
Family History:Premature coronary artery disease- father with MI
age 62
Physical Exam:
Physical Exam: [**2160-7-3**]
Pulse:72 Resp:18 O2 sat:95/RA
B/P Right:119/74 Left:120/74
Height:5'3" Weight:130 lbs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] SEM grade III/VI
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: dop
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
Echocardiogram [**2160-7-10**]
Conclusions
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 left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricle displays normal free wall contractility. There
are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
are three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area 0.6cm2). Mild to moderate ([**1-21**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The posterior leaflet is calcified and immobilized.
Mild to moderate ([**1-21**]+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
POST BYPASS The patient is AV paced. There is normal
biventricular systolic function. There is a bioprosthesis in the
aortic position. It appears well seated. The ;leaflets can not
be definitively seen. There is trace valvualr and trace
paravalvular aortic regurgitation seen. At a cardiac output of
4.5 liters/minute, the maximum gradient through the valve was 35
mmHg with a mean of 17 mmHg at an effective area of 1.4 cm2. The
mitral regurgitation is improved and is now mild. The tricuspid
regurgitation is also improved, now mild. The thoracic aorta is
intact after decannulation.
.
[**2160-7-15**] 04:51AM BLOOD WBC-10.9 RBC-3.11* Hgb-9.2*# Hct-28.3*
MCV-91 MCH-29.6 MCHC-32.5 RDW-16.5* Plt Ct-172
[**2160-7-14**] 04:28AM BLOOD WBC-9.8 RBC-2.51* Hgb-7.3* Hct-23.3*
MCV-93 MCH-29.0 MCHC-31.2 RDW-17.4* Plt Ct-127*
[**2160-7-15**] 04:51AM BLOOD Glucose-85 UreaN-54* Creat-1.7* Na-141
K-3.9 Cl-97 HCO3-34* AnGap-14
[**2160-7-14**] 04:28AM BLOOD Glucose-80 UreaN-46* Creat-1.7* Na-138
K-3.7 Cl-100 HCO3-32 AnGap-10
Brief Hospital Course:
The patient was brought to the operating room on [**2160-7-10**] where
the patient underwent Aortic valve replacement ([**First Name8 (NamePattern2) 17167**] [**Male First Name (un) 923**])
and coronary artery bypass graft (SVG-distal RCA). Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. She extubated POD1. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. The patient was transferred
to the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication.
Respiratory: Aggressive pulmonary toilet, nebs and ambulation
her oxygenation improved. Inhalers were continued.
Cardiac: hemodynamically stable in sinus rhythm. SBP 130-140's
low-dose Lisinopril was started. Statin restarted.
GI: history of constipation. Her previous laxatives were
resumed.
Renal; gently diuresed toward her preop weight- contiues to
require diuresis. Baseline CRE 1.7-2.0. Electrolytes were
repleted as needed.
Endocrine: Insulin sliding scale to maintain BS < 150.
Colchicine was restarted for her history of gout.
Skin: She was followed by the wound care service for a
longstanding stage 4 pressure ulcer following pilonidal cyst
measuring 2 x1 cm with minimal depth. Some undermining. Peri
wound tissue is macerated with copious serous drainage. They
recommended pressure ulcer guidelines and dressing changes.
Neuro: Antidepressant was restarted. Valium held secondary to
lethargy. once mental status returned to baseline her Oxycodone
for standing back pain was resumed and toelrated well. Nicotine
patch applied.
Disposition: She was followed by physical therapy. She was
returned to [**Hospital 392**] Rehabilitation & Nursing Center [**Telephone/Fax (1) 92342**]
on POD# 5.
Medications on Admission:
CITALOPRAM 10 mg Daily
COLCHICINE 0.6 mg Daily
DIAZEPAM 10 mg HS
ADVAIR DISKUS 500 mcg-50 mcg/Dose Disk with Device - one puff
inhaled [**Hospital1 **]
FUROSEMIDE 20 mg daily.
HYDROCORTISONE ACETATE 25 mg Suppository - PRN
METOPROLOL TARTRATE 12.5 mg [**Hospital1 **]
OXYCODONE 15 mg - 1-2 Tablets every six hours
POLYETHYLENE GLYCOL 3350 17 gram/dose Powder - one capful Daily
SIMVASTATIN 10 mg Daily
ASPIRIN 81 mg Daily
DULCOLAX as directed PRN
DOCUSATE SODIUM 100 mg Daily
MULTIVITAMIN Dosage 1 tablet daily
SENOKOT 8.6 mg Daily
Nicotine patch
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN fever, pain
2. Aspirin EC 81 mg PO DAILY
3. Bisacodyl 10 mg PR DAILY:PRN constipation
4. Citalopram 10 mg PO DAILY
5. Colchicine 0.6 mg PO EVERY OTHER DAY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
8. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
9. Milk of Magnesia 30 ml PO HS:PRN constipation
10. Nicotine Patch 7 mg TD DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
13. Ranitidine 150 mg PO DAILY
14. Simvastatin 10 mg PO DAILY
15. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-22**] Tablet(s) by mouth every four (4) hours
Disp #*90 Tablet Refills:*0
16. Amlodipine 5 mg PO DAILY
17. Furosemide 40 mg PO BID
18. Senna 1 TAB PO BID
19. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Transitional Care and Rehab - [**Hospital1 392**]
Discharge Diagnosis:
Coronary artery disease
Aortic stenosis
Diastolic heart failure
Myocardial infarction
Mitral regurgitation
CVA [**60**] yrs ago
Anxiety/Depression
Hyperlipidemia
Hypertension
Gout
History of blood clot in left leg/? iliac
chronic neck/back pain
osteoarthritis chronic
sacral ulcer colitis
tobacco abuse recently stopped
anemia recent fall left thigh hematoma
decubitus of coccyx
Discharge Condition:
Alert and oriented x3 nonfocal
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema 1+, ecchymotic RLE from thigh to knee (ace wrap right
thigh daily)
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) **] [**Telephone/Fax (1) 170**] [**8-6**] at 2pm in the [**Hospital **]
medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 39662**] in [**4-24**] weeks
Cardiologist Dr. [**Last Name (STitle) **] upon discharge from rehab
**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:[**2160-7-21**]
ICD9 Codes: 4241, 412, 4280, 4240, 2724, 4019, 2749, 2859, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5441
}
|
Medical Text: Admission Date: [**2160-5-29**] Discharge Date: [**2160-6-6**]
Date of Birth: [**2086-7-12**] Sex: F
Service: MEDICINE
Allergies:
Colchicine / Atorvastatin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
Colonoscopy [**2160-5-30**], [**2160-6-1**]
History of Present Illness:
73 y.o. F w/ DM, ESRD on HD, CHF presenting with BRBPR.
underwent a colonoscopy on [**5-21**] (Dr. [**Last Name (STitle) 6880**] for ongoing
diarrhea with biopsy x2. The colonoscopy showed: A single
sessile 7 mm polyp of benign in the cecum. A single-piece
polypectomy was performed using a hot snare. AS per recent note,
polyps coagulated and unavailable for retrieval. A single
semi-pedunculated 1.4 cm polyp of benign appearance was found in
the distal ascending colon. A piece-meal polypectomy was
performed using a hot snare.
.
Recent admission from [**Date range (1) 33900**] with BRBPR, episode of
lightheadedness and syncope in that setting. HCT to 28.5 lowest,
responded to 2 units PRBC, and pt stable at discharge monday.
Wednesday daughter reported [**3-16**] painless clot fulled bowel
movements, dark colored, not black. Associated mild nausea, and
one episode of non bloody, non bilious emesis. This AM, pt felt
lightheaded at HD. 30 minutes into session. Given concern to ED.
Denies fever/chills/abdominal pain/mucus in stool/sick contacts.
.
In ED T 97, HR 58, BP 145/55, 18 stable, 100%RA. Protonix 40 mg
IV given. 300 cc NS given. HCT 26.7 from 33. One unit PRBC
given. GI consulted. Admitted for further work up.
Past Medical History:
-Post polypectomy bleed recent admission [**Date range (1) 35112**] for BRBPR
-ESRD on HD: Right upper extremity fistula. Revision AV limb
[**1-20**], thrombectomy [**1-21**], placement of tunneled right IJ,
[**2159-2-23**] right AV thrombectomy and revision complicated by
bacteremia (+cx tunneled cath)
-CHF: Echo [**11-17**] LVEF >55%, LVH, mild AS, pulm art systolic
hypertension, [**2-13**]+ MR
[**Name13 (STitle) 35113**]
-Type 2 DM: dx 40 years ago, complicated by ESRD, controlled on
insulin
-Sarcoidosis with ocular involvement: seen q3 months for eye
exam
-Gout: last flair [**10-18**]; usually occurs in R toes
-Knee surgery s/p fall
-CVA ~20 yrs ago w/out residual deficits
Social History:
Patient lives with her daugther. She denies tobacco, alcohol or
illicit drug use.
Family History:
HTN, DM
Physical Exam:
98.4, 138/74, 67, 99% RA
GEN: well appearing female in no acute distress
HEENT: OP clear, dry MM
NECK: difficult to assess JVP
CHEST: CTAB, no wheezes, rales
CV: III/VI systolic murmur throughout
ABD: soft, redundant skin, +bowel sounds, non tender, non
distended
EXT: no edema, cyanosis or clubbin
NEURO: AO x3
Rectal: in ED, BRB, no pain. Defer exam as just performed
Pertinent Results:
CHEST (PORTABLE AP) [**2160-5-29**]
IMPRESSION: Low lung volumes and left ventricular enlargement,
with no CHF or infiltrate
.
ECG Study Date of [**2160-5-29**]
Sinus rhythm. Left bundle-branch block. Compared to the previous
tracing
the axis is slightly more to the right.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2160-6-6**] 05:10AM 5.7 3.94* 11.6* 35.0* 89 29.5 33.3 15.4
249
[**2160-5-29**] 01:00PM 5.1 2.85* 8.4* 26.7* 94 29.3 31.3 17.8*
278
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2160-6-6**] 05:10AM 80 19 4.9* 139 4.6 100 29
[**2160-5-29**] 01:00PM 123* 37* 5.4* 139 4.41 102 26
Brief Hospital Course:
ASSESSEMENT/PLAN: 73 yo F with ESRD on HD, DM, chronic diastolic
CHF re-admitted with hematochezia s/p polypectomy x 2 sites ~ 1
week prior to admission. Underwent colonscopy x 2, initial
procedure not effective & pt continued to bleed. Pt received
DDAVP as possibility of uremic platelets given chronic dialysis.
.
# Hematochezia: Likely s/p polypectomy sites which have
continued to bleed. Underwent colonscopy x 2 with good effect -
clips to both polypectomy sites. Pt received total 5U PRBC
during admission. Gastroenterology service were closely
involved. Hematocrit levels have remained stable for at least 4
days prior to discharge; pt had brown bowel movement prior to
discharge, will require stool softners to prevent constipation.
Pt being discharged to rehab prior to d/c home.
.
# HTN: Poorly controlled during admission. Held BP meds
initially with GI bleed, however despite restarting, BP still
poorly controlled. We made some changes to her medication
regimen. We have discontinued Labetalol 600mg po TID. Current
regimen include Irbesatan 150mg po BID including dialysis days,
Toprol XL 100mg po daily, Amlodipine increased from 5mg to 10mg
po daily & Clonidine 0.1mg po BID. Pt will require close
monitoring of BP given recent medication changes.
.
# ESRD on HD: [**Year (4 digits) **]/thurs/sat. Continued pt on hemodialysis
during admission. We continued pt on home regimen Cinacalcet &
Sevelamer.
.
# Chronic diastolic CHF: No evidence of overload, no acute
issues. Continued pt on Irbesatan at home regimen. Aggressive BP
control was done, see above for medication changes.
.
# DM: Initially held NPH 12U qam while pt NPO for colonscopies,
however restarted once pt tolerating regular diabetic diet.
.
# Gout: No evidence of an acute flare. Allopurinol, Lidocaine
TD, Vicodin PRN continued while on admission.
.
# Hyperlipidemia: Continued pt on home regimen Pravastatin
.
FULL CODE
Medications on Admission:
-Allopurinol 100 mg Tablet Sig EOD
-Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
-Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
-Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
-Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
-Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
-Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
-Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
-Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
-Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
-Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 75mg PO BID on dialysis days tue/[**Last Name (un) **]/sat.
-Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) unit Subcutaneous qam.
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Last Name (un) **]:*30 Tablet(s)* Refills:*2*
8. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous Every morning.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Last Name (un) **]:*60 Capsule(s)* Refills:*2*
11. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please hold for SBP < 120.
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please hold for SBP < 120.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Please hold for SBP < 120 or HR < 60.
14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a
day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please hold for loose stools.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary:
- Postpolypectomy bleeding
- Acute blood loss anemia
- Accelerated hypertension
.
Secondary:
- CKD stage V on HD
- Diabetes mellitus type II
- Chronic diastolic heart failure
- Sarcoidosis with ocular involvement
- Gout
- CVA NOS
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with bleeding per rectum for which you
underwent procedures (colonscopy x 2) to stop the bleeding. Your
blood count has been stable for several days prior to discharge.
.
We have increased your amlodipine from 5 -> 10mg po daily.
Please take Irbesatan 150mg po BID everyday including on
dialysis days. Please d/c Labetalol, take Toprol XL 100mg po
daily & Clonidine 0.1mg po BID for BP control. We have also
started you on a stool softner, Docusate. Please discuss all
this medication changes with your PCP.
.
Please come to the ED or call your PCP if you develop more
bleeding per rectum, shortness of breath, dizziness or any other
worrisome symptoms.
Followup Instructions:
PCP: [**Name10 (NameIs) 357**] [**Name Initial (NameIs) **]/u with Dr.[**Last Name (STitle) **] on [**2160-6-10**] at 1210pm.
Phone# [**Telephone/Fax (1) 608**]. Location: 545A Centre street, [**Location (un) 35114**] MA
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2160-7-23**] 4:45
ICD9 Codes: 5856, 2851, 2762, 4280, 4589, 2875, 2749, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5442
}
|
Medical Text: Admission Date: [**2144-7-25**] Discharge Date: [**2144-7-30**]
Date of Birth: [**2144-7-25**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**First Name4 (NamePattern1) 50434**] [**Known lastname **] is the former
2.065 kilogram product of a 35 and [**12-14**] week gestation
pregnancy born to a 31-year-old G2 P0 now 1 woman. Blood type
B positive. Antibody negative. Rubella immune. RPR
nonreactive. Hepatitis B surface antigen negative. Group beta
strep status unknown. The pregnancy was notable for a
prenatal echo showing premature patent ductus arteriosus
closure and right ventricular hypertrophy and valvular
regurgitation. The pregnancy was also complicated by insulin
dependent diabetes. Due to the abnormal echocardiogram
results the mother was monitored in labor and delivery. There
was a nonreassuring fetal heart rate tracing prompting a
cesarean section under spinal anesthesia. Nuchal cords x2 was
noted at delivery. The infant emerged with spontaneous
respirations. He required blow by O2 and routine care in the
delivery room. Apgars were 8 at 1 minute and 8 at 5 minutes.
He was admitted to the neonatal intensive care unit with blow
by oxygen.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit. Weight 2.065 kilograms 25th percentile.
Length 44.5 cm 25th to 50th percentile. Head circumference
31.5 cm 25th to 50th percentile. General nondysmorphic,
slightly preterm male in mild respiratory distress. Head,
eyes, ears, nose and throat anterior fontanel soft and flat.
Nondysmorphic facies. Intact [**Last Name (un) **]. Red reflex present both
eyes. Chest clear breath sounds. Good aeration.
Cardiovascular no murmur. Normal pulses. Well perfused.
Abdomen soft, 3 vessel cord. No hepatosplenomegaly. GU normal
male genitalia. Testes descended into the scrotum. Anus
patent. Musculoskeletal no hip, click. Spine straight with
normal sacrum. Neurological normal tone. Normal reflexes.
Moving all extremities.
HOSPITAL COURSE/PERTINENT LABORATORY DATA:
1. Respiratory. The initial respiratory distress resolved,
however, the infant continued to have hypoxemia requiring
oxygen, which was administered by [**Doctor Last Name **]. An arterial blood
gas was a pH of 7.37, a PCO2 of 42, PO2 of 153. The
oxygen was gradually weaned and by day of life #1 he was
in room air. He had several episodes of desaturation
associate with crying, but these resolved by day of life
#2. He has continued in room air and has had no episodes
of oxygen desaturation for 72 hours prior to discharge.
At the time of discharge he is in room air, breathing
comfortably with a respiratory rate to 30 to 40 breaths
per minute. A chest x-ray showed normal lung fields.
1. Cardiovascular. Four extremity blood pressures were
within normal limits. He maintained normal heart rates
and blood pressures. On chest x-ray heart was slightly
enlarged, but with normal pulmonary blood flow. An
echocardiogram was performed on [**2144-7-25**] showing
no patent ductus arteriosus, a patent foramen ovale. Mild
right ventricular dysfunction, but otherwise normal. The
baby was evaluated by the cardiology service from
[**Hospital3 1810**]. As he was clinically doing well. No
further intervention was undertaken. Cardiology follow up
is recommended one month after discharge at [**Hospital1 62374**] with Dr. [**Last Name (STitle) 57100**]. At the time of discharge,
[**Location (un) 69296**] heart rates are 110 to 150 beats per minute
with no murmurs noted. Recent blood pressure is 73/49
mmHg with a mean of 57 mmHg.
1. Fluids, electrolytes and nutrition. Enteral feeds were
started on day of life number one and gradually advanced.
His calories were increased to 24 calorie per ounce to
facilitate catch up growth. At the time of discharge he
is ad lib po feeding taking in a minimum of 140
milliliters per kilo per day of Similac 24 calorie per
ounce or breast milk fortified to 24 calories per ounce
with Similac powder. Weight on the day of discharge is
1.98 kilograms, which is 4 lbs 6 oz.
1. Infectious disease. Due to the unclear etiology of the
respiratory disease and unknown group beta strep status
of the mother, [**Name (NI) 50434**] 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 and was no growth at 48 hours. No treatment with
antibiotics was given.
1. Hematological. Hematocrit at birth was 54.3%.
1. Gastrointestinal. Serum bilirubin on day of life number 3
was a total of 9.1 mg per deciliter. Repeat on day of
life 5 day of discharge is a total of 10.8 mg per
deciliter. Due to his prematurity, we would recommend a
bilirubin check in 2 to 3 days after discharge.
1. Neurology. [**Location (un) 50434**] has maintained a normal neurological
exam during admission. There are no neurological concerns
at the time of discharge.
1. Sensory. Audiology, hearing screening was performed with
automated auditory brain stem responses. [**Location (un) 50434**] passed
in the right ear, but referred in the left ear. The
information for further evaluation has been provided to
the parents.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 11312**] [**Last Name (NamePattern1) 17562**], MD, 7 [**Location (un) 61259**]
[**Location (un) **], [**Numeric Identifier 69297**], phone number ([**Telephone/Fax (1) 69298**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding, ad lib po feeding or breast feeding. Breast milk
fortified to 24 calories per ounce with Similac powder or
Similac 24 calorie formula.
2. No medications.
3. Car seat position screening was performed. [**Location (un) 50434**] was
observed in his car seat for 90 minutes without any
episodes of bradycardia or oxygen desaturation.
4. State newborn screen was sent on [**2144-7-28**] with no
notification of abnormal results to date.
5. Immunizations, hepatitis B vaccine was administered on
[**2144-7-29**].
6. Immunizations recommended. Synagis RSV prophylaxis should
be considered fro [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria; first born at less
than 32 weeks; second, born between 32 and 35 weeks with
2 of the following; day care during RSV season, a smoker
in the household, neuromuscular disease, airway
abnormalities or school age siblings, or thirdly with
chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home care givers.
1. Follow up appointments recommended. 1. Appointment with
primary pediatrician with bilirubin check within 2 to 3
days of discharge. 2. Pediatric cardiology at [**Hospital1 62374**] Dr. [**Last Name (STitle) 57100**] one month after discharge. The phone
number to set up an appointment is [**Telephone/Fax (1) 37115**].
DISCHARGE DIAGNOSES:
1. Prematurity at 35 and 1/7 weeks gestation.
2. Transitional respiratory distress.
3. Premature closure of the patent ductus arteriosus.
4. Pulmonary hypertension with mild right ventricular
dysfunction.
5. Suspicion for sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Dictator Info 69299**]
MEDQUIST36
D: [**2144-7-30**] 06:02:43
T: [**2144-7-30**] 07:03:37
Job#: [**Job Number 69300**]
ICD9 Codes: V053, V290
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5443
}
|
Medical Text: Admission Date: [**2187-9-25**] Discharge Date: [**2187-10-18**]
Date of Birth: [**2105-9-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2187-10-9**] - Coronary bypass grafting x2 with left internal mammary
artery to left anterior descending coronary artery, reverse
saphenous vein single graft from the aorta to the first obtuse
marginal coronary artery.
[**2187-10-3**] - Cardiac Catheterization
History of Present Illness:
Ms. [**Known lastname **] is an 81 year old woman with multiple medical
problems, including DM, chronic renal insufficiency, recent
NSTEMI (3 weeks prior to admission)did not have cardiac
catheterization secondary to poor renal function, diastolic CHF,
requiring lasix gtt on last admission, discharged without lasix,
but recently started on Lasix 20mg po by Dr. [**Last Name (STitle) **] on an
outpatient visit, who presents with 3-4 days of progressive
shortness of breath with intermittent substernal chest pressure.
She has had increasing trouble walking around the house and even
completing full sentences. Her visiting nurse visited her
yesterday and instructed her to call her doctor; her doctor
referred her to the ED today. The chest pressure did not radiate
anywhere but was associated with some nausea and diaphoresis.
.
In the ED, EKG showed an old LBBB, and first set of cardiac
enzymes were negative. She was given 40mg IV Lasix. The chest
pressure resolved with the addition of oxygen. Given an elevated
D-dimer, a heparin drip was entertained; however, given the
presence of alternate explanations for shortness of breath in
conjunction with elevated INR (3.8), it was not.
.
Of note, she has had two nosebleeds in the past week which
resolved with pressure and application of ice. She had an
episode of nausea and vomiting last night after dinner, as well
as decrease in appetite. She denies fevers, chills, abdominal
pain, muscle cramps, lower extremity edema, constipation. She
has had looser stools since she was discharged from the hospital
several weeks ago, likely secondary to being discharged on senna
and colace.
Past Medical History:
1) PVD s/p cath
2) HTN
3) DMII-HgAlc 6.1% on [**2187-8-20**] at OSH
4) hypercholesterolemia
5) Rheumatic Fever
6) hypothyroidism
7) peptic ulcer disease
8) Recent Urinary Tract Infection-On admission to OSH, patient
moderate leukocyte esterase and 30-40 WBC. Treated with
bactrim.
9) s/p thyroidectomy
10) s/p hysterectomy
11) s/p R mastectomy [**3-16**] breast ca
[**92**]) Chronic renal insufficency-Baseline Cr of 2.0. At OSH, Cr
trended upwards from 2.0 on admission to 2.6 at discharge.
Social History:
Ms. [**Known lastname **] is a widow who lives alone. She denies current
tobacco, alcohol, or drug use. In the past, she smoked and has
a thirty pack year history.
Family History:
Non-contributory
Physical Exam:
Admission:
Vitals: T 98.1, BP 154/61, HR 78, RR 16, Sat 94%RA
Gen: Appears in mild respiratory distress, unable to complete
full sentences
HEENT: EOMI, PERRL, OP clear
Neck: No carotid bruit, no JVD appreciated (but + hepatojugular
reflex)
Cardiac: RRR, normal S1/S2, no m/r/g appreciated
Lungs: Crackles [**2-13**] way up bilaterally. No wheezes.
Abd: Soft, obese, non-distended, non-tender, normal active bowel
sounds. No hepatosplenomegaly. + hepatojugular reflex.
Back: No CVA tenderness
Ext: No clubbing, cyanosis, peripheral edema. 1+ DP pulses
bilaterally
Skin: No rashes appreciated
Neuro: A&O x 3, moving all four extremities
Discharge:
VS T98.2 HR 62SR BP 159/69 RR 18 O2sat 97%/2LNP
Gen: NAD
Neuro: A&Ox3, nonfocal exam
CV RRR, sternum stable incision CDI
Pulm CTA-bilat
Abdm: soft,NT/+BS
Ext: Warm 1+ pedal edema bilat. Bilat leg wounds CDI
Pertinent Results:
[**2187-9-25**] 11:33PM CK(CPK)-48
[**2187-9-25**] 11:33PM CK-MB-NotDone cTropnT-0.02*
[**2187-9-25**] 05:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2187-9-25**] 05:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2187-9-25**] 05:22PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2 RENAL EPI-0-2
[**2187-9-25**] 04:57PM K+-4.0
[**2187-9-25**] 04:30PM GLUCOSE-183* UREA N-36* CREAT-1.6* SODIUM-135
POTASSIUM-6.0* CHLORIDE-97 TOTAL CO2-22 ANION GAP-22*
[**2187-9-25**] 04:30PM estGFR-Using this
[**2187-9-25**] 04:30PM CK(CPK)-89
[**2187-9-25**] 04:30PM CK-MB-NotDone cTropnT-<0.01 proBNP-[**Numeric Identifier 6338**]*
[**2187-9-25**] 04:30PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.2
[**2187-9-25**] 04:30PM WBC-11.6* RBC-3.88* HGB-10.6* HCT-32.1*
MCV-83 MCH-27.3 MCHC-33.0 RDW-15.5
[**2187-9-25**] 04:30PM NEUTS-78.5* LYMPHS-15.2* MONOS-5.3 EOS-0.8
BASOS-0.2
[**2187-9-25**] 04:30PM PLT COUNT-627*
[**2187-9-25**] 04:30PM PT-34.8* PTT-41.3* INR(PT)-3.8*
[**2187-9-25**] 04:30PM D-DIMER-2051*
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-10-17**] 08:00AM 11.0 3.53* 10.2* 32.0* 91 28.7 31.7 16.5*
618*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2187-10-17**] 05:55AM 92 26* 1.8* 135 5.0 100 22 18
[**2187-10-17**] 05:55AM 15.2* 33.5 1.4*
[**2187-9-25**]-BILATERAL LOWER EXTREMITY VEIN DOPPLER ULTRASOUND:
Grayscale and Doppler
examination of the bilateral common femoral, superficial femoral
and popliteal
veins were performed. Normal compressibility, augmentation,
waveforms and
Doppler flow is demonstrated. There is no evidence of
intraluminal clot.
Renal US [**2187-9-29**]-
1) No hydronephrosis.
2) Hypoechoic nodule in upper pole of left kidney not
definitively
identified on recent priors. In absence of clinical signs to
suggest an acute pathology, recommend follow-up in [**4-17**] months to
reevaluate.
Cardiac Cath 8/22/07-1. Coronary angiography of this right
dominant system revealed a LMCA
with an eccentric 60% lesion extending into the ostial/proximal
portion
of the LCX. The LAD was without significant coronary disease.
The RCA
was without apparent angiographic significant disease.
2. Resting hemodynamics revealed severe systemic hypertension
with an
SBP of 176 mm Hg. Left sided pressures were severely elevated
with an
LVEDP of 32 mm Hg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Markedly elevated LVEDP suggestive of severe diastolic
dysfunction.
[**2187-10-5**]- CT-chest w/o contrast-
1. Extensive calcifications of the ascending aorta, normal in
caliber.
2. Mediastinal lymphadenopathy of uncertain significance.
3. Upper normal limit size of pulmonary arteries. Small left
pleural
effusion.
[**2187-10-5**]-Echo-Symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic LV dysfunction with
elevated filling pressures. Mild mitral regurgitation.
[**2187-10-6**]-Femoral U/S bilateral-
No pseudoaneurysm or hematoma.
[**2187-10-9**] ECHO
PRE-BYPASS:
1. Mild spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A left atrial appendage thrombus cannot be
excluded.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Overall left ventricular systolic function is severely
depressed (LVEF= 25%.
4. The right ventricular cavity is mildly dilated.
5. There are complex, mobile atheroma in the aortic arch. There
are complex
(>4mm) atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. Trace aortic regurgitation is
seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
Post bypass
1. Initial attempt at coming off CPB was associated with severe
MR and high PA pressures . Back on CPB and started milrinone and
epinephrine.
2. Septal and anteroseptal walls of the LV shows improved
function. RV
function unchanged.
3. Trace mitral regurgitation present.
4. Aorta intact post decannulation.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2187-10-16**] 1:32 PM
CHEST (PA & LAT)
Reason: r/o effusion
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with CAD to go for CABG
REASON FOR THIS EXAMINATION:
r/o effusion
TYPE OF EXAMINATION: Chest PA and lateral.
INDICATION: Coronary artery disease, scheduled for bypass
surgery. Evaluate for effusion.
FINDINGS: AP single view of the chest has been obtained with
patient in sitting semi-upright position. Comparison is made
with a similar preceding study of [**2187-10-11**]. There is mild
blunting of the lateral pleural sinuses confirmed by blunting of
the posterior pleural sinuses in the lateral view. The amount is
considered mild to moderate. There remain some linear densities
on the left base, but these densities have not progressed in
comparison with the previous study. On the right base, the
previously identified linear atelectasis has improved with only
one remaining. Also, the previously existing perivascular haze
has improved slightly. No new parenchymal infiltrates are
identified. Position of previously described right-sided
internal jugular vein approach central venous line is unchanged.
The previously existing post-operative mediastinal widening has
regressed.
IMPRESSION: Improvement of post-operative changes.
Mild-to-moderate amount of bilateral pleural effusions. No
pneumothorax or any other complication.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2187-9-25**] for further
management of her shortness of breath and NSTEMI. Diuresis was
initiated and cardiac enzymes were negative. Her BNP was noted
to be quite elevated. A lower extremity ultrasound was negative
for a deep vein thrombosis. Her renal function stuides suggested
some mild renal failure. A renal ultrasound was performed which
showed no hydronephrosis and a hypoechoic nodule in upper pole
of left kidney not definitively identified on recent priors. A
[**4-17**] month follow-up was recommended. Slowly her renal function
improved. She was treated for a urinary tract infection. Ms.
[**Known lastname **] continued to have episodes of chest pain treated with
nitroglycerin with relief. Her coumadin was reversed with the
plan for a cardiac catheterization. A cardiac catheterization
was performed which showed left main and circumflex artery
disease. Heparin was continued. Given the anatomy and severity
of her disease, the cardiac surgical service was consulted for
surgical management. She was worked-up in the usual preoperative
manner including a carotid duplex ultrasound which showed
moderate plaque with bilateral 40-59% carotid stenosis. She was
tranfused to maintain a hematocrit of greater then or equal to
30%. Plavix was allowed to clear while her INR normalized in
anticipation of surgery. A superficiall phlebitis was treated.
On [**2187-10-9**], Ms. [**Known lastname **] was taken to the operating room where she
underwent coronary artery bypass grafting to two vessels.
Postoperatively she was taken to the intensive care unit for
monitoring. On postoperative day one, Ms. [**Known lastname **] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. A hematology consult
was obtained for thrombocytosis however her platelets quickly
normalized and it was assummed she had a reactive
thrombocytosis. Amiodarone was started for atrial fibrillation.
On postoperative day two, Ms. [**Known lastname **] was transferred to the step
down unit for further recovery. She was gently diuresed towards
her preoperative weight. The physical therapy service was
consulted for assistance with her postoperative strength and
mobility. Coumadin was resumed for anticoagulation. Over the
next several days the patient worked with PT to increase
endurance without much gain, it was decided she would benefit
from a short rehabilitation stay and on POD 9 she was
transferred to rehab.
Medications on Admission:
Aspirin 325mg daily
Levothyroxine 150mcg daily
Pantoprazole 40mg [**Hospital1 **]
Clopidogrel 75mg daily
Epoietin Alfa 10,000 units/mL QMoWeFr
Cyanocobalamin 500 mcg daily
Atorvastatin 40mg daily
Warfarin 5mg QHS
Metoprolol 75mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Ipratropium Neb Q4H
Fexofenadine 60mg [**Hospital1 **]
Senna 8.6mg [**Hospital1 **]
Calcium Acetate 667 PO TID with meals
Metformin (unknown dose)
Lasix 20mg daily (recently started by cardiologist)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day:
Adjust dose to target INR 1.5-2.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): 40mg QD x 10 days then decrease to 20mg QD.
12. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**])
units Injection Q Mo-We-Fri.
15. Ferrous Sulfate 325 (65) mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 245**] [**Hospital6 **] Hospital
Discharge Diagnosis:
CAD s/p CABG
Congestive heart failure exacerbation, supratherapeutic INR
Diastolic heart failure
Coronary artery disease, status post myocardial infarction
Atrial fibrillation
peripheral vascular disease
hypertension
hypercholesterolemia
chronic renal insufficiency
diabetes
hypothyroidism
peptic ulcer disease
Discharge Condition:
stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Contact surgeon at ([**Telephone/Fax (1) 1504**]
with any wound issues.
2) Report any weight gain of greater the 2 pounds in 24 hours or
5 pounds in 1 week.
3) No lifting greater the 10 pounds for 10 weeks.
4) No driving for 1 month.
5) You may wash incision and gently pat it dry. No swimming or
bathing until wound has healed. Please shower daily. No lotions,
creams or powders to incision until it has healed.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] [**Telephone/Fax (1) 8506**]
Dr. [**Last Name (STitle) **] [**2190-10-29**]:20am [**Telephone/Fax (1) 2386**]
Please call all providers for appointments.
Completed by:[**2187-10-18**]
ICD9 Codes: 4280, 4111, 9971, 5849, 5859, 2449, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5444
}
|
Medical Text: Admission Date: [**2181-2-7**] Discharge Date: [**2181-2-11**]
Date of Birth: [**2157-11-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
OSH transfer for possible liver transplant after Acetaminophen
OD
Major Surgical or Invasive Procedure:
Intubation/extubation
Central venous line
History of Present Illness:
Mr. [**Known lastname 81685**] is a 23 M w/o significant PMH presented to [**Hospital1 112**] w/
altered mental status. Pt took 150 tablets of Tylenol PM on
[**2-7**], and was found vomiting and sedated by his roommates who
called 911. Initial tylenol level was 364 at 8 hours. At [**Hospital1 112**], CT
head, urine and serum tox otherwise unremarkable. He had a
lumbar puncture which showed 1 WBC, 16 RBC and normal glucose
and protein. He was intubated for airway protection as he was
hypoxic on 6L NC. He was started on NAC and underwent charcoal
lavage. He was transferred to [**Hospital1 18**] for transplant evaluation.
Past Medical History:
None
Social History:
RA at [**University/College 5130**] [**Location (un) **]. Drinks heavily socially. No
tob/illicits.
Family History:
Not obtained on H&P due to intubation.
Physical Exam:
Initial vs were: T 97.2 P 97 BP 135/81 Vent at 60%, PEEP of 5, R
12 X 500, O2 sat 99%.
General: Alert, no acute distress, follows commands
HEENT: Sclera anicteric, ETT in place, PERRLA
Neck: RIJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly TTP in RUQ, non-distended, hypoactive
bowel sounds, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, trace bilateral ue and le
edema
Pertinent Results:
Admission Labs:
[**2181-2-7**] 05:35PM BLOOD WBC-9.0 RBC-4.52* Hgb-14.2 Hct-40.1
MCV-89 MCH-31.5 MCHC-35.5* RDW-13.0 Plt Ct-199
[**2181-2-7**] 05:35PM BLOOD Neuts-85.9* Lymphs-11.7* Monos-2.0
Eos-0.2 Baso-0.2
[**2181-2-7**] 05:35PM BLOOD PT-14.3* PTT-25.1 INR(PT)-1.2*
[**2181-2-8**] 08:02AM BLOOD PT-16.2* PTT-26.4 INR(PT)-1.4*
[**2181-2-7**] 05:35PM BLOOD Glucose-105 UreaN-12 Creat-1.2 Na-138
K-4.7 Cl-107 HCO3-23 AnGap-13
[**2181-2-7**] 05:35PM BLOOD ALT-85* AST-52* CK(CPK)-1278* AlkPhos-47
TotBili-1.3
[**2181-2-8**] 04:45AM BLOOD ALT-70* AST-42* CK(CPK)-822* AlkPhos-49
TotBili-1.6*
[**2181-2-8**] 10:58AM BLOOD ALT-65* AST-37 LD(LDH)-236 CK(CPK)-675*
AlkPhos-52 TotBili-1.6*
[**2181-2-7**] 05:35PM BLOOD Calcium-9.1 Phos-2.6* Mg-2.2
Discharge Labs:
[**2181-2-10**] 06:20AM BLOOD WBC-7.4 RBC-4.00* Hgb-12.6* Hct-35.5*
MCV-89 MCH-31.6 MCHC-35.6* RDW-12.8 Plt Ct-210
[**2181-2-10**] 06:20AM BLOOD Glucose-91 UreaN-12 Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2181-2-10**] 06:20AM BLOOD ALT-35 AST-18 LD(LDH)-204 AlkPhos-63
TotBili-1.0
[**2181-2-10**] 06:20AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.8 Mg-1.9
[**2-7**] CXR: The endotracheal tube is 5 cm above the carina at the
thoracic inlet. Right jugular central venous catheter has tip in
the mid SVC. NG tube has its tip in the stomach. There is right
lower and mid lung airspace disease, consistent with aspiration
or pneumonia. Minimal left retrocardiac opacity could represent
a small amount of aspiration or simply atelectasis with
patient's mildly low lung volumes. No concerning bone findings.
[**2-9**] CXR: PORTABLE AP CHEST RADIOGRAPH: Unchanged appearance of
opacity in right lower lobe. Elsewhere, the lungs are clear. No
pleural effusion. Heart size is within normal limits.
IMPRESSION: Unchanged appearance of the right lower lobe
opacity.
Brief Hospital Course:
This is a 23M transfered from OSH for liver transplant
evaluation in setting of tylenol overdose.
# Tylenol overdose: Patient ingested 150 pills, and initial
tylenol 8hrs out was 364. Per tylenol nomogram, he was in the
"probable hepatic toxicity" range. Pt was started on NAC w/in 8
hours of ingestion. In ICU patient was followed by toxicology
and hepatology. He was extubated on arrival to [**Hospital1 **] ICU. NAC
was continued until [**2-8**]. Transplant surgery was also consulted
and patient felt not to need liver transplant given improvement
in liver function tests. His LFTs continued to trend down and
normalized by the time of discharge. INR also normal.
# Benadryl overdose: CKs also improved over hosiptal stay and
EKG without widened QRS.
# Aspiration PNA: Patient had been intubated at outside
hospital, extubated upon arrival here. CXR showed RLL opacity
and he was started on clindamycin on [**2-7**] to complete 7 day
course. He had low grade fevers on [**2-11**] treated with
cooling blankets - no tylenol. O2 saturation improved and at
time of discharge he was oxygenating well on room air. He
should continue Clindamycin 300mg four times daily for another 3
days to complete the course.
.
# Suicide attempt: Mr. [**Known lastname 81685**] was followed by psychiatry for
suicide attempt. He was given ativan PRN but no other
medications started at this time. Plan is for inpatient psych
admission once medically stable. He currently denies SI.
Medications on Admission:
Medications upon transfer:
Acetylcysteine 10gm IV x1
Peridex Mouthwash
Famotidine 20mg IV q12H
Fentanyl Citrate IV
Magnesium Sulfate INJ
Propofol IV 0-5mg/kg/hr
Combivent 8 puff INH QID
.
Home medications: None
Discharge Medications:
1. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for cough. Capsule(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Last Name (LF) 86**], [**First Name3 (LF) **] 4
Discharge Diagnosis:
Suicide attempt
Tylenol overdose
Acute hepatitis
Aspiration pneumonia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted after a tylenol overdose. You were treated
with a medication to help prevent liver toxicity and your liver
function tests normalized within days. You were followed by the
liver team who feels that there is nothing further to do
medically.
You were also seen by psychiatry for a suicide attempt. You
were monitored by a sitter during your stay. It is felt that
you would benefit from a psychiatric hospitalization upon
discharge from the hospital.
You were also noted to have a aspiration pneumonia. You were
started on Clindamycin for this. You should complete a 7 day
course.
You will be discharged to a psychiatric facility for further
care.
If you have any further thoughts of hurting yourself or other
please call 911 immediately. If you develop any worsening
shortness of breath, further fevers, chest pain or other
concerning symptoms please call your doctor.
Followup Instructions:
You should follow up with your primary care doctor once you are
released from the psychiatric facility.
.
If you do not have a primary care doctor, please call [**Company 191**] at [**Telephone/Fax (1) 14384**] to schedule a new appointment for primary care.
ICD9 Codes: 5070, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5445
}
|
Medical Text: Admission Date: [**2141-5-4**] Discharge Date: [**2141-5-11**]
Date of Birth: [**2098-10-13**] Sex: F
Service: MED
Allergies:
Demerol / Compazine / Reglan / Betadine Surgi-Prep / Tape /
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
ATTENDING IS DR. [**First Name8 (NamePattern2) 2415**] [**Name (STitle) 2416**] ON MEDICINE SERVICE; DR. [**First Name (STitle) **]
[**Doctor Last Name **] IS ATTENDING FROM MICU;
clogged central line
Major Surgical or Invasive Procedure:
tunnelled catheter placement w/ stent x 3
History of Present Illness:
42 yo W w/ hx [**Location (un) **] syndrome s/p colectomy and small bowel
resections now w/ short [**Location (un) **] syndrome on TPN since [**2123**]
complicated by sepsis from fungemia and most recently clots. Pt
was admitted for line placement by IR, then transferred to MICU
for tPA to dissolve clot and now s/p R fem vein stent [**2141-5-5**].
Pt did well post-op w/ now R fem line placed. She spiked O/N to
101.6, now defervesced. Her cultures are still pending. She was
hypotensive to 73/40's (baseline SBP's 80-100's) s/p 500cc NS,
now SBP 80-90's.
Pt reports no cough, no dyspnea, no CP, no hematuria, no
dysuria, no LBP, no new syptoms. She reports some residual R
groin pain post-op, but o/w feels well.
Past Medical History:
[**Location (un) **] syndrome, diagnosed at age 23 s/p colectomy '[**21**], then
repeated small bowel resections [**12-26**] persistent polyp growth, now
w/ short [**Month/Day (2) **] syndrome and on chronic TPN since '[**23**].
s/p dermoid cyst removal, originally in small bowel, then
extended to ovaries
Fungemia/ staph epi sepsis
fibromyalgia
osteoporosis (no long term steroid use) s/p b/l hip fx, and b/l
ORIF
scoliosis s/p repair
s/p TAH
Social History:
lives at home w/ her mother, no hx tobacco, no EtOH, no
IVDA/other drugs; worked as a nanny while going to college
studying RN and special ed, did not finish, now lives at home.
Family History:
father w/ [**Name2 (NI) **] syndrome, 6 of 8 siblings w/ [**Location (un) **]
syndrome. Diagnosed when sister was going to the marines, then
had testing given her father's dx's and diagnosed w/ Gardners
(by colonoscopy, no genetic testing of family per pt) => all
family testing => [**5-2**] siblings have it. Mother and relatives w/
HTN and resulting CVA; sister w/ breast ca;
father died of pancreatitis at 42 yo from polyp blocking
pancreatic duct -> pancreatitis
Physical Exam:
Tm 101.6 Tc 98.3 84/47 (82-98/30-50) 93 (88-100) 17 99%RA
Gen: cauc W lying in bed in NAD watching TV conversing w/ the RN
Neuro: PERRL, EOMI, CN II-[**Doctor First Name 81**] intact, tongue deviates to R; motor
[**3-29**] b/l, [**Last Name (un) 36**] intact; AA & Ox3;
HEENT: OP clear, no petechiae, MMM
Neck; no thyromegaly, no nodules appreciated
Heart: tachy, RRR, S1, S2, no m/r/g
Lungs: CTBLA, no wheezing, no rales
Abd: + RLQ colostomy w/ liquid stool; mult abd scars, well
healed; RLQ tenderness w/ palpation, no HSM, o/w S/no rebound,
no guarding;
Groin: R groin mild T w/ palpation, no hematoma, R upper thigh
line secured; L groin no hematoma
Back; No CVAT, midline scar (s/p scoliosis Sx)
Ext: NVI, dp 2+ b/l; no edema; long scars b/l thighs (ORIF b/l)
Pertinent Results:
hct 25, stable (27-30 baseline)
plt 114 dropping (<-<-<- 300 [**2-26**])
[**2141-5-6**] hep dep Ab Pending?
[**11-26**] hep dep Ab negative
U/A lg bld, sm leuks
BCx x 2 P today
CXR: no effusion, no pna, clear, c/w previous CXR L pleural
effusion is resolved
[**2-25**] TTE: w/ secundum type ASD w/ L->R flow
[**2141-5-10**] 05:54AM BLOOD WBC-5.3 RBC-3.55* Hgb-10.9* Hct-31.6*
MCV-89 MCH-30.7 MCHC-34.4 RDW-15.0 Plt Ct-181
[**2141-5-9**] 06:15AM BLOOD WBC-5.3 RBC-3.63* Hgb-11.0* Hct-32.1*
MCV-88 MCH-30.3 MCHC-34.3 RDW-14.8 Plt Ct-181
[**2141-5-8**] 10:40AM BLOOD WBC-4.8 RBC-2.70* Hgb-8.7* Hct-24.5*
MCV-90 MCH-32.3* MCHC-35.7* RDW-13.6 Plt Ct-182
[**2141-5-6**] 04:00PM BLOOD Hct-25.6* Plt Ct-114*
[**2141-5-6**] 02:15AM BLOOD WBC-4.6 RBC-2.72* Hgb-8.6* Hct-24.9*
MCV-91 MCH-31.6 MCHC-34.6 RDW-13.2 Plt Ct-130*
[**2141-5-5**] 07:18AM BLOOD WBC-6.5 RBC-2.91* Hgb-9.0* Hct-27.4*
MCV-94 MCH-30.9 MCHC-32.7 RDW-13.1 Plt Ct-188
[**2141-5-4**] 02:55PM BLOOD WBC-6.6 RBC-3.34* Hgb-10.3* Hct-30.9*
MCV-92 MCH-30.8 MCHC-33.3 RDW-13.2 Plt Ct-214
[**2141-5-11**] 06:21AM BLOOD Plt Ct-221
[**2141-5-9**] 06:15AM BLOOD PT-12.4 PTT-30.1 INR(PT)-1.0
[**2141-5-7**] 06:45AM BLOOD Plt Ct-138*
[**2141-5-7**] 06:45AM BLOOD PT-12.8 PTT-31.7 INR(PT)-1.1
[**2141-5-6**] 04:00PM BLOOD Plt Ct-114*
[**2141-5-5**] 02:58AM BLOOD PT-12.8 PTT-34.7 INR(PT)-1.1
[**2141-5-4**] 11:50PM BLOOD PT-12.9 PTT-36.3* INR(PT)-1.1
[**2141-5-4**] 08:00PM BLOOD PT-13.0 PTT-39.3* INR(PT)-1.1
[**2141-5-4**] 04:27PM BLOOD PT-12.9 PTT-44.7* INR(PT)-1.1
[**2141-5-4**] 02:55PM BLOOD Plt Ct-214
[**2141-5-5**] 07:18AM BLOOD Fibrino-198
[**2141-5-4**] 11:50PM BLOOD Fibrino-169
[**2141-5-4**] 08:00PM BLOOD Fibrino-173
[**2141-5-4**] 06:13PM BLOOD Fibrino-178
[**2141-5-4**] 04:27PM BLOOD Fibrino-207
[**2141-5-7**] 11:00PM BLOOD Ret Aut-1.3
[**2141-5-7**] 06:45AM BLOOD Glucose-238* UreaN-7 Creat-0.5 Na-140
K-4.2 Cl-112* HCO3-21* AnGap-11
[**2141-5-5**] 02:58AM BLOOD Glucose-104 UreaN-16 Creat-0.5 Na-141
K-3.0* Cl-106 HCO3-28 AnGap-10
[**2141-5-7**] 06:45AM BLOOD ALT-21 AST-16 LD(LDH)-147 AlkPhos-237*
TotBili-0.2
[**2141-5-11**] 06:21AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.0
[**2141-5-10**] 05:54AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9
[**2141-5-5**] 02:58AM BLOOD Calcium-7.8* Phos-2.6*# Mg-1.9
[**2141-5-7**] 06:45AM BLOOD calTIBC-246* Hapto-110 Ferritn-817*
TRF-189*
[**2141-5-10**] 07:08PM BLOOD Vanco-17.9*
[**2141-5-8**] 10:40AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
Brief Hospital Course:
Patient came to IR for outpt stent which failed. She was
admitted to the MICU for tpa, then had 3 stents placed by Dr.
[**First Name (STitle) **] in the Common femoral vein and superficial femoral vein
(see op note for further details). Pt was then transferred to
the floor where she was started on anticoagulation for her DVT
w/ 80sc lovenox per Heme recommendations w/ further
recommendations for outpt hypercoagulability work up. She also
received 2U PRBC's for a hct of 24-25 which was stable w/
appropriate increase of hct to 30-32. Additionally, pt was
continued on her TPN.
Blood cultures (including fungal Cx) were drawn on [**2141-5-6**] and
[**2141-5-8**] which remained negative. Her last Cx from [**2141-4-20**] at
[**Hospital 111732**] Hospital were negative and per ID her abx course is
Vanco 1g IV q12h and fluc 400mg IV q24h for a month since her
last negative culture -- abx to end [**2141-5-21**]. A vanco trough was
checked at that dose and found to be 18 and pt was continued on
the current doses. Per OSH records pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 48411**]
was sensitive to fluconazole, thus no capsofungin was added.
Short [**Name (NI) **] - pt was continued on TPN during her hospitalization
[**Location (un) **] syndrome - per pt hx of GI scope w/ mult polyps and
recommendation for resection ~ 1 yr ago. CT torso no evidence
of mass, abscess, 5mm lung nodule and decreased L pleural
effusion c/w previous CT scan. Pt to have GI f/u as oupt for
rescope and likely further resection. To f/u w/ PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
as outpt regarding coordination of small bowel transplant.
Medications on Admission:
1. Vancomycin HCl 10 g Recon Soln Sig: One (1) g Intravenous
Q24H (every 12 hours): to end [**2141-5-21**].
Disp:*30 g* Refills:*0*
2. Fluconazole in Normal Saline 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 2
weeks: to end [**2141-5-21**].
Disp:*5600 mg* Refills:*0*
3. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
4. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Discharge Medications:
1. Vancomycin HCl 10 g Recon Soln Sig: One (1) g Intravenous
Q12H (every 12 hours): to end [**2141-5-21**].
Disp:*30 g* Refills:*0*
2. Fluconazole in Normal Saline 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 2
weeks: to end [**2141-5-21**].
Disp:*5600 mg* Refills:*0*
3. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
4. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
5. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q24H (every 24 hours).
Disp:*2400 mg* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA [**Location (un) 1157**]
Discharge Diagnosis:
common femoral vein thrombosis, stenosis
short [**Location (un) **] syndrome
[**Location (un) **] syndrome
Discharge Condition:
stable on RA, on TPN, ambulating well, LLQ T stable;
Discharge Instructions:
Please follow up with your appointments and take your
medications as prescribed. Please seek medical attention if you
have any swelling in your R leg, feel short of breath or feel
acutely ill.
Followup Instructions:
Heme: Please call [**First Name4 (NamePattern1) 2659**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 58019**] for follow up
with Dr. [**Last Name (STitle) 2805**] or Dr. [**Last Name (STitle) 3060**] in [**12-27**] weeks for hypercoagulability
work up.
Primary Care: Please follow up with Dr. [**First Name (STitle) **],[**First Name3 (LF) **] A
[**Telephone/Fax (1) 111733**] regarding further work up and timing for your small
bowel transplant. Additionally, please follow up with her
regarding your additional GI scopes and timing of small bowel
resection.
GI: please follow up with your gastroenterologists in [**12-27**] weeks
for repeat scope for evaluation of polyps
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2141-5-11**]
ICD9 Codes: 2875, 5119
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5446
}
|
Medical Text: Admission Date: [**2169-9-25**] Discharge Date: [**2169-10-9**]
Date of Birth: [**2106-2-15**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Gangrenous left third toe.
HISTORY OF PRESENT ILLNESS: History of present illness was
obtained from the husband and computer records since the
patient is aphasic. This is a 63 year-old white female with
a history of atrial fibrillation status post cerebrovascular
accident times four, peripheral vascular disease, status post
popliteal peroneal bypass graft with a left TMA resulting in
a left below the knee amputation in [**Month (only) 958**] of this year and a
right popliteal peroneal nonrevealing saphenous vein in
[**Month (only) 956**] of this year who developed right third toe
discoloration a few weeks prior to admission. She was seen
by her podiatrist initially and then on follow up noted to
have gangrenous changes. The patient was referred to Dr.
[**Last Name (STitle) **] who saw her in the office today. She is now
admitted for further evaluation and treatment of her
gangrene.
ALLERGIES: Vancomycin hives. Coumadin and aspirin cause
retinal bleed. Tape causes rash.
MEDICATIONS:
1. Insulin 75/25 30 units q.a.m. and 30 units at supper.
2. Lexapro 20 mg q day.
3. Aggrenox one b.i.d.
4. Fosamax 70 mg q Sunday.
5. Multivitamin tablet one q.d.
6. Vitamin E, C and B-6 one q.d.
7. __________ with fiber one can with breakfast.
8. Altace 2.5 mg q.a.m.
9. Co-enzyme Q.
10. Betacarotene.
PAST MEDICAL HISTORY:
1. Atrial fibrillation initially diagnosed in [**2168-6-13**].
2. Cerebrovascular accident in [**2167-1-15**] and [**2168-6-13**]
treated with Plavix with residual expressive aphasia.
3. Diabetes since the age of 50 with neuropathy and
retinopathy.
4. History of left deep venous thrombosis in [**2162**] treated
with Coumadin.
5. Thyroid nodule with subtotal thyroidectomy.
6. Osteoporosis on Fosamax.
7. Depression.
8. Mature cataracts OU.
9. VRE infection.
10. Left below the knee amputation stump in [**2169-5-14**].
11. Peripheral vascular disease.
PAST SURGICAL HISTORY;
1. Subtotal thyroidectomy.
2. Amputation of the right first toe.
3. Left popliteal peroneal nonreverse saphenous vein in [**2168-6-13**].
4. Left TMA in [**2168-6-13**].
5. Left below the knee amputation in [**2169-2-11**].
6. Right AK popliteal peroneal in [**2169-1-14**].
7. Revision of left below the knee amputation in [**2169-1-14**].
8. Vitrectomy left.
SOCIAL HISTORY: She is married and lives with her husband.
She uses left prosthesis part of the day and wheel chair the
rest of the day.
PHYSICAL EXAMINATION: Vital signs temperature 98.6. 142/76,
64, 18, O2 sat 96% on room air. General appearance, alert,
cooperative white female in no acute distress. HEENT
examination unremarkable. Tongue is midline. Carotids are
palpable without bruits. Pulse examination shows palpable
carotids, radials 2+, femoral on the right is 1+, popliteal
nonpalpable. Dorsalis pedis pulse and posterior tibial pulse
are nondopplerable. On the left the popliteal is nonpalpable
and she has a below the knee amputation. There are no
femoral bruits. Chest examination lungs are clear to
auscultation. Heart is irregular regular rhythm. Abdominal
examination was obese with bowel sounds, nontender, no masses
or organomegaly. Left below the knee amputation is a 1 cm
lateral incision opening with foul odor and surrounding
erythema. There is a 1 cm diameter traumatic lesion on the
dorsum of the right hand and right knee with surrounding
erythema, but no drainage. The right leg is moderate ankle
edema and erythema of the distal two thirds of the leg. The
leg is cool to touch. There is small dry eschar on the right
first toe amputation and the second toe with gangrenous right
third toe changes with minimal drainage from the lateral
aspect. Right heel is without fissures or pressure ulcers.
Neurologically she has expressive aphasia and emotionally is
very labile.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. She is placed on VRE precautions. Routine
laboratories were obtained, white blood cell count 11.1,
hematocrit 35.2, platelets 450 K, BUN 22, creatinine 1.0, K
4.6, PT/INR 12.7 and 1.1. Chest x-ray showed no active
cardiopulmonary disease. Electrocardiogram showed atrial
fibrillation. Wound cultures were obtained. Initial swab
grew beta streptococcus group B, moderate growth and
Corynebacterium. Blood cultures were obtained on [**2169-9-26**],
which were no growth and finalized on [**2169-10-2**]. Blood
cultures were no growth and finalized. Stool cultures were
obtained, because of loose stools. C-diff was negative. The
patient's swab cultures grew beta streptococcus group B and
Corynebacterium. The patient was continued on antibiotics.
She was intravenously hydrated and underwent arteriogram on
[**2169-9-26**]. Arteriogram demonstrated abdominal aorta widely
patent with infrarenal aorta with bilateral renal arteries
and brisk filling nephrograms. There is a widely patent
common iliac and external iliac arteries, hypogastric
bilaterally are patent. The run off to the right lower
extremity, patent common femoral profunda and superficial
femoral artery. The superficial femoral artery occludes at
the [**Doctor Last Name **] canal. There is a blind segment of popliteal and
reconstitutes and then occludes. A TB constitutes just
distal to its origin. The PT and peroneal are occluded at
its origins. The AT fills the distal peroneal artery the
collaterals above the ankle. The peroneal artery then fills
retrograde and is patent in the upper calf. The PT
reconstitutes at the level of the ankle. The dorsalis pedis
is poorly visualized. These findings were discussed with Dr.
[**Last Name (STitle) **].
Post angio creatinine was 1.0, remained stable. Vein mapping
of the upper extremity and lower extremity including
saphenous was obtained to determine vein conduit. The
patient underwent on [**2169-9-30**] a right distal superficial
femoral artery proximal anterior tibial nonreverse saphenous
vein graft bypass using two segments of the greater saphenous
from the right and left thighs, angioscopy with valve lysis.
The patient tolerated the procedure well. JPs were placed in
the right thigh. The patient was transferred to the PACU in
stable condition. Immediately postoperatively she was
hemodynamically stable. Postoperative hematocrit was 32.6,
BUN 11, creatinine 0.8, K 4.0. The patient continued to do
well and showed a dopplerable dorsalis pedis and posterior
tibial and popliteal pulses on the operative side. The JP
drainage was serosanguinous output. The patient was in
atrial fibrillation and she required beta blockade for rate
control. She continued to do well and was transferred to the
VICU for continued monitoring and care. The patient required
neo-synephrine postoperative and fluid boluses for systolic
hypotension. Her temperature max was 100.4 to 100.3. She
remained in atrial fibrillation with a V rate of 77, systolic
was 132, diastolic 49, CVP 2. The patient's hematocrit
drifted to 28.5, BUN and creatinine remained stable.
Blood cultures were obtained, which were finalized at no
growth. C-diff was obtained, which was negative.
Neo-synephrine wean was begun. Diet was advanced as
tolerated. The patient was transfused 1 unit of packed red
blood cells. Her calcium was repleted. Intravenous
antibiotics were continued. She was placed on subcutaneous
heparin for deep venous thrombosis prophylaxis and remained
in the VICU. Postoperative day two the patient required 2
units of packed red blood cells. Post transfusion hematocrit
was 28.5 to 27. The following morning hematocrit was 27.7
with a white blood cell count of 13.3. BUN and creatinine 15
and 1.0, K 4.3. Physical examination was unremarkable. She
had dopplerable dorsalis pedis pulses and posterior tibial
pulses and palpable popliteal. Wounds were clean, dry and
intact. Morphine for analgesic control was converted to
Oxycodone. Neo-synephrine was weaned off and she continued
on her Lopressor systolic blood pressure is 114/40. She
required additional unit of blood with Lasix. She was
delined and transferred to the regular nursing floor,
ambulation to chair was begun. Postoperative day three the
patient defervesced to 99.2. She was continued on Linezolid,
Zosyn and Flagyl. Hematocrit post transfusion was 29.5, BUN
12, creatinine 0.7. Zosyn was discontinued. Levofloxacin
was started for enterococcus coverage. The Foley was
discontinued. CVL was converted to a peripheral line.
Case management was requested to begin rehab screening. The
patient underwent toe amputation on [**2169-10-6**] of toes two,
three, four and five without incident. The initial dressing
was removed on postoperative day one. The wound was clean,
dry and intact. Physical therapy felt that she would require
rehab to bring her to baseline. Her white blood cell count
remained stable at 15.2 her hematocrit was 33. Oxycodone and
morphine were utilized for pain. The remaining hospital
course was unremarkable. The patient was discharged to rehab
on [**2169-10-9**]. Her wounds were clean, dry and intact. Skin
clips were intact. The distal left saphenous vein harvest
site showed skin dehiscence, normal saline wet to dry
dressings were begun. The amputation sites were clean, dry
and intact without erythema, ecchymosis or ischemic skin
changes. The first metatarsal head showed some ulceration,
superficial normal saline wet to dry dressings were begun on
this. The patient will be allowed to ambulate full weight
bearing with healing sandle on the right foot. Skin clips
sutures remain in place for a total of seven more days and
then could be discontinued on [**2169-10-17**]. The toe amputation
site sutures remain in place for a total of four weeks until
seen in follow up. The patient will continue on antibiotics
for a total of seven days post discharge.
DISCHARGE MEDICATIONS:
1. Aspirin/Persantine 25/200 mg tables one b.i.d.
2. Fosamax 70 mg one q Sunday.
3. Citalopram oxalate 10 mg tablets two for a total dose of
20 q.a.m.
4. Senna tabs two q.d. prn.
5. Dulcolax suppository q.d. prn.
6. Multivitamin capsules one q.d.
7. Oxycodone 5 mg tablets one q 4 to 6 hours prn for pain.
8. Acetaminophen 325 mg tablets one to two q 4 to 6 hours
prn for pain.
9. Linezolid 600 mg q 12 hours for a total of fourteen days.
10. Ramipril 1.25 capsules two q.a.m.
11. Lopressor 25 mg b.i.d.
12. Flagyl 500 mg t.i.d. times fourteen days.
13. Levofloxacin 500 mg q.d. times fourteen days.
14. Zyloprim 5 mg at h.s. prn.
15. Miconazole powder to affected areas t.i.d. prn.
DISCHARGE DIAGNOSES:
1. Right third toe gangrene and leg cellulitis.
2. Failed right AK popliteal peroneal bypass graft.
3. Status post right femoral anterior tibial bypass with
composite bilateral saphenous vein.
4. Right toe amputations two through four.
5. Blood loss anemia corrected.
6. Systolic hypotension corrected.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2169-10-9**] 08:37
T: [**2169-10-9**] 09:54
JOB#: [**Job Number 38097**]
ICD9 Codes: 3572
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5447
}
|
Medical Text: Admission Date: [**2146-7-13**] Discharge Date: [**2146-7-29**]
Date of Birth: [**2092-6-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pain, SOB
Major Surgical or Invasive Procedure:
Cardiac Catheterization
MVR (27mm St. [**Male First Name (un) 923**] mechanical) via right thoracotomy, rib
removal
History of Present Illness:
54 yo female, h/o [**Hospital3 107887**] AV in [**2137**], CHF, CAD, IVDU, HCV,
presenting from clinic with symptoms of chest pain with
worsening SOB and fatigue.
Past Medical History:
1. Recurrent endocarditis, first aortic then mitral involvement.
On chronic suppressive fluconazole therapy given history of
candidal endocarditis
AVR with St. Jude's valve in [**2137**] c/b embolic CVA and seizure.
MRV possible will be replaced in the future.
2. chronic venous stasis
3. PVD - s/p left fem ant tibial bypass graft with saf vein for
non healig ulcers [**1-/2142**]
4. venous stasis ulcer for 4 years, s/p failed skin graft. .
plastics considering VAC.
5. anemia, iron deficiency
6. h/o UGIB [**1-20**] gastritis with Hct of 23 -
7. IV drug use on methadone
8. Hepatitis C - hep c viral load [**2143**]-over 2 mill.no bx done
9. peripheral neuropathy
10. hearing loss (ad)
11. mild gastritis
12. CAD with 60-70% LAD lesion, rt. dominant - PMIBI on [**11-22**]
showed fixed defects.
Social History:
Has a history of IV heroin use 20 years ago, denies any current
drug use. Denies current tobacco use but used to smoke [**12-20**]
cigarettes/day for 15 years (quit 2 yrs prior). Denies any EtOH
use. She currently lives with her mother and is on disability.
Family History:
N/A
Physical Exam:
VS: 99.0 97/67 76 18 99% RA 43.3 kg
Gen: very thin appearing woman, speech somewhat slowed, NAD,
very pleasant
HEENT: PERRL, OP clear, no LAD, no carotid bruits, no JVD
Neck: no JVD, no bruits
Lungs: CTA bilat, no w/r/r
Heart: rrr, mech s2, 4/6 SEM heard throughout but most
prominently at apex
Abd: soft, nt/nd, nabd
Ext: DP 2+ bilat; no c/c/e. On LLE, ulcer on posterior
ankle/calf, with granulation tissue, no surrounding erythema
Pertinent Results:
[**2146-7-29**] 05:37AM BLOOD WBC-8.8 RBC-3.34* Hgb-9.8* Hct-29.8*
MCV-89 MCH-29.3 MCHC-32.8 RDW-14.0 Plt Ct-521*
[**2146-7-29**] 05:37AM BLOOD PT-25.0* PTT-28.1 INR(PT)-2.5*
[**2146-7-28**] 04:15AM BLOOD PT-22.8* PTT-94.4* INR(PT)-2.3*
[**2146-7-27**] 08:28PM BLOOD PT-21.7* PTT-111.2* INR(PT)-2.1*
[**2146-7-29**] 05:37AM BLOOD Glucose-92 UreaN-12 Creat-0.7 Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
[**2146-7-29**] 05:37AM BLOOD ALT-20 AST-27 LD(LDH)-356* AlkPhos-105
Amylase-158* TotBili-0.2
[**2146-7-26**] CXR:Comparison demonstrates that the multiple linear
atelectasis and local right- sided pleural thickening is related
to the most recent mitral valve replacement. A linear left lower
lobe posterior segment atelectasis that is present now was not
found on the preoperative examination. There is, however, no
evidence of any significant CHF, nor are there any new
parenchymal infiltrates identified.
Brief Hospital Course:
Pre-operative:
CHF: symptoms may be worsening, perhaps [**1-20**] Mitral failing
valve. LV systolic diameter abnormal, necessitating valve
replacement before permanent damage ensues. She was continued
on her lasix/ACEI and remained clinically euvolemic. Valve
replacement as below.
MV: Cardiac surgery was consulted for consideration of
replacement of the mitral valve. She underwent pre-operative
workup, including UA, CXR, CT of the head, and carotid US. All
were normal. CT of the head showed evidence of old stroke. She
was taken for surgery on [**2146-7-19**].
PVD: Vascular surgery was consulted for input on her Left lower
extremity non-healing ulcer. They felt that it was not infected
and recommended continued wet to dry dressing changes. It was
not felt that this would be a contraindication to surgery.
IVDU: Methadone and percocet were continued in-house as per her
outpatient regimen.
CVA: she sustained a stroke during aortic valve surgery and has
been on tegretol since that time for seizure prophylaxis. This
was continued in-house.
Disposition: She was taken for Mitral valve replacement on
[**2146-7-19**] and transferred to the cardiac surgery service at this
time.
Taken to the operating room on [**2146-7-19**], for a mitral valve
replacement ([**Street Address(2) 11599**]. [**Male First Name (un) 923**] mechanical) via right thoracotomy
with rib removal. Post-op, she was transferred to the cardiac
surgery recovery unit in stable condition, on Epinephrine and
neosynephrine gtts. Sedation and vasopressors were weaned off,
but she was slow to wake. On POD # 2, the neurology service was
consulted due to continued decreased responsiveness. EEG at
that time did show some seizure activity, and tegretol was
subsequently increased. MRI showed multiple [**Last Name (un) **] appearing
infarcts, with no acute lesions. She began to awaken over the
next few days, had remained hemodynamically stable, and was
ultimately transferred to the post-op telemetry floor on POD #
5. Anticoagulation was started with heparin, and transitioned
to Coumadin as her INR increased.
A wound care consult was obtained for her foot ulcer, and
Silvadene dressings were recommended. Physical therapy was
begun, but the patient is slow to progress with ambulation and
stability. Her Methadone dose had been decreased during her
post-operative course (from her pre-op dose of 30 mg daily) to
10 mg daily due to her decreased mental status and overall
sedation. She has remained hemodynamically stable, and is ready
for discharge to rehab for physical therapy and progression to
independent ambulation.
Medications on Admission:
Meds:
Coumadin
Enalapril 5 mg
Fe 325
Fluconazole 200 mg [**Hospital1 **]
Lasix 40 mg
Methadone 15 ml (30 mg) daily
Prilosec
Percocet PRN
Folic Acid 1 mg
Thiamine 100 mg
Tegretol 200 mg
.
All: PCN - ?out of body feeling
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
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. Methadone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day for 3
days: 4mg (2 tablets) on [**7-8**], and [**7-31**], then INR check
and dose for target INR 3.0-3.5.
13. Silvadene 1 % Cream Sig: One (1) Topical twice a day for
10 days: to foot ulcer.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
CHF
Mitral regurgitation
Lower extremity non-healing ulcer
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications exactly as prescribed and
described in this discharge paperwork.
[**Month (only) 116**] shower, no bathing for 1 month
no creams, lotions or powders to any incisions
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**First Name (STitle) 437**] in [**1-21**] weeks
with Dr. [**Last Name (STitle) **] in [**1-21**] weeks
[**Doctor Last Name 22939**] Dr. [**Last Name (Prefixes) **] in 4 weeks
Other appointments:
Provider: [**Name10 (NameIs) 9977**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-8-2**]
10:20
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2146-8-2**] 11:20
Completed by:[**2146-7-29**]
ICD9 Codes: 4240, 4280, 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5448
}
|
Medical Text: Admission Date: [**2147-11-12**] Discharge Date: [**2147-11-19**]
Date of Birth: [**2089-12-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic insufficiency, coronary artery disease
Major Surgical or Invasive Procedure:
Redo sternotomy, aortic valve replacement (23mm St. [**Male First Name (un) 923**]
Mechanical), coronary artery bypass grafts x 1 (LIMA-LAD)
History of Present Illness:
this 57 year old white male developerd atrial fibrillation
recently. he ha sa history of mitral valve repair in [**2136**].
Aortic insufficiency was diagnised during the AF workup and
cardiac catheterization on [**10-18**] reveled 50-60% LAD lesion,
normal right sided pressures and LVEF of 50%. He was referred
for surgery. He was admitted early for heparin cross over
preoperatively.
Past Medical History:
mitral valve repair
hypertension
atrial fibrillation
noninsulin dependent diabetes mellitus
gastric reflux
dyslipidemia
Social History:
non smoker
no ETOH
lives with his wife
stocks shelves
Family History:
noncontributory
Physical Exam:
VS: T: 98.8, 150/95 P:68 SR, RR:20 O2 SAT R/A=97%
GENERAL: A&O X3,NAD
CVS: RRR
LUNGS: CTA
ABD: BENIGN
EXTR: BILATERAL LOWER EXTR. EDEMA (R)>(L)
WOUNDS: C/D/I, STERNUM STABLE, NO [**Doctor Last Name **]/CLICK
Pertinent Results:
[**2147-11-15**] 05:20AM BLOOD WBC-12.8* RBC-3.52* Hgb-10.9* Hct-31.0*
MCV-88 MCH-31.0 MCHC-35.2* RDW-15.0 Plt Ct-174
[**2147-11-15**] 05:20AM BLOOD PT-12.9 INR(PT)-1.1
[**2147-11-13**] 01:38PM BLOOD PT-14.2* PTT-29.7 INR(PT)-1.2*
[**2147-11-13**] 12:18PM BLOOD PT-15.9* PTT-26.6 INR(PT)-1.4*
[**2147-11-15**] 05:20AM BLOOD Glucose-118* UreaN-32* Creat-1.4* Na-131*
K-4.5 Cl-96 HCO3-25 AnGap-15
[**2147-11-18**] 03:53AM BLOOD WBC-9.2 RBC-3.45* Hgb-10.5* Hct-30.5*
MCV-88 MCH-30.5 MCHC-34.6 RDW-15.0 Plt Ct-269#
[**2147-11-19**] 08:15AM BLOOD PT-20.7* PTT-58.1* INR(PT)-1.9*
[**Known lastname 80000**],[**Known firstname **] L [**Medical Record Number 80001**] M 57 [**2089-12-2**]
Radiology Report CHEST (PA & LAT) Study Date of [**2147-11-17**] 9:04 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2147-11-17**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 80002**]
Reason: f/u atx
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with s/p redo sternotomy, cabg
REASON FOR THIS EXAMINATION:
f/u atx
Provisional Findings Impression: LCpc FRI [**2147-11-17**] 10:57 AM
Right basal atelectasis increased, left basal atelectasis
improved. No
pneumothorax. No overload.
Final Report
CHEST, PA AND LATERAL
REASON FOR EXAM: 57-year-old man with status post redo
sternotomy, CABG.
Follow up.
Since [**2147-11-6**], right Swan-Ganz was removed in this
patient with prior
sternotomy for CABG, AVR, and MVR.
Right basal atelectasis increased but left basal atelectasis
improved. Minimal
bilateral pleural effusion persist. There is no volume overload
and no
pneumothorax. The cardiomediastinal silhouette and hilar
contours are
otherwise unchanged.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2147-11-17**] 12:57 PM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 80000**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80003**] (Complete)
Done [**2147-11-13**] at 8:35:08 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2089-12-2**]
Age (years): 57 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Atrial
fibrillation. Chest pain. Coronary artery disease. H/O cardiac
surgery. Hypertension. Mitral valve disease. Shortness of
breath.
ICD-9 Codes: 402.90, 427.31, 786.05, 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2147-11-13**] at 08:35 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *7.5 cm <= 5.2 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: *4.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.1 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Findings
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal regional LV systolic function.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Moderate to severe (3+) AR.
MITRAL VALVE: Mitral valve annuloplasty ring. Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
Conclusions
PRE BYPASS:
The left atrium is markedly dilated. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. Moderate to severe (3+) aortic
regurgitation is seen. A mitral valve annuloplasty ring is
present. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
POST BYPASS:
Left and right ventricular function is preserved. The aorta is
intact. A mechanical aortic valve is in good position with an
appropriate degree of regurgitation . The aortic valve peak and
mean gradients are approximately 35 and 20 mmHg. The remainder
of the study is unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results at the time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Known firstname **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2147-11-13**] 17:43
?????? [**2142**] CareGroup IS. All rights reserved.
Brief Hospital Course:
[**11-13**] Mr.[**Known lastname **] [**Last Name (Titles) 1834**] Redosternotomy/ CABGx
1(Lima->LAD)/AVR(#[**Street Address(2) 11688**].[**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **])with Dr.[**Last Name (STitle) **]. Please
refer to the operative note for further details. He was
transferred to the CVICU intubated and sedated requiring
epinephrine to optimize CO. He awoke neurologically intact and
was weaned off epi and extubated.All lines and tubes were
discontinued in a timely fashion. He transferred to the SDU on
POD#1 for further recovery and monitoring. Anticoagulation was
resumed with Cumadin and a Heparin bridge. Postoperatively he
remained in sinus rhythm. He continued to progress and on POD#6
when his INR was therapeutic at 2.1, he was discharged to home
with VNA. He was advised to resume INR/Coumadin dosing with his
cardiologist Dr.[**Last Name (STitle) 5686**]. All neccessary follow-up
appointments were advised.
Medications on Admission:
Metformin 1000(1)
Triamterene/HCTZ 75/50(1)
Toprol Xl 50
Glipizide 10
Amiodarone 400
Lisinopril 5
Coumadin 5mg daily/8mg on Sundays.
prilosec prn
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Ranitidine HCl 150 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO BID (2
times a day).
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*0*
3. 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*
4. Oxycodone-Acetaminophen 5-325 mg [**Last Name (STitle) 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 [**Last Name (STitle) 8426**](s)* Refills:*0*
5. Atorvastatin 40 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY
(Daily).
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
6. Glipizide 10 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY (Daily).
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
7. Metformin 500 mg [**Last Name (STitle) 8426**] Sig: Two (2) [**Last Name (STitle) 8426**] PO DAILY (Daily).
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
8. Metoprolol Tartrate 25 mg [**Last Name (STitle) 8426**] Sig: 0.5 [**Last Name (STitle) 8426**] PO BID (2
times a day).
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
9. Amiodarone 200 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY
(Daily).
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
10. Warfarin 5 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 8426**] PO once a day.
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
11. Furosemide 20 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times
a day) for 7 days.
Disp:*14 [**Last Name (Titles) 8426**](s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
aortic insufficiency
coronary artery disease
dyslipidemia
atrial fibrillation
noninsulin dependent diabetes mellitus
hypertension
s/p mitral valve repair
gastric reflux
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds in a day or 5
pounds a week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 80004**] [**Name (STitle) **] in [**1-18**] weeks ([**Telephone/Fax (1) 39260**])
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Please call for appointments
Resume INR/Coumadin dosing daily with Dr. [**Last Name (STitle) 5686**]
Completed by:[**2147-11-19**]
ICD9 Codes: 4241, 4019, 2724
|
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|
Medical Text: Admission Date: [**2154-4-8**] Discharge Date: [**2154-4-15**]
Service: VSU
CHIEF COMPLAINT: Acute ischemic right lower extremity.
The patient was initially evaluated in the emergency room. A
vascular consult was requested. The patient had baseline labs
obtained and Mucomyst was instituted and IV hydration was
begun.
HISTORY: This is a [**Age over 90 **] year old female who presents to the
emergency room with right foot pain that started at 7 a.m. on
[**2154-4-8**]. The patient was awakened secondary to the pain
and denies any previous episodes of right leg pain. She
admits to rest pain this morning and was unable to ambulate
without assistance. She denies any constitutional symptoms.
She denies chest pain, shortness of breath. Her last meal was
coffee and toast at noon. The patient is admitted to the
vascular service for urgent thrombectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Atenolol 25 mg daily, Lasix 40 mg
daily, Tums p.r.n., Biotin 1000 mg daily, Zocor and
Zaroxolyn.
ILLNESSES: History of congestive heart failure, right bundle
branch block with a history of tuberculosis, history of
degenerative joint disease, hypothyroidism, history of carpal
tunnel, history of cataracts, history of allergic rhinitis,
history of UTI, history of intermittent right leg swelling,
history of endocarditis 20 or 30 years ago. She denies any
history of atrial fibrillation.
PAST SURGICAL HISTORY: Includes abdominal surgery for
inflammation of the "stomach" 40 years ago in [**Country 532**].
SOCIAL HISTORY: She is Russian-speaking. She is a nonsmoker
and nondrinker.
PHYSICAL EXAMINATION: Pulse rate is 86, respirations 18,
oxygen saturation 100% on room air. Blood pressure is 154/68.
General appearance is a pleasant [**Age over 90 **] year old female in no
acute distress. Chest examination - lungs are clear to
auscultation. The heart is a regular rate and rhythm. No
murmurs, rubs or gallops. There is no JVD. The abdomen is
soft, nontender, nondistended, well-healed midline incision
above the umbilicus. Extremity exam shows on the left a
palpable DP and PT and palpable popliteal artery with
dopplerable DP, PT and popliteal. On the right, the DP and PT
are absent both by Doppler and palpation. The foot is cold to
palpation. The popliteal artery is faintly palpable. The
femoral pulse on the right is faintly palpable. The patient's
motor and sensory is intact.
HOSPITAL COURSE: The patient was initially seen in the
emergency room. Vascular was consulted. The patient underwent
an urgent arteriogram and a right femoral thromboembolectomy
with a patch angioplasty. She tolerated the procedure well.
She was transferred to the PACU in stable condition with a
dopplerable right DP and absent right PT. Postoperatively,
the patient remained hemodynamically stable. Her hematocrit
was 43, BUN 48, creatinine 1.1. Total CKs are 283, MBs 9,
troponin 0.1. Troponin index was 83. The patient was started
on a heparin drip for a goal PT of 45. The patient was
transferred to the VICU for continued monitoring and care.
There were no overnight events. Cardiology was requested to
see the patient. The patient was also followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], her medical physician. [**Name10 (NameIs) **] Cardiology service
recommended an echocardiogram, preferably a TEE, to rule out
intracardiac source of thrombus. They did not feel that she
had an acute MI. They felt that the total CKs were related to
muscle injury. An echocardiogram was obtained. The ejection
fraction was greater than 60%. The left atrium was of normal
size. There was no left atrial mass or thrombus. The left
ventricle had moderate left ventricular hypertrophy with
normal left ventricular cavity size and normal regional LV
systolic function, overall normal ejection fraction greater
than 55%. The right side was unremarkable. There was no
evidence of intracardiac thrombus. The patient on
postoperative day 2 experienced rapid atrial fibrillation
requiring beta blockade and amiodarone IV with stabilization
of her blood pressure. There was a long discussion with
Cardiology regarding anticoagulation given the patient's
intermittent atrial fibrillation. The surgical service felt
that the patient should be anticoagulated on a long term
basis. IV heparin was continued and Coumadinization was
instituted. The goal INR is [**2-7**]. The patient will remain in
the hospital until fully anticoagulated and will be
discharged to home and primary care physician will monitor
her INRs and adjust her Coumadin accordingly. Physical
therapy will evaluate the patient for home safety. Final
recommendations were pending at the time of dictation.
DISCHARGE INSTRUCTIONS: The patient should follow up with
Dr. [**Last Name (STitle) **] in 2 weeks' time. She should follow up with her
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], upon discharge
for INR monitoring and Coumadin dosing adjustment. She should
call the physician if she has any reoccurrence of right leg
pain or leg or foot discoloration. She should call her
primary care physician's office if she develops gum bleeding
and easy bruising while being treated with Coumadin.
DISCHARGE MEDICATIONS: Acetaminophen 650 mg q.4-6h. p.r.n.
and this is in the liquid form, amiodarone 400 mg b.i.d.,
follow up with her primary care physician for adjustment of
dosing, warfarin 2 mg at bedtime, metolazone 5 mg every
Tuesday.
DISCHARGE DIAGNOSES:
1. Right femoral embolus status post embolectomy with patch
angioplasty.
2. Atrial fibrillation, anticoagulated.
3. History of congestive heart failure, compensated.
4. History of hyperlipidemia, on Zocor.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2154-4-11**] 13:00:42
T: [**2154-4-11**] 14:09:42
Job#: [**Job Number 103002**]
ICD9 Codes: 2449
|
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|
Medical Text: Admission Date: [**2126-12-7**] Discharge Date: [**2127-1-16**]
Date of Birth: [**2067-1-31**] Sex: F
Service: CT [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This a 59 year old female with
diabetes mellitus and known coronary artery disease who was
cathed in [**Month (only) 547**] at [**Hospital6 **]. Cath at that time
showed severe three vessel coronary artery disease, but
patient was elected to be treated medically due to poor
targets. Since her cardiac catheterization she had two
episodes of heart failure and presented to [**Hospital1 346**] emergency department on [**2126-12-7**], with an acute MI. Cardiac catheterization was
performed on [**2126-12-7**], the day of admission, which
revealed left main coronary artery disease with 30% stenosis,
diffuse disease of the left anterior descending with 80%
midocclusion. Left circumflex was occluded. Mid-right
coronary artery with 40% stenosis and diffuse disease in the
posterior descending artery. An intra-aortic balloon pump
was placed at that time. Patient was referred to the cardiac
surgery service for coronary artery bypass grafting. Patient
underwent coronary artery bypass grafting times three on
[**2126-12-10**]. Saphenous vein graft to distal left
anterior descending, saphenous vein graft to obtuse marginal,
saphenous vein graft to right posterolateral. Total
cardiopulmonary bypass time was 113 minutes. Total clamp
time was 59 minutes. Patient was transferred in normal sinus
rhythm at 82 beats per minute, hemodynamically stable, to the
cardiac surgery recovery unit on 0.3 mcg per kg per minute of
milrinone, 1.2 mcg per kg per minute of Neo-Synephrine, 10
mcg per kg per minute of propofol and an insulin drip at 2
units per hour.
PAST MEDICAL HISTORY: Significant for coronary artery
disease; type 1 diabetes mellitus complicated by diabetic
retinopathy, diabetic nephropathy and diabetic neuropathy;
chronic renal insufficiency with baseline creatinine of 2.0;
peripheral vascular disease status post right fem-[**Doctor Last Name **]
surgery.
MEDICATIONS ON ADMISSION: Humulin 25/10, Lasix 40 mg q.d.,
atenolol 100 mg q.d., aspirin, Imdur 30 mg p.o. q.d., Ambien
10 mg p.o. q.d., Lipitor 10 mg p.o. q.d., Accupril 10 mg p.o.
q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient does not have a history of
tobacco use nor does patient have a history of alcohol use or
abuse.
LABORATORY DATA: White count 11.6, hematocrit 27.8, platelet
count 106. Sodium 139, potassium 5.2, BUN 46, creatinine
1.2, glucose 201. Magnesium 2.7.
HOSPITAL COURSE: The patient was extubated on [**2126-12-11**], which was postoperative day one. On postoperative day
one patient had a low grade temperature of 100.8 with t-max
of 101.7, with an intra-aortic balloon pump still at 1:1, on
Neo-Synephrine at 3.5, off milrinone. Physical exam benign.
Plan was to wean Neo-Synephrine and wean the balloon pump.
On postoperative day two patient still with low grade
temperature of 100.2 and t-max of 101.7. Still on
Neo-Synephrine at 0.9. Intra-aortic balloon pump at 1:2.
White count 9.8, hematocrit 24.5, platelet count 80. Sodium
139, potassium 4.7, BUN 47, creatinine 1.4, glucose 130.
Physical exam still remained benign. Patient was awake and
alert with good cardiac index with the intra-aortic balloon
pump at 1:2. Plan was to change the balloon pump to 1:3 in
the morning and to possibly discontinue the intra-aortic
balloon pump and subsequently wean Neo-Synephrine. Plan was
also to transfuse one unit for hematocrit of 24.5.
On postoperative day three patient was afebrile, however,
t-max of 101.3 which was at 6:00 o'clock p.m. Patient was
still on milrinone and Neo-Synephrine with an index of 2.05,
making good urine. Chest tube was putting out minimal
amount. White count 14.1, hematocrit 28, platelet count 79.
Sodium 137, potassium 4.5, BUN 53, creatinine 1.7. Physical
exam remained benign. Over the last 24 hours patient was in
and out of a-fib and a-flutter throughout the night for which
she was placed on amiodarone. Currently in atrial
fibrillation at 77 beats per minute. Cardiology came by to
see patient for atrial fibrillation. They recommended to
possibly taper off milrinone which may be exacerbating the
situation. They also recommended oral amiodarone versus IV
amiodarone and to transfuse patient for low hematocrit.
On postoperative day four patient now in normal sinus rhythm,
however, with decreased urine output, on dobutamine at 4.5,
Neo-Synephrine at 1.4, amiodarone and insulin. Afebrile.
Normal sinus rhythm at 88 beats per minute. Otherwise vital
signs stable. White count 14.2, hematocrit 32, platelet
count 117. Creatinine up from 1.7 to 1.9 with BUN of 55. On
physical exam patient had decreased breath sounds at both
bases with 1+ edema of the lower extremities. Patient was
alert with no deficits.
On postoperative day five patient still on dobutamine at 2.5,
insulin, milrinone at 0.5, Neo-Synephrine at 0.25. Twenty
four events included an episode of pulmonary edema. Patient
afebrile in normal sinus rhythm at 99 beats per minute.
Vital signs otherwise stable. White count 14.4, hematocrit
28.1, platelet count 125. Creatinine increasing from 1.9 to
2.1. On physical exam lungs had coarse breath sounds
bilaterally with bibasilar crackles. Patient with adequate
urine output after administering Lasix three times. Patient
was also noted to be confused, requiring frequent
reorientation. Heart failure team came by to see patient at
which time they recommended that if blood pressure decreases
or mean arterial pressure decreases to less than 60, they
would add vasopressin. They also recommended Zaroxolyn 2.5
mg p.o. times one, to start a Lasix drip and can increase up
to 20 mg drip per hour. If Lasix does not work, to change to
Bumex 2 mg IV b.i.d., increasing up to 4 mg IV b.i.d. To
also increase milrinone to 0.6 if MAO2 is in the 50s.
Renal came by and saw patient on [**12-16**] at which time
they recommended sending urine sodium, creatinine, urea and
protein to assess pre-renal and ATN parameters. They also
recommended a renal ultrasound to determine the etiology of
the underlying renal disease. They also planned to initiate
CVVHD given the significant CHF necessitating 100%
nonrebreather with poor response to diuretics. They also
said that we could discontinue the Lasix drip.
On postoperative day six patient afebrile in normal sinus
rhythm, alert and awake with increasing white count from 14.4
to 19.4, hematocrit stable at 31. Creatinine was 2.3.
Physical exam unchanged aside from 2+ pitting edema in all
extremities. Patient now on CVVH for fluid overload and
renal insufficiency. On milrinone, amiodarone with cardiac
index of 2.74, now making urine so Lasix was discontinued.
Patient was reintubated on [**12-16**] at the request of the
SSCU staff for respiratory failure.
On postoperative day seven patient still afebrile in normal
sinus rhythm at 94, intubated on SIMV and pressure support
500 and 12 breathing 5 above the vent 80% FIO2 with adequate
urine output. White count coming down from 19.4 to 14.5 with
stable hematocrit. Creatinine was 2.2. Extremities will
less edema. Otherwise exam unchanged. Plan is to continue
with CVVH and to continue amiodarone and milrinone. Renal
came by and saw patient on [**12-17**] at which time they
recommended to continue patient on milrinone to optimize
cardiac function. To continue CVVH. They also recommended
to recheck sodium in the afternoon for patient's
hyponatremia. If still low, to consider changing replacement
fluids to normal saline. To continue anticoagulation with
heparin 500 units per hour with a goal PTT of 50 to 80.
On postoperative day eight patient with low grade temperature
of 99.9, still intubated with rising white count to 17.5,
stable hematocrit. Creatinine was 1.8. On physical exam
patient was intubated and sedated with coarse upper airway
noise and decreased edema in the lower extremities. Plan was
to begin weaning milrinone. To continue CVVH.
On postoperative day nine 24 hour events included CVVH being
clotted. Patient afebrile with cardiac index of 2.2, in
sinus rhythm at 78, good urine output, still intubated and
sedated with minimal lower extremity edema. Plan was to try
to attempt to wake up patient and to attempt extubation. To
continue milrinone, Neo-Synephrine and Pitressin. The heart
failure team came by again at which time they recommended to
continue present pressor support and to check lactate and to
continue CVVHD. Renal came by and saw patient and restarted
CVVH which was clotted overnight. Restarted it at 9:00 a.m.
On [**12-19**] patient underwent placement of a right
subclavian Cordis and Swan-Ganz.
On postoperative day 10 patient on vancomycin and levo as
well as vasopressin, Neo-Synephrine, milrinone and insulin.
Afebrile, in sinus rhythm at 65. Still intubated and
sedated. On physical exam the left foot appeared more
mottled than normal and cool with a faintly dopplerable DP
pulse and palpable pulse on the right DP. Plan was to
attempt to wean Pitressin and try to extubate. Continue
CVVH. To continue levo for patient's upper respiratory tract
infection, as patient grew out Neisseria in sputum, and
vancomycin for an infected right IJ site. Extubation was
attempted on the 15th, however, anesthesia was called to
reintubate patient for respiratory failure after extubation
trial.
On postoperative day 11 patient still on vanco and levo as
well as vasopressin, milrinone, insulin, Neo-Synephrine.
Afebrile, in normal sinus rhythm at 82, intubated, on CVVHD
with creatinine of 1.5 and white count of 14.6 and stable
hematocrit of 27.5. On physical exam the neck was very
erythematous with purulent right IJ site.
On postoperative day 12 still on the same drips. Twenty four
events included increasing CVVH to 100 per hour. Patient was
afebrile with stable output and index. Still intubated with
decreased white blood cell count of 11.7, stable hematocrit
and creatinine of 1.5. On physical exam left toe was mottled
and cold, otherwise unchanged.
On postoperative day 13, 24 hour events included CVVH being
clotted overnight. Patient still on the same drips with an
index of 2.0 and CVP of 14. Still intubated. Physical exam
remained unchanged. White count down to 10.7, hematocrit
stable with creatinine of 1.5. Plan was to continue to watch
hematocrit. Patient was transfused one unit of packed red
blood cells bringing hematocrit up to 27. Plan was also to
put patient on Nepro tube feeds. Renal evaluated patient on
[**12-23**] at which time they recommended sending a
urinalysis for patient's hematuria and for patient's
metabolic acidosis which was improved after antibiotics.
They wanted us to follow patient's ABGs and to continue to
transfuse red blood cells, increase intravascular volume with
a goal of 1 to 2 liters negative a day. That same day a left
femoral central venous Quinton catheter was placed with CVVH
flow now being excellent through this new catheter since
there was a clot in the IJ catheter. Renal recommended
keeping PTT at 60 to 80, however, closer to 80 to avoid
clotting again.
On postoperative day 14 patient on day six of vanco and levo.
Still on milrinone, Neo-Synephrine, Pitressin, propofol,
still intubated and sedated with a rising white count of
13.3, stable hematocrit of 29.9, creatinine of 1.4. Physical
exam remained unchanged. Plan was to continue tube feeds.
Patient was v-paced overnight due to slow junctional rhythm.
Possible discontinuation of patient's amiodarone. Continue
vanco and levo for Enterobacter and E.coli which grew out of
the cultures. To continue to watch patient's hematocrit.
On postoperative day 15 patient in normal sinus rhythm,
afebrile, still intubated and sedated with stable white count
and hematocrit. Slightly hyponatremic at 131 with BUN of 27,
creatinine of 1.3. Physical exam unchanged. Plan was to
continue levofloxacin for the URI and the Enterobacter in
blood and sputum. Renal came by and saw patient at which
time they noted that patient responded to 40 mg IV of Lasix
with a decreased Neo-Synephrine drip today. They recommended
adding Lasix IV q.d. and b.i.d. and to decrease the amount
removed by CVVH to transition her off CVVH. They recommended
increasing intravascular volume and keeping hematocrit
greater than 30.
On postoperative day 16 patient with low grade temperature of
99.5, still in sinus rhythm at 78. Stable white count of
12.1 with hematocrit of 27. BUN and creatinine stable.
Physical exam unchanged. On milrinone and Pitressin with
good cardiac index. Plan was to have a trial off CVVH today
and to increase Lasix to increase patient's urine output.
Plan was also to transfuse one unit of packed red blood cells
and to continue levofloxacin. Renal again saw patient on
[**12-26**] at which time they recommended to discontinue
heparin and to discontinue CVVH machine. To administer
patient 40 to 60 mg IV of Lasix b.i.d. to keep patient even
and to continue with blood transfusion.
On postoperative day 17 patient with low grade temperature of
100.6, in sinus rhythm at 79. Still intubated, opening eyes.
Physical exam remained unchanged. White count of 13.8,
hematocrit stable at 30.5. BUN 32, creatinine 1.4. Still on
milrinone, Pitressin and propofol. Plan was to continue tube
feeds and erythromycin. To continue with Lasix. Patient
with good urine output without CVVH. To continue levo for
Enterobacter and E.coli.
On postoperative day 18 patient still with low grade
temperature of 100.4, in sinus rhythm at 95, index of 3.29.
White count increasing to 15.2 with stable hematocrit of
31.8. BUN 43, creatinine 1.6. On milrinone and propofol
now. Physical exam remained unchanged. Patient still
intubated and following commands. Plan was to possibly wean
milrinone and check the mixed venous. Continue Lasix.
Patient still with good urine output. Plan was to also pull
the Quinton catheter because of patient's rising white count
and low grade temperature.
On postoperative day 19, day 11 of levofloxacin, with a low
grade temperature of 100.8 and t-max of 102, in sinus rhythm
at 89, now just on insulin and propofol with an index of
2.81. Still intubated, following commands, in no apparent
distress with a rising white count of 19.7 and stable
hematocrit of 32.4. Physical exam remained unchanged. Plan
was to check blood cultures, urine cultures, stool cultures,
chest x-ray and to pull the Swan and the left subclavian line
due to patient's spike in temperature.
On postoperative day 20, day 12 of levofloxacin, with low
grade temperature of 99.7, t-max of 101.3, in sinus rhythm at
99 with rising white count now at 24.4, stable hematocrit
32.4 with stable platelet count of 376. BUN 51, rising
creatinine of 1.8. Patient still intubated, in no apparent
distress. Physical exam unchanged. Gram negative rods were
found in patient's sputum. Chest x-ray was going to be
checked. Patient still with good urine output on Lasix drip.
Sputum with gram negative rods on levofloxacin. Plan is to
add vancomycin. Other cultures were pending.
On postoperative day 21, day 13 of levofloxacin and day two
of restarted vancomycin, with t-max of 102, t-current of
99.3, in sinus rhythm at 84. Still intubated, however, awake
and alert. Physical exam remained unchanged. White count
down to 17.7, hematocrit stable. BUN 68, creatinine rising
at 2.2. Plan was to try to extubate patient and to continue
Promote tube feeds. Patient had adequate urine output. Plan
was to continue to check creatinine. ID recommended adding
fluconazole. Thoracic surgery came by to consult patient to
evaluate the airway. They stated that patient had no
symptomatic edema and they stated that we would perform a
T-piece trial to rest patient overnight with the possibility
of extubating patient in the morning. The following morning
there was an excellent cuff fit. Patient went 1 1/2 hours on
T-piece trial yesterday and extubated without problems on
[**2127-1-1**].
On postoperative day 22, day 14 of levofloxacin, day three of
vancomycin, day two of fluconazole, patient with low grade
temperature of 99.5, currently afebrile, in sinus rhythm at
75. Awake and alert, answering questions. White count 15.1,
stable hematocrit. BUN was 79, creatinine 2.1. Physical
exam remained unchanged.
On postoperative day 23 patient afebrile, in sinus rhythm at
87. White count down to 13.4, hematocrit stable. BUN 72,
creatinine 1.7. Plan was to start patient on p.o. diet and
to possibly discontinue Lasix and to continue current
antibiotic regimen.
On postoperative day 24, day 16 of levofloxacin, day five of
vancomycin, day four of fluconazole, in normal sinus rhythm
at 82, afebrile. White count 12.8, hematocrit 27.7. BUN 76,
creatinine 1.7. Physical exam remained unchanged. Plan was
to have a Jocelin consult for patient's diabetes management.
Jocelin came by to see patient at which time they recommended
patient to follow up at Jocelin for diabetic care. Jocelin
had an extensive discussion with patient's husband and
patient. They arrived at the decision to change to glargine
and Humalog.
On postoperative day 25 patient now on day six of vancomycin,
in sinus rhythm at 93, afebrile with white count of 12.6,
stable hematocrit. BUN 69, creatinine 1.8. Resting
comfortably. Physical exam benign. Plan was to continue
vancomycin for two weeks. Jocelin came by to see patient
again at which time they recommended continuing IV insulin
and adjust the rate from now until pre-supper and then before
supper to check blood glucose and to give the sliding scale
of Humalog. To increase Lantus to 20 units q.h.s. To use
the new Humalog scale.
On postoperative day 26 patient on vancomycin.
Hemodynamically stable. Physical exam unchanged. Patient
now on fluconazole three out of five days.
On postoperative day 27 patient on day seven of 14 of
vancomycin and day four of five of fluconazole. Patient
afebrile. Sinus tach at 101. Physical exam remained benign
with stable hematocrit and stable white count. Jocelin came
by and saw patient again on [**1-5**] at which time they
recommended to continue Lantus at 25 units q.h.s. To check
3:00 o'clock finger stick blood glucose. To be on guard for
lows. To increase pre-meal Humalog sliding scale and to
watch BUN and creatinine closely with start of ACE inhibitor
post MI. Hem/onc came by and saw patient on [**1-6**] at
which time they felt that patient's condition was most
consistent with reactive thrombocytosis which may also be due
to iron deficiency, although the rather abrupt onset of the
rise in the platelet count was not consistent with that.
They thought that since these are normal platelets, the risk
of thrombosis is very low and is not a concern until the
platelet count exceeds 1,000,000. They also felt that one
issue is that in those patients with platelet counts this
high, which is over 400,000, serum potassium level may be
falsely elevated. Therefore if serum potassium came back
elevated, they would recommend that this be followed up with
plasma potassium before treating. They said they would
continue to follow patient during her hospitalization.
On postoperative day 28, on day eight of 14 of vancomycin and
day five of five of fluconazole, 24 events included atrial
fibrillation versus atrial tachycardia overnight. Started on
Lopressor. With a low grade temperature of 100. Physical
exam remained unchanged. White count 12.7, stable
hematocrit. BUN 40, creatinine 1.3. Plan was to continue
Lopressor and to consider restarting amiodarone. To continue
antibiotics.
On postoperative day 29, [**1-8**], anesthesia was called to
see patient to reintubate patient for respiratory distress
and confusion. Patient was reintubated without
complications. Pulmonary came by to see patient for the
reintubation at which time they recommended to continue pip,
tazo and vanco, to obtain sputum for gram stain and culture,
to obtain chest CT angio as planned. To cycle cardiac
enzymes and repeat EKG. To repeat a surface echo and when
extubated to obtain a speech and swallow evaluation for
aspiration risk. CT angio of the chest was reviewed. There
was no clear consolidation. There was a large pleural
effusion, right greater than left and a tiny PE noted. The
assessment leaned more toward decompensation and CHF.
Additional recommendations by pulmonary included treating for
CHF and checking daily weights. A therapeutic thoracentesis
and to send the fluid for pH, LDH, protein, cell count with
diff and culture.
On postoperative day 30, 24 hour events included transfusion
of two units of packed red blood cells. CT of the chest and
abdomen. Intubation for CHF. Panculturing. Pulmonary and
general surgery consults. Patient afebrile, in normal sinus
rhythm at 70. Still intubated, sedated, but arousable.
Physical exam remained unchanged. White count 17.7, stable
hematocrit 34.1. Plan was to drain the pleural effusion
today and to try to work toward extubating patient. GI to do
percutaneous cholecystostomy today and to start tube feeds
once stable. To follow up BUN and creatinine after dye load.
To continue vanco and Zosyn. General surgery came by to see
patient on [**1-9**] at which time they stated that they
could not rule out calculus cholecystitis. They recommended
to drain the gallbladder with a catheter through the liver.
A cholecystostomy tube 8 French was inserted under ultrasound
guidance on [**1-9**] and approximately 60 cc of thin bile
was aspirated. It was sent for culture and sensitivity. The
plan was to leave this in for six weeks even if it stopped
draining. Pulmonary came by to see patient again on [**1-9**] at which time they recommended to decrease FIO2 to 40%. To
perform thoracentesis of the right sided effusion. To send
pleural fluid for LDH, protein, cell count and culture. To
check troponin and CK.
On postoperative day 31, day 11 of 14 of vancomycin and day
three of Zosyn, 24 hour events included percutaneous
cholecystostomy, PICC being removed, bilateral pleural
effusion drainage, right draining 600, left draining 350.
Propofol drip. White count down to 15.7, stable hematocrit.
BUN 30, creatinine 1.5. Physical exam remained unchanged.
On postoperative day 32 physical exam remained unchanged.
White count down to 11.5, hematocrit stable. Creatinine up
to 1.8. Plan was to restart the standing Lasix, continue
Lopressor and to possibly extubate patient today with the
possibility of trach placement.
On postoperative day 33, day 13 of 14 on vancomycin, day four
of Zosyn, patient with low grade temperature of 99.6, still
intubated, however, comfortable. Physical exam unchanged.
White count and platelet count and hematocrit unchanged. BUN
42, creatinine 1.9. Plan was to possibly perform a trach
tomorrow and to possibly discontinue the chest tubes. Due to
the rising white blood cell count and low grade temperature,
to possibly panculture patient again.
On postoperative day 34, day 14 of 19 of vancomycin and day
six of Zosyn with a low grade temperature of 100.4. Plan was
to trach patient today. On [**1-13**] patient underwent
percutaneous tracheostomy without complications.
On postoperative day 36 patient's condition remained
unchanged. NPH of 10 b.i.d. was started. Stable hematocrit
and white count. BUN 43, creatinine 1.5. Speech and swallow
came by and saw patient on the 11th at which time they stated
that patient is not a good candidate for a video swallow
study to rule out aspiration because patient presents without
overt signs and symptoms of aspiration at the bedside.
Recommendations were to limit the wear schedule of the
Passy-Muir valve to every four hours for no more than 15
minutes trial. Monitor O2 sats and patient's respirations.
Maintain tube feeds. Remain NPO. Obtain a video swallow
study tomorrow to rule out aspiration.
The remainder of the chart will be dictated upon discharge of
the patient.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 182**]
MEDQUIST36
D: [**2127-1-16**] 15:38
T: [**2127-1-16**] 17:39
JOB#: [**Job Number 41936**]
ICD9 Codes: 5185, 486, 5849, 5990
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5451
}
|
Medical Text: Admission Date: [**2101-6-1**] Discharge Date: [**2101-6-10**]
Date of Birth: [**2048-5-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Diarrhea, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, this is a 53yoM with h/o EtOH abuse, depression w/ SI
who was admitted to the MICU on [**2101-6-1**] for guiaic + stool,
diarrhea, fevers, and hypotension. In the ED, he was
aggressively fluid resuscitated, NG lavage returned coffee
grounds. GI was [**Date Range 4221**] and decided no emergent scope was
indicated; started octreotide and pantoprazole. For fever,
elevated WBC, and hypotension, he was treated empirically with
Vanc/Zosyn.
.
In the ICU, the patient's BP improved after fluid resuscitation.
For profuse diarrhea, stool studies returned C.diff +. CT Abd
showed severe pancolitis. Hct fell to 23.9 on [**6-2**], and he was
transfused 2U PRBC. Since yesterday, Hct has stabilized ~ 30.
Stool has turned from black to brown, no longer guiaic +. He
remains on [**Hospital1 **] pantoprazole. Last fever was yesterday. GI has
plans for inpatient EGD on Monday and outpatient colonoscopy.
Last EGD at [**Hospital1 2177**] in [**4-15**] showed gastritis and esophagitis in the
lower 1/3 esophagus, no varices. Patient's antibiotics have been
tapered to IV flagyl and PO vancomycin. He is currently
tolerating clears. SW has been following the case and has
arranged for his house to be cleaned on Tuesday (apparently,
large amts of C.diff + stool in home) and patient has expressed
intermittent interest in substance abuse program. Per MICU
resident, patient last scored on CIWA yesterday.
.
Currently, VS 99.2 103 117/75 96% on RA. The patient is A&Ox3.
He has extensive cuts and brusing on body. Abdomen is soft,
nontender. Flexiseal in place with liquid brown stool. He denies
abdominal pain. He denies SI.
.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
nausea, vomiting, constipation, dysuria, hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
Depression w/ SI (recent admit to psych from [**4-26**] to [**4-29**])
Anemia/leukopenia
EtOH abuse
Social History:
Admits to drinking heavily (~[**2-6**] pint vodka/day); last drink 3
days PTA. No tobacco or illicits. Lives by himself.
Family History:
Father committed suicide.
Physical Exam:
On transfer to floor:
GENERAL - disshevled appearing, sutured L eyebrow lac, R
forehead bruise
HEENT - NC/AT, anisocoria - longstanding, EOMI, sclerae
anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - pneumoboots in place, WWP, extensive bruising on
legs, no c/c/e, 2+ peripheral pulses (radials, DPs)
GU/GI: foley and flexiseal in place
NEURO - awake, A&Ox3, CN II-XII intact, muscle strength 4/5
throughout (RN reports wobbly getting into chair), normal
cerebellar exam
Access: 4 PIVs
.
ON discharge:
Pertinent Results:
[**2101-6-1**] 06:40PM BLOOD WBC-23.3*# RBC-3.92* Hgb-11.1* Hct-33.6*
MCV-86 MCH-28.4 MCHC-33.0 RDW-17.6* Plt Ct-348#
[**2101-6-1**] 06:40PM BLOOD Neuts-92.6* Lymphs-5.0* Monos-1.9*
Eos-0.1 Baso-0.4
[**2101-6-1**] 06:40PM BLOOD PT-16.8* PTT-30.4 INR(PT)-1.5*
[**2101-6-3**] 03:18PM BLOOD Ret Aut-0.3*
[**2101-6-1**] 06:40PM BLOOD Glucose-132* UreaN-13 Creat-1.1 Na-135
K-3.3 Cl-97 HCO3-21* AnGap-20
[**2101-6-1**] 06:40PM BLOOD ALT-8 AST-13 CK(CPK)-65 AlkPhos-72
TotBili-0.9
[**2101-6-1**] 06:40PM BLOOD Lipase-12
[**2101-6-1**] 06:40PM BLOOD cTropnT-<0.01
[**2101-6-1**] 06:40PM BLOOD Albumin-3.4* Calcium-9.9 Phos-0.6*#
Mg-1.8
[**2101-6-2**] 06:25AM BLOOD VitB12-1244* Folate-7.5
[**2101-6-1**] 06:40PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2101-6-1**] 06:54PM BLOOD Glucose-131* Lactate-1.5 Na-134* K-3.4*
Cl-97* calHCO3-21
[**2101-6-1**] 06:54PM BLOOD freeCa-1.26
CT HEAD [**2101-6-1**]
1. No acute intracranial hemorrhage or fractures.
2. Mild bifrontal soft tissue swelling.
CXR [**2101-6-1**]
Normal chest.
CT ABD/PELVIS [**2101-6-2**]
1. Severe pancolitis with imaging features consistent with the
provided
history of Clostridium difficile. No radiographic findings of
obstruction,
perforation, or other complication noted.
2. Cholelithiasis.
3. Trace right pleural effusion and mild-to-moderate amount of
intra-
abdominal/pelvic ascites. Mild soft tissue anasarca.
Brief Hospital Course:
53yoM with h/o EtOH abuse, depression w/ SI who was admitted to
the MICU on [**2101-6-1**] with hypotension, C.diff colitis and an
upper GI bleed.
.
Severe C.difficile: Treated initially with oral vancomycin 500mg
q6H and flagyl, then narrowed to oral vancomycin 125mg which
will be continued for a total of 3 weeks. He initially required
a flexiseal due to copious stool output, but this was
discontinued on [**2101-6-8**] and he remained continent of stool. He
tolerated a regular diet. His house was found to have residual
stool and was cleaned by his case manager prior to discharge.
.
UGIB/Esophagitis: EGD was completed which showed esophagitis
attributable to his chronic alcohol abuse. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 95728**]
revealed active esophagitis without evidence of Barrett's
esophagus. He was treated with pantoprazole [**Hospital1 **] and will
continue this upon discharge. Once the esophagitis heals and he
remains abstinent from alcohol, the PPI can be weaned by his
primary care doctor.
.
Alcohol Abuse: He was initially placed on a CIWA with IV valium
as needed, he required valium on [**6-1**], but no longer after [**6-2**].
Given thiamine, folate and multivitamin. Social work was
closely involved with the patient and offered ETOH abstinence
counseling and close outpatient follow up has been arranged.
.
Recurrent Falls: Believed to be secondary to ETOH abuse. Recent
head CT's were negative. B12 and folate were normal. 2 month
old sutures were removed from a left eyelid laceration without
complication.
.
The patient was FULL CODE for this admission.
Medications on Admission:
Home: (reports he was only taking seroquel)
thimaine 100 mg qday
folic acid 1 mg qday
MVI qday
ferrous sulfate 325 mg qday
omeprazole 20 mg qday
quetiapine 25 mg qday
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:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO once a day
for 14 days.
Disp:*14 Capsule(s)* Refills:*0*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Severe C.difficile colitis
Esophagitis causing Upper Gastrointestinal Bleeding
ETOH abuse
.
Secondary:
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for GI bleeding and diarrhea.
Stool studies showed that you had an infection called
clostridium difficile. We treated you with antibiotics and you
improved - you will need to complete a continue with antibiotics
for the diarrhea. The gastroenterology doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**]
and performed an endoscopy, which showed that you have
esophagitis (inflammation of the esophagus, likely due to acid
reflux). This should heal with continuing acid-reflux
medications. The most important intervention for your health is
to stop drinking alcohol entirely.
.
We made the following changes to your medications:
- INCREASE pantoprazole to 40mg twice daily
- START multivitamin 1 tab daily
- START vancomycin 125mg every 6 hours for 14 days
- START tramadol 50mg PO q6H as needed for pain
.
Your follow-up information is listed below.
Followup Instructions:
[**Hospital 12091**] Community Health Center
Structured outpatient Substance Abuse Program
Monday [**2100-6-13**] at 9:00AM
[**Location (un) 95729**]Basement
[**Location (un) 669**], MA
Phone: [**Telephone/Fax (1) 95730**]
*They can arrange (also with Dr.[**Name (NI) 95731**] help) for you to see a
psychiatrist and therapist.
Department: Internal Medicine
Physician: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Time: [**2101-6-23**] 11:00AM
Location: [**Last Name (un) 95732**], [**Location (un) 86**], [**Numeric Identifier 4809**]
Phone:([**Telephone/Fax (1) 95733**]
Completed by:[**2101-6-10**]
ICD9 Codes: 2851, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5452
}
|
Medical Text: Admission Date: [**2109-4-19**] Discharge Date: [**2109-4-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yoW with diastolic CHF, pulmonary fibrosis, htn, recently
hospitalized at [**Hospital1 **] [**Location (un) 620**] for sob thought possibly due to
pneumononia (ambiguous cxr) presents to [**Hospital1 18**] ED with sob, htn >
200/100. Admitted to ICU for BP control.
Past Medical History:
pulmonary fibrosis
htn
chf (diastolic)
mild as
1+MR
Social History:
lives on [**Location (un) **] in apartment, daughter [**Name (NI) **] [**Name (NI) 103645**] very
involved in care
Family History:
nc
Physical Exam:
On arrival to ICU:
T 100.2 BP 113/52 HR 73 RR 22 Sat 96% on 4 L/min nc
Gen: thin elderly woman thrashing around in bed
HEENT: dry MM, no OP lesions
Neck: supple, unable to assess JVP due to lack of pt cooperation
Chest: fine bibasilar rales, several inches up from the bases;
no wheezes/ronchi; exam limited by patient's lack of cooperation
in sitting up and sitting still
CV: rrr, nl s1s2, no m/r/g
Abd: soft, nondistended, no grimacing with deep palpation,
normal BS, no masses/HSM
Extr: warm, 2+ DP pulses, no edema
Skin: warm, dry, no rashes or jaundice
Neuro: thrashing around in bed, localizes vision to verbal
stimuli, EOMI, PERRL, moving all extremities equally
Brief Hospital Course:
1)Fever: Unclear whether this was due to pneumonia or viral URI.
CXR cleared quicly after diuresis in ICU. Sputum grew MRSA, but
pt appeared well. It was felt in discussion with the pulmonary
team that this likely represented colonization rather than MRSA
pneumonia. She was treated conservatively for course of
possible community acquired pneumonia.
2)SOB: Hypoxia on arrival to ICU. Improved shortly there after.
Unclear whether represented pulmonary edema in setting of htn
or pneumonia. Diuresed to 4 pounds below normal weight
(euvolemic weight approx 98-100 lbs). Once on the floor
diuresis was discontinued as pt had developed hyponatremia.
Case was discussed with pt's cardiologist, pulmonologist, and
[**Name (NI) 3390**]. [**Name10 (NameIs) 3390**] asked to send pt home on prn lasix regimen - lasix 20
mgs po only if gains weight from one day to next. Echo
unchanged.
3)Htn: Pt continued on atenolol 50, imdur 60. She had recently
had losartan dc'd by her cardiologist, who recommended
restarting as her SBPs continued to be in the 140s-150s. This
was restarted, she did have morning htn to 150s/80s just before
receiving morning meds but was otherwise well controlled
throughout the day. Cardiologist, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] see her
in 2 weeks and decide whether losartan needs to be increased.
4)Frequent urination at night. Post void residual bladder scan
was normal. This was when pt was not receiving lasix. Pt
referred to outpt urology.
Send home with telemonitoring and VNA.
Daughter [**First Name4 (NamePattern1) **] [**Known lastname 103645**] had multiple concerns throughout the
hospital course, including concern that patient was not safe for
home. Meeting required with case management and myself due to
inflammatory comments and behavior by pt's daughter to nursing
and physician [**Name Initial (PRE) **]. At end of meeting, daughter seemed
satisfied with discharge plan.
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 1 days: Take on [**2109-4-28**].
Disp:*3 Tablet(s)* Refills:*0*
7. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Only
take if patient has gained more than 4 pounds in 48 hours.
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
pneumonia
diastolic heart failure
hypertension
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] with any concerning delerium, problems
breathing, or other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2109-5-23**] 2:25
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2109-5-23**] 2:45
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2109-5-23**] 2:45
[**5-29**] at 10:50am with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital6 733**].
Recommend scheduling this for sooner, within next 2 weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2109-5-1**]
ICD9 Codes: 486, 2761, 2930, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5453
}
|
Medical Text: Admission Date: [**2172-1-30**] Discharge Date: [**2172-2-1**]
Date of Birth: [**2116-10-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Percutaneous Coronary Intervention with 2 drug-eluting stents to
Right Coronary Artery
History of Present Illness:
55 year old male with history of Hypertension who presented to
ED with 2hrs of sudden onset crushing 10/10 chest pain radiating
to left arm while vacuuming at work, also with diaphoresis.
Initial EKG in the ED showed ST changes in leads II, III, aVF,
and he was given morphine, aspirin. Second EKG showed ST
elevations in leads II, III, avF with reciprocal T wave
inversions, and STEMI pager was activated. Patient was started
on heparin drip and integrilin and was sent for emergent Cardiac
Catheterization. Patient continued to have 10/10 chest pain
until end of catheterization procedure. Two drug eluting stents
placed in mid RCA, where 100% occlusion was found. Had
percutaneous closure right groin.
.
Upon arrival to the CCU, the patient was chest pain free with no
other symptoms.
.
Patient notes that he has been having similar chest pain, though
significantly more mild, while in bed resting about 2 nights per
week for the past two years. He describes the pain as very mild
and often radiating to his right arm, slowly increasing in
frequency and intensity.
.
On review of systems, he denies any prior history of stroke,
pulmonary embolism. He has had history of GI bleeding [**Month (only) **]
[**2169**].
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. OTHER PAST MEDICAL HISTORY:
GI Bleed ([**2170-10-20**], no transfusions)
Gastric Ulcer
Diverticulosis
Depression
Left Inguinal Hernia (needing repair)
Social History:
Speaks Portuguese but can understand some English and Spanish.
Works in custodial services and at a junkyard lifting heavy
objects. Married. Has a daughter.
-Tobacco history: None
Family History:
Father and many other family members with HTN, HLD. Uncle with
Acute MI in early 60s. No family hx of Diabetes.
Physical Exam:
VS: T=98.3 BP= 139/93 HR=62 RR=14 O2sat=98% 2LNC
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, dry
mucus membranes
NECK: Supple with JVP up to jaw when lying supine w mild reverse
trendelenberg.
CARDIAC: Regular Rhythm with occ irreg beats, normal S1, S2. No
m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, Nontender, Nondistended. No HSM or tenderness.
EXTREMITIES: No c/c/e. Left groin inguinal hernia, Right groin
w clean bandage, nontender, no hematoma
PULSES: Bilateral DP 1+
Pertinent Results:
[**2172-1-30**] 04:45PM BLOOD WBC-14.0* RBC-4.82 Hgb-13.7* Hct-40.7
MCV-85 MCH-28.4 MCHC-33.6 RDW-13.1 Plt Ct-216
[**2172-2-1**] 08:45AM BLOOD WBC-8.1 RBC-4.48* Hgb-12.7* Hct-38.3*
MCV-85 MCH-28.4 MCHC-33.2 RDW-13.3 Plt Ct-196
[**2172-1-30**] 04:45PM BLOOD Neuts-74.9* Lymphs-19.9 Monos-3.2 Eos-1.7
Baso-0.3
[**2172-1-31**] 03:06AM BLOOD PT-12.1 PTT-28.5 INR(PT)-1.0
[**2172-1-30**] 04:45PM BLOOD Glucose-191* UreaN-28* Creat-1.1 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
[**2172-2-1**] 08:45AM BLOOD Glucose-101* UreaN-21* Creat-1.0 Na-141
K-4.0 Cl-106 HCO3-24 AnGap-15
[**2172-1-30**] 04:45PM BLOOD CK(CPK)-392*
[**2172-1-31**] 03:06AM BLOOD CK(CPK)-916*
[**2172-1-31**] 11:28AM BLOOD CK(CPK)-920*
[**2172-2-1**] 08:45AM BLOOD CK(CPK)-426*
[**2172-1-30**] 04:45PM BLOOD cTropnT-<0.01
[**2172-1-31**] 03:06AM BLOOD CK-MB-113* MB Indx-12.3*
[**2172-1-31**] 11:28AM BLOOD CK-MB-96* MB Indx-10.4* cTropnT-2.49*
[**2172-2-1**] 08:45AM BLOOD CK-MB-23* MB Indx-5.4 cTropnT-1.24*
[**2172-1-31**] 03:06AM BLOOD %HbA1c-6.0*
[**2172-1-31**] 03:06AM BLOOD Triglyc-73 HDL-34 CHOL/HD-5.1 LDLcalc-124
[**2172-1-30**] 05:45PM BLOOD Type-ART pO2-295* pCO2-33* pH-7.44
calTCO2-23 Base XS-0 Intubat-NOT INTUBA Comment-O2 DELIVER
Cardiology Report Cardiac Cath Study Date of [**2172-1-30**]
1. Coronary angiography in this right dominant system
demonstrated one
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD had mild diffuse disease but no angiographically significant
stenoses. The LCx had no angiographically apparent disease but
had a
small aneurysmal segment in mid-vessel. The RCA was occluded in
its
mid-portion.
2. Limited resting hemodynamics demonstrated moderate systemic
arterial
hypertension with SBP 162 mmHg and DBP 106 mmHg.
3. Successful PCI of the RCA with overlapping 3.5x28mm and
3.5x15mm
Promus DES, post-dilated to 3.75mm in the proximal and
mid-segments.
4. Successful closure of the right femoral arteriotomy site
with a
Perclose device.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Acute inferior myocardial infarction.
3. Successful PCI of the RCA with DES.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2172-1-30**] 5:02
PM
FINDINGS: The lungs are clear without consolidation or edema.
The
mediastinum demonstrates mild tortuosity of the thoracic aorta.
The cardiac
silhouette is within normal limits for size. No effusion or
pneumothorax is
noted. There is mild gaseous distention of the stomach
incidentally noted.
Mild degenerative disease is seen throughout the thoracic spine.
No displaced
fractures are evident.
IMPRESSION: No acute pulmonary process.
[**Known lastname 86758**], [**Known firstname 86759**] [**Hospital1 18**] [**Numeric Identifier 86760**]Portable TTE
(Complete) Done [**2172-1-31**] at 9:24:06 AM FINAL
The left atrium is mildly dilated. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal inferior wall. The remaining segments contract normally
(LVEF = 55 %). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The ascending aorta is
mildly dilated at the sinus level. The aortic arch 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 to moderate ([**12-21**]+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Very mild regional left ventricular systolic
dysfunction c/w CAD. Mild-moderate mitral regurgitation with
normal valve morphology suggestive of underlying papillary
muscle dysfunction. Mild thoracic aorta dilation.
[**2172-1-31**] Transthoracic echo:
The left atrium is mildly dilated. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal inferior wall. The remaining segments contract normally
(LVEF = 55 %). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The ascending aorta is
mildly dilated at the sinus level. The aortic arch 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 to moderate ([**12-21**]+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Very mild regional left ventricular systolic
dysfunction c/w CAD. Mild-moderate mitral regurgitation with
normal valve morphology suggestive of underlying papillary
muscle dysfunction. Mild thoracic aorta dilation.
Brief Hospital Course:
55 year old male with hx of HTN, HLD who presented to ED with 2
hours of substernal crushing 10/10 chest pain and evolving ST
elevations.
.
# s/p STEMI:
Patient had 2 hours of chest pain by time of arrival in ED,
continued chest pain through Catheterization until end of
procedure, found to have 100% occlusion mid RCA. Two
drug-eluting stents placed in mid RCA. ST elevations in
inferior leads resolved after PCI. Patient appears to have had
unstable angina for the past two years at night while at rest in
bed. He continued to have some intermittent chest pain
immediately post catherization. The patient was chest pain free
in the 24 hours prior to discharge and had no arrythmias on
telemetry in hours 24-48 post-cardiac catherization.
He did have some runs of VT and transient bradycardia to 40s
that were thought secondary to reperfusion. CKMB peaked at 113
and troponin T at 2.49. The patient was started on integrellin
for 18 hours, aspirin, plavix, atorvastatin and metoprolol.
Echo showed nearly preserved ejection fraction with some mild
posterior hypokinesis. He was set up with a follow up with Dr.
[**Last Name (STitle) 171**], with plan for cardiac rehabilitation.
# Hypertension:
Patient reported blood pressure baseline to be about 170/110.
He takes lisinopril 40mg [**Hospital1 **] at home, used to take HCTZ but
stopped taking it 2-3 months ago because of nocturia and because
his Rx ran out. The patient was continued on lisinopril and
started on metoprolol.
.
# Hyperlipidemia:
Patient was told to attempt to control lipids with diet and
exercise first but has not been able to make many changes. He
was started on atorvastatin 80mg daily
.
# Gastritis:
History of GI bleed, no transfusions, in [**2170-10-20**], either
from gastric ulcer or from diverticulosis. Was explained that
he should no longer take omeprazole while on plavix. This was
changed to ranitidine.
.
# Depression:
He was continued on fluoxetine 20mg.
Medications on Admission:
Lisinopril 40mg [**Hospital1 **]
Aspirin 81mg
Omeprazole 20mg
Fluoxetine 20mg
HCTZ 25mg (stopped taking 3mo ago b/c nocturia x5 and Rx ran
out)
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO QHS (once a
day (at bedtime)).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 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:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
ST Elevation Myocardial Infarction
Secondary Diagnoses:
Hypertension
Discharge Condition:
Stable.
Alert and Oriented x3.
Ambulatory.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital after a having a heart attack.
You were taken immediately for a Cardiac Catheterization
procedure to place 2 stents into your right coronary artery,
where you were found to have complete blockage, which had caused
your heart attack.
It would benefit you to participate in a Cardiac Rehabilitation
program, during which you can work on improving diet and
exercise habits. You should discuss this with Dr. [**Last Name (STitle) 171**] when
you see him.
The following changes have been made to your medications:
- you have been started on plavix (clopidogrel) 75mg a day. Do
NOT stop this medication unless instructed by your cardiologist.
- Your aspirin dose has been increased from 81mg to 325mg a day.
- You have been started on metoprolol, a drug that controls your
heart rate, at 25mg a day.
- You have been started on atorvastatin (lipitor) 80mg a day to
control your cholesterol.
- You have been started on ranitidine, a drug that helps stop
stomach acid. This is to replace your omeprazole.
- Please STOP taking omeprazole, as it may interfere with plavix
Please be sure to keep all of your followup appointments.
Please seek medical attention if you experience any symptoms
concerning to you.
Followup Instructions:
Please be sure to keep all of your followup appointments. You
have been made the following appointment with Dr. [**Last Name (STitle) 171**], the
cardiologist that took care of you while you were in the
hospital.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2172-2-24**]
1:00
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**].
Completed by:[**2172-2-1**]
ICD9 Codes: 4271, 4240, 311, 2724, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5454
}
|
Medical Text: Admission Date: [**2154-2-8**] Discharge Date: [**2154-2-16**]
Date of Birth: [**2085-9-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2154-2-8**] Redo sternotomy, with Patch Repair of Pseudoaneurysm
under Deep Hypothermic Circulatory Arrest
History of Present Illness:
This is a 65 year old male with known coronary disease, status
post coronary artery bypass grafting surgery in [**2137**]. He is an
active smoker and has severe COPD confirmed by PFT and recent CT
scan. On a CT scan in [**2151-8-14**], there was an incidental
finding of a focal aneurysmal outpouching of his ascending aorta
along with a left lingula mass. Further review by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
thought it looked like a penetrating atherosclerotic plaque that
had ulcerated and that it was only covered by a very thin aortic
wall and thus was at risk for rupture. He underwent a stent
graft repair of this in [**2151-11-14**]. Follow-up CT scan has
shown an endoleak with expanding pseudoaneurysm into his aortic
arch. Given his endoleak and expanding psuedoaneurysm, it has
been decided to return to the operating room for repair.
Past Medical History:
- Pseudoaneurysm of aortic arch and endoleak
- Coronary Artery Disease
- COPD
- Hyperlipidemia
- Hypertension
- Calcified aorta
- New finding of Left lingula lung mass
- Bilateral Pleural Effusions
- Hypothyroidism
- Trauma to lower extremities
- Emphysema
- Past Myocardial infarction [**11/2137**]
- Trauma from fall with multiple broken bones
- s/p coronary artery bypass grafting surgeryx5 in [**2137**] - [**Hospital3 **] Dr. [**Last Name (STitle) **]
- s/p Polypectomy [**2151**]
- s/p Right elbow seroma, s/p debridement and drainage
- s/p Appendectomy
- s/p Abdominal Aortic Aneurysm Repair [**2152-6-26**]
- s/p 1. Left subclavian to left common carotid artery bypass
with
8-mm PTFE graft. 2. A left common carotid to right common
carotid
artery bypass using 8-mm ring PTFE graft. 3. Exposure of left
axillary artery. 4. Ultrasound-guided access of right common
femoral artery. 5. Exposure of left common femoral artery. 6.
Bilateral placement of catheter into the aorta. 7. Selective
catheterization of coronary artery bypass graft. 8. Coronary
angiogram. 9. Aortogram. 10.Endovascular stent graft repair of
ascending thoracic pseudoaneurysm with Talent 40 x 40 x 46-mm
endograft. 11.Perclose closure of right common femoral
arteriotomy.
- Prior Left thoracentesis
Social History:
Occupation: retired
Lives with wife in [**Name (NI) 1411**]
Race:Caucasian
Tobacco:[**1-14**] cigarettes daily
ETOH:[**4-18**] glasses of wine daily
Family History:
Brothers with CAD. One brother died of MI at age 57, another
brother with CABG in early 50's. No known aneurysmal disease
Physical Exam:
PREOP EXAM
Physical Exam
Pulse: 63 SR Resp: 16 O2 sat: 96% RA
B/P Right: 160/76 Left: 158/82
Height: 69" Weight: 220lb
General: WDWN gentleman appearing mildly short of breath with
conversation. Smells of smoke.
Skin: Warm, dry, chronic lower extremity venous stasis changes.
No cyanosis noted. There is some clubbing noted. Well healed
sternotomy. Multiple well healed incisions on neck and
supraclavicular area.
HEENT: NCAT, PERRL, Sclera anicteric, OP benign, remaining upper
teeth in fair repair, lower teeth absent
Neck: Supple [X] Full ROM [X] No JVD
Chest: Diminished breath sounds at bases left>right. Insp/Exp
crackles. Delayed expiration.
Heart: RRR, Nl S1-S2, No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X] Well healed left abdominal incision
Extremities: Warm [X], well-perfused [X] Trace LE Edema
Varicosities: Left GSV surgically absent from open saphenectomy.
Right GSV may have been disrupted below knee due to trauma.
Multiple incisions along R GSV tract below knee. Thigh may be
usable.
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: Trace Left: Trace
PT [**Name (NI) 167**]: Trace Left: Trace
Radial Right: 2 Left: 2
Carotid Bruit Right: None Left: quiet left bruit
Pertinent Results:
[**2154-2-8**] Intraop TEE:
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with mild global free wall hypokinesis.
The descending thoracic aorta is mildly dilated.
The aortic valve leaflets are moderately thickened. Trace aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
There is a stent in the ascending aorta beginning just outside
the valve. No residual aneurysm is seen. Image quality
limitation may be due to clot from the leak.
Post-CPB:
The patient is A-Paced, on no inotropes.
EF is slightly reduced to 45-50%.
RV systolic fxn remains mildly reduced.
MR remains 1+
Trace AI. Aorta intact.
[**2154-2-16**] 04:20AM BLOOD WBC-11.2* RBC-2.77* Hgb-8.4* Hct-26.6*
MCV-96 MCH-30.3 MCHC-31.6 RDW-15.3 Plt Ct-267
[**2154-2-16**] 04:20AM BLOOD Glucose-124* UreaN-24* Creat-1.4* Na-137
K-4.2 Cl-104 HCO3-29 AnGap-8
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent redo sternotomy repair of
pseudoaneurysm involving the distal ascending aorta with bovine
pericardial patch using deep
hypothermic circulatory arrest. For surgical details, please see
the operative note. Within 24 hours, he awoke neurologically
intact and was extubated without incident. He was transfused
with PRBC's to maintain a hematocrit near 30%. He remained in
the CVICU for aggressive bronchial hygiene and tenuous pulmonary
status with baseline COPD. He maintained stable hemodynamics and
was transferred to the step down unit on postoperative day two.
Physical therapy was consulted for evaluation of his strength
and mobility. He became acutely confused on POD#3. This
confusion was felt to be related to Ativan which was discontined
and within 24-48 hrs his confusion had resolved. Also on POD#3
serous sternal drainage was noted on his sternal wound without
any erythema or sternal click. He was placed on emperic
antibiotic coverage. He remained afebrile with stable white
blood counts and without any sign of infection. He remained in a
normal sinus rhythm. He had an pleural air leak
postoperatively, however chest tubes and pacing wires were
removed without incident. He remained in the hospital for
extended period due to continued drainage and on post-operative
day eight this drainage had resolved and he was discharged with
ten days of Keflex to Newbridge on the [**Hospital **] Rehabilitation
Center.
Medications on Admission:
Crestor 40mg daily, Lisinopril 10mg daily, Synthroid 137mcg
daily, Lasix 20mg daily, metoprolol tartrate 25mg daily, Aspirin
81mg daily, Ferrous sulfate 325mg twice daily, Folic acid 1mg
daily, Proventil inhaler prn.
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days: sternal drainage.
5. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
- Pseudoaneurysm of Aortic Arch with Endoleak, s/p repair
- Coronary Artery Disease, s/p CABG [**2137**]
- COPD
- Hyperlipidemia
- Hypertension
- Calcified aorta
- Hypothyroidism
- Emphysema
- s/p Abdominal Aortic Aneurysm Repair [**2152-6-26**]
- s/p Left subclavian to left common carotid artery bypass with
8-mm PTFE graft. 2. A left common carotid to right common
carotid
artery bypass using 8-mm ring PTFE graft.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
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 cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time:[**2154-3-11**] at 2:30
in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2154-2-27**] at 3:00p [**Location (un) 620**] office
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**] in [**4-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2154-3-20**] 11:15
Completed by:[**2154-2-16**]
ICD9 Codes: 496, 3051, 412, 2449, 5859, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5455
}
|
Medical Text: Admission Date: [**2112-11-30**] Discharge Date: [**2112-12-5**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nitroglycerin / Naprosyn
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
weakness and abdominal fullness on initial presentation then
transferred with hypotension, tachycardia, intubated.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F s/p AAA repair, patient brought to [**Hospital3 **]
following episode of weakness, and vomitted, followed by patient
"slumping over" and becoming unresponsive. She was intubated
and
then transferred to [**Hospital1 18**] for tachycardia and hypotension to 70s
sBP. She was, by report, pale, cool and diaphoretic). At
[**Location (un) 620**] the patient's blood pressure reportedly responded to
fluids and pressors. It is uncertain whether she experienced
abdominal pain previously but on presentation to this hospital
she was noted to have a positive FAST scan for fluid in
[**Location (un) 6813**] pouch. Given her history of AAA repair, patient was
assessed by vascular surgery. Patient was incontinent of large
amounts of liquid stool which was guaiac negative. She was
reportedly afebrile throughout.
Patient's family reports that she had a ?septic joint for the
past 10 days. Per report review of systems was otherwise
negative.
Past Medical History:
PMH:
Hypothyroidism
Afib on Coumadin
CHF
Asthma
Past MIs
PSH:
CABG
AAA repair
Social History:
Lives in [**Location 620**]; daughter [**Name (NI) 319**] [**Name (NI) **] [**Telephone/Fax (1) 50063**]
No ETOH
No tobacco
Family History:
non contributory
Physical Exam:
T 98.3 125 (Neo @ 2)137/95 20 97% (intubated CMV 100% 416 x 20
8/-)
CVS: normal S1, S2, no murmurs
Resp: mild bilateral coarse breath sounds
[**Last Name (un) **]: soft, no apparent tenderness, non-distended, patient
otherwise intubated and sedated), not tympanitic
Ext: cold, mottled, peripheral signals dopplerable
Pertinent Results:
[**2112-11-29**] 10:53PM WBC-17.3* RBC-4.03* HGB-10.7* HCT-33.8*
MCV-84 MCH-26.6* MCHC-31.7 RDW-15.6*
[**2112-11-29**] 10:53PM PT-64.3* PTT-37.0* INR(PT)-7.4*
[**2112-11-29**] 10:53PM ALT(SGPT)-21 AST(SGOT)-40 CK(CPK)-185 ALK
PHOS-113* TOT BILI-1.3
[**2112-11-29**] 10:53PM ALBUMIN-2.7* CALCIUM-7.2* PHOSPHATE-3.5
MAGNESIUM-2.3
[**2112-11-29**] 10:53PM GLUCOSE-194* UREA N-53* CREAT-1.9*
SODIUM-132* POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-21* ANION
GAP-12
[**2112-11-30**] 12:19PM WBC-14.5* RBC-3.36* HGB-9.2* HCT-27.2*
MCV-81* MCH-27.3 MCHC-33.6 RDW-15.8*
[**2112-11-30**] 12:19PM PLT COUNT-250
[**2112-11-30**] 12:19PM PT-15.2* PTT-27.9 INR(PT)-1.3*
[**2112-11-30**] 12:19PM GLUCOSE-171* UREA N-44* CREAT-1.7* SODIUM-136
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
[**2112-11-29**] CT Abd/pelvis :
1. Interval development of a small amount of intra-abdominal
ascites in a
perisplenic and perihepatic location with also ascites tracking
down the
paracolic gutters.
2. Segment of bowel wall thickening and associated colonic
stranding and
fluid, most indicative of a colitis involving the descending
colon. The
SMA/[**Female First Name (un) 899**] origins are heavily calcified.
3. Extensive atherosclerotic disease as detailed above with no
evidence of
acute rupture. Focal areas of outpouching do not demonstrate
contrast within them and are likely related to prior
post-surgical change/hematoma.
[**2112-11-29**] Head CT : 1. No acute intracranial process.
2. Subcutaneous emphysema in the left masticator space of
uncertain etiology, the majority immediately medial to the left
temporal-mandibular joint. Clinical correlation with the
findings in this region is advised.
NOTE ADDED IN ATTENDING REVIEW: The abundant fluid and
aerosolized secretions occupying the nasopharynx, nasal choanae
and dorsal aspect of the nasal cavity likely relates to
intubation and supine positioning. The pockets of subcutaneous
emphysema, largely in the left masticator space, may reside in
the pterygoid venous plexus and its tributaries, but should be
correlated with history of recent placement of intravenous
access, possibly of relatively large-bore.
[**2112-12-3**] Right arm duplex scan : 1. No right upper extremity
DVT.
2. Mild subcutaneous edema.
Brief Hospital Course:
Ms. [**Known lastname 50064**] was evaluated by the Acute care Service in the
Emergency Room and her scans were reviewed. Based on her
presenting symptoms to [**Location (un) 620**] and he CT scan she was admitted
to the ICU for ischemic colitis, placed on broad spectrum
antibiotics, hydrated and her blood pressure was supported with
pressors initially. She was also evaluated by the Vascular
Surgery service as there was some question of a possible
pseudoaneurysm from her AAA repair in [**2102**]. The repair was
intact, all arteries were patent and there was no evidence of
any vascular events to explain her possible low flow state.
Prior to admission her family remembered that she complained of
large amounts of liquid stool. Her rectal exam was normal and
her stool was guiac negative. A stool for C difficile was also
negative. Her elevated WBC was gradually trending down and her
abdominal exam improved daily.
Her INR at [**Location (un) 620**] was 5.7 and she received 2 units of FFP to
try to normalize it. Her hematocrit on admission was 29 and
gradually decreased to 21 but she was asymptomatic and therefore
not transfused. Prior to discharge her hematocrit was 23.8.
She was easily extubated from the respirator on [**2112-12-1**] and
remained free of any pulmonary complications during her stay.
from a cardiovascular standpoint she was easily weaned off her
pressors after she was fully fluid resuscitated. Her pre
admission medications were resumed and her blood pressure was
140/80-90 without any hypotension. She was on an ACE inhibitor,
beta blocker as well as Lasix for her chronic diastolic heart
failure and she tolerated these medications well.
Following transfer to the Surgical floor she continued to make
good progress. Her abdominal pain resolved and she was working
with the Physical Therapist daily to improve her endurance. Her
appetite was only fair but she would gladly take protein shakes
for supplementation. She had some right shoulder pain weeks
prior to admission although no injury was noted on scans. The
Physical Therapy service gave her some exercises to do to
improve her ROM which she will continue with.
On [**2112-12-3**] she had a duplex scan done of the right upper
extremity to rule out DVT as she had noticible swelling in the
lower arm and hand. She did have a right subclavian line in
place in the ICU. The scan was negative and elevation helped a
bit but she will need to continue that as well as staying off
her right side.
She will complete a 7 day course of Flagyl and Cipro on [**2112-12-7**]
which she has done well with. Her Coumadin has been on hold
since admission but there is no reason to withhold it any
longer. Her home dose was 3 mg daily and can begin tonight.
She was discharged to rehab on [**2112-12-5**] and will follow up in
the Acute Care Clinic in [**2-24**] weeks.
Medications on Admission:
Lasix 80mg qod alt with 40mg qod
Lovastatin 60 mg daily
Lopressor 200 mg daily
Moexipril 30 mg daily
Coumadin 3mg daily
Aspirin 81mg daily
Vitamin D3 1000 units daily
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. moexipril 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. lovastatin 60 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: thru [**2112-12-7**].
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: thru [**2112-12-7**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**]
Discharge Diagnosis:
ischemic colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with colitis possibly due to
poor circulation. Your symptoms improved with bowel rest,
antibiotics and hydration.
* You are now able to tolerate a regular diet and should try to
have a little something at each meal. taking protein shakes
will also help until your appetite improves.
* You are being transferred to rehab for a short stay to
increase your stamina and endurance with more physical therapy.
* If your pain recurs or if you develop any other symptoms that
concern you please return to the Emergency Room.
* Your Coumadin has been held but you can safely resume it now.
you will need to have your blood tested daily initially so that
you will be on an appropriete dose.
* You should elevate your right arm on pillows to decrease the
swelling.
Followup Instructions:
Please follow up in [**2-24**] weeks in Acute Care Clinic Call
[**Telephone/Fax (1) 600**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2112-12-5**]
ICD9 Codes: 0389, 2449, 4280, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5456
}
|
Medical Text: Admission Date: [**2179-11-29**] Discharge Date: [**2179-12-10**]
Date of Birth: [**2105-10-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
1. Billroth II gastrectomy with antecolic isoperistaltic
gastrojejunostomy.
2. Primary duodenal stump closure with omental patch overlay.
History of Present Illness:
74 year old male with schizophrenia presenting with complaints
of suprapubic abdominal pain for the last few days, which he
thinks is due to eating bad chicken. He is a poor historian and
is somewhat uncooperative. He complains
mostly of suprapubic pain. He has had long-standing bilateral
inguinal hernias for which he has refused surgical repair. He
states that they are mildly tender. He has been nauseated and
has tried to vomit, but cannot. He rates the pain as a 9 or
[**10-29**], despite receiving 6mg of morphine in the last 45 minutes.
He denies fevers or chills. He refuses to answer any more
questions. Looking at the limited records we have here, it
appears he was supposed to get radiation for his prostate CA ,
but did not make the appointment. He has a history of a small MI
as well.
Past Medical History:
PMH: Schizophrenia, Prostate CA, Hyperlipidemia, Bilateral
inguinal hernias, CAD s/p small MI.
Social History:
1ppd smoker "forever". Denies EtOH or drug use. Pt??????s apartment
reported as unsanitary and a fire [**Doctor Last Name 13205**].
She reports that the Health Dept and Fire Dept are working to
intervene on this matter.
Physical Exam:
97.2 66 127/77 16 100RA
Gen: Moaning in discomfort holding lower abdomen. A&Ox2 (person
and place). Cachectic. Unkempt. Foul-smelling.
HEENT: Anicteric. Tacky mucosal membranes. Some brown, dried
vomit around mouth. poor dentition.
Neck: Thin. Mild JVD.
CV: RRR.
Pulm: Coarse. Diminished at bases.
Abd: Thin. Rigid. Diffusely tender. ND. Hypoactive BS. More
tender in suprapubic region. Bilateral, large, completely
reducible inguinal hernias. Hernias non-tender.
DRE: Normal tone. No masses. No gross or occult blood.
Ext: Onychomycosis. Warm and well perfused.
Neuro: Motor and sensation grossly intact. Follows commands.
Difficult to understand secondary to mumbling. Conversant. Odd
affect, but appropriate.
Pertinent Results:
[**2179-11-29**] 01:35AM BLOOD WBC-9.3 RBC-6.21*# Hgb-18.7*# Hct-56.3*#
MCV-91 MCH-30.2 MCHC-33.3 RDW-13.4 Plt Ct-261
[**2179-12-5**] 04:20AM BLOOD WBC-10.9 RBC-3.48* Hgb-10.8* Hct-31.1*
MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-321#
[**2179-11-29**] 11:26AM BLOOD Neuts-62 Bands-27* Lymphs-8* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2179-12-9**] 05:22AM BLOOD Glucose-107* UreaN-16 Creat-0.7 Na-141
K-3.5 Cl-108 HCO3-27 AnGap-10
[**2179-11-29**] 01:35AM BLOOD Lipase-25
[**2179-11-30**] 01:41AM BLOOD CK-MB-6 cTropnT-<0.01
[**2179-12-9**] 05:22AM BLOOD Calcium-7.4* Phos-2.4* Mg-2.1
[**2179-12-3**] 04:16AM BLOOD Triglyc-113
[**2179-11-30**] 06:40PM BLOOD Vanco-15.8
.
SPECIMEN SUBMITTED: gastric antrum & perforated ulcer.
DIAGNOSIS:
Gastric antrum, partial gastrectomy:
1. Gastric fundus and antrum with marked chronic active
gastritis.
2. Numerous bacteria morphologically consistent with H. pylori
identified.
3. Pylorus/proximal duodenum with chronic active mucosal
inflammation and acute serositis; no perforation identified on
histologic sections (see note).
Note: No definite ulceration with perforation is identified on
gross or histologic examination. The presence of serositis at
only the distal resection margin and pyloric/early duodenal
sections is suggestive of a more distal perforation in [**Last Name (un) **].
Clinical correlation is suggested.
.
Radiology Report CHEST (PA & LAT) Study Date of [**2179-11-29**] 3:11 AM
IMPRESSION: Free air under the diaphragm. Findings discussed
with Dr. [**First Name4 (NamePattern1) 916**]
[**Last Name (NamePattern1) **] at 4:15 a.m. on [**2179-11-29**]. The patient was take to surgery
and a
perforated duodenal ulcer was found.
Clinical: Intestinal perforation.
.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of [**2179-11-29**]
4:07 AM
IMPRESSION:
1. Intra-abdominal free air found at surgery to be caused by
perforated
duodenal ulcer.
2. Left lower quadrant and intragastric rounded densities of
unclear
significance.
.
Cardiology Report ECG Study Date of [**2179-12-5**] 9:38:54 AM
Sinus rhythm with atrial premature complexes
[**Month (only) 116**] be otherwise normal ECG, but baseline artifact makes
assessment difficult
Since previous tracing of [**2179-12-2**], atrial ectopy present and
precordial lead
QRS voltage more prominent
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 136 96 354/403 54 -13 72
.
Brief Hospital Course:
This is a 74-year-old gentleman Perforated pyloric
channel/antral
ulcer. The patient was taken emergently to the OR and is s/p a
BII resection.
He was admitted to the ICU post-operatively.
NEUROLOGIC: Initially Sedated on propofol. He was successfully
weaned.
Pain: Fentanyl gtt in the ICU. Once tolerating a diet and on the
floor, he was transitioned to PO pain meds.
CARDIOVASCULAR: HR and BP stable, off pressors. He was triggered
for SPO2 80s LLL left lower lobe atelectasis and small L pl eff.
Stable R Pl eff. responds to O2. CE neg x 3.
PULMONARY: Ventilated initially. Was successfully weaned.
GI / ABD: NGT to suction, wound dressing is c/d/i. NGT was
removed on POD 4.
NUTRITION: NPO. He was on TPN. His diet was advanced as he had
return of bowel funciton and TPN was weaned off.
RENAL: Adequate UOP, Cr 0.8. follow-up with Dr.[**Last Name (STitle) 103429**] for
catheter removal and void trial next week.
HEMATOLOGY: Hct 36.5
ENDOCRINE: RISS
ID: Continue broad spectrum coverage with Vanc, Zosyn and Fluc.
ABX were stopped on [**2179-12-6**].
WOUNDS: abdominal wound c/d/i. The staples were removed prior to
discharge.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Amoxicillin 250 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours) for 14 days: 14 days total. Started [**2179-12-6**].
Stop [**2179-12-20**].
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 14 days: 14 days total. Started [**2179-12-6**]. Stop
[**2179-12-20**].
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Perforated pyloric channel/antral ulcer.
Discharge Condition:
Good
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.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2180-1-3**] at 8:30am. Call
[**Telephone/Fax (1) 2835**] with questions or concerns.
Call Dr. [**Last Name (STitle) 656**] (Radiation Oncology) to schedule an appointment
in 3 weeks. Call ([**Telephone/Fax (1) 8082**] to schedule an appointment.
Follow-up with Dr. [**Last Name (STitle) 103429**] (Urology) in 1 week for Foley
catheter removal. Call to schedule an appointment. ([**Telephone/Fax (1) 93948**]
Completed by:[**2179-12-10**]
ICD9 Codes: 5180, 5119, 412, 3051, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5457
}
|
Medical Text: Admission Date: [**2184-6-13**] Discharge Date: [**2184-6-18**]
Date of Birth: [**2121-6-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Soreness
Major Surgical or Invasive Procedure:
Right sided CVL placement
History of Present Illness:
This is a 62 year old female with hepatitis and stage III
chronic kidney disease who presented with one day of soreness,
weakness, and nausea/vomiting as well as worsening of her
chronic diarrhea. She has had an increased frequency of her
bowel movements and loose stools for months per her report, but
this had been dramatically worse over the week preceding
admission. This was non-bloody, liquid diarrhea with greater
than 10 bowel movements per day and one episode of fecal
incontinence. This was associated with generalized and
intermittent mild cramping abdominal pain. She denied fevers
though she did feel subjectively chilled. On the evening prior
to admission she developed some nausea in association with her
diarrhea and vomited one or two times. This emesis was
non-bloody. She also developed weakness and diffuse myalgias
with soreness in multiple areas particularly her back,
shoulders, and legs. She had some mild, non-productive cough
but denied shortness of [**First Name3 (LF) 1440**] or other respiratory symptoms. Of
note, the patient was recently discharged from the surgery
service on [**2184-6-7**] after a five day admission for SBO that
responded to conservative management.
In the ED initial vital signs were T 97.0, P 64, BP 132/74, RR
16, O2 Sat 100% on RA. Labs revealed a leukocytosis, acute
kidney injury, and metabolic acidosis with ABG of 7.18/38/65.
CXR and CT abdomen were unremarkable. She received vancomycin,
levofloxacin, and metronidazole for empiric treatment of colitis
and ? pneumonia. She was also started on IV fluids with
bicarbonate and admitted to the ICU secondary to her acidosis.
Review of Systems: Positive per HPI. Otherwise negative
particularly for headache, facial pain, rhinnorhea, congestion,
cough, shortness of [**Date Range 1440**], chest pain, palpitations, dysuria,
or hematuria. No weight loss or night sweats.
Past Medical History:
-Chronic Kidney Disease stage III (etiology unknown)
-Hepatitis C
-Emphysema/COPD
-Pulmonary Hypertension
-Left lower lobe nodule
-Gastroesophageal reflux disease
-Hiatal hernia
-Polysubstance abuse
-Left hip fracture s/p ORIF [**5-16**]
-Right hip osteoarthritis status post total hip replacement
-Psoriasis
-History of gram negative bacteremia
Social History:
She reports only having a beer once or twice in the last three
months though prior to that she was consuming a half pint of
vodka per day. She has smoked one pack per day of cigarettes
for 30+ years. She has a history of cocaine use recently and
IVDU within the last year. She lives with her fiance. She
denies sick contacts.
Family History:
Noncontributory.
Physical Exam:
VS: T 98.6, P 79, BP 112/59, RR 12, O2 Sat 96% on RA
Gen: Cachectic African American female in NAD
HEENT: Normocephalic, anicteric, OP notable for extremely poor
dentition (lower front incisors mobile with considerable decay),
no blood or lesions
Neck: Supple, no masses
CV: RRR, no M/R/G; there is no jugular venous distension
appreciated; Pulm: Breathing is unlabored, CTAB
Abd: Mildly tender to palpation in all quadrants w/o rebound or
guarding, soft, ND, BS+, no organomegaly or masses appreciated
Extrem: Warm and well perfused, no C/C/E, DP pulses 1+
bilaterally, no swollen joints appreciated
Neuro: A and O*3 and able to relate history without difficulty,
strength 5-/5 everywhere, DTR's symmetric and WNL,
Psych: Pleasant, cooperative
Pertinent Results:
LABORATORY RESULTS
======================
On Admission:
WBC-14.7*# RBC-3.88*# Hgb-12.0# Hct-36.2# MCV-94 RDW-15.9* Plt
Ct-207
----Neuts-74.1* Lymphs-22.9 Monos-1.9* Eos-0.8 Baso-0.3
Glucose-153* UreaN-25* Creat-2.9*# Na-127* K-9.0* Cl-107
HCO3-11*
ALT-73* AST-90* CK(CPK)-13* AlkPhos-188* TotBili-0.3 Lipase-38
On Discharge:
WBC-7.1 RBC-2.85* Hgb-8.6* Hct-25.7* MCV-90 RDW-15.7* Plt Ct-154
Glucose-83 UreaN-9 Creat-1.7* Na-134 K-4.1 Cl-101 HCO3-31
ALT-45* AST-51* AlkPhos-139* TotBili-0.4
Other Labs:
calTIBC-140* VitB12-270 Folate-greater than assay Hapto-88
Ferritn-291* TRF-108*
TSH-1.5
Cortsol-3.7 and 19 post dexamethasone stim
PEP-polyclonal hypergammaglobulinemia IgG-2431* IgA-514* IgM-121
IFE-NO MONOCLONAL GAMMOPATHY
tTG-IgA-18 (normal
Urine;
[**2184-6-13**]: Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
RBC-10* WBC-7* Bacteri-FEW Yeast-NONE Epi-0
Creat-80 Na-68 K-27 Cl-46 Osmolal-310
[**2184-6-15**]: Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
URINE RBC-2 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
MICROBIOLOGY
==============
Blood Cultures *2 ([**2184-6-13**]): No growth
Urine Culture ([**2184-6-13**]): No growth
Stool Cultures ([**2184-6-13**], [**2184-6-14**], and [**2184-6-15**]): Campylobacter and
bacterial cultures negative, C diff toxin negative, cyclospora
and microsporidia stain negative, Ova and Parasite exam
negative, Cryptosporidium and Giardia DFA negative
PATHOLOGY
===========
Small bowel and colon biopsies pending at discharge
IMAGING STUDIES
================
CT Abdomen and Pelvis W/O Contrast [**2184-6-13**]:
IMPRESSION:
1. No abnormalities in the abdomen or pelvis to explain pain.
2. Stably distended gallbladder without evidence of acute
cholecystitis.
3. No change in enlarged common bile duct without visualized
stone or other obstructive lesion.
4. Extensive atherosclerotic calcification.
Chest Radiograph [**2184-6-13**]:
IMPRESSION: No acute cardiopulmonary process. Right IJ CV
catheter tip in the cavoatrial junction.
Brief Hospital Course:
This is a 62 year old female with hepatitis C, chronic diarrhea
and history of polysubstance abuse presenting with metabolic
acidosis, diarrhea and renal failure.
1) Metabolic acidosis: The patient presented with a non-gap
metabolic acidosis and low bicarbonate consistent with chronic
GI losses. On evaluation of previous labs she had a chronically
low bicarbonate, which may be due to the chronic diarrhea she
reported has been an issue for months. With fluids with
bicarbonate she normalized and actually exceeded the normal
range. Generally, focus of work up for low bicarbonate was on
trying to find the etiology of her chronic diarrhea (see below)
though she was also worked up for adrenal insufficiency.
Cortisol stim test was within normal limits virtually ruling out
adrenal insufficiency and thus her chronic diarrhea was
considered the most likely cause of her chronic acidosis.
2) Diarrhea: The patient reported diarrhea being worse in the
week or so prior to presentation but overall she was reporting
months of increased stool frequency. Of course, given multiple
recent hospitalizations the first concern was that this could be
secondary to C difficile colitis but this was not found on toxin
assay. Other concerns remained for other infectious etiologies
of chronic diarrhea like cryptosporidium, giardia, or more
rarely cyclospora or microsporidia but these assays were all
negative and the patient had no clear risk factors (despite
history of IVDU, HIV had recently been tested and negative).
Other etiologies considered were non-infectious inflammatory
conditions like IBD or celiac sprue. ESR was elevated but the
patient had no other signs of inflammatory bowel disease and her
CT showed no inflammatory segments. TTG-IgA was within normal
limits thus making Celiac Sprue unlikely. GI consult was
obtained and assisted with this work up and eventually took the
patient for colonoscopy and upper endoscopy. These were grossly
normal and biopsies were pending at the time of discharge.
Regarding management of her diarrhea she had a fecal management
system placed in the ICU that was removed on the day prior to
discharge. She was given choleystyramine and loperamide with
some improvement in her diarrhea. Ultimately the etiology of
the patient's diarrhea remained unknown at the time of
discharge, but as she was able to remain hydrated with PO's and
was stable she was disharged to follow up with GI as an
outpatient. By the time of that follow-up the results of her GI
biopsies should be known.
3) Weakness/ Soreness: Overall, this appeared to be associated
with new development of nausea and worsening of chronic diarrhea
and thus was though most likely due to a viral syndrome.
Influenza DFA was checked and was negative and CK was within
normal limits suggesting there was no actual myositis. Exam was
without joint swelling and no other signs of an active
rheumatological condition. Over her hospitalization her symptoms
improved. Her pain was treated with tramadol and acetaminophen
with good effect. PT evaluated her and thought she was safe for
home discharge despite some level of deconditioning.
4) Acute kidney injury on chronic kidney disease: The patient
has a baseline creatinine of 1.8 that was increased to 3.2 at
admission and was back to baseline at the time of discharge.
The sediment was largely benign and after a questionable first
UA a repeat was WNL and cultures remained negative. Likely,
this was secondary to prerenal failure secondary to the
patient's dehydration due to diarrhea and nausea with poor PO
intake.
5) History of Hepatitis C, Genotype 1: The patient evidenced no
signs of decompensated cirrhosis and LFT's trended down over her
admission so no acute inpatient management was done.
Nevertheless, she has active disease (per viral load on previous
admission) and treatment should be considered, though she is
probably still abusing alcohol and/or other substances. The
patient was discharged with GI follow up for her diarrhea. They
and the patient's new PCP can help set her up for liver follow
up.
6) Polysubstance abuse: The patient was somewhat inconsistent in
her reports of drug use though social work and the primary
team's impression was that she has significantly decreased her
use over the past months. She was commended on this and the
incentives of further/continuing sobriety were explained to her
and she expressed understanding. She was referred for community
resources and set up to see an [**Company 191**] PCP for further support in
managing her chronic health problems and continued abstinence.
8) Anemia: The patient's anemia was relatively stable throughout
her hospitalization and iron studies suggested anemia of chronic
disease. She did get one unit of packed red blood cells prior
to her procedure as she was complaining of fatigue and weakness.
No signs of active bleeding.
The patient was kept on SC heparin for DVT prophylaxis. There
was no indication for GI prophylaxis. She was tolerating a full
diet and was no longer on IVF for the day prior to discharge.
She was discharged with GI and PCP follow up.
Medications on Admission:
-Docusate Sodium 100 mg PO BID
-Folate 1 mg PO daily
-Metoprolol tartrate 25 mg PO BID
-Trazodone 150 mg PO HS: PRN insomnia
-Calcitriol 0.25 mcg PO daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Trazodone 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
Disp:*60 Packet(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for pain.
Disp:*8 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Non-anion gap metabolic acidosis
Chronic diarrhea
Hepatitis C
Hypertension
Acute on chronic kidney disease
Discharge Condition:
Good, tolerating PO's, all vital signs stable
Discharge Instructions:
You were admitted because you were dehydrated and needed fluids.
We gave you fluids and you improved. Since you had reported
chronic diarrhea we did tests to try and find a cause of this
diarrhea. We ruled out most common infections but there are
still results of biopsies pending at this time. You will follow
up in the gastroenterology clinic to discuss the results of
these biopsies and work on further management of your diarrhea.
You also had some worsening of your kidney disease when you were
admitted that we think was due to dehydration. This improved
back to your baseline with fluids.
Your medications have been changed. Your DOCUSATE (COLACE) has
been stopped because this is a stool softener and you came in
with diarrhea. You have been started on CHOLESTYRAMINE a
medication to help with your diarrhea. You can also use
LOPERAMIDE (IMMODIUM) over the counter to help your diarrhea
more. Finally, you have been given a prescription for TRAMADOL
(ULTRAM) to help treat your muscle aches. These should improve
as you are able to ambulate more. Your other medications have
remained the same.
Please return to your local emergency department of call your
doctor if you have chest pain, shortness of [**Hospital 1440**], increased
abdominal pain, inability to tolerate food or liquids by mouth,
fevers, chills, or any other concerning changes in your health.
Followup Instructions:
You have an appointment with a new Primary Care Doctor so you
cna establish care at [**Hospital1 18**]. You are scheduled to see Dr. [**First Name8 (NamePattern2) 636**]
[**Last Name (NamePattern1) 3315**], MD on [**2184-6-23**] at 2:30 pm. This is on the [**Hospital Ward Name 516**]
of [**Hospital1 69**] in the [**Hospital Ward Name 23**] building.
You can reach her office at [**Telephone/Fax (1) 250**].
You have a follow up scheduled in the gastroenterology clinic to
follow up on your diarrhea symptoms and discuss the results of
your biopsies. You have an appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD on
[**2184-6-30**] at 1:00 pm. This is in the [**Hospital Unit Name **] on the [**Hospital Ward Name 5074**] on the [**Location (un) 448**]. You can reach their clinic at
[**Telephone/Fax (1) 463**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2184-11-10**] at 10:30 AM. Phone:[**Telephone/Fax (1) 2422**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5849, 2762, 4168
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5458
}
|
Medical Text: Admission Date: [**2134-6-25**] Discharge Date: [**2134-7-19**]
Date of Birth: [**2089-5-17**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
STEREPTACTIC BRAIN BIOPSY
RIGHT CRANIOTOMY AND RESECTION OF BRAIN MASS
EVD PLACEMENT
History of Present Illness:
HPI:This is a 45 year old gentleman that has for the last month
been feeling anxious and experiencing atypical headaches with
some self reported memory issues. He saw his PCP for these
symptoms and was given ativan without any significant
improvement
in his symptoms. His PCP then recommended cognitive neurology
evaluate the patient and after seeing him and conferring with
his
PCP it was recommended that he obtain a MRI scan of the Brain
which was obtained on [**6-25**]. Immediately following the scan he
was sent to [**Hospital1 18**] for further workup as the MRI showed a right
sided lesion compressing the right lateral ventricle. We were
consulted to help direct his care given this new diagnosis.
Other
than the headaches he ellicits and self reported memory issues
which are not reproduceable on exam. He denies nausea,
vomiting,
dizziness, difficulty ambulating, changes in vision, hearing, or
speech, or changes in bowel or bladder habits.
Past Medical History:
PMHx: seasonal allergies
Social History:
Social Hx:works in finance, married with two children
Family History:
Family Hx:significant for parkinsons and breast cancer
Physical Exam:
PHYSICAL EXAM:
O: T:98.8 BP: 134/82 HR:73 R 16 O2Sats 100%
Gen: WD/WN, comfortable, anxious
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-28**] 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, 4mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-1**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Discharge exam:
Pt is aaox3, PERRL, EOM intact, mild short term memory loss,
Left hemineglect, motor is full
Pertinent Results:
[**2134-6-25**]: CXR
IMPRESSION: Widened right paratracheal stripe may represent a
combination of vascular structures and mediastinal fat, although
underlying lymphadenopathy cannot be excluded. Consider chest CT
for further evaluation.
[**2134-6-26**]
CT TORSO
CT OF THORAX: Normal appearance of the thyroid gland. No
pathologically
enlarged mediastinal, hilar or axillary lymph nodes are
identified.
A tiny 3mm peripheral density is seen adjacent right oblique
fissure and is of unlikely cinical significance. The lungs are
otherwise clear.
No pleural or pericardial effusions.
CT OF ABDOMEN:
Note is made of a 6-mm hypodensity in segment VII of the right
lobe of liver. Findings are likely those of a small hepatic
cyst. No suspicious liver lesions are identified. Normal
appearance of the portal and hepatic vein. There is mild
periportal edema, but no biliary obstruction. Normal appearance
of the gallbladder, pancreas and spleen. Multiple tiny
low-attenuation lesions are seen in both kidneys. Whilst these
lesions are too small to fully characterize, they likely
represent small cysts. The largest lesion measures 9 mm in the
lower pole of the left kidney (3:77). Normal appearance of both
adrenal glands. No pathologically enlarged upper abdominal,
retroperitoneal or mesenteric lymph nodes. There is no ascites.
Normal appearance of the stomach bowel.
CT OF PELVIS: The prostate is enlarged, measuring 5.8 x 4.7 cm
in maximal
axial dimensions. Foci of prostatic calcification are noted.
Normal
appearance of the rectum and sigmoid colon. Again no pelvic
ascites. No
pathologically enlarged inguinal or pelvic sidewall lymph node.
OSSEOUS
STRUCTURES: No lytic or sclerotic bone lesions are identified.
Note is made of two cannulated screws within the left femoral
neck and head.
IMPRESSION:
1. Subcentimeter low-attenuation lesions in the right lobe of
liver and both kidneys are too small to characterize but likely
represent small cysts.
2. No convincing evidence of thoracic or abdominal malignancy.
[**2134-6-28**] CTA
1. Large peripherally hyperdense, centrally hypodense mass
arising from the right thalamus and extending to the mid brain
with associated mass effect and compression of the third
ventricle resulting in hydrocephalus.
2. No evidence of enlarged arterial feeders to the right
thalamic mass;
however, the veins that are normally present near the cisterns
are draped
around the posterior margin of the mass. The posterior cerebral
arteries are coursing in normal orientation. The thalamic
perforating vessels are not well visualized on this exam.
[**2134-6-30**] CT head
Impression: Expected post-biopsy changes as above and
redemonstration of a
right intracranial mass with consequent obstructive
hydrocephalus.
[**2134-7-1**] Functional MRI
IMPRESSION: Relatively stable intra-axial mass lesion centered
in the right thalamus and extending ventrally in the right mid
brain.
The functional MRI of the brain demonstrates the expected
activation areas in the primary motor cortex, with no evidence
of areas of activation adjacent to the mass lesion. The language
paradigm demonstrates the majority of the activity in the right
operculum.
The DTI color maps with tractography demonstrate deviation of
the
corticospinal tracts towards the right.
[**2134-7-1**] CT head
IMPRESSION:
1. Status post ventricular catheter placement with the tip in
the region of the septum pellucidum. Mild decrease in the size
of the lateral ventricles. Correlate with catheter function.
2. Heterogeneous mass lesion in the region of the right
thalamus/ pineal
gland with extension into the brainstem and mass effect on the
right lateral ventricle. Please see prior studies for details.
[**2134-7-5**] MRI Brain Wand study
FINDINGS: The patient is status post right frontal
ventriculostomy with the tip of the drainage catheter abutting
the septum pellucidum. When compared to the previous MRI, there
is no interval change regarding size and configuration of the
ventricular system.
The heterogeneously, predominantly peripherally enhancing right
thalamic mass demonstrates a significant one-week interval
growth, notably from 41 mm to 48 mm in an axial plane and from
47 mm to 49 mm in a coronal orientation. The mass is
infiltrating the posterior [**Doctor Last Name 534**] of the right ventricle and
likely invades the choroid plexus. It inferiorly extends into
the mesencephalon and thereby compresses the aqueduct of
midbrain. There is significant mass effect on the posterior limb
of the right internal capsule as well as on the third ventricle
with distortion and considerable midline shift.
As far as evaluable from the given sequences, there is no
interval
complication such as associated hemorrhage.
IMPRESSION: Significant short term interval growth of the
thalamic lesion as described above.
[**2134-7-5**] postop Head CT:
IMPRESSION:
1. Small extraaxial right parietal and temporal, but moderate
bifrontal
pneumocephalus, correlate clinically and repeat CT is
recommended to monitor for tension pneumocephalus.
2. Small amount of postoperative hemorrhage in the postsurgical
cavity and
tract.
3. Small to moderate amount of right parietal and temporal
subarachnoid
hemorrhage.
4. Increased mass effect on the right lateral ventricle and
effacement of the third ventricle, but unchanged midline shift.
[**2134-7-5**] CXR
FINDINGS: In the interval, the patient has received an
endotracheal tube.
The tip of the tube projects roughly 4 cm above the carina. The
patient has also received a nasogastric tube. The course of the
tube is unremarkable, the tip of the tube projects over the
distal parts of the stomach. No evidence of complications,
notably no pneumothorax. Otherwise, the radiograph is unchanged.
[**2134-7-6**] BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND: Grayscale
and Doppler son[**Name (NI) 1417**] of the bilateral common femoral,
superficial femoral, popliteal, posterior tibial, and peroneal
veins were obtained. There is normal flow,
compressibility, and augmentation.
IMPRESSION: No evidence of DVT.
[**2134-7-6**] MRI brain with and without contrast
IMPRESSION: Evidence of residual tumor at the medial and caudal
margin of the resection cavity. No postsurgery complication such
as significant hemorrhage, intraventricular hemorrhage or
infarction.
[**2134-7-11**] CT Head
Slight increase in size of lateral ventricles when compared to
previous scan.
[**7-12**] CT Head
1. Post-surgical changes in right thalamus are again seen and
unchanged.
2. Unchanged position of extra-axial ventricular drain position.
3. Stable midline shift to the left with unchanged mass effect
on the third ventricle.
[**7-13**] CT Head
1. No change in enlargement of the lateral and third ventricles
following
removal of the external ventricular drain.
2. No change in the degree of leftward shift of normally midline
structures and compression of the third ventricle.
Brief Hospital Course:
Pt was admitted through the emergency department to the ICU
after outpatient MRI revealed new brain mass. Pt was admitted
to the ICU for initial observation and placed on antiepileptic
agents. He was not placed on steroids.
His exam remained stable and he was transferred to the stepdown
unit. He was prepped for stereotactic brain biopsy. He
underwent screening CT torso to eval for primary malignancy -
this was negative. He remained stable in the stepdown unit and a
CTA of the head was otbained to assess the vasculature
surrounding the lesion. He was planned for a stereotactic brain
biopsy for [**6-30**] to aid in diagnosing the lesion in order to
direct further care. On [**6-30**] he underwent the biopsy without
difficulty and he tolerated the procedure well and was
transferred to the ICU for Q1 hour neurochecks and SBP control
less than 140.
On the morning of [**7-1**] he underwent a fMRI with tractography to
aid in planning for a potential resection of the lesion.
He underwent placement of a right frontal EVD in the OR on [**7-1**]
for hydrocephalus by radiographic imaging. Exam was stable
before and after EVD placement. CT head demostrated catheter
placement within the right lateral ventricle without interim
hemorrhage.
EVD was dropped to 10cm above the tragus to encourage drainage.
Mental status remained stable.
He had peri-oral numbness intermittently on [**7-3**] and this was
felt to be seizure activity. His dilantin was subtherpeautic and
this was corrected. A pre-op work up and consent for surgery was
done on [**7-4**].
On [**7-5**] he underwent Craniotomy for debulking of tumor. He
remained intubated until POD1 after a postop MRI could be done.
POstop CT demonstated normal changes without hemorrhage. MRI
demostrated subtotal resection as exoected witout stroke.
EVD was raised to 20 for attempted wean on [**7-7**] but patient
became more lethargic and so the drain was dropped back down to
10.
On [**7-8**] & [**7-9**] the patient remained in ICU for close observation
and was neurologically stable.
On [**7-10**] the EVD was raised to 20 and the patient tolerated this
well. A repeat CT scan on [**7-11**] did show slightly enlarged
ventricles when compared to previous exam but his neurologic
exam remained stable. On the morning of [**7-11**] his EVD was
clamped.
It was removed in routine fashion. He was then transferred to
SDU then floor in stable condition. A repeat CT showed no
evidence of hydrocephalus. A repeat LENIs showed no evidence
for DVT. He was stable on the floor while awaiting further care
planning. He was scheduled for XRT planning on [**7-15**].He was seen
by the physical therapy team and the plan was for a rehab
facility to continue with mobilization and further care.
Now DOD, patient is afebrile, VSS, and neurologically stable.
Patient's pain is well-controlled and the patient is tolerating
a good oral diet. Pt's incision is clean, dry and inctact
without evidence of infection. He is set for discharge home in
stable condition and will follow-up accordingly.
Medications on Admission:
flonase
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
5. Dilantin Kapseal 100 mg Capsule Sig: Two (2) Capsule PO three
times a day for 4 weeks.
Disp:*168 Capsule(s)* Refills:*0*
6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
10. phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO BID (2 times a day).
11. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO tid () for
7 days.
12. dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO tid ()
for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
RIGHT THALAMIC BRAIN MASS
ACUTE DELERIUM / HALLUCINATIONS
Seizures
Hydrocephalus
Dysphagia
Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
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 [**6-6**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on 11 a.m on
[**7-26**]. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2134-7-19**]
ICD9 Codes: 2930
|
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"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5459
}
|
Medical Text: Admission Date: [**2167-1-5**] Discharge Date: [**2167-1-9**]
Date of Birth: [**2116-5-26**] Sex: F
Service: MEDICINE
Allergies:
Pentothal
Attending:[**First Name3 (LF) 5134**]
Chief Complaint:
hypotension, AMS, hypoxia
Major Surgical or Invasive Procedure:
Central line
History of Present Illness:
(see MICU [**Location (un) **] note for full details)
50yoF with remote h/o PE, schizophrenia, anxiety, DMII, COPD,
and MSSA meningitis who was admitted to the MICU on [**1-5**] after
being found hypotensive (SBP 70s), hypoxic (80% on RA) and with
AMS at home. The entire story is unclear, but apparently the
patient became altered, slid off her chair, and was evidently
down for an extended period of time. She does not remember the
events.
.
Initially, the patient was resuscitated with 7L IVF, was found
to be in [**Last Name (un) **] and with rhabdomyolysis. CT head was negative. CXR
was suspicious for RLL infiltrate and broad-spectrum antibiotics
were started empirically. She did not require intubation. In the
unit, the patient was on levophed for < 24 hours. Hypoxia and
hypotension resolved with supportive care and Cr normalized with
IVF. Mental status also improved over the course of the past 2
days. Psychiatry was consulted in the unit given the patient's
history of psychiatric problems and concern for medication side
effect as the root cause of the patient's presentation. Given
the patient's history of PE, she was treated empirically with a
heparin drip, however this was stopped yesterday given the
resolution of hypoxia, tachycardia, and hypotension. LENIs were
negative for DVT bilaterally and TTE showed normal systolic
function.
.
Currently, the patient states that she feels better than her
normal self. She does not remember the events that led to her
hospitalization. She complains of R foot pain, left shoulder
pain (is scheduled for operation), and some worsened SOB over
baseline. Current VS are 97.1 91 125/67 18 94% on RA. The
patient states that she lives alone at home, ambulates with a
cane, and has [**Name Initial (MD) **] home RN and home health aide who assist her each
day. She is able to list her medications and doses. Her
psychiatrist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12262**]. She denies overdosing on
medications at home or wanting to hurt herself.
Endorses cough with deep inspiration.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
.
Past Medical History:
Morbid obesity
Bipolar disorder
Schizophrenia
Anxiety
Depression
PTSD
Diabetes x 15 years, complicated by diabetic neuropathy
Hyperlipidemia
Pulmonary embolism in [**2134**]
Endometriosis
Glaucoma
COPD
Hypertension
DJD
MSSA meningitis
Cervical C2 osteomyelitis in [**3-/2166**], completed 7 week course of
nafcillin.
s/p cholecystectomy
s/p C-section
s/p hysterectomy
Social History:
Lives with herself, however according to father has been
increasingly disabled and may need [**Hospital3 **]. Is disabled,
divorced,
unemployed. Son, father, and sisters live in the area and are
supportive. Usually smokes 2 ppd - has smoked for 35 years. She
very rarely drinks alcohol. Remote h/o cocaine abuse. She
completed twelfth grade. She completed twelfth grade.
Family History:
History of diabetes, Crohn's colitis, cystitis in the family.
Mother died at 61 from failure to thrive.
Physical Exam:
On transfer from the intensive care unit to the floor:
VS - 97.1 91 125/67 18 94% on RA
GENERAL - morbidly obese woman in NAD, a&ox3, answers questions
appropriately
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, difficult to assess JVP, triple
lumen R IJ in place, no carotid bruits
LUNGS - end-expiratory wheezing throughout lung fields, no
accessory muscle use, no crackles, good bs throughout
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - obese abdomen, NABS, soft/NT/ND
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs); complains of R heel pain on the plantar surface
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-26**] throughout, cerebellar exam intact
Pertinent Results:
On admission:
[**2167-1-5**] 08:10AM BLOOD WBC-12.0*# RBC-4.55 Hgb-13.5 Hct-40.0
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.4 Plt Ct-201
[**2167-1-5**] 08:10AM BLOOD Neuts-74* Bands-13* Lymphs-7* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2167-1-5**] 08:10AM BLOOD PT-12.2 PTT-22.5 INR(PT)-1.0
[**2167-1-5**] 08:10AM BLOOD Glucose-291* UreaN-41* Creat-5.3*#
Na-130* K-7.1* Cl-94* HCO3-22 AnGap-21*
[**2167-1-5**] 08:10AM BLOOD ALT-123* AST-378* CK(CPK)-[**Numeric Identifier 106896**]*
AlkPhos-83 TotBili-0.3
[**2167-1-5**] 08:10AM BLOOD Albumin-4.0 Calcium-8.4 Phos-7.9*# Mg-2.6
[**2167-1-5**] 01:38PM BLOOD Type-ART Temp-37.2 pO2-76* pCO2-67*
pH-7.15* calTCO2-25 Base XS--6 Intubat-NOT INTUBA
Comment-VENTIMASK
[**2167-1-5**] 08:19AM BLOOD Lactate-2.2* K-5.4*
.
Blood and urine cultures: negative
.
CXR:
FINDINGS: A supine portable AP view of the chest was obtained.
The left
costophrenic angle is excluded from the film. A right internal
jugular
catheter terminates in the mid SVC. There has been interval
worsening of
moderate pulmonary vascular congestion. Hazy opacity at the
right lung base
may represent developing consolidation versus crowding of
vessels secondary to
low lung volumes. No pleural effusions or pneumothorax are
identified.
Surgical pins are noted in the left glenoid.
.
Normal Head CT
.
Echo:
The left atrium is elongated. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
70%). Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2166-3-14**], no obvious change but the technically
suboptimal nature of both studies precludes definitive
comparison.
.
Renal U/S: Normal study
.
LENIs: negative for DVT bilaterally
.
On discharge:
[**2167-1-8**] 04:35AM BLOOD WBC-5.3 RBC-3.61* Hgb-11.1* Hct-31.7*
MCV-88 MCH-30.9 MCHC-35.1* RDW-14.4 Plt Ct-201
[**2167-1-9**] 05:50AM BLOOD Glucose-216* UreaN-10 Creat-0.7 Na-135
K-4.2 Cl-100 HCO3-24 AnGap-15
[**2167-1-9**] 05:50AM BLOOD CK(CPK)-1466*
[**2167-1-9**] 05:50AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.6
Brief Hospital Course:
50 y.o woman with history of PE and MSSA meningitis last year
complicated by osteomyelitis who presents today with change in
mental status, hypoxia, shock and rhabdomyelysis.
.
#Shock - Patient presented with hypotension, likely due to a
combination of hypovolemia and sepsis secondary to a pneumonia.
The patient responded to fluids and was on norepinephrine for
blood pressure support. Levophed weaned off and a-line d/c-ed.
Resolved. Patient was normotensive after transfer to the floor
and anti-hypertensives were slowly restarted.
.
#Respiratory failure/pneumonia - ABG showed a hypercarbic
respiratory failure and acute respiratory acidosis. The patient
has a history of COPD and also has a urine tox screen that was
positive for opiates. The patient did receive 1mg of narcan in
the emergency room, without any improvement. It is possible
that the patient has a pneumonia that was exacerbating her COPD.
Did not require intubation. Patient was treated with 5-days of
ceftriaxone and azithromycin. For the 2 days prior to discharge,
oxygen saturations were >95% on RA.
.
#Change in mental status - Thought to be secondary to
hypercarbia, although potential contributing etiology may
include narcotic overdose or other medication side
effect/accumulation in renal failure. Mental status cleared in
the unit. Upon transfer to the floor, the patient was alert,
oriented, and able to recount her list of medications and health
problems. She was not able to relay the events that led to her
hospitalization. [**Month/Day/Year **] was consulted and the patient's home
psychiatric medicines were restarted.
.
#Rhabdomyolysis - Was likely secondary to lying on the ground
for several hours. Improved with fluids. Creatinine normalized
with IV hydration. Statin was held - to be restarted after
discharge.
.
#Acute renal failure - Thought to be multifactorial - prerenal,
rhabdomyolysis, continuing to take Ace-I in renal failure. Cr
improved to baseline with IV hydration.
.
#DM - Patient was on insulin sliding scale and standing lantus
during hospitalization. Metformin was restarted on discharge.
.
#Schizophrenia/anxiety/depression: Home psychiatric medications
celexa, risperdal, clonazepam were restarted prior to discharge.
.
# COPD: Continued fluticasone inhaler and albuterol prn.
.
# Communication: HCP [**Telephone/Fax (1) 106897**]-FATHER CELL ([**Name2 (NI) **])
# Code: Full (discussed with HCP)
.
Transitional Issues:
-BP medications may need uptitrated
-restarting statin
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 puffs(s) every 4 to 6 hours as needed for
sob
PT STATES SHE DOESN'T REALLY USE THIS.
AMLODIPINE - (Dose adjustment - no new Rx) - 2.5 mg Tablet - 1
Tablet(s) by mouth once a day
CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 20 mg
Tablet - one Tablet(s) by mouth daily.
CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) -
1 mg Tablet - 3 Tablet(s) by mouth twice a day
CYCLOBENZAPRINE - 10 mg Tablet - 1 Tablet(s) by mouth q8hrs as
needed for neck and shoulder pain
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2
puffs(s) inhaled twice a day
GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth three times a
day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 20 units at
bedtime
LATANOPROST [XALATAN] - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) -
0.005 % Drops - 1 drp OU at bedtime
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METFORMIN [GLUCOPHAGE] - 1,000 mg Tablet - One Tablet(s) by
mouth
twice a day
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for pain
RISPERIDONE [RISPERDAL] - (Prescribed by Other Provider) - 2 mg
Tablet - 1 Tablet(s) by mouth twice a day
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clonazepam 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
6. Lantus 100 unit/mL Solution Sig: Twenty (20) Units
Subcutaneous at bedtime.
7. latanoprost 0.005 % Drops Sig: One (1) Drop(s) each eye
Ophthalmic HS (at bedtime).
8. risperidone 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Sepsis
Hypotension
Pneumonia
Anxiety
Depression
Rhabdomyolysis
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for confusion, low oxygen
levels, and low blood pressure. We are not certain what caused
the event, but you were extremely sick and required intesive
care unit attention - you required medicines to help support
your blood pressure as well. You completed a 5-day course of
antibiotics to treat pneumonia.
.
We made the following changes to your medications:
We STOPPED cyclobenzaprine (because this can interact with
Celexa)
We STOPPED lovastatin (because your muscle breakdown levels were
high; Dr. [**Last Name (STitle) **] may restart this medication as your blood test
normalizes)
We HELD amlodipine (because your blood pressure was low on
admission; Dr. [**Last Name (STitle) **] may restart this medicine if your blood
pressures are high)
We CHANGED lisinopril from 40 mg per day to 20 mg per day (Dr.
[**Last Name (STitle) **] may increase this medicine if your blood pressures are
low)
.
Your follow-up information is listed below.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: FRIDAY [**2167-1-16**] at 11:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 496, 4589, 2724, 3572, 3051, 0389, 486, 5849
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5460
}
|
Medical Text: Admission Date: [**2131-9-17**] Discharge Date: [**2131-10-25**]
Date of Birth: [**2074-3-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hip Pain
Major Surgical or Invasive Procedure:
- Endotracheal Intubation
- Central Venous Line
- Arterial Line
- Peripherally Inserted Central Catheter
History of Present Illness:
57M w hx of IVDU, endocarditis, recent diagnosis of cutaneous
lupus treated only with cream, presenting w/ severe left hip
pain. Approx 5 days ago, had 3 days of nausea, vomiting,
diahrrea which he claims was secondary to eating bad steak tips,
these symptoms have resoved. resolved. Nausea was consistency of
coffee grounds per patient. No gross blood, No blood in his
stool. He also reported general malaise which persisted. Approx
2 days ago, developed severe left hip pain, worse with walking
and movement, and worsened despite taking ibuprofen and tylenol.
Hip ROM severely limited with flexion and extension [**1-29**] pain,
ABduction and ADduction more or less preserved. No obvious
erythema or deformity. Denied fevers, night sweats, chills. he
is unsure when he last used IV heroin, reporting it may have
been 1 week or several months ago.
.
In the ED, initial vs were: T97.6 P101 BP 107/65 R 17 O2 sat 98%
RA. The patient had a CXR which showed right lung opacity
concerning for pneumonia. Multiple lab abnormalities were also
present, including hyponatremia, hypokalemia, elevated
creatinine to 2.2, thrombocytopenia with plts of 21, bandemia of
24, elevated LFTs. Also, INR 1.5 and PTT 100. Patient was given
vancomycin, levaquin, ceftriaxone, and 3.5 liters of fluid.
Orhopedics saw patient and recommended pelvis CT, which was
unrevealing, though limited because it was without contrast.
RUQUS was also done which was negative for cholecystitis,
negative son[**Name (NI) 493**] [**Name2 (NI) **]. However, multiple hyperechoic
splenic lesions were identified. After 3.5l of fluid the
patient's heart rate increased to 130's, RR increased to 40's. A
right EJ and left IJ were placed. Also received 40mEq Potassium,
ativan 1mg IV x1, morphine 4mg IV X2.
.
Past Medical History:
-Cutaneous lupus, diagnosed last year at [**Hospital1 2177**] and treated
topically
-MRSA TV endocarditis, treated at [**Hospital1 112**] ([**4-5**]) with daptomycin
complicated by multiple septic pulmonary emboli and splenic
abscess
-Hepatitis B
-Hepatitis C, negative viral load
Social History:
no tobacco, no alcohol, IV heroin use 2-3 months ago or
potentially sooner.
Family History:
Mother alive at 88 with hypertension.
Physical Exam:
At Admission
Vitals: T:99.4 axillary BP:129/64 P:149 R:35 O2: 97% 5LNC
General: tachypneic, cachectic, dyspneic
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, no m/g/r
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no clubbing, cyanosis or edema
MSK: tenderness to palpation over lateral hip and anterior hip.
tenderness with passive extension, passive internal and external
rotation. patient does not actively move his hip joint.
Skin: multiple scars and excoriations on arms.
Pertinent Results:
LABS ON ADMISSION:
[**2131-9-16**] 09:45PM BLOOD WBC-8.6 RBC-6.08 Hgb-14.6 Hct-44.5
MCV-73* MCH-24.1* MCHC-32.9 RDW-16.0* Plt Ct-21*
[**2131-9-16**] 09:45PM BLOOD Neuts-64 Bands-24* Lymphs-4* Monos-5
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2131-9-16**] 09:45PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-3+
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-2+ Burr-3+
Acantho-OCCASIONAL
[**2131-9-16**] 09:45PM BLOOD Plt Smr-VERY LOW Plt Ct-21*
[**2131-9-17**] 06:44AM BLOOD Fibrino-159 Thrombn-12.3
[**2131-9-16**] 09:45PM BLOOD Glucose-130* UreaN-76* Creat-2.2* Na-125*
K-2.8* Cl-88* HCO3-16* AnGap-24*
[**2131-9-16**] 09:45PM BLOOD ALT-68* AST-92* CK(CPK)-52 AlkPhos-136*
TotBili-2.9* DirBili-2.2* IndBili-0.7
[**2131-9-16**] 09:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2131-9-17**] 04:30AM BLOOD Calcium-7.6* Phos-1.9* Mg-2.6
[**2131-9-17**] 06:44AM BLOOD calTIBC-230* Hapto-168 Ferritn-443*
TRF-177*
[**2131-9-16**] 09:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-25.9*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-9-17**] 02:00AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2131-9-17**] 02:00AM URINE RBC-0-2 WBC-[**6-6**]* Bacteri-MOD Yeast-NONE
Epi-0-2 TransE-[**3-1**]
[**2131-9-17**] 02:00AM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-6.5 Leuks-TR
--------------------
RUQ US [**10-22**]: No intra- or extra-hepatic biliary dilatation.
Small gallbladder polyp. Otherwise unremarkable study.
WBC SCAN [**10-17**]: Focal areas of increased radiotracer uptake
projecting over site of known cavitary lesions on recent chest
CT involving the posterior aspect of the right lower lobe most
compatible with lung abscesses.
CT-TORSO [**10-16**]: 1. New right pneumothorax. In a patient with
risk of lung necrosis from complicating infection, differential
diagnosis includes possibility of bronchopleural fistula,
although less likely. Correlate with history of recent
instrumentation. 2. Innumerable cavitary lesions within the
lungs for which the differential diagnosis includes septic
emboli, cavitary pneumonia such as staphylococcus, or less
likely metastasis or acute presentation of Wegner's
granulomatosis. There is interval improvement of air
opacification in the lungs. Interval improvement of appearance
of the pleural effusion, with remaining small right pleural
effusion. 3. Splenic hypodense lesions some could be
hemangiomas; however in keeping with lung findings cannot
exclude septic emboli. 4. Lytic small iliac lesions bilaterally,
incompletely characterized on this study. 5. Multiple bilateral
cystic lesions in the kidneys, likely simple cysts.
MR HEAD [**10-10**]: 1. Multiple small lesions scattered throughout
the bilateral frontal and parietal lobes with varying degrees of
restricted diffusion representing infarcts of varying ages, very
likely embolic and related to known bacterial endocarditis.
There is no hemorrhage.
2. Series of lesions within the paramedian right frontal and
temporo-occipital regions, which appear more acute and may
represent watershed infarcts, in the appropriate clinical
setting (ie. acute [relative] hypotensive event]; there is no
evidence of vascular territorial infarction. 3. Scattered
punctate lesions in the posterior frontal lobes, bilaterally,
corresponding to some of the older foci of resolving restricted
diffusion, above, and likely representing septic emboli. There
is no evidence of microabscess or pathologic leptomeningeal
enhancement. 4. There is no evidence of cerebral venous
thrombosis.
MR [**Name13 (STitle) **] [**10-10**]: 1. C6-7: Findings involving the contiguous
endplates, intervening disc and annuloligamentous complexes,
characteristic of vertebral osteomyelitis/discitis, in this
clinical setting. Though there is no epidural phlegmon or
discrete abscess, there is a likely focal phlegmon in the left
anterolateral prevertebral space, subjacent to that longus [**Last Name (un) **]
muscle, at the C6 level. 2. C5-6: Contiguous findings, though
less marked, are suspicious for a second level of involvement
with discitis/vertebral osteomyelitis; again, no discrete
epidural phlegmon or abscess is seen. 3. No non-contiguous
vertebral involvement, elsewhere in the imaged spine. 4. Normal
cervical spinal cord caliber and intrinsic signal intensity,
with no pathologic leptomeningeal or intramedullary enhancement.
CT HEAD [**9-22**]: Since the CT head of four days prior, there is
increased
conspicuity of subcortical white matter hypodensities which are
bilateral but slightly more prominent on the right. Etiology is
indeterminate. MRI with diffusion-weighted imaging and
post-contrast imaging is recommended for further assessment.
TEE [**9-18**]: The left atrium and right atrium are normal in cavity
size. No atrial septal defect is seen by 2D or color Doppler.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. No mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is likely
partial flail of the anterior tricuspid valve leaflet with
possible leaflet perforation without evidence of a tricuspid
valve abscess. There is a large vegetation measuring 2.8 cm by
1.7 cm in largest dimension on the atrial side of the anterior
leaflet of the tricuspid valve. Severe [4+] tricuspid
regurgitation is seen. There is a small pericardial effusion.
IMPRESSION: Large tricuspid valve vegetation with partial flail
and likely perforation of the anterior tricuspid valve leaflet
in the setting of severe tricuspid regurgitation. Small
pericardial effusion.
MRI HIPS [**9-17**]: IMPRESSION:
1. Fluid tracking along the gluteal muscles bilaterally, left
more than right extending to the greater trochanter likely
represents bursitis.
2. Mild intramuscular edema may be inflammatory or reactive in
nature.
3. Diffuse signal abnormality of the visualized osseous
structures signifying anemia or chronic disease.
CT TORSO [**9-17**]: IMPRESSION:
1. Innumerable cavitatory lesions within the lungs, for which
the
differential includes septic emboli (favored given the lesions
in the spleen), cavitatory pneumonia (such as Staph aureus) or
less likely metastases or acute presentation of Wegener's
granulomatosis.
2. Splenic lesions likely represent septic emboli less likely in
this
clinical context of neoplasm/metastases.
3. Bilateral pleural effusions and associated relaxation
atelectasis.
4. Lytic lesions in the iliacs bilaterally are incompletely
characterized onthis study. In the absence of prior imaging
stability/acutity cannot be
assessed. Recommend bone scan and/or MR are for further
characterization.
5. Multiple bilateral renal hypodensities, simple in attenuation
and
structure, likely simple cysts.
MICROBIOLOGY:
[**2131-9-17**] 06:44AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HAV-NEGATIVE
[**2131-9-17**] 11:10AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2131-9-17**] 03:05PM BLOOD HIV Ab-NEGATIVE
[**2131-9-17**] 06:44AM BLOOD HCV Ab-POSITIVE*, HCV VIRAL LOAD NEGATIVE
[**2131-9-17**] Urine culture: STAPH AUREUS COAG +. >100,000
ORGANISMS/ML..
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
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 +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2131-9-19**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 26976**] [**Last Name (NamePattern1) **] AT 10:50PM ON
[**2131-9-19**].
GRAM STAIN (Final [**2131-9-18**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2131-9-20**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
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----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
This is a 57 year old man with pmh IV drug use, cutaneous SLE,
endocarditis, presenting with three days of gastrointestinal
symptoms, followed by intense left hip pain, along with multiple
lab abnormalities including bandemia, thrombocytopenia, elevated
transaminases, and coagulopathy found to have a large MRSA
vegetation on tricuspid valve.
# Sepsis / Endocarditis: patient intially presented with sepsis
was intubated and started on pressors. Initial TTE showed a TV
vegetation and mild TR with moderate pulmonary HTN and systolic
HTN. A follow up TEE showed large TCV vegetation with partial
flail and possible perforation of anterior tricuspid valve
leaflet with severe TR, small pericardial and complex pleural
effusions. Blood cultures were also possitive for MRSA. ID was
consulted and patient was started on IV Vancomycin. Additional
imaging was performed which showed multifocal lung lesions and
splenic lesions consistent with septic emboli. Imaging was also
performed for his initial complaint of hip pain which was only
significant for bursitis. Cardiac surgery was consulted and felt
the patient was an extremely poor surgical candidate given the
severity of his condition. Patient remained persistently
tachycardic throughout his stay. Cardiology was consulted and
felt his persistent sinus tachycardia was a physiologic response
to TR in an effort to maintain adequate cardiac output. They
initially advised diuresis as appropriate as the only potential
medical therapy to help reduce RV strain. A repeat TTE was
performed on [**9-21**] which showed worsening TR and RV strain. On
[**9-22**] a CT head was performed to evaluate altered mental status
(patient remained unresponsive despite no sedation) and concerns
for ICH given setting of multiple septic emboli which showed
foci of subcortical white matter hypodensities in bifrontal
lobes extending from the superior convexity to the inferior
frontal lobes. Gentle diuresis with lasix gtt was continued and
then stopped for increased pressor requirements. On [**9-24**] a
repeat TTE was performed which showed mild interval improvement.
Clinical exam began to change with improving mental status and
decreased ventilation requirements. On [**9-27**] a power PICC line
was placed in hopes of decreasing the line burden. On [**9-28**] the
patient was successfully extubated. He remained alert,
interactive, able to follow commands but appeared very weak
overall. At the time of transfer to the floor, he continued to
have daily fever spikes and tachycardia, to be expected with his
underlying endocarditis. On the floor he had an episode of
hypoxia and tachycardia and was transferred back to the ICU.
With each progressing day he gained strength in his upper and
lower extremties as well as his voice. His fevers were less
frequent and his white count decreased. An abdominal u/s was
done due to rising AP which was negative for obstruction.
He was transferred to the medical floor for further management.
The patient remained in sinus tachycardia throughout his stay,
near the 130's, likely a hyperdynamic response to severe TR and
underlying infection. He required around the clock alternating
Acetaminophen and Motrin for fever control. His fever curve was
periodically checked off the anti-inflammatories but
persistently returned, associated with rigors. ID felt this will
be his prolonged clinical picture in the setting of multiple
pulmonary abscesses [**1-29**] the endocarditis. Additional fever
workup was also performed including an opthomology consult which
ruled out endopthalmitis, a WBC scan which targetted the lungs,
and a MRI which showed a C5-6 and C6-7 discitis and possible
osteomyelitis. Cardiac surgery followed patient as well and felt
that no surgical intervention was appropriate at this time. This
may be revisted after the course of antibiotic therapy is
complete.
Also of note, the patient began to have large urine outputs
while on the floor in the setting of known septic emboli to his
brain. The pituitary looked unaffected on MRI but there is some
suspicion that he may be suffering from central DI. A water
deprivation test was performed which was inconclusive. Patient
was able to keep up with his urine output as long as he has
access to adequate PO fluids.
Also of note, liver was consulted regarding an isolated alkaline
phosphatase elevation that progressed throughout his
hospitalization. [**Doctor First Name **], AMA, [**Last Name (un) 15412**] and IgG were all sent and
pending at the time of discharge. Initial differential for
possible etiologies included infiltrative process vs. drug
induced process. The patient will require an outpatient
ultrasound guided percutaneous liver biopsy to rule out
infiltrative process. He should also follow up with Liver at
[**Hospital1 18**] for further evaluation. They are aware and expecting
patient.
Infectious Disease followed throughout the hospitalization and
recommended continued INTRAVENOUS VANCOMYCIN (no substitutions)
with goal trough of 20 through [**11-18**]. They will be
following his labs and appointments have been made for follow
up. They will evaluate if patient will require additional
antibiotcs after complete of this 2 month course.
Patient was advised never to use drugs again.
# Respiratory status/sedation: Patient was intubated for
respiratory distress (intially presented with RR to 50's).
Imaging showed a multifocal PNA c/w septic emboli from his TCV
endocarditis. He was initially started on an ardsnet protocol
but was later switched to PSV. His ventilator requirements
gradually improved throughout his MICU stay and he was
successfully extubated on [**9-28**]. He now is saturating well on RA.
Throughout his stay on the medical floor, his respiratory exam
substantially improved. Repeat CT-chest imaging showed marked
interval improvements in lung infection; however, it did reveal
a small, stable retrocardiac pneumothorax. IP felt no
interventions were required. The patient continued to have
fevers throughout his stay and interventional pulmonology were
consulted to evaluate for possible drainage; after additional
imaging was obtained, they recommended persistent medical
management.
# Tachycardia: Pt was found to have worsening tachycardia
several days into his MICU stay. Repeat TTE showed worsening TR.
Cardiology was consulted and felt that this was a physiologic
response to poor forward flow. They also noted that B-blockade
would be dentrimental. They also recommended gentle lasix gtt to
help offload the RV which was attempted and limited by pressor
requirements. The episodes of worsening tachycardia were also
noted to correlate with fever spikes. The patients tachycardia
persists at discharge and likely represents a hyperdynamic
response to poor forward flow [**1-29**] TR. This is exacerbated by
fevers which is responsive to Tylenol, Motrin and gentle fluid
boluses
# Weakness: Pt initially slow to recover s/p extubation. Initial
differential included myopathy of chronic disease vs. central
process. MR of the head and C-spine showed areas of likely
septic embolization. Neuro exam and strength gradually
increased throughout hospital stay and patient was near baseline
and non-focal at time of discharge.
# Microcytic anemia: Fe studies showed low Fe with elevated
Ferritin (likely [**Month (only) **]). Hemolysis labs were unremarkable. The
anemia is likely multifactorial with possible component of Fe
deficiency and anemia of chronic disease. HCT were reoutinely
monitored throughout his stay and remained stable.
# Liver abnormalities: transaminases were noted to be slightly
elevated throughout his admission. AP also noted to gradually
rise in the setting of a normal BR. A GGT level was tested which
verified the AP was a biliary source. Hepatitis serologies were
performed which showed no active disease. There were no findings
on abdominal u/s to suggest liver abnormalties or obstruction.
Liver was consulted regarding the isolated alkaline phosphatase
elevation (it progressed throughout hospitalization). [**Doctor First Name **], AMA,
[**Last Name (un) 15412**] and IgG were all sent and pending at the time of discharge.
Initial differential for possible etiologies included
infiltrative process vs. drug induced process. Unsuccessful
attempts were made to obtain an in-patient liver biopsy. The
patient will require an outpatient ultrasound guided
percutaneous liver biopsy to rule out infiltrative process. He
should also follow up with Liver at [**Hospital1 18**] for further
evaluation. They are aware and expecting patient.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours. Tablet(s)
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for fever. Tablet(s)
4. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
5. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
every twelve (12) hours for 1 months: This Medication Should Be
continued until [**11-18**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Dx
- Tricuspid Valve Endocarditis
Secondary Dx
- severe Triscuspid Regurgitation with persistent sinus
tachycardia
- septic emboli to lung, spleen, brain
- C [**5-2**] and C [**6-3**] discitis with extra-epidural phlegmon
- trochanteric bursitis
- anemia of chronic disease
- retrocardiac pneumothorax - stable
- isolated alkaline phosphatase elevation
Discharge Condition:
Improved
- sinus tachycardia to 130's at baseline
- persistent fevers (likely from pulmonary abscesses) suppressed
by around the clock Tylenol and Advil
Discharge Instructions:
Mr. [**Known lastname 66673**],
You were admitted to the hospital for a serious infection
involving your heart. This infection is caused by bacteria. This
bacteria was introduced into your body most likely from your
intravenous drug use. Parts of this heart infection broke off
and spread throughout your body, also infecting your lungs,
spine and potentially your brain and spleen. This was a very
serious infection which almost took your life. You will require
an extensive course of IV antibiotics (NOT ORAL) for this
infection and close follow up with the Infection sepcialists at
[**Hospital1 18**]. Please stay at the rehab facility and complete your
entire course of IV antibiotics. This infection is very serious,
and any pause in your treatment may cause you to become very
very sick.
Once you leave the rehab facility, please call your primary care
doctor listed below or return to the emergency department for
any of the following:
- increased fevers, shaking chills
- chest pain, shortness of breath
- increasing weakness, confusion
- nausea, vomiting, abdominal pain
- any other symptoms which concern you
Please note the follow-up appointments we have made for you
Infectious Diseases - [**Hospital1 18**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2131-11-13**] 9:00
Liver Center - [**Hospital1 18**] [**Hospital Unit Name **]
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] / [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-19**] 8:10
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2131-11-13**] 9:00
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] / [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-11-19**] 8:10
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2131-11-15**] 3:15
Patient should also be re-evaluated by cardiology or cardiac
surgery after completion of his medical management to evaluate
for any surgical interventio
ICD9 Codes: 486, 5849, 5119, 2761, 2760, 2875, 4168, 2768, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5461
}
|
Medical Text: Admission Date: [**2146-10-20**] Discharge Date: [**2146-10-25**]
Date of Birth: [**2082-12-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cefepime / Bactrim
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
shortness of breath, fever
Major Surgical or Invasive Procedure:
Chest tube placement
History of Present Illness:
Mr. [**Known lastname 24735**] is a 63 y/o M with a history of AML s/p allo SCT
[**10/2144**], chronic GVHD (liver, skin, ?lung) on prednisone and
cyclosporine who presents from home with fever and worsening
shortness of breath after bronchoscopy/biopsy on the day prior
to admission. He reports that there were no immediate
complications following the procedure. The next morning, the
patient reports worsening dyspnea and the onset of fever. Per ED
report, the patient's wife also reports that he has had altered
mental status on the day of admission.
.
Of note, the patient was recently seen by pulmonary in
consultation for daily productive cough over at least five
months. He was prescribed moxifloxacin for ten days after a CT
chest ([**2146-8-30**]) demonstrated mosaic ground-glass attenuation
with bronchiectasis throughout and in left lower lobe a
tree-in-[**Male First Name (un) 239**] pattern also notable for a lingular consolidation
(pulmonary read). There was also diffuse mosaic attenuation
affecting small airway obstruction and the thought that this
could be a transplant-related bronchiolitis obliterans. The
patient completed the moxifloxacin without change in his
respiratory symptoms. He subsequently underwent bronchoscopy
with transbronchial biopsy on the day prior to admission.
.
In the ED inital vitals were, 120 25 97% on NRB 156/86. Exam
significant for diffuse rhonchi throughout, alert and oriented
to person place and month but easily distractible and answers
questions slowly. Labs were significant for Na 125, WBC 13.4,
lactate 2.6. Chest x-ray revealed large left pneumothorax
without mediastinal shift. A 28 French chest tube was placed in
the ED, and
repeat chest x-ray showed lung re-expansion, with the chest tube
curving inferiorly. Patient was given vancomycin, zosyn,
azithromycin (BAL from [**10-19**] showing Moraxella Catarrhalis, G+
cocci in pairs and chains, and G- diplococci). He recived
fentanyl 250 mg IV X 1 during the chest tube insertion. He was
also given stress dose Solu-Medrol 125 mg IV X 1.
.
On arrival to the ICU, the patient reports improvement in his
breathing, he is A+OX3. Denies any SOB, cough, sputum.
Past Medical History:
1. AML s/p allo SCT D+105:
- [**3-/2144**]: presented to [**Hospital **] hospital with fatigue and
weakness. His Hgb was 4.9, WBC 14.8 (16% neutrophils, 2%
bands,26% lymphocytes, and 55% monocytes). BMBx was notable for
a population of monoblasts and promonocytes which appeared to
approach 20%. He was diagnosed with AML-M5. Cytogenetics were
notable for +8.
- initially treated with 7 and 3 (idarubicin and ARA-C, however,
day 14 marrow showed persistent blasts. He was enrolled in the
randomized trial of HiDAC with or without clofarabine and began
treatment on [**2144-4-27**]. This course was c/b fevers to 105, rashes,
LFTs 300s.
- [**2144-6-23**]: Bone marrow showed a mildly hypercellular erythroid
dominant bone marrow with no morphologic evidence of leukemia.
- [**2144-8-17**]: received single cycle Dacogen due to donor issues
- [**2144-11-5**]: started reduced intensity conditioning with
Fludarabine-Busulfan and ATG. Day 0 was [**2144-11-12**]. He received
one bag CD34/kg x 10e6= 8.40. His post-transplant course was
uncomplicated with the exception of a mild transaminitis. He was
discharged to the apartments on Day +14.
Donor Info: recipient is CMV(+), ABO:Opos donor NMDP#5188-3407-2
male CMV(-), ABO:Apos.
2. EBV-related lymphoproliferative disease
3. ABO mismatch
4. Testicular Cancer: s/p orchiectomy and chemotherapy 20 years
ago at [**Hospital3 328**]
5. Hypertension
6. Renal insufficiency
Social History:
Married with 2 children and 3 grandchildren. Formerly in sales,
now on disability. He has no history of tobacco use, one drink
every other day.
Family History:
Father died from liver cancer. Mother with [**Name (NI) 2481**]. All
siblings have HTN.
Physical Exam:
Admission Physical Exam:
Vitals: T: 96.7 BP: 139/78 P: 105 R: 20 O2: 94% NRB
General: Alert, oriented, no acute distress, slow to respond
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: BS b/l, course rhochi b/l, no wheezes or rales
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
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
Discharge Physical Exam:
Pertinent Results:
MICROBIOLOGY:
Sputum culture ([**2146-10-21**])- GRAM STAIN (Final [**2146-10-21**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Blood culture ([**2146-10-20**])- pending, no growth to date
Blood culture ([**2146-10-20**])- STREPTOCOCCUS PNEUMONIAE.PRELIMINARY
SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
VANCOMYCIN------------ S
Aerobic Bottle Gram Stain (Final [**2146-10-21**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39446**] [**2146-10-21**]
@1900.
Anaerobic Bottle Gram Stain (Final [**2146-10-21**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Bronchoalveolar lavage (left lower lobe, [**2146-10-19**])-
GRAM STAIN (Final [**2146-10-19**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
MORAXELLA CATARRHALIS. >100,000 ORGANISMS/ML..
STREPTOCOCCUS PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Tissue biopsy (left lower lobe, [**2146-10-19**])-
GRAM STAIN (Final [**2146-10-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 12:50PM ON
[**2146-10-20**].
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
RARE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH.
MORAXELLA CATARRHALIS. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2146-10-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Tissue culture (Left upper lobe transbronchial biopsy,
[**2146-10-19**])-
GRAM STAIN (Final [**2146-10-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2146-10-22**]):
Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 12:50 PM ON
[**2146-10-20**].
STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
335-7795G
[**2146-10-19**].
MORAXELLA CATARRHALIS. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # 335-7795G
[**2146-10-19**].
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2146-10-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING:
CXR ([**2146-10-22**])- Slight interval improvement in aeration.
Persistent patchy opacity of the left base and unchanged
subcutaneous emphysema. However, there is no evidence of
pneumothorax. Stable cardiac and mediastinal contours. No
evidence of pulmonary edema.
CXR ([**2146-10-20**])- AP upright portable view of the chest was
obtained. In the
interval since the prior study, there has been development of a
very large
left pneumothorax with collapse of the left lung. There may be
slight tension component. The right lung is clear. No pleural
effusion. The left cardiac border appears somewhat flattened,
which may be due to tension.
IMPRESSION: Interval development of large left pneumothorax
CT Chest ([**8-30**]):
1. Since [**2146-4-20**], left lower lobe and lingular consoldation
has resolved leaving behind brochiolitis and bronchiectasis, and
previous multifocal bronchiolitis has minimally decreased.
Overall improvement in lung consolidation is probably resolving
infection , but focal consolidation in inferior lingular segment
is new and could be infectious or non-infectious organzing
pneumonia. Similarly, the multifocal bronchiolitis picture can
be infectious or non-infectious, transplant-related,
bronchiolitis obliterans.
2. Diffuse mosaic attenuation reflects small airway obstruction,
a finding often seen with transplant-related, bronchiolitis
obliterans
Brief Hospital Course:
Mr. [**Known lastname 24735**] is a 63 y/o male with a history of AML s/p allo SCT
[**10/2144**] (D+703), chronic GVHD (liver, skin, ?lung) on prednisone
and cyclosporine who presented from home with fever to 102 and
increasing shortness of breath after bronchoscopy/biopsy on the
day prior to admission, found to have left pneumothorax and
persistent LLL consolidation.
.
#.PNEUMOTHORAX: Patient had a bronchoscopy with biopsy on the
day prior to admission which likely caused pneumothorax to
develop. Chest tube was placed in the ER with re-expansion of
the lung. Patient was followed by interventional pulmonology
Patient self-discontinued chest tube on the evening of
admission, and serial chest x-rays showed that the lung remained
expanded without need for replacement of chest tube. Patient was
weaned off of oxygen successfully and repeat chest x-rays
continued to show no reaccumulation of pneumothorax.
.
#.LLL CONSOLIDATION: patient had fever and leukocytosis on
admission, likely secondary to infectious vs. non-infectious
organizing pneumonia. Other possible cause was strep pneumo
bacteremia, although less likely (see below). Patient has h/o 3
episodes of pneumonia in early [**2145**]. Also has chronic cough
since [**2146-3-20**], thought to be [**12-22**] GVHD versus organizing
pneumonia. Bronchoalveolar lavage on [**10-19**] showed moraxella
catarrhalis and strep pneumoniae, strep sensitive to
levoquin/PCN G/tetracycline/bactrim/vancomycin. On [**10-23**],
vancomycin was discontinued and pt started on Levoquin. As
patient reported history of achilles tendon swelling on
Levoquin, as well as h/o diarrhea with penicillins and
macrolides (augmentin and azithromycin are best agents for
moraxella), he was switched to moxifloxacin 400mg PO BID to
complete 2 week course. He has tolerated moxifloxacin in the
past without complications. White count and fever curve rapidly
trended back to normal during hospitalization.
.
#.STREP PNEUMO BACTEREMIA: pt with 2/4 bottles growing strep
pneumo on [**10-20**], sensitive to levofloxacin, tetracycline,
bactrim, vancomycin. [**Month (only) 116**] have been secondary to disruption of
pulmonary parenchyma during transbronchial biopsy, given pt's
chronic immunosuppression putting him at greater risk for this
issue. Per above, patient treated with moxifloxacin rather than
levoquin due to h/o achilles tendon swelling on levoquin.
Surveillance blood cultures all without growth to date.
.
#.AML s/p ALLOGENEIC STEM CELL TRANSPLANT: pt is s/p 7+3 with
idarubacin and ARA-C, followed by HiDAC consolidation. He
received allogeneic SCT from an unrelated on [**2144-11-12**] after
conditioning with fludarabine, busulfan, and ATG. His course has
been complicated by liver, skin and ?lung GVHD. Also developed
EBV, which caused lymphoproliferative disease. Has also been
found CMV positive.
.
# GVHD OF LIVER, SKIN AND ?LUNG: complication of patient's
allogeneic stem cell transplant in [**2143**]. Patient followed by Dr.
[**Last Name (STitle) **]; purpose of preceding transbronchial biopsy was to
determined whether lung GVHD was present. Patient continued on
home Prednisone 10mg PO daily and Cyclosporin 25mg PO daily.
.
#.HYPONATREMIA: hypovolemic hyponatremia. Resolved with IV
fluids.
.
#.HYPOTHYROIDISM: continued home levothyroxine.
.
#.HYPERTENSION: continued home moexipril 15mg PO daily.
.
=========================
TRANSITION OF CARE:
-galactomannan/bglucan pending
Medications on Admission:
ACYCLOVIR - 400 mg Tablet by mouth three times a day
ATOVAQUONE - 10 mL by mouth daily (1500 mg)
BENZONATATE - 100 mg by mouth three times a day as needed for
cough
CLOBETASOL - 0.05 % Cream - twice a day
CYCLOSPORINE MODIFIED - 25 mg by mouth once a day
ERGOCALCIFEROL - 50,000 unit by mouth every other week
FOLIC ACID 1 mg by mouth once a day
LEVOTHYROXINE - 88 mcg by mouth once a day
MOEXIPRIL - 15 mg by mouth daily
PREDNISONE - 10 mg by mouth daily
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cyclosporine modified 25 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO QDAY () for
14 days: First day = [**2146-10-23**]
Last day = [**2146-11-5**].
Disp:*11 Tablet(s)* Refills:*0*
9. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed for cough.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
Disp:*1 inhaler* Refills:*2*
11. nebulizer machine
Please dispense one nebulizer machine.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Pneumothorax
2. Pneumonia
SECONDARY DIAGNOSES:
1. Graft Versus Host Disease (GVHD)
2. Acute Myelogenous Leukemia, in remission
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 24735**],
It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the hospital with
a punctured lung (pneumothorax) after having a bronchoscopy.
This was treated with a chest tube. You were also found to have
a pneumonia, which was treated with antibiotics.
Please attend the follow-up appointments listed below with your
oncologist Dr. [**Last Name (STitle) **] and your pulmonologists Dr. [**Last Name (STitle) 4011**] and Dr.
[**Last Name (STitle) **] to follow up on your pneumonia and your chronic lung
problems.
We made the following changes to your medications:
1. ADDED moxifloxacin 400mg by mouth daily for 14 days (first
day = [**2146-10-23**], last day = [**2146-11-5**])
2. ADDED albuterol nebulizer once every 6 hours as needed for
wheezing or shortness of breath
Please see your doctor if you develop increased swelling or pain
in your Achilles tendons while you are on Moxifloxacin, as this
could be a side effect of the medication.
Followup Instructions:
Department: PULMONOLOGY
When: Monday, [**2146-11-7**] at 3:10 PM
With: Dr. [**Last Name (STitle) 4011**] and Dr. [**Last Name (STitle) **]
Building: [**Hospital6 **] [**Location (un) **], [**Apartment Address(1) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2146-11-3**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2146-11-3**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2146-11-3**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 7907, 496
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5462
}
|
Medical Text: Admission Date: [**2157-5-5**] Discharge Date: [**2157-5-9**]
Date of Birth: [**2092-8-26**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
descending thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2157-5-5**] - Total percutaneous thoracic aneurysm stent graft
repair, with Zenith TX2 30-120, bilateral femoral artery access
using ultrasound guidance, bilateral catheter in the aorta,
stent graft repair of descending thoracic aortic aneurysm,
thoracic and abdominal aortography
History of Present Illness:
The patient is a 64-year old male who has a penetrating aortic
ulcer or a focal dissection that has become aneurysm which has
increased in size. He was not a candidate for open surgery. He
was admitted for descending thoracic aortic aneurysm repair.
Past Medical History:
PMH: thoracic aortic aneurysm, history of pulmonary emboli (s/p
IVC filter), h/o infected infrarenal aortic aneurysm/aortitis,
bacterial meningitis (S. pneumoniae), anterior spinal artery
infarct, colonic diverticulosis, diabetes mellitus,
hypertension, hyperlipidemia, thoracic vertebral fracture
PSH: s/p IVC filter, s/p infrarenal aortobiiliac reconstruction
([**4-/2155**]), s/p umbilical hernia repair, s/p eye laser surgery for
macular edema
Social History:
From the [**Country 13622**] Republic, lives alone but his daughter lives
nearby; retired from work, ceased smoking 20-years prior, denies
alcohol use
Family History:
no history of premature coronary artery disease
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. No evidence of carotid bruits.
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: The right lower extremity is warm well-perfused and is
without erythema, drainage or edema. The left lower extremity is
warm well-perfused and is without erythema, drainage or edema.
Percutaneously closed groin incisions clean, dry and intact
without hematoma or drainage.
PULSE EXAM: weakly palpable DP pulses bilaterally
Pertinent Results:
[**2157-5-7**] 02:39AM BLOOD WBC-7.7 RBC-3.06* Hgb-9.7* Hct-28.5*
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.6 Plt Ct-255
[**2157-5-7**] 02:39AM BLOOD PT-13.9* PTT-25.2 INR(PT)-1.2*
[**2157-5-7**] 02:39AM BLOOD Glucose-154* UreaN-9 Creat-1.0 Na-137
K-3.9 Cl-104 HCO3-22 AnGap-15
[**2157-5-7**] 02:39AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.9
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#0-1. The
patient remained neurologically intact and without change from
baseline during their stay. The patient remained alert and
oriented to person, location and place. His neurologic exam
following the procedure was assessed frequently and was
reassuring. A lumbar drain was placed pre-op to maintain
cerebral perfusion pressures for neurologic cord protection. The
patient had CSF removed to maintain 10 cmH20 of pressure. The
lumbar drain was removed on POD#2 without issue. Initially the
patient was maintained in the cardiovascular ICU with transfer
to the VICU when stable.
CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. The patient
was maintained on IV anti-hypertensive medication (Nitroglycerin
IV gtt) in the immediate post-op period to maintain SBP between
120-160 mmHg, with transition to their oral home
anti-hypertensives on POD#[**1-27**]. Their vitals signs were closely
monitored with telemetry. A beta-blocker was initiated, as well
as a statin medication upon admission,
The patient did well following their vascular procedure. The
patient was closely monitored with serial pulse exams in the
post-op period. If appropriate, doppler signaling was frequently
assessed in the involved extremity. Their post-op pulse exam
demonstrated bilaterally dopplerable DP pulses. The patient's
cardioprotective dose of Aspirin was continued post-op. The
patient was restarted on his home dosing of Coumadin of 2.5-5 mg
PO daily on POD#2. His PCP will [**Name9 (PRE) 702**] his INR in clinic on
discharge and he will continue his Coumadin medication.
RESPIRATORY: The patient was extubated in the immediate post-op
period successfully. The patient had no episodes of desaturation
or pulmonary concerns. The patient denied cough or respiratory
symptoms. Pulse oximetry was monitored closely and the patient
maintained adequate oxygenation.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#2. The
patient experienced no nausea or vomiting. The patient was
transitioned to a regular/cardiac healthy diet on POD#3 and IV
fluids were discontinued once adequate PO intake was
established.
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. The
patient's intake and output was closely monitored for UOP > 30
mL per hour output. The patient's creatinine was stable. The
Foley catheter was replaced for some mild urinary retention on
POD#3 and he was sent with a Foley leg bag with PCP [**Name9 (PRE) 702**]
for [**Name Initial (PRE) **] void trial.
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
stable, patient was on Coumadin. The patient had no evidence of
bleeding from their incision.
ID: The patient showed no signs of infection and remained
afebrile in the post-op period, with the exception of a
low-grade temperature on POD#1. Blood cultures were unrevealing.
Their white count was stable post-operatively and their incision
was closely monitored for any evidence of infection or erythema.
The patient received only standard peri-operative antibiotics,
and did not require further antibiotics post-op.
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. Home hypoglycemic medications were held while the
patient was NPO--these medications were resumed with a sliding
insulin scale once oral intake was tolerated.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID 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 will continue with
outpatient PT services.
Medications on Admission:
Amitryptiline 10 mg', Gabapentin 900 mg''', Glipizide 5 mg'',
Metoprolol 50 mg'', Simvastatin 20 mg', Warfarin 4 mg', Zolpidem
5 mg', Docusate 100 mg', Ferrous gluconate 325 mg''', Senna 8.6
mg''
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. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. 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*
5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. 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*
13. warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: 2.5
mg daily (Monday, Tuesday and Wednesday), 5 mg daily (Thursday
through Sunday).
Disp:*50 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Please have Foley catheter/leg bag removed by your PCP for void
trial
15. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Descending thoracic aortic aneurysm
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:
THORACIC AORTIC STENT GRAFT:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-30**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2157-6-14**] 1:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2157-6-14**] 2:15
You have an appointment with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
Tuesday, [**2157-5-10**] at 11:15 AM. Your INR will be checked and
a voiding trial will commence.
ICD9 Codes: 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5463
}
|
Medical Text: Admission Date: [**2116-6-1**] Discharge Date: [**2116-6-13**]
Date of Birth: [**2050-4-3**] Sex: M
Service: MEDICINE
Allergies:
Neupogen / Neurontin / Dilaudid
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
HD catheter change over wire
Midline placement
History of Present Illness:
Mr. [**Known lastname **] is a 66 yo M with Obesity hypoventilation syndrome,
?COPD, afib s/p cardioverson, ESRD on HD, PVD with recent
admission for TMA ulcer s/p debridement who presents with
altered mental status, shortness of breath, and hypotension. The
patient was found to be confused at [**Hospital3 2558**] with T96,
HR102, BP70/52, RR21, 80%RA -> 90%3L. Underwent routine [**Hospital3 2286**]
on saturday, but stopped 15 min short because his [**Hospital3 2286**]
catheter clotted. His wife states that he has been declining
over the last few weeks. He has also complained of burning in
his urine over the last few days. At baseline he is oriented,
though occationally confused.
.
In the ED, T 103.4, BP 60-70s systolic. R femoral line placed.
Given vanco, zosyn, 125mg solumedrol for wheezing on exam. CXR,
CT torso performed. His BP remained <90 systolic after 2L IVF ->
levohed started. ABGs 7.14/81/220 on NRB. Lactate normal.
Patient was put on CPAP with ABG 7.13/71/75. He was then takn
off CPAP because he seemed more somnolent. However, respiratory
then placed him on BiPAP with improvement in his symptoms. Per
the family, the patient is DNI. Responds to voice but is sleepy.
.
On arrival to the floor, he is somnolent but arousable, though
quickly falls back asleep.
Past Medical History:
PMH:
1) Atrial Fibrillation - s/p cardioversion in [**10-13**]. Was
maintained on coumadin for 6 months. Currently not
anticoagulated due to fall risk.
2) Pericardial effusion - s/p drainage, unclear etiology
3) ESRD from ATN in setting of acute gastroenteritis, s/p failed
cadaveric kidney transplant in [**2109**]. Dialyzed at [**Location (un) **] Tues,
Thurs, Sat.
4) Abdominal wall hernia - s/p repair after transplant
5) Multiple knee surgeries 20 years ago
6) Poor access, Right Tunnelled line
7) Baseline SBP's in 90s
9) Hypercapnia due to obesity hypoventilation syndrome
10) non-melanoma skin cancer
11) septic knee
Social History:
Denies any history of Tobacco use, no EtOh use for [**Last Name (un) **] than 20
years, no drug use. Lives with his wife, now on disability. Used
to work as a spray painter. Has 3 children and multiple
grandchildren.
Family History:
History of CAD (mother died at age 70), cancer
Physical Exam:
Gen: somnolent/sleeping, snoring, arousable to painful stimuli
HEENT: anicteric sclera, MM dry, PERRL
Neck: large, supple, no LAD
Heart: Irregularly irregular, no m/r/g
Lung: Coarse BS anteriorly, ppor inspiratory effort,
uncooperative
Abd: obese, soft NT/nD +BS no rebound or guarding
Ext: s/p R foot amp with VAC in place, no pitting edema
Skin: diffuse ecchymosis in upper ext
Neuro: somnolent, arousable, moving arms
Pertinent Results:
Lab Data:
141 \ 102 \ 22 \ 69
5.7 \ 23 \ 5.1
.
ALT: 15 AP: 111 Tbili: 0.3 Alb:
AST: 54
Lip: 9
.
11.6 \ 10.7 / 181
/ 35.5 \
.
N:86.7 L:8.1 M:3.1 E:1.3 Bas:0.7
.
PT: 15.6 PTT: 33.6 INR: 1.4
.
U/A: large blood, few bacteria
.
ABG: 7.13/71/75
.
Imaging:
CXR:
UPRIGHT RADIOGRAPH OF THE CHEST: The heart size is mildly
enlarged. Mild perihilar congestion is noted bilaterally.
Mediastinal contours are prominent. Increased interstitial
markings are noted in the right
perihilar region. The distal tip of [**Last Name (un) 2286**] catheter projects
into the right atrium.
IMPRESSION: Increased interstitial markings of the right hilum.
DIfferentials include asymmetric pulmonary edema or aspiration.
.
CT Head:
No acute processes
.
CT Torso:
No PE
Small R pleural effusion.
No acute intraabdominal findings.
.
EKG: Afib with RVR at 115bpm, no chage otherwise from prior.
.
TTE [**6-2**]:
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
IMPRESSION: Suboptimal technical quality. Global left
ventricular function is probably normal, but a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen. No pathologic valvular abnormality seen. Pulmonary
artery systolic pressure is mildly elevated.
.
Compared with the prior study (images reviewed) of [**2116-5-13**],
there is less tricuspid regurgitation. Left ventricular function
appears slightly more vigorous. The heart rate is now slower.
Brief Hospital Course:
66 yo M with obesity hypoventilation, atrial fibrillation not on
coumadin, ESRD on HD, and PVD with recent TMA ulcer s/p
debridement, who presents with altered mental status and
hypotension in the setting of HD catheter related VRE line
sepsis.
# VRE Sepsis: Due to contaminated HD line. Patient presented
with altered mental status and hypotension requiring pressors
(levophed) and high dose steroids in ICU. Initially was treated
with Vancomycin/Zosyn until line cultures from HD line grew VRE,
then switched to Daptomycin. No evidence of endocarditis on TTE,
although was of poor quality. Negative surveillance cultures and
no new murmurs on exam or stigmata of endocarditis. Patient
eventually became more hemodynamically stable, defervesced, and
pressors were weaned off. Treated with daptomycin (dosed on HD
days) for [**Last Name (un) **] related sepsis (start date from day of HD line
removal on [**5-7**]). Was placed on a steroid taper
(prednisone) to be eventually weaned down to his home dose of 5
mg PO daily. Patient underwent a TTE and subsequently a TEE to
evaluate for possible endocarditis which was negative. HD line
was removed and new line was placed. Patient to complete 14 day
course of IV antibiotics to be completed on [**2116-6-19**].
.
#Hypercarbic Respiratory Failure:
ABG on presentation consistent with acute on chronic respiratory
acidosis which improved on BiPAP and was continued on the floor.
Continued albuterol nebs. Eventually weaned off oxygen and
satting > 90% on room air on discharge.
.
#Altered Mental Status: Likely due to sepsis + hypercarbia.
Required haldol and zyprexa in the ICU. Eventually recovered and
was AOx3 and back to baseline status after sepsis and
hypercarbia were both treated (see above) and when called out to
the floor.
.
#Atrial fibrillation: Rate controlled. Not anticoagulated due to
fall risk. Held meds in setting of sepsis, but were restarted
once hemodynamically stable (digoxin and metoprolol).
# ESRD on HD: Patient is s/p failed cadaveric renal transplant,
and receives HD on TThSat. Was noted to be confused and
hypotensive at HD. Renal followed while in house. HD tunneled
line was pulled and a femoral line was placed for HD
temporarily. Once surveillance cultures were negative, tunnelled
HD line was replaced in R subclavian position and HD was
continued.
# PVD s/p TMA debridement: He is s/p surgery on [**5-11**] with wound
vac placement. Has known peripheral [**Month/Day (4) 1106**] disease. Tissue
culture without growth on culture. Was seen on [**5-22**] by Dr.
[**Last Name (STitle) 3407**] with good granulation tissue. Patient was continued on
plavix and aspirin. Wound care saw the patient and was concerned
about right foot where vac tissue had been. [**Last Name (STitle) **] surgery was
reconsulted regarding possible bone exposure and question of
osteomyelitis. [**Last Name (STitle) **] surgery replaced a wound vac which needs
to be changed every three days. He will will need follow up with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within the next week as he will likely need a
skin graft on his right metatarsal.
# L knee pain: Subacute onset, appears to be in patellar space.
[**Month (only) 116**] be due to chronic osteoarthritis from obesity. LENIs
negative for DVT. No popliteal cyst palpated. Does have history
of septic arthritis of the knees in the past, but no effusions
noted on exam. Continued percocet prn for pain and monitored.
# Hyperglycemia: No history of DM. [**Month (only) 116**] be elevated in setting of
recent infection.
Treated with humolog insulin sliding scale and will be
discharged back to rehab on sliding scale.
#Code: DNR/DNI
Medications on Admission:
Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours)
Clopidogrel 75 mg PO DAILY
Omeprazole 20 mg PO DAILY (Daily).
Prednisone 5 mg PO at bedtime.
Simvastatin 10 mg PO DAILY
Vitamin A 10,000 unit (1) Tablet PO once a day.
Heparin (5000 Units) Injection TID
Digoxin 125 mcg PO EVERY OTHER DAY
Aspirin 325 mg PO DAILY (Daily).
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID
Bisacodyl 10 mg PO DAILY (Daily)
Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
unit dwell Injection PRN (as needed) as needed for line flush:
Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
Morphine 15 mg PO Q8H (every 8 hours) as needed for pain.
Nephro-Vite 0.8 mg PO once a day.
Metoprolol Tartrate 1.25 mg PO twice a day
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-10**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): please start [**2116-6-18**].
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) for 3 days: please start [**2116-6-12**].
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) for 3 days: please start [**2116-6-15**].
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO T,TH,SAT ().
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): please hold for BM > 2 per day.
15. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day:
please hold for BM > 2 per day.
16. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): please hold for BP < 100.
19. Morphine 15 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: please hold for sedation or RR < 12.
20. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
21. Insulin Lispro 100 unit/mL Solution Sig: please see insulin
sliding scale Subcutaneous ASDIR (AS DIRECTED).
22. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 9 days: end date
[**2116-6-19**]. Please give dose after Hemodialysis.
23. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1' Diagnosis
Vancomycin Resistant Enterococci Sepsis
Delirium
2' Diagnosis
End Stage Renal Disease on Hemodialysis
Obesity Hypoventilation
Atrial Fibrillation
Discharge Condition:
afebrile, hemodynamically stable, tolerating POs
On a wet to dry dressing, will need Wound vac when returning to
[**Hospital3 2558**].
Discharge Instructions:
You were admitted with confusion and low blood pressures. You
were diagnosed with a bacterial infection in the blood stream
likely from your hemodialysis line. You required admission to
the ICU and were treated with IV fluids, medications to support
your blood pressure, and IV antibiotics. Your HD line was
removed, and you were treated with Daptomycin. Your HD line was
replaced and you underwent a TEE to rule out endocarditis which
was negative. You were evaluated by infectious disease team as
well as by [**Hospital3 1106**] surgery.
You will need to have your wound vac replaced when you are at
rehab.
Please take your medications as directed.
1. Take daptomycin Intravenous until [**2116-6-19**].
2. Continue to taper your steroids as directed.
Return to the hospital or call your PCP if you experience any of
the following symptoms: fever > 101 F, worsening confusion,
chest pain, abdominal pain, diarrhea, or any other symptoms not
listed here concerning enough to warrant physician [**Name Initial (PRE) 2742**].
Followup Instructions:
YOU WILL NEED YOUR WOUND VAC RE-PLACED WHEN YOU GET BACK TO
[**Hospital3 **].
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 1241**] for
appointment within the next 7 days.
You should follow up with your primary care doctor within [**1-10**]
weeks of discharge from rehab. Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) 2946**] S.
can be reached at [**Telephone/Fax (1) 2205**].
You should also continue to follow up with your nephrologist
within 1 month of discharge.
Listed below are the appointments that you already have
scheduled:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2116-6-15**] 11:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2116-6-14**]
ICD9 Codes: 5856, 2875
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5464
}
|
Medical Text: Admission Date: [**2199-1-10**] Discharge Date: [**2199-1-14**]
Date of Birth: [**2128-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Abnormal ETT
Major Surgical or Invasive Procedure:
[**2199-1-10**] - CABGx3 (Left internal mammary artery->Left anterior
descending artery, Vein->Obtuse marginal, Vein->Posterior
descending artery)
History of Present Illness:
70 y/o man with peripheral vascular disease who underwent an
abnormal ETT. A recent cardiac catheterization revealed left
main and three vessel disease. He is now referred for surgical
revascularization.
Past Medical History:
CAD
HTN
Hyperlipidemia
PVD
Diabetes mellitus type 2
Prostate cancer
Social History:
Retired postal clerk. Lives with wife.
Family History:
Mother died of MI at age 54.
Physical Exam:
74 180/75 70" 225lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis. Multiple solar/actinic
kertosis and nevi. Venous stasis changes of RLE.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally
HEART: RRR, Normal S1-S2, No M/R/G
ABD: Soft, ND/NT/NABS
EXT:warm, pulses dopplerable in righ DP/PT, no bruits, right leg
with enlarged veins, mild peripheral edema
NEURO: No focal deficits.
Pertinent Results:
[**2199-1-10**] ECHO
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. The estimated right atrial pressure is
0-5 mmHg. The left ventricular cavity size is normal. There is
mild to moderate regional left ventricular systolic dysfunction
with mild anterior wall hypokinesis The remaining left
ventricular segments contract normally. Right ventricular
chamber size is normal. with borderline normal free wall
function. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. 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 pericardial effusion.
POST CPB:
Improved biventricular systolic function.
No change in valve structure and function
[**2199-1-12**] CXR
There is no pneumothorax or appreciable pleural fluid residual
following removal of pleural tubes and tracheal extubation.
Mild-to-moderate infrahilar atelectasis in both lungs is
worsened. Heart is normal size and cardiomediastinal silhouette
is normal postoperative appearance, including small residual of
retrosternal air.
Brief Hospital Course:
Mr. [**Known lastname 13058**] was admitted to the [**Hospital1 18**] on [**2199-1-10**] for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. Within 24
hours, Mr. [**Known lastname 13058**] had awoke neurologically intact and was
extubated. He was then transferred to the step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. As
his blood sugars were elevated, his preoperative metformin and
avandia were resumed. Mr. [**Known lastname 13058**] continued to make steady
progress and was discharged home on postoperative day 5. He will
follow-up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) 216**] as an
outpatient.
Medications on Admission:
Aspirin 81'
Lipitor 20'
Cymbalta 60'
Zetia 10'
Glipizide 10"
Metformin 1000"
Zestril 10'
Avandia 8'
Flomax 0.4'
Verapamil 240'
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
7. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
11. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: Take for 7 days with potassium and then stop.
Disp:*5 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p CABGx3
HTN
Hyperlipidemia
PVD
Diabetes mellitus type 2
Prostate Cancer
Discharge Condition:
Stable
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) 1504**].
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.
6) No driving for 1 month.
7) Take lasix 40mg once daily with potassium 20mEq for 5 days
then stop.
8) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 5003**]
Please follow-up with Dr. [**First Name (STitle) 216**] in 2 weeks.[**Telephone/Fax (1) 250**]
Please call all providers for appointments.
Completed by:[**2199-1-14**]
ICD9 Codes: 2762, 4111, 4439, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5465
}
|
Medical Text: Admission Date: [**2178-7-13**] Discharge Date: [**2178-7-19**]
Date of Birth: [**2133-5-12**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This young gentleman with a
long-standing history of coronary disease complained most
recently of increasing chest tightness with exertion prior to
his last percutaneous coronary intervention in [**2178-5-21**]. He
has a past history of coronary artery bypass graft times
three in [**2167**]. Most recently, his history was that in [**2167**],
he developed chest pain with pressure and nausea which led
him directly to the cardiac catheterization laboratory and
ultimately to coronary artery bypass graft. Since then over
the past decade, he has had multiple angioplasties and stent
placement times ten with his most recent stenting on
[**2178-5-26**], for severe chest pain and unstable angina.
PAST MEDICAL HISTORY:
1. Coronary artery bypass graft times three in [**2167**].
2. Hypertension.
3. Myocardial infarction (during his PCI in [**2177**]).
4. Hypercholesterolemia.
5. Multiple PCI/stents.
6. Lower back pain.
7. Old right rib fracture.
PAST SURGICAL HISTORY: His past surgical history also
includes tonsillectomy.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o. twice a day.
2. Plavix 75 mg p.o. once daily, last done on [**2178-7-7**].
3. Mavik 2 mg p.o. once daily.
4. Folgard undetermined dose.
5. Lipitor 80 mg p.o. once daily.
6. Wellcol unknown dose.
7. Aspirin 325 mg p.o. once daily.
ALLERGIES: Penicillin and he had an aversion to
Nitroglycerin which gives him severe headaches.
PHYSICAL EXAMINATION: On examination, he is a well nourished
active young man. Blood pressure on the right was 116/62,
blood pressure on the left was 116/66, height five foot six
inches, 160 pounds, with a stable heart rhythm at 52 beats
per minute. At the time of the examination, he had poison
[**Female First Name (un) **] on both lower extremities and otherwise, his skin was of
normal condition. He had normal buccal mucosa. His pupils
are equal, round, and reactive to light and accommodation.
Extraocular movements are intact. The eyes are nonicteric
and noninjected. He had no jugular venous distention or
carotid bruits. His lungs were clear bilaterally. His heart
was regular rate and rhythm with S1 and S2 sounds and no
murmur appreciated. His abdominal examination was benign
with positive bowel sounds, no hepatosplenomegaly or
costovertebral angle tenderness. On his extremities, he had
right midthigh and right groin to midthigh open areas of
unused saphenectomy site. His extremities were warm and well
perfused with no cyanosis, clubbing or edema. No
varicosities were noted. Neurologically, he had a nonfocal
examination, grossly intact, with excellent strength in all
four extremities. He had good peripheral pulses with 2+
femorals, nonpalpable dorsalis pedis pulses but 2+ posterior
tibial and radial pulses.
He was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for redo coronary artery
bypass grafting with bilateral radial arteries scheduled
tentatively for [**2178-7-13**]. He was given instructions to not
take any more Plavix. His last dose was on [**2178-7-7**].
LABORATORY DATA: Preoperative chest x-ray showed no evidence
of any acute cardiopulmonary disease and evidence of
calcification in his saphenous vein bypass graft.
Preoperative laboratory work showed a white blood cell count
of 5.3, hematocrit 41.8, platelet count 161,000. Prothrombin
time 13.8, partial thromboplastin time 33.9 with INR of 1.3.
Urinalysis was negative. Chem7 showed a sodium of 142,
potassium 4.1, chloride 102, bicarbonate 26, blood urea
nitrogen 20, creatinine 1.1, with a blood sugar of 77 and
anion gap of 18, ALT 27, AST 28, alkaline phosphatase 86,
total bilirubin 1.9, albumin 4.4.
Prior cardiac catheterization data from [**2178-5-26**], showed left
internal mammary artery to left anterior descending was 100%
occluded. The RIMA to the right coronary artery was patent.
Vein graft to the diagonal was diseased. Vein graft to the
left anterior descending was diseased. Native right coronary
artery 100% and left main native disease 100% occlusion.
HOSPITAL COURSE: On [**2178-7-13**], the patient underwent redo
coronary artery bypass grafting times two with a radial
artery anastomosed to the vein graft to the left anterior
descending and the radial artery to the diagonal by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. The patient was transferred to Cardiothoracic
Intensive Care Unit in stable condition on an Neo-Synephrine
drip at 1.5 mcg/kg/minute, Nitroglycerin drip at 0.3
mcg/kg/minute and Propofol drip at 10 mcg/kg/minute.
On postoperative day one, the patient remained intubated and
stayed on a Propofol drip as well as Neo-Synephrine and
Nitroglycerin drips with a blood pressure of 106/67, sinus
rhythm in the 80s. His cardiac index was 3.32. He was
having good urine output and was switched over to CPAP mode.
Postoperatively, his hematocrit went from 18 to 25.7. He
continued on his perioperative Vancomycin. Potassium was 3.6
with a blood urea nitrogen of 11 and creatinine 1.0. He also
remained on an insulin drip with a Swan-Ganz in place.
On postoperative day two, he was transferred out to the floor
to begin his ambulation. He was seen by physical therapy for
support and additional pain management issues were addressed
by the nurse and the house staff. He was also seen by the
occupational therapy staff for evaluation for activities of
daily living issues given that both radial arteries were
harvested. It was thought that an occupational therapy
consultation would be received well by the patient.
On postoperative day two, the patient also had some continued
oozing after his central line access site was pulled.
Additional pressure was applied. Otherwise, the examination
was unremarkable. His heart was regular rate and rhythm. He
had no rales, and his lungs were clear. Incisions were
clean, dry and intact. His platelet count decreased to
89,000 with a corresponding hematocrit of 28.3. Prothrombin
time was 12.1 and partial thromboplastin time was 27.0 and
INR of 1.0. His electrolytes were otherwise unremarkable.
He was given Magnesium Oxide for repletion.
On postoperative day four, he had no complaints and felt
better overnight. His sternum was stable. His wounds were
clean, dry and intact. He continued to improve and was doing
very well with his ambulation. His Lopressor was increased
to 75 mg p.o. twice a day to bring his heart rate down which
was in the mid90s. He was followed daily by physical
therapy. Discharge teaching and planning was begun by the
nursing staff.
On postoperative day five, the patient was feeling much
better. His incisions were looking good. He was alert and
oriented. He had some erythema along both of his radial
artery incisions. His sternum was clean, dry and intact and
his lungs were clear. His heart rate was regular. His blood
pressure was 152/84, sinus rhythm at 101 beats per minute,
oxygen saturation 95% in room air. His arms were evaluated
and determined that they were not cellulitic. His energy
level was also greatly improved.
On postoperative day six, the patient had no events
overnight. He had a temperature of 98.8, sinus rhythm in the
80s with a blood pressure of 157/94, respiratory rate 16,
oxygen saturation 95% in room air. His lungs were clear.
His heart was regular rate and rhythm, his sternum was clean,
dry and intact. He would periodically have episodes of
atrial fibrillation but converted back to sinus rhythm. He
started Diltiazem 240 mg extended release p.o. once daily.
and was discharged to home on [**2178-7-19**], in stable condition.
MEDICATIONS ON DISCHARGE:
1. Potassium Chloride 12 meq p.o. twice a day times two
weeks.
2. Colace 100 mg p.o. twice a day.
3. Aspirin 81 mg p.o. once daily.
4. Hydromorphone 2 mg p.o. q4-6hours p.r.n. for pain.
5. Lipitor 80 mg p.o. once daily.
6. Metoprolol 100 mg p.o. twice a day.
7. Lasix 20 mg p.o. twice a day times fourteen days.
8. Diltiazem 240 mg p.o. once daily times thirty days.
DISCHARGE DIAGNOSES:
1. Status post redo coronary artery bypass grafting times
two.
2. Status post coronary artery bypass grafting in [**2167**].
3. Hypertension.
4. Myocardial infarction.
5. Hypercholesterolemia.
6. Status post multiple PCI/stents.
7. Lower back pain.
8. Old right rib fracture.
9. Status post tonsillectomy as a child.
FOLLOW-UP: The patient was discharged to home with
instructions to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in the office
in approximately three to four weeks and to follow-up with
Dr. [**Known firstname **] [**Last Name (NamePattern1) 7774**], his primary care physician, [**Name10 (NameIs) 5983**] in
approximately three to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2178-10-29**] 11:10
T: [**2178-10-31**] 11:03
JOB#: [**Job Number 33368**]
ICD9 Codes: 4111, 4019, 2720, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5466
}
|
Medical Text: Admission Date: [**2192-2-9**] Discharge Date: [**2192-2-24**]
Date of Birth: [**2142-7-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
from OSH for workup of pancreatic mass
Major Surgical or Invasive Procedure:
Whipple
History of Present Illness:
The patient is a 49 yo M who is being transferred from [**Hospital1 1474**]
for further workup of a pancreatic mass. He originally
presented to his PCP for [**Name Initial (PRE) **] 1 week h/o fatigue, nausea, and a
12lb weight loss over a one week period. He further reports
intermittent RUQ abdominal pain over the past week. Decreased
PO intake over this time frame. He denied fevers, chills,
vomiting, diarrhea, or observed skin changes.
On admission to the OSH, AP 726, AST 303, ALT 122, TB 6.3, DB
2.5, Alb 3.2, INR 1.2, triglycerides [**2186**]. A RUQ U/S was
performed which showed a slightly increased common bile duct
diameter, but was otherwise unremarkable. An MRCP was then
performed which showed a suspicious lesion at the head of the
pancreas which is concerning for pancreatic carcinoma. A
decision was made to tranfer the patient to a tertiary care
center. During his stay at the OSH, he was started on bactrim
for an asymptomatic UTI. A flu shot and pneumovax were given at
the OSH.
Patient was subsequently transferred to the [**Hospital1 18**] for further
work-up and treatment.
Past Medical History:
PMH:
MI,
HTN,
35 pack-year smoker
PSH:
R CEA ([**7-18**]),
knee scope,
?SFA angioplasty
Social History:
The patient lives in [**Location 1475**] in an apartment with his wife
and 1 [**Name2 (NI) **] daugther. no other children. Drinks 4-5 beers per day
until 1 week priorago. Per OSH records patient has drank more
heavily in the past. He smoked 2 ppd x 40 years, he quit 1
month ago. Grew up on a farm.
Family History:
Father with liver cirrhosis from ETOH use
Physical Exam:
VS - 98.7 108/60 80 16 100%RA
General - lying in bed, pleasant caucasion male, jaundiced
HEENT - PERRL, EOMI, icteric
Neck - supple, no JVP
CV - RRR, 2/6 systolic murmur best heard at LUSB
Chest - good air sounds b/l; minimal scattered wheezes
throughout
Abd - soft, NT/ND, no caput, no hepatosplenomegaly, large healed
midline scar
Ext - no edema; + clubbing of fingers bilaterally
Skin - jaundiced
Pertinent Results:
Imaging:
[**2192-2-9**] U/S (at OSH) - findings suggests fatty infiltration of
the liver. small granuloma within the spleen. pancreas not
well seen due to bowel gas. common bile duct normal (5mm).
[**2192-2-9**] MRCP (at OSH) - no evidence of gallstones, borderline
dilatation of common bile duct and mild dilatation of the
pancreatic dict without ductal stones seen. abnormal
heterogeneous enhancing infiltrative changes are seen in the
enlarged pancreatic head and uncinate process. these changes
could represent pancreatic carcinoma, but differentiation from
changes due to chronic pancreatitis is difficult.
Labs (OSH):
Admission to OSH --> AP 726, AST 303, ALT 122, TB 6.3, DB 2.5,
Alb 3.2, INR 1.2.
[**2192-2-10**] CT-A:
1. Findings most consistent with pancreatic carcinoma. There
is no biliary
or pancreatic duct dilatation. There is an accessory right
hepatic artery
which is encased by tumor. The main right hepatic artery and
left hepatic
arteries are normal as are the proper and common hepatic
arteries.
2. No evidence of distant metastases.
3. Diffuse atherosclerosis. Aortobifemoral bypass graft is
patent. There is
marked mural thrombus present within the proximal SMA, but the
distal SMA is
patent.
[**2192-2-13**] P-MIBI:
1. Normal myocardial perfusion. 2. Normal left ventricular
cavity
size and function. 3. LVEF of 71%.
No anginal symptoms or ischemic ST segment changes.
[**2192-2-10**] 05:10AM BLOOD WBC-6.4 RBC-3.24* Hgb-10.7* Hct-30.6*
MCV-95# MCH-32.9* MCHC-34.8 RDW-17.1* Plt Ct-104*
[**2192-2-16**] 04:32PM BLOOD WBC-11.8* RBC-3.42* Hgb-10.7* Hct-31.3*
MCV-92 MCH-31.2 MCHC-34.0 RDW-19.5* Plt Ct-343
[**2192-2-19**] 02:36AM BLOOD WBC-16.9* RBC-2.78* Hgb-8.6* Hct-25.6*
MCV-92 MCH-31.0 MCHC-33.6 RDW-17.8* Plt Ct-439
[**2192-2-22**] 05:04AM BLOOD WBC-10.7 RBC-3.08* Hgb-10.0* Hct-27.9*
MCV-91 MCH-32.3* MCHC-35.7* RDW-17.2* Plt Ct-556*
[**2192-2-18**] 04:21AM BLOOD Neuts-85.0* Lymphs-9.8* Monos-4.1 Eos-0.8
Baso-0.2
[**2192-2-10**] 05:10AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0
[**2192-2-18**] 04:21AM BLOOD PT-15.2* PTT-29.7 INR(PT)-1.4*
[**2192-2-21**] 02:46AM BLOOD PT-14.0* PTT-26.6 INR(PT)-1.2*
[**2192-2-10**] 05:10AM BLOOD Glucose-105 UreaN-4* Creat-0.7 Na-134
K-3.3 Cl-103 HCO3-24 AnGap-10
[**2192-2-17**] 03:48AM BLOOD Glucose-110* UreaN-5* Creat-0.6 Na-134
K-4.1 Cl-103 HCO3-24 AnGap-11
[**2192-2-20**] 03:01AM BLOOD Glucose-100 UreaN-6 Creat-0.5 Na-136
K-3.8 Cl-98 HCO3-30 AnGap-12
[**2192-2-24**] 04:43AM BLOOD Glucose-120* UreaN-6 Creat-0.4* Na-135
K-3.4 Cl-105 HCO3-22 AnGap-11
[**2192-2-10**] 05:10AM BLOOD ALT-61* AST-108* LD(LDH)-147 AlkPhos-507*
TotBili-2.9*
[**2192-2-14**] 06:20AM BLOOD ALT-21 AST-35 AlkPhos-280* TotBili-1.1
[**2192-2-17**] 11:42AM BLOOD Lipase-20
[**2192-2-10**] 05:10AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7
[**2192-2-16**] 06:18AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.8
[**2192-2-24**] 04:43AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.8
[**2192-2-12**] 08:00AM BLOOD calTIBC-199* Ferritn-573* TRF-153*
[**2192-2-18**] 12:25PM BLOOD Cortsol-13.9
[**2192-2-18**] 02:04PM BLOOD Cortsol-20.0
[**2192-2-10**] 05:10AM BLOOD CA [**05**]-9 -Test
[**2192-2-10**] 09:22AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-12* pH-8.0 Leuks-NEG
[**2192-2-10**] 09:22AM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.010
[**2192-2-10**] 09:22AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**Known lastname **],[**Known firstname **] [**2142-7-7**] 49 Male [**Numeric Identifier 61225**]
[**Numeric Identifier 61226**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: GALLBLADDER, WHIPPLE SPECIMEN.
Procedure date Tissue received Report Date Diagnosed
by
[**2192-2-16**] [**2192-2-16**] [**2192-2-21**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma??????
Previous biopsies: [**-5/2637**] CAROTID PLAQUE
DIAGNOSIS
I. Gallbladder: Chronic cholecystitis.
II. Pancreaticoduodenectomy, partial pancreatectomy:
1. Multiple foci of fat necrosis primarily involving
peripancreatic adipose tissue.
2. Unremarkable duodenum, common bile duct, and pancreas.
3. Two reactive lymph nodes.
Brief Hospital Course:
The pt. presented from an outside hospital for further workup of
a newly-diagnosed pancreatic mass. A CT-A scan done here at the
[**Hospital1 18**] identified a low density mass at the uncinate process;
accessory R hepatic artery was encased by tumor but no evidence
for distant mets. Surgery was consulted, and an ERCP, which had
been pending, was postponed to proceed with the Whipple
procedure without a formal tissue diagnosis. As part of the
pre-op workup, the pt. had a normal P-MIBI on [**2-13**] and nl CXR
and U/A. Treatment of the pt's coronary artery disease was
continued with aspirin and metoprolol while the pt. was in the
hospital.
.
In addition to the pancreatic mass, the pt. also presented with
a transaminitis. pt's liver enzyme levels trended down lower
each day and normalized before his surgery.
.
While here, the pt. spiked a fever to 102.5. Because of concern
for cholangitis/sepsis, the pt. was started on ampicillin,
levofloxacin, and metronidazole. Urine and blood cultures were
negative, and antibiotics were discontinued after 3 days.
.
The pt. also presented with a normocytic anemia. Iron studies
most consistent with anemia of chronic inflammation: Fe low
normal, decreased TIBC, increased ferritin. Because the pt's
hematocrit drifted lower while in the hospital, he was
transfused with 2 units PRBCs the day before surgery, which he
tolerated without incident.
.
Although the pt. had a history of high alcohol intake, he did
not require the CIWA scale while in the hospital. As
prophylaxis, he was given thiamine and folate during his stay in
the hospital.
.
Patient was taken to the OR on [**2-16**] for a pylorus
sparing pancreaticoduodenectomy (for more operative details see
dictated operative report). Patient tolerated the procedure well
and was transferred to the PACU extubated. Post-operatively,
patient became hypotensive and febrile to 103. Epidural was
stopped and patient was transitioned to a PCA for pain control.
He was aggressively fluid resuscitated. Neosynephrine drip was
started for BP control. On POD 1 patient was weaned off of
neosynephrine and blood pressures stabilized in 90-100 range. He
continued to spike fevers. On the evening of POD 2 patient
developed increased work of breathing and de saturations into
80's. On exam, wet crackles were appreciated. CVP was [**6-21**]
range. Lasix was administered with good diuresis. CXR was
obtained and showed bilateral lower lobe processes concerning
for aspiration pneumonia vs. ARDS and pulmonary congestion,
pulmonary edema. EKGs were normal. ABG was 7.32/55/73/31/1.
During the next several days his pulmonary status and blood
pressures stabilized and started to improve. All urine and blood
cultures were without growth. Cortisol stimulation test was
normal. Aggressive pulmonary toilet was continued as patient
required frequent suctioning for excessive mucus production.
On POD 6 patient was transferred to a regular floor. He
continued to be stable. His diet was advanced without
complications. He was continued on Protonix and Reglan.
He was discharged home in good condition with JP drain in place
and instructions for follow-up with Dr. [**Last Name (STitle) 468**] in clinic.
Medications on Admission:
Medications at OSH:
ASA 81mg
Thiamine
Folate
Bactrim
Medications at Home:
ASA
Diovan
Darvan
Atenolol
Lipitor (recently stopped)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
Disp:*1 tube* Refills:*2*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Head of pancreas mass
Discharge Condition:
good
Discharge Instructions:
please seek meical attention if you experience fever > 101.5,
severe nausea, vomitting, or pain, or a very large increase in
drain output
please take all meds as prescribed
please care for your JP and change the dressing as shown by your
nurses
Followup Instructions:
please follow up with [**Doctor Last Name 468**] ([**Telephone/Fax (1) 2835**]) in 1 week to have
staples removed.
Completed by:[**2192-2-24**]
ICD9 Codes: 496, 5119, 2768, 4019, 412
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5467
}
|
Medical Text: Admission Date: [**2195-4-30**] Discharge Date: [**2195-5-8**]
Date of Birth: [**2140-9-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
ESLD
Major Surgical or Invasive Procedure:
liver transplant [**2195-4-30**]
History of Present Illness:
54 y.o. male with HCV cirrhosis and HCC with 2 lesions s/p RF
ablation. Had previously been trialed on interferon and
ribaviron without response. Chest CT and bone scan without
evidence of metastasis. Has felt well in last month without any
n/v/c/d illness or sick contacts.
Past Medical History:
HCV, HCC, HTN, DM2
Social History:
married with 2 children, high school teacher
Physical Exam:
97.1 71-148/83 18 94% RA, wt 95Kg, height 189.9cm
NAD
A&Ox3
neck -free range of motion, anicteric, no LAD,no thyromegaly,
neck supple
cor rrr
lungs clear
ext wwp
Pertinent Results:
99.1-93-111/70-20-100%
NAD aaox3
CTA B
RRR +S1/S2
Soft appropriately tender, ND
c/d/i
No c/c/e
Brief Hospital Course:
-He was taken to the OR on [**2195-5-1**] for piggyback liver transplant
for HCV related
cirrhosis, hepatocellular carcinoma, status post radiofrequency
ablation. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. The donor was high
risk who died of an IV overdose. Please see operative report for
details. He received solumedrol and cellcept induction
medication. EBL was 500cc and he received 14 units of prbc and
plasmalyte. No t tube was placed. Two [**Doctor Last Name 406**] drains were placed.
Postop, he was monitored in the SICU where he started on prograf
on pod 1. LFTs trended down. Protocol u/s showed normal duplex
examination of transplanted liver. A trace amount of free fluid
was seen within the abdomen. He was extubated without
difficulty. Solumedrol was tapered per protocol. Diet was
advanced without problems. [**Name (NI) **] initially required an insulin drip
that was later changed to long acting subcutaneous insulin.
On pod 2 he spiked a temp to 102. Blood and urine cultures were
done one [**5-3**]. Urine was negative. Blood cultures were negative
to date. JPs were removed on pod 3 & 5.
On pod 5, alk phos increased to 139 from 79 and t.bili 1.1 from
0.9. Alk phos decreased to 131.
He was ambulatory and tolerating a regular diet prior to
discharge home.
Medications on Admission:
ursodiol 300', colchicine 40', nadolol 40', Lantus 16qAM
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Tacrolimus 1 mg Capsule Sig: Seven (7) Capsule PO twice a
day.
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow
sliding scale Subcutaneous four times a day: Follow sliding
scale.
Disp:*2 bottles* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous once a day.
Discharge Disposition:
Home With Service
Facility:
Diversified VNA and hospice
Discharge Diagnosis:
HCV/HCC
Discharge Condition:
good
Discharge Instructions:
Call the Transplant Office [**Telephone/Fax (1) 673**] if fevers, chills,
nausea, vomiting, inability to take medications, jaundice,
increased abdominal pain, pain over liver, fluid retention,
incision redness/bleeding or drainage.
Labs every Monday & Thursday for cbc,chem 10, ast, alt, alk
phos, t.bili, albumin and trough prograf level. Please fax to
[**Telephone/Fax (1) 697**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-5-13**] 9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2195-5-13**]
9:30
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-5-21**] 2:00
Provider: [**Name10 (NameIs) 15144**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 15145**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule
appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2195-5-8**]
ICD9 Codes: 2875, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5468
}
|
Medical Text: Admission Date: [**2146-8-15**] Discharge Date: [**2146-8-23**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
84F with increased SOB, nausea, edema.
Major Surgical or Invasive Procedure:
s/p AVR(23mm tissue)/MV repair(28mm [**Doctor Last Name 405**] Band) [**8-18**]
History of Present Illness:
This 84 year old white female has a 2 yr. history of difficulty
ambulating. Over the past 2-3 months she has had increased SOB,
PND, nausea, and pedal edema. Cardiac echo revealed severe
aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.5cm2, and moderate MR with an
EF of 30%. She underwent cardiac cath at [**Hospital1 18**] on [**2146-8-15**] which
revealed clean coronaries. She is now admitted for AVR/MV
repair.
Past Medical History:
Hiatal hernia
Aortic stenosis
Mitral regurgitation
Anemia
Asthma
Afib
Social History:
cigs: none
ETOH: none
Lives alone.
Family History:
unremarkable
Physical Exam:
Elderly WF in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat. without bruits.
Lungs: Clear to A+P
CV: IRRR without R/G, 4/6 SEM
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext: without C/C/E, pulses 2+=throughout.
Neuro: nonfocal
Pertinent Results:
[**2146-8-22**] 05:50AM BLOOD WBC-8.2 RBC-3.65* Hgb-12.0 Hct-35.6*
MCV-98 MCH-32.9* MCHC-33.7 RDW-14.5 Plt Ct-109*
[**2146-8-23**] 06:30AM BLOOD PT-14.4* PTT-25.9 INR(PT)-1.4
[**2146-8-22**] 05:50AM BLOOD Glucose-102 UreaN-14 Creat-0.6 Na-137
K-3.9 Cl-97 HCO3-32 AnGap-12
Brief Hospital Course:
This pt. was admitted on [**2146-8-15**] and started on heparin and had
an echo. She has an INR of 1.4. On [**8-17**] she underwent AVR with
23mm pericardial tissue valve/MV repair with 28mm [**Doctor Last Name 405**] band.
She tolerated the procedure well and was transferred to the
CSRU in stable condition on Epinephrine and Propofol. She was
extubated on the post op night and the Epi and chest tubes were
d/c'd on POD#1. She was transferred to the floor on POD#2 and
she continued to so well. Her wires were d/c'd on POD#3 and she
was anticoagulated with coumadin. She was discharged to rehab
in stable condition on POD#6.
Medications on Admission:
Cartia XT 120 PO daily
Pepcid 20 PO daily
Prednisone 5 PO daily
Flovent 110mcg 2 puffs [**Hospital1 **]
Albuterol nebs
Coumadin 5 mg PO daily
Lasix 20mg PO daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Continue until INR>1.8.
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior HealthCare of [**Location (un) 55**]
Discharge Diagnosis:
Aortic stenosis
Mitral regurgitation
Anemia
Asthma
Atrial fibrillation
Hiatal hernia
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not lift more than 10 lbs. for 2 months.
You should not drive for 4 weeks.
Do not use lotions, powders, or creams on wounds.
You should shower, let water flow over wounds, pat dry with a
towel.
Call our office for sternal drainage, temp. > 101.5
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) 216**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2146-8-23**]
ICD9 Codes: 2859
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5469
}
|
Medical Text: Admission Date: [**2187-12-17**] Discharge Date: [**2187-12-20**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypertensive urgency and hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 39 M with DM, ESRD on HD, gastroparesis, autonomic
dysfunction, CAD (STEMI, NSTEMI), ; was admitted to MICU with
usual nausea, vomiting, abdominal pain and hypoxemia of unknown
origin. Mr [**Known firstname 6164**] was recently admitted from [**2103-12-5**] with
concern of line infection/positive blood cultures; started on
vancomycin with HD.
.
Pt. reported sudden onset N/V x4 on day of admission. Emesis was
non-bloody or bilious. No prodorome or associated symptoms,
except slight abdominal pain, no diarrhea, occasional dry cough
x 2+ months.
.
Pt also reports being "high on fluid" as he notes that he senses
that with increased abdominal girth and neck swelling. This
onset of these symptoms could not be clarified by the patient.
He reports being at a party the day before and drinking
cranberry juice and water, but denies use of EtOH, drugs or
dietary indiscretions. This episode is similar in nature to
previous exacerbations of gastroparesis per patient and renal
attending who knows patient well (Dr. [**Last Name (STitle) 1366**]. Saw Dr. [**Last Name (STitle) **]
(his cardiologist) on day of admission; was feeling ill at the
time. He recommended increasing lisinopril and labetalol, adding
HCTZ and stopping clonidine patch.
.
From ICU admit note: "In the ED, patient received 20 IV
labetalol for elevated BP; 4 mg IV ativan and 2 mg IV dilaudid.
Femoral CVL placed. Initial vitals 97.8, HR 90, 190/120, 97% on
RA. Desatted to upper 80s on RA and ?lower into 70s per ED
signout (but not documented in written notes), ABG with pO2 of
71. Placed on 3 L NC. CXR with volume overload; CTA obtained due
to hypoxemia and was negative for PE. SBP range 170s-180s. In
ICU pt c/o [**9-23**] abdominal pain, asking for dilaudid and ativan,
2 mg of each."
.
While in ICU, patient completed ROMI, CTA and repeat XRs did not
show apparent PNA and he continued to have a 2L O2 requirement.
He was started NPO, abdominal pain and N/V impoved and was then
advanced to clears. Pain was treated with IV dilaudid, IV ativan
and zofran. CTA review revealed a new LAD aneurysm. Pt underwent
HD today where he received Vanco per HD protocol and was deemed
stable enough for transfer to floor.
.
Pt. was seen in HD, NAD, somewhat sleepy s/p Ativan for nausea.
In addition to above, he reported one episode of CP 2 d PTA,
lasting 30seconds, w/o associated symptoms and resolution on its
own. He denied N/V, CP, SOB, diarrhea, fevers, chills, HA,
diplopia.
Past Medical History:
- Diabetes Mellitus Type I
- Gastroparesis with chronic hospitalizations
- ESRD on HD since [**2-/2184**]
- Autonomic dysfunction, frequent HTN emergency & orthostatic
hypotension
- Peripheral neuropathy
- Coronary artery disease, STEMI [**2186-12-17**] in setting of
cocaine, s/p BMS to LAD
- Aortic valve endocarditis ([**4-21**]) and [**2187-9-12**] (MSSA tx with
nafcillin)
- Frequent bacteremia/line infections, often coag neg staph.
- prior line sepsis with klebsiella and enterobacteremia
- Esophageal ulceration: H pylori neg, active esophagitis seen
on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
- History of substance abuse (cocaine, marijuana, alcohol)
- History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in
place
- Fungemia completed caspofungin IV on [**2187-7-12**]
- GI bleed associated with hypotension-colonscopy showed friable
and inflammed ascending and transverse colon,suggestive either
of ischemia or infection [**2187-7-19**]
- NSTEMI in setting hypertension on [**2187-10-21**]
Social History:
Patient has a prior history of tobacco and marijauna use, but he
does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs. Currently lives
with his mother and brothers.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. Two sisters, one with diabetes. Six brothers, one
with diabetes. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
On admission to MICU:
Tmax: 36.3 ??????C (97.4 ??????F)
Tcurrent: 36.3 ??????C (97.4 ??????F)
HR: 81 (81 - 86) bpm
BP: 133/90(100) {133/90(100) - 167/123(134)} mmHg
RR: 14 (14 - 25) insp/min
SpO2: 97%
General Appearance: No acute distress
Eyes / Conjunctiva: No(t) PERRL, + anisocoria, R 4->3, L 2.5->2
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, No(t) Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
apical SM
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : faint end inspiratory crackles at bases, No(t)
Wheezes : , Diminished: bilat bases)
Abdominal: Soft, Bowel sounds present, No(t) Distended, Tender:
diffuse in abdomen, voluntary guarding, hypoactive BS
Extremities: Right: Absent, Left: Absent
Skin: Cool, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): place, day -1, Movement: Not assessed,
Tone: Not assessed, slightly lethargic
On transfer to the floor
VS: Tc: 96 ??????F HR: 84 BP: 149/110mmHg RR: 18 SpO2: 95% RA
General Appearance: No acute distress
HEENT - normocephalic, No LAD. PERRL, R 2->1.5, L 2->1.5
CV: S1, S2 nl, [**3-21**], SEM at apex.
Pulm: CTA b/l.
Abdominal: Soft, Bowel sounds present, NT/ND, BS+
Skin: warm, dry, no edema, no lesions
Ext: warm, dry, no edema, R tunneled catheter, C/D/I.
Neuro: slightly sleepy, but arouses and maintains attention to
voice, CN 2-12 intact, strength 5/5 b/l UE and LE, sensory
grossly intact, DTRs 2+.
Pertinent Results:
Laboratory studies:
[**2187-12-17**] 02:30PM BLOOD WBC-9.9 RBC-3.80* Hgb-9.6* Hct-32.5*
MCV-86 MCH-25.3* MCHC-29.6* RDW-20.4* Plt Ct-275
[**2187-12-18**] 03:25AM BLOOD WBC-8.5 RBC-3.43* Hgb-8.8* Hct-29.2*
MCV-85 MCH-25.6* MCHC-30.0* RDW-19.1* Plt Ct-288
[**2187-12-19**] 07:00AM BLOOD WBC-6.3 RBC-3.85* Hgb-10.0* Hct-33.6*
MCV-87 MCH-25.9* MCHC-29.7* RDW-19.4* Plt Ct-251
[**2187-12-20**] 04:09AM BLOOD WBC-4.8 RBC-3.78* Hgb-9.9* Hct-31.6*
MCV-84 MCH-26.2* MCHC-31.3 RDW-20.3* Plt Ct-272
[**2187-12-17**] 02:30PM BLOOD Neuts-85.5* Lymphs-7.6* Monos-4.4 Eos-2.2
Baso-0.4
.
[**2187-12-17**] 02:30PM BLOOD PT-12.9 PTT-29.0 INR(PT)-1.1
.
[**2187-12-17**] 02:30PM BLOOD Glucose-274* UreaN-60* Creat-9.3*# Na-140
K-5.8* Cl-98 HCO3-28 AnGap-20
[**2187-12-18**] 03:25AM BLOOD Glucose-124* UreaN-69* Creat-10.5*#
Na-143 K-5.4* Cl-101 HCO3-29 AnGap-18
[**2187-12-19**] 07:00AM BLOOD Glucose-64* UreaN-37* Creat-7.4*# Na-138
K-4.3 Cl-95* HCO3-25 AnGap-22*
[**2187-12-20**] 04:09AM BLOOD Glucose-101 UreaN-45* Creat-9.0*# Na-136
K-4.8 Cl-92* HCO3-28 AnGap-21*
.
[**2187-12-17**] 02:30PM BLOOD ALT-12 AST-16 CK(CPK)-164 AlkPhos-115
TotBili-0.1
[**2187-12-17**] 10:30PM BLOOD CK(CPK)-123
[**2187-12-18**] 03:25AM BLOOD CK(CPK)-112
.
[**2187-12-17**] 02:30PM BLOOD cTropnT-0.22*
[**2187-12-17**] 10:30PM BLOOD CK-MB-6 cTropnT-0.24*
[**2187-12-18**] 03:25AM BLOOD CK-MB-6 cTropnT-0.26*
.
[**2187-12-18**] 03:25AM BLOOD Calcium-9.2 Phos-8.6*# Mg-2.1
[**2187-12-19**] 07:00AM BLOOD Calcium-8.4 Phos-7.0*# Mg-1.7
[**2187-12-20**] 04:09AM BLOOD Calcium-8.7 Phos-7.7* Mg-1.9
.
[**2187-12-18**] 03:25AM BLOOD Vanco-13.3
.
[**2187-12-17**] 02:50PM BLOOD Type-ART Rates-/1 pO2-71* pCO2-48*
pH-7.36 calTCO2-28 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU
Micro: Blood culture from [**12-18**] - negative.
.
Imaging/Studies:
.
CXR [**12-17**] - IMPRESSION: Findings most compatible with volume
overload. Repeat PA and
lateral radiographs may be helpful once symptoms resolved.
.
CTA [**12-17**] -
CT OF THE CHEST WITH IV CONTRAST: There are extensive
atherosclerotic
calcifications involving the left anterior descending, left
circumflex, and
right coronary arteries. A focal area of aneurysmal dilatation
of the distal
left anterior descending coronary artery is evident, measuring
2.7 x 0.7 cm in
the sagittal plane (2:81, 302b:43). The heart is moderately
enlarged in size.
There is no pericardial effusion. The aorta is normal in caliber
and contour.
There are no filling defects within the pulmonary arterial
vasculature. A tiny
linear defect within a right lower lobe subsegemental branch may
represent
mixing of contrast or other artifact (2:71). The pulmonary
artery is enlarged,
measuring 3.6 cm in diameter. Prevascular lymph nodes measuring
10 and 6 mm in
short- axis diameter are evident (2:35). A precarinal
mediastinal lymph node
measures 10 mm in short- axis diameter (2:34). There are no
pathologically
enlarged hilar or axillary lymph nodes. There is a small right-
sided pleural
effusion. Lung windows demonstrate extensive septal thickening
and diffuse
ground-glass changes compatible with pulmonary edema. Small
hiatal hernia is
noted. The imaged portions of the upper abdomen are otherwise
unremarkable.
There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. No acute pulmonary embolism.
2. Aneurysmal dilatation of the left anterior descending
coronary artery.
3. Enlarged pulmonary artery, indicative of pulmonary
hypertension.
4. Evidence of volume overload including small right-sided
pleural effusion.
5. Extensive coronary artery atherosclerotic calcifications.
6. Mediastinal lymphadenopathy, likely reactive.
.
ECG [**12-18**] - Sinus rhythm. Anteroseptal myocardial infarction, age
indeterminate. Possible
left atrial abnormality. Since the previous tracing of [**2187-12-5**]
no significant
change.
TRACING #1
Read by: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 184 78 396/434 37 11 46
.
CXR [**12-18**] -
FINDINGS: In comparison with the study of [**12-17**], the pulmonary
vascularity is
now essentially within normal limits. Enlargement of the cardiac
silhouette
persists. No evidence of acute focal pneumonia.
.
ECG [**12-19**] - Sinus rhythm with one ventricular premature beat.
Probable left atrial
abnormality. Anteroseptal myocardial infarction, age
indeteminate.
Compared to the previous tracing of [**2187-12-18**] no significant
change.
TRACING #2
Read by: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 182 80 392/439 55 -15 39
Brief Hospital Course:
39 M with history of ESRD on HD, DM c/b gastroparesis and
autonomic dysfunction, CAD s/p STEMI, frequent admissions for
nausea/vomiting and abdominal pain; now admitted with
N/V/abdominal pain and hypoxemia. In the MICU he was stabilized
with pain medication and underwent HD with subsequent
improvement of volume overload and resporatory function. He was
transferred to the floor for further management on HD2.
.
# Hypoxemia. Patient had a new O2 requirement in ED/MICU that
had resolved with ESRD. Differential included hypoventilation
from narcotics, pain/splinting (elevated pCO2 on ABG) and volume
overload [**3-17**] ESRD, CAD/ischemia. He was ruled out for PE and MI,
had no apparent focal pneumonia clinically or on CT, but did
have pulmonary edema on CT at presentation. After HD, this had
resolved. Repeat ECG was unchanged from priors w/ anteroseptal
MI and possible LAE. Patient was continued on ASA, statin,
Plavix and BBK.
.
# N/V/abdominal pain. Similar to prior presentations was felt to
be likely related to DM gastroparesis. His lipase and LFTs were
wnl. The abdominal pain improved slightly from HD2 to 3,
however patient could not tolerate PO diet w/ return of
abdominal pain and N/V. He was given Dilaudid IV for pain
control and ativan IV as an antiemetic. Reglan 10mg IV/PO was
continued throughout hospitalization. By HD 4, the
nausea/emesis and abdominal pain improved significantly. Pt.
was switched to PO medications and advanced to regular diet with
good tolerance. He was discharged home with PO reglan,
dilaudid, vicodin and ativan for pain/nausea control and
prevention of future episodes.
.
# ESRD on HD & Bacteremia. Patient underwent two HD sessions
while hospitalized. He had a tunnelled femoral line. His
vancomycin for coagulase negative staph bacteremia from prvious
hospitalization was completed. Vanco trough measured was 13.3
and his dosing was adjusted per HD protocol. Blood cultures were
repeated and were negative. Patient's phosphate levels were
significantly elevated. He received only one dosde of aluminum
hydroxide while hospitalized due to n/v. He was continued on
Lanthanum, Nephrocaps as per home regimen.
.
# LAD aneurysm. Noted on CTA, was new since [**2186**]. The case was
discussed with cardiology and it was felt that no further work
up or anticoagulation were required at this time, given the
location distal to previous STEMI site. This was also discussed
with Mr. [**Known firstname 6164**]' outpatient cardiologist and will be followed as
OP.
.
# DM. Poorly controlled during hospitalization with inconsistent
dietary intake. He was continued on home dosing NPH plus
sliding scale. On HD4, BG control improved to BG > 150
throughout the day. Patient was discharged w/ 5U of NPH qAM and
regular insulin SS. Gastroparesis was treated as above.
Gabapentin was continued as per home regimen.
.
# HTN. This was poorly controlled since admission and required
IV labetalol prn in MICU. On the floor BPs reanged to
160s/110s. Antihypertensive medication reconcilliation was
performed in consultation with Dr. [**Last Name (STitle) 1366**]. It was noted that
the patient has not benefited from HCTZ and relative hypotension
with [**Name (NI) 8213**]. Mr. [**Known firstname 6164**]' labetalol was increased to 200mg [**Hospital1 **],
clonidine patch was continued at 0.3mg Qweekly and lisinopril
was started at 20 and advanced to 40mg QD at time of discharge.
BP at discharge 142/100 mmHg.
.
# CAD s/p STEMI. Patient was asymptomatic. He was continued on
ASA, plavix, statin, BB. Lisinopril was started prior to
discharge. He will be scheduled as OP for catheterization.
.
For prophylaxis he was placed on heparin SC and continued
outpatient PPI regimen.
.
He was discharged in a hemodynamically stable condition with
appropriate follow up. Patient was pain free and free of n/v.
Medications on Admission:
1. Aspirin 325 mg daily
2. Clopidogrel 75 mg daily
3. Simvastatin 40 mg daily
4. Clonidine 0.3 mg/24 hr Patch Weekly qSunday
5. Labetalol 200 mg [**Hospital1 **]
6. Lanthanum 1000 mg TID c meals
7. Metoclopramide 10 mg QIDACH
8. B Complex-Vitamin C-Folic Acid 1 daily
9. Gabapentin 300 mg with HD
10. Pantoprazole 40 mg daily
11. Zofran 4 mg TID
12. Ativan 1 mg q4-6hrs prn
13. Insulin NPH 5 U qAM
14. Vicodin 5-500 mg TID prn
15. Vancomycin with HD
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
Disp:*14 Patch Weekly(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
Disp:*30 Capsule(s)* Refills:*2*
7. 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*
8. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID with meals.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
9. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
12. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection three times a day: as per your sliding scale provided
to you.
Disp:*10 cartriges* Refills:*2*
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO QAM.
Disp:*30 Tablet(s)* Refills:*2*
15. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5)
Units Subcutaneous QAM.
16. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for abdominal pain: gastroparesis.
Disp:*30 Tablet(s)* Refills:*0*
17. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
18. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastroparesis, pulmonary edema, uncontrolled
hypertension
Secondary: Diabetes type I, Coronary artery disease, autonomic
dysfunction.
Discharge Condition:
Hemodynamically stable, without pain.
Discharge Instructions:
You were admitted to the hopital because you have developed an
exacerbation of your recurrent abdominal pain and nausea and
vomiting. In addition you were found to have fluid in your
lungs, likely due to drinking too much fluid between dialysis
sessions. Initially, you had low blood oxygen levels and
required supplemental oxygen, but once you went to dialisis,
your oxygen levels improved as did your breathing.
You were treated with pain medication, nause medication and went
to dialisis. You were also continued on Vancomycin for a blood
infection, you did not have any fevers. You completed this
antibiotic while in the hospital.
You went to dialisis on your regularly scheduled days. At
Dialysis more blood cultres were drawn.
In addition, you were found to have an anneurysm (small
outpouching) of a blood vessel around your heart. Your
cardiologist's team saw you and felt that this will not require
further intervention. You will need to follow up with your
cardiologist for this as well as to have a heart
catheterization.
Your blood pressure was also high during this admission. This
was discussed in detail with your Nephrologist Dr. [**Last Name (STitle) 1366**] and
the new regimen was provided for you (new medication includes
Lisinporil and you will continue Labetalol and clonidine). You
will need to follow up the blood pressure regimen and the blood
culture results with Dr. [**Last Name (STitle) 1366**].
Should you experience new abdominal pain, chest pain, shortness
of breath, palpitations, fever, chills, cough, faintness or any
other symptoms concerning to you, please call your primary care
provider or go to the nearest emergency room.
Please adhere to a regular diabeti, heart healthy diet. You
were provided with prescriptions and refills for medications you
are taking.
Followup Instructions:
Please follow up with you PCP and the following providers:
Please call your PCP to follow up within two weeks. [**First Name4 (NamePattern1) 31804**]
[**Last Name (NamePattern1) 7405**] ([**Company 191**] resident). [**Telephone/Fax (1) 250**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2187-12-31**] 11:00. [**Hospital6 29**], [**Location (un) **], CC7
CARDIOLOGY
Please call Dr.[**Name (NI) 4857**] office to arrange follow up within one
to two weeks: ([**Telephone/Fax (1) 773**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2188-1-19**]
ICD9 Codes: 5856, 7907, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5470
}
|
Medical Text: Admission Date: [**2123-4-27**] Discharge Date: [**2123-5-2**]
Date of Birth: [**2045-12-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**4-27**] AVR (#21 pericardial), ASD repair
History of Present Illness:
77 yo F with known AS with worsening DOE and LE edema
Past Medical History:
AS
RHD
lipids
arthritis
HTN
diverticulosis
PVD
Bells Palsy
DM2
Social History:
no tob, etoh
Family History:
NC
Physical Exam:
Pleasant F in NAD
RRR diffuse systolic murmur radiating throughout
Obese, NT/ND abdomen
2+ BLE edema
L facial paralysis/droop
Pertinent Results:
[**2123-4-30**] 07:55AM BLOOD Hct-28.4* Plt Ct-95*
[**2123-4-29**] 01:35AM BLOOD WBC-10.1 RBC-3.86* Hgb-10.7* Hct-31.3*
MCV-81* MCH-27.7 MCHC-34.2 RDW-15.6* Plt Ct-102*
[**2123-4-30**] 07:55AM BLOOD Plt Smr-LOW Plt Ct-95*
[**2123-4-29**] 01:35AM BLOOD Plt Ct-102*
[**2123-4-30**] 07:55AM BLOOD K-4.4
[**2123-4-28**] 02:12AM BLOOD Type-ART pO2-123* pCO2-46* pH-7.35
calHCO3-26 Base XS-0
Brief Hospital Course:
After undergoing AVR and ASD closure, the patient was brought to
the CSRU post-operatively; please see operative report for
details. An ETT, OGT, RIJ Swan, Foley, mediastinal chest tubes,
and pacing wires in place. She was extubated on POD #1, weaned
from her vasoactive drips and transferred to the floor the
following day after PIV placement and CVL removal. A swallowing
evaluation on POD #2 showed mild dysphagia, and recommendations
included no thin liquids, only ground solids and nectar thick
liquids and aspiration precautions. Two episodes of atrial
fibrillation were treated with amiodarone and she subsequently
converted to a normal sinus rhythm. Chest tubes were removed
after insufficient output per protocol, and the pacing wires
were removed on POD 3 per protocol. The patient participated
with physical therapy per cardiac rehab protocol and was ready
for discharge on POD 5.
Medications on Admission:
metformin 500'', glyburide 2.5'', inderal LA 80', lescol 20',
ASA 81', lasix 40', prilosec 20', centrum, tylenol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. 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*
7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Disp:*60 Packet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 1 week, then 400 QD x 1 week, then 200 QD
ongoing.
Disp:*120 Tablet(s)* Refills:*2*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
13. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 6978**] House of [**Location (un) 5871**]
Discharge Diagnosis:
AS
RHD
DM2
HTN
Hypercholesterolemia
arthritis
PVD with claudication
h/o bells palsy (L facial paralysis)
diverticulosis
s/p unknown childhood intestinal surgery
s/p knee arthroscopy
s/p c-section
s/p elbow surgery
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 5263**] 2 weeks
Dr. [**Last Name (STitle) 20222**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
ICD9 Codes: 9971, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5471
}
|
Medical Text: Admission Date: [**2102-2-15**] Discharge Date: [**2102-2-21**]
Date of Birth: [**2046-8-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 4 (LIMA-LAD,
SVG-Dg1,SVG-Dg2,SVG-OM)
History of Present Illness:
This is a 55 year old white male with several months of
progressive dyspnea on exertion. Catheterization on [**2-1**]
revealed triple vessel disease with preserved LV by echo (55%).
He is admitted now for elective revascularization.
Past Medical History:
Coronary artery disease
obesity
obstructive sleep apnea
insulin dependent diabetes mellitus
hypertension
hyperlipidemia
diabetic neuropathy
Social History:
Works as a mechanic for UPS.
Social ETOH use.
Stopped smoking 23 years ago.
Lives with his wife.
Family History:
Father underwent CABG in his 70s
Physical Exam:
Admission:
VSS, afebrile. BP 92/52
Awake, alert and intact.
Lungs- clear
Cor- SR w/o murmur.
Abd- obese but benign.
Exts-no edema, Charcot Joint L foot
Vasc- [**Last Name (un) **] pulses present PT/DP bilat.
Pertinent Results:
[**2102-2-19**] 07:00AM BLOOD WBC-13.9* RBC-3.95* Hgb-11.1* Hct-32.3*
MCV-82 MCH-28.2 MCHC-34.5 RDW-13.2 Plt Ct-269
[**2102-2-21**] 06:40AM BLOOD WBC-11.5* RBC-4.33* Hgb-11.7* Hct-35.1*
MCV-81* MCH-27.1 MCHC-33.4 RDW-13.5 Plt Ct-338
[**2102-2-19**] 07:00AM BLOOD Glucose-111* UreaN-27* Creat-0.8 Na-137
K-4.1 Cl-100 HCO3-27 AnGap-14
[**2102-2-21**] 06:40AM BLOOD UreaN-25* Creat-1.0 K-4.8
[**2102-2-21**] 06:40AM BLOOD Mg-2.4
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81479**] (Complete)
Done [**2102-2-15**] at 1:19:19 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2046-8-19**]
Age (years): 55 M Hgt (in): 72
BP (mm Hg): 120/70 Wgt (lb): 270
HR (bpm): 72 BSA (m2): 2.42 m2
Indication: CABG
ICD-9 Codes: 402.90, 786.05
Test Information
Date/Time: [**2102-2-15**] at 13:19 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The patient appears to be in sinus rhythm.
patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 40 cm
from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on Mr.[**Name13 (STitle) 81480**]
at 10AM before initiation of surgery.
POST-BYPASS:
Preserved biventricular systolic function. LVEF 55%.
Normal RV systolic function.
Intact thoracic aorta. Other exam is unchanged.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2102-2-15**] 15:20
?????? [**2096**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2-15**] the patient was brought to the Operating Room where
quadruple bybass grafting was performed as noted. He weaned
from bypass in stable condition on neo synephrine and Propofol.
As he was a difficult intubation, anesthesia was at the bedside
when he was extubated. He spent the night on CPAP mask due to
his sleep apnea, having refused to use the mask in the past. He
weaned from pressors easily. An insulin infusion was necessary
to control his hyperglycemia. His preoperative Lantus and
sliding scale insulin were give the day after surgery.
His chest tubes were removed on POD 1. His insulin was resumed
and sugars adequately controlled to transfer to the floor.
Pacing wires were removed on the second postoperative day and
diuresis was continued towards his preoperative weight. The
physical therapy staff worked with the patient for mobilization
and endurance.
The patient was noted to have serosanguinous drainage from the
lower portion of his incision on POD 4. The incision was opened
approximately 4 inches longitudinally and [**3-22**]" deep. This
revealed apparently healthy tissue, with no pus or signs of
infection. The patient was started on empiric antibiotics and
the infectious disease service was consulted. He remained
afebrile, and the wound remained stable. Wet to dry dressings
were started at the open site. Gram stain did not reveal any
microorganisms, and blood cultures were pending at the time of
discharge. He was discharged home on Keflex with instructions
to follow up with Dr. [**Last Name (STitle) 914**] in 1 week. VNA was arranged to
follow up with a wound-vac in the home. The patient was
discharged on POD 5.
Medications on Admission:
Lantus 110U [**Hospital1 **]
Humalog 30U bkfst, 40U lunch, 30U dinner
Gabapentin 300mg TID
Crestor 10mg/D
Atenolo25mg/D
ASA 325mg/D
MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 1 months.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: 100 units
Subcutaneous twice a day.
Disp:*qs * Refills:*2*
13. Insulin Lispro 100 unit/mL Insulin Pen Sig: varies
Subcutaneous four times a day: see sliding scale.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafts x 4
obesity
obstructive sleep apnea
insulin dependent diabetes mellitus
hypertension
hyperlipidemia
diabetic neuropathy
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
wound clinic in 2 weeks
Dr. [**Last Name (STitle) **] in [**1-20**] weeks ([**Telephone/Fax (1) 30453**])
Dr. [**Last Name (STitle) 1270**] in 2 weeks
please call for appointments
Completed by:[**2102-2-21**]
ICD9 Codes: 5990, 3572, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5472
}
|
Medical Text: Admission Date: [**2149-9-22**] Discharge Date: [**2149-10-3**]
Date of Birth: [**2080-8-7**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Unresectable Colonic Polyp.
Major Surgical or Invasive Procedure:
#1 Laparoscopic Right Colectomy
#2 Exploratory laparoscopy and flexible sigmoidoscopy for
suspected post-procedure bleeding.
History of Present Illness:
The patient is a 69-year-old male who was on a routine screening
found to have a large polyp at the hepatic flexure which was
unamenable to endoscopic removal; it was entered by biopsy. The
patient also has 2 mechanical valves
and he is on Coumadin. The risks and benefits of surgery
including but not limited to infection, bleeding, leak, need for
reoperation, need for further procedures, bowel injury, need for
drain or tubes was discussed. The patient agreed. He has
stopped his Coumadin a week ago and was changed to Lovenox, and
he stopped his Lovenox 2 days prior to presenting.
Past Medical History:
Past Medical History:
sCHF EF 30%
Colonic adenomas
Rheumatic heart disease s/p mechanical AVR/MVR in [**2137**]
Hypertension
Atrial fibrillation
?Osteoporosis
BPH
.
Past Surgical History:
b/l shoulder arthroplasties
Ankle surgery
surgery for gynecomastia
Social History:
Supportive wife and daughter.
Physical Exam:
General: NAD, A&OX3, Appears well, ambulating the floor
independantly, no pain, passing bowel movements, +flatus per
rectum.
VS: 99.4, 75, 117/51, RR18, RR 18, 99 RA
Cardiac: no MRG, Audbile click of valves, irregular rythm
Lungs: CTA, no distress
Abd: NBS, soft, nontender, no rebound/no gaurding
Wounds: Laparoscopic sites intact, open to air, umbilical site
intact
Pertinent Results:
[**2149-9-23**] 08:54AM BLOOD Hct-25.9*
[**2149-9-22**] 06:35PM BLOOD WBC-6.1 RBC-3.04*# Hgb-10.3*# Hct-29.9*
MCV-98 MCH-33.8* MCHC-34.3 RDW-12.7 Plt Ct-110*#
[**2149-9-22**] 10:53AM BLOOD Hct-37.1*
[**2149-9-22**] 06:35PM BLOOD Plt Ct-110*#
[**2149-9-22**] 08:50AM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.2*
[**2149-9-23**] 08:50AM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-135
K-4.3 Cl-103 HCO3-29 AnGap-7*
[**2149-9-22**] 06:35PM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-136
K-4.1 Cl-103 HCO3-31 AnGap-6*
[**2149-9-22**] 10:53AM BLOOD Na-135 K-4.4 Cl-102
[**2149-9-23**] 08:50AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.9
[**2149-9-22**] 06:35PM BLOOD Calcium-7.6* Phos-2.2* Mg-2.0
[**2149-9-22**] 10:53AM BLOOD Mg-2.2
[**2149-9-23**] 01:49PM BLOOD WBC-5.0 RBC-2.89* Hgb-9.7* Hct-28.2*
MCV-98 MCH-33.6* MCHC-34.5 RDW-13.6 Plt Ct-128*
[**2149-9-23**] 08:20PM BLOOD WBC-4.4 RBC-3.22* Hgb-10.3* Hct-30.8*
MCV-96 MCH-31.9 MCHC-33.4 RDW-14.7 Plt Ct-117*
[**2149-9-24**] 01:07AM BLOOD Hct-28.7*
[**2149-9-24**] 03:57AM BLOOD WBC-2.8* RBC-2.94* Hgb-9.6* Hct-27.6*
MCV-94 MCH-32.7* MCHC-34.8 RDW-14.7 Plt Ct-94*
[**2149-9-24**] 12:11PM BLOOD Hct-28.7*
[**2149-9-24**] 05:36PM BLOOD WBC-2.4* RBC-3.18* Hgb-10.2* Hct-29.4*
MCV-92 MCH-32.2* MCHC-34.8 RDW-15.7* Plt Ct-100*
[**2149-9-24**] 11:27PM BLOOD Hct-27.7*
[**2149-9-25**] 05:30AM BLOOD WBC-2.9* RBC-3.14* Hgb-10.3* Hct-29.1*
MCV-93 MCH-32.7* MCHC-35.3* RDW-16.1* Plt Ct-110*
[**2149-9-25**] 05:00PM BLOOD WBC-2.9* RBC-3.35* Hgb-11.0* Hct-31.2*
MCV-93 MCH-32.7* MCHC-35.1* RDW-16.1* Plt Ct-137*
[**2149-9-26**] 04:40AM BLOOD WBC-2.8* RBC-3.12* Hgb-10.2* Hct-29.3*
MCV-94 MCH-32.6* MCHC-34.7 RDW-15.8* Plt Ct-141*
[**2149-9-26**] 12:01PM BLOOD WBC-2.6* RBC-3.23* Hgb-10.4* Hct-30.2*
MCV-94 MCH-32.3* MCHC-34.5 RDW-15.7* Plt Ct-146*
[**2149-9-27**] 04:16AM BLOOD WBC-3.4* RBC-3.11* Hgb-9.9* Hct-28.7*
MCV-92 MCH-31.7 MCHC-34.5 RDW-15.7* Plt Ct-172
[**2149-9-27**] 12:25AM BLOOD Hct-29.1*
[**2149-9-26**] 07:33PM BLOOD Hct-30.3*
[**2149-9-27**] 04:28PM BLOOD Hct-28.2*
[**2149-9-28**] 09:46PM BLOOD WBC-5.1 RBC-3.20* Hgb-10.2* Hct-29.6*
MCV-92 MCH-31.9 MCHC-34.6 RDW-15.5 Plt Ct-192
[**2149-9-29**] 06:50AM BLOOD WBC-4.6 RBC-3.44* Hgb-10.9* Hct-32.0*
MCV-93 MCH-31.8 MCHC-34.1 RDW-15.3 Plt Ct-221
[**2149-9-30**] 07:13AM BLOOD WBC-4.6 RBC-3.23* Hgb-10.4* Hct-30.4*
MCV-94 MCH-32.2* MCHC-34.3 RDW-15.8* Plt Ct-252
[**2149-9-22**] 08:50AM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.2*
[**2149-9-22**] 06:35PM BLOOD Plt Ct-110*#
[**2149-9-23**] 01:49PM BLOOD PT-12.8 PTT-28.0 INR(PT)-1.1
[**2149-9-23**] 01:49PM BLOOD Plt Ct-128*
[**2149-9-23**] 08:20PM BLOOD PT-12.3 PTT-28.6 INR(PT)-1.0
[**2149-9-23**] 08:20PM BLOOD Plt Ct-117*
[**2149-9-24**] 03:57AM BLOOD PT-12.7 PTT-28.7 INR(PT)-1.1
[**2149-9-24**] 03:57AM BLOOD Plt Smr-LOW Plt Ct-94*
[**2149-9-24**] 05:36PM BLOOD PT-12.7 PTT-29.8 INR(PT)-1.1
[**2149-9-25**] 05:00PM BLOOD Plt Smr-LOW Plt Ct-137*
[**2149-9-25**] 10:01PM BLOOD PTT-28.9
[**2149-9-26**] 04:40AM BLOOD PT-12.6 PTT-29.3 INR(PT)-1.1
[**2149-9-26**] 04:40AM BLOOD Plt Ct-141*
[**2149-9-26**] 12:01PM BLOOD Plt Ct-146*
[**2149-9-26**] 05:13PM BLOOD PTT-28.2
[**2149-9-26**] 05:13PM BLOOD PTT-28.2
[**2149-9-27**] 12:25AM BLOOD PT-12.8 PTT-31.7 INR(PT)-1.1
[**2149-9-27**] 04:16AM BLOOD PT-12.4 PTT-38.0* INR(PT)-1.0
[**2149-9-27**] 04:16AM BLOOD Plt Ct-172
[**2149-9-27**] 08:06AM BLOOD PTT-37.5*
[**2149-9-27**] 04:28PM BLOOD PT-13.0 PTT-39.5* INR(PT)-1.1
[**2149-9-27**] 09:47PM BLOOD PT-12.9 PTT-40.6* INR(PT)-1.1
[**2149-9-28**] 04:25AM BLOOD PT-13.6* PTT-54.5* INR(PT)-1.2*
[**2149-9-28**] 01:53PM BLOOD PTT-52.3*
[**2149-9-28**] 09:46PM BLOOD Plt Ct-192
[**2149-9-28**] 10:45PM BLOOD PTT-53.2*
[**2149-9-29**] 06:50AM BLOOD PT-15.0* PTT-55.1* INR(PT)-1.3*
[**2149-9-29**] 06:50AM BLOOD Plt Ct-221
[**2149-9-30**] 07:13AM BLOOD PT-18.7* PTT-64.4* INR(PT)-1.7*
[**2149-9-30**] 07:13AM BLOOD Plt Ct-252
[**2149-10-1**] 06:10AM BLOOD PT-18.9* PTT-65.1* INR(PT)-1.7*
[**2149-10-2**] 06:15AM BLOOD PT-21.9* PTT-77.6* INR(PT)-2.0*
[**2149-10-3**] 06:25 PT 24.4* PTT 87.5* INR 2.3*
[**2149-9-24**] Chest Xray
FINDINGS: In comparison with study of [**2142-9-1**], there are
continued low lung volumes that may account for some of the
prominence of transverse diameter of the heart. There is
indistinctness of engorged pulmonary vessels, consistent with
the clinical impression of some volume overload. Intact midline
sternal wires and prosthetic valve is in place.
CT Abdomen [**2149-9-26**]
1. Unremarkable-appearing ileocolonic anastomotic site with no
peri-anastomotic fluid collection or significant inflammation.
Minimal
peritoneal fluid and mesenteric stranding as expected.
2. Small bowel ileus.
3. Pockets of hematoma within the abdomen and lower pelvis left
rectus sheath likely at prior port site as detailed above.
Expected mild-to-moderate amount of residual postoperative
pneumoperitoneum.
4. Mild perihepatic ascites.
Brief Hospital Course:
The patient was admitted to the inpatient unit after a
laparoscopic right colectomy for removal of an colonic adenoma.
Pre-operatively the patient was found to have hematocrit of
37.1. Post-operatively a complete blood count was sent and the
hematocrit was 29.9. The patient complained of pain overnight
despite management with Hydromorphone PCA. The patient was seen
on morning rounds by the surgical team and appeared well with
only the complaint of pain. On the morning of post-operative day
one, the patient was found to have management reduced urine
output of 10-12cc/hr and hypotension to 78/42. The patient was
triggered for hypotension, repeat laboratory values were sent
and the patient's hematocrit was 25.9. The patient was given a
bolus of 500 cc normal saline with little response, the patient
was ordered to receive two units of packed red blood cells. An
EKG and showed atrial fibrillation with a rate of 88 which was
his baseline rhythm. Because of persistent hypotension, the
patient was transferred to the [**Hospital Unit Name 153**] for closer monitoring. In
the [**Hospital Unit Name 153**], the patient continued to have borderline blood
pressure readings. The patient received 2 unites of packed red
blood cells and the hematocrit was Serial hematocrit levels were
drawn and was 28.2. Because of recent anticoagulation, the
appearance of the patients tissue during the case, a moderate
amount of ecchymosis around the port sites of the original
laparoscopic procedure and persistent hypotension the patient
was taken back to the operating room on [**2149-9-23**] for exploratory
laparoscopy and flexible sigmoidoscopy to view the anastomosis
and lumen of the colon. During this case, little blood was
visualized at the anastomosis however site, however a large
amount of blood and clot was seen on flexible sigmoidoscopy
which was washed out. It was determined that this was not an
anastomotic bleed, just oozing of blood at the staple line. The
patient received 2 units of packed red blood cells during the
case. The patient returned to the FI CU for further monitoring.
Serial hematocrits were drawn and remained stable with the goal
to transfuse the patient if his hematocrit was below 25.
Throughout this time, the patient was not anticoagulated for his
prosthetic heart valves. The patient was kept in the [**Hospital Unit Name 153**] for
close monitoring while initiating intravenous heparin at 500u/hr
with a goal PTT 50-70 on [**2149-9-25**]. At this time the patient was
distended but denied nausea and it was thought that the patient
most likely had a post-operative ileus, he tolerated sips of
clears. Because of pancytopenia with a notable monocytosis
oncology was consulted to comment on abnormal lab values and
determined that the patient's anemia was most likely related to
acute blood loss, thrombocytopenia related to possibly a stress
reaction from acute illness, and leukopenia with monocytosis
also likely a stress reaction. The patients platelet level
slowly improved over time. An abdominal CT scan was obtained
[**2149-9-26**] which showed: Unremarkable-appearing ileocolonic
anastomotic site with no
peri-anastomotic fluid collection or significant inflammation,
Small bowel ileus with no transition point to suggest
obstruction, pockets of hematoma within the abdomen and lower
pelvis as well as within the lower left rectus sheath likely at
port site as delineated above, expected mild-to-moderate amount
of residual postoperative pneumoperitoneum, with Mild amount of
perihepatic ascites. The patient transferred to the inpatient
floor in stable condition on [**2149-9-27**]. On the inpatient [**Hospital1 **] the
patient did well, slowly progressed his diet and level of
activity tolerated. The patient began passing gas and had
multiple post-operative bowel movements. He remained on the
intravenous heparin awaiting elevation of his INR to above 2.5
for Aortic/Mitral prosthetic valves. The patients INR progressed
to 2.3 on the day of discharge. The patient's cardiologist Dr.
[**Last Name (STitle) **] was aware for three days prior to the patients discharge of
his INR level. Because of insurance issues, the patient was
unable to be discharged with a Lovenox bridge. On [**2149-10-3**], the
INR level reached 2.3, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] by [**Name (NI) 636**] [**Last Name (NamePattern1) 28528**],
NP and consulted. Dr.[**Last Name (STitle) **] was satisfied with this result and
requested that the patient be discharged on 7mg of Coumadin
daily until [**2149-9-26**] when he would monitor his INR level at home
(the patient tests his INR at home) and call his office for
advice. The patient was given these instructions in detail and
returned home post-operative day 10. The patient had been taking
Diovan however this was held at discharge because of stable
blood pressure and the patient was asked to follow-up with is
outpatient cardiologist.
Medications on Admission:
Alendronate
Carvedilol PO 6.25mg [**Hospital1 **]
Eplerenone PO 50mg qd
Flomax PO 0.4mg qd
Diovan PO 320mg qd,
Warfarin PO 61/2mg and 7mg every other day,
Calcium
Magnesium.
Discharge Medications:
1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Eplerenone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 7mg of Coumadin daily until Monday [**2149-10-6**] when you
should call Dr. [**Last Name (STitle) **] for any needed dose adjustment. .
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 7mg of Coumadin daily until Monday [**2149-10-6**] when you
should check your INR and call Dr.[**Name (NI) 29343**] office for any dose
adjustment needed. .
5. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Unresectable Colonic Polyp and Anastomotic bleed.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgical managment of the
polyp in your colon that was not removed during you colonoscopy.
After the procedure, you developed low blood pressure and were
found to have some bleeding in your abdomen where the procedure
was done. The surgical team beleives that this was related to
the coumadin that you take at home to prevent dangerous clots
from your heart valves. This bleeding caused you to need
transfer to the intensive care unit and ultimately being
transfered to the operating room to look inside of your abdomen.
Your abdomen was washed out and the anastomosis looked great.
You were recovered in the intesive care until until your blood
level returned to [**Location 213**] and anticoagulation was initiated and
you were transferred to the inpatient unit. We monitored you
vital signs, lab values, and restarted your coumadin. You are
ready to be discharged home, you are tolerating a regular diet,
your pain is controlled and you will return home on your usual
coumadin regimen. We have kept you in the hospital on a heparin
drip while your INR returned to goal with coumadin therapy. Your
INR is now 2.3 which is close to your goal and you are now able
to return home. It is very important that you continue to manage
your INR as you were doing previously to prevent any chance of
the formation blood clots from your heart valves. You should see
Dr. [**Last Name (STitle) **] in follow up in 7 days, please call his office to make
an appointment. Please check your INR at home on Monday and call
his office for any dose adjustment needed, your INR should be
between 2.5-3.5. Please check your INR level tomorrow at home
and be sure your INR has not decreased. Dr. [**Last Name (STitle) **] would like you
to take 7mg of Coumadin daily until Monday [**2149-10-6**] when you will
call his office for advice. You have reported that you have 2mg
and 5mg tablets of Coumadin at home. Please take one 2mg tablet
and one 5mg tablet for a total of 7mg daily until Monday
[**2149-10-6**]. We have stopped your Diovan which is a medication for
your blood pressure because your blood pressure has been under
good control to slightly low during your hospitalization. You
should continue to take your other medications on your discharge
medication list. The night before your discharge your blood
pressure was 117/31. Please monitor your blood pressure at home
it the top number should be above 100 but not higher than
120-130. Check your blood pressure everyday and adress this with
your with Dr. [**Last Name (STitle) **] when you see him at his clinic and he can
adjust your blood pressure medications.
Please monitor your bowel function closely. If you develop:
nausea, vomiting, increasing abdominal pain, loose/bloody
stools, abdominal distension, or inability to tolerate food or
liquid, please call the office or if your symptoms are severe
return to the emergency room. You may take a stool softener,
colcace, while you are taking pain medications as the pain
medications will constipate you.
Please monitor your surgical incision. Currently the
laparoscopic sites are closed with skin glue and steri-strips.
These may be left open to air, you may shower, please pat the
area dry and do not rub. Watch for signs and symptoms of
infection including: increased redness, drainage
(white/green/yellow) drainage, foul smelling odor, increased
pain at the site, or if you develop a fever please call the
office or go to the emergency room if your symptoms are severe.
Avoid lifting greater than 6 pounds for 6 weeks after your
surgery unless told otherwise by Dr. [**Last Name (STitle) **]. You may shower
however no swimmingor taking baths for 6 weeks after surgery.
You have not needed pain medication for a number of days. Please
call the office if you develop pain. It is important to report
this symptom if it occurs.
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in 1 week. Call
[**Telephone/Fax (1) 7728**] to make an appointment. Please check your INR on
Monday [**2149-10-6**] and call Dr.[**Name (NI) 29343**] office to report your INR and
any recieve any needed dose adjustment.
Please make an appointment to see Dr. [**Last Name (STitle) **] in follow up in [**3-12**]
weeks. Call ([**Telephone/Fax (1) 3378**] to make an appointment.
Completed by:[**2149-10-3**]
ICD9 Codes: 2851, 4019, 3051
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5473
}
|
Medical Text: Admission Date: [**2109-3-6**] Discharge Date: [**2109-3-20**]
Date of Birth: [**2046-12-21**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 62 year old male with
multiple medical problems including tracheobronchial malacia
status post tracheoplasty in [**2108-5-29**] and then status
post tracheostomy on [**2108-12-18**] complicated by
aspiration and pulmonary problems most likely due to his non-
surgical neurologic issues. His last pneumonia was two weeks
ago. He has no complaints of chest pain, shortness of breath,
but has been complaining of persistent abdominal pain with
nausea requiring Compazine and occasional extreme pain
requiring morphine sulfate, no fevers, chills, nausea or
vomiting, diarrhea, constipation or other stool changes.
PAST MEDICAL HISTORY: Significant for COPD, asthma,
aspiration pneumonia, coronary artery disease status post
distant MI, diabetes mellitus, peripheral neuropathy,
tracheobronchial malacia, hypertension, increased
cholesterol, gastroesophageal reflux disease.
MEDICATIONS: He takes Compazine, morphine sulfate, insulin,
aspirin, Lipitor, Atrovent, simethicone, guaifenesin.
PHYSICAL EXAMINATION: On admission, temperature was 98.4
degrees, heart rate 94, blood pressure 102/56, respiratory
rate 18, 100 percent on 2 liters nasal cannula oxygen. The
trach is noted to be in place with a Passy-Muir valve. Neck
is supple. Heart rate was in regular rate and rhythm.
Bilaterally, there were rales with a few scattered wheezes.
Abdomen was nondistended with a G-tube in place with some
signs of tympany. Abdomen revealed well healed incision
sites.
HOSPITAL COURSE: Thus, at this time, the patient was
admitted for further evaluation and treatment at [**Hospital1 346**]. He was to be preoperatively
prepared for a [**Hospital1 **] fundoplication and colostomy take-down.
The patient was appropriately preoperatively prepared with a
GoLYTYELY prep. He was given intravenous antibiotics. Beta
blockers were given and an EKG was performed which showed no
significant changes as well as a chest x-ray which also
showed no significant changes. The patient was typed and
screened and consent was signed for the procedure. On [**2109-3-7**], the patient proceeded to the Operating Room without
incident and underwent the following procedure. An
exploratory laparotomy was performed with lysis of adhesions.
An open [**Year (4 digits) **] fundoplication was performed. A colocolostomy
was performed times two and a colostomy take-down as well.
The patient received general anesthesia and also received an
epidural at this time. The patient received 2 units of packed
red blood cells in the Operating Room and a 14-French
jejunostomy tube was also placed during this time for feeding
purposes in the background of his recurrent aspiration. The
patient was brought to the Post-Anesthesia Care Unit shortly
thereafter and was noted to be hypotensive at this time with
blood pressures into the 80s/40s. This was noted likely to be
secondary to epidural that was bolused in the Operating Room.
He received Neo-Synephrine in the Post-Anesthesia Care Unit
and was given albuterol nebulizer treatments and when the
blood pressure rose appropriately, the Neo-Synephrine drip
was stopped and esmolol was given to control tachycardia. A
chest x-ray was done which showed no evidence of pneumothorax
at this time. Also, of note, the patient's temperature was to
103 degrees F. The patient remained on the ventilator during
this time as he was retaining some carbon dioxide still.
Also, at this time, a central venous line had been placed and
this was checked for position on chest x-ray and adjusted
appropriately. The patient was brought to the Trauma
Intensive Care Unit at this time and received 3 liters of IV
fluids bolused and was started on a Dilaudid patient
controlled analgesia device. Also, at this time, the epidural
was stopped. On postoperative day #2, the patient was again
noted to be febrile. However, he was able to be weaned to a
tracheostomy mask and he was also started on a clear diet at
this time without difficulty. He was also started on TPN at
this time. Also of note, the patient was continually followed
by Acute Pain Service during is inpatient stay who made
frequent recommendations in regards to his care and on
postoperative day #4, the patient was able to be sent to the
floor from the Intensive Care Unit. He did complain at this
time of brief chest tightness that was nonradiating without
diaphoresis or shortness of breath. An EKG was done that was
normal. Nitroglycerin was given sublingually one time with
some improvement. Enzymes were ordered to be cycled. They
were all found to be negative and to show no significant rise
that would be indicative of myocardial damage. The patient
continued to progress on the floor. The patient was also
followed by Thoracic Service during his time as an inpatient
as the patient was familiar to Dr. [**Last Name (STitle) 952**]. The patient was
then seen by Physical Therapy on postoperative day #4 to
improve his activity. The patient at times was recalcitrant
to instructions to getting out of bed. Attitude was described
as lack luster. However, this began to improve during his
hospital stay as he slowly increased his activity with the
encouragement of the Surgical Team and the physical
therapists. The patient was also placed on antibiotics
levofloxacin, cephazolin and vancomycin on [**3-12**],
postoperative day #5, for a culture that came back growing
Pseudomonas. On [**3-15**], postoperative day #8, a VAC
dressing was started on his midline abdominal wound. This
required only a very small strip of VAC sponge. The patient
tolerated the procedure well. Also of note during his stay on
postoperative day #12, the patient was seen again by the
Acute Pain Service that suggested an increase of methadone to
10 mg p.o. t.i.d., start Topamax 25 mg p.o. q.h.s., for
neuropathic pain, to continue Tylenol, to start ibuprofen 400
mg q.6h. and to continue Dilaudid 4 mg p.o. q.4h. as needed
for pain. These recommendations were followed. The case was
discussed again at length with the Acute Pain Service and the
VAC dressing was replaced again on the day of discharged,
[**2109-3-20**], by Dr. [**First Name (STitle) **] and the appropriate paperwork
was completed for discharge to a rehabilitation facility.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to a
rehabilitation facility and to receive aggressive physical
therapy and to receive VAC dressing changes every three days.
The patient is to continue to receive tube feeds as he has
been while in the hospital. These instructions are to
accompany the rest of his paperwork.
FINAL DIAGNOSIS: Chronic obstructive pulmonary disease,
asthma, hypertension, hypercholesterolemia, diabetes
mellitus, peripheral neuropathy, gastroesophageal reflux
disease, recurrent pneumonia, tracheobronchial malacia,
tracheoplasty, tracheostomy, colostomy, Clostridium
difficile, methicillin-resistant staph aureus.
RECOMMENDED FOLLOW-UP: The patient is to follow up with Dr.
[**Last Name (STitle) 952**] in [**12-30**] weeks at [**Telephone/Fax (1) 52342**]. The patient is to follow
up with Dr. [**First Name (STitle) 2819**] in [**10-11**] days at [**Telephone/Fax (1) 2998**].
DISCHARGE MEDICATIONS: Ipratropium bromide 18 mcg aerosol
two puffs inhaled q.i.d., guaifenesin [**5-7**] ml p.o. q.6h. as
needed, ipratropium bromide 0.02% solution, one inhalation
q.6h. as needed, insulin Regular human as directed, heparin
sodium porcine 5000 units b.i.d., metoprolol 100 mg b.i.d.,
famotidine 20 mg b.i.d., acetaminophen 1000 mg t.i.d.,
atorvastatin calcium 20 mg daily, miconazole nitrate powder
to be applied to the J-tube site t.i.d., hydromorphone 4 mg
p.o. q.4h. as needed for pain, topiramate 25 mg p.o. q.h.s.,
methadone 10 mg p.o. t.i.d., vancomycin 1 g q.12h for 6 days,
metronidazole 500 mg q.8h. for six days, ceftazidime 2 g
q.8h. for 6 days.
DISPOSITION: The patient will be discharged to
rehabilitation facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18475**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2109-3-20**] 11:30:35
T: [**2109-3-20**] 12:50:43
Job#: [**Job Number **]
ICD9 Codes: 496, 4019, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5474
}
|
Medical Text: Admission Date: [**2134-5-6**] Discharge Date: [**2134-5-7**]
Date of Birth: [**2089-4-26**] Sex: M
Service: PSYCHIATRY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6494**]
Chief Complaint:
Paranoia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 45 year old male with alcohol dependence, cocaine
abuse, and schizoaffective disorder who was admitted to
[**Hospital1 **] 4 on [**2134-5-1**] with hallucinations, suicidal ideation
and alcohol withdrawal. He was transferred to the MICU on
[**2134-5-3**] for delirium tremens. He was followed by the psychiatry
consult team who recommended transfer back to [**Hospital1 **] 4 on
[**2134-5-6**] after monitored detoxification with benzodiazepines for
continued paranoia about "the men who know what I am doing, they
say what I am doing all the time" and occasionally reported
auditory hallucinations. He denied suicidal or homicidal
ideation and reported mood as "fine".
Past Medical History:
* history of pancreatitis (not active)
* HTN
* ARF, for which pt was hospitalized [**9-3**] at [**Hospital1 18**]
* S/P GSW to abdomen in [**2114**] (OMR reports [**2128**])
* anemia
* history of DTs and alcohol withdrawal seizures
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4036**] [**Last Name (NamePattern1) **] at [**Hospital6 12736**]
PAST PSYCHIATRIC HISTORY:
* Diagnoses: polysubstance abuse (alcohol, cocaine),
schizoaffective disorder, PTSD (related to ? childhood abuse and
being assaulted by gang members in [**2126**])
* reports "at least a half dozen" psychiatric hospitalizations
in last 4-5 years, usually at [**Hospital 8**] Hospital
* At least one prior suicide attempt by OD on sleeping pills in
[**2117**]-91. (+) assaultive behavior (domestic violence), for which
pt was on probation years ago
* followed in the past at [**Hospital **] Hospital (reports multiple
treaters, including Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5448**], Dr. [**Last Name (STitle) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**],
and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3441**]), has not been there since [**7-5**]
* Past med trials include Trazodone, Prozac, Risperdal, and
Clonidine
* Outpatient therapist Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) 10166**] ([**Telephone/Fax (1) 100307**])
* Outpatient psychiatrist Dr. [**First Name (STitle) **]
* Case Manager (per OMR): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 100308**])
Social History:
Born in [**State 9512**]; moved to [**Location (un) 86**] at age 8. Never knew his
biological father, was raised by mother and stepfather, who was
in the military. Denies any abuse growing up. Put into [**Doctor Last Name **]
care at age 14 for unclear reasons. Education: did okay in
school, graduated from HS. Took a few college courses and joined
National Guard (from ages 20-26). Worked as a counselor at
non-profit agency for several years before being fired related
to substance use. He was homeless after this. He just moved into
a new apartment about 1 month ago (lives alone). He felt safe
and comfortable there, and subsequently decided to stop taking
his medications. He says he is now homeless again because he no
longer feels safe
in his apartment. Never married, no children. Legal: 2 DUI's
and assault and battery (last charge was [**2125**]). Finances: gets
money from SSI [**3-5**] psychiatric illness.
SUBSTANCE ABUSE HISTORY:
* EtOH: a fifth of brandy per day for the past few months. Has
had DT's and seizures in the past when he stopped drinking.
Longest period of sobriety was 1-2 years. Multiple past
detoxes; most recent detox at [**Hospital1 18**] in [**12-7**] (on medical floor).
Last EtOH use was "a few sips" 1 day PTA and heavy drinking 2
days PTA.
* Tob: [**2-2**] PPD.
* MJ: occassional, "here and there". Last use was 1 day PTA.
* Crack: about 1x/month. Last use was more than 1 week ago.
Denies any other illicits or IVDA.
Family History:
Thinks his brother has problems with substance abuse and might
have other psychiatric problems as well.
Physical Exam:
MSE: 45 yo man appearing his stated age, cooperative, overall
slowed; fair eye contact; mild horizontal nystagmus, no tongue
tremor or asterixis; no diaphoresis; not agitated; speech: soft,
slowed, not slurred; paucity of detailed content and latency of
response; mood:"fine"; affect: flat; TP: goal directed though
tangential at times; TC: currently denies suicidal/homicidal
ideation but fears becoming suicidal at home; both denies and
states he has auditory hallucinations of men commenting on his
activities; worries that he is being watched and followed;
overall guarded and suspicious; no visual or tactile
hallucinations; HIF: alert, oriented to self, [**Hospital3 **]
Hospital, Wed [**2134-5-5**]; months of year backward correctly;
[**4-3**] obj immed, [**3-6**] at 5", [**4-3**] with prompt; digit span 5 forward
correctly; months of year backward correctly; I/J: limited
Pertinent Results:
[**2134-5-7**] 07:50AM BLOOD WBC-2.9* RBC-3.63* Hgb-11.6* Hct-36.3*
MCV-100* MCH-31.9 MCHC-31.9 RDW-15.8* Plt Ct-255
[**2134-5-6**] 04:00AM BLOOD WBC-3.2* RBC-3.43* Hgb-11.4* Hct-33.9*
MCV-99* MCH-33.2* MCHC-33.6 RDW-16.4* Plt Ct-194
[**2134-5-5**] 03:52AM BLOOD WBC-3.4* RBC-3.55* Hgb-11.4* Hct-35.2*
MCV-99* MCH-32.2* MCHC-32.5 RDW-16.2* Plt Ct-180
[**2134-5-7**] 07:50AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-138
K-4.5 Cl-102 HCO3-26 AnGap-15
[**2134-5-7**] 07:50AM BLOOD ALT-13 AST-21 AlkPhos-39 TotBili-0.3
[**2134-5-7**] 07:50AM BLOOD Calcium-10.2 Phos-4.7* Mg-1.9
[**2134-5-7**] 07:50AM BLOOD VitB12-271
Brief Hospital Course:
Mr. [**Known lastname **] was transferred to the [**Hospital1 18**] inpatient psychiatric unit
from the MICU on [**2134-5-6**]. He signed a conditional voluntary on
arrival to the unit. Mr. [**Known lastname **] was in good behavioral control
throughout his stay and participated appropriately in individual
therapy. He was alert and oriented x 3 on arrival and his CIWAs
remained flat and he did not require any Valium prn on the unit.
He denied any mood symptoms and had mild fears on admission
interview that there may be men in his neighborhood who wished
him harm, but he stated that he generally only became paranoid
and heard voices when he had been withdrawing from alcohol; his
fears dissipated over the next day and at the time of discharge,
he denied any paranoia or hallucinations. He was continued on
Risperdal 1 mg PO tid which was switched back to 3 mg PO qHS
(his outpatient dose) on discharge. He tolerated this well with
no side effects. The importance of alcohol abstinence for his
health was discussed with him and he indicated that he
understood. Mr. [**Known lastname **] was discharged home in stable and improved
condition on [**2134-5-7**].
Medications on Admission:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed.
3. Nicotine 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as
needed.
4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO q2hrs as needed
for CIWA >10.
6. Risperidone 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): use only if non-ambulatory.
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Risperidone 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablets* Refills:*0*
4. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
AXIS I: Cocaine abuse, alcohol dependence, schizoaffective
disorder
AXIS II: none
AXIS III: status post recent delirium tremens, hypertension,
anemia, history of delirium tremens and alcohol withdrawal
seizures
Discharge Condition:
MSE: African-American male, lying comfortably on left side in
bed, covers pulled up. No abnormal movements noted. Good eye
contact. Speech slightly decreased rate and volume, normal
prosody. Mood 'good' Affect flattened but does smile
occasionally. Though process linear. Thought content no
delusions, no preoccupations. Denies suicidal or homicidal
thoughts, plans, or intent. Denies auditory, tactile or visual
hallucinations. Insight/judgement - fair/fair.
Mr. [**Known lastname **] appears safe and appropriate for discharge.
Discharge Instructions:
Please take your medications as prescribed and follow up with
outpatient treaters. Please abstain from alcohol use. Return
to the emergency department if you are feeling unsafe.
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 4036**] [**Last Name (NamePattern1) **] at [**Hospital6 12736**] on [**5-11**] at 2:10 PM. office ([**Telephone/Fax (1) 87420**]; fax ([**Telephone/Fax (1) 100455**]
Therapist: Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) 10166**] on [**5-10**] at 3 PM. office ([**Telephone/Fax (1) 100456**]; fax ([**Telephone/Fax (1) 100457**]
Psychopharmacologist: Dr. [**First Name (STitle) **] on [**5-10**] at 4 PM.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 6498**]
Completed by:[**2134-5-9**]
ICD9 Codes: 2875, 2859, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5475
}
|
Medical Text: Admission Date: [**2173-10-30**] Discharge Date: [**2173-11-9**]
Date of Birth: [**2137-6-17**] Sex: M
Service: SURGERY
Allergies:
Unasyn
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Budd Chiari/HCC/cirrhosis
Major Surgical or Invasive Procedure:
[**2173-10-31**] Orthotopic deceased-donor liver
transplant (piggyback) with portal vein to portal vein
anastomosis, common hepatic artery in the donor to branch
patch of the left hepatic artery in the recipient, common
bile duct to common bile duct anastomosis.
[**2173-11-3**] Exploratory laparotomy, Roux-En-Y hepaticojejunostomy,
and Liver biopsy for bile leak
History of Present Illness:
36M w/ hx of HCC, cirrhosis, Budd-Chiari w/ esophageal
varices and portocaval shunt being admitted for OLT. He was
diagnosed w/ Budd-Chiari at age 12 but did not undergo a
side-to-side portocaval shunt at that time. He did well until
[**2164**], when he experienced hematemesis/melena and required
banding
of esophageal varices. Since [**2169**], he has had multiple
additional episodes of variceal bleeding, some requiring
transfusions. A liver biopsy in [**2169**] showed cirrhosis, and he
did receive a portocaval shunt in [**2170**]. In late [**2171**], he had a
biopsy showing HCC and has undergone both TACE and RFA since.
Patient has recently been feeling well. He denies chest pain,
shortness of breath, abdominal pain, nausea, vomiting, diarrhea,
food intolerance, jaundice, swelling, recent encephalopathy.
Of note the patient has been working out recently.
AB compatible liver donor was available and patient was called
to come in for preoperative assessment.
Revision of systems
Denies nausea, vomiting, fever, abdominal pain, hematemesis,
melena, BRBPR, chest pain, shortness of breath, urinary symptoms
or any other symptoms
Past Medical History:
# Hepatocellular carcinoma, dx 12/[**2171**].
# Budd-Chiari Syndrome, dx age 12.
- Esophageal varices, first in [**2164**] with recurrent episodes.
- EGD [**6-/2170**] with grade II and III esophageal varices s/p
banding, and portal hypertensive gastropathy.
- Portocaval shunt [**2170-8-17**].
# History of positive PPD, quantiferon +, s/p 9 months of INH
treatment.
# Cholecystectomy.
Social History:
Originally from El [**Country 19118**]. Adopted, moved to the United
States at the age of 6 months. Former roofer, currently on
disability. Lives with his girlfriend. [**Name (NI) **] denies smoking,
drinking alcohol, or illicit drug use.
Family History:
Adopted.
Physical Exam:
Preop PE:
Vitals:
98.4 66 123/79 18 100%RA
Exam:
GEN NAD, looks well
HEENT PERRL, MMM, anicteric sclera
CV RRR
RESP CTAB
GI Soft NT/ND, nml BS, liver edge palpable, well
healed right subcostal scar
EXT WWP, no C/C/E, 2+ DPs
NEURO CN 2-12 grossly intact
PSYCH AOx3
Labs:
139 104 15
------------<86 AGap=12
3.5 27 1.0
estGFR: >75 (click for details)
Ca: 8.9 Mg: 2.1 P: 2.9
ALT: 90 AP: 394 Tbili: 1.7 Alb: 4.1
AST: 110
12.7
4.7 >--< 91
37.1
PT: 14.4 PTT: 37.4 INR: 1.3
Fibrinogen: 302
UA: neg for UTI
EKG: No acute ischemic changes
CXR:
Heart size and mediastinum are stable. Lungs are clear. Right
middle lobe opacity seen on multiple prior studies is
re-demonstrated on the current
examination with no appreciable change since prior exams
Pertinent Results:
[**2173-10-30**] 04:25PM BLOOD WBC-4.7 RBC-4.15* Hgb-12.7* Hct-37.1*
MCV-89 MCH-30.6 MCHC-34.2 RDW-16.5* Plt Ct-91*
[**2173-11-9**] 05:10AM BLOOD WBC-12.5* RBC-3.65* Hgb-11.2* Hct-32.8*
MCV-90 MCH-30.7 MCHC-34.3 RDW-16.8* Plt Ct-182
[**2173-11-9**] 05:10AM BLOOD PT-11.9 INR(PT)-1.1
[**2173-11-9**] 05:10AM BLOOD Glucose-82 UreaN-11 Creat-0.9 Na-139
K-3.5 Cl-107 HCO3-25 AnGap-11
[**2173-11-8**] 04:10AM BLOOD ALT-135* AST-76* AlkPhos-96 TotBili-0.6
[**2173-11-9**] 05:10AM BLOOD ALT-152* AST-76* AlkPhos-130 TotBili-0.5
[**2173-11-8**] 04:10AM BLOOD tacroFK-9.9
[**2173-11-9**] 05:10AM BLOOD tacroFK-10.4
Brief Hospital Course:
On [**2173-10-31**], he underwent Orthotopic deceased-donor liver
transplant (piggyback) with portal vein to portal vein
anastomosis, common hepatic artery in the donor to branch
patch of the left hepatic artery in the recipient, common bile
duct to common bile duct anastomosis. Two JP drains were placed
as well as Roux tube. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details.
On [**11-3**], medial drain became bilious on postoperative day 2. An
angiogram demonstrated appropriate flow in the hepatic artery
and he was taken back for surgical revision of his biliary tree.
Exploratory laparotomy, Roux-En-Y hepaticojejunostomy and Liver
biopsy were done. Surgeon was Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. See operative
note for details. Biopsy demonstrated rare portal area with mild
neutrophilic infiltrate and minimal bile duct proliferation, see
note. No rejection. Iron stains were pending.
Postop, he was cared for in the SICU. JP drains were
non-bilious. Roux tube had bilious drainage. LFTs decreased. He
was extubated. NG was removed and sips were started. Diet was
advanced and tolerated. Abdominal incision was intact with
staples. He had a scant amount of serosanguinous drainage at the
apex of the incision.
He was transferred out of the SICU and was ambulating
independently on [**11-8**]. Lateral JP was removed on [**11-8**]. Medial JP
output was 290cc on [**11-8**]. Gravity cholangiogram was done on
[**11-8**]. However, the roux tube was in the bowel and anastomosis
was unable to be assessed. Roux tube was capped. The next day
alt and alk phos were increased ( alt 152 from 135, t.bili 130
from 96).
He was started on a heparin drip on [**11-8**] for Budd Chiari unknown
etiology. Coumadin 2mg was started on [**11-8**]. Heparin was switched
to Lovenox as a bridge. He was taught how to self inject and was
able to demonstrate injection.
Immunosuppression consisted of tapering steroid down to 20mg per
day per protocol. He required minimal insulin for slightly
elevated glucose. Cellcept was well tolerated. Prograf was
adjusted per trough levels.
PT cleared him for home without PT serices. He was anxious to go
home and medication teaching was reviewed on several days.
[**Hospital1 **] VNA was arranged to assist him at home with drain care
as well as review of medications. Given slight elevation in
LFts, labs were to be drawn on [**11-11**] a C lab. INR/Coumadin was to
managed by [**Hospital1 18**] Transplant service.
Medications on Admission:
- amiloride 10 PO mg DAILY
- furosemide 60 PO mg DAILY
- omeprazole 40 PO mg DAILY
- lactulose 15 ml daily
- rifaximin 550 mg ordered [**Hospital1 **] but taking daily
- multivitamin DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 120 mg SC DAILY
3. Fluconazole 400 mg PO Q24H
4. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg [**2-8**] tablet(s) by mouth every
four (4) hours Disp #*60 Tablet Refills:*0
5. Mycophenolate Mofetil 1000 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. PredniSONE 20 mg PO DAILY
POD #6 and ongoing
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. ValGANCIclovir 900 mg PO Q24H
10. Warfarin 2 mg PO ONCE Duration: 1 Doses
11. Tacrolimus 1.5 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Budd Chiari
Bile leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Hospital1 **] Visiting Nurse Service has been arranged. You will
receive a call from nurse to set up a visit.
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, inability to eat/drink or take any of your
medication, increased incision/abdominal pain or abdominal
distension, incision or drain site appears red or has drainage,
constipation or diarrhea, or any concerns
-You will have blood drawn twice weekly for transplant lab
monitoring. ***You need to have next labs on [**11-11**]***
-You may shower with soap and water, but no tub baths or
swimming
-Do not apply powder,lotion or ointment to incision
-Take all of your medication as instructed/ordered
-Please avoid sun exposure, and always wear sun screen when you
are outside on all exposed skin
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2173-11-18**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2173-11-24**] 9:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2173-11-24**] 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2173-11-9**]
ICD9 Codes: 5849, 5715
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5476
}
|
Medical Text: Admission Date: [**2200-7-23**] Discharge Date: [**2200-7-25**]
Date of Birth: [**2129-1-11**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain.
Transfer from OSH for inferior ST elevated MI.
Major Surgical or Invasive Procedure:
Cardiac catheterization with Cypher DES to proximal RCA.
History of Present Illness:
This 71 year old woman with a history of hypertension and
hyperlipidemia was transferred from [**Hospital3 **] ED for
emergent cardiac catheterization. She was in her USOH until
yesterday. She had taken a NSAID for R shoulder pain and
developed "sticking sensation" in the her chest - initially she
thought it was GERD. The discomfort, however continued on
through til the next morning. By that time the pain was
considerably worse and was radiating to back; she began having
symptoms of nausea/vomiting diaphoresis. Initial EKG in ER
looked OK with minor ST changes. After getting GI medication and
some narcotics, the patient continued to have pain. A repeat EKG
at noon revealed 1mm ST elevations in inferior and lateral T
wave changes. Got nitrates which resulted in hypotension.
Treated w/ ASA 325mg, plavix 600mg, heparin gtt, integrilin,
morphine, and dilaudid. The patients chest pain subsequently
resovlved and she was transferred to [**Hospital1 18**] for emergent
catheteriztion. Was pain free on arrival to [**Hospital1 18**].
.
Pt was taken to the cath lab where a 100% occluding lesion was
seen in the RCA, this appeared acute. 70-80% stenosis in OM1 was
also seen. At 1:47 PM the RCA lesion was successfully stented
with Cypher DES with successful restoration of flow.
Subsequently, the patient was noted to be bradycardic to 30-40
range with associated hypotension with SBP in 60's. The patient
was given 1x atropine with normalization of the heart rate and
SBP. While still in the laboratory however, the patient was
noted to go into atrial fibrillation.
.
Pt denies any shortness of breath, orthopnea or dyspnea. Denies
palpitations. She does say she has felt generally more fatigued
over the last 2 or 3 months.
Past Medical History:
- hypertension: no current medications, had been diagnosed this
year and only recently was started on identified medication. She
didn't tolerate the medication, getting a constant cough. They
were to try a different medication this week
- hyperlipidemia (on Zocor)
- GERD
- hemochromatosis
Oncologic:
- [**2195**] bladder cancer: s/p BCG treatment last year
- [**2194**] L kidney tumor: s/p nephrectomy
- [**2166**] Vaginal cancer s/p vagectomy
- [**2165**] Cervical cancer s/p hysterectomy
- h/o C. diff colitis
Social History:
Married, 9 grown children. Used to smoke over 50 years ago but
rarely. Drinks on rare occasions.
Family History:
Sister with arrhythmia (type unknown), diabetes on both sides of
family. No known CAD.
Physical Exam:
Wt 154lbs
Afebrile P 80-90 irregular BP 110/53 R 14 O2 98 on 2L
Gen: WD/WN woman in NAD, alert, pleasant, and cooperative.
Eyes: Sclerae anicteric
Mouth: MMM
Neck: JVP to 6 cm.
Pulm: Lungs CTA b/l no wheezes, rubs, or rhonchi
CV: Irregularly irregular, no murmur, no rub.
Abd: NT, ND, normal bowel sounds.
Groin: R groin, no hematoma, no bruit
Ext: No edema, DP pulses nl.
Pertinent Results:
[**2200-7-23**] 04:49PM BLOOD WBC-11.0 RBC-3.63* Hgb-10.6* Hct-30.6*
MCV-84 MCH-29.1 MCHC-34.5 RDW-13.4 Plt Ct-233
[**2200-7-23**] 04:49PM BLOOD Glucose-192* UreaN-16 Creat-0.8 Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
[**2200-7-23**] 04:49PM BLOOD CK(CPK)-656*
[**2200-7-23**] 04:49PM BLOOD CK-MB-100* MB Indx-15.2*
[**2200-7-23**] 11:48PM BLOOD CK(CPK)-881*
[**2200-7-23**] 11:48PM BLOOD CK-MB-105* MB Indx-11.9*
[**2200-7-24**] 05:30AM BLOOD CK(CPK)-837*
[**2200-7-24**] 05:30AM BLOOD CK-MB-77* MB Indx-9.2* cTropnT-2.93*
[**2200-7-25**] 05:25AM BLOOD CK(CPK)-397*
[**2200-7-25**] 05:25AM BLOOD CK-MB-18* MB Indx-4.5 cTropnT-2.22*
[**2200-7-23**] 04:49PM BLOOD TSH-1.0
Cardiac catheterization of [**2200-7-23**]:
1. Coronary angiography revealed a right dominant system with
RCA
occlusion. The LMCA showed mild diffuse disease with no
stenosis more
than 20%. The LAD showed a proximal and midsegment 60% stenosis
that
did not angiographically appear to be flow-limiting. The LCx
showed a
70% midsegment stenosis with an ostial 70-80% OM1 stenosis. The
RCA
showed a 100% stenosis of the midsegment which appeared acute.
2. Resting hemodynamic studies demonstrated mildly elevated
pulmonary
capillary wedge pressure mean of 15mmHg. The cardiac index was
preserved at 2.7L/min/m2. There was no pressure gradient across
the
aortic valve or between the left ventricular end diastolic
pressure and
pulmonary capillary wedge pressure to suggest aortic stenosis.
3. Left ventriculography demonstrated normal left ventricular
systolic
function with no evidence of mitral regurgitation. The ejection
fraction was calculated at 59%.
4. Successful stenting of the RCA with a 3.0 mm Cypher
drug-eluting
stent, post-dilated to 3.25 mm.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
3. Normal systolic function with preserved cardiac output.
4. Acute inferior myocardial infarction, managed by placement of
drug-eluting stent.
5. Successful stenting of the RCA.
Brief Hospital Course:
This 71 year old woman with a history of hypertension,
hyperlipidemia, GERD, hemochromatosis, and an extensive
oncological history presented to an outside hospital with chest
pain over 12 hours and was found by EKG to have changes
consistent with an inferior ST elevated myocardial infarction.
She was started on aspirin, plavix, integrilin and heparin and
thereafter was emergently transferred to [**Hospital1 18**] for cardiac
cathetherization. On catheterizaion she was found to have a
total occlusion of the proximal RCA which appeared acute and
also a 70-80% lesion in the OM1. The RCA lesion was
successfully opened with a Cypher drug eluting stent. Procedure
complicated by bradycardia with hypotension resolved with
atropine. Also complicated by onset of atrial fibrillation
during the procedure.
.
Given the episode of hypotension and the new onset atrial
fibrillation, the patient was admitted to the CCU. On
presentation, the patient was hemodynamically stable, chest pain
free with normal respiratory function. She was still in atrial
fibrillation and low dose metoprolol was started. The night
after the catheterization the patient was noted to again become
bradycardic with hypotension. This resolved with 0.5 mg
atropine and one normal saline fluid bolus. Shortly thereafter,
the patient's rhythm returned to sinus. Metoprolol was
discontinued.
.
The patient remained hemodynamically stable and chest pain free
after this. Her enzymes trended down from a peak CK 881 MB 105
(the night after catheterization). e She was discharged with
instructions to follow up with [**Hospital1 18**] cardiology with a
persantine MIBI to determine whether she would need repeat
catheterization for the OM1 lesion. She was aslo to continue
aspirin, plavix, lipitor, and lisinopril
.
In summary, this is 71 year old woman admitted with inferior
STEMI secondary to 100% lesion of the proximal RCA. This was
successfully treated with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. Course complicated by
two episodes of bradycardia associated with hypotension
successfully treated with atropine. These episodes were likely
secondary to increased vagal tone associated with IMI. Course
also complicated by atrial fibrillation which spontaneously
converted to sinus.
.
Issues and plan from this hospitalization.
1)
a) Perfusion: Status post IMI, s/p DES to 100% proximal lesion
in RCA, known disease in OM1 (70-80%)
-to continue ASA, plavix, and lipitor
-will undergo repeat stress testing with imaging and then will
follow up with [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], NP (who works with Dr.
[**Last Name (STitle) **] of [**Hospital1 18**] Cardiology)
-If P-Mibi reveals reversible defects in OM1 territory, will
need repeat cath and stent to OM1.
-started low dose lisinopril
-held metoprolol given bradycardic,hypotensive episodes, will
consider resumption of metoprolol as outpatient.
b)IMI vagal abnormalities. Night after admission was turned and
became acutely nauseous. HR dropped to 60's in AFib with sBP in
70's. Was given atropine and converted to NSR in 80's, sBP to
high 80's. Pt was given IV fluids and BB held.
-held metoprolol.
.
c) Pump, nl EF on LV gram, no [**Male First Name (un) 4746**] abnormalities, PA pressure only
mildly elevated.
-no need for diuretic therapy
.
d) Rhythm, atrial fibrillation initially, now converted to NSR.
AFib was likely new onset in the cath lab, although pt has felt
more fatigued as of late.
-TSH nl
-consider metoprolol at later time.
.
2) R shoulder pain, secondary to recent rotator cuff injury
-used oxycodone PRN
.
3) GERD/GI issues
-use protonix in place of nexium for hospital stay
-continue zelnorm
4) GU issues.
-pt continued to take own "Flora Q", urocit.
.
5) Extensive cancer history
-no active issues during stay.
.
6) Prophylaxis: included Anzemet, Protonix, Colace. Heparin
while pt had been in AF.
.
Code status remains full.
Medications on Admission:
Flora Q
Zocor 10 mg PO daily
Zelnorm 6 mg PO daily
Nexium 40 mg PO daily
Calcium 500 mg PO BID
MVI
Urocit 20 qHS
Medications on transfer:
- ASA 325mg daily
- plavix 75mg daily
- lipitor 80mg daily
- heparin gtt
- integrillin
- NTG SL prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Potassium Citrate 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO every night ().
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO
every morning ().
9. Flora-Q 8 Billion cells Capsule Sig: One (1) Capsule PO qd
().
10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevated inferior MI
Discharge Condition:
Good. Chest pain free. Hemodynamically stable and breathing
normally on room air.
Discharge Instructions:
Please return to hospital if you experience chest pain,
shortness of breath or persistent nausea/vomiting.
Please continue the medications you were prescribed from this
hospital.
It is especially important you take aspirin and plavix every
day.
You will take lipitor every day also, this will replace zocor.
We will start you on lisinopril
You aren't currently on metoprolol at this time. This will be
re-addressed on your follow up appointment at [**Hospital1 18**] next week
(see below)
Please continue all other medications.
Followup Instructions:
You will undergo an exercise stress test with imaging next week
[**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], NP for Dr. [**Last Name (STitle) **], is arranging to schedule
this bmer. The number for the stress laboratory is
[**Telephone/Fax (1) 1566**]. Based on the stress test, it wil be determined
whether you will need another cardiac catheterization
.
Please follow up with [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], within 1 week She,
along with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] review your stress test. Your
medications will be reviewed and they may decide to adjust your
antihypertension medications.
[**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**] works with Dr. [**Last Name (STitle) **] who was your attending
physician in hospital, their office phone is [**Telephone/Fax (1) 285**].
Make sure to arrange for cardiac rehabilitation, you may do this
at [**Hospital6 33**].
Please follow up with your primary care physician/cardiologist
Dr. [**Last Name (STitle) 1637**] in one month.
ICD9 Codes: 9971, 4019, 2724
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5477
}
|
Medical Text: Admission Date: [**2169-3-3**] Discharge Date: [**2169-5-6**]
Date of Birth: [**2120-6-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Right upper quadrant pain with jaundice s/p PTCA stent placement
Major Surgical or Invasive Procedure:
[**2169-3-3**] cholecystectomy, common bile duct excision, left hepatic
lobectomy, Roux-en-Y hepaticojejunostomy, repair of right
hepatic artery with inferior mesenteric vein interposition and
graft
[**2169-3-10**] exploratory laparotomy, evacuation of ascites, wound
closure of dehisence
[**2169-3-18**] exploratory laparotomy, evacuation of intraabdominal
hematoma and blood, ligation of the right hepatic artery.
[**2169-4-12**] Open tracheostomy.
History of Present Illness:
This patient is a 48 year old male with a past medical history
of hepatits C and herniated lumbar disc who was found to have
biliary obstruction during work-up for right upper quadrant pain
with jaundice. The patient underwent PTCA on [**2169-2-17**] with
dilation of a stricture ant the confluence o fthe right and left
hepatic ducts. The stricture was biopsied and showed chronic
infalmmation with fibrosis. The patient now presents for hepatic
resection with Roux-en-Y hepaticojejunostomy.
Past Medical History:
HepC ([**2157**])
Herniated disk
Recurrent sinus infection
Social History:
35+ pk/yr Hx of tobacco use
Denies EtOH
Works for rehab company
Physical Exam:
T 98.4 HR 84 BP 147/80 SpO2 97%RA
RRR, normal S1 and S2
CTA b/l
Abdomen soft, NT/ND with +bowel sounds. PTCA tubes in place and
draining.
Extremeties warm/well-perfused
Brief Hospital Course:
The patient was admitted to the hospital and was taken to the
operating room on [**2169-3-3**] for a cholecystectomy, common bile
duct excision, left hepatic lobectomy, Roux-en-Y
hepaticojejunostomy. The case was complicated by hepatic artery
dissection and required repair of right hepatic artery with
inferior mesenteric vein interposition and graft. The patient
tolerated this procedure well but was transferred to the PACU
intubated and in guarded condition. The patient was admitted to
the SICU, where, after a prolonged hospital course, he expired
on [**2169-5-6**]. The hospital course will be dictated by systems.
Neuro:
Patient remained sedated post-operatively. His pain was
controlled with morphine. POD 7, PO pain medications were given.
Following return to OR for wound dehisence, post-op pain was
controlled with morphine. POD [**9-4**] patient noted to be anxious
but responsive with well-controlled pain. POD 15/8 patient
attempted to get out of bed to go to bathroom unassisted. Got
dizzy and fell. No neurological sequelae from fall. POD 16/9/1
morphine stopped, dilaudid started for improved pain control.
POD 23/16/8 began propofol wean to off in attempt to extubate.
When re-intubated that day, patient was again sedated. POD
41/34/27/2 propofol drip weaned, patient started on fentanyl
drip and haldol prn.
Cardiovascular:
Patient was tachycardic immediately post-op, and was felt to be
septic secondary to pancreatitis. He was placed on neosynephrine
to maintain blood pressure. He was monitored carefully and
agressively hydrated post-operatively. MAP was kept >65. On
post-op day #2, the patient was taken off pressors. POD 6 beta
blockade started for mild hypertension/tachycardia. POD [**10-6**]
sustained tachycardia w/o changes on EKG noted, likely secondary
to anxiety and pain. POD [**1-8**] tachycardia noted to be improving
with stable BP's. POD 15/8 patient noted to be tachycardic after
slipping and falling. Moved to SICU and became
tachycardic/hypotensive. Taken to OR on [**2169-3-18**] emergently for
GI bleeding. Right hepatic artery ligated in OR. POD 16/9/1
patient noted to be tachycardic with stable BP. Patient
continued to remain tachycardic thereafter. On POD 38/31/23
patient became hypotensive. neosynephrine started to maintain
blood pressure. POD 46/39/31/7 TTE demonstrates no evidence of
vegetations in heart. POD 48/41/33/9 blood pressure begins to
decrease. Beta-blockade held. POD 53/46/38/14 patient found to
be hemodynamically unstable, unresponsive to fluid boluses,
developing signs of shock. Pressors started. POD 63/56/48/24
patient becomes hemodynamically unstable. He is made CMO by his
family and expires on [**2169-5-6**].
Respiratory:
The patient was initially supported by ventilator immediately
after surgery. This was weaned and patient extubated by POD#3.
Incentive spiromety encouraged. POD 7/0, extubated after return
to OR for wound dehisence. POD [**11-6**] patient noted to have some
respiratory distress though responsive to diuresis. POD 18/5
noted to be short of breath and diaphoretic shortly before
emergent return to OR [**2169-3-18**] for GI bleeding. Patient remained
intubated after procedure. Attempted to wean starting POD
17/10/2. POD 22/15/7 CPAP trials began but failed. POD 23/16/8
sedation weaned and on POD 24/17/9 patient self-extubated. Later
that day, due to increased work of breathing and fatigue,
patient was re-intubated. Daily chest xrays continued to
demonstrate atelectasis with pulmonary edema. POD 28/21/13 CT
guided thoracocentesis performed due to difficulty weaning from
vent. POD 39/32/25 patient undergoes open tracheostomy after
failing to wean from ventillatory support. POD 54/47/39/15
patient in septic shock with large right plerual effusion found
on CXR. This is tapped via ultrasound guidance. Patient remains
ventilator dependent until death on [**2169-5-6**].
Gastrointestinal:
The patient was kept NPO immediately after surgery with T-tubes
to gravity. Total bilirubin noted to be 3.4. On post-op day #2,
ultrasound showed patent hepatic artery and vein. POD 4
ultrasound repeated and showed right anterior portal vein
reverlsal of flow. LFT's checked and found to be improving with
exception of stable bilirubin at 5.2. Patient taken to OR on
[**2169-3-10**] for wound dehisence. On examination, found to have
intraluminal clot, dilated stomach and proximal small bowel,
marked ascited and approx. 500cc old hematoma. Total bilirubin
noted to be 4.1. GI service consulted. POD [**10-6**], noted to be
stable, sips started. POD [**11-6**], small amount of BRBPR, passing
flatus. POD [**12-8**], ultrasound noted to show patent hepatic flow.
POD [**1-8**] through POD 17/4, continued GI bleeding. POD 18/5 taken
to OR on [**2169-3-18**] for continued GI bleeding. Right hepatic artery
ligated in OR. Total bilirubin noted to rise from 3.2 to 6.5 on
POD 19/6/1. On POD 21/14/6, CT scan obtained, showing moderate
amount of intra-abdominal ascites, patchy areas of nonperfusion
involving segments 5, 6 and 8 of the liver, and a patent right
portal vein. PTCA drain placed to decompress the right biliary
duct system. Total bilirubin noted to fall from 6.5 to 5.9. POD
25/18/10 CT abdomen failed to demonstrate evidence of
intra-abdominal infection. Stable amount of ascites. Patent
poral vein noted. Total bilirubin noted to be 5.5. POD 34/27/19
trophic tube feeds started. Total bilirubin noted to be 7.3. POD
37/30/22 CT scan obtained which showed unchanged appearance of
the hepatic parenchyma with areas of infarction and unchanged
size and appearance of three intraperitoneal fluid collections.
Total bilirubin noted to be 6.4. POD 38/31/23 Dobhoff feeding
tube placed. POD 42/36/28/3 CT scan performed, showing little
change in the appearance of multiple fluid collections and
drains. Total bilirubin noted to be 9.1. POD 44/37/29/5 Total
bilirubin found to be 10.7. Cholangiogram performed, which
showed existing right biliary internal external drain in place
with tip in the
jejunum, no intrahepatic biliary ductal dilatation and contrast
leak seen at the anastomotic site. POD 45/38/30/6 Tube feeds
advanced to goal. Total bilirubin found to be 13.1. POD
47/40/32/8 tube feeds advanced to goal. Total bilirubin 16.1.
POD 51/44/11 repeat CT scan shows stable fluid collections,
necrosis of liver. Total bilirubin found to be 17.8. POD
53/46/38/13 bilirubin continues to rise, now to 18.9.
Transaminases noted to be rising as well. POD 54/47/39/15
patient in septic shock, bilirubin climbing to 20.2. POD
62/55/47/23 biliary catheter drainage is assessed due to rising
bilirubin to 23.1. The catheter is exchanged and there is found
to be large persistent leak at the anastamotic site. Patient
expires next day due to multi-system organ failure.
Hematalogic:
Serial hematocrits were obtained, as were coags. Heparin was
held initially. On post-op day #1, the patient was transfused 2
units of PRBC's and 2 units of FFP for hematocrit of 27 and PTT
on 107. Aspirin and plavix started on POD 3. On POD 4,
hematocrit found to be 23. Transfused 4 units PRBC's to HCT 30.
POD 7 hematocrit found to be 23.3. 2 units PRBC's given. [**2169-3-10**]
Patient returned to OR for wound dehisence, 4 units PRBC's 1
unit FFP given intraop. ASA/plavix held post-op. POD [**9-4**] serial
HCT noted to be stable. POD [**10-6**] 1 unit PRBC's given for HCT
27.2. POD [**11-6**], 2 units PRBC's given for HCT 27.8. POD [**12-8**]
continued GI bleeding, transfused 4 units PRBC's, 1 unit
platelets, 1 unit cryo, 2 units FFP. POD [**1-8**] 5 units PRBC's
transfused. POD 13/6 required 6 units PRBC's, 7 units platelets,
3 units FFP, 2 units cryo for continued bleeding. POD 15/8,
patient slipped and fell. After falling, serial HCT showed drop
from 32 to 26. 4 units PRBC's and 2 units platelet transfused.
Patient taken to OR [**2169-3-18**] where he received 10 units PRBC's, 7
units FFP, 4 units platelets, 3 units cryo. POD 18/11/3, HCT 28,
transfused 1 unit PRBC's to HCT 30.5. POD 20/13/5 transfused 2
units PRBC's to keep HCT>30. POD 21/14/6 transfused 1 unit
PRBC's. POD 29/18/10 HCT 28.1, transfused 1 unit PRBC's. POD
32/25/17 CT scan demonstrated left inferior epigastric artery
pseudoaneurysm, which was injected with thrombin. POD 33/26/18
HCT dropped to 24. Patient transfused 2 units PRBC's, 2 units
FFP. CT scan obtained to r/o hemorhage and failed to show
evidence of bleed. POD 40/34/26/1 transfused 1 unit PRBC's for
persistent ooze around tracheostomy collar. POD 42/36/28/3
neosynephrine weaned. TTE obtained, demonstrating mild LVH.
Beta-blockade restarted. POD 57/50/42/18 in the setting of
multi-system organ failure, diffuse bleeding noted. 2 units
PRBC's transfused, 1 unit platelets transfused. POD 60/53/45/21
levophed weaned off. Patient expires soon after.
Fluids/Electrolytes/Nutrition:
Patient was kept NPO after surgery with aggressive IV hydration.
Albumin infusion was started immediately post-operatively to
maintain level greater than 2.5. TPN started on POD#3. POD 4
clear liquid diet started. POD 6 diet advanced to regular diet.
POD [**9-4**] patient kept NPO, TPN continued. POD 19/6/1 patient kept
NPO, TPN continued. POD 23/16/8 albumin infusions stopped. POD
34/27/19 trophic tube feeds started. TPN continued. POD 38/31/23
Dobhoff feeding tube placed. POD 42/36/28/3 tube feeds started.
POD 47/40/32/8 tube feeds advanced to goal. TPN discontinued.
Endocrine:
Patient was maintained on RISS.
Genitourinary:
Urine output was initially good. Electrolytes were checked daily
and repleted PRN. A foley catheter was placed and kept to
gravity. Patient began to autodiurese on POD3. On POD4, lasix
10mg started to help diuresis. POD 6 foley catheter was removed.
POD [**9-4**] lasix continued for diuresis. POD 16/9/1 lasix continued
for diuresis after OR. POD 24/17/9 diamox started. POD 27/20/12
lasix drip started. POD 30/23/15 lasix drip discontinued due to
falling BP. POD 34/27/19 Urology service consulted for
hematuria. This was found to be self-limited. POD 52/45/37/13
creatinine bumped to 1.6, lasix drip held. POD 54/47/39/15
patient in septic shock, renal consulted to start CVVH. This is
continued until expiration on [**2169-5-6**].
Tubes/Lines/Drains:
On post-op day #1, the PA line was changed because of
infiltration of propofol into the PA catheter sheath. On POD#4,
the Swan line was changed to triple-lumen catheter, NG tube
removed. POD 7/0, NGT, foley catheter replaced intraop. POD 14/7
ultrasound showing biliary tube had been pulled back into
peritoneum. POD 18/5 blood noted in JP drain prior to emergent
return to OR [**2169-3-18**]. JP drain placed above liver, JP drain
placed near biliary anastamosis. POD 17/10/2 left cordis changed
to triple lumen catheter. POD 23/16/8 CVL changed over wire. POD
24/17/9 NGT removed with self-extubation but replaced when
patient re-intubated. POD 28/21/13 central lines changed and
re-sited. POD 42/36/28/3 RIJ CVL changed over wire. POD
53/46/38/14 a cordis/swan-ganz catheter is placed for
monitoring.
Infectious Diseases:
Patient was initially placed on Zosyn for prophylaxis. On
post-op day #2, the patient spiked a temperature and was
pan-cultured. Blood culture showed [**2-5**] positive for gram
positive cocci. Vancomycin was started. On POD 4, Zosyn
discontinued and meropenem started. POD 5, levofloxacin and
fluconazole started for coag negative staph and [**Female First Name (un) **] growing
from peritoneal fluid. POD [**11-6**] fluconazole stopped. POD 15/8,
patient spiked temp to 103. Unclear if related to transfusion of
blood products. Caspofungin started, vancomycin and meropenem
continued. Patient started spiking fevers daily after [**2169-3-18**].
POD 20/13/5 gram positive rods found in sputum cx. POD 21/14/6
peritoneal fluid from [**2169-3-20**] growing lactobacillus. POD 22/15/7
Flagyl added for coverage. POD 27/16/8 PTC drainage growing
psudomonas and enterobacter. POD 26/19/12 paracentesis
performed, fluid growing lactobacillus. Sputum culture from same
day grew pseudomonas. ID service consulted. POD 30/23/15
paracentesis performed, cultures grow psudomonas, enterococcus,
lactobacillus. POD 32/25/17 patient underwent CT guided drainage
of a left subdiaphragmatic and left lower quadrant collection.
Cultures grow lactobacillus. POD 33/26/18 antibiotics changed to
vancomycin, piperacillin, Flagyl and caspofungin. POD 36/29/21
wound swab growing psudomonas. POD 37/30/22 subdiaphragmatic
fluid collection aspirated via CT guidance. Flagyl was
discontinued and patient started on clindamycin for
lactobacillus coverage. POD 41/34/27/2 ambisome started for
disseminated fungal disease. POD 41/35/27/2 sputum growing
pseudomonas. POD 42/36/28/3 CT scan performed, showing little
change in the appearance of multiple fluid collections and
drains. POD 45/38/30/8 blood culture growing pseudomonas. POD
47/40/32/8 clindamycin discontinued in favor of Zosyn. POD
48/41/33/9 vancomycin discontinued, amikacin started. POD
49/42/34/10, colistin started. POD 53/46/38/14 patient begins to
develop multi-system organ failure in setting of resistant
pseudomonas. POD 61/51/46/22 patient started on cefipime.
Wound:
Immediately after surgery, the wound was noted to be clean and
intact. POD 4 wound noted to be cellulitic. POD6 wound opened,
no purulence. Wet-to-dry dressings applied. POD 7 patient
reported bloody drainage from wound after fit of coughing. Wound
probed and found to have dehisced. Patient taken to OR on [**2169-3-10**]
for washout of wound and closure. POD 29/21/14 abdominal wound
found to be infected again. POD 37/30/18 wound VAC placed.
Medications on Admission:
Protonix 40mg PO Qdaily.
Discharge Disposition:
Expired
Discharge Diagnosis:
Multisystem organ failure secondary to pseudomonas infection
Hepatic necrosis and failure secondary to ligated hepatic artery
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
ICD9 Codes: 5715, 2762, 4271, 5119, 5180, 5849
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5478
}
|
Medical Text: Admission Date: [**2124-7-23**] Discharge Date: [**2124-7-23**]
Date of Birth: [**2063-10-16**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
Central line placement
Arterial line placements
Intubation
History of Present Illness:
60 year old male with a history of bipolar disorder, alcohol
abuse and suicide attempt in [**2123**] presenting with lithium and
diltiazem overdose. The patient has been actively drinking
recently. Per his wife, he was displaying manic behavior the
night prior to admission and went to bed early. He was
drinking. This morning, he called out for her and asked for
water. He gulped down the water (atypical for the patient as he
is s/p gastric bypass surgery) and then began vomiting. He
displayed a generalized tremor, but no seizure activity. Upon
retriving the waste basket for him to vomit in, Mrs. [**Known lastname 4186**] found
empty pill bottles for Trazodone, and half empty bottles of
Diltiazem and Lithium--all chronic medications for the patient.
His wife urged him to come to the [**Name (NI) **].
At [**Hospital1 18**]-[**Location (un) 620**], he was intubated and started on pressors.
Lithium level was 2.46, he had a leukocytosis and new renal
failure. He had a CVL placed in the right groin and a radial
arterial line placed. He was transferred to [**Hospital1 18**] for further
management. He received 7 liters of fluid
He presented with refractory hypotension and received additional
fluid and started on an epinephrine drip. Due to his
overwhelming acidosis he was started on bicarbonate at 900
cc/hr. Renal was consulted who recommended aggressive
management of acidosis, but no indication for acute dialysis was
determined. He had a junctional rhythm with range 40-50 and
received insulin/glucose and glucagon for CCB toxicity. His
heart rate improved to 60. The patient continued to be
hypotensive and was tranferred to MICU for further management.
At arrival, discussion with his wife ensued. She reported that
the patient would not have wanted these aggressive measures and
asked that he be made comfort measures.
Past Medical History:
Psychiatry history per [**6-9**] discharge summary: he was given the
diagnosis of bipolar disorder 5 years ago and depression. [**Month/Year (2) 4273**]
any manic episodes, cannot elaborate on his symptoms. Reports he
is seeing [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the VA as a psychiatric nurse. [**First Name (Titles) **] [**Last Name (Titles) 13230**] any previous suicide attempts. per wife: patient has been
hospitalized x 2. 1st at [**Hospital1 46444**] in [**2091**] when his first wife
left him and he proceeded to be aggressive, he was hospitalized
for a total of 60 days and during that time transferred to the
VA. He was also hospitalized at [**Location (un) 1475**] in [**2093**]. She notes
he gets very manic at times where he will spends tons of money,
speak and act differently. She reports they have run out of
funds because of him and he has ruined his credit. Notes he has
seen [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] once, has no providers in place and gets his
meds prescribed by his PCP.
Medical History:
1 Single direct post-traumatic seizure [**2122-11-2**], admitted [**Hospital1 18**]
to hospitalist, neurology not consulted, documented as
withdrawal
seizure. Started on LTG. No documented seizures since.
2 Long Hx of recurrent falls, with in [**2122-11-2**] normal B12 and
FA,
attributed to frequent intoxication.
3 Bipolar disorder
4 HTN
5 Morbid obesity, gastric bypass surgery [**Hospital3 **] (NW)
[**515-8-5**] lbs -> 200 lbs
6 Abdominoplasty and multiple hernia repairs (NW)
7 Foot surgery [**1-8**] for # [**Hospital3 2783**] (WH), complicated
by extensive purulent infections and chronic pain,
conservatively
treated by his wife and multiple [**Name (NI) **]
8 Pancreatitis
9 Acute acetaminophen intoxication (3 grams, liver tolerates max
2 grams)
10 Per wife, decreased medication clearing sec to liver
dysfunction
11 OSAS, not on CPAP
12 Refractory Etoh abuse
13 Glucose intolerance
14 Cardiac evaluation (ETT, cath) negative in [**2118**]
Social History:
Per [**6-9**] Psychiatry discharge summary
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): Per wife,
long standing history of ETOH use dating back to his teens. Did
have period of sobriety of 15 years until mid 90s. Stated that
he began drinking again after gastric bypass surgery. Has been
in multiple rehabs, discharged from [**Last Name (un) **] wood and [**Hospital1 882**] just
in the last few months. [**Hospital1 4273**] any other illicit drug use. A
Section 35 has never been filed on him
Per patient: reports he is unsure if he wants to be sober.
[**Hospital1 4273**] any DTs or withdrawal symptoms. Reports he drinks 1 quart
of hard liquor (vodka) daily, [**Hospital1 **] any other illicit drug use
SOCIAL HISTORY
per wife mostly: [**Name2 (NI) **] grew up in [**Name (NI) 46445**], parents divorced
when he was young. Mother was paranoid schizophrenic who
committed suicide by crawling into a refrigerator when the
patient was in his early twenties. Was in the [**Country 3992**] war when
he was young then returned and was a police officer for a bit of
time. He had a "shootout" with other police officers which
resulted in his termination from the police department. Was
hospitalized after his dissolution of his first marriage. This
is second marriage and he has one son. Wife is a nurse. He
states that he has a troublesome relationship with his brother,
who he states has a warrant against him.
Started his own computer business, which he has let go recently,
currently not working or employed, in + debt. Last year left his
wife for another woman who was an alcoholic for 6 months. No
current legal charges. Patient [**Country **] any history of sexual or
physical abuse. Wife reports that the patient has always been a
"strange" person, that people are afraid of him, and that when
the patient has called 911 for help for falling etc, they have
come with guns
drawn and reported they were expecting an ambush. He has a
violence history in the 70s when he attacked a doctor, does not
appear to have a significant violence history since.
Family History:
father and grandfather-alcoholism
mother- paranoid schizophrenia vs bipolar, mother committed
suicide by crawling into refrigerator
He has a son who suffers from depression and drug abuse.
Physical Exam:
VS: 72/39 HR 61 O2 85% AC/500/22/10/100%
Gen: intubated off all sedation, no response to name or painful
stimuli
Heart: distant, regular
Resp: Clear/vent sounds
Abd: s/nt/Foley
Ext: edema
Pertinent Results:
[**2124-7-23**] 03:50PM WBC-22.4* RBC-3.99* HGB-11.3* HCT-35.3*
MCV-88 MCH-28.2 MCHC-31.9 RDW-17.6*
[**2124-7-23**] 03:50PM NEUTS-81.3* LYMPHS-12.8* MONOS-5.3 EOS-0.4
BASOS-0.4
[**2124-7-23**] 03:50PM PT-13.5* PTT-24.3 INR(PT)-1.2*
[**2124-7-23**] 03:50PM PLT COUNT-310
[**2124-7-23**] 03:50PM LITHIUM-1.7*
[**2124-7-23**] 03:50PM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-7-23**] 03:50PM ALBUMIN-3.4 PHOSPHATE-5.3* MAGNESIUM-1.9
[**2124-7-23**] 03:50PM CK-MB-NotDone cTropnT-<0.01
[**2124-7-23**] 03:50PM LIPASE-22
[**2124-7-23**] 03:50PM ALT(SGPT)-32 AST(SGOT)-102* CK(CPK)-34* ALK
PHOS-75 TOT BILI-2.5*
[**2124-7-23**] 03:50PM GLUCOSE-337* UREA N-29* CREAT-3.2* SODIUM-141
POTASSIUM-5.0 CHLORIDE-111* TOTAL CO2-16* ANION GAP-19
CXR: Portable supine chest radiograph is obtained. The ET tube
is
positioned with its tip approximately 4.1 cm above the carina.
An NG tube is seen coursing inferiorly extending into the left
upper quadrant with its tip excluded from view. The lungs are
grossly clear bilaterally though the left CP angle is excluded.
Cardiomediastinal silhouette is suboptimally assessed given
portable supine technique. There is no pneumothorax. Osseous
structures appear grossly intact.
Brief Hospital Course:
Patient admitted from ED hypotensive on maximum dose of 3
pressors and after 12 liters of fluid with 150 cc total urine
output. No plans for dialysis initiated. He was hypoxic on
FiO2 100% and PEEP of 10. ABG after aggressive resuscitation in
ED with worsening acidosis, higher lactate and decreaseing PaO2
on same vent settings. His wife asked that the patient be made
CMO, as they have extensively discussed end of life wishes and
he would not wish for the ventilator or these aggressive
resuscitation measures. He was terminally extubated and expired
at [**2072**] pm on [**2124-7-23**]. Medical examined accepted the case.
Medications on Admission:
Unknown
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 5849, 2762
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5479
}
|
Medical Text: Admission Date: [**2182-5-15**] Discharge Date: [**2182-6-11**]
Date of Birth: [**2134-4-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2182-5-15**]
1. Replacement of ascending aorta with a 28-mm Gelweave
Dacron graft.
2. Bentall procedure with a composite St. [**Male First Name (un) 923**] mechanical
graft, size 21 mm, reference number [**Serial Number 89248**].
[**2182-5-29**] Tunneled hemodialysis catheter placement-
History of Present Illness:
This patient is a 48 year old female who complains of abdominal
pain. Patient presents with abdominal pain to an outside
hospital. Patient reports having intermittent abdominal pain
became more constant over last day. Patient underwent a CT scan
which showed a descending aortic aneurysm. Patient transferred
to [**Hospital1 18**]. CT reviewed and found to show type A dissection
starting at the root and extending to the iliac bifurcation. She
was brought emergently to the operating room for repair.
Past Medical History:
Mild mental retardation, hypertension
Social History:
Lives independently with husband
works at Stop and Shop
Cigarettes: no
ETOH: no
Family History:
Family History: heart disease; HTN
Physical Exam:
General: awake, somewhat anxious
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + []
Extremities: Warm [x], well-perfused [x] no Edema
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: no Left: no
Pertinent Results:
[**2182-6-10**] 07:10AM BLOOD WBC-7.2 RBC-3.49* Hgb-10.5* Hct-30.5*
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.4 Plt Ct-434
[**2182-6-9**] 05:50AM BLOOD WBC-7.3 RBC-3.54* Hgb-10.6* Hct-30.5*
MCV-86 MCH-30.1 MCHC-35.0 RDW-15.4 Plt Ct-381
[**2182-6-7**] 06:10AM BLOOD WBC-8.2 RBC-3.26* Hgb-9.9* Hct-28.1*
MCV-86 MCH-30.4 MCHC-35.3* RDW-15.5 Plt Ct-326
[**2182-6-11**] 06:54AM BLOOD PT-44.6* INR(PT)-4.6*
[**2182-6-10**] 07:10AM BLOOD PT-42.5* INR(PT)-4.4*
[**2182-6-9**] 05:50AM BLOOD PT-39.6* PTT-32.3 INR(PT)-4.0*
[**2182-6-8**] 05:10AM BLOOD PT-44.1* INR(PT)-4.6*
[**2182-6-7**] 06:10AM BLOOD PT-46.0* PTT-33.0 INR(PT)-4.8*
[**2182-6-6**] 03:15PM BLOOD PT-44.2* INR(PT)-4.6*
[**2182-6-11**] 06:54AM BLOOD Glucose-104* UreaN-22* Creat-2.6*#
Na-126* K-3.4 Cl-86* HCO3-30 AnGap-13
[**2182-6-10**] 07:10AM BLOOD Glucose-91 UreaN-73* Creat-4.7* Na-134
K-4.7 Cl-93* HCO3-23 AnGap-23*
[**2182-6-9**] 05:50AM BLOOD Glucose-84 UreaN-54* Creat-4.2*# Na-135
K-4.2 Cl-94* HCO3-23 AnGap-22*
[**2182-6-8**] 05:10AM BLOOD Glucose-98 UreaN-28* Creat-2.7*# Na-136
K-4.5 Cl-95* HCO3-25 AnGap-21*
[**2182-6-9**] 05:50AM BLOOD ALT-13 AST-19 LD(LDH)-303* AlkPhos-109*
Amylase-66 TotBili-0.7
[**2182-6-10**] 07:10AM BLOOD Mg-2.3
[**2182-6-9**] 05:50AM BLOOD Albumin-3.2* Calcium-8.7 Phos-8.2*#
Mg-2.3
Admission labs:
[**2182-5-15**] 09:30AM PT-13.9* PTT-25.1 INR(PT)-1.2*
[**2182-5-15**] 09:30AM PLT SMR-NORMAL PLT COUNT-208
[**2182-5-15**] 09:30AM WBC-22.7* RBC-5.34 HGB-14.6 HCT-45.0 MCV-84
MCH-27.3 MCHC-32.4 RDW-14.6
[**2182-5-15**] 09:30AM CALCIUM-7.5* PHOSPHATE-5.9* MAGNESIUM-2.1
[**2182-5-15**] 09:30AM cTropnT-0.04*
[**2182-5-15**] 09:30AM ALT(SGPT)-50* AST(SGOT)-56* ALK PHOS-53 TOT
BILI-1.2
[**2182-5-15**] 09:30AM GLUCOSE-366* UREA N-20 CREAT-1.3* SODIUM-137
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-14* ANION GAP-27*
[**2182-5-15**] 10:30AM FIBRINOGE-209
Discharge labs:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Pericardium - Effusion Size: 1.0 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Bidirectional shunt
across the interatrial septum at rest. Secundum ASD.
LEFT VENTRICLE: Normal LV wall thickness. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildy dilated aortic root. Mildly dilated ascending
aorta. Normal descending aorta diameter. Ascending aortic
intimal flap/dissection.. Aortic arch intimal flap/dissection.
Descending aorta intimal flap/aortic dissection.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Moderate to severe (3+) AR. Eccentric AR jet.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: Moderate pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. An ASD is present. There is a
bidirectional shunt across the interatrial septum at rest.
Left ventricular wall thicknesses are 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. A mobile density is seen in
the ascending aorta consistent with an intimal flap/aortic
dissection. A mobile density is seen in the aortic arch,
extending through the descending aorta, consistent with an
intimal flap/aortic dissection. There are multiple fenestrations
in the dissection flap with flow across. There are three aortic
valve leaflets which fail to completely coapt. Moderate to
severe (3+) eccentric aortic regurgitation is seen.
The mitral valve leaflets are structurally normal.
There is a moderate sized pericardial effusion.
POST-CPB:
There is a mechanical valve in the aortic position. The valve
appears well seated with normal leaflet mobility. There are the
normal washing jets. Otherwise no AI is seen. The peak gradient
across the aortic valve is 7mmHg, the mean gradient is 4mmHg
with CO of 3L/min. There is a tube graft in the ascending aorta.
A dissection flap is seen in the distal arch extending through
the descending thoracic aorta.
The LV systolic function appears normal, estimated EF is 65%.
The RV appears moderately hypokinetic. This improved mildly with
initiation of epinephrine infusion. The TR appears to be
mild-to-moderate.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2182-5-15**] 19:42
Radiology Report RENAL U.S. [**2182-5-18**] 4:52 PM Clip # [**Clip Number (Radiology) 89249**]
Final Report: Right kidney measures 11.5 cm, demonstrating no
hydronephrosis, or focal lesion. The Doppler images demonstrate
flow within the right kidney with limited spectral waveforms
obtained due to venous contamination. Main right renal vein
appears patent. The left kidney measures 11.5 cm without focal
lesion or hydronephrosis. As on the right, there is blood flow
to the left kidney though the spectral waveform is limited due
to venous contamination. Main left renal vein appears patent.
IMPRESSION: No hydronephrosis. Renal vascularity is confirmed
though
spectral waveforms are suboptimal to evaluate for renal artery
stenosis or
subtle changes. Consider CTA to further assess given h/o aortic
dissection.
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Radiology Report CT HEAD W/O CONTRAST [**2182-5-19**] 2:12 PM
Final Report: There is no acute intracranial hemorrhage, edema,
mass effect or major vascular territorial infarct. Ventricles
and sulci are normal in size and symmetric in configuration.
There is no shift from normally midline structures. [**Doctor Last Name **]-white
matter differentiation is well preserved. Fluid in the bilateral
paranasal sinuses and mastoid air cells is likely related to
intubation. No osseous abnormality is identified. Subcutaneous
lesions at the right parietal and left temporal regions may be
lipomas.
IMPRESSION: No acute intracranial process.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
[**2182-5-24**] CT Head
1. No evidence of acute intracranial process. If clinical
suspicion for
stroke or an embolic event is high, MR is the recommended study
of choice.
2. Increased interval opacification of the mastoid air cells and
paranasal
sinuses.
[**2182-5-24**] Renal Ultrasound
IMPRESSION:
1. No hydronephrosis.
2. Mildly elevated intrarenal resistive indices are nonspecific
and may be
seen with medical renal disease.
3. Limited evaluation for subtle changes associated with renal
artery
stenosis.
Brief Hospital Course:
Ms [**Known lastname 5395**] was amitted through the emergency room with a
presumed Type B aortic dissection. Once in the ER a review of
the CT scan revealed a type A aortic dissection, once discovered
the patient was brought emergently to the operating room for
dissection repair. Please see operative report for details, in
summary she had:
1. Replacement of ascending aorta with a 28-mm Gelweave Dacron
graft.
2. Bentall procedure with a composite St. [**Male First Name (un) 923**] mechanical graft,
size 21 mm, reference number [**Serial Number 89248**].
Her cardiopulmonary bypass time was 267 minutes, with a cross
clamp time of 81 + 43 + 85 = 209 minutes and a circulatory
arrest time of 22 minutes. She tolerated the operation and
post-operatively was transferred to the cardiac surgery ICU on
Epinephrine, Levophed and Propofol infusions. She was
hypotensive and coagulopathic upon arrival to the ICU and was
therefore kept sedated to allow for volume resuscitation and
correction of coagulopathy. She was also quite hypoxic, a chest
xray revealed a left effusion for which a chest tube was placed.
Her cardiac indices remained poor and additional inotropic
support with Milrinone was begun (weaned off by POD4).
She continued to be hypoxic, diuresis was begun with Lasix
infusion and an esophogeal ballon was placed to optimize PEEP
levels. She was kept sedated and ultimately chemically paralyzed
for several days while attempts were made to diurese the patient
and to optimize her pulmonary status. During this period she
developed acute renal failure and did required dialysis to take
volume off. When sedation was minimized the patient became
hypertensive requiring multiple antihypertensives to control her
BP. She also was encephalopathic and slow to wake from sedation.
A head CT was done that showed no acute process. Sedation was
held and the patient's neuro status slowly improved. She
developed thrombocytopenia and was found to have heparin
dependent antibodies so she was placed on argatroban. By POD 7
she was noted to have Serratia in her urine and sputum and was
treated with appropriate antibiotics. She developed diarrhea
which was positive for c-diff and she was placed on Vanco and
Flagyl.
On post-operative day fifteen she was extubated successfully.
Her epicardial wires were removed and coumadin was started for
her heparin dependent antibodies and mechanical aortic valve.
She developed atrial fibrillation and was started on Amiodarone.
She did convert to Sinus Rhythm. Speech Pathology was
consulted for swallowing evaluation and diet modification
recommendations. The patient received Physical Therapy for
assistance with range of motion exercises, strength and
mobility. Occupational Therapy evaluated for ADL
recommendations. [**2182-5-29**] a tunnel line was placed for
hemodialysis.
[**2182-6-5**] she was transferred to the step down unit for further
monitoring. POD#22 there was concern that the patient had a
seizure. Neurology was consulted. An MRI and 24 hour EEG was
performed. Per Radiology the MRI showed three discrete small
foci of susceptibility artifact at the [**Doctor Last Name 352**]-white matter
junction supratentorially and in the right cerebellar
hemisphere, with a separate small focus of slow diffusion
demonstrated within the left occipital lobe. EEG was
non-specific and did not reveal evidence of seizure.
INR became supratherapeutic at 4.5 on [**6-5**], coumadin has been
held since. INR will be checked daily upon discharge to rehab,
and results will be called to cardiac surgery office for
coumadin management until stable.
The patient is discharged to [**Hospital1 **] of [**Location (un) 1110**] with appropriate
follow-up instructions.
Medications on Admission:
lisinopril or labetolol
hydrochlorthiazide
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for mechanical Aortic Valve
Goal INR 2.5-3.0
First draw [**2182-6-12**]- please draw DAILY and call results to
[**Telephone/Fax (1) 170**], on-call PA/NP
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever or pain.
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-18**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes .
4. ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily).
5. sodium citrate 4 % (3 mL) Syringe Sig: One (1) ML
Miscellaneous ASDIR (AS DIRECTED) as needed for catheter not in
use: Do not inject intravenously. For catheter dwell only.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash.
8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
16. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
17. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days: through [**2182-6-19**], OK to substitute oral
liquid.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
Type A Aortic dissection with tamponade- s/p Bentall(21 StJude
mech)Hemiarch(28 Gelweave)
Hypertension, Mild mental retardation
Discharge Condition:
Alert and oriented x 3
Max assist
Incisions:
Sternal - healing well, no erythema or drainage
Edema - trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
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:
Labs: PT/INR for mechanical Aortic Valve
Goal INR 2.5-3.0
First draw [**2182-6-12**]- please draw DAILY and call results to
[**Telephone/Fax (1) 170**], on-call PA/NP
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2182-7-3**] at 1:00pm #[**Telephone/Fax (1) 170**] [**Hospital **]
Medical Building [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 4610**] in [**Location (un) 1110**] office ([**Hospital1 89250**]
Medical office next to [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**] Hospital) on [**2182-7-5**] at
2:00pm
Please call to schedule an appointment with your:
PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 25493**] in 4 weeks
Completed by:[**2182-6-11**]
ICD9 Codes: 5856, 5185, 5849, 5990, 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5480
}
|
Medical Text: Admission Date: [**2107-9-6**] Discharge Date: [**2107-9-19**]
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old white male
who was initially evaluated by the trauma service on the [**8-25**] after a fall on the commode. At that time, he was
noted to have multiple rib fractures and a small splenic lac.
He had stable hematocrits in the hospital and was discharged
to rehab on [**8-29**]. He was readmitted on [**9-6**],
brought in via the [**Last Name (un) 4068**] ER, for lethargy and hypotension
into the 80s/50s. The outside hospital hematocrit was listed
at 15 prior to the 3 units transfused. He was found to have
a posttransfusion hematocrit of 26, which was down from his
previous of 35. He was scanned and then transferred here
after being given 3 units of PRBCs and being intubated.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Parkinson's disease.
3. Lower leg elephantiasis.
4. COPD.
PAST SURGICAL HISTORY: Left total knee replacement.
HOME MEDICATIONS:
1. Serevent.
2. Advair.
3. Levoxyl.
4. Vicodin.
ALLERGIES: NKDA.
SOCIAL HISTORY: No use of tobacco or alcohol. Nursing home
report indicates alert and oriented at baseline.
INITIAL PHYSICAL EXAM: Vital signs - temperature 94.3, blood
pressure initially 121/30, remeasured at 145/57, heart rate
80, sat 100. The gentleman was intubated and sedated. He
had a regular rate and clear lungs bilaterally. He had a
distended and tense abdomen. He had bilateral right greater
than left lower extremity edema. This was consistent with
his previous history of especially right-sided elephantiasis.
The CT from outside hospital indicated a large amount of
intraperitoneal fluid. He had a trauma line placed in his
left groin in the trauma bay, and he was taken urgently to
the OR for suspected delayed onset of splenic bleed.
HOSPITAL COURSE: The gentleman was taken to the operating
room on the [**9-7**] and had an exploratory laparotomy,
during which was noted a large splenic bleed. He had a
splenectomy at that time. He had no other internal injuries
noted. The patient was sent to the Trauma SICU after the
operation. He had a left subclavian and Swan-Ganz catheter
placed secondary to decreasing urine output and rising
creatinine preoperatively. Opening pressures were within
normal limits with a wedge of 17-23, CVP 10-16, CCO [**4-30**] with
a CI greater than 3, SVO2 77-83%. His initial postoperative
crit was 26.1, and he was transfused with an additional 2
units of PRBCs with repeat hematocrit of 34. He required
calcium repletion, but his other lytes were within normal
limits.
The patient was initially hypothermic on presentation and was
warmed gradually with a bear-hugger. The patient was
extubated by evening on [**9-7**]. The Swan-Ganz catheter
was removed by [**9-8**], secondary to hemodynamic
stabilization. He remained afebrile on cefazolin and
Levaquin. His NG tube was DC'd on [**9-9**], and he was
taking small amounts of clear liquids without nausea or
vomiting in the unit. He was transferred over to the floor
on [**9-10**].
On the floor, Mr. [**Known lastname **] was noted to have a moderate
amount of abdominal distention with tympany. He had no
abdominal pain and no nausea. His incision from the surgery
remained intact with midline staples. There was also some
serous drainage noted from the site of the left groin Cordis
that had been pulled, but this resolved over the next several
days. He resolved chest PT q 4 h, as well as physical
therapy to attempt to improve the deconditioning that had
occurred while he was in the hospital. In addition, his
abdominal exam was closely followed while he was on the
floor.
The patient continued to tolerate POs well; however, he
remained distended. He reported that he was passing flatus,
but had had no bowel movement in many days. Dulcolax PR
seemed to have no effect. A KUB was checked on [**9-12**]
which just showed nonspecific bowel gas pattern with no
evidence of obstruction or perforation. His amylase was 51,
indicating no sign of pancreatic injury or inflammation. TSH
was checked to see if inadequate treatment of his
hypothyroidism might be contributing to his ileus, and it
turned out to be 13. So, his dose of levothyroxine was upped
from 50 mcg po to 75 IV with a plan to recheck a T4 in a
couple of days. He had a small bowel movement on that day,
the [**9-12**], but still remained quite distended. His
abdominal exam was closely followed.
His distention did not resolve by the following day, so a PO
and IV contrast abdominal CT was obtained in order to
determine if there was sign of obstruction or abscess. The
CT from the 21 showed no focally drainable collections, no
findings to suggest bowel obstruction, a small amount of
abdominopelvic ascites consistent with ex-lap, and mild
distention of the gallbladder without any discrete fluid
around it, and with some calculi. Since there was no
indication or obstruction or abscess, and the patient was
still tolerating POs, it was assumed that this distention and
lack of bowel movements was probably due to ileus. We
continued a bowel regimen with PO Dulcolax, as well as tid
ambulation to encourage return of bowel function. A free T4
was checked on the 23 which showed 0.9 at the lower end of
normal, so his levothyroxine was increased to 100 qd. He was
placed on [**Hospital1 **] lactulose which caused him to have several
large quantity bowel movements, and so the lactulose was
discontinued.
The patient required occasional albuterol nebs in order to
treat some mild expiratory wheezes. The patient also
required a few doses of lasix 20 mg IV for fluid overload.
Lower extremity and scrotal edema improved with lasix. His K
was repleted along with diuresis. The patient was noted to
be very weak and continued to require PT and assist with
ambulation. Prior to discharge to rehabilitation, he was
given the pneumococcal, meningococcal and H. flu vaccines.
LABS ON ADMISSION: CBC showed a white count of 17,
hematocrit 26, platelet count 185. Coags were PT 12.5, PTT
27.9, INR 1.0. Chem-7 - sodium 136, potassium 4.2, chloride
105, CO2 22, BUN 55, creatinine 2.2, and glucose 126. His UA
was positive which was why he was placed on Levaquin for 3
days for the urinary tract infection
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation unit.
DIAGNOSIS: Status post fall with delayed bleed from splenic
laceration, status post exploratory laparotomy with
splenectomy.
DISCHARGE MEDICATIONS:
1. Levothyroxine sodium 100 mcg po qd.
2. Bisacodyl 10 mg po qd prn.
3. Nystatin ointment applied up to qid prn.
4. Famotidine 20 mg po qd.
5. PRN Tylenol
6. Metoprolol 12.5 po bid.
7. Docusate 100 mg po bid.
8. Albuterol nebulizers q 6 h prn.
9. Heparin 5,000 U subcu q 12 h.
FOLLOW-UP in 2 weeks with Trauma Clinic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**MD Number(1) 107103**]
MEDQUIST36
D: [**2107-9-19**] 09:27
T: [**2107-9-19**] 09:33
JOB#: [**Job Number 107104**]
ICD9 Codes: 496, 5990, 2449
|
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|
Medical Text: Admission Date: [**2130-4-27**] Discharge Date: [**2130-5-3**]
Date of Birth: [**2076-4-9**] Sex: F
Service:
CHIEF COMPLAINT: The patient is a 54 year old woman with
known coronary artery disease who was admitted to [**Hospital6 1760**] on [**4-14**] for cardiac
catheterization. Please see catheterization report for full
details. At that time catheterization showed three vessel
disease with an ejection fraction of 50%. At that time the
patient was scheduled for coronary artery bypass grafting.
The patient is a same-day admit on [**4-26**]. She was admitted
to the Operating Room for coronary artery bypass grafting.
PAST MEDICAL HISTORY: Significant for insulin dependent
diabetes mellitus, hypertension, hypercholesterolemia,
arthritis bilaterally in the shoulders, peptic ulcer disease
and gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION: Medications prior to admission
include aspirin 325 q.d., Isosorbide 60 mg q.d., Ranitidine
300 mg prn, Nitroglycerin sublingually, prn Celebrex 200 mg
q.d., Zocor 40 mg b.i.d., Zestril 10 mg q.d., Toprol XL 100
mg q.d., Metformin 850 mg t.i.d., Glyburide 5 mg b.i.d., NPH
10 units along with regular insulin 8 units at noontime only.
LABORATORY DATA: White count was 8.7, hematocrit 44.7,
platelets 269, PT 11.6, INR 0.9. Sodium 137, potassium 4.4,
chloride 100, carbon dioxide 25, BUN 22, creatinine 0.6,
glucose 279. Electrocardiogram, sinus rhythm at 74,
nonspecific T wave changes. Chest x-ray no congestive heart
failure or pneumonia.
PHYSICAL EXAMINATION: On physical examination height is 5
foot 3, weight 129, heartrate 74, blood pressure 111/69.
Neurological was intact. Head, eyes, ears, nose and throat,
pupils equally round and reactive to light, no jugulovenous
distension and no bruits. Cardiovascular, S1 and S2, no
murmur or gallop. Lungs clear to auscultation bilaterally.
Abdomen is benign. Extremities are warm and well perfused
with no cyanosis, clubbing or edema.
HOSPITAL COURSE: As stated previously the patient was
admitted directly to the Operating Room where she underwent
coronary artery bypass grafting times five. Please see
operation report for full details. In summary the patient
had a coronary artery bypass graft times five with left
internal mammary artery to the left anterior descending,
saphenous vein graft to the right coronary artery, saphenous
vein graft to the left posterior descending artery with a
sequential graft to the obtuse marginal. The patient
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 an arterial line,
Swan-Ganz catheter, two ventricular and two atrial pacing
wires, two mediastinal and one left pleural chest tube. Her
mean arterial pressure was 72. She was atrially paced at 80
beats/minute. She had Neo-Synephrine 0.3 mcg/kg/min and
insulin infusion as well as Propofol infusion. The patient
did well in the immediate postoperative period. She was
reversed from her anesthesia, weaned from the ventilator and
successfully extubated. She remained hemodynamically stable
throughout the night of postoperative day #1. On
postoperative day #1 the patient remained hemodynamically
stable, however, she continued to require a small amount of
Neo-Synephrine to maintain an adequate blood pressure. She
also required insulin to keep her blood sugar under control.
She was therefore kept in the Intensive Care Unit throughout
the day of postoperative day #1. Her mediastinal chest tubes
were removed, leaving in place a left pleural chest tube. On
postoperative day #2, the patient continued to require
Neo-Synephrine to maintain an adequate blood pressure. Her
remaining chest tube was discontinued and she was begun on an
activity regime with the assistance of the Physical Therapy
Department. She was also seen by [**Hospital1 **] Consult Service to
manage her diabetes. On postoperative day #3 the patient
remained hemodynamically stable. Her Neo-Synephrine drip had
been weaned to off on postoperative day #2. A central venous
access was discontinued. The Foley catheter was discontinued
and she was transferred from the Cardiothoracic Intensive
Care Unit to Far 6 for continuing postoperative care and
cardiothoracic rehabilitation. Once on the floor, the
patient continued to do well. She remained hemodynamically
stable. Her blood sugar was under better control with the
assistance of the [**Hospital1 **] Consult Service. Her activity
level was increased on a daily basis with the assistance of a
nursing staff and physical therapy. On postoperative day #6
it was decided that the patient was stable and ready to be
discharged to home with [**Hospital6 407**] follow up.
The patient's physical examination on the day of discharge
revealed temperature 98.2, heartrate 81 in sinus rhythm,
blood pressure 100/56, respiratory rate 18 and oxygen
saturation 95% on room air. Physical examination, generally
comfortable. Heartsounds regular rate and rhythm, S1 and S2
no murmur. Breathsounds slightly diminished bilaterally in
the bases. Abdomen soft, nontender, nondistended, positive
bowel sounds. Extremities are warm and well perfused with
trace edema. Incisions were clean and dry and open to air.
DISCHARGE MEDICATIONS:
1. Glyburide 5 mg b.i.d.
2. Zantac 150 mg b.i.d.
3. Enteric coated Aspirin 325 q.d.
4. Zocor 40 mg q.d.
5. Celebrex 200 mg q.d.
6. Percocet 5/325 1 to 2 tablets q. 4 hours prn
7. Ibuprofen 400 mg q. 6 hours prn
8. Lantus 25 units q.h.s.
9. Regular insulin sliding scale
10. Metoprolol 25 mg b.i.d.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass grafting times five with the left internal mammary
artery to the left anterior descending, saphenous vein graft
to diagonal, saphenous vein graft to right coronary artery
and saphenous vein graft to the posterior descending artery
with sequential to the obtuse marginal.
2. Insulin dependent diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
5. Gastroesophageal reflux disease.
6. Peptic ulcer disease.
7. Arthritis.
8. Diabetic retinopathy.
FOLLOW UP: She is to have follow up in the [**Hospital **] Clinic in
one week, follow up with her primary care physician in two to
three weeks and follow up with 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:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2130-5-3**] 16:08
T: [**2130-5-3**] 17:01
JOB#: [**Job Number 34431**]
ICD9 Codes: 4111, 4019, 2720
|
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|
Medical Text: Admission Date: [**2151-8-17**] Discharge Date: [**2151-8-20**]
Date of Birth: [**2099-5-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 52 year old female with extensive PVD s/p
recent interventions, as well as known CAD and multiple
cardiovascular risk factors (HTN, IDDM), who is transferred from
[**Hospital6 33**] where she presented this a.m. from rehab
with chest pain and hypotension. She was recently discharged
from [**Hospital1 18**] after a stay from [**7-22**] - [**8-16**] during which time she
underwent multiple revascularization procedures of the RLE,
culminating with a R BKA on [**2151-8-10**] after multiple thrombosis of
stents/bypasses which had been placed. She had a PICC placed
for intended 2 weeks of vancomycin (through [**8-30**]) - when exactly
this was placed is unclear, however appears to have been
sometime between [**7-27**] and [**8-9**], and was transferred to [**Hospital 38**]
rehab on [**8-16**]. Her hospital course also appears notable for a
UTI, treated with cipro from [**8-10**] through [**8-13**].
The patient says that she woke up this morning with a [**10-11**]
fleeting chest pain, lasting only seconds. At that time, her
blood pressure was noted to be 60/palp, T 99.5. Labs at
[**Location (un) 38**] were wbc 9.9, HCT 27.1, plt 672, BUN 24, creat 1.7.
She was transferred to [**Hospital6 33**] for further
management. At [**Hospital3 **] her pressure was 86/palp and labs
were notable for WBC count of 23.1, hct 26.5 (stable), platelets
547, BUN/creat 25/2.1. 1st set of cardiac enzymes were negative
and an EKG was unchanged from baseline. CXR was without
infiltrates, and possibly mild congestion. She was given 1.5 L
NS, 1 dose of levaquin, and transferred to [**Hospital1 18**].
In the [**Hospital1 18**] ED her vitals were T 100.1, BP 73/30
non-invasively, HR 86, 99% on RA. She was started on IVF, and
multiple A-line attempts were unsuccessful. She had received 4
L lactated ringers in the ED prior to transfer to the [**Hospital Unit Name 153**], as
well as a dose of vancomycin. She was started on dopamine with
increase of her blood pressure to around 110-120 systolic. A
second set of cardiac enzymes were negative. [**Hospital Unit Name **] surgery
saw the patient in the ED.
On review of systems the patient denies any recent cough,
shortness of breath, abdominal pain. She does say she has had
dysuria, but denies hematuria. She also is complaining of L 5th
toe pain. ROS otherwise negative.
Past Medical History:
1. Severe peripheral [**Hospital Unit Name 1106**] disease status post right and left
femoral-popliteal bypass, underwent Rsided venous bypass in
[**10-6**] which failed, then underwent amputation below knee.
2. Status post thoracic aortic replacement for thoracic aortic
dissection approximately 10 years ago.
3. COPD.
4. CAD with 90% RCA and 60% LAD lesions by recent
catheterization.
5. Severe hyperlipidemia, cholesterol level of about 600 and
triglycerides of approximately 3,000.
6. Insulin dependent diabetes.
7. Hypothyroidism.
8. Hypertension.
9. h/o Pancreatitis.
10. Degenerative joint disease status post laminectomy.
11. Status post cholecystectomy.
12. Status post right femoral embolectomy.
13. Obesity.
Social History:
She admits to a 45 pack year history of tobacco, however she
quit smoking about 2 months ago. She denies any IVDU or alcohol
use. She lives alone. She has 3 children.
Family History:
Non-contributory.
Physical Exam:
VS: T 101.0, HR 82, BP 100/45 non-invasive L wrist, 97% on 2L,
on dopa 12.
Gen: Obese spanish speaking female appearing slightly lethargic
but responding to verbal stimuli appropriately.
MS: Says she is at [**Hospital1 18**], [**2151**], doesn't know the month or the
president.
HEENT: PEARL, moist MM, anicteric sclerae
Neck: JVP not visible secondary to body habitus. Bilateral
carotid bruits.
Chest: ? subclavian bruit on L.
Cor: RR, normal rate, 2/6 systolic murmur heard best at RUSB but
heard throughout the pre-cordium, with radiation to carotids.
Lungs: CTA anteriorly. Mild end-expiratory wheezes.
Abd: NABS, soft, NT/ND.
Extr: R BKA site with mild area of erythema, area around
incisions non-erythematous, no exudate able to be expressed. L
DP non-palpable but present with doppler, PT non-dopplerable. L
5th toe with slight mottling.
Lines: R PICC line with mild erythema, no exudate or
fluctuance.
Pertinent Results:
[**2151-8-17**] 11:54PM GLUCOSE-139* UREA N-16 CREAT-1.1 SODIUM-144
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-22 ANION GAP-15
[**2151-8-17**] 11:54PM CK(CPK)-223*
[**2151-8-17**] 11:54PM CK-MB-2 cTropnT-<0.01
[**2151-8-17**] 02:30PM cTropnT-<0.01
[**2151-8-17**] 02:30PM CK-MB-3
[**2151-8-17**] 11:54PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.8
[**2151-8-17**] 11:54PM CORTISOL-40.8*
[**2151-8-17**] 09:53PM URINE HOURS-RANDOM CREAT-16 SODIUM-71
[**2151-8-17**] 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2151-8-17**] 02:47PM LACTATE-0.7
[**2151-8-17**] 02:30PM WBC-8.8 RBC-3.18* HGB-8.6* HCT-28.1* MCV-88
MCH-27.2 MCHC-30.8* RDW-16.1*
[**2151-8-17**] 02:30PM PT-13.9* PTT-21.3* INR(PT)-1.3
Brief Hospital Course:
In the [**Hospital Unit Name 153**], non-invasive blood pressure was thought to be
unreliable in this patient given her known severe PVD. She was
mentating well, with adequate UOP, making non-invasive BP seem
even less reliable. Multiple a-line attempts were unsuccessful.
Patient was not tachypneic, not tachycardic, repeat WBC count
was within normal limits and lactate was 0. 2 sets of enzymes
were negative, EKG was unchanged and patient did not appear to
be in failure. A cortisol stimulation test was performed and
the patient's response was determined to be adequate, ruling out
adrenal insufficiency. The patient's hematocrit was stable and
there were no obvious sources of bleeding or volume loss. Blood
and urine cultures were sent. A repeat chest X-ray showed a
small pleural effusion, was consistent with mild congestive
heart failure but was not consistent with pneumonia. Vancomycin
was continued to cover staph/strep for presumed stump
cellulitis. Dopamine drip was continued.
R BKA site was with mild erythema, no exudate or fluctuance and
the PICC site was only mildly erythematous. Patient did have a
murmur on exam that has been present on past hospitalizations.
Patient's BUN/creatinine was 25/1.9 which was elevated from
13/0.9 on [**2151-8-14**], concerning for an intrinsic renal process,
such as vancomycin nephrotoxicity. However, with hydration,
patient's Creatinine decreased to 0.9 by hospital day 2.
Patient's blood pressure medications (lisinopril and beta
blocker) were held but niacin and gemfibrozil were continued.
Patient was complaining of left 5th toe pain, with mild mottling
on exam, concerning for thrombus vs. embolus vs. pressor
related. [**Date Range **] surgery was consulted and on exam the
appearance of the toe was thought to be due to ischemia.
On hospital day 2, patient was transferred to medicine service
from the intensive care unit. She was normotensive and afebrile
upon transfer. Urine culture returned negative. Blood pressure
medications continued to be held as patient's pressure was not
elevated.
On hospital day 3, patient was complaining of severe LE pain so
pain regimen was switched to MS contin 30mg [**Hospital1 **] with dilaudid
2-4mg Q4-6hours as needed for breakthrough pain. The pain was
thought to be more neurogenic so her gabapentin was increased
from 300mg QD to 300mg [**Hospital1 **]. A physical therapy consult was
obtained. ON discharge, it was noted that pt was on lower dose
of neurontin while in-house; this may have contributed to
increased pain. Pt was restarted on home dose of neurontin. Pt
should try trial off ms contin to see if pain better controlled
on higher dose of neurontin; if not, should restart ms contin.
Patient's hematocrit was 24 so patient was transfused 1 unit
packed red blood cells as patient has known CAD. Iron studies
were consistent with iron deficiency, which requires further
evaluation as outpatient.
Medications on Admission:
SQ heparin
gemfibrozil 600 mg [**Hospital1 **]
Neurontin 1200 mg Q8
Atenolol 50 mg qday
Vancomycin 1 g IV Q12
Quetiapine 25 mg QHS
Senna 1 tab PO QHS
Protonix 40 mg qday
Zocor 80 mg QHS
Niacin 100 mg daily
rosiglitazone 4 mg [**Hospital1 **]
Colace 100 mg PO BID
ECASA 325 mg daily
lisinopril 10 mg daily
hydromorphone 8 mg Q 3 PRN
Discharge Medications:
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Niacin 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. glargine Sig: One (1) 45U qPM.
12. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: AS DIRECTED.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15)
ML PO Q6H (every 6 hours) as needed.
14. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Ibuprofen 400 mg Tablet Sig: 1-1.5 Tablets PO Q8H (every 8
hours) as needed.
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
18. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): last day is [**8-30**].
20. Gabapentin 800 mg Tablet Sig: 1.5 Tablets PO three times a
day.
21. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
22. MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Hypovolemia
2. Peripheral [**Location (un) **] Disease status-post multiple
interventions including recent right below the knee amputation.
3. Coronary artery disease
Discharge Condition:
1. Afebrile, vital signs stable
2. Normotensive
3. Improved pain management
Discharge Instructions:
1. Please return to Emergency Room, call your PCP [**Last Name (NamePattern4) **] 911 if you
have chest pain, shortness of breath, fevers/chills or become
dizzy, lightheaded or pass out.
2. Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12300**] for a follow up appointment
within 2-3weeks.
3. Please attend all follow up appointments.
4. Please take all of your medications regularly. You will be
going to the rehabilitation facility on a new medication, MS
contin 30mg po BID for your pain. Your dose of gabapentin has
also been increased from 300mg po QD to 300mg po BID.
Followup Instructions:
1. Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12300**] at his office (phone # [**Telephone/Fax (1) 12301**]) for a follow up appointment within 2-3weeks.
2. Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-10-26**] 11:00
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2151-10-26**] 1:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 496, 4280, 486, 5849, 2765, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5483
}
|
Medical Text: Admission Date: [**2144-7-4**] Discharge Date: [**2144-7-16**]
Date of Birth: [**2144-7-4**] Sex: M
Service: NB
HISTORY: [**Known lastname 35861**] is a 35 year old gestation twin one, who was
born to a 31 year old, Gravida I, Para 0, who underwent IVF.
The pregnancy was complicated by complete previa. Prenatal
labs were 0 positive, antibody negative, RPR nonreactive,
Rubella immune. Hepatitis B surface antigen negative. GBS
status unknown. She went into spontaneous preterm labor and
delivered the twins by cesarean section in the setting of
known placenta previa. Rupture of membranes was at delivery
and there had been no maternal fever. There were no
intrapartum antibiotics. Baby one emerged with a spontaneous
cry, requiring routine care in the operating room. Apgars
were eight and nine. He was transferred to the new born
nursery where he developed grunting, respirations,
hypothermia to 96.9 and was transferred to the newborn
Intensive Care Unit for further evaluation and management.
PHYSICAL EXAMINATION: In the newborn Intensive Care Unit,
his weight was 2,255 which was 50th percentile. He was
tachypneic with retractions and shallow respiratory effort
but clear breath sounds, regular rate and rhythm without
murmur. Normal pulses. Everything else on his examination
was normal. His glucose on admission was 42 and he was cold
and so he was admitted and observed in the newborn Intensive
Care Unit.
HOSPITAL COURSE: Respiratory: Initially, the patient was
infant was placed on an oxygen saturation monitor and had
mild respiratory distress which resolved, requiring small
amounts of oxygen for the fr ist day of life, which slowly
resolved to room air. His tachypnea, grunting and retractions
resolved quickly in the first 24 hours of life. He did not
seem to have pneumonia or respiratory distress syndrome. He
has remained on room air without any concerns and has only had
one episode of apnea on day three of life and has not had any
apnea since [**7-7**].
Cardiovascular: He has had no clinical issues. There have
been no murmurs and his blood pressures have remained stable.
There are no concerns from a cardiovascular standpoint.
Fluids, electrolytes and nutrition: The infant was initially
made n.p.o. with intravenous fluids and he started feeding on
day of life two. He has had poor p.o. initially and required
gavage feeding. He slowly advanced and improved his p.o.
ability throughout his hospitalization and for the past two
days, he has been taking approximately 130 to 140 cc per kg
per day, all p.o. We did fortify his formula to 24 cals per
ounce formula, in the setting of not taking a full 150 cc and
being a little bit small. He is tolerating 24 cals formula
well and has continued to p.o. a reasonable amount. His
discharge weight is and he will need this followed closely.
[**Known lastname 35861**] had some problems with hyperbilirubinemia with a
maximum bilirubin on day of life four of 11. This decreased
with phototherapy and the most recently bilirubin was 7.1 on
[**7-11**], which had decreased spontaneously off of lights.
Hematology: The infant had an initial hematocrit of 47.9 on
admission and has not had one subsequently and has had no
concerns from this standpoint.
Infectious disease: He has not shown any signs or symptoms
of infection and has not been treated for it.
Neurology: He has had no issues from this standpoint and has
had no screening ultrasounds. Sensory hearing screen was
performed with automated auditory brain stem responses and
the baby passed. [**Name2 (NI) **] did not require an ophthalmology
examination.
[**Hospital1 69**] social work was involved
with the family. The contact social worker can be reached at
[**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable. He was discharged to home.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **], M.D., [**Hospital1 6687**].
CARE AND RECOMMENDATIONS: The infant was discharged on p.o.
feeds of Similac 24 calories per ounce and the parents were
taught how to mix this. This can be adjusted by his doctor.
MEDICATIONS: None.
He had a car seat test prior to discharge and received his
newborn screening and received his hepatitis B immunization.
DISCHARGE DIAGNOSES: Prematurity.
Respiratory distress.
Hyperbilirubinemia.
Feeding difficulty.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2144-7-15**] 16:27:50
T: [**2144-7-15**] 17:08:36
Job#: [**Job Number 58603**]
ICD9 Codes: 7742
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5484
}
|
Medical Text: Admission Date: [**2196-7-6**] Discharge Date: [**2196-7-8**]
Date of Birth: [**2126-9-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Throat swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69M with HTN presented to [**Hospital6 8283**] after
awaking with R>L sore throat, hoarseness, an inability to
swallow his secretions, odynophagia, and dysphagia. Initial V/S
at OSH 98.6 (Tmax 100) 120 153/89 18 100%2L. CXR was clear. Neck
XR indeterminate for epiglottitis. Neck CT with contrast showed
diffuse epiglottic and upper airway swelling but no abscess or
LAD. Rapid strep A was negative. Reported to be in
newly-observed AFib with RVR. He was given decadron 10 mg IV and
ceftriaxone 2 g IV at OSH ED and medflighted to [**Hospital1 18**]. Initial
V/S here 98.8 130 137/112 11 98%RA. He reported feeling much
improved, able to handle secretions normally, with his voice
having almost returned to [**Location 213**]. Given vancomycin 1 g, unasyn
3g IV, dexamethasone 10 mg IV, and NS+40mEq KCl. Seen by ENT who
noted that he was breathing comfortably without stridor, with
epiglottic/aryepiglottic erythema and exudate. Case discussed
with anesthesia. Admitted to MICU for close observation. Vital
signs prior to transfer 107 145/69 20 97%RA. On arrival to the
MICU, reports feeling nearly at his baseline. Denies fever,
chills, runny nose, watery eyes, tongue swelling, stridor,
wheezing, shortness of breath, rash, sick contacts,
environmental trigger, or new meds.
Past Medical History:
HTN
tonsillectomy
seasonal allergies
Social History:
Retired employee of [**Company 2318**] and shipyard worker. Lives in [**Hospital1 392**]
with his wife. Former [**Name2 (NI) 1818**]. Drank [**11-24**] scotch per day over the
last few 3-4 days, none prior to that over the prior 10 months.
Family History:
No history of angioedema or severe allergic reaction.
Physical Exam:
V/S: T 98.6 HR 110 BP 1138/92 RR 21 O2sat 96%RA
GEN: Appears well, resp nonlabored
HEENT: No tongue/uvula swelling
NECK: No stridor, JVP flat
CV: irreg irreg no m/r/g
Pulm: CTAB no w/r/r
Abd: benign
Extremities: warm, dry no edema
Skin: spider angiomata
Neuro: AA&Ox3
Pertinent Results:
ADMISSION LABS:
.
[**2196-7-6**] 07:14PM GLUCOSE-118* LACTATE-1.7 NA+-143 K+-3.5
CL--104 TCO2-26
[**2196-7-6**] 07:14PM freeCa-1.03*
[**2196-7-6**] 07:05PM GLUCOSE-132* UREA N-19 CREAT-0.9 SODIUM-139
POTASSIUM-6.0* CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
[**2196-7-6**] 07:05PM ALT(SGPT)-21 AST(SGOT)-59* ALK PHOS-35* TOT
BILI-1.0
[**2196-7-6**] 07:05PM WBC-8.0 RBC-4.49* HGB-14.4 HCT-41.9 MCV-93
MCH-32.0 MCHC-34.3 RDW-14.2
[**2196-7-6**] 07:05PM NEUTS-86.2* LYMPHS-8.1* MONOS-4.3 EOS-1.2
BASOS-0.3
[**2196-7-6**] 07:05PM PLT COUNT-239
[**2196-7-6**] 07:05PM PT-13.2 PTT-24.3 INR(PT)-1.1
.
IMAGING:
EKG [**7-6**] 19:03:36 irregular SVT ~125 bpm (atrial fibrillation)
LAD nonspecific anteroseptal/lateral T-wave changes, rhythm is
new compared with [**2190-4-14**] exam.
.
Imaging:
OSH CT neck with contrast read: thickening of epiglottic folds
and AE folds, no abscess seen. No LAD.
.
CT reviewed with [**Hospital1 18**] Rads: no abscess, no cartilage erosion,
diffuse epiglottic and upper airway swelling
.
MICRO:
[**2196-7-7**] Blood cx: No growth to date
Brief Hospital Course:
69 year old man with a history of HTN and alcohol abuse
admitted to the ICU with epiglottitis.
.
#Epiglottitis: Upon arrival to the ICU patient was breathing
comfortably. Given his intial degree of swelling the ENT
service recommended airway monitoring for 48 hours. He was
treated with steroids and IV antibiotics initially. Given his
excellent response overnight to steroids they were discontinued
the following day and patient was monitor overnight. He did
well on antibiotics alone and had no furhter evidence of airway
compromise. Patient was tolerating po diet and medications on
day of discharge and continued to maintain normal oxygen
saturations without supplemental oxygen. He was instructed to
complete a 10 day course of oral antibiotics (Augmentin) for
presumed bacterial epiglottitis. He had no prodrome consistent
with viral etiologies. He was instructed to schedule an
appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**Hospital **] clinic within one week
of discharge. Patient was counseled on warning signs of
inflammation and when to seek medical attention.
.
#Atrial fibrillation: Intermittent SVT on telemetry monitoring
appeared consistent with atrial fibrillation. He remained
asymptomatic during the episodes. He denies any known history of
atrial fibrillation but admits to a history of intermittent
palpitations, lightheadedness and racing heart. He was
instructed to continue his atenolol for rate control and to
discuss the role of anticoagulation with his primary care
physician. [**Name10 (NameIs) **] was not started on any coumadin or aspirin during
his hospitalization given his low CHADS2 score (1) and his
reported alcohol intake.
.
#ETOH abuse: Patient describes long history of excessive alcohol
use ([**11-24**] gallon of scotch = 750 mL per day). He was monitored
in the ICU on a CIWA scale and did not show any evidence of
withdrawal in his 48 hour hospital stay. He was counseled on
the dangers of excessive alcohol use and more specifically the
relationship his alcohol use may have in his heart arrhythmia.
Patient recognized our concern and declined offers for
treatment.
.
#HTN: Patient instructed to continue home atenolol.
.
#Code: FULL
#Communication: [**First Name4 (NamePattern1) **] [**Known lastname 87601**](wife) [**Telephone/Fax (1) 87602**]
#Dispo: HOME
Medications on Admission:
Atenolol 50 mg
Unknown diuretic medication
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Epiglottitis
Alcohol abuse
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the [**Hospital1 18**] Emergency Room after experiencing a
sore throat and throat swelling. You were found to have a very
serious condition called epiglottitis (swelling in your throat).
You were treated with antibiotics and steroids and admitted to
the ICU for close monitoring. You did well on the treatment and
your swelling improved. You were able to tolerate an oral diet
and medications. It is very important that you complete the
course of antibiotics and follow up with the ENT physicians in
clinic.
.
During your admission you were also found to have an irregular
heart rhythm called atrial fibrillation. It is very important
that you follow up with your primary care provider to discuss
the need for blood thinning medications and to monitor your
heart rate.
.
We were very concerned about your excessive alcohol use. This
amount of alcohol can contribute to your irregular heart rhythm
as well as cause other life threatening ilnesses.
.
.
The following changes were made to your home medications:
.
1) START Amoxicillin-Clavulanic Acid (AUGMENTIN) 500 mg by mouth
every 8 hours for 9 days. Last dose on [**2196-7-17**].
.
Followup Instructions:
Please make an appointment with your primary care provider
within two weeks of discharge to discuss treatment for you
abnormal heart rhythm.
.
Please follow up with your new ENT physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **]
within 1 week of discharge. Please call [**Telephone/Fax (1) 2349**] to
schedule your appointment.
ICD9 Codes: 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5485
}
|
Medical Text: Admission Date: [**2155-12-10**] Discharge Date: [**2155-12-20**]
Date of Birth: [**2086-6-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Coronary Artery Disease
Major Surgical or Invasive Procedure:
[**2155-12-10**]: Emergent coronary artery bypass grafting x4 with the
left internal mammary artery to left anterior descending artery
and reverse saphenous vein graft to the right coronary artery,
ramus intermedius artery and the diagonal artery
[**2155-12-18**] Right femoral thromboembolectomy with a bovine patch
angioplasty
History of Present Illness:
69 y/o male admitted to MWMC with mid-sternal chest jpain
([**10-10**]). Started at 0700 on [**2155-12-10**]. Patient has not seen a
primary care physician [**Name Initial (PRE) **] 40 years. In ER, patient given ASA
325 mg and 4000 units heparin. He was taken to cath lab at MWMC
for urgent cath. Cath revealed 3 VD. Had ongoing pain in the
cath lab. IABP placed. See cardiac cath procedure event log
for meds/dosages.
Also given 2.5 mg lopressor IV at 1640. IABP placed for ongoing
chest pain. Transferred for emergency CABG and taken to the
operating room.
Troponin ([**2155-12-10**] at 1526) - 0.14. EKG showed ST elevations
anteriorly.
Past Medical History:
Social History:
Denies ETOH, smoking 1 PPD x 40 years (stopped 10 years ago)
Family History:
Father died MI at 79
Physical Exam:
PE: T - 97 BP - 174/64 HR - 88 RR - 19 SAT -
99%
General - NAD, alert, cooperative
HEENT - EOMI, PERRLA
Neck - supple, FROM
Lungs - CTA
Cardio - nl S1 and S2, no S3, S4 or murmur; RRR
Abdomen - soft, nontender, no hepatosplenomegaly
Ext - no edema, DP and PT pulses 1+ bilaterally, IABP in right
groin
Neuro - oriented x3, moves all extremities, follows commands,
answers questions appropriately
Pertinent Results:
[**2155-12-15**] Echo: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Overall left ventricular systolic
function is severely depressed (LVEF= 25-30 %). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. with depressed free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. 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 (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
[**12-17**] CTA Aorta/Bifem/Iliac: 1. 3-cm area of occlusion in the
right common femoral artery just distal to the inguinal
ligament. There is rapid reconstitution. Otherwise patent
vasculature with atherosclerotic areas as desribed above. 2.
Moderate bilateral pleural effusions with compressive
atelectasis. 3. Prominent bilateral ureters with enlarged
prostate suggest bladder outlet obstruction.
[**12-19**] CXR: Moderate edema, left effusion and retrocardiac
atelectasis, all slightly increased from prior.
[**2155-12-10**] 06:02PM BLOOD WBC-9.1 RBC-4.40* Hgb-12.4* Hct-35.8*
MCV-81* MCH-28.2 MCHC-34.7 RDW-13.0 Plt Ct-288
[**2155-12-13**] 02:07AM BLOOD WBC-16.9* RBC-4.32* Hgb-12.5* Hct-35.6*
MCV-82 MCH-29.0 MCHC-35.3* RDW-13.9 Plt Ct-173
[**2155-12-20**] 06:00AM BLOOD WBC-7.4 RBC-3.75* Hgb-10.9* Hct-31.8*
MCV-85 MCH-29.1 MCHC-34.3 RDW-13.7 Plt Ct-412
[**2155-12-10**] 06:02PM BLOOD PT-13.7* PTT-52.1* INR(PT)-1.2*
[**2155-12-13**] 02:07AM BLOOD PT-16.9* PTT-31.1 INR(PT)-1.5*
[**2155-12-19**] 04:40AM BLOOD PT-20.4* PTT-29.7 INR(PT)-1.9*
[**2155-12-10**] 06:02PM BLOOD Glucose-471* UreaN-14 Creat-1.1 Na-134
K-4.7 Cl-99 HCO3-26 AnGap-14
[**2155-12-15**] 03:44AM BLOOD Glucose-113* UreaN-27* Creat-1.0 Na-138
K-4.2 Cl-102 HCO3-23 AnGap-17
[**2155-12-20**] 06:00AM BLOOD Glucose-123* UreaN-17 Creat-1.0 Na-136
K-4.0 Cl-97 HCO3-28 AnGap-15
[**2155-12-10**] 06:02PM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.8 Mg-1.9
[**2155-12-14**] 02:46AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.7
[**2155-12-19**] 04:40AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.7
[**2155-12-18**] 04:35AM BLOOD ALT-17 AST-27 LD(LDH)-363* AlkPhos-342*
Amylase-40 TotBili-0.7
Brief Hospital Course:
69 y/o male admitted to MWMC with mid-sternal chest pain - taken
to cath lab at MWMC for urgent cath which revealed 3 vessel
disease. He did experience ongoing pain in the cath lab and had
IABP placed. He was transferred to [**Hospital1 18**] for emergency CABG. On
[**2155-12-10**] he underwent an emergent coronary artery bypass
grafting x 4 with the left internal mammary artery to left
anterior descending artery and reverse saphenous vein graft to
the right coronary artery, ramus intermedius artery and the
diagonal artery. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. IABP was pulled
on post operative day 1 and the patient initially was noted not
have a dopplerable PT or DP pulse but PT pulse did return as
dopplerable signal. [**Date Range **] surgery was consulted on POD 7 when
he noted sensory differences to lower extremities. At this time
he still had an absent Right DP and monophasic PT signals with
Right CFA occlusion likely from thrombus secondary to
intra-aortic balloon pump. The leg did not look threatened as pt
was able to ambulate, move all toes and had no ischemic pain.
Symptoms were bilateral and only sensory. He was taken to the
operating room for a femoral thrombectomy and femoral
endarterectomy with the [**Date Range 1106**] surgery team. He had a silver
dressing placed intra op and this was to be removed on Sun
[**12-21**]. He does not need any further anticoagulation per the
[**Month/Year (2) 1106**] surgery team. POD 1 the patient was extubated after the
balloon pump was pulled. He was alert and oriented and
breathing comfortably. He did develop pulmonary edema and
required BIPAP after extubation. He was placed on Milrinone x 2
days, was taken off and dropped his mixed venous saturations and
was put back on for Milrinone x 2 days with a slow wean. The
patient was neurologically intact and hemodynamically stable on
no inotropic or vasopressor support after several days on
Milrinone. 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. His
Foley was removed and he had urinary retention with preoperative
symptoms and Flomax was started. Foley is to remain in place
until urology follow up. 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 10 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to [**Hospital 24591**]
Rehab at [**Location (un) 5176**] in good condition with appropriate follow up
instructions.
Medications on Admission:
Took 1 lorazepam on morning of admission
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks. Tablet(s)
2. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
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. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
7. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
9. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 2 200mg tablets [**Hospital1 **] x 7 days. The 1 200mg tablet
[**Hospital1 **] x 7 days. Finally 1 200mg tablet until stopped by
cardiologist.
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for back for 2 weeks.
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) for 4 days.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft
Right Common Femoral Artery occlusion s/p thromboembolectomy
Past medical history:
Hypertension
Diabetes
Stroke/TIA
Renal issues
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema - trace
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) **] for Dr [**Last Name (STitle) **] at [**Hospital1 **] on [**1-15**] at 9am
Cardiologist: Dr [**Last Name (STitle) 31888**] at [**Hospital1 **] on [**1-19**] at 10am
[**Month/Year (2) **] surgeon: [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **])
[**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2156-1-21**] 9:15
Provider: [**Name10 (NameIs) 14633**],EQUIPMENT [**Name10 (NameIs) **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2156-1-21**] 9:15
Urologist follow up in 1 week for BPH at [**Hospital1 **]- Foley to be
kept in until urology follow-up
Please call to schedule appointments with your
Primary Care in [**5-5**] weeks **needs PCP**
**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:[**2155-12-20**]
ICD9 Codes: 2859, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5486
}
|
Medical Text: Admission Date: [**2144-2-9**] Discharge Date: [**2144-2-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
hypotension with positive blood cultures
Major Surgical or Invasive Procedure:
Ultrasound guided left hip fluid drainage
left PICC placement
History of Present Illness:
88 yo f with PMH of atrial fibrillation and HTN presented to the
ED on [**2144-2-9**] with failure to thrive. According to patient's
daughter, patient with increased fatigue and sleepiness x 2 days
with associated worsening mobility x 1 day. Patient's daughter
then called the geriatrics on-call attending (Dr. [**Last Name (STitle) 1603**] who
recommended that she come into the ED. Upon admission to the ED,
patient had a fever to 100.1 and was given tylenol. She was
given 1L NS as patient looked very dry. She was admitted to the
medicine service.
.
Initially, she was noted to have low grade temps, left hip pain
and leukocytosis. Given previous hip replacements, ortho was
consulted. Initial XR showed no fracture. Ortho recommended
ultrasound of hip and US guided arthrocentesis. LENIs showed no
DVT but flattening of the waveform suggsting more proximal
obstruction. US hip showed mostly solid 4 cm hematoma extending
anteriorly from the femoral prosthesis to the proximal femoral
diaphysis with no definite signs of abscess.
.
Over the next two days, she triggered on [**2-10**] for rigoring, temp
to 102, and hypertension. Her abx were broadened to include
vancomycin and zosyn. She triggered again on [**2-11**] for BP 79/48
and HR 120, and was bolused with fluids with improved BP to
90's. Initial blood cultures were negative, but repeat cultures
on [**2-10**] were noted to be growing 4/4 bottles with GPC's in pairs
and chains. She received a total of about 1.5 liters of fluid on
the floor. Given possibility of sepsis, she was transferred to
the ICU for closer monitoring and treatment despite DNR/DNI.
.
Initial BP in the MICU was 101/57and HR 100's. She has mild left
hip pain, denies chest pain, shortness of breath, other pain.
She feels generally "unwell" but is mildly disoriented as is ber
baseline by report. She is unwilling to provide further ROS.
Past Medical History:
PMH:
1. Dementia with memory loss over 20 years
2. Congestive heart failure. Last ejection fraction greater than
55% on last echocardiogram in [**2139**]
3. Atrial fibrillation on coumadin
4. Hypertension
5. History of transient ischemic attacks
6. History of PEs and DVTs 30 years ago
7. Venous stasis changes in bilateral lower extremities
8. Degenerative joint disease with bilateral total hip
replacements.
Social History:
Social Hx: Patient lives with daughters and depends upon them
for all ADLs. Patient requires transfer assistance and attends
daycare MWF. No Etoh, Tob, Drug use hx. Wears depends as
chronically incontinent
of urine and uses walker at daycare but not at home. Memory is
very poor at b/l.
Family History:
NC
Physical Exam:
HOME MEDS:
Aricept 5mg PO daily
Celebrex 100mg PO bid
Colace 100mg PO daily
MVI 1 tab PO daily
Calcium 600Vit D 125 PO bid
Coumadin 2mg PO daily
Diltiazem HCl 240mg PO daily
Lasix 80mg PO daily
Lidoderm patch [**Hospital1 **] prn pain
Lisinopril 5mg PO daily
KCl 20 PO daily
Senna 2 tab PO qhs
T3 q4h prn pain
.
MEDS ON TRANSFER:
Lidocaine 5% Patch 1 PTCH TD Q12H
Lorazepam 0.5 mg IV ONCE MR1 for MRI
Miconazole Powder 2% 1 Appl TP QID:PRN
Multivitamins 1 CAP PO DAILY
Acetaminophen 325-650 mg PO Q6H:PRN
Pantoprazole 40 mg PO Q24H
Acetaminophen w/Codeine [**12-3**] TAB PO Q6H:PRN
Phytonadione 5 mg PO ONCE
Calcium Carbonate 500 mg PO TID
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Diltiazem Extended-Release 240 mg PO DAILY
Senna 1 TAB PO BID
Docusate Sodium 100 mg PO BID
Donepezil 5 mg PO HS
Vancomycin HCl 1000 mg IV Q48H
Erythromycin 0.5% Ophth Oint 0.5 in OU QID
Vitamin D 800 UNIT PO DAILY
Pertinent Results:
[**2144-2-14**] 02:30AM BLOOD WBC-6.8 RBC-3.20* Hgb-9.2* Hct-28.0*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.8* Plt Ct-140*
[**2144-2-14**] 02:30AM BLOOD Plt Ct-140*
[**2144-2-14**] 02:30AM BLOOD PT-23.4* PTT-33.3 INR(PT)-2.3*
[**2144-2-10**] 05:45AM BLOOD Fibrino-668*
[**2144-2-10**] 05:45AM BLOOD ESR-74*
[**2144-2-14**] 02:30AM BLOOD Glucose-161* UreaN-34* Creat-1.2* Na-143
K-3.8 Cl-113* HCO3-22 AnGap-12
[**2144-2-11**] 05:45AM BLOOD ALT-19 AST-24 LD(LDH)-217 AlkPhos-57
TotBili-1.2
[**2144-2-9**] 01:50PM BLOOD CK-MB-NotDone cTropnT-0.04* proBNP-[**Numeric Identifier 7456**]*
[**2144-2-9**] 02:01PM BLOOD Lactate-2.4* K-4.2
[**2144-2-11**] 11:26AM BLOOD Lactate-2.5*
.
EKG:A fib with left anterior fasicular block but narrow QRS. No
ST elevations.
.
IMAGING:
- Hip Unilateral XR - [**2144-2-9**] - Bilateral hip prostheses with
multiple chronic abnormalities as described above. No acute
fracture or change in alignment.
- Left unilateral US - [**2144-2-9**] - No DVT in the imaged veins.
However, flattening of the left venous waveforms suggests a more
proximal obstruction and further evaluation of the proximal
vessels with CT or MR is recommended.
- [**2144-2-9**] - Portable CXR - IMPRESSION: Decrease in the size of
the chronic right-sided pleural effusion since the prior study
of [**Month (only) 547**]
- MRI read pending
- Hip ultrasound: mostly solid 4 cm hematoma extending
anteriorly from the femoral prosthesis to the proximal femoral
diaphysis with no definite signs of abscess
.
[**2-10**] MRI Pelvis: Bilateral masses with a large intrapelvic
component, larger on the right, which appear related to the
joints. Evaluation is suboptimal. These masses were present on
the prior CT examination, but appear somewhat smaller in size.
Hematoma is not considered likely due to the chronicity.
However, given the history of multiple hip replacements, the
bilaterallity, and the unusual appearance of these lesions,
foremost consideration is given to a foreign-body reaction. Less
likely would be a proliferative synovial condition such as PVNS,
or synovial chondromatosis.
.
[**2-11**] US EXTREMITY NONVASCULAR LEFT LE: Findings most consistent
with a hematoma extending anteriorly from the femoral prosthesis
to the proximal femoral diaphysis. There are no son[**Name (NI) 493**]
findings of an abscess, however, an element of superimposed
infection cannot be excluded.
.
[**2-12**]: US MULT/COMP ABSC/CYST DRAIN/I; GUIDANCE FOR ABSCESS:
Successful ultrasound-guided aspiration of left thigh hematoma.
5-6 cc of dark red fluid was sent for Gram stain and culture.
Brief Hospital Course:
88 yo f with past medical history significant for atrial
fibrillation on coumadin, hypertension, and s/p bilateral hip
replacements who presented with lethargy and found to have left
hip hematoma now transfered to the MICU for possible sepsis from
GPCs.
.
#) Sepsis: She presented with hypotension in the setting of
fevers and elevated WBC count and Group-B streptococcal
bacteremia c/w septic physiology. She was admitted to the MICU
and was originally started on Vancomycin/Pip-Tazo on [**2-11**]
however antibiotics were changed to Penicillin G when hip fluid
and blood cultures grew out Group B strep sensitive to
penicillin. She defervesced and BPs stabilized and she was
transferred out of the unit to the general medicine service.
TTE was negative for vegetations. Orthopedics was consulted who
offered possible surgical intervention for removal of her
hardware from previous total hip replacement, however patient
and her family and HCP opted against surgical intervention.
Thus, she will need continued IV antibiotics (3 million units IV
Pen G q6h) for 6-8 weeks and then will likely need oral
antibiotics following IV course. She is scheduled for follow in
the infectious disease clinic.
.
#) Left hip hematoma with secondary infection with Group B strep
and source of GBS bacteremia. Her pain was managed with
lidoderm patch, standing tylenol and prn morphine IV. She was
noted to have had on admission a significant hematocrit drop
from her baseline, but her hct remained stable not requiring
prbc transfusion. She did, however, receive 3U FFP on admission
to the ICU as her INR was supratherapeutic at that time. Her
coumadin was held, but her INR did not adequately come down so
she required PO vitamin K in order to decrease her INR. As her
hct remained stable without any signs of expanding hemotoma,
orthopedics was okay with the reinitiation of coumadin for her
a. fib, so it was restarted at her home dose.
.
#) Congestive heart failure: On admission, she had elevated BNP
and right-sided pleural effusion. However, she appeared
intravascularly dry by labs and initial exam. She was found to
be in acute renal failure on presentation thought [**1-3**] to
prerenal etiology so her diuretics were held. Echocardiogram
revealed moderate LVH with preserved LV systolic function, mild
aortic regurgitation, moderate tricuspid regurgitation, and
moderate pulmonary hypertension. Upon transfer to the floor,
however, she had persistent supplemental oxygen requirement and
crackles on pulmonary exam. As her renal function had improved,
diuresis was reinitiated and at time of discharge, she was
maintaining O2 saturation on room air. She will be discharged
on home dose lasix and lisinopril.
.
#) Acute Renal Failure: Creatinine was elevated to 1.9
intitially, with baseline 0.9-1.1. This was thought most likely
secondary to pre-renal etiology possibly secondary to septic
physiology and ATN in the setting of hypotension on
presentation. Her ACEI and lasix were held and her renal
function normalized. Her lasix was restarted and her renal
function remained stable. Her ACEI was then restarted with
renal function remaining stable at her baseline.
.
#) Atrial Fibrillation: On chronic anticoagulation as an
outpatient, however INR was 4 upon admission. Her coumadin was
held, but her INR did not adequately come down likely secondary
to dietary vitamin K deficiency so she received additional PO
vitamin K with good response of her INR. She does have
significant risk of thromboembolic event based on her CHADS
score, so hct remained stable without evidence of expanding
hematoma when cleared by orthopedics for reinitiation, she was
restarted on her home dose of coumadin. INR at time of
discharge was 1.9. Additionally, she was continued on diltiazem
for rate control.
.
#) Elevated blood sugar: Although she has no clear documented
history of diabetes mellitus and was not on any oral medications
upon admission, her blood sugar remained elevated during her
entire stay. She was placed on insulin sliding scale while
inpatient with goal for tight control in the setting of her
infection. This will need to be continued upon discharge and
further management evaluated by her primary care physician upon
follow up.
.
#) Hypertension: Although she orinally presented hypotensive,
treatment of her infection improved her blood pressure. Her
lasix and ACEI were originally held, but were restarted with
improvement in her renal function and increase in her blood
pressure.
.
#) Dementia: She was continued on Aricept 5mg PO daily.
.
#) Osteoporosis: She was continued on calcium and Vitamin D per
home regimen 600/125 PO bid.
Medications on Admission:
HOME MEDS:
Aricept 5mg PO daily
Celebrex 100mg PO bid
Colace 100mg PO daily
MVI 1 tab PO daily
Calcium 600Vit D 125 PO bid
Coumadin 2mg PO daily
Diltiazem HCl 240mg PO daily
Lasix 80mg PO daily
Lidoderm patch [**Hospital1 **] prn pain
Lisinopril 5mg PO daily
KCl 20 PO daily
Senna 2 tab PO qhs
T3 q4h prn pain
.
MEDS ON TRANSFER:
Lidocaine 5% Patch 1 PTCH TD Q12H
Lorazepam 0.5 mg IV ONCE MR1 for MRI
Miconazole Powder 2% 1 Appl TP QID:PRN
Multivitamins 1 CAP PO DAILY
Acetaminophen 325-650 mg PO Q6H:PRN
Pantoprazole 40 mg PO Q24H
Acetaminophen w/Codeine [**12-3**] TAB PO Q6H:PRN
Phytonadione 5 mg PO ONCE
Calcium Carbonate 500 mg PO TID
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Diltiazem Extended-Release 240 mg PO DAILY
Senna 1 TAB PO BID
Docusate Sodium 100 mg PO BID
Donepezil 5 mg PO HS
Vancomycin HCl 1000 mg IV Q48H
Erythromycin 0.5% Ophth Oint 0.5 in OU QID
Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): Not to exceed 4g daily.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Oxycodone 5 mg Capsule Sig: [**12-3**] Capsules PO every 4-6 hours
as needed for pain.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
16. Celebrex 100 mg Capsule Sig: One (1) Capsule PO twice a day.
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
18. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
Sig: 3,000,000 Units Intravenous Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary:
Left hip hematoma with secondary Group B strep infection
Group B strep sepsis
Congestive heart failure
Acute renal failure
Elevated blood sugar
Hypertension
Dementia
Atrial fibrillation on chronic anticoagulation
Supratherapeutic INR
Discharge Condition:
Stable, afebrile and without elevated white blood cell count,
hemodynamically stable.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
develop fevers, chills, lightheadedness, dizziness, incresed
swelling, redness, warmth of your left hip, inability to
tolerate food and fluids, worsening shortness of breath or any
other symptoms that concern you.
.
Please follow up with your appointments as below.
.
Please ensure that you continue to take your antibiotics.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 719**] on Thursday, [**2-27**] at 11:00am.
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Infectious
Disease clinic on [**3-23**] at 9:30am.
.
As you have opted against surgical intervention at this time,
you can follow up with orthopedics as needed. Dr. [**Last Name (STitle) 1005**] saw
you in the hospital and his office phone is ([**Telephone/Fax (1) 2007**].
.
Appointment scheduled prior to this admission:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2144-4-8**] 10:00
ICD9 Codes: 4280, 5849, 2875, 4019
|
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"dataset_name": "ehrcomplete-icdfiltered",
"id": 5487
}
|
Medical Text: Admission Date: [**2124-5-14**] Discharge Date: [**2124-5-17**]
Date of Birth: [**2041-11-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is an 82 year old man with hx of T3, N0, M0 colon ca
s/p transverse colectomy in [**2122**] c/b incisional hernia,
dementia, T2DM, HTN presents with fever and lethargy.
.
Pt is a resident of [**Location 10059**] Nursing Centre. He had 3 days of
cold symptoms, 2 days of constipation and was noted to have
decreased appetite and overall depressed functioning compared to
baseline. Today he had a fever to 100.8 and vomited yellowish
(nonbloody) emesis x 2 and he was referred to the ED.
.
In the ED, initial vs were: T 106.1 P 111 BP 161/82 R 18 94%O2on
RA, Patient was given 1 g Vanc, 4.5 g Zosyn, Tylenol 1g and 2
litres of NS. Ice packs were placed to cool him and he was
afebrile on arrival to the floor. He had no complaints.
.
Review of sytems:
(+) Per HPI
(-) Denies cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied diarrhea, or abdominal pain.
Past Medical History:
DM II on insulin
Colon cancer T3N0M0, dx [**8-3**] (as part of GIB w/u) s/p transverse
colon resection [**2122**]->complicated by poor wound healing (finally
closed)
Ant abdominal wound->stage II ulceration, chronic since
colectomy
Advanced Dementia, A&OX1, has guardian
incisional hernia, large, asymptomatic
GIB [**8-3**], EGD with possible diulefoy
Anemia, Fe def
CKD III baseline 1.3 (on [**3-/2124**])
chronic dCHF on lasix
Hypertension
Hearing loss
Constipation
H/o delirium
Social History:
Lives at [**Hospital 10138**] nursing home in [**Location (un) 538**]. Married but
wife has been living in [**Name (NI) 760**] for past 18 yrs, still in
contact with pt per Mr. [**Last Name (Titles) 79682**].
<br>
Guardian: [**Name (NI) **] [**Last Name (NamePattern1) 79682**] Is the power of attorney.
-[**Telephone/Fax (2) 79683**]h
-[**Telephone/Fax (2) 70408**]w
-[**Telephone/Fax (2) 79684**]c
<br>
Elder Resources: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79685**]
[**Telephone/Fax (2) 79686**]w
[**Telephone/Fax (2) 79687**]c
.
[**Hospital 10138**] nursing home
[**Telephone/Fax (1) 79688**]
Family History:
NC. None given by patient or known by power of attorney.
Physical Exam:
Vitals: T 98.7 BP 132/69 HR 86 RR 27 97%RA
General: Alert, oriented to person, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, dentures in
place
Neck: supple, JVP not elevated, no LAD
Lungs: Few scattered rhonchi, no wheezes or crackles. Otherwise
clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Large ventral hernia with clean dressing in placement.
soft, non-tender, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
on discharge
Vitals:97.1 137/75 77 18 100%RA
Pain: denies
Access: PIV
Gen: nad, calm and pleasant
HEENT: mm dry
CV: RRR, [**4-1**] SM all over
Resp: CTAB with slight basilar crackles, no wheezing
Abd; soft, obese, nontender, large ventral hernia, +BS
Ext; no edema
Neuro: A&OX1 at baseline, otw nonfocal
Skin: ant abdominal wound with stage II ulceration (present on
admission) well healing
psych: pleasant, calm
.
Pertinent Results:
WBC 5.6->4s
hgb 12->10s (after fluids)
HCT 31->28.9
Plt 160s ->225
Creat 1.6-->1.2 stable X2 days (baseline 1.3)
lactate 1.3
.
U/A [**5-14**]: >50 WBCs, +bacteria, +RBCs, <1 epis
UCx [**5-14**] >100K enterobacter cloacae, pansensitive
Blood cx X2 [**5-14**] NTD
.
.
.
.
Imaging/results:
CXR [**5-14**]: No acute process
.
CXR [**5-15**]: low lung volumes, mild pulm edema, no consolidation,
mild CM
.
Brief Hospital Course:
Briefly, Mr. [**Known lastname **] is an 82 year old man with h/o DM, colon ca
s/p transverse colectomy in [**2122**] c/b incisional hernia/poor
wound healing, advanced dementia, and HTN. He presented from his
[**Hospital1 1501**] with fever, abd distention, vomiting X2, and lethargy. Pt is
a resident of [**Location 10059**] Nursing Centre. He had 3 days of cold
symptoms, 2 days of constipation and was noted to have decreased
appetite and overall depressed functioning compared to baseline.
On [**5-14**], he had a fever to 100.8 and emesis of yellowish
nonbloody material X2 which led to transfer to ED.
In the ED, initial vs were: T 106.1 P 111 BP 161/82 R 18 94%O2on
RA, Patient was given 1 g Vanc, 4.5 g Zosyn, Tylenol 1g and 2
litres of NS. Ice packs were placed to cool him. He was admitted
to MICU for consideration of artic sun for cooling.
However, since in MICU, remained afebrile. Hemodynamically
stable. MS appears to be at his baseline. Was found to have UTI
so Abx changed to CTx. CXR was negative for PNA. Blood cx
negative. He got total 3L IVFs in ICU and ER. Given his prompt
improvement he was transfered out of MICU next day. On the floor
he continued to do well. MS appeared at baseline, occasional
sundowning but was redirectable. Abx were converted to cefpodox
for UCx showing pansensitive enterobacter, for total 10day
course. He had ARF on CKD on admission, which resolved back to
baseline 1.2 with fluids. He developed mild pulm edema after 3L
on admission, but this improved when resuming his home dose of
lasix. As for his constipation, he had several BMs here that
were well formed. There were no other issues. Discharged back to
[**Hospital1 1501**].
.
See progress note below for details of plan:
82 year old man with h/o DM, colon ca s/p transverse colectomy
in [**2122**] c/b incisional hernia/poor wound healing, advanced
dementia, chronic dCHF and HTN. He presented from his [**Hospital1 1501**] with
fever and lethargy and is found to have enterobacter UTI.
Transfered to floor after brief MICU stable. Doing well and
ready for t/f back to [**Hospital1 1501**].
.
UTI, bacterial: Temp 106 reported in ED on admission (?error,
may be was 100.6) but otherwise has been stable hemodynamically.
Mild delirium that has resolved. Recieved empiric vanc/zosyn in
ER, then CTX X3 days, will change to cefpodox on discharge per
sensitivities of Enterobacter for 7day course. Blood Cx NTD.
foley placed in ER and removed next day. Other infectious w/u
with CXR (given URI symptoms) was negative.
.
ARF on CKD III: Recent baseline is 1.3 since 3/[**2124**]. Was 1.6 on
admission. Improved to 1.2 after fluids and treatment of UTI
which was stable on discharge.
.
Bicytopenia: hct and plt all lower this admission than previous.
Unclear what hct baseline is (prior ones are during GIB and post
op). Repeat HCT here were stable around 28-29 after fluids. Plt
in past 300s, now 160s on admission for few days, likely [**2-29**]
infection. Repeat plt improved to 220s on discharge. Coags were
okay.
.
Acute Delirium in setting of advanced dementia: report of
increased lethargy on admission, which is likely due to UTI.
This resolved by next day. He appeared to be at baseline. He had
occ episodes of agitation which may be sundowning rather than
delirium. He did not need any medications.
.
Colon cancer: s/p resection. No abdominal pain. ventral hernia
stable but pt has chronic abd stage II ulceration/wound. Seen by
wound care who provided some recs which will be relayed to [**Hospital1 1501**].
.
Chronic dCHF: Did develop mild pulm edema on CXR after fluids
with some wheezing. This improved once his lasix was resumed and
he did very well, never required O2. Kept on his BB/CCB.
.
DMII: SSI. resumed glipizide. Was on SSI here but resumed his
insulin regimen on discharge. kept on statin.
.
HTN: stable on prior doses of verapamil, lopressor, lasix
.
GERD and h/o UGIB: Continued on PPI.
.
Constipation: resolved with bowel regimen. kept on this on
discharge.
.
Dispo/Code: DNR/DNI, POA is [**Name (NI) **] [**Name (NI) 79682**] [**Telephone/Fax (1) 70408**],
[**Telephone/Fax (1) 79684**]. Updated on admission/discharge. Will d/c back to
[**Hospital1 1501**] today.
.
.
Medications on Admission:
Medications:
Colace
Milk of Mag
Dulcolax
MVI
Iron 325
Lasix 20
Glipizide 5
Humalog ISS
Lantus 9 U qHS
Lipitor 10 mg
Lopressor 25 TID
Verapamil 120
Trazodone 50 qhs
Protonix 40
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: Three (3)
Tablet Extended Rel 24 hr PO DAILY (Daily): total 7.5mg.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
14. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 6 days.
15. Lantus 100 unit/mL Cartridge Sig: 12U Subcutaneous at
bedtime.
16. Lantus 100 unit/mL Cartridge Sig: see below Subcutaneous
three times a day: 7 U before breakfast, 3U before lunch and
dinner. also continue sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 10140**] Nursing Center - [**Location (un) 10059**]
Discharge Diagnosis:
UTI, enterobacter
mild acute dCHF
ARF on CKD resolved
hypoactive delirium resolved
abd chronic wound
Discharge Condition:
Mental Status: Confused - sometimes-->baseline dementia and
A&OX1.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for fever, lethargy, and found to have UTI.
You will complete Abx course as prescribed.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 4154**] in a couple weeks. The [**Hospital1 1501**] will
call for an appointment
ICD9 Codes: 5990, 5849, 2930, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5488
}
|
Medical Text: Admission Date: [**2200-8-25**] Discharge Date: [**2200-8-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
Abdominal distension and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year old Cantonese-only speaking female with past medical
history significant for dementia, psychosis, and hypertension
who presents with pseudoobstruction. Per her son, her appetite
has been extremely poor and has had to try and force things down
in order to maintain proper nutrition. He has also noticed that
her belly has gotten bigger over the past few days and has not
been able to fit into her usual diapers or pants. Last BM [**2-24**]
days ago prior to admission. Son also reports of low grade
fevers ~100 over the past few days.
.
In the ED her initial vitals were T 99.9 BP 188/97 AR 124 RR 16
O2 sat 95% RA. BPs as high as 243/117. Received 2L NS. She
received Hydralazine 10mg IV x2, Ativan 1mg IV, Ceftriaxone 1gm
IV, and Flagyl 500mg IV x1.
.
This is a [**Age over 90 **] year old Cantonese speaking female with history of
dementia with psychosis, depression, and HTN who presented to
the ED 2 days ago with pseudoobstruction of the large bowel.
According to her son, he began to note increasing abdominal
distention 3 days ago in the setting of no BMs for 3-5 days. She
was also having difficulty fitting into her usual pants and
diapers and was having low grade fevers to 100F along with a dry
cough, for which he gave her pseudoephedrine and codeine. On the
day of admission, he noticed a rash along her R groin which had
not been there previously. The pt was also complaining of slight
headache and dizziness.
.
In the ED her initial vitals were T 99.9 BP 188/97 AR 124 RR 16
O2 sat 95% RA. BPs as high as 243/117. Received 2L NS. She
received Hydralazine 10mg IV x2, Ativan 1mg IV, Ceftriaxone 1gm
IV, and Flagyl 500mg IV x1. A KUB was significant for dilated
loops of large bowel c/w ileus and CT abd/pelvis showed
pseudoobstruction without any definitive transition point. She
was admitted to the MICU given hypertensive urgency and
pseudoobstruction. Her BPs were controlled with metoprolol 10 mg
IV tid and hydralazine 10 mg IV q6h for SBP > 150. Dermatology
was consulted for the R groin rash and thought this was most
consistent with zoster, for which she was started on valcyte. GI
was also consulted for pseudoobstruction who recommended
conservative mgmt for now with serial KUBs. The pt is now being
transferred to the floor for further care.
Past Medical History:
)Dementia with psychosis
2)Hearing loss
3)Depression
4)Hypertension
5)Osteoarthritis
6)Cholelithiasis s/p cholecystectomy and hepatojejunostomy in
[**2190**]
7)Constipation
8)Hypercholesteremia
9)s/p subdural hematoma and seizures
10)Urinary incontinence
Social History:
Lives with son, who is her primary caretaker. [**Name (NI) **] current
tobacco, alcohol, or intravenous drug use.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
vitals T 97.7 BP 179/74 AR 115 RR 21 O2 sat 94% RA
Gen: Patient difficult to arouse, responsive to tactile stimuli
HEENT:Unable to visualize oral cavity
Heart: Sinus tachycardia, no audible m,r,g
Lungs:CTAB, no crackles
Abdomen: firm, distended, decreased bowel sounds
Extremities: No edema, 2+ DP/PT pulses bilaterally
Skin: Erythematous rash along right groin into vaginal area with
evidence of blisters/vesicles
Rectal: Guaiac negative in ED
Pertinent Results:
CHEST (PA & LAT)
Reason: eval acute process, free air.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with cough, low grade temps, abd distension
REASON FOR THIS EXAMINATION:
eval acute process, free air.
INDICATION: [**Age over 90 **]-year-old woman with cough, low-grade temperature,
abdominal distention.
PA AND LATERAL CHEST RADIOGRAPH: Comparison was made with the
prior chest radiograph dated [**2199-5-27**]. The heart is top normal
in size allowing the technique. Again note is made of markedly
elongated and tortuous aorta. Lung volumes are low, probably due
to low inspiratory level. There is faint opacity at the lung
bases, probably representing atelectasis. No evidence of CHF or
other consolidation is noted. Degenerative changes of
thoracolumbar spine is noted. No evidence of free air below the
diaphragm. The lateral view is limited due to overlying soft
tissue.
IMPRESSION: Somewhat limited study. Probable bibasilar
atelectasis. Tortuous aorta.
CT PELVIS W/CONTRAST [**2200-8-25**] 1:59 AM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: eval obstruction.
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with distension, no BM, h/o surgeries,
dementia
REASON FOR THIS EXAMINATION:
eval obstruction.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: [**Age over 90 **]-year-old woman with distension, no bowel
movement, history of surgeries and dementia.
TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis
were obtained with administration of intravenous contrast [**Doctor Last Name 360**].
Multiplanar reformation images are reconstructed.
There is no prior CT study for comparison. Ultrasound dated
[**2195-3-30**] was referred.
FINDINGS: The evaluation of the bowel loops is limited due to
poor oral prep, in this patient who did not tolerate enough oral
contrast. The patient is status post cholecystectomy and
hepaticojejunostomy, with extensive intrahepatic ductal
dilatation with pneumobilia, probably due to surgery. The
intrahepatic duct in the right lobe measures up to 1 cm, and the
left lobe measures up to 1.4 cm. CBD is also dilated, measuring
up to 1.5 cm. There is no focal liver lesion identified on this
single-phase study. Spleen is unremarkable. In the body of the
pancreas, there is 7 mm hypodense lesion, which appears to be
connected from the main pancreatic duct. The rest of the
pancreas enhances homogeneously and is unremarkable. Adrenal
glands and kidneys are unremarkable without evidence of
hydronephrosis. Again note is made of diffusely distended large
bowel with feces material in the ascending colon. There is
focally dilated loop of small bowel in the right upper quadrant
measuring up to 5.1 cm, however, there is no definitive
transition point. The oral contrast is present both proximal and
distal to this dilated loop of small bowel. There is no ascites
or significant lymphadenopathy.
PELVIS: Rectum is dilated with air-fluid level. Feces material
is seen in distal ileum, however, no definitive transition point
is noted.
In the visualized portion of the lung bases, there is
peribronchial thickening with basilar atelectasis. There are
cystic changes at the right lung base, of uncertain clinical
significance. There is dilated esophagus filled with contrast.
There is compression fracture of L1 vertebral body. There are
degenerative changes of the thoracolumbar spine.
IMPRESSION:
1. Status post hepaticojejunostomy and cholecystectomy, with
marked intrahepatic and extrahepatic ductal dilatation with
pneumobilia.
2. Diffusely distended large bowel loops and focally dilated
proximal small bowel loop as described above, without transition
point. Feces material in the ascending colon, as well as in
distal ileum, however, again there is no transition point.
3. Peribronchial thickening with atelectasis at the lung bases.
Dilated esophagus. Nonspecific cystic changes of the lung.
4. Compression fracture of L1, chronicity uncertain.
5. 7 mm hypodense lesion in the pancreas. Differential diagnosis
include cyst or segmental IPMT. Evaluation is limited on this
single phase study.
The wet read was provided to ED dashboard.
ABDOMEN (SUPINE & ERECT)
Reason: eval stool, volvulus.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with distension, constipation
REASON FOR THIS EXAMINATION:
eval stool, volvulus.
INDICATION: [**Age over 90 **]-year-old woman with distention and constipation.
SUPINE AND UPRIGHT ABDOMINAL RADIOGRAPH: Comparison was made
with the prior abdominal radiograph dated [**2198-1-14**].
Diffusely distended bowel gas is seen throughout the abdomen,
involving both large and small bowel, however, the gas is seen
down to the rectum. No evidence of free air is identified on
this radiograph. Residual stool in the ascending colon.
Degenerative changes of thoracolumbar spine is again noted.
Bibasilar opacities are again noted, probably representing
atelectasis.
IMPRESSION: Diffusely distended bowel gas with rectal gas
present, probably representing ileus, however, clinical
correlation is recommended.
[**2200-8-24**] 10:30PM PT-11.9 PTT-28.6 INR(PT)-1.0
[**2200-8-24**] 10:30PM PLT COUNT-331#
[**2200-8-24**] 10:30PM NEUTS-78.8* LYMPHS-13.9* MONOS-6.2 EOS-0.3
BASOS-0.7
[**2200-8-24**] 10:30PM WBC-10.0# RBC-4.41 HGB-12.9 HCT-40.1 MCV-91
MCH-29.4 MCHC-32.3 RDW-15.2
[**2200-8-24**] 10:30PM ALBUMIN-3.8 CALCIUM-9.6 PHOSPHATE-3.7
MAGNESIUM-2.4
[**2200-8-24**] 10:30PM ALT(SGPT)-43* AST(SGOT)-43* ALK PHOS-116
AMYLASE-62 TOT BILI-0.3
[**2200-8-24**] 10:30PM estGFR-Using this
[**2200-8-24**] 10:30PM GLUCOSE-155* UREA N-29* CREAT-0.7 SODIUM-145
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-26 ANION GAP-16
[**2200-8-24**] 10:42PM LACTATE-1.3
[**2200-8-25**] 09:48AM TSH-0.86
[**2200-8-25**] 11:45AM PLT COUNT-303
[**2200-8-25**] 11:45AM WBC-12.2* RBC-4.22 HGB-12.2 HCT-37.4 MCV-89
MCH-28.9 MCHC-32.6 RDW-15.0
[**2200-8-25**] 11:45AM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-2.1
[**2200-8-25**] 11:45AM GLUCOSE-149* UREA N-20 CREAT-0.6 SODIUM-143
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] year old female with past medical history as
listed above who presents with increasing abdominal distention,
found to have pseudo-obstruction on CT scan.
.
1)Pseudoobstruction: Patient presented with worsening nausea,
abdominal distention, and no bowel movements over past few days.
A CT scan did not show any inflammation, ischemia, or evidence
of significant adhesions. She has a history of abdominal surgery
but in [**2190**], and no recent procedures. Her abdominal exam
remained benign, and she has no history of inflammatory bowel
disease. It was thought that her zoster was likely to be playing
a role in delaying her gut motility.
- Patient was initially kept NPO, and [**First Name8 (NamePattern2) **] [**Last Name (un) **]-gastric tube was
placed for decompression. After she had a bowel movement and her
abdomen was much less distended, she was started on clears and
her diet was advanced as tolerated.
- GI and surgery were consulted and recommend a rectal tube
which was placed to help with decompression. Serial x-rays of
her abdomen were followed to assess the amount of dilation of
her bowel, which showed some improvement over time.
- At the time of discharge, her abdominal exam had returned to
baseline--it was soft, non-tender, and not distended. She was
tolerating her diet and passing flatus without any problems or
pain. An aggressive bowel regimen was continued.
.
2) Hypertension: Patient presented with systolic [**Last Name (un) **] pressures
as high has 230's in the ED. Per son, her [**Name2 (NI) **] pressure and
heart rate are elevated in the setting of psychosis, and she had
received pseudoephedrine at home for a cold. In the ED, she
received Hydralazine with little effect. Per OMR, her BP has
been well controlled as an outpatient, and per family and OMR,
she was not on any medications at home.
- She was initially kept on intravenous agents, then
transitioned to Metoprolol 12.5 mg TID, with goal systolic
[**Name2 (NI) **] pressure 120-140s, to avoid risk of hypotension.
.
3)Right sided groin rash: Patient found to have erythematous
rash with blister like lesions on right groin. Per son, this is
new for her. Dermatology was consulted and testing revealed that
the rash was consistent with zoster, DFR was negative for HSV 1
and 2, while direct antigen test was VZV positive. The rash was
confined primarily to the L2 dermatome on the right side, and
improved daily, with crusting and less erythema of the lesions.
- Patient was initially treated with intravenous Acyclovir since
she was being kept NPO, then trasitioned to valacyclovir per
dermatology recommendations.
- Patient denied any pain from the rash.
.
4) Dementia with psychosis: Patient has longstanding history of
severe psychosis which is triggered by insomnia. She is followed
closely by geriatrics and also has an upcoming appointment in
psychiatry. Aside from her urinary frequency which led to the
patient frequently trying to get out of bed unassisted, she had
little symptoms during this stay. A 1:1 sitter was kept for
patient when needed.
- Once patient was able to take oral medications, we continued
her outpatient regimen of Risperidone, Ativan, and Trazadone.
.
5) Urinary frequency: Patient denied any dysuria, but it was
noted that she was having to urinate frequently, about once an
hour, and a bladder scan revealed large amounts of urine in the
bladder. An urinalysis was sent off which was not very
impressive for urinary tract infection (moderate LE, [**2-24**] WBC),
however urine culture grew pseudomonas and gram positive
bacteria 10-100 thousand colonies, which was thought to be a
contaminant since foley was in place. Patient may also have had
a component of neurogenic bladder secondary to zoster
involvement. Per family, has never had any difficulties with
retention. Patient was not taking any medications that would
cause retention either.
- Several voiding trials were given to patient with foley
removed, however she had the urge to urinate, but would only
pass small amounts with large amount of urine (700-800cc)
remaining in bladder. Due to difficulty placing foley catheter
by nursing and medical team, urology was consulted to [**Month/Day (1) **]
with placement. It was decided that due to the patient's
retention on several occasions, she would leave with foley in
place and, as her zoster was treated, follow up with urology for
another voiding trial and removal of foley.
- Follow up urology appointment was made for week after
discharge.
.
6) Code status: Patient was DNR/DNI during this hospitalization
per discussions with patient and son.
.
Medications on Admission:
Actigall 300mg PO BID
Amoxacillin prior to dental procedures
Aspirin 81mg PO daily
Glucosamine-Chondroitin
Ativan 0.5mg PO daily PRN
Risperdal 0.25mg PO daily
Trazodone 25mg PO QHS
Vitamin D
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): For [**Month/Day (1) **] pressure.
Disp:*30 Tablet(s)* Refills:*2*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for PRN.
4. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): To prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): To prevent constipation.
Disp:*60 Tablet(s)* Refills:*2*
8. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO daily ()
for 5 days: For zoster (shingles) rash.
Disp:*10 Tablet(s)* Refills:*0*
9. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Continue taking Amoxicillin prior to dental procedures.
Continue glucosamine-chondroitin and Vitamin D as you were prior
to admission.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
- Pseudo-obstruction
Secondary Diagnoses:
- Urinary Retention
- Zoster
- HTN
- Diabetes
- Dementia with psychosis
- Depression
- Hearing loss
- Cholelithiasis
- Urinary incontinence
Discharge Condition:
Stable.
Vital Signs:
Temperature 98.1
Heart Rate 92
Respiratory rate 16, Saturating 95% on room air.
Discharge Instructions:
You were admitted due to concern for an obstruction in your
intestines and for very elevated [**Hospital **] pressure. A number of
tests were completed and no clear cause for your abdominal pain
and distention was found, although it was likely it was due to
pain medications and zoster activation (shingles rash). You
should continue to eat as tolerated.
.
While hospitalized, your [**Hospital **] pressure was very high. A
medication called metoprolol was added to help control this. You
should continue taking this medication unless directed by Dr.
[**Last Name (STitle) 713**].
.
It was also discovered that you had a rash in your groin that
was found to be zoster (shingles). Others should avoid
contacting this rash until it resolves further. You should take
the medication valacyclovir for another 5 days to help clear the
rash. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with caring for your rash and
dressings.
.
During your stay, you developed difficulty urinating and urine
retention. A foley catheter was placed to help with these
symptoms. You will need to follow up with urology within one
week for further care of the foley and urinary retention. A
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with the care of your foley.
.
Please return to your primary care doctor or the Emergency Room
if you experience any abdominal pain, chest pain, headache,
visual changes, shortness of breath, difficulty urinating,
worsening abdominal distention, fever, chills, worsening rash,
or other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 713**],
within one week. The number for the office is ([**Telephone/Fax (1) 6846**].
.
You will also need to follow up with urology for further care of
your Foley catheter and urinary retention. Please follow up
within one week as well. The number for urology clinic is ([**Telephone/Fax (1) 18591**].
.
Your son will be called tomorrow morning after we try to set up
these appointments for you.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
ICD9 Codes: 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5489
}
|
Medical Text: Admission Date: [**2134-6-1**] Discharge Date: [**2134-6-5**]
Date of Birth: [**2068-3-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Azithromycin / Dextromethorphan / Doxycycline / Keflex / Xanax
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
presents for stent placement for tracheobronchomalacia
Major Surgical or Invasive Procedure:
[**2134-6-1**] Rigid bronchoscopy, flexible bronchoscopy, Y silicone
stent placement (#16 with a tracheal limb of 6.5 cm, a left
mainstem limb of 2.5 cm and a right mainstem limb of 1.1 cm.)
History of Present Illness:
66 year old female with hx of tracheobronchomalacia s/p Y stent
in [**6-2**], complicated by granulation tissue in right and left
mainstem bronchi s/p stent removal in [**12-3**]. After initial
stent placement reported improvement in respiratory symptoms.
Unfortunately developed granulation tissue at the distal end of
the silicone stent requiering removal. Since removal, reports
increase in dyspnea and recurrent respiratory infections. She
reports a weight gain of about 37lbs over 4 months. She is
admitted to [**Hospital1 18**] on [**2134-6-1**] for a flexible +/- rigid
bronchoscopy with possible re-stenting.
Past Medical History:
tracheobronchomalacia s/p Silicone Y stent in [**6-2**], removed in
[**12-3**]
COPD-oxygen and steroid dependent
Diabetes mellitus type 2 on insulin with diabetic neuropathy
Seizue disorder
Posttraumatic stress disorder since she had a fire accident in
her house
Hypercoagulable state with deep venous thrombosis and pulmonary
emoblism for which she is on chronic coumadin
Hypercholesterolemia
GERD
Essential Tremor
Thyroid nodules biopsy [**2132**] showed colloid
Anxiety
Chronic (stable) Diastolic Dysfunction
Social History:
Married, lives with husband.
[**Name (NI) 1139**]: 100 pack year, discontinued in [**10-3**]
ETOH none, denies any exposure history
Family History:
Mother had diabetes and lung cancer. Father had emphysema. She
has a brother with a heart condition, another brother with [**Name2 (NI) 499**]
cancer, and a sister with diabetes. She had three children who
died in an accidental fire in [**2100**].
Physical Exam:
99.0 84 130/64 24 100%3L NC
NAD
RRR
rales b/l
soft NT/ND
Pertinent Results:
Admission labs:
[**2134-6-1**] 10:32PM BLOOD WBC-26.5*# RBC-4.28 Hgb-11.8* Hct-36.2
MCV-85 MCH-27.6 MCHC-32.7 RDW-15.3 Plt Ct-466*#
[**2134-6-2**] 04:40AM BLOOD PT-12.9 PTT-26.5 INR(PT)-1.1
[**2134-6-1**] 10:32PM BLOOD Glucose-150* UreaN-22* Creat-0.8 Na-142
K-3.8 Cl-100 HCO3-27 AnGap-19
[**2134-6-1**] 10:32PM BLOOD Calcium-9.5 Phos-3.7 Mg-1.6
At discharge:
[**2134-6-5**] 06:40AM BLOOD WBC-14.8* RBC-3.68* Hgb-10.1* Hct-31.5*
MCV-86 MCH-27.5 MCHC-32.2 RDW-15.5 Plt Ct-366
[**2134-6-5**] 06:40AM BLOOD PT-14.4* INR(PT)-1.3*
[**2134-6-5**] 06:40AM BLOOD UreaN-35* Creat-1.0 K-3.6
[**2134-6-4**] 07:30AM BLOOD Calcium-9.5 Phos-2.8 Mg-2.3
Imaging:
[**2134-6-1**] CXR: There may be some atelectasis in the right lower
lobe, but lung volumes are generally normal, and the portions of
the lungs are not obscured by cardiac silhouette, appear clear.
There is no pleural effusion. Heart is borderline enlarged,
exaggerated by mediastinal fat. Lordotic positioning exaggerates
caliber of the upper mediastinum, which the CT scan showed is
infiltrative with fat.
[**2134-6-2**] CXR: Nonphysiologic straightening of the walls of the
lower trachea and main bronchi are the only indication of the
tracheobronchial Y-stent, which is barely radiopaque. New
heterogeneous opacification in the right lower lobe is
consistent with substantial aspiration or developing pneumonia.
The lungs are otherwise clear. Heart size top normal. There is
no pleural effusion or evidence of central adenopathy. ET tube
and nasogastric tube are in standard placements. No pneumothorax
Microbiology:
[**2134-6-2**] 4:56 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2134-6-4**]**
GRAM STAIN (Final [**2134-6-2**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2134-6-4**]):
RARE GROWTH OROPHARYNGEAL FLORA ABSENT.
MORAXELLA CATARRHALIS. HEAVY GROWTH.
Brief Hospital Course:
Mrs. [**Known lastname 431**] was admitted to the interventional
pulmonology/thoracic surgery service following a Rigid
bronchoscopy, flexible bronchoscopy, Y silicone stent placement
(#16 with a tracheal limb of 6.5 cm, left mainstem limb of 2.5
cm and a right mainstem limb of 1.1 cm.) on [**2134-6-1**]. Post-
procedure she was doing well, althought 8 hrs after developed
acute respiratory distress, failed NIV and required endotracheal
intubation. She also had low urine output, which she received
2-250cc LR boluses and Lasix. She was transferred to the
surgical ICU for close monitoring and care. On POD 1 ([**6-2**]) she
underwent a bedside flexible bronchoscopy with clearing of a
mucous plug. A chest xray showed likely pneumonia and she was
started on vancomycin and levaquin. She was able to be
extubated and was continued on BIPAP for respiratory support.
ON POD 2 ([**6-3**]) she was tolerating 02 by nasal cannula and she
was started on a diet and transferred to the floor. The
vancomycin was d/c'd and she was continued on Levaquin. She was
also started on Prednisone 60mg to be tapered over 2 weeks. She
was continued on advair, mucinex, albuterol/mucomyst nebs,
spiriva and nebulized saline with chest PT. She continued to do
well on the floor and was seen by physical therapy who
recommended outpatient pulmonary rehab. Her prednisone was
slowly tapered and she was given a prescription for a continued
taper at d/c. She was ambulating well, voiding normally and
tolerating a regular diet. She was restarted on Lovenox on [**6-3**]
and given a 5mg dose of Coumadin on [**6-4**]. Her INR at discharge
was 1.3. She will have an INR drawn Monday and follow up with
her previous coumadin clinic for dosing. She will continue
Lovenox until her INR>2.0. She was stable for discharge home
on [**2134-6-5**]. She will continue on her home 02. She will
continue on levaquin for a total of 8 days and was given a
prescription and contact information for pulmonary rehab. She
will follow up with Dr. [**Last Name (STitle) **] in [**2-28**] weeks.
Medications on Admission:
albuterol, lipitor 20', benzonatate 200"', sinemet 25/100",
klonopin 0.5', cardizem 240', lovenox 80" (in lieu of coumadin
5'), tricor 48', [**Doctor First Name 130**] 180', flovent 220", vicodin, atrovent,
isosorbide mono 30', metolazone 2.5' (off lasix 80'),
mirtazapine 15', singulair 10', prilosec 20', KCL, prednisone
10', zoloft 100', theophylline 200", spiriva 1', fe 325',
guaifenesin 600", NPH 35am 9pm + SS
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Klor-Con M20 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One
(1) Tab Sust.Rel. Particle/Crystal PO once a day.
7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Mucinex 600 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO twice a day.
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Until INR 2.0 or greater then stop.
Disp:*12 80mg/0.8ml* Refills:*2*
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed to Maintain INR 2.0-3.0.
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
12. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
twice a day.
13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
15. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a
day.
16. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
17. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Prednisone 5 mg Tablet Sig: take as directed Tablet PO once
a day: Taper start Sunday [**6-6**]: take 50mg x 1 days, 45mg x 3
days, 40mg x 3 days & 35mg x 3days, 30mg x 3 days, 25 mg x
3days, 20 mg x 3 days, 15 mg x 3days, then continue 10 mg
maintenance dose daily.
Disp:*120 Tablet(s)* Refills:*0*
20. Xopenex 1.25 mg/0.5 mL Solution for Nebulization Sig: One
(1) Inhalation three times a day.
21. Theophylline 200 mg Capsule, Sust. Release 12 hr Sig: One
(1) Capsule, Sust. Release 12 hr PO twice a day.
22. Tessalon Perle 100 mg Capsule Sig: Two (2) Capsule PO three
times a day.
23. Serevent Diskus 50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
24. Novolin N 100 unit/mL Suspension Sig: as directed
Subcutaneous twice a day.
25. Keppra 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
26. Hydrocodone-Acetaminophen 5-500 mg Capsule Sig: [**1-27**] Capsules
PO three times a day as needed for pain.
27. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
28. Mucomyst
20% solution {800/4ml} and mix with Xopenex 1.25/0.5 mg/ml
nebs q6hrs
29. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
30. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
31. nebulizer
continue saline nebulizer treatment every 6 hours
32. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day as needed for pain: apply for
12 hours on, 12 hours off.
Disp:*14 patches* Refills:*0*
33. Outpatient Physical Therapy
outpatient pulmonary rehab:
Eval and treat
dx: tracheobronchomalacia, COPD with home O2 use
Discharge Disposition:
Home
Discharge Diagnosis:
TBM s/p Y-stent placement [**2134-6-1**]
Complicated by mucus plug and post operative respiratory
distress requiring intubation for 8hrs
COPD (steroid dependent, home O2),
DM2, seizure disorder, PTSD, PE on Coumadin,
hypercholesterolemia, GERD, essential tremor, thyroid nodule,
anxiety, depression, and diastolic CHF, hypertension
Discharge Condition:
stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 10084**] if experience: fever > 101 or
chills, cough, increased shortness of breath, sputum production,
chest pain.
Prednisone taper: 50mg for 1 days, 45mg x 3 day, 40mg, 3 days &
35mg x 3days, 30mg x 3 days, 25 mg x 3days, 20 mg x 3 days, 15
mg x 3days, then continue 10 mg maintenance dose daily
Lovenox 80 mg twice daily: until INR 2.0 or greater then stop
take Coumadin 5mg on Saturday, coumadin 2.5 mg Sunday: Blood
draw on Monday for INR check and follow-up with [**Hospital 8117**] [**Hospital 197**]
Clinic as previous to manage your coumadin dose.
Continue the Levaquin antibiotic for 6 more days.
You have a prescription order for outpatient pulmonary rehab.
Please call one of the facilities on the list you were given to
schedule an appointment.
Followup Instructions:
Call Dr.[**Name (NI) 5070**] office on Monday for a 2 week follow-up
appointment [**Telephone/Fax (1) 10084**]
You have a prescription order for outpatient pulmonary rehab.
Please call one of the facilities on the list you were given to
schedule an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
ICD9 Codes: 486, 4280, 3572, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5490
}
|
Medical Text: Admission Date: [**2138-9-4**] Discharge Date: [**2138-9-6**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 86-year-old woman history of [**First Name3 (LF) 499**] cancer s/p
resection who presented to her primary care physician [**Last Name (NamePattern4) **] [**9-4**]
with a 1-week history of feeling fatigued and increased
abdominal distension. Per the office note, patient has felt
"miserable" with extreme fatigue and weakness for one week. She
has also had dry cough with occasional left-sided chest pain
occurring with cough. She endorsed anorexia and minimal urine
output. She has not had nausea or vomiting, but she has had a
few episodes of diarrhea with no significant bleeding. She was
referred to the ED from her primary care physician's office.
.
In the ED, her initial vitals were significant for hypotension
(SBP 90s-100) despite 1.5 liters intravenous fluid. Heart rate
was 82 on initial vitals, and patient was mentating fine. She
was guiaic negative on exam. Her blood work showed acute kidney
injury with a creatinine of 1.7 from baseline 1.0. Slight bump
in AST/ALT. Tn neg. ECG unchanged from prior. CT [**Last Name (un) 103**]/pelvis
with contrast showed numerous enlarged lymph nodes and renal
hypodensities. As she remained persistently hypotensive after
volume rescuscitation in the ED, she was admitted to the
intensive care unit. At time of admission, she had received 3L
IVF, with SBPs ranging 90-100 and very low urine output. Access
included peripheral IV x1 in right arm.
As per HPI. Also reports drenching sweats upon awakening for the
past one year. Denies significant weight loss.
Past Medical History:
--OSTEOPOROSIS: only intermittently on Actonel b/c of GERD
--HYPERLIPIDEMIA
--HYPOTHYROIDISM
--[**Last Name (un) **] CANCER s/p left colonic resection for [**Location (un) **] B tumor, in
[**State 2748**]; last surveillance colonoscopy done in [**2136**], notable
for ascending and sigmoid diverticulosis
--CLAUSTROPHOBIA
--CATARACTS
--HYPERTENSION
--URINARY INCONTINENCE
--GASTROESOPHAGEAL REFLUX
--HEARING LOSS
Social History:
Lives at home with husband. [**Name (NI) 55343**]. Occasional social etoh,
denies tobacco or illicits.
Family History:
Both parents died of strokes. Sister had [**Name2 (NI) 499**] cancer, followed
by "cancer of the forehead," presumed to be skin cancer.
Physical Exam:
VS: Temp:98.9 BP: 131/73 HR: 76 RR: 20 O2sat: 98%RA
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. Thyroid not tender to
palpation
RESP: mild crackles right base, good air movement throughout, no
wheezes
CV: RRR, normal S1 and S2, no m/r/g
ABD: Soft, distended, non-tender. No rebound tenderness or
guarding. Well-healed transverse surgical scar over mid-abdomen.
EXT: no c/c/e
SKIN: lightly erythematous reticular rash over chest, abdomen,
legs. No secondary excoriations. No jaundice.
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
Admission EKG: Sinus rhythm at 75 bpm. Mild left axis
deviation, possibly physiologic. No ischemic ST-T wave changes.
CT Abdomen/ Pelvis [**2138-9-4**]:
IMPRESSION: Numerous enlarged retroperitoneal, intra-abdominal
and mesenteric lymph nodes, as well as prominent spleen.
Lymphoma is the most likely diagnosis. Generalized
lymphadenopthy from a coincident nonneoplastic systemic illness
may be considered, but felt less likely. Reactive nodes to an
infection is felt less likely by distribution and severity.
Please clinically correlate.
Chest Radiograph [**2138-9-4**]:
IMPRESSION: No acute intrathoracic abnormality.
Brief Hospital Course:
in summary an 86-year-old woman with remote history of [**Year (4 digits) 499**]
cancer s/p resection, hypertension, and hyperlipidemia presents
from primary care office with one week of increasing abdominal
distension, anorexia, fatigue and poor urine output, admitted to
the ICU for further work-up of hypotension and acute kidney
injury.
.
#. Hypotension: Pt vaguely described intermittent anorexia and
mild nausea over the last week, concerning for volume depletion.
No clear signs of infection, though perhaps symptoms of fatigue,
malaise, anorexia, and drenching sweats point to systemic
process. Not on recent steroid therapy, making adrenal
insufficiency less likely. Responded well to volume
resuscitation, with no need for vasopressors.
Home anti-hypertensives (amlodipine, HCTZ, lisinopril, and
metoprolol) were held; metoprolol only restarted at discharge.
.
#. Acute kidney injury (Cr 1.7): likely perfusion-related kidney
injury in the setting of poor po intake. UA negative, though
specific gravity of 1.030 suggests volume depletion. FeNa 0.8%,
FeUrea 30.6%, consistent with pre-renal state. At discharge her
creatinine was 1.0.
.
#. Enlarged abdominal lymph nodes, splenomegaly,
thrombocytopenia and atypical lymphocytosis: In setting of one
year of drenching night sweats, this is concerning for
lymphoproliferative disorder vs hematologic malignancy. LDH
elevated to 373. Alterantively could be viral infection; EBV
less likely given patient's advanced age. Flow and peripheral
smear sent for review. Pt will follow up with general surgery
on Monday for evaluation for LN biopsy. Will also be given
appointment with heme-onc in the next 1-2 weeks.
.
# Transaminitis: Elevated ALT/AST from prior. Denies significant
etoh intake. [**Month (only) 116**] represent viral infection (viral hepatitis vs
systemic viral infection). No referable symptoms to right upper
quadrant. Statin and fenofibrate held during hospitalization;
statin only restarted at discharge.
.
# History of hypertension: antihypertensives held in the
setting of low blood pressure, BP was stable throughout her
stay.
.
# Hypothyroidism: no active issues, home levothyroxine
continued.
.
# Hyperlipidemia: patient with elevated transaminases; statin
and fibrate held as above
Medications on Admission:
--Amlodipine 2.5 mg once daily
--Atorvastatin 40 mg once daily
--Fenofibrate 145 mg once daily
--Hydrochlorothiazide 25 mg once daily
--Levothyroxine 125 mcg once daily
--Lisinopril 40 mg once daily
--Metoprolol succinate 75 mg once daily
--Potassium chloride 10 mEq once daily
--Aspirin 81 mg once daily
--Multivitamin once daily
--calcium dose unclear
--[**Name2 (NI) 42298**]-3 fatty acids dose unclear
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Hypotension
Acute Renal Failure
Pelvic and Retroperitoneal Lymphadenopathy
Secondary Diagnoses:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the intensive care unit due to low blood
pressure and abnormal kidney function. You were given fluids
with improvement in both your blood pressure and kidney
function. Some of your blood pressure medications may have built
up and contributed to your low blood pressure. Your liver tests
also showed some mild inflammation in your liver. As a result,
some changes have been made to your medications until you follow
up with Dr [**Last Name (STitle) 131**] and Dr [**Last Name (STitle) **].
1. STOP fenofibrate.
2. STOP amlodipine.
3. STOP hydrochlorothiazide.
4. STOP lisinopril.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) 519**], one of the general surgeons,
to arrange a lymph node biopsy. You should see him in clinic
this Monday [**9-8**]; please call [**Telephone/Fax (1) 6554**] to make an
appointment.
Someone from the oncology office will call you early this week
to set up a follow up appointment with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **].
Department: RADIOLOGY
When: FRIDAY [**2139-6-26**] at 1 PM
With: RADIOLOGY [**Telephone/Fax (1) 1125**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2138-9-8**]
ICD9 Codes: 5849, 4589, 2875, 2449, 4240, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5491
}
|
Medical Text: Admission Date: [**2115-2-4**] Discharge Date: [**2115-2-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC: dyspnea
.
HPI: 86yo man with h/o CVA, CHF, recent episodes of aspiration
pneumonia, who p/w dyspnea from his NH. Per the pt's daughter,
the patient has had 2-3 episodes of asp pna in the last 2
months, for which he has received IV abx at the NH with apparent
resolution of symptoms. The daughter says that on the day PTA,
when she visited the patient at the NH, he was "having a good
day," more interactive than usual and in good spirits. She was
called at 430am today from the NH with the news that the pt was
not doing well, and she came to the ED to meet up with her
father.
.
Of note, the patient's daughter and son-in-law confirm his
desire to be DNR/DNI, stating that they want him to be
comfortable. However, when asked if she thinks he would want
comfort measures even if it meant that his respiratory status
would worsen, the pt's daughter says that he would not. In
particular, she feels that the pt would not want a morphine drip
if it would negatively impact his respiratory function.
ROS: patient unable to communicate at current time
Past Medical History:
PMH:
-DM2, with mild background diabetic retinopathy
-CVA x 2, [**2079**] and [**2105**]
-HTN
-CAD
-CHF, LVEF unknown
-PVD, s/p femoral-popliteal bypass
-renal cell ca, s/p left nephrectomy [**2101**]
-BPH
-dementia, since [**2101**], baseline MMSE 21/29
-s/p fall with right hip fx and ORIF
-moderate R sided macular degeneration
-Depression
-s/p right inguinal hernia repair
Social History:
Social hx: came to the States 10 yrs ago with his wife. [**Name (NI) **] a
daughter who lives in [**Name (NI) 1439**]. Used to work as an engineer at an
automobile plant. World War II veteran. Currently living at
[**Hospital 100**] Rehab. Russian-speaking only.
Family History:
noncontributory
Physical Exam:
Vitals: T 102.8 HR 113 BP 157/85 RR 35 Sat 97% on BIPAP
[**11-7**]
Gen: frail, elderly caucasian man lying in stretcher, HOB at 45
degrees, breathing in moderate distress with accessory muscle
use
HEENT: BIPAP mask in place with no apparent leak, eyes closed,
mouth open, no rhinorhea or oral discharge visible
Neck: JVP flat
CV: difficult to assess heart sounds over respiratory sounds,
but appears to have RRR, nl s1 s2, no murmurs
Lungs: R lower [**2-4**] with coarse BS and rales; L side clear; no
wheezing
Abd: thin, nd, nt, soft, no masses palpable
Ext: thin, no edema, multiple old well-healed scars on R leg
Skin: warm and dry, no rash or breakdown noted though could not
examine sacrum
Neuro: reactive to pain, otherwise
Pertinent Results:
[**2115-2-4**] 05:30AM BLOOD WBC-10.9 RBC-4.63 Hgb-13.6* Hct-40.3#
MCV-87 MCH-29.3 MCHC-33.7 RDW-14.0 Plt Ct-393#
[**2115-2-4**] 05:30AM BLOOD Neuts-82.6* Lymphs-14.5* Monos-2.2
Eos-0.2 Baso-0.4
[**2115-2-4**] 02:08PM BLOOD PT-13.2 PTT-27.4 INR(PT)-1.2
[**2115-2-4**] 05:30AM BLOOD Plt Ct-393#
[**2115-2-4**] 05:30AM BLOOD Glucose-334* UreaN-22* Creat-0.9 Na-144
K-5.0 Cl-108 HCO3-25 AnGap-16
[**2115-2-4**] 02:08PM BLOOD CK(CPK)-275*
[**2115-2-4**] 05:30AM BLOOD ALT-15 AST-22 LD(LDH)-254* CK(CPK)-398*
AlkPhos-125* TotBili-0.5
[**2115-2-4**] 02:08PM BLOOD CK-MB-9 cTropnT-0.08*
[**2115-2-4**] 05:30AM BLOOD cTropnT-0.05*
[**2115-2-4**] 05:30AM BLOOD CK-MB-7
[**2115-2-4**] 05:30AM BLOOD Albumin-3.2* Calcium-9.3 Phos-4.2 Mg-1.8
ABGs:
[**2115-2-4**] 10:46PM BLOOD Type-ART pO2-148* pCO2-129* pH-7.03*
calHCO3-37* Base XS--1
[**2115-2-4**] 11:49AM BLOOD Type-ART PEEP-5 FiO2-60 pO2-75* pCO2-56*
pH-7.29* calHCO3-28 Base XS-0 Intubat-NOT INTUBA Comment-BIPAP
[**2115-2-4**] 10:46PM BLOOD Glucose-114* Lactate-1.8 K-4.8
[**2115-2-4**] 11:49AM BLOOD Lactate-3.0* K-5.1
[**2115-2-4**] 11:49AM BLOOD freeCa-1.19
CXR:
IMPRESSION: Focal consolidation in the medial aspect of the
right lower lung
Brief Hospital Course:
This 86yo man with h/o CVA, CHF, recent episodes of aspiration
pneumonia, presented with dyspnea from his NH, likely from new
RLL pneumonia. He was started on Zosyn and Vanco for his
presumed aspiration, "hospital" aquired PNA. PE was considered
but less likely given his fevers and clear pneumonia on CXR. He
was supported on BIPAP for his respiratory status. An ABG was
attempted in the ED however it was limited by pt discomfort.
ABG on arrival to the ICU was 7.29/56/75. He was continued on
BIPAP. Blood cultures and sputum cultures were sent. Over the
course of the day he continued to decline. He was given some
prn Morphine for comfort. In the evening of the day of
admission he was noted to be increasingly somnolent. A repeat
ABG was performed which was 7.03/129/148. His family was
notified that he was doing worse and came in to visit him. It
was his family's wish that he be made comfortable. Based upon
this wish the BIPAP was removed and he was placed on nasal
cannula. He was written for a morphine drip however he expired
before this could be initiated.
.
Secondary issues
Elevated lactate: This was concerning for early sepsis given RLL
PNA. His blood pressures remained elevated and he was hydrated
with NS conservatively, given h/o CHF and dyspnea.
DM2: He was covered with a Insulin drip while unstable
.
CV: CAD: He was not taking any PO medications per [**Hospital 100**] Rehab
so all medications were held.
Medications on Admission:
.
Meds:
-Paxil
-Terazosin
-Glucophage
-Glyburide
-Atenolol
-Imdur
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 486, 4280, 4019, 311
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5492
}
|
Medical Text: Admission Date: [**2101-9-1**] Discharge Date: [**2101-9-3**]
Date of Birth: [**2020-8-24**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol / Dyazide
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is an 81 yo f with a history of diverticulosis and 2
recent episodes of GIB who had another GIB on [**2101-8-31**] prompting
her admission to [**Hospital 8**] Hospital. In the AM of [**8-31**], patient
had mild incontinence followed by a bloody bowel movement,
accompanied by clots. She described a dark hue to the contents
of her BM. Then, on the AM of [**9-1**], she had another bloody BM.
She denied any lightheadedness, changes in vision, abdominal
pain or chest pain with these episodes. (Though, a note from the
[**Hospital1 8**] ED notes that the patient had a syncopal type episode
while in the ED) She had a tagged RBC scan which was unable to
identify the source of bleeding. Hence, she is being transferred
here with the objective of IR guided embolization. On admission
to [**Hospital 8**] hospital, her Hct dropped from 30->22. She was
transfused with 2U PRBC and given 2 PIVs. Her Hct rose from 22
to 25.4 and thus she was transfused another 2 units PRBCs.
Past Medical History:
- LGIB w/ [**Month (only) **] HCT [**7-/2099**]
- Diverticulosis - diagnosed after 1st GIB
- HTN - on Lisinopril, Procardia, metoprolol
- CVA - in the [**2054**]
- Ulcer operation ? in the [**2054**]. Apparently surgery was done on
a part of her stomach.
- S/P TAH-BSO
- gastritis - s/p trt for duodenitis, PUD and H Pylori [**2098**], tx
w/ Prevpack
- Subarachnoid hemorrhage - per OSH report
Social History:
Lives alone. 32 pack yr history smoking. Social EtOH use.
Closest relatives are a son and a sister.
Family History:
NC
Physical Exam:
T: BP: 155-195/53-67 P:72-80 RR:18-20 O2 sats: 100% on 2L
Gen: alert, thin elderly woman
HEENT: dry MM
CV: 3/6 SEM RUSB and L apex, RRR
Resp: rales R lung base, no wheezes, no rhonchi
Abd: Soft NT ND, NABS
GU: per ED admit note last night guaic +
Ext: mild RUE non-pitting swelling, rt ankle mildly swollen
Neuro: AOx3.
Pertinent Results:
Laboratory Data:
.
[**2101-9-1**] 08:06PM WBC-9.8 RBC-3.83* HGB-12.1 HCT-33.2* MCV-87
MCH-31.6 MCHC-36.5* RDW-15.1
[**2101-9-1**] 08:06PM NEUTS-77.2* LYMPHS-15.0* MONOS-3.9 EOS-3.6
BASOS-0.4
[**2101-9-1**] 08:06PM PLT COUNT-309
[**2101-9-1**] 08:06PM PT-12.0 PTT-25.4 INR(PT)-1.0
[**2101-9-1**] 08:06PM GLUCOSE-120* UREA N-27* CREAT-1.5*
SODIUM-146* POTASSIUM-3.2* CHLORIDE-107 TOTAL CO2-28 ANION
GAP-14
[**2101-9-1**] 08:06PM ALT(SGPT)-11 AST(SGOT)-21 LD(LDH)-228 ALK
PHOS-66 TOT BILI-0.6
[**2101-9-1**] 08:06PM ALBUMIN-3.4 CALCIUM-8.6 PHOSPHATE-4.4
MAGNESIUM-1.8
.
Urinalysis:
.
[**2101-9-1**] 11:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2101-9-1**] 11:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2101-9-1**] 11:27PM URINE HOURS-RANDOM UREA N-151 CREAT-18
SODIUM-152
.
Imaging:
[**9-1**]: CXR: No evidence of focal consolidation.
.
[**2101-9-2**]: RUE ultrasound: No evidence of right upper extremity
DVT. Cephalic vein not visualized.
.
[**2101-9-3**]: Renal ultrasound: 1. No evidence of hydronephrosis or
kidney stones.
2. Increased echogenicity of the right kidney may represent
medical-renal disease.
3. Bilateral pleural effusions.
.
[**2101-9-3**]: Echo
Measurements:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.17 (nl >= 0.29)
Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *2.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.7 m/sec
Mitral Valve - E/A Ratio: 0.65
Mitral Valve - E Wave Deceleration Time: 205 msec
TR Gradient (+ RA = PASP): *44 to 54 mm Hg (nl <= 25 mm Hg)
.
Official read pending. Prelim report of normal EF and
obstructive hypertrophic cardiomyopathy
.
OSH records:
OSH Colonoscopy: [**2101-8-24**]: Done to cecum.
- Severe L sided diverticulosis. No active bleeding.
.
EGD: [**2101-8-24**]:
- benign appearing gastric mucosa and duodenal mucosa (to the
3rd portion of the duodenum
.
[**2101-8-31**]: Tagged RBC scan: 2 areas of increased activity in the
deep pelvis - There was no evidence of GI Bleed.
Brief Hospital Course:
# GIB: 81 yo f with PMH diverticulosis and history of GIB was
transferred from OSH with recent GIB. Per report, source was
identified on tagged RBC at OSH and she was transferred here for
IR embolization. We obtained records from [**Hospital 8**] Hospital
which showed that the tagged RBC scan didn't reveal any source
of bleeding. Pt had a previous colonoscopy which showed severe
left sided diverticulosis. Pt's source of recent GIB was most
likely secondary to diverticulosis. During this hospitalization,
pt didn't have any bowel movements. Serial hematocrits remained
stable. Pt was evaluated by IR and surgery who didn't feel that
any immediately intervention was indicated. Pt was evaluated by
GI who recommended a repeat colonoscopy. If pt were to re-bleed,
she will need a repeat tagged RBC scan and possible
embolization. Please continue to check serial [**Hospital1 **] hematocrits.
Pt has not had a BM in 4 days - please titrate bowel
medications, for a BM.
.
# CRI: Lisinopril was held in setting of elevated creatinine.
Further data revealed that baseline creat is around 1.8, and pt
was restarted on Lisinopril. Urine lytes showed low FeNa and
FeUrea, suggestive of pre-renal state; however, urine Na was not
low. Clinically pt appears to be volume overloaded.
.
# CHF: Pt noted to be in mild CHF, likely in setting of volume
rescusitation. Pt has bilateral pleural effusions. Pt was
diuresed with IV Lasix. Pt needs to continue with diuresis. Echo
was performed - final read is pending. Prelim tech read is
normal EF with evidence of obstructive hypertrophic
cardiomyopathy.
.
# HTN: - Initially BP meds were held in setting of GIB. Then, pt
was restarted on lopressor and lower dose of nifedipine.
Lisinopril was initially held in setting of elevated creatinine,
and pt was put on IV hydralazine. Further data revealed that
creatinine is at baseline, so Lisinopril was restarted. Pt was
also restarted on home dose of nifedipine.
.
# RUE swelling: Pt was noted to have RUE swelling, which is most
likely secondary to IV infilatration. RUE U/S was negative for
DVT.
.
# Hypercholesterolemia: Pt was continued on lipitor.
.
# Code: DNR/DNI - confirmed with patient.
.
# Contacts: Sister - [**Name (NI) 50665**] [**Name (NI) 50666**]: [**Telephone/Fax (1) 50667**]
Medications on Admission:
Lisinopril 40 QD
Metoprolol 100mg TID
Procardia XL 90mg QD
Lasix 10mg QD
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
2. Atorvastatin 20 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).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses:
GIB (likely [**12-23**] diverticulosis)
RUE swelling
.
Secondary diagnoses
HTN
CRF
Hyperlipidemia
Discharge Condition:
Stable, no further GIB, stable Hct
Discharge Instructions:
Please continue doing the following:
1. Daily hematocrits
2. Diurese with IV Lasix
3. Titrate BP meds
3. Please titrate bowel medication to BM (last BM on [**8-31**])
Followup Instructions:
Follow up with your primary care doctor within 2 weeks of
discharge from the hospital.
ICD9 Codes: 4280, 5859, 2720
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5493
}
|
Medical Text: Admission Date: [**2125-1-24**] Discharge Date: [**2125-2-1**]
Date of Birth: [**2055-11-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2121-1-24**] Aortic Valve Replacement (23mm CE Magna pericaridal),
Coronary Artery Bypass Graft x 4 (Saphenous vein graft to left
anterior descending, Saphenous vein graft to diagonal, Saphenous
vein graft to obtuse marginal, Saphenous vein graft to posterior
descending artery)
History of Present Illness:
This 69 year old male with cardiomyopathy, worsening dyspnea on
exertion and pedal edema, who has opted for medical management
in the past. In [**Month (only) 956**] he had cardiac catheterization that
revealed severe three vessel disease coronary artery disease and
echocardiogram showed severe aortic stenosis, at which time he
was referred for surgical evaluation.
Past Medical History:
Cardiomyopathy
Congestive heart failure
noninsulin dependent Diabetes Mellitus
Benign prostatic hypertrophy
Gastric ulcers
s/p prostatectomy
s/p Tonsillectomy
Social History:
Lives with: Family.
Occupation: Retired bookkeeper
Tobacco quit [**8-30**] 40 pack year history
ETOH: occassional
Family History:
Non-contributory
Physical Exam:
Admission:
VS: 73 23 104/44 5'8" 156#
Gen: No acute distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear lungs bilaterally
Heart: Regular rate and rhythm 2/6 systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused +3 edema
Neuro: Grossly intact, alert and oriented x 3
Pertinent Results:
[**2125-2-1**] 09:20AM BLOOD WBC-7.6 RBC-3.88* Hgb-12.0* Hct-34.8*
MCV-90 MCH-31.1 MCHC-34.6 RDW-16.2* Plt Ct-121*
[**2125-1-24**] 01:11PM BLOOD WBC-15.5*# RBC-3.62* Hgb-11.0* Hct-32.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.5 Plt Ct-63*#
[**2125-2-1**] 09:20AM BLOOD Plt Ct-121*
[**2125-1-24**] 01:11PM BLOOD Plt Ct-63*#
[**2125-1-24**] 01:11PM BLOOD PT-26.4* PTT-150* INR(PT)-2.6*
[**2125-1-24**] 06:43PM BLOOD Fibrino-245#
[**2125-2-1**] 09:20AM BLOOD Glucose-217* UreaN-14 Creat-1.0 Na-135
K-4.3 Cl-101 HCO3-27 AnGap-11
[**2125-1-24**] 03:25PM BLOOD UreaN-61* Creat-1.7* Cl-118* HCO3-23
[**2125-1-30**] 06:13AM BLOOD ALT-22 AST-29 LD(LDH)-293* AlkPhos-68
Amylase-33 TotBili-1.4
[**2125-2-1**] 09:20AM BLOOD Calcium-7.9* Phos-2.0* Mg-1.7
[**2125-1-25**] 09:38PM BLOOD Calcium-8.2* Phos-4.2 Mg-2.0
[**Known lastname **],[**Known firstname **] JR [**Medical Record Number 101423**] M 69 [**2055-11-25**]
Radiology Report CHEST (PA & LAT) Study Date of [**2125-1-31**] 2:51 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2125-1-31**] 2:51 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 101424**]
Reason: evaluate effusion, atx
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with s/p avr, cabg
REASON FOR THIS EXAMINATION:
evaluate effusion, atx
Final Report
REASON FOR EXAMINATION: Follow up of a patient after aortic
valve
replacement.
PA and lateral upright chest radiographs were compared to [**1-28**], [**2124**].
The right internal jugular line has been removed in the interum.
The
cardiomediastinal silhouette is stable. The position of the
replaced aortic
valve is unchanged. The bilateral pleural effusions are small to
moderate and
are unchanged as well. There is no evidence of pneumothorax.
There is no
evidence of failure. Bibasilar atelectasis most likely secondary
to pleural
effusion.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: WED [**2125-1-31**] 4:07 PM
[**Known lastname **],[**Known firstname **] JR [**Medical Record Number 101423**] M 69 [**2055-11-25**]
Cardiology Report ECG Study Date of [**2125-1-27**] 12:03:02 PM
Sinus rhythm with ventricular premature complex
Probable left atrial abnormality
Left axis deviation may be due in part to left anterior
fascicular block and/or
possible prior inferior myocardial infarction
Delayed R wave progression with late precordial QRS transition
ST-T wave abnormalities
These findings are nonspecific but clinical correlation is
suggested
Since previous tracing of [**2125-1-24**], probably no significant
change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 0 100 400/419 0 -26 120
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 101425**]Portable TTE
(Complete) Done [**2125-1-26**] at 11:00:00 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2055-11-25**]
Age (years): 69 M Hgt (in): 75
BP (mm Hg): 102/51 Wgt (lb): 176
HR (bpm): 75 BSA (m2): 2.08 m2
Indication: H/O cardiac surgery s/p AVR with bioprosthesis..
Left ventricular function
ICD-9 Codes: V42.2, 424.1, 424.0
Test Information
Date/Time: [**2125-1-26**] at 11:00 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: *5.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.0 cm
Left Ventricle - Fractional Shortening: *0.15 >= 0.29
Left Ventricle - Ejection Fraction: 20% to 30% >= 55%
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: *4.3 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *20 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 12 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.20
Mitral Valve - E Wave deceleration time: *253 ms 140-250 ms
TR Gradient (+ RA = PASP): *33 to 40 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2124-12-28**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. False LV tendon (normal variant). Severely depressed
LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV
cavity. Mild global RV free wall hypokinesis.
AORTA: Mildly dilated aortic sinus. Moderately dilated ascending
aorta. Mildly dilated aortic arch.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR gradient.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**11-24**]+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Suboptimal image quality - poor subcostal views.
Suboptimal image quality - bandages, defibrillator pads or
electrodes.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 20-30 %) secondary to hypokinesis of the
septum, anterior free wall, inferior wall, and apex; there is
relative sparing of the posterior and lateral walls. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
arch is mildly dilated. A bioprosthetic aortic valve prosthesis
is present. The transaortic gradient is normal for this
prosthesis. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension.
IMPRESSION: normal aortic bioprosthesis
Compared with the prior study (images reviewed) of [**2124-12-28**], the
aortic valve has been replaced; left ventricular ejection
fraction is similar, but the mitral regurgitation is reduced,
and there is evidence of reduced diastolic dysfunction of the
left ventricle; the pulmonary artery pressure is significantly
reduced.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-1-26**] 15:07
Brief Hospital Course:
Admitted same day and went to surgery. Underwent coronary
artery bypass graft and aortic valve replacement. See operative
report for further details. He received Cefazolin for
perioperative antibiotics. He was transferred to the intensive
care unit for hemodynamic management on Vasopressin, Levophed,
epinephrine and insulin infusions. He received multiple blood
products and protamine for bleeding that resolved. Medication
drips were weaned down and levophed was discontinued, he
remained hemodynamically stable. He was weaned from sedation,
awoke neurologically intact and was extubated without
complications. Epinephrine and vasopressin were weaned off in
the afternoon on post operative day one but due to hypotension
the levophed was restarted. He was gently diuresed toward
preoperative weight, beta blocker and ace inhibitor were held
due to pressor requirement. On [**1-27**] he was weaned off levophed
but atrial paced for blood pressure. He was noted for free air
under the diaphragm and dilated loops of bowel, but physical
exam benign. He was followed clinically, narcotics
disconintued, and serial radiograph with resolution.
He was started on betablockers and ace inhibitors which he
tolerated. Physical therapy worked with him on strength and
mobility. He was ready for discharge home with services on post
operative day 8. Plan for him to follow up with Dr [**Last Name (STitle) **] in
next seven to ten days to evaluate diuresis due to heart
failure.
Sternal incision: steri strips, no erythema no drainage, sternum
stable
Left EVH sites with no erythema no drainage.
Lower extremity edema +3 pitting, from knees down
Weight preoperative 76.5 kg discharge weight 74.6 kg
Medications on Admission:
Aspirin 81mg qd, Advair 100/50 daily, Carvedilol 3.125mg [**Hospital1 **],
Glucophage 1000mg qAM and 500mg qPM, Lasix 80mg [**Hospital1 **], Zestril
40mg qd, Lanoxin 0.125mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO qpm: in
afternoon .
Disp:*30 Tablet(s)* Refills:*0*
10. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day:
in am .
Disp:*30 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day:
please take twice a day - follow up with cardiologist in next
7-10 days to evaluate diuresis .
Disp:*60 Tablet(s)* Refills:*0*
13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Coronary artery disease s/p coronary artery bypass graft surgery
Acute on chronic systolic heart failure
Post operative atrial fibrillation
Cardiomyopathy
Diabetes Mellitus
Benign prostatic hypertrophy
Gastric ulcers
s/p Prostate surgery
s/p Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**6-1**] days
Dr. [**Last Name (STitle) 101422**] in 2 weeks ([**Telephone/Fax (1) 90222**])
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2125-2-1**]
ICD9 Codes: 4241, 4254, 9971, 4280
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5494
}
|
Medical Text: Admission Date: [**2127-7-7**] Discharge Date: [**2127-7-26**]
Date of Birth: [**2064-10-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Patient admitted from OSH for vascular surgery evaluation of
nonhealing right foot ulcer
Major Surgical or Invasive Procedure:
Angiogram with right leg runoff [**7-8**]
Sigmoidoscopy [**7-10**]
Oversewing of rectal ulcer [**7-12**]
rigid sigmoidoscopy [**7-13**]
PICC Line [**7-25**]
Cardiac cath with PTCA Dg1,RCA [**2127-7-15**]
Rt. CFA pseudoaa resection with dacron patch angioplasty, Rt.
CFA-Ant Tib artery with issg bpg [**7-17**]
Sigmoidocopy with polypectomy [**2127-7-24**]
History of Present Illness:
62yo male with right foot infection/ulcer since 6/[**2126**]. In [**Month (only) 205**]
at [**Hospital3 **], patient's course was complicated by CHF,
renal failure requiring HD, reportedly at MSSA infection.
Patient was transferred to [**Hospital1 **] ([**2127-7-4**]) for
podiatry care, and now moved to [**Hospital1 18**] for above mentioned CC:
Patient has h/o right calf claudication after one mile. No rest
pain.
Past Medical History:
CRI
ARF re: HD
CHF
IDDM2
CAD
Social History:
Retired printer, ex-smoker that quit 20 years ago, married with
children
Family History:
Non-contributory
Physical Exam:
On Admission:
VS: T-99.2, HR-66, BP 154/62, RR-16, SaO2-95%RA, 81.6kg
Gen: NAD , pleasant
Neck: No carotid bruit
Chest: CTAB, RRR
Abdomen: soft, nt, nd
Extremity: Warm, non-cyanotic
Pulses: Rad Carotid Fem [**Doctor Last Name **] DP PT
R 2+ 2+ 2+ 1+ [**Hospital1 **] Mono
L 2+ 2+ 2+ 2+ [**Hospital1 **] Mono
Right Foot: Dry eschar on lateral dorsal surface of foot. Open
wound with bone/tendon involvement on medial/planter foot
surface. Evidence of arterial insufficiency without signs of
cellulitis
Pertinent Results:
[**2127-7-8**] 03:25AM BLOOD WBC-12.0* RBC-3.56* Hgb-9.9* Hct-31.4*
MCV-88 MCH-27.7 MCHC-31.4 RDW-15.3 Plt Ct-401
[**2127-7-8**] 03:25AM BLOOD Neuts-76.8* Lymphs-15.5* Monos-3.8
Eos-3.5 Baso-0.4
[**2127-7-8**] 03:25AM BLOOD Hypochr-1+
[**2127-7-8**] 03:25AM BLOOD PT-13.8* PTT-29.1 INR(PT)-1.3
[**2127-7-8**] 03:25AM BLOOD Plt Ct-401
[**2127-7-12**] 01:36PM BLOOD Fibrino-483*
[**2127-7-8**] 03:25AM BLOOD Glucose-100 UreaN-18 Creat-0.8 Na-140
K-4.4 Cl-107 HCO3-25 AnGap-12
[**2127-7-12**] 01:36PM BLOOD CK(CPK)-17*
[**2127-7-12**] 09:59PM BLOOD CK(CPK)-20*
[**2127-7-13**] 04:11AM BLOOD CK(CPK)-23*
[**2127-7-15**] 10:36PM BLOOD CK(CPK)-33*
[**2127-7-16**] 04:02AM BLOOD CK(CPK)-55
[**2127-7-12**] 01:36PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2127-7-12**] 09:59PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2127-7-13**] 04:11AM BLOOD CK-MB-3 cTropnT-0.07*
[**2127-7-8**] 03:25AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.6
[**2127-7-8**] 04:23AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2127-7-8**] 04:23AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2127-7-8**] 04:23AM URINE RBC-[**5-16**]* WBC->50 Bacteri-RARE Yeast-MOD
Epi-[**2-8**]
[**2127-7-8**] 1:54 am FOOT CULTURE Site: FOOT RIGHT.
**FINAL REPORT [**2127-7-12**]**
WOUND CULTURE (Final [**2127-7-11**]):
STAPH AUREUS COAG +. RARE 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
[**2127-7-12**] 5:56 pm CATHETER TIP-IV Source: PICC.
**FINAL REPORT [**2127-7-14**]**
WOUND CULTURE (Final [**2127-7-14**]): No significant growth
[**2127-7-14**] 12:30 pm SWAB Site: RECTAL
**FINAL REPORT [**2127-7-19**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2127-7-19**]):
ENTEROCOCCUS SP.. SPARSE GROWTH STRAIN 1.
Sensitivity confirmed by Sensititre.
ENTEROCOCCUS SP.. SPARSE GROWTH STRAIN 2.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S =>32 R
CHLORAMPHENICOL------- <=4 S 8 S
LEVOFLOXACIN---------- =>8 R =>8 R
PENICILLIN------------ 4 S 32 R
VANCOMYCIN------------ =>32 R =>32 R
Foot Xrays [**2127-7-8**]:IMPRESSION: Findings consistent with
osteomyelitis involving the proximal first, second, and likely
the first tarsometatarsal joint. The base of the third
metatarsal may also be involved
pMIBI [**2127-7-10**]: IMPRESSION: Markedly abnormal study with a
large, reversible anterolateral wall defect and a moderate,
reversible inferior wall defect. Severe global hypokinesis with
a calculated EF of 22%.
TTE [**2127-7-10**]: Resting regional wall motion abnormalities include
moderate to severe inferior, septal, anterior, and apical
hypokinesis. Mild (1+) Ao regurg is seen. Mild (1+) MR is seen.
The left ventricular inflow pattern suggests impaired
relaxation. There is moderate pulmonary artery systolic
hypertension.
Polypectomy [**2127-7-25**]: 3.5cm polyp removed piecemeal using loop
wire excision. 14cm from rectum
Brief Hospital Course:
Patient admitted [**2127-7-7**] for above mentioned CC/HPI. Patient
given angio on [**7-8**] that showed SFA and infrageniculate vessel
disease. On vascular work-up, cardiology was consulted for
pre-operative clearance with pMIBI and TTE that were both
positive for significant reversible anterolateral defects and a
moderate, reversible inferior wall defect. Severe global
hypokinesis with a calculated EF of 22%. While in pre-op holding
for cardiac cath, patient had sudden, massive BRBPR. Cath was
canceled and when back on the floor, patient deteriorated and
was hemodynamically unstable. He was transferred to the SICU,
and GI was consulted. Flex sig showed large sessile polyp
(approx 4cm in diameter) that was possibly the site of bleeding.
On colonoscopy, the actual area of bleeding was seen to be a
rectal ulcer for which the patient was taken to the OR by
general surgery on [**2127-7-13**] and the ulcer was oversewn. On [**7-15**],
patient was given cardiac cath, without stent placement, and on
[**7-17**] patient had BPG performed from Right Fem to distal Anterior
Tib artery with additional resection of right common femoral
pseudoaneurysm with a Dacron patch angioplasty. Patient
tolerated procedure well with strong RLE pulses and re-perfusion
edema and hyperemia. Following vascular intervention, patient
was taken off of his aspirin for five days, and GI completed
patient's workup by removing a 3.5cm sessile polyp, 14cm from
his rectum, in a piecemeal fashion. Patient d/c'ed to rehab
center on HD 20 with f/u appointments for general surgery,
vascular surgery, plastic surgery and GI.
Medications on Admission:
ASA 81', Lipitor 40', Carvedilol 12.5'', Kefzol, Colace, Nexium,
NPH 30am/15pm, Regular insulin 8am/4 at 1600, Lisinopril 20',
Tylenol PRN, Ambien 5'
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3.5 weeks from [**2127-7-24**] weeks.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3.5 weeks from [**2127-7-25**] weeks.
11. Oxacillin Sodium 10 g Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 3.5weeks from [**2124-7-24**] weeks.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous twice a day: breakfast 30units NPH
bedtime 7 units NPH
.
13. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection twice a day: breakfast: 8units regular
dinner: 4units.
14. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection every six (6) hours: glucoses <120/no insulin
glucoses 121-140/2u
glucoses 141-160/4u
glucoses 161-180/6u
glucoses 181-200/8u
glucoses 201-220/10u
glucoses 221-240/12u
glucoses 241-260/14u
glucoses 261-280/16u
glucoses 281-300/18u
glucoses 301-320/29u
glucoses > 320 [**Name8 (MD) 138**] md.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Please start taking one aspirin per day starting on [**2127-8-1**],
NOT before then .
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
right cfa pseudoaa and fem-tibia pvd
GI bleed, colon polyps
divticulosis by sigmoid oscopy
CAD s/p + Pmibi, s/p cardiac cath s/p angioplasty of Dg1, rca w
3 Vessel dz ef 23%
history of CRI with ARF req HS [**6-10**]
Dm2, insulin dependant, controlled
history of CHF [**6-10**]
Discharge Condition:
stable
Discharge Instructions:
Please return to hospital for fever greater than 101 degrees, if
wound opens or if wound begins to drain blood or purulent fluid.
Return to hospital if you begin to experience fevers and chills
or vomiting. Do not drive while taking pain medications. Take
all of your antibiotics and follow-up with all of your
appointments.
Followup Instructions:
Please follow up in 2 weeks with Dr. [**Last Name (STitle) **] at [**Hospital1 **]. Please
call [**Telephone/Fax (1) 2395**] to schedule an appointment at [**Hospital1 **] with her
Dr. [**First Name (STitle) 679**] from GI, 1 week after discharge: call [**Telephone/Fax (1) 682**] for
appointment
Follow up with plastic surgery for recommendations for rt. wound
closure. call for appointment at [**Telephone/Fax (1) 274**]
Please follow up with General Surgery, Dr. [**Last Name (STitle) **]. Call
[**Telephone/Fax (1) 10533**] to schedule an appointment in two weeks
Completed by:[**2127-7-26**]
ICD9 Codes: 2851
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5495
}
|
Medical Text: Admission Date: [**2124-1-27**] Discharge Date: [**2124-1-30**]
Date of Birth: [**2052-8-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Diplopia
Major Surgical or Invasive Procedure:
L Crani for SDH evacuation
History of Present Illness:
71 M who presented to the [**Hospital1 18**] on [**2123-10-31**] with a traumatic
SAH after a mechanical fall. He was admitted for observation
and
discharged the ensuing day after a head CT demonstrating no
interval change. His follow up head CT at that time revealed a
new L SDH measuring 8 mm. This was followed up with a CT on
[**2123-12-9**] that revealed stable hematoma size. He returned on
[**2124-1-20**] for a follow up with a head CT that showed liquidation
of
the SDH but with increased size. There is no evidence of
significant midline shift. The patient was asymptomatic and
opted against surgical evacuation. In this context, he was going
to be monitored with serial imaging.
Since discharge from clinic, the patient had begin to complain
of
visual blurring and diplopia, the patient denied any other
symptoms, including HA, N/V, weakness of arms/leg, or seizure
like activities. All other ros negative. He returned to clinic
for
assessment of the diplopia. THe decision was made to evacuate
the SDH via craniotomy
Past Medical History:
TYpe II DM
Hypertension
Hyperlipidemia
Social History:
Unknown
Family History:
Unknown
Physical Exam:
Admission Exam:
The patient is awake, alert, and appropropriate. He is oriented
x 3. Speech is fluent and comprehension intact.
PERRL 3 to 2 and symmetric. VFF. There is a subtle deficit on
lateral gaze and the patient complained of increased diplopia on
leftward gaze. FS. T/U midline. hearing and SS symmetric. Full
strength throughout. Sensation intact to LT. Normal gait.
Romberg negative.
Discharge Exam:
Patient is awake and alert x 3, his pupils are [**2-26**] bilaterally
and symmetric, he does have complaints of diplopia and is
wearing an eye patch of his left eye. He will follow up with
neurology outpatient for [**Last Name 84280**] problem. he has no pronator
drift, and he is full strength
Pertinent Results:
IMAGING:
Head CT on [**2124-1-27**] compared to [**2124-1-20**]. There are no significant
changes between the two scans. The majority of the SDH is
remain isodense though there remains a hyperdense component in
the inferior aspect.
MRI [**2124-1-27**]:
MRA HEAD: Head MRA demonstrates normal flow signal within the
arteries of
anterior and posterior circulation. No evidence of vascular
occlusion,
stenosis or an aneurysm greater than 3 mm in size is seen.
IMPRESSION: No significant abnormalities on MRA of the head.
LAB DATA:
[**2124-1-27**] 11:26PM GLUCOSE-180* UREA N-20 CREAT-0.9 SODIUM-137
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-31 ANION GAP-12
[**2124-1-27**] 11:26PM WBC-7.8 RBC-4.81 HGB-16.0 HCT-43.3 MCV-90
MCH-33.2* MCHC-36.9* RDW-12.9
[**2124-1-28**] 05:10AM BLOOD %HbA1c-7.6* eAG-171*
[**2124-1-28**] 05:10AM BLOOD CRP-2.3
Brief Hospital Course:
The patient was admitted to Far 11 from the [**Hospital 4695**] Clinic
for a thorough work up of his CN III and VI palseys; this
included a MRI/MRA (which revealed no abnormalities), CRP, ESR
levels (all WNL), and a neurology consult. There was no
resultant explanation for the patient's neurologic findings,
other than the possibility of mass effect from his SDH. He was,
thus, taken to the OR on [**2124-1-28**] for a L craniotomy for SDH
evacuation. The patient's neurologic examination remained
unchanged post-operatively. He was observed in the SICU for a
day prior to transfer to the floor. Neuromedicine recommended
that the patient be discharged home with follow up in the
neurology clinic within 72 hours. The patient was discharged
thereafter.
Medications on Admission:
glipizide 5/metformin 20, codfish oil, vitamin D, multivitamin,
Prozac 5 mg QD, lisinopril 5 mg QD
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q 4-6 hours
PRN as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
SDH
Cranial Nerve III, VI Palsey
Discharge Condition:
Stable - A&O x 3
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? 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
??????You have dissolvable sutures, you do nto need suture removal
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in [**2-29**] weeks.
??????You will need a CT scan of the brain without contrast.
?????? You will need a follow up appointment in the [**Hospital 878**]
clinic. Please call ([**Telephone/Fax (1) 2528**] on Monday to arrange for an
appointment
Completed by:[**2124-2-1**]
ICD9 Codes: 311, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5496
}
|
Medical Text: Admission Date: [**2176-7-20**] Discharge Date: [**2176-7-27**]
Date of Birth: [**2112-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain with exertion
Major Surgical or Invasive Procedure:
[**2176-7-23**] CABG x 4 (LIMA to LAD, SVG to Diag sequenced to OM, SVG
to RCA) Maze cryoablation/left atrial appendage ligation
History of Present Illness:
63 yo male with known AFib who presented to OSH ER with angina
on exertion. Cardiology workup included cath which revealed 80%
LM , 100% RCA, and EF 50%.
Transferred to [**Hospital1 18**] for cabg evaluaton with Dr. [**Last Name (STitle) 914**].
Past Medical History:
AFib
HTN
elev. chol.
pacer for tachy-brady syndrome
CAD
Social History:
[**3-15**] drinks per day
smokes one PPD for 40 years
no recr. drugs
lives with wife
Family History:
both parents with ruptured [**Name (NI) 67655**]
father with MI
Physical Exam:
96.6 105/81 HR 69 97% RA sat
CTAB
S1 S2
soft, NT, ND
+ radials/fem/DP/ PT pulses
Pertinent Results:
[**2176-7-25**] 07:25AM BLOOD WBC-13.4* RBC-3.27* Hgb-10.9* Hct-32.1*
MCV-98 MCH-33.3* MCHC-34.0 RDW-12.4 Plt Ct-149*
[**2176-7-26**] 08:10AM BLOOD Hct-29.3*
[**2176-7-27**] 04:59AM BLOOD PT-19.9* INR(PT)-1.9*
[**2176-7-25**] 07:25AM BLOOD Glucose-149* UreaN-12 Creat-0.7 Na-138
K-3.8 Cl-102 HCO3-26 AnGap-14
[**2176-7-26**] 08:10AM BLOOD K-4.4
[**2176-7-24**] 01:40AM BLOOD ALT-39 AST-227* LD(LDH)-605* AlkPhos-53
Amylase-18 TotBili-0.4
[**2176-7-25**] 07:25AM BLOOD Mg-2.1
[**2176-7-20**] 07:23PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 67656**] (Complete)
Done [**2176-7-23**] at 10:04:14 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2112-8-3**]
Age (years): 63 M Hgt (in): 71
BP (mm Hg): 118/58 Wgt (lb): 170
HR (bpm): 85 BSA (m2): 1.97 m2
Indication: Aortic valve disease. Coronary artery disease.
Mitral valve disease. Intraop CABG, eval aorta, lv function
ICD-9 Codes: 424.1, 424.0, 440.0
Test Information
Date/Time: [**2176-7-23**] at 10:04 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2006AW599-0:07 Machine: 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.2 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: *0.26 >= 0.29
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Valve Level: 2.4 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 0.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: 3.4 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.6 m/sec
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.2 m/sec
Mitral Valve - E/A ratio: 3.00
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA. No
spontaneous echo contrast in the body of the LA. No
mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No spontaneous echo contrast is
seen in the LAA. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Mild-moderate regional LV systolic dysfunction.
Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root. Normal ascending aorta diameter. Normal aortic arch
diameter. There are complex (>4mm) atheroma in the aortic arch.
Normal descending aorta diameter. There are complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened
aortic valve leaflets (3). No AS. No AS. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was under
general anesthesia throughout the procedure.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre bypass: The left atrium is moderately dilated and elongated.
No spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild to moderate
regional left ventricular systolic dysfunction. Resting regional
wall motion abnormalities include inferobasal akinesis, mid to
distal inferior moderate to severe hypokinesis, distal
anteroseptal moderate hypokinesis. Septal wall motion
paradoxical, consistent with ventricular pacing. The remaining
left ventricular segments contract normally. Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the distal aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) central aortic
regurgitation is seen. Aortic regurgitatant jet takes up less
than 25% of LVOT area by color m-mode analysis. The mitral valve
leaflets are mildly thickened, but structurally normal. . Mild
(1+) central mitral regurgitation is seen, with a slight.
component to posterior direction. The mitral annulus measures
4-4.5 cm on average. Vena contracta measures 2-5 mm. Mitral
regurgitation changes with loading conditons,but at worst is no
more than mild to moderate. Some of the subvalvular appratus
feeding the anterior mitral leaflet is calcified, but the
leaflet itself is freely mobile. Pacing wires are seen in the RA
and RV. A Pulmonary artery catheter is seen entering the PA via
the RA and RV. There is mild tricuspid regurgitation
Post Bypass: Pt is av paced, on phenylepherine infusion. LVEF
improved to 50%. Basal inferior wall remains severely
hypokinetic to akinetic, but mid and distal inferior wall now
only mildly hypokinetic. Distal anterioseptal wall motion
improved to mild hypokinesis. Septum motion remains paradoxical
c/w pacing. Mitral regurgitation remains mild (1+) and central.
Aortic insufficiency remains mild (1+) and central. Tricuspid
regurgitation remains mild (1+). Aortic contours intact.
Remaining exam unchanged. Findings discussed with surgeons at
the time of the exam.
Post bypass:
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
STUDY: Carotid series complete.
REASON: Preop CABG.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries.
There is minimal plaque noted bilaterally.
On the right, peak systolic velocities in cm/sec are 80, 87 and
125 in the
ICA, CCA, and ECA respectively. ICA end-diastolic velocity is
35. ICA/CCA
ratio is 0.9. This is consistent with less than 40% stenosis.
On the left, peak velocities are 81, 80, and 66 in the ICA, CCA,
and ECA
respectively. ICA end-diastolic velocity is 32. ICA/CCA ratio is
1.0. This
is consistent with less than 40% stenosis.
There is antegrade vertebral artery flow bilaterally.
IMPRESSION: Bilateral less than 40% carotid stenosis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2176-7-24**] 1:23 PM
Procedure Date:[**2176-7-22**]
?????? [**2173**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted on [**7-20**] and underwent pre-op work-up for cabg.Remained
on a heparin drip and had an EP evaluation. Carotid US results
as noted above. CABG x4/Maze performed on [**7-23**] by Dr. [**Last Name (STitle) 914**].
Transferred to the CSRU in stable condition on a propofol drip.
Extubated successfully and sotalol restarted. Had some RUQ abd
pain and US ruled out cholelithiasis. Total bilirubin was
normal.Symptoms then resolved. Coumadin started on POD #1. Chest
tubes were removed and he was transferred to the floor to begin
increasing his activity level. Followed by the EP service.
Pacing wires removed without incident on POD #2.Received abx
coverage for some chest tube site drainage on POD #3. Cleared
for discharge to home with [**Doctor Last Name **] of Hearts monitor and VNA
services on POD #4. Coumadin dosing and INR to be followed by
Dr. [**Last Name (STitle) 6062**]. First blood draw Monday [**7-29**] with results to Dr.
[**Last Name (STitle) 6062**]. Dr. [**Last Name (STitle) **] will do follow up for KOH monitor.
Medications on Admission:
sotalol
coumadin
lipitor
lopid
digoxin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Sotalol 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
9. Sotalol 120 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily) for 5 days.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
13. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*- dosing per Dr. [**Last Name (STitle) 6062**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
CAD
PAF
SSS s/p PPM
HTN
tobacco abuse
elev. chol
Discharge Condition:
Good.
Discharge Instructions:
Shower, no baths, no lotions creams or powders to incisions.
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 6062**] 2 weeks and for coumadin dosing
Dr. [**Last Name (STitle) **] for [**Doctor Last Name **] of Hearts follow up
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) 13175**] 2 weeks
Completed by:[**2176-8-12**]
ICD9 Codes: 4111, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5497
}
|
Medical Text: Admission Date: [**2140-10-23**] Discharge Date: [**2140-10-26**]
Date of Birth: [**2101-3-30**] Sex: F
Service: MEDICAL ICU.
CLINICAL ATTENDING:[**Last Name (NamePattern1) 44800**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 39-year-old
female who was transferred from [**Hospital3 **] status post
an overdose. The patient, at 4 PM, on [**2140-10-23**], apparently
antidepressants, Tylenol, Neurontin, Seroquel, and Paxil in
unknown quantities, as well as inhaled cocaine. There is
also question of possible intake of rubbing alcohol as two
bottles were found near the patient. The patient was brought
to [**Hospital3 **] via ambulance. When she arrived at the
hospital, vital signs were pulse of 80, blood pressure
120/80, respiratory rate 18, pulse oximetry 100%. However,
treated with 2 mg Ativan, 1 mg Narcan, 12 grams
acetylcysteine bicarbonate, 1 mg Atropine, as well as
activated charcoal. EKG at this time showed a QRS complex
equal to 0.106. At this point, she was started on a
bicarbonate drip. QTC was 0.45. The patient was then
intubated secondary to CNS depression. Post intubation, the
systolic blood pressure dropped to the 60s. The patient was
then started on a dopamine drip. The patient also had a head
CT, which was negative. Further laboratory data revealed an
arterial blood gas with a pH of 7.29, pCO2 15, pAO2 65.
Bicarbonate at this time was 18. The patient was found to
have an anion gap of 23. Urine toxicology screen was
positive for cocaine and tricyclics, however, negative for
alcohol. Tylenol level at 5 PM, which was approximately two
to three hours after ingestion was 103.8. At this time the
liver function tests, as well as the PT/INR and glucose were
all within normal limits. At this point, the patient was
transferred to [**Hospital1 69**] Emergency
Department.
In the [**Hospital1 18**] emergency department, here, the patient
was found to have a pulse of 80, blood pressure of 85/33.
She was treated with three ampules of bicarbonate that were
pushed sequentially without any change in the QRS interval
after an EKG had shown a wide QRS complex at 0.116. Chest
x-ray at this time was negative. The patient had one episode
of emesis of black charcoal with a question of aspiration, as
well as one large bowel movement incontinence.
PAST MEDICAL HISTORY: Per patient's husband, medical history
was unknown aside from a history of hypertension, as well as
history of depression. The husband has no prior history of
suicide attempts. She has been in multiple detoxification
facilities in the past.
MEDICATIONS: The patient is unable to answer questions about
her home regimen and medications. In addition, he husband is
unaware of her home regimen of medications. Clearly, the
patient did have access to Neurontin, Seroquel, and Paxil.
(Per patient history, obtained later in the hospitalization,
the patient is on Metoprolol and Vasotec for hypertension.
She also admits to stopping the Paxil approximately two weeks
prior to admission).
ALLERGIES: The patient reportedly has no known drug
allergies. However, one sheet from the outside hospital
medical record does note an ALLERGY to CLEOMYCIN.
SOCIAL HISTORY: The patient is married and lives with her
husband, however, reportedly, she has been having issues with
him, which are unclear at the time of admission. She does
have a history of polysubstance abuse including cocaine and
alcohol. The patient has recently quit her job and she is
unemployed.
FAMILY HISTORY: Unknown secondary to patient unable to
answer questions and husband not knowing any further
information regarding the family history.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 96.4, pulse 89, blood pressure 101/42 on a
dopamine drip at 10 and respiratory rate 14 on control
ventilation. Vent settings at that time included
assist-control ventilation with tidal volume 600, respiratory
rate 20, FIO2 of 60% with PEEP of 5. GENERAL: The patient
is intubated, sedated, and unresponsive. HEENT: Examination
revealed pupils, which are 5 mm and sluggishly reactive and
equal. Moist mucous membranes. HEAD: Normocephalic,
atraumatic. CARDIOVASCULAR: Normal S1 and S2, 2/6 systolic
ejection murmur at the left upper sternal border, regular
rate and rhythm. PULMONARY: Clear to auscultation
bilaterally. No wheezes, no rales. ABDOMEN: Positive bowel
sounds, soft, nondistended, liver edge palpable 4 cm below
the right costal margin. EXTREMITIES: 2+ dorsalis pedis
pulses bilaterally, no edema, no cyanosis, axillary sweat
present. NEUROLOGICAL: The patient is unresponsive,
sedated. SKIN: Warm, dry, not flush.
LABORATORY DATA: Data revealed the following: Arterial
blood gases pH 7.44, pCO2 37, PO2 226 on FIO2 of 60%. White
blood cell count 16.5, hematocrit 36.8, platelet count 278,000,
PT 13.7, INR 1.3, PTT 25.4, sodium 146, potassium 2.8, chloride
104, bicarbonate 23, BUN 12, creatinine 1.7, glucose 135, anion
gap of 19, calcium 8.7, magnesium 1.6, phosphatase 0.8.
Urinalysis revealed specific gravity of 1.002, negative
nitrite, negative leukocyte esterase, no glucose, no ketones,
and 30 protein. Serum toxicology screen reveals Tylenol
level of 123, aspirin level of 12, which is subtherapeutic,
no tricyclic antidepressants, no alcohol, no barbiturates,
and no benzodiazepines. Urine toxicology screen is positive
for cocaine, but negative for benzodiazepines, barbiturates,
opiates, amphetamines, and methadone.
EKG: Normal sinus rhythm, rate of 90, and normal axis. No S
waves in leads 1, AVL, no large R waves in leads AVR, QRS
complex 116. T-wave inversions V1 to V4, with question of
biphasic T waves.
Chest x-ray: No acute cardiopulmonary process. No evidence
of aspiration pneumonia. No pneumothorax. No evidence of
pulmonary edema. EG tube position is adequate.
HOSPITAL COURSE:
#1. NEUROLOGICAL/PSYCHIATRIC: The patient is status post
overdose with multiple medications, unclear quantity taken,
given positive serum TCA at outside hospital and borderline
EKG changes with widened QRS complex, as well as borderline
QTC prolongation. The patient was followed with serial EKGs.
The EKG changes, QRS, as well as prolonged QT resolved. The
electrolytes including calcium, magnesium, and potassium were
repleted aggressively. The patient was ruled out for
myocardial infarction given concern of tricyclic overdose as
well as concomitant cocaine use, the patient was initially
hypotensive. She was weaned off the dopamine drip in the six
hours after she was admitted. She was given fluid boluses
for hypotension to which she responded appropriately. After
being weaned off pressors, the patient actually had episodes
of hypertension, given her history of hypertension. She was
started on Hydrochlorothiazide 25 mg q.d.; however, this was
discontinued once the home regimen was evaluated and she was
started on Metoprolol 25 mg b.i.d. as well as
Enalapril 2.5 mg q.d. The patient was maintained with a 1:1 24-
hour sitter, and evaluated by Psychiatry Consultation Service.
#2. INFECTIOUS DISEASE: Given presentation with hypotension
of unclear etiology, the patient was worked up with blood and
urine cultures, both of which showed no growth. Chest x-ray
remained clear with no evidence of aspiration pneumonia and
the patient did not receive any antibiotics.
#3. RESPIRATORY FAILURE: The patient was quickly weaned off
assist control and changed to pressure support and extubated
within a day of her admission as her mental status improved
and she had a good gag and cough reflex. The patient
continues to have sputum, but is able to clear it adequately.
#4. RENAL: The patient's initial elevated creatinine
improved with hydration and she had good urine output. She
was initially treated with aggressive IV fluids at 125 cc an
hour normal saline. The patient then developed hyponatremia.
IV fluids were discontinued, and the patient was treated with
free water with good resolution of sodium. Upon discharge,
the patient's sodium level was 140.
#5. GI: Given the concern of abnormal liver function tests
subsequent to Tylenol overdose, the patient's LFTs, INR, and
glucose were followed. They remained normal throughout the
hospital course. The patient was treated with acetylcysteine
total of 17 doses.
#6. PROPHYLAXIS: The patient was initially on Lansoprazole,
which was switched to Protonix. The patient was also kept on
heparin subcutaneously, given that she was bed bound.
DISPOSITION: The patient was cleared medically with no
active medical issues. The hypertension was well controlled
on her current regimen. The patient was seen by the
Department of Psychiatry, who recommended hospitalization at
[**Hospital 16093**] Hospital if the patient was not actively suicidal
during the rest of her hospital, 1:1 sitter was discontinued.
The patient will benefit from inpatient stay with support,
clarification of medication goals, and further set up of
outpatient treatment, as well as meetings with her husband.
DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] 12-664
Dictated By:[**Name8 (MD) 44801**]
MEDQUIST36
D: [**2140-10-26**] 11:19
T: [**2140-10-26**] 11:27
JOB#: [**Job Number 44802**]
ICD9 Codes: 2762, 4589, 4019
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5498
}
|
Medical Text: Admission Date: [**2166-3-27**] Discharge Date: [**2166-4-1**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Atrial fibrillation with RVR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 86F with PMH HTN, hyperlipidemia,
hypothyroidism sent from PCP office for evaluation of afib with
RVR. The patient has complained of nonproductive cough and
fatigue x 1 week. No f/c, SOB. + sick contacts in [**Name2 (NI) **]. The
patient presented to her PCP office the day of admission for
these symptoms and was found to have new afib with RVR 130s and
was sent to the ED for further evaluation. She denied
[**Name2 (NI) 15420**], CP, SOB, or dizziness.
.
In the ED, vitals: T: 97.2 BP: 127/76 P: 86 RR: 16 SpO2: 97%RA.
Initial EKG showed atrial fibrillation with rapid ventricular
rate 170s that resolved without intervention. She had one
epidose of SSCP with cough lasting seconds and resolving without
intervention. Given aspirin 325 mg and levofloxacin 750 mg.
.
ROS: Denied headache, rhinorrhea or congestion. No orthopnea,
PND, LE edema. Denied nausea, vomiting, diarrhea, constipation
or abdominal pain. No melena or BRBPR. No dysuria. Denied
arthralgias or myalgias. No rash.
Past Medical History:
1. History of depression
2. Dementia
3. Hypothyroidism
4. Osteoarthritis
5. Hypertension
6. Hyperlipidemia
7. Gait disorder with high falls risk
8. Status post right humerus fracture
9. Right hip replacement
10. Left inguinal hernia repair
Social History:
The patient lives at [**Location **] Crossing [**Hospital3 **] facility.
Daughter involved in care and lives in area. Non-smoker, no
EtOH.
Family History:
NC
Physical Exam:
Vitals: T: 96.4 BP: 158/80 P: 87 RR: 16 SpO2: 97%2L
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MMM, OP without
lesions
Neck: Supple, no JVD or carotid bruits appreciated
Pulm: Decreased BS bases, good air flow, increased expiratory
phase, scattered expiratory wheeze
Cardiac: RRR, nl S1/S2, 2/6 systolic diamond-shaped murmur to
carotids
Abdomen: Soft, NT/ND, + BS, no masses or hepatomegaly noted
Ext: No edema b/t, 2+ DP and PT pulses b/l
Lymphatics: No cervical, supraclavicular LAD
Skin: No rashes or lesions noted.
Neurologic: Alert & Oriented x 2, CN II-XII grossly intact, MAEW
Pertinent Results:
[**2166-3-27**] 04:30PM BLOOD WBC-8.1 RBC-4.12* Hgb-12.6 Hct-38.6
MCV-94 MCH-30.6 MCHC-32.7 RDW-14.3 Plt Ct-277
[**2166-3-27**] 04:30PM BLOOD Glucose-90 UreaN-15 Creat-1.4* Na-141
K-4.4 Cl-104 HCO3-24 AnGap-17
[**2166-3-27**] 04:30PM BLOOD CK(CPK)-98 cTropnT-<0.01
[**2166-3-28**] 03:28AM BLOOD CK(CPK)-83 cTropnT-<0.01
[**2166-3-27**] 04:30PM BLOOD TSH-3.0
.
EKG 1 14:08 Atrial fibrillation with RVR, rate 179, NA, LBBB
(old), TWI V5-V6
EKG 2 16:38 NSR rate 93, NA, LBBB, TWI V5-V6
.
Radiologic Data:
[**2166-3-27**] CHEST (PORTABLE AP): IMPRESSION: Mild pulmonary edema and
moderate bilateral effusions and atelectasis.
.
[**2166-3-28**] Echo: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is moderate global left ventricular
hypokinesis (LVEF = 30-40 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. 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. There is moderate thickening of the mitral valve
chordae. Mild to moderate ([**12-25**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is no pericardial
effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2158-11-8**], the left
ventricular ejection fraction is reduced.
.
IMPRESSION: moderately reduced left ventricular contractile
function; heavy calcification of mitral annulus and support
structures
.
MICRO:
[**3-27**] BCx: P x 2
[**3-29**] UCx: P
Brief Hospital Course:
The patient is a 86F with PMH of HTN, hyperlipidemia, and
hypothyroidism presenting with cough and fatigue, found to be in
pAF with new systolic heart failure.
.
Paroxysmal atrial fibrillation: Patient was admitted with AF in
rate of 130s in ED, but had spontaneous conversion to NSR. This
was the first documented episode of afib for this patient.
Infectious w/u negative. TSH was WNL. There was no e/o acute MI,
with negative cardiac enzymes x 2 and no acute ST-T changes
consistent with ischemia on EKG. She remained in NSR during
much of her hospital course; however, she did have several
recurrent episodes of AF requiring IV medications for rate
control. On [**3-30**], the patient was transferred to the CCU for
altered mental status and AF with RVR to 140s despite IV BB and
CCB. She was started on an amiodarone load with amiodarone 400
[**Hospital1 **]. She should be continued on amiodarone 400 [**Hospital1 **] for a 7 day
course ([**Date range (1) 13500**]), followed by 200 [**Hospital1 **] x 7 days, then 200 daily
for maintenance dose. She was also started on a BB which she
tolerated well. Her CHADS2 score was 3; however, after
discussion of risks and benefits with the patient and her family
they declined anticoagulation given her high fall risk. She was
continued on ASA 325mg. She was scheduled a follow up
appointment with Cardiology clinic prior to discharge.
.
CHF: She was noted to have a new global hypokinesis with EF
30-40% on this admission. As above, there was no e/o acute MI
on admission given negative cardiac enzymes and no acute ST-T
changes consistent with ischemia on EKG. Echo showed no WMA.
She was diursed to euvolemia during this hospitalization. She
should have a repeat ECHO in [**1-27**] months to reassess with her
LVEF.
.
Chronic renal failure: Likely due to long-standing HTN. Renal
function stable.
.
Hypertension: Continued on BB and ACEI.
.
Hyperlipidemia: Continued on home dose of simvastatin.
Medications on Admission:
Buspirone 15 mg [**Hospital1 **]
Lisinopril 10 mg DAILY
Olanzapine 2.5 mg [**Hospital1 **]
Simvastatin 20 mg DAILY
Synthroid 75 mcg DAILY
Venlafaxine 225 mg DAILY
Aspirin 81 mg DAILY
Calcium-Vitamin D3-Vitamin K 500 mg-100 unit-[**Unit Number **] mcg [**Hospital1 **]
Multivitamin DAILY
Lorazepam 0.5 mg PRN
Lactulose [**Hospital1 **] PRN
Discharge Medications:
1. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: until [**4-6**].
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: [**4-7**] until [**4-13**].
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
from [**4-14**].
11. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO QID (4
times a day).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary
Atrial Fibrillation
Secondary
Congestive Heart Failure
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with fatigue and cough. You were noted to
have a new atrial fibrillation (an abnormal heart rhythm). You
were also found to have heart failure.
You were treated with several agents for your heart conditions,
including amiodarone, high dose aspirin and metoprolol. You
should take all of your medication as directed.
Your effexor was decreased.
If you have any of the following symptoms you should return to
the emergency room or see your PCP:
[**Name10 (NameIs) **], chest pain, shortess of breath, fever, chills or
any other serious concerns.
Followup Instructions:
We have scheduled the following appointments for you. Please
attend them as directed:
Cardiology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2166-4-16**] 9:40
Primary Care Provider:
[**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2166-5-29**] 2:30
Completed by:[**2166-4-1**]
ICD9 Codes: 4280, 5859, 2724, 2449
|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 5499
}
|
Medical Text: Admission Date: [**2109-1-8**] Discharge Date: [**2109-2-1**]
Date of Birth: [**2055-2-17**] Sex: M
Service: MEDICINE
Allergies:
Nortriptyline
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
aspiration s/p intubation for [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**2109-1-8**] [**Month/Day/Year **] and intubation
[**2109-1-11**] Placement of post pyloric Doppoff feeding tube
[**2109-1-16**] Dobhoff replacement in post pyloric position
[**2109-1-19**] Extubation
[**2109-1-20**] Pulled Dobhoff feeding tube
History of Present Illness:
This is a 53 year-old male with a history of depression who was
admitted to the [**Hospital Unit Name 153**] after [**Hospital Unit Name **] complicated by aspiration and
hypoxic respiratory failure. Briefly, this patient was admitted
to an outside hospital initially with abdominal pain and concern
for choleycystitis. He was transferred to [**Hospital1 18**] on [**2108-12-31**] for
[**Date Range **] as there was a presumed stone in the CBD, but no stone was
seen. Therefore, he was transferred back to [**Hospital1 392**] and
underwent a laparascopic choleycystectomy. This procedure was
complicated by a very friable gallbladder and a persistent by
duct leak. He was then transferred back to [**Hospital1 18**] for stenting.
He was intubated for his procedure. During a successful stent
placement he vomited and aspirated. Anesthesia performed a
bronchoscopy and there was a significant quantity of bile in the
RML. He was transferred to the ICU on a ventilator given
concern he would develop [**Doctor Last Name **]/ARDS after his severe aspiration
event. His vent settings at the time of transfer were AC, Tv
600,RR 14,PEEP 8,FiO2 100%. ABG was 7.42/45/207.
Review of Systems: Unobtainable at presentation
Past Medical History:
Depression
Social History:
He does not use tobacco and rarely uses alcohol. He works at
[**Hospital6 **] Health Center. He is recently divorced. He has
two brothers from whom he is somewhat estranged.
Family History:
Non-contributory
Physical Exam:
On Presentation:
-----------------
Tmax: 37 ??????C (98.6 ??????F)
Tcurrent: 37 ??????C (98.6 ??????F)
HR: 93 (93 - 94) bpm
BP: 94/51(62) {94/51(62) - 99/54(65)} mmHg
RR: 17 (17 - 25) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Height: 73 Inch
Gen: intubated; appears comfortable
HEENT: PEERL; NGT in place; intubated. Bilious fluid in NGT
CV: RRR no murmurs
Lungs: BS heard throughout, coarse rhonci bilaterally R>L
Abd: distended, hypoactive BS; incision sites C/D/I. JP drain
in place, bilious fluid; no grimace to palpation. No guarding
Ext: no edema
Neuro: sedated; normal tone. No clonus
Pertinent Results:
Admission labs:
----------------
[**2109-1-8**] 06:05PM BLOOD WBC-19.7* RBC-3.60* Hgb-10.8* Hct-32.5*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.4 Plt Ct-218
[**2109-1-8**] 06:05PM BLOOD Neuts-93.4* Lymphs-2.9* Monos-2.9 Eos-0.7
Baso-0.1
[**2109-1-8**] 06:05PM BLOOD PT-13.6* PTT-27.1 INR(PT)-1.2*
[**2109-1-8**] 06:05PM BLOOD Plt Ct-218
[**2109-1-8**] 06:05PM BLOOD Glucose-109* UreaN-6 Creat-0.7 Na-136
K-3.4 Cl-99 HCO3-28 AnGap-12
[**2109-1-8**] 06:05PM BLOOD ALT-16 AST-20 LD(LDH)-332* AlkPhos-77
Amylase-94 TotBili-0.6
[**2109-1-8**] 06:05PM BLOOD Lipase-46
[**2109-1-8**] 06:05PM BLOOD Calcium-7.7* Phos-2.6* Mg-2.0
[**2109-1-8**] 05:09PM BLOOD Type-ART pO2-207* pCO2-45 pH-7.42
calTCO2-30 Base XS-4
[**2109-1-8**] 05:09PM BLOOD Na-130* K-3.0* Cl-98*
[**2109-1-8**] 11:11PM BLOOD Lactate-1.4
[**2109-1-8**] [**Month/Day/Year **]: IMPRESSION:
1. Persistent bile leak from the cystic duct stump with contrast
directed
away from the drainage catheter.
2. Status post cholecystectomy with cholecystectomy clips and
drainage
catheter at the end of the cystic duct remnant.
3. On this study the tip of the endotracheal tube is near the
right main stem bronchus however on radiographs from subsequent
days, the tip of the
endotracheal tube is appropriately positioned.
[**2109-1-10**]: CT Abdomen and Pelvis:
IMPRESSION:
1. Necrotizing pancreatitis characterized by lack of enhancement
of the
pancreatic head, neck and proximal body with marked
peripancreatic
inflammatory stranding.
2. No evidence of hematoma in the abdomen or pelvis. The
previously
described abnormality in Morison's pouch likely represented the
surgical drain in this region.
3. Multifocal nodular opacities throughout the bilateral lung
fields, near-
complete consolidation of the bilateral lower lobes and small
bilateral
pleural effusions. These findings are suspicious for an
infectious etiology and given the bibasilar consolidation,
aspiration pneumonia is suspected.
4. Colonic diverticulosis without evidence of diverticulitis.
[**2109-1-14**]: CT Torso
IMPRESSION:
1. Interval worsening of diffuse patchy alveolar opacities
throughout both
lungs and persistent bibasilar consolidations concerning for
pneumonia.
Aspiration pneumonia remains a diagnostic consideration.
2. CT evidence of necrotizing pancreatitis as previously
described. Although the study was not specifically tailored to
assess the enhancement of the pancreas, decreased areas of
enhancement in the head and body are again evident. Enlarged
mesenteric lymph nodes likely reactive and related to ongoing
inflammatory and/or infectious process. Markedly attenuated SMV.
3. Prominence of the left intrahepatic biliary ducts in the
setting of a
biliary stent, could represent obstruction, but unchanged.
4. Anasarca and increase in bilateral pleural effusions and
small amount of intra-abdominal ascites.
[**2109-1-14**] CT Head:
IMPRESSION: No evidence of acute intracranial abnormalities.
[**2109-1-25**] TTE:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (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 root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No masses
or vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No apparent valvular vegetations identified. Mild
left ventricular hypertrophy with preserved biventricular
regional and global systolic function.
[**2109-1-28**] 3:41 pm STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT [**2109-1-29**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2109-1-29**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 76625**] ON [**2109-1-29**] AT 0540.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2109-1-23**] 10:30 am BLOOD CULTURE
**FINAL REPORT [**2109-1-29**]**
Blood Culture, Routine (Final [**2109-1-29**]):
[**Female First Name (un) **] ALBICANS. FINAL SENSITIVITIES.
Fluconazole = Sensitive , sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**] This test has not been FDA approved but has been
verified
following Clinical and Laboratory Standards Institute
guidelines
by [**Hospital1 69**] Clinical
Microbiology
Laboratory..
Aerobic Bottle Gram Stain (Final [**2109-1-25**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) 81313**],[**First Name3 (LF) **] @ 0700 ON
[**2109-1-25**].
BUDDING YEAST.
[**2109-1-21**] 5:09 pm CATHETER TIP-IV Source: Right IJ.
**FINAL REPORT [**2109-1-23**]**
WOUND CULTURE (Final [**2109-1-23**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. >15
colonies.
Brief Hospital Course:
This is a 53 year-old male with a history of depression
transferred to the [**Hospital1 18**] with a persistent bile leak after
laparoscopic choleycystectomy.
Current active issues are treatment for line-associated
fungemia, c.difficile colitis and recurrent ileus.
1) Hypoxia: The patient was intubated for [**Hospital1 **] after being
somewhat hypoxic during his procedure. The primary etiology of
his initial respiratory failure was considered to be aspiration
pneumonia/pneumonitis after having frank bile in the lung on
bronchoscopy. As his hospitalization progressed he required
large amounts of IV fluids for volume resuscitation in the
context of vasodilatory shock. Initially, the patient was kept
on AC and low volume settings given the high perceived risk of
developing ARDS. His PaO2/FiO2 ratio never dropped below 100,
however, and he was eventually successfully weaned to pressure
support in the context of initiating diuresis. He had been
advanced to minimal settings with good oxygenation and
ventilation but was maintained on CPAP for [**1-1**] more days while
his mental status resolved. On [**2109-1-19**] he was extubated and
maintained good O2 saturations and showed no signs of
hypercarbia thereafter.
2) Vasodilatory Shock: The patient was not hypotensive on his
initial presentation to the [**Hospital Unit Name 153**] but over his first night in the
unit developed severe hypotension with persistently low CVP's so
that over his first two nights in the unit he required >15 L of
NS and then LR in order to aim for a goal CVP of 15 and a MAP of
>60. This shock was considered likely to be septic/inflammatory
and due to cholangitis +/- pancreatitis. Surgery strongly
recommended avoiding the pressors in the setting of known
pancreatitis and these were never required except for briefly on
the night of [**2109-1-15**] when he received norepinephrine briefly in
order to get enough blood pressure to allow furosemide bolusing.
His hypotension resolved and he required no further fluid
boluses after [**2109-1-15**].
3)Choleycystitis/Cholangitis: The patient was febrile shortly
after his arrival in the ICU and given his complicated procedure
and the sequelae he was placed on pipercillin-tazobactam and
vancomycin for cholangitis in this heavily instrumented patient.
The patient completed a 10 day course of
pipercillin-tazobactam/meropenem and vancomycin for this
problem.
4)Fevers/VAP: Despite being well covered for cholangitis and HAP
organisms the patient remained febrile. Numerous blood and
urine cultures remained negative but the patient did have growth
of E. coli *2 in his sputum. After the second of these showed
resistance to pipercillin-tazobactam the patient was switched to
meropenem on [**2109-1-15**]. He defervesced slightly thereafter and he
completed a 10 day course of meropenem for VAP.
5) Pancreatitis: CT scan on [**2109-1-10**] showed necrotizing
pancreatitis. Surgery was consulted and recommended NPO status,
avoiding pressors, and supportive care. The patient had a
repeat scan on [**2109-1-14**] to rule out subdiaphragmatic abscess as
he had persistent hiccups on the ventilator; this showed no
interval change. Surgery recommends outpatient follow up in
order to rescan his abdomen weeks in the future to look for
developing phlegmon that may need eventual drainage.
-Patient will need f/u with Dr. [**Last Name (STitle) 1924**] in surgery clinic
[**Telephone/Fax (1) 7508**] on Tuesday, [**2-12**] at 9am, [**Last Name (un) 469**] [**Location (un) 470**].
He will perhaps form a pseudocyst that may potentially need
drainage in the future.
6) Ileus: The patient developed a functional ileus presumably
due to his pancreatitis and inflammatory stunning of his bowel.
This led to persistently high NG tube outputs on low
intermittent suction. By the day he was transferred from the
ICU on [**2109-1-22**] he was only putting out a liter/day. This
decreased subtsantially and his NG tube was removed, however the
patient was not able to comfortably tolerate full liquids and
after replacement of the NG tube on [**1-31**], the patient started
have further bilious NG tube drainage. The patient will be
discharged with a NG tube with plan for enteral feeding via
J-tube.
-Can remove NG tube when drainage significantly decreases and
patient's nausea and vomiting improves.
7) Altered Mental Status: The patient was slow to wake up after
sedation was stopped. He was extubated when he was able to
regularly follow commands. He remained persistently confused
with waxing and [**Doctor Last Name 688**] mental status but no focal findings
consistent with ICU delirium. After his arrival on the floor,
the patient's delirium significantly improved.
8)Nutrition: The patient was started on PPN on [**2109-1-10**] and then
advanced to TPN on [**2109-1-11**]. The patient then had a post-pyloric
feeding tube and was advanced to tube feeds on [**2109-1-12**].
Unfortunately, we had repeated issues with the patient pulling
out post-pyloric feeding tubes so he was put back on TPN on
[**2109-1-20**]. Due to the patient's fungemia, his TPN was
discontinued on [**1-31**]. Interventional radiology placed a J-tube on
[**2-1**].
-Initiate tube feeds and advance as tolerated.
.
9) Line-associated [**Female First Name (un) 564**] Albicans Fungemia) The patient is
on a 2 week course of IV fluconazole to be completed on [**2-8**].
Surveillance cultures to date had no growth.
.
10) Clostridium difficile) The patient had a positive [**1-28**] stool
cx for c.difficile. The patient was treated with IV flagyl with
improvement in his symptoms. With J-tube placement on [**2-1**], this
can be changed to oral flagyl.
Full Code
Medications on Admission:
Medications at home: per records
Cymbalta 60 mg daily
.
Medications on transfer from OSH:
Heparin sc
Flagyl 500 mg IV q8H
Ambien 10 mg QHS PRN
Zofran 4 mg IV q6h PRN
Famotidine 20 mg [**Hospital1 **]
Duloxetine 60 mg QHS
Hydromorphone 1-2 mg IV q4h PRN
Zosyn 4.5 gm q6H
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig:
Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 7
days.
3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 12
days.
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
5. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
6. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
9. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
10. Morphine 10 mg/mL Solution Sig: 1-2 mg Intravenous Q4H
(every 4 hours) as needed.
11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
12. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
13. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
three times a day: Use per sliding scale.
14. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Hypoxemic respiratory failure from aspiration
Severe Sepsis
Cholangitis
Cystic Duct Stump Leak
Ileus
Vent-associated pneumonia
Line-associated fungemia
C. difficile colitis
Delirium
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Patient is to return to the ED if he is having high fevers,
confusion, symptomatic hypotension.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**]
Date/Time:[**2109-2-12**] 9:00
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2109-2-26**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2109-2-26**] 8:30
ICD9 Codes: 0389, 5070, 2930, 311, 2859
|
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